Hemorrhagic low grade glioma

Intracerebral hematoma is an unusual clinical presentation for low grade gliomas and it has been described in a small number of cases in adults 1) 2) 3).

Hemorrhagic low grade glioma (LGG) without malignant transformation is rare, accounting for less than 1% of cases.

It is now generally accepted that the main cause of mortality in these tumors is their dedifferentiation to a higher degree of malignancy 4) 5) 6).

Case reports

Hemorrhagic LGG with an arteriovenous(AV)shunt has not been reported.

Matsuura et al., from the Toho University Medical Center Omori Hospital, report the case of a 17-year-old man with low grade glioma (LGG) with an arteriovenous fistula. He presented to the hospital with seizureComputed tomography(CT) demonstrated a hypodense lesion with mass effect in the right frontal lobeT1-weighted images(WI)and T2WI on magnetic resonance imaging(MRI) revealed acute-onset hemorrhage in the right frontal lobe. Furthermore, a ring enhancing lesion was noted on gadolinium (Gd)-DTPA T1WI, and an AV shunt was found in the same region on angiographyGross total tumor resection was performed. The pathological diagnosis was diffuse astrocytoma with pilomyxoid features (WHO grade II). Without adjuvant therapy, no residual tumor was found on MRI at the 6-year follow-up examination. They treated a case of hemorrhagic LGG with an AV shunt. Intratumoral hemorrhage in LGG may occur and should be considered for the differential diagnosis 7).

A 53-year old woman presenting to the hospital with a hemorrhagic low-grade glioma (LGG). She was admitted to a nearby general hospital where she had presented with aphasia, right hemiplegia and change of mental status. Computer tomography (CT) images showed a left temporo-parietal hemorrhage with mass effect. She was transferred to the neuro-intensive care unit where emergency craniotomy was performed. A tumor with hematoma was removed and further histopathology analysis revealed tumor progression. They reviewed the literature reporting cases of central nervous system tumors hemorrhage and found that these types of events are exquisitely rare in adults with LGG. However these events are possible, suggesting that it should be included in the differential diagnosis of any patient presenting with intracranial hemorrhage. This case raises questions regarding the benefit of early versus late intervention for patients known to have LGG 8).

Della Puppa et al., reviewed the literature of such cases and reported another case of a haemorrhagic low-grade glioma in a 54-year-old woman presenting with a left hemiparesis. Computer tomography (CT) images showed a right basal ganglia haemorrhage with no mass effect. Vascular malformations were ruled out by angiography. Eighteen fluoro-fluoro deossiglucosio (18F-FDG) positron emission tomography (PET/CT) showed a large hypometabolic area corresponding to the lesion. We waited for patient’s improvement. Late magnetic resonance images revealed a low-grade glioma at the bleeding site. Tumour was removed and histopathologic examination revealed a WHO grade II mixed glioma. The authors emphasize that this evidence has to be kept in mind since it has important therapeutic implications 9).

Memon et al., treated three cases of brain tumor that presented with intracranial hemorrhage. Two of the three tumors were metastatic. They presented with hemorrhage into the tumor, but no blood in the cerebrospinal fluid. One tumor was a low grade astrocytoma that presented as subarachnoid and intraventricular hemorrhage in a 15-year-old child. It was removed with no neurological sequelae 10).



Gottfried ON, Fults DW, Townsend JJ, Couldwell WT: Spontaneous hemorrhage associated with a pilomyxoid astrocytoma: Case report. J Neurosurg 99: 416-420, 2003

Kondziolka D, Bernstein M, Resch L, Tator CH, Fleming JF, Vanderlinden RG, Schutz H: Significance of hemorrhage into brain tumor: clinicopathological study. J Neurosurg 67:852–857, 1987

Licata B, Turazzi S: Bleeding cerebral neoplasm’s with symptomatic hematoma. J Neurosurg Sci 47:201–210, 2003

Mineo JF, Bordron A, Baroncini M, Maurage CA, Ramirez C, Siminski RM, Berthou C, Dam Hieu P: Low HER2-expressing glioblastomas are more often secondary to anaplastic transformation of low-grade glioma. J Neurooncol 85:281-287, 2007

Radulović D: Natural history of supratentorial low-grade astrocytoma: Case report. Srp Arh Celok Lek 134:537-540, 2006

Tungaria A, Sahu RN, Kumar R, Srivastava A: Intratumoral hemorrhage in brainstem low-grade glioma. Neurol India 60: 243-245, 2012

Matsuura C, Sakaeyama Y, Node Y, Ueda K, Ando S, Masuda H, Kondo K, Harada N, Nemoto M, Sugo N. [Diffuse Astrocytoma with Pilomyxoid Features Presenting as Intratumoral Hemorrhage:A Case Report]. No Shinkei Geka. 2018 Dec;46(12):1073-1079. doi: 10.11477/mf.1436203870. Japanese. PubMed PMID: 30572304.

Joković M, Bogosavljević V, Nikolić I, Jovanović N. Spontaneous Intracerebral Hematoma in Low-Grade Glioma After 14 Years of Follow-Up. Turk Neurosurg. 2016;26(3):452-5. doi: 10.5137/1019-5149.JTN.11004-14.1. PubMed PMID: 27161476.

Della Puppa A, Zustovich F, Gardiman M, Manara R, Cecchin D, Scienza R. Haemorrhagic presentation of low-grade glioma in adults. Acta Neurochir (Wien). 2007 Nov;149(11):1151-5; discussion 1155. Epub 2007 Aug 6. Review. PubMed PMID: 17676407.

Memon MY, Neal A, Imami R, Villareal N. Low grade glioma presenting as subarachnoid hemorrhage. Neurosurgery. 1984 May;14(5):574-7. PubMed PMID: 6728165.

Neutrophil to lymphocyte ratio for intracerebral hemorrhage

Inflammatory response plays a vital role in the pathological mechanism of intracerebral hemorrhage. It has been recently reported that neutrophil to lymphocyte ratio (NLR) could represent a novel composite inflammatory marker for predicting the prognosis of intracranial hemorrhage (ICH).

The clinical data of 558 consecutive patients from the Ulanqab Central Hospital, with intracerebral hemorrhage (ICH) were retrospectively analyzed. Neutrophil to lymphocyte ratio is calculated by absolute lymphocyte count divided by absolute monocyte count.

Of these patients, 166 patients experienced neurological deterioration (ND) during the first week after admission and 72 patients died within 90 days. Multivariate analysis indicated that white blood cells (WBC), absolute neutrophil count (ANC), absolute lymphocyte count (ALC), neutrophil-to-lymphocyte ratio (NLR), LMR were significantly associated with ND during the initial week after ICH onset and also were associated with 90-day mortality. Moreover, NLR and LMR showed a higher predictive ability in ND during the initial week after ICH onset than 90-day mortality in receiver operating characteristic analysis. The best cut-off points of NLR and LMR in predicting ND and 90-day mortality were 10.24 and 2.21 and 16.81 and 2.19, respectively.

The results suggest that LMR on admission is a predictive factor for ND during the initial week after ICH onset, as well as 90-day mortality 1).

104 patients with acute ICH admitted to West China Hospital, Sichuan University, ChengduChina, from October 2016 to January 2018 were retrospectively enrolled. Admission absolute neutrophil count, lymphocyte count and white blood count were extracted from electronic medical records of patents with ICH. The associations between outcome and laboratory biomarkers were assessed by multivariable logistic regression analysis. The comparison of predictive power of independent predictors was evaluated by receiver operating characteristic curves (ROC).

59 ICH patients with surgical treatment exhibited unfavorable outcome, which associated with higher admission NLR (OR 0.692, 95%CI 0.518-0.925, P=0.01; OR 1.148, 95%CI 1.078-1.222, P<0.01; OR 1.215, 95%CI 1.015-1.454, P=0.03), lower GCS and larger hematoma. NLR showed the best predictive power by comparing with other laboratorial variables (area under the curve [AUC] 0.668, 95%CI 0.569-0.757, P<0.01), and was also found to linearly correlate with GCS at admission, hematoma volume, ANC, ALC and hydrocephalus. Meanwhile, the best predictive cutoff point of 6.46 for NLR was also identified.

Other than the association of prognosis of ICH patients, NLR exhibited potential independently predictive ability for 90-day functional outcome of ICH patients after surgery 2).


Qi H, Wang D, Deng X, Pang X. Lymphocyte-to-Monocyte Ratio Is an Independent Predictor for Neurological Deterioration and 90-Day Mortality in Spontaneous Intracerebral Hemorrhage. Med Sci Monit. 2018 Dec 20;24:9282-9291. doi: 10.12659/MSM.911645. PubMed PMID: 30572340.

F Z, C T, X H, J Q, X L, C Y, Y J, M Y. Association of neutrophil to lymphocyte ratio on 90-day functional outcome in intracerebral hemorrhage patients undergoing surgical treatment. World Neurosurg. 2018 Aug 10. pii: S1878-8750(18)31791-1. doi: 10.1016/j.wneu.2018.08.010. [Epub ahead of print] PubMed PMID: 30103056.
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