Clinical study Intratumoral haemorrhage Kayhan Kuzeyli 1 , Ertu grul Cakir 1 , Haydar Usul 1 ,G€ okalp Karaarslan 1 ,U gur Yazar 1 ,S€ uleyman Baykal 1 , Abdulkadir Reis 2 , € Umit Cobanoglu 2 1 Department of Neurosurgery and 2 Department of Pathology, Karadeniz Technical University Medical School, 61080 Trabzon, Turkey Summary Although the incidence of spontaneous intracranial haemorrhage associated with meningioma is 1.3%, the incidence of intratumoral haemorrhage could not be determined. The authors report on 11 patients, six men and five women, with meningiomas that presented as spontaneous intratumoral haemorrhage, among 126 meningioma cases which were evaluated radiologically and histopathologically. The average age of patients was 58.9 years (range 45–72 years). Two (1.5%) cases showed radiological, and nine cases (7.9%) showed microscopic bleeding. Most of these cases also showed microcysts (9.7%) and necrosis (6.3%). The location, histopathological types, sex, age, blood dyscrasia, hypertension do not influence the occurrence of intratumoral haemorrhages in meningiomas. We concluded that microcysts and necrosis are important in the occurrence of intratumoral haemorrhage in meningiomas. ª 2003 Elsevier Ltd. All rights reserved. Keywords: intratumoral haemorrhage, meningioma, microcyst, necrosis INTRODUCTION Although intratumoral or subarachnoid haemorrhages from glio- blastoma multiforme, pituitary adenomas, metastatic carcinomas, and malignant melanomas are not uncommon, intratumoral and intracranial haemorrhage associated with meningiomas are rare and carry a mortality of over 40%. 1–23 Haemorrhages in reported cases of “meningioma and haemor- rhage” were generally intracranial and extratumoral. Haemorrhages were mostly seen at subarachnoid, 1;6;10;12;14;24–26 and subdural spaces; 4;6;20–22;24;26–28 but intracerebral 1;6;10;16;18;24–26 and intraven- tricular haemorrhages 25 have also been reported. In this paper, 11 more cases of meningiomas with pure intratumoral haemorrhages (ITH) are added, and the clinical aspects and pathogenesis of the haemorrhages in all these cases are summarized and analyzed. We think that the presence of microcysts and necrosis is strongly associated with ITH seen in meningiomas beside the other reported factors in the literature. SUMMARY OF PRESENT CASES Between January 1990 and December 2001, we operated on 126 patients with meningiomas and 11 of them had pure ITH. Accu- rate diagnosis was achieved by histopathological examination. Two of them showed radiological macroscopic haemorrhages and nine showed microscopic haemorrhages. The histopathological diagnoses of the two cases with radio- logical haemorrhages were meningothelial and transitional me- ningioma. These cases are summarized in Table 1. Of the 11 patients, six were male and five were female. Their ages ranged from 45 to 72 years (average age, 58.9 years). Mean age for patients with ra- diological macroscopic haemorrhages was (57 Æ 6) years and (58.5 Æ 13.5) years for patients with microscopic haemorrhages. Radiological necrosis was only seen in two cases (case 1–2) and microscopic necrosis in 8 cases (6.3%). Microcysts have been observed in six cases (4.7%). The cases with radiological haemorrhages were convexity meningiomas. The cases with micronecrosis were located at convexity (four cases), temporal fossa (two cases), falx cerebri (one case) and tuberculum cella (one case). The cases with mi- crocysts were located at convexity (four cases), falx (one case) and skull base (one case). The two patients with radiological haemorrhage presented with progressive neurological deficits, and emergency operations (cra- niotomy and tumor excision) were performed for both of them. One of them died on the postoperative eleventh day and the other one was discharged on the postoperative 23rd day in good condition. The cases with microhaemorrhages did not show acute clinical deterioration like the macrohaemorrhages. They did not need any emergency procedures. Computerized tomography (CT), magnetic resonance imaging (MRI) and digital subtraction angiography (DSA) of the patients have been retrospectively evaluated for intratumoral macroscopic hemorrhages. Accompanying arterio-venous malformations and aneurysms have also been excluded. The surgical artifacts in the histopathological slides were ex- cluded. The presence of hemosiderin-rich macrophages, and/or organized blood clot, visualization of ruptured vessels in areas of haemorrhage and visualization of haemorrhage directly adjacent to areas of tissue necrosis were accepted as criteria for sponta- neous intratumoral bleeding (Figs. 1–4). The haemorrhages were also evaluated for their central or peripheral location. DISCUSSION Most of the ITH occurs in pituitary adenomas, highly vascularized tumors such as; medulloblastoma, neuroblastoma, ependymoma, oligodendroglioma 1–3;7–10;12;14 or metastatic tumors such as ma- lignant melanoma, metastatic adenocarcinoma, anaplastic carci- noma and choriocarcinoma. 2;12;14 But ITH is a rare event in primary brain tumors and meningiomas. ITH has a mortality of 40–55%. 1–3;5–7;11–15;17;19;22;23 The incidence of ITH in meningiomas is estimated at 2.3%. 1 Intracranial haemorrhage in meningiomas is mostly seen in the sub- arachnoid space. 1;3;6;29 Intracerebral, 1;6;16;18;24–26 subdural 4;6;20–22;24;27 and intraventricular 25 hemorrhages have also been reported. Journal of Clinical Neuroscience (2004) 11(5), 490–492 0967-5868/$ - see front matter ª 2003 Elsevier Ltd. All rights reserved. doi:10.1016/j.jocn.2003.10.012 Received 13 November 2002 Accepted 14 October 2003 Correspondence to: Dr. Kayhan Kuzeyli, Karadeniz Teknik Universitesi, Farabi Hastanesi, Tip Fakultesi, Beyin ve Sinir Cerrahi Anabilim dalı, 61080 Trabzon, Turkey. Tel.: +90-462-377-57-00; E-mail: ertugrulcakir@hotmail.com 490