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).



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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.

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