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LETTER TO EDITOR
Year : 2010  |  Volume : 58  |  Issue : 6  |  Page : 972-974

Pediatric cerebellar pilocytic astrocytoma presenting with hemorrhage


Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences, Mumbai - 400 020, Maharashtra, India

Date of Acceptance17-Aug-2010
Date of Web Publication10-Dec-2010

Correspondence Address:
Ashish Kumar
Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences, Mumbai - 400 020, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.73775

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How to cite this article:
Kumar A, Deopujari CE, Biyani N, Mhatre MV. Pediatric cerebellar pilocytic astrocytoma presenting with hemorrhage. Neurol India 2010;58:972-4

How to cite this URL:
Kumar A, Deopujari CE, Biyani N, Mhatre MV. Pediatric cerebellar pilocytic astrocytoma presenting with hemorrhage. Neurol India [serial online] 2010 [cited 2021 May 9];58:972-4. Available from: https://www.neurologyindia.com/text.asp?2010/58/6/972/73775


Sir,

Clinical presentation with spontaneous intracerebral hemorrhage in central nervous system tumors is an uncommon but a well described entity. Mostly, hemorrhage is seen in primary and metastatic central nervous system tumors. Pilocytic astrocytomas in posterior fossa rarely present with hemorrhage, and only sporadic case reports are available in the literature.

A 16-year-old girl presented with history of intermittent suboccipital headaches, gait disturbances and blurring of vision for 10-15 days with worsening of symptoms and recurrent episodes of vomiting in the last 2 days. Neurologic examination revealed bilateral papilledema and positive cerebellar signs. Cranial magnetic resonance imaging (MRI) revealed a right cerebellar solid-cystic lesion, which was isointense on T1-weighted images and hyperintense on T2-weighted images with irregular peripheral rim-like enhancement [Figure 1]. The gradient echo sequence showed evidence of bleed within the tumor [Figure 2]. She underwent midline suboccipital craniotomy and gross total excision of tumor. Intraoperatively, the tumor was highly vascular, and an organized blood clot was present within the lesion [Figure 3]. The histopathology revealed typical biphasic pattern of pilocytic astrocytoma with compact areas marked by piloid cells and rosenthal fibers and loose microcystic areas along with hyalinization of vessels [Figure 4]. Postoperative MRI after an interval of 3 months confirmed complete excision of tumor.
Figure 1: Gadolinium scan showing irregular peripheral rim-like enhancement

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Figure 2: Coronal gradient echo sequence showing blood pigments within the tumor

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Figure 3: Intraoperative picture showing organized blood clot within the tumor cavity

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Figure 4: Histological slide (hematoxylin and eosin stain, ×200) showing the biphasic pattern of a pilocytic astrocytoma and rosenthal fibers

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The reported rate of hemorrhage in primary gliomas has been around 3.7% to 7.2% (mainly in glioblastoma and oligodendrogliomas), while the low-grade astrocytomas account for less than 1% of cases. [1],[2] Lieu et al.[2] reported an incidence of 3.5% in their series of 761 brain tumors. Acute cerebellar hemorrhage in adults occurs in 10% of the cases and is associated with hypertension and anticoagulant therapy. In children, acute cerebellar hemorrhage which is neoplastic in origin is very rare. Only a few case reports of cerebellar pilocytic astrocytoma presenting with hemorrhage are found in the literature. Mesiwala et al.[3] reported a case of spontaneous intracerebellar hemorrhage in posterior fossa pilocytic astrocytoma in 2001, and only 6 other cases of intratumoral bleed in pediatric posterior fossa tumors were found by them in literature since 1977. In their first ever series assessing the rate of spontaneous hemorrhage in histologically proven pilocytic astrocytomas, White et al.[4] reviewed 138 cases in both supratentorial and infratentorial locations during a span of 11 years, with 8% of cases presenting with hemorrhage. They concluded that there was no particular location susceptible for hemorrhage; however, no bleeding occurred in cerebellum in their series. The etiology of intratumoral hemorrhage in pilocytic astrocytomas is unclear. In contrast to higher-grade tumors, where hemorrhage has been linked to rapid tumor cell proliferation, abundant neo-vascularization, and necrosis of blood vessels, the cause of hemorrhage in pilocytic astrocytomas is still debated, some possible explanations being endothelial proliferation, rupture of encased aneurysms and dysplastic capillary beds. Also, fibrinolytic activity due to the thromboplastin activity of brain tissue has been thought of as a contributing factor. Kondziolka et al.[5] reported 24 cases of mixed oligodendroglioma-astrocytoma, of which 7 cases were associated with gross bleeding. There was no bleeding encountered within the cerebellum. A literature review by Joung et al.[6] summarizes various sites and histological diagnosis in children with spontaneous cerebellar hemorrhage in the posterior fossa tumors [Table 1]. Pilocytic astrocytomas, although benign, can present with hemorrhage evident on imaging at a higher rate than expected. Their presentation seems to be acute in nature, and high index of suspicion is required in the diagnosis of these posterior fossa tumors, which can deteriorate rapidly.
Table 1: Spontaneous cerebellar hemorrhage in pediatric posterior fossa tumors[6]

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 » References Top

1.Bitoh S, Hasegawa H, Ohtsuki H, Obashi J, Fujiwara M, Sakurai M. Cerebral neoplasms initially presenting with massive intra-cerebral hemorrhage. Surg Neurol 1984;22:57-62.  Back to cited text no. 1
[PUBMED]    
2.Lieu AS, Hwang SL, Howng SL, Chai CY. Brain tumors with hemorrhage. J Formos Med Assoc 1999;98:365-7.  Back to cited text no. 2
[PUBMED]    
3.Mesiwala AH, Avellino AM, Roberts TS, Ellenbogen RG. Spontaneous cerebellar hemorrhage due to a juvenile pilocytic astrocytoma: Case report and review of the literature. Pediatr Neurosurg 2001;34:235-8.  Back to cited text no. 3
[PUBMED]  [FULLTEXT]  
4.White JB, Piepgras DG, Scheithauer BW, Parisi JE. Rate of spontaneous hemorrhage in histologically proven cases of pilocytic astrocytoma. J Neurosurg 2008;108:223-6.  Back to cited text no. 4
[PUBMED]  [FULLTEXT]  
5.Kondziolka D, Bernstein M, Resch L, Tator CH, Fleming JF, Vanderlinden RG, et al. Significance of hemorrhage into brain tumors: Clinicopathological study. J Neurosurg 1987;67:852-7.   Back to cited text no. 5
[PUBMED]  [FULLTEXT]  
6.Joung Y, Cheong J, Bak K, Kim C. Cerebellar glioblastoma presenting as a cerebellar hemorrhage in a child. J Korean Neurosurg Soc 2006;39:374-7.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1]

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