Clinical Review & Education
Images in Neurology
Suspected Subdural Hematoma Ozlem Ozkul-Wermester, MD; Evelyne Guégan-Massardier, MD; Aude Triquenot-Bagan, MD; Olivier Langlois, MD; Romain Lefaucheur, MD; Bertrand Bourre, MD
A 71-year-old woman was admitted for 3 inaugural right-sided focal seizures. Shortly before, she had experienced a minor head trauma. Her neurological examination finding was normal. A brain computed tomographic scan and magnetic resonance imaging (MRI) showed abnormalities supporting the diagnosis of chronic subdural hematoma (SDH), with a subcutaneous collection regarding this subdural hematoma (Figure, A-C). She did not undergo surgery, and monitoring with brain MRI was recommended. Three months later, while partial seizures persisted despite anti-epileptic treatment (levitiracetam, 2000 mg/d), follow-up brain MRI showed increased extra-axial and subcutaneous gadolinium-enhanced masses (Figure, D and E). Given this unusual subdural hematoma evolution and radiological worsening of the suspected hematoma, craniotomy and biopsies were performed. The histopathology findings revealed a low-grade B-cell marginal zone lymphoma involving dura with bone and scalp invasion. The patient underwent radiotherapy after surgery, which reduced the residual mass. Six months later, her neurological condition deteriorated with progressive appearance of a right hemiparesis, aphasia, and drug-resistant epilepsy.
Discussion Arising from dura mater, primary dural lymphoma (PDL) is a subentity of primary leptomeningeal lymphoma, which is very rare,
representing less than 0.1% of all non-Hodgkin lymphoma and less than 3% of all primary central nervous system lymphoma cases.1 Primary dural lymphoma is usually a low-grade marginal zone lymphoma, while other types of primary central nervous system lymphoma are usually high grade, diffuse, large B-cell lymphomas.2 The incidence of PDL is unknown, more often occurring in middle-aged women. Marginal zone lymphoma occurs more frequently in the gastrointestinal tract, also called mucosa-associated lymphoid tissue lymphoma. The pathogenesis of PDL remains unclear because dura does not contain any lymphoid tissue. Surgery, radiotherapy, and chemotherapy can be proposed but there are no standard guidelines for treatment. The diagnosis of PDL is difficult because the imaging appearance usually is of an extra-axial mass mimicking meningioma, subdural or extradural hematoma, and dural metastasis. In our case, invasion of the sulci on the initial MRI was atypical for a subdural hematoma and should have suggested a biopsy rather than follow-up. In conclusion, our observation emphasizes the misleading MRI aspects of the PDL, which delay introducing an optimal treatment. Primary dural lymphoma should be considered in the differential diagnosis of intracranial or dural mass lesions.
Figure. Brain Computed Tomographic (CT) Scan and Magnetic Resonance Imaging (MRI) Follow-up Demonstrating a Presumed Left Frontoparietal Subdural Hematoma
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B
D
E
C
JAMA Neurology July 2014 Volume 71, Number 7
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A, Brain CT scan without injection showing discrete left frontoparietal hypodensity compatible with a subdural hematoma and subcutaneous collection (arrowhead). Fluid-attenuated inversion recovery sequence (B) and T2-gradient echo brain MRI (C) showing left frontoparietal isointense lesion. Axial (D) and coronal T1-weighted brain MRI (E) at 3 months showing a homogeneously gadolinium-enhanced hyperintensity (arrowhead).
jamaneurology.com
Images in Neurology Clinical Review & Education
ARTICLE INFORMATION Author Affiliations: Department of Neurology, Rouen University Hospital, University of Rouen, Rouen, France (Ozkul-Wermester, Guégan-Massardier, Triquenot-Bagan, Lefaucheur, Bourre); Department of Neurosurgery, Rouen University Hospital, University of Rouen, Rouen, France (Langlois). Corresponding Author: Ozlem Ozkul-Wermester, MD, Department of Neurology, Rouen University Hospital, 76031 Rouen Cedex, France ([email protected]).
Published Online: May 12, 2014. doi:10.1001/jamaneurol.2013.6013.
2. Iwamoto FM, Abrey LE. Primary dural lymphomas: a review. Neurosurg Focus. 2006;21(5):5.
Conflict of Interest Disclosures: None reported. REFERENCES 1. Taylor JW, Flanagan EP, O’Neill BP, et al. Primary leptomeningeal lymphoma: International Primary CNS Lymphoma Collaborative Group report. Neurology. 2013;81(19):1690-1696.
jamaneurology.com
JAMA Neurology July 2014 Volume 71, Number 7
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archneur.jamanetwork.com/ by a J H Quillen College User on 06/05/2015
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Images in Neurology
Suspected Subdural Hematoma Ozlem Ozkul-Wermester, MD; Evelyne Guégan-Massardier, MD; Aude Triquenot-Bagan, MD; Olivier Langlois, MD; Romain Lefaucheur, MD; Bertrand Bourre, MD
A 71-year-old woman was admitted for 3 inaugural right-sided focal seizures. Shortly before, she had experienced a minor head trauma. Her neurological examination finding was normal. A brain computed tomographic scan and magnetic resonance imaging (MRI) showed abnormalities supporting the diagnosis of chronic subdural hematoma (SDH), with a subcutaneous collection regarding this subdural hematoma (Figure, A-C). She did not undergo surgery, and monitoring with brain MRI was recommended. Three months later, while partial seizures persisted despite anti-epileptic treatment (levitiracetam, 2000 mg/d), follow-up brain MRI showed increased extra-axial and subcutaneous gadolinium-enhanced masses (Figure, D and E). Given this unusual subdural hematoma evolution and radiological worsening of the suspected hematoma, craniotomy and biopsies were performed. The histopathology findings revealed a low-grade B-cell marginal zone lymphoma involving dura with bone and scalp invasion. The patient underwent radiotherapy after surgery, which reduced the residual mass. Six months later, her neurological condition deteriorated with progressive appearance of a right hemiparesis, aphasia, and drug-resistant epilepsy.
Discussion Arising from dura mater, primary dural lymphoma (PDL) is a subentity of primary leptomeningeal lymphoma, which is very rare,
representing less than 0.1% of all non-Hodgkin lymphoma and less than 3% of all primary central nervous system lymphoma cases.1 Primary dural lymphoma is usually a low-grade marginal zone lymphoma, while other types of primary central nervous system lymphoma are usually high grade, diffuse, large B-cell lymphomas.2 The incidence of PDL is unknown, more often occurring in middle-aged women. Marginal zone lymphoma occurs more frequently in the gastrointestinal tract, also called mucosa-associated lymphoid tissue lymphoma. The pathogenesis of PDL remains unclear because dura does not contain any lymphoid tissue. Surgery, radiotherapy, and chemotherapy can be proposed but there are no standard guidelines for treatment. The diagnosis of PDL is difficult because the imaging appearance usually is of an extra-axial mass mimicking meningioma, subdural or extradural hematoma, and dural metastasis. In our case, invasion of the sulci on the initial MRI was atypical for a subdural hematoma and should have suggested a biopsy rather than follow-up. In conclusion, our observation emphasizes the misleading MRI aspects of the PDL, which delay introducing an optimal treatment. Primary dural lymphoma should be considered in the differential diagnosis of intracranial or dural mass lesions.
Figure. Brain Computed Tomographic (CT) Scan and Magnetic Resonance Imaging (MRI) Follow-up Demonstrating a Presumed Left Frontoparietal Subdural Hematoma
916
A
B
D
E
C
JAMA Neurology July 2014 Volume 71, Number 7
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archneur.jamanetwork.com/ by a J H Quillen College User on 06/05/2015
A, Brain CT scan without injection showing discrete left frontoparietal hypodensity compatible with a subdural hematoma and subcutaneous collection (arrowhead). Fluid-attenuated inversion recovery sequence (B) and T2-gradient echo brain MRI (C) showing left frontoparietal isointense lesion. Axial (D) and coronal T1-weighted brain MRI (E) at 3 months showing a homogeneously gadolinium-enhanced hyperintensity (arrowhead).
jamaneurology.com
Images in Neurology Clinical Review & Education
ARTICLE INFORMATION Author Affiliations: Department of Neurology, Rouen University Hospital, University of Rouen, Rouen, France (Ozkul-Wermester, Guégan-Massardier, Triquenot-Bagan, Lefaucheur, Bourre); Department of Neurosurgery, Rouen University Hospital, University of Rouen, Rouen, France (Langlois). Corresponding Author: Ozlem Ozkul-Wermester, MD, Department of Neurology, Rouen University Hospital, 76031 Rouen Cedex, France ([email protected]).
Published Online: May 12, 2014. doi:10.1001/jamaneurol.2013.6013.
2. Iwamoto FM, Abrey LE. Primary dural lymphomas: a review. Neurosurg Focus. 2006;21(5):5.
Conflict of Interest Disclosures: None reported. REFERENCES 1. Taylor JW, Flanagan EP, O’Neill BP, et al. Primary leptomeningeal lymphoma: International Primary CNS Lymphoma Collaborative Group report. Neurology. 2013;81(19):1690-1696.
jamaneurology.com
JAMA Neurology July 2014 Volume 71, Number 7
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archneur.jamanetwork.com/ by a J H Quillen College User on 06/05/2015
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