Formosan Journal of Surgery (2012) 45, 132e135

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CASE REPORT

Intracranial metastasis of colon cancer with acutesubdural hematoma

Fu-Yuan Shih a, Tao-Chen Lee a, Jui-Wei Lin b, Tsung-Ming Su a,Hsiang-Lin Lee c, Tsung-Han Lee d,*

aDivision of Neurosurgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung UniversityCollege of Medicine, Kaohsiung, TaiwanbDepartment of Pathology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine,Kaohsiung, TaiwancDepartment of Surgery, Chung Shan Medical University Hospital, Taichung, TaiwandDivision of Trauma, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung UniversityCollege of Medicine, Kaohsiung, Taiwan

Received 12 August 2011; received in revised form 11 October 2011; accepted 11 December 2011Available online 27 April 2012

KEYWORDScolon cancer;dural metastasis;subdural hematoma

* Corresponding author. Division oSurgery, Kaohsiung Chang Gung MemRoad, Niaosong District, Kaohsiung Ci

E-mail address: tsunghan927@gma

1682-606X/$ - see front matter Copyrdoi:10.1016/j.fjs.2012.03.004

Summary We report a case of acute subdural hematoma as the first manifestation of coloncancer and emphasize the need for careful assessment and consideration of clinical and radio-logical data for patients with nontraumatic subdural hematoma.Copyright ª 2012, Taiwan Surgical Association. Published by Elsevier Taiwan LLC. All rightsreserved.

1. Introduction

Nontraumatic subdural hematomas are mostly caused byvascular disorders, coagulopathies, intracranial hypoten-sion, and meningitis.1 Subdural hematoma resulting fromneoplastic invasion of the meninges or pachymeningitiscarcinomatosa is rare.2 We herein report a case of

f Trauma, Department oforial Hospital, No.123, Dapity 83301, Taiwan, ROC.il.com (T.-H. Lee).

ight ª 2012, Taiwan Surgical Asso

spontaneous subdural hematoma as the first manifestationof colon cancer, with a literature review of subduralhematoma in this setting.

2. Case report

A 64-year-old woman with underlying hypertension andatrial fibrillation was presented at our emergency depart-ment with a 6-day history of progressive dull headache anddizziness. She and her family denied any recent history oftrauma. She had been receiving anticoagulation therapywith warfarin for chronic atrial fibrillation. The results of

ciation. Published by Elsevier Taiwan LLC. All rights reserved.

Figure 2 Axial T2-weighted brain magnetic resonanceimaging shows multiple left subdural signal intensities withmidline deviation to right side and effacement of left sulci.

Colon cancer with acute subdural hematoma 133

blood tests revealed a prothrombin time (PT) of >50 seconds (normal range: 8e12 seconds), an internationalnormalized ratio (INR) of > 5 (range: 0.9e1.15), anda partial thromboplastin time (PPT) of 72 seconds (range:24.6e33.8 seconds). Computed tomography (CT) of thebrain showed an acute subdural hematoma in the leftfrontotemporoparietal area (Fig. 1). Preoperatively, onedose of vitamin K1 (10 mg) was intravenously administeredand four units of frozen fresh plasma were transfused tocombat the obvious coagulopathy. She underwent a burrhole surgery first to relieve intracranial mass effectresulting from the acute subdural hematoma. Her headachegradually subsided postoperatively. Because of no traumahistory, we arranged an enhanced magnetic resonanceimaging (MRI) of the brain for follow-up, which was per-formed 10 days after the burr hole surgery. The MRI showedmultiple left subdural signal intensities with a midlinedeviation to the right side and effacement of cerebral sulcion the left, but there was no sign of an appreciable intra-cranial tumor (Fig. 2). Examination of preoperative bloodtests had shown normal PT, PPT, and an INR. Because of theobvious mass effect resulting from the recurrent leftsubdural hematoma, the patient then underwent a leftfrontotemporoparietal craniotomy for more completeremoval of the subdural hematoma. During the surgery,the dura mater appeared grossly normal. Blood clots andsome liquefied hematoma, about 60 cc in amount withoutformation of membranes, were found in the subduralspace. Microscopic examination of the subdural hematomashowed blood clots with vascular proliferation, glandularformation, and clusters of neoplastic epithelial cells havingpleomorphic nuclei, prominent nucleoli and pinkish

Figure 1 Preoperative brain computed tomography withoutcontrast shows acute subdural hematoma in the left fronto-temporoparietal regions and deviation of the tentorium andmidline to the right.

cytoplasm (Fig. 3). The pathologic diagnosis was hematomawith metastatic adenocarcinoma. During immunohisto-chemical analysis, the tumor cells were found to be positivefor cytokeratin 20 (CK 20), cytokeratin low molecularweight (CK LMW), villin, and CDX2 (Fig. 4). Therefore,adenocarcinoma of colon origin was thought to be the mostlikely cause. Colonoscopy was subsequently performed, andit showed a protruding nodular mass at the distal ascendingcolon. The brain MRI, performed 15 days after the leftfrontotemporoparietal craniotomy, showed regression ofthe left subdural hematoma (Fig. 5). On the 18th day afterthe burr hole surgery, the patient underwent a right

Figure 3 Histopathology of subdural hematoma harboringirregular neoplastic glands, some of which contain luminaldetritus (hematoxylin and eosin stain, original magnification,�100).

134 F.-Y. Shih et al.

hemicolectomy with side-to-side anastomosis because ofintestinal obstruction. During the surgery, a tumormeasuring 4.0� 4.0� 1.5 cm3 was found near the ileocecalvalve. Metastasis to the greater omentum with serosalpenetration was also intraoperatively noted. Pathologi-cally, the ascending colon tumor appeared to be a moder-ately differentiated colon adenocarcinoma that hadinvaded the surrounding soft tissue and involved the ileo-cecal valve and ileum. The results of immunohistochemicalanalysis were identical to those of the subdural hematoma.However, on the 36th day from the first cranial surgery, thepatient died on account of pulmonary insufficiency.

Figure 5 Axial T2-weighted brain magnetic resonanceimaging shows residual subdural hematoma over the leftfrontotemporoparietal regions with effacement of left sulci.

3. Discussion

Spontaneous subdural hematoma associated with duralmetastasis was first documented as early as in 1904.3 Duralmetastases account for approximately 3%e13% of allintracranial metastatic involvements.4 The most commonneoplasms associated with dural metastases are melanomaand cancers of the breast, gastrointestinal tract, andprostate.5 A review of 198 cases from English and Frencharticles in the medical literature published between 1904and 2003 shows that 41% of patients with intracranial duralmetastases had subdural hematoma manifestations.6 Thusfar, only two cases of subdural effusion7 and subduralhematoma4 associated with pachymeningitis carcinomatosaresulting from colorectal cancer have been reported in theliterature. The majority of patients presenting with symp-tomatic colon cancer have hematochezia or melena,abdominal pain, otherwise unexplained iron deficiencyanemia, a change in bowel habits, or both.8,9 However,

Figure 4 Immunohistochemical stains of tumor cells in subdural hCK HMW and CK 7. CKZ cytokeratin; HMWZ high molecular weigh

acute subdural hematoma was the first manifestation ofcolon cancer in the present case.

With regard to subdural hematoma, the most widelyaccepted theory is that of Russel and colleagues,2 who have

ematoma. Positive staining for CK LMW and CK 20; negative fort; LMWZ low molecular weight.

Colon cancer with acute subdural hematoma 135

suggested that impaired blood perfusion occurs because oftumor embolism in the dural vein, thereby causing thedilation and breakdown of capillary vessels, resulting insubdural hematoma. Subdural hematomas in this settingcould be exacerbated by thrombocytopenia or coagulationdisorders caused by the underlying cancer or its treat-ment.10 Kunii and others5 analyzed 51 reported cases ofsubdural hematoma associated with dural metastasis andshowed that the most common histological type wasadenocarcinoma and that the most common primary tumorwas located in the stomach.

Acute subdural hematoma was the first manifestation inthe present case with underlying bleeding tendency andcolon cancer. Since subdural hematoma with bleedingtendency is often fatal, those patients are usually treatedconservatively. However, Sato and coworkers11 stressedthat chronic subdural hematoma with bleeding tendencyshould be surgically treated; if after checking the bloodconditions carefully, then the patient is considered to needsurgery. Hashiguchi and colleagues12 reported that subduralhematoma associated with dural metastasis causesa mortality rate of 69% within 3 weeks. Treatment optionsfor subdural hematoma with dural metastasis, especiallywith regard to surgical treatment, have been controversial.

4. Conclusion

Our case highlights that biopsy analysis of the dura materand cytological or histological examination of subduralhematoma in patients with nontraumatic or recurrentsubdural hematoma are indispensable to rule out an intra-cranial mass, even if there is no evidence of cancer history,skull lesions, or intracranial mass.

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