Skull Metastasis of
Hepatocellular Carcinoma
Associated with Acute Epidural
Hematoma: A Case Report
Kentaro Hayashi, M.D.,* Takayuki Matsuo, M.D.,* Masaki Kurihara, M.D.,*
Manabu Daikoku, M.D.,† Gaspar Kitange, M.D.,‡ and Shobu Shibata, M.D.‡
*Department of Neurosurgery, Juzenkai Hospital; †Department of Internal Medicine,
Nagasaki City Hospital; and ‡Department of Neurosurgery, Nagasaki University School of
Medicine, Nagasaki, Japan

Hayashi K, Matsuo T, Kurihara M, Daikoku M, Kitange G, Shibata
S. Skull metastasis of hepatocellular carcinoma associated with
acute epidural hematoma: a case report. Surg Neurol
2000;53:379 – 82.
BACKGROUND

Although epidural hematoma is well documented in
trauma patients, its association with other etiologies,
such as neoplasms, is not widely known. Here the authors
report a case of acute epidural hematoma that originated
from a metastatic hepatocellular carcinoma (HCC) in the
skull.

kull metastases from hepatocellular carcinoma (HCC) have rarely been reported [6 – 8].
Commonly, patients with skull tumors present with
headache or subcutaneous masses and rarely with
features of acute epidural hematoma [6,10]. Here,
we report a spontaneous epidural hematoma that
originated from a metastatic HCC in the skull with
interesting magnetic resonance imaging (MRI) findings, and review the associated literature.

S

CASE DESCRIPTION

A 70-year-old male was admitted to our hospital with
left-sided hemiparesis. Preoperative computed tomography (CT) revealed a lenticular high-density area adjacent
to the right parietal bone, consistent with an acute epidural hematoma. A subsequent magnetic resonance image (MRI) showed a skull tumor adjacent to the epidural
hematoma. Removal of the tumor and evacuation of the
hematoma were performed and the pathological diagnosis was metastatic HCC. Postoperatively, the patient gradually recovered but he died of pneumonia 2 months later.
CONCLUSION

This report represents an additional example of a rare
case of metastatic skull tumor associated with acute epidural hematoma. The authors suggest that metastatic
skull tumors may be one of the important differential
diagnoses in patients with acute epidural hematoma.
© 2000 by Elsevier Science Inc.
KEY WORDS

Hepatocellular carcinoma, skull metastasis, acute epidural
hematoma.

Address reprint requests to: Dr. Kentaro Hayashi, Department of Neurosurgery, Nagasaki University School of Medicine, 1-7-1 Sakamoto,
Nagasaki-city, Nagasaki 852-8501, Japan.
Received October 8, 1999; accepted January 25, 2000.
© 2000 by Elsevier Science Inc.
655 Avenue of the Americas, New York, NY 10010

Case Report
A 70-year-old man with a history of transcatheter
embolization of the hepatic artery attributable to
HCC and a progressively enlarging right parietal
swelling presented to our hospital due to a sudden
onset of headache and left-sided weakness. On examination, he was found to have left hemiparesis
and a 3.0 ⫻ 3.0 ⫻ 1.5 cm elastic hard mass in the
right parietal region. No scalp wound was found.
Computed tomography (CT) showed a lenticular
high-density area adjacent to the right parietal bone
(Figure 1). Laboratory examination demonstrated
liver dysfunction, coagulopathy, and severe anemia. We suspected a skull metastasis of HCC presenting with acute epidural hematoma. For this reason we performed an MRI examination, which
demonstrated a skull tumor adjacent to the epidural hematoma. The tumor enhanced homogeneously with Gd-DTPA as shown in Figure 2. Cerebral angiograms showed a tumor stain in the right
parietal bone, which was richly supplied by
branches of the right external carotid artery (Figure
3). After the patient’s general condition had im0090-3019/00/$–see front matter
PII S0090-3019(00)00208-1

380 Surg Neurol
2000;53:379 –82

1

CT showed a large epidural hematoma in the right
parietal region.

proved, a right parietal craniotomy was performed.
Elevation of the skin flap revealed a reddish-brown,
smooth, and elastic hard swelling of the skull. Removal of the bone flap revealed the epidural hematoma. The tumor was removed en bloc, carefully
separating it from the dura mater, and this was
followed by evacuation of the hematoma. The surgical specimen showed sinusoidally arranged tumor cells with eosinophilic cytoplasm and hyper-

T1-weighted MRI with Gd-DTPA shows the skull tu2 mor (arrow) adjacent to the epidural hematoma.
The tumor is enhanced well with Gd-DTPA.

Hayashi et al

Cerebral angiograms showed a tumor stain (arrow)
in the right parietal bone, which was richly supplied
by branches of the right external carotid arterial system
(A-P view).

3

chromatic nuclei within the skull bone structure.
Several intratumoral hemorrhages were also found.
Pathological diagnosis was a metastatic skull tumor
from HCC (Figure 4).
Postoperatively, the patient gradually recovered,
but 1 month later his condition deteriorated because of liver failure. He died of pneumonia 2
months later.

Photomicrograph of the operative specimen shows
tumor cells with eosinophilic cytoplasm and hyperchromatic nuclei in a sinusoidal arrangement within the
bone structure (⫻50, H&E).

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Skull Metastasis of Hepatocellular Carcinoma

Discussion
Although skull metastases may arise from primary
sites in various organs and tissues, they are frequently seen with bronchogenic, breast, and prostate cancers. Unlike these tumors, HCC commonly
metastasizes to the lung, regional lymph nodes,
peritoneum, and adrenal glands, but rarely to the
skull. For example, Yanase et al reviewed 4140 autopsy reports on Japanese patients with HCC and
found only 17 skull metastases among 278 cases of
bone involvement [12], which further supports the
view that skull metastasis from HCC is a rare event.
Several authors have reported skull metastases
associated with chronic epidural hematomas [7,8],
but their association with acute epidural hematomas is rarely seen. To the best of our knowledge,
only one case of skull metastasis from HCC associated with acute epidural hematoma has been reported [6]. In contrast, several primary skull tumors, such as Ewing’s sarcoma [11], epidermoid
[1], and hemangioendothelioma [5] have frequently
been found to be associated with epidural hematoma, especially in young patients. Moreover, dural
metastases from several malignancies have presented as epidural hematomas [2,3]. Our report,
therefore, represents the second case of a very rare
skull metastasis from HCC presenting with acute
epidural hematoma.
Generally, tumor hemorrhage occurs from thin,
fragile tumor vessels. The present tumor had many
sinusoid-like blood vessels, which probably led to
hemorrhage and formation of epidural hematoma.
Indeed, some intratumoral hemorrhages were
found in the operative specimen. Kuga et al reported that eight of nine patients with brain metastasis from HCC developed intracranial hemorrhage,
suggesting that bleeding from such tumors is not
unusual [4]. Bleeding from the middle meningeal
artery, emissary vein, or venous sinus could be a
possible source of the epidural hematoma in our
case. However, this possibility was not supported
by our cerebral angiograms, which demonstrated
an intact superior sagittal sinus. In addition, no
evidence of active vessel bleeding was seen intraoperatively. Although the patient denied a history
of bleeding tendencies, a hemorrhage caused by
liver dysfunction and coagulopathy was suspected
in this case.
This is the first case presenting the MRI findings
of a case of epidural hematoma originating from a
skull tumor. Skull tumors usually expand the middle
table of the skull bone, resulting in displacement of
the inner and outer tables in the opposite direction
[9]. It is therefore difficult to differentiate the skull

Surg Neurol 381
2000;53:379 –82

tumor from the epidural hematoma with CT alone.
In our case, MRI demonstrated a skull tumor adjacent to the hematoma, which suggested that the
epidural hematoma originated from the skull tumor.
Furthermore, MRI showed dural invasion by the
tumor, a finding which was very useful for the diagnosis and the subsequent surgical management.
Thus, although the CT findings are usually diagnostic for intracranial hemorrhages we propose that
MRI should be performed on patients with a history
of malignancies who present with acute intracranial
hemorrhage.

Conclusions
Epidural hematoma usually stems from trauma, yet
it may be caused by other rare etiologies, such as
metastatic skull tumors from HCC. We emphasize
the possibility of brain or skull metastasis from HCC
in patients with acute intracranial hemorrhage.
REFERENCES
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Cranial epidermoid tumor associated with subacute
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Hayashi et al

bone presenting as acute epidural hematoma: case
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COMMENTARY

This is an interesting and rare case of metastatic
hepatocellular carcinoma to the skull as the source
of an epidural hematoma at the tumor site. The
patient’s initial complaint was associated with the
epidural hematoma (left hemiparesis) and obvious

soft tissue mass in the scalp with bone involvement.
CT, MRI, and angiography show the tumor stain
with involvement of the underlying dura as the
source of the epidural hematoma.
The rarity of this type of case gives the clinician
the suspicion of such associations when confronted
with a patient with liver dysfunction and a soft mass
arising from the skull.

f opportunity doesn’t knock, build a door.

I

Jose L. Salazar, M.D.
Neurosurgeon
Chicago, Illinois