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| LETTER TO EDITOR |
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| Year : 2012 | Volume
: 60
| Issue : 2 | Page : 243-245 |
Intratumoral hemorrhage in brainstem low-grade glioma
Arun Tungaria, Rabi Narayan Sahu, Raj Kumar, Arun Srivastava
Department of Neurosurgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Utttar Pradesh, India
| Date of Submission | 02-Nov-2011 |
| Date of Decision | 06-Nov-2011 |
| Date of Acceptance | 04-Mar-2012 |
| Date of Web Publication | 19-May-2012 |
Correspondence Address:
Arun Tungaria
Department of Neurosurgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Utttar Pradesh
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0028-3886.96427
How to cite this article:
Tungaria A, Sahu RN, Kumar R, Srivastava A. Intratumoral hemorrhage in brainstem low-grade glioma. Neurol India 2012;60:243-5 |
Sir,
Intratumoral hemorrhage in brainstem glioma, although previously reported in children, has not been reported in adults, hence this letter to editor.
A 37-year-old lady presented with progressive holocranial headache of one-year duration and gradual-onset progressively increasing ascending spastic right-sided hemiparesis and gradual-onset hearing loss in left ear without tinnitus of three months' duration. Examination showed bilateral papilledema with a visual acuity of 6/9 in both eyes, left 6th, 7th (House and Brakeman Grade 3) and 8th (sensorineural hearing loss) cranial nerve involvement. Motor examination revealed right-sided hemiparesis and left-sided cerebellar signs. Magnetic resonance imaging (MRI) showed a well-defined extra-axial brainstem lesion on the left side extending from the lower midbrain to the lower medulla. It was hypointense on T1- and T2-weighted image with no restricted diffusion and not enhancing on gadolinium administration. Forth ventricle was compressed with obstructive hydrocephalus [Figure 1]a. Patient went home and planned to come for surgery after a few days. About four weeks later she had severe headache at home and became unconscious and brought in emergency. She was urgently intubated and put on ventilator support and an urgent external ventricular drainage (EVD) was done suspecting acute hydrocephalus, with which she improved and started obeying simple commands with right-sided hemiplegia. Computed tomogram (CT) scan revealed a large intratumoral hemorrhage [Figure 1]b. Left retromastoid suboccipital craniectomy was done with the aim of tumor decompression. Intraoperatively the tumor was arising from the brainstemwith blood clots in it. It was greyish white, firm, partly suckable, and moderately vascular. The seventh and eighth nerve complex was free from the tumor and was pushed anteriorly. The third and sixth cranial nerves were identified and preserved. Evacuation of hematoma with near total tumor decompression was done [Figure 1]c. In the postoperative period patient was conscious, obeying simple commands with right-sided hemiparesis (Grade 3/5), left 6th and 7th nerve paresis (House and Brakeman Grade 4) with no useful hearing on the left side. Patient developed ventilator-associated pneumonia, severe septicemia and acute respiratory distress syndrome (ARDS) and succumbed on postoperative day 15. Histopathology revealed low-grade glioma with rounded tumor cells of irregular hyperchromatic nuclei, coarse chromatin, in fibrillary background [Figure 1]d and Ki-67 stain showed 4-5% positivity [Figure 1]e. | Figure 1: a: Preoperative MRI of the patient showing a well-defined extra-axial lesion in the brainstem on the left side not enhancing on gadolinium-enhanced MR imaging
Figure 1: b: Computed tomogram of the patient at the time of presentation with unconsciousness, revealing large intratumoral hemorrhage in the tumor
Figure 1: c: Postoperative CT scan showing complete excision of the tumor in the posterior fossa
Figure 1: d: Tumor displaying hyperchromatic nuclei, coarse chromatin disposed in fibrillary background (H and E, × 400)
Figure 1: e: Ki-67 stain showing 4-5% positivity (H and E, × 400)
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Low-grade brainstem gliomas in adults are rare, with a heterogeneous clinical course. Incidence of massive hemorrhage in low-grade gliomas is 4-12% [1] and intratumoral brainstem glioma hemorrhage is rare, mostly reported in children. An exhaustive literature search did not reveal a similar incident in adult brainstem low-grade glioma. Broniscer et al., [2] demonstrated intratumoral hemorrhage in approximately 6% of diffuse brainstem gliomas in children at the time of diagnosis. They hypothesized that the necrotic areas within these tumors are responsible for the occurrence of intratumoral hemorrhage. The hemorrhage is thought to originate from vessels that traverse the necrotic areas or from tumoral invasion of large vessels, which leads to thinning and rupture of the vessel wall. Another cause for intratumoral hemorrhage could be relatively weak tumor vessels, which are not well invested with glial meshwork which may contribute to reduced resistance to the shearing forces of the brain. [3] This hypothesis is in the context of high-grade gliomas. In the present patient, this may not be the likely explanation for intratumoral hemorrhage, as histopathology of the resected tumor revealed low-grade glioma. Hemorrhage in low-grade glioma can be attributed to vascular proliferation, which is an occasional feature of these tumors. [1],[4] Retiform capillaries have been found to be associated with hemorrhage in astrocytomas and glioblastoma multiforme. [5] These capillaries take a convoluted, tortuous route while lacking external support. The present patient is the first ever reported case of intratumoral hemorrhage in a brainstem low-grade glioma in an adult patient.
| » References | |  |
| 1. | Matsumoto K, Akagi K, Abekura M, Maeda Y, Kitagawa M, Ryujin H, et al. Hypothalamic pilocytic astrocytoma presenting with intratumoral and subarachnoid hemorrhage. Neurol Med Chir (Tokyo) 1997;37:849-51. 
[PUBMED] [FULLTEXT] |
| 2. | Broniscer A, Laningham FH, Kocak M, Krasin MJ, Fouladi M, Merchant TE, et al. Intratumoral hemorrhage among children with newly diagnosed, diffuse brainstem glioma. Cancer 2006;106:1364-71.
[PUBMED] [FULLTEXT] |
| 3. | Can SM, Aydin Y, Turkmenoglu O, Aydin F, Ziyal I. Giant cell glioblastoma manifesting as traumatic intracerebral hemorrhage-case report. Neurol Med Chir (Tokyo) 2002;42:568-71.
[PUBMED] [FULLTEXT] |
| 4. | Russel DS, Rubenstein LJ. Pathology of Tumours. 3 rd ed. Philadelphia: Williams and Wilkins; 1979. p. 147-54.
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| 5. | Liwnicz BH, Wu SZ, Tew JM Jr. The relationship between the capillary structure and hemorrhage in gliomas. J Neurosurg 1987 66:536-41.
[PUBMED] [FULLTEXT] |
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