- Department of Neurosurgery, Faculty of Clinical Medicine, University of the Ryukyus, Okinawa, Japan
Department of Neurosurgery, Faculty of Clinical Medicine, University of the Ryukyus, Okinawa, Japan
DOI:10.4103/2152-7806.148054Copyright: © 2014 Watanabe T. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Watanabe T, Nagamine H, Ishiuchi S. Progression of cerebellar chronic encapsulated expanding hematoma during late pregnancy after gamma knife radiosurgery for arteriovenous malformation. Surg Neurol Int 30-Dec-2014;5:
How to cite this URL: Watanabe T, Nagamine H, Ishiuchi S. Progression of cerebellar chronic encapsulated expanding hematoma during late pregnancy after gamma knife radiosurgery for arteriovenous malformation. Surg Neurol Int 30-Dec-2014;5:. Available from: http://sni.wpengine.com/surgicalint_articles/progression-cerebellar-chronic-encapsulated-expanding-hematoma-late-pregnancy-gamma-knife-radiosurgery-arteriovenous-malformation/
Background:The etiology and appropriate management strategy of chronic encapsulated expanding hematoma during pregnancy after gamma knife radiosurgery for arteriovenous malformation (AVM) remain unclear.
Case Description:A 34-year-old female developed chronic encapsulated expanding hematoma during late pregnancy, after angiographic disappearance of cerebellar AVM following two courses of gamma knife radiosurgery. The present case implicates pregnancy as a potential promoter of growth and enlargement of chronic encapsulated expanding hematoma, which may become life-threatening and require surgical intervention.
Conclusion:Immediate surgical management after delivery may be associated with a favorable outcome, so close follow-up management and patient education are very important in women planning pregnancy.
Keywords: Arteriovenous malformation, gamma knife, pregnancy, radiosurgery
Gamma knife radiosurgery is an effective treatment for cerebral arteriovenous malformation (AVM) resulting in angiographic disappearance in more than 80-90% of cases. Actual rates of obliteration of cerebellar AVMs, with median target volume of 3.85 cm3 and median marginal dose of 21 Gy, were 53% at 3 years and 76% at 5 and 10 years.[
A 20-year-old female presented with sudden onset of severe headache associated with nausea followed by disturbance of consciousness, and was admitted to another hospital. The diagnosis of cerebellar and subarachnoid hemorrhage from AVM supplied by the posterior inferior cerebellar artery (PICA) was based on the findings of computed tomography (CT) [
(a) CT scan at initial onset demonstrating left cerebellar hemorrhage with subarachnoid hemorrhage. (b) Left vertebral angiogram before first gamma knife radiosurgery showing a left cerebellar hemispheric AVM supplied by posterior inferior cerebellar artery (arrow). (c) Left vertebral angiogram at 3 years after first radiosurgery revealing residual nidus in the left cerebellar hemisphere (arrowhead). (d) Left vertebral angiogram obtained at 5 years after the second radiosurgery revealing no residual AVM nidus
Axial T2-weighted MR image (a) and postcontrast T1-weighted MR image (b) demonstrating appearance of the enhanced lesion adjacent to the cyst formation in the left cerebellar hemisphere at 7 years after second radiosurgery. (c) CT scan showing an irregularly shaped, mixed density lesion with extensive edema in the left cerebellar hemisphere. (d) Postoperative gadolinium-enhanced T1-weighted MR image demonstrating total removal of the lesion
The patient had headache and nausea, but no other neurological deficits were identified except for House–Brackmann grade 3 facial palsy persisting since her childhood. Other medical history was unremarkable. On admission, CT demonstrated an irregularly shaped, heterogeneous high density hematoma with perifocal edema in the vermis extending to the left cerebellar hemisphere [
Midline suboccipital craniotomy was performed and cerebrospinal fluid was released from the ventricular drainage. A very firm, reddish angiomatous nodular granuloma with adjacent cyst was visualized in the cerebellar hemisphere. Indocyanine green videoangiography confirmed the absence of abnormal vasculature around the lesion. The lesion contained angiomatous capsule and firm organized hematoma. Gross total resection was achieved without injury to the surrounding structures. No AVM nidus was observed during surgery. Her symptom was completely resolved immediately after surgery and the postoperative course was uneventful. Postoperative MR imaging revealed total resection of the hematoma with the adjacent cyst [
Histological examination of the lesion obtained during surgery demonstrated encapsulated hematoma consisting of a dense collagenous outer layer and a granulated, newly vascularized, angiomatous inner layer with extensive multinodular hemorrhage at various stages of organization [
(a) Photomicrographs of the chronic encapsulated expanding hematoma demonstrating angiomatous abnormal vessels, multifocal hemorrhage, and coagulation necrosis. HE, original magnification ×100. (b) Areas of coagulation necrosis and extensive hemorrhage. HE, original magnification ×200. (c) Angiomatous region showing thickening of the vessel walls with hyaline degeneration and inflammatory infiltration. HE, original magnification ×200. (d) Immunohistochemical examination demonstrating strong staining for CD34 in the microvasculature. Original magnification ×200
Chronic encapsulated expanding hematoma after gamma knife radiosurgery
Chronic encapsulated expanding hematoma is a rare but very important late onset complication after gamma knife radiosurgery for AVMs, and may develop even if angiographic disappearance has been achieved. Surgical treatment may be required due to progression in some cases.[
Chronic encapsulated expanding hematoma during pregnancy
The present case of cerebellar chronic encapsulated expanding hematoma occurred during pregnancy, 9 years after the second radiosurgery. Such occurrence of chronic encapsulated expanding hematoma during pregnancy has not been reported previously, and the etiology and appropriate management strategies remain unclear. Several studies have demonstrated rapid enlargement of intracranial meningiomas during pregnancy.[
Recent experimental studies have revealed that representative histological changes in smaller arterioles or the microvasculature after irradiation are likely to be caused by microvasculitis, which consists of hyaline degeneration, fibrinoid necrosis, lymphocytic infiltration, and adventitial fibrosis.[
The optimum timing for neurosurgical intervention in pregnant patients remains to be elucidated. The indications for surgery and delivery must be determined in relation to the severity of the neurological symptoms in the mother, the aggressiveness of the lesion, and the gestational period.[
The present case implicates pregnancy as a potential promoter of growth and enlargement of chronic encapsulated expanding hematoma, which may become life-threatening and require surgical intervention. Accurate diagnosis and immediate surgical management after delivery are likely to result in favorable outcome. We suggest that cesarean section followed by craniotomy is indicated for patients with chronic encapsulated expanding hematoma who are neurologically unstable with conservative therapy in late pregnancy.
The present case shows that chronic encapsulated expanding hematoma after gamma knife radiosurgery may develop and increase the risk of hemorrhage, with more aggressive behavior during late pregnancy. Craniotomy and total removal of the lesion after delivery by cesarean section under general anesthesia resulted in good outcome. However, the patient should be warned of the risk of this life-threatening complication prior to attempts at becoming pregnant. Therefore, follow-up examinations should be regularly scheduled for young women of child bearing age after gamma knife radiosurgery for AVMs, despite the confirmation of angiographic disappearance of AVM nidus, because of the difficulty in predicting rapid progression of the chronic encapsulated expanding hematoma during pregnancy.
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