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| NEUROIMAGE |
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| Year : 2021 | Volume
: 69
| Issue : 5 | Page : 1492-1493 |
Intratumoral Hemorrhage in Vestibular Schwannoma: An Unusual but Alarming Clinical Entity
Sandesh Onkarappa, Raghavendra Nayak, Girish Menon
Department of Neurosurgery, Kasturba Medical College, Manipal, Manipal Academy of Higher Education (MAHE), Manipal, Karnataka, India
| Date of Submission | 26-Jun-2020 |
| Date of Decision | 04-Jul-2020 |
| Date of Acceptance | 15-Jul-2020 |
| Date of Web Publication | 30-Oct-2021 |
Correspondence Address:
Raghavendra Nayak
Department of Neurosurgery, Kasturba Medical College, Manipal, MAHE, Manipal, Karnataka
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0028-3886.329608
How to cite this article:
Onkarappa S, Nayak R, Menon G. Intratumoral Hemorrhage in Vestibular Schwannoma: An Unusual but Alarming Clinical Entity. Neurol India 2021;69:1492-3 |
Presentation of brain tumors with intratumoral hemorrhage occurs in about 1.4–10% of cases; usually in metastatic brain tumors, aggressive high-grade gliomas, melanomas, and even in choroid plexus papilloma.[1] But the hemorrhage in the vestibular schwannoma is unusual and happens in less than 1% of cases.[2]
A 48-year-old lady with a 3-year history of left-side decreased hearing, presented to us with giddiness, vomiting, and facial asymmetry of two days. On examination, she had a left lower motor facial palsy (House-Brackmann grade 4) and severe left cerebellar signs. Magnetic resonance imaging of the brain was done which showed an extra-axial well-defined mass in the left cerebellar pontine cistern with a cone-like protrusion into the widened internal auditory canal. It was hypointense on T1 and heterogeneously hyperintense on both T2 and fluid-attenuated inversion recovery. There was a heterogeneous enhancement of gadolinium post-contrast. It showed an intense focus of blooming on susceptibility-weighted images indicating the intratumoral hemorrhage [Figure 1]. Our diagnosis was vestibular schwannoma with Intra tumoral hemorrhage (ITH) although the exophytic brainstem glioma and metastasis were also considered in the differential. | Figure 1: Magnetic resonance imaging showing T1 hypointense (a), T2, and fluid-attenuated-inversion-recovery (FLAIR) heterogeneously hyperintense (b and c), heterogeneously contrast-enhancing (d) mass in the cerebellar pontine cistern with intratumoral hemorrhage as evidence by susceptibility-weighted image (SWI) blooming (e). No evidence of diffusion restriction noted. The lesion was noted to cause mass effect seen in the form of buckling of the adjacent left cerebellar hemisphere, brainstem, and compression of the fourth ventricle. Postoperative computer tomography showing complete excision of the tumor (f)
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We did a left retrosigmoid suboccipital craniotomy and complete excision of the tumor. Intraoperatively tumor had both organized and liquid clots. Histopathology was suggestive of schwannoma.
The mechanism of hemorrhage in the tumor is still poorly understood. The proliferation of thin-walled, dilated, and sinusoidal vasculature could be blamed for.[3] As the occurrence of ITH is rare, causes are always debatable. Likely risk factors include large tumor size (>2 cm), Cystic tumor, hypertension, physical exertion, anticoagulation therapy rapid tumor growth, and increased tumor vascularity.[4] A high correlation has been observed between hypertension and ITH.[5] Clinical outcome of ITH is substantially poor. Increased death rates (10%) and higher facial nerve weakness (31.3%) have been observed in Vestibular Shwannoma (VS) with ITH when compared to the VS without any hemorrhage (mortality: 0.2% and facial weakness: 6%).[3]
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| » References | |  |
| 1. | Diyora B, Sharma A, Badhe P, Nayak N. Hemorrhage in acoustic neurinoma. Neurology India 2010;58:329-30.  |
| 2. | Carlson ML, Tombers NM, Driscoll CL, Van Gompel JJ, Lane JI, Raghunathan A, et al. Clinically significant intratumoral hemorrhage in patients with vestibular schwannoma. Laryngoscope 2017;127:1420-6. |
| 3. | Niknafs YS, Wang AC, Than KD, Etame AB, Thompson BG, Sullivan SE. Hemorrhagic vestibular schwannoma: Review of the literature. World Neurosurg 2014;82:751-6. |
| 4. | Dehdashti AR, Kiehl TR, Guha A. Vestibular Schwannomas presenting with haemorrhage: Clinical presentation and histopathological evaluation of an unusual entity. Br J Neurosurgery 2009;23:431-6. |
| 5. | Yang X, Liu J, Zhang Y, Richard SA. Tumor-associated hemorrhage in patients with vestibular schwannoma. Acta Neurochir (Wien) 2018;160:1563-9. |
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