British Journal of Neurosurgery

ISSN: 0268-8697 (Print) 1360-046X (Online) Journal homepage: http://www.tandfonline.com/loi/ibjn20

Chronic encapsulated intracerebral haematoma in
a patient with medically intractable epilepsy
H. Kurita,, S. Ichi, & Y. Shiokawa
To cite this article: H. Kurita,, S. Ichi, & Y. Shiokawa (1998) Chronic encapsulated intracerebral
haematoma in a patient with medically intractable epilepsy, British Journal of Neurosurgery,
12:1, 51-53, DOI: 10.1080/02688699845537
To link to this article: http://dx.doi.org/10.1080/02688699845537

Published online: 06 Jul 2009.

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Date: 21 March 2016, At: 22:05

B ritish Journal of N eurosurgery (1998);12(1):51± 53

S HORT REP ORT

C hronic encapsulated intracerebral haem atom a in a patient with
m edically intractable epilepsy
H. KURITA, S. ICHI & Y. SHIOK AW A

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D epartm ent of N eurosurgery, Fuji Brain Institute and H ospital, Fujinomiya, Shizuoka, Japan

A bstract
A patient with a chronic encapsulated intracerebral haem atom a presenting with medically intractable epilepsy is described.
A tough capsule containing an old haematom a was con® rmed surgically, and consisted of dense collagenous tissue with
rich neovascularization. The radiological features, aetiology and treatment of this rare occurrence are discussed.
K ey w ords: Chronic encapsulated intracerebral haem atom a, clinical feature, aetiology , epilepsy, treatment

Introduction
An encapsulated intracerebral haem atom a (ICH )
associated with intractable sym ptom atic seizures is
reported. The radiological features of the
haem atom a were sim ilar to those of a cavernous
angioma. Histological exam ination revealed that the
lesion w as an old clot arising from rupture of the
surrounding richly neovascularized capsule. T he
clinical features of this type of haem atom a are not
w ell understood. O ur exp erience adds to the knowledge about this peculiar form of haem atom a and
should help to de® ne its characteristics.

(C T) show ed a well dem arcated right frontal hyperdense m ass; enhanced CT yielded no further inform ation (Fig. 1A,B). M agnetic resonance im aging
(M RI) was perform ed and a T 1-weighted im age
demonstrated a high-intensity core surrounded by a
strati® ed low -intensity rim without G d-D TPA
enhancement (Fig. 2A,B), T 2-weighted im age
revealed a hypointense lesion without perifocal brain
oedema (Fig. 2C). Cerebral angiography revealed
that the lesion w as avascular. The presum ptive diagnosis was a cavernous angiom a and right frontal
craniotom y was perform ed in July 1992.

C ase report
T he patient was a 12-year-old girl w ith no fam ily
history of epilepsy. She was born after an uncom plicated pregnancy and delivery, and her developm ent
w as normal. Left-sided clonic convulsions began
w hen she w as 10 years old. D espite receiving
antiepileptic drugs (phenytoin and zonisiam ide,
plasm a levels within reference values) at a local
hospital, the frequency of the hem iconvulsive
attacks increased occurring weekly, and they were
followed by secondary generalization on occasions.
She w as referred to our institute for further evaluation in April 1992.
O n adm ission, physical and neurological exam inations w ere norm al. An interictal scalp electroencephalogram (EEG ) revealed sporadic sharp waves
in the right frontal region. Com puted tomography

F IG . 1. Axial computed tomographic scan. (A) Precontrast
scan showing a homogeneous high-density mass in the right
frontal lobe. (B) Postcontrast scan showing no apparent
contrast enhancem ent.

Correspondence to: Hiroki Kurita, Department of Neurosurgery, University of Tokyo H ospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113, Japan.
T el: 1 81 3 3815 5411 ; Fax: 1 81 3 3811 8647.
Received for publication 8th Novem ber 1996 . Accepted 12th Decem ber 1996 .
0268-869 7/98/010051 ± 03 $9.50

Ó

T he Neurosurgical Foundation

52

H. Kurita et al.

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F IG . 2. Axial magnetic resonance images. (A) T1-weighted image showing a high-intensity core with a strati® ed low-intensity
rim. (B) Gd-DTPA-enhanced T1-weighted image showing no apparent enhancement.(C) T2-weighted image showing a
hypointense mass.

The lesion was exposed via a trans-sulcal
approach, and a thick elastic capsule 1 cm below the
surface of the cortex w as found. Incision of the
capsule disclosed its content to be an organized
haem atom a. T he brain surface surrounding the capsule showed reactive gliosis, but no vascular anom alies were noted. T he entire capsule, including the
haem atom a, was rem oved (Fig. 3).
Histopathological exam ination revealed
the
haem atom a contained an old calci® ed clot. T he
capsule wall consisted of dense hyaline collagenous
tissue that was richly neovascularized. H aem osiderin-laden m acrophages were present in the intracapsular vascular zones and inner thin granulation
layer, which suggested repeated intracapsular and
subcapsular haem orrhages had occurred (Fig.
4A,B ).
Following surgery, the patient show ed no neurological de® cit, a postoperative EE G showed no epileptic discharges and she was discharged am bulatory
10 days after surgery. Subsequently, her condition

F IG . 3. Surgical specimen demonstrating the thick elastic
capsule containing an old calci® ed clot.

im proved and at her 4-year follow -up, she had been
seizure-free for 3 years while receiving antiepileptic
therapy with a low dose of phenytoin.

D iscussion
C hronic encapsulated intracerebral haem atom a is a
rare, but de® ned entity characterized by a gradual
clinical onset, capsule form ation and occasional selfperpetuating expansion. In our literature review, we
found 32 cases of this entity had been reported. 1± 18
H istologically veri® ed vascular anom alies were frequently detected as bleeding sources, including ® ve
angiographically occult arteriovenous m alform ations
(AVM s), 1± 4 one radiosurgically treated degenerate
AVM , 5 six cavernous angiom as, 6± 10 one venous
angiom a 11 and one unclassi® ed vascular m alform ation. 12 Even in patients w ithout a clear bleeding
source, destroyed or throm bosed vascular m alform ations were suggested to have caused the initial
haem orrhage and capsule formation. 1± 3,5 Histological exam ination of our patient suggested that the
organized haem atom a resulted from rupture of the
newly developed fragile vessels in the capsule. However, sm all vascular m alform ations that probably
had been destroyed during subclinical haemorrhage
m ight have been a source of ® broblasts and contributed to the capsule form ation.
The clinical and radiological features of this peculiar haem atom a are sim ilar to those of cavernous
angiom as, and the m ost frequent initial symptom s
associated with both entities are seizures, headache
and progressive neurological de® cits. 2,7,8,13± 15,19 A
M RI appearance of a core of m ixed signal intensities
with a surrounding low-intensity rim is considered
characteristic of cavernous angiom as. 20 However,
these ® ndings indicating various stages of an organized clot were observed in our patient w ith this
type of haem atom a w ith repetitive bleeding from the
neovascularized capsule.

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Encapsulated haematoma and epilepsy

F IG . 4. Photomicrograph of the dense collagenous
haematoma capsule (EVG staining). Thin-walled dilated
capillaries (arrowheads) can be seen in the capsule (A), and
inner ® brotic granulation layer (B). Haemosiderin-laden
m acrophages, suggestive of repetitive bleeding, can be seen
in these perivascular areas. (Magni® cation 3 60).

In conclusion, accurate preoperative diagnosis of
this type of haematom a is dif® cult. W hen a thick
elastic capsule is encountered during surgery, this
haem atom a entity should be considered and a
search for a bleeding source should be carried out.
T otal rem oval of the haem atom a with the capsule is
the only recom m ended m ethod of treatm ent.
References
1 Hirsh LF, Spector HB, Bogdanoff BM. Chronic
encapsulated intracerebral hematoma. N eurosurgery
1981;9:169± 72.

53

2 Pozzati E, Giuliani G, Gaist G, Piazza G, Vergoni G.
Chronic expanding intracerebral hem atoma. J Neurosurg 1986;65:611± 14.
3 Roda JM , Carceller F, Pe rez-Higueras A, M orales C.
Encapsulated intracerebral hematomas: a de® ned
entity. C ase report. J Neurosurg 1993;78 :829± 33.
4 Sakaida H, Sakakura M , Tochio H, Nakao K,
Taniguchi A, Yabana T. Chronic encapsulated intracerebral hem atom a associated with angiographically
occult arteriovenous m alform ation. C ase report. N eurol M ed C hir (Tokyo) 1993;33 :638± 42.
5 Kurita H, Sasaki T, Kawamoto S, Taniguchi M,
Kitanaka C, Nakaguchi H, et al. Chronic encapsulated
expanding hematoma in association with gamma knife
radiosurgery for cerebral arteriovenous malformation.
Case report. J N eurosurg 1996;84:874± 8.
6 M abuchi S, Kamiyama H, Iw asaki Y, Abe H. [M ultilocular encapsulated intracerebral hematom a: a case
report.] No Shinkei Geka 1991;19 :677± 9. (In
Japanese.)
7 M asuzawa T, Saito K, Shim abukuro H, Iwasa H, Sato
F. Chronic encapsulated hematom as in the brain. A cta
Neuropathol (B erl) 1985;66:24± 8.
8 M onm a S, Ohno K, Hata H, Komatsu K, Ichimura
K, Hirakawa K. Cavernous angiom a with encapsulated intracerebral hem atoma: report of two cases.
Surg Neurol 1990;34 :245± 9.
9 M urakami S, Sotsu M , Morooka S, Suzuki T.
Chronic encapsulated intracerebral hem atom a associated with cavernous angioma: a case report. Neurosurgery 1990;26:700± 2.
10 Okuno S, Hisanaga M , Miyasaki A, Tsunoda S,
Sakaki T. [Chronic encapsulated intracerebral
hematom a associated with cavernous angioma: case
report and review of the literature.] N o Shinkei Geka
1993;21 :655± 9. (In Japanese.)
11 Kumabe T, Kayama T, Sakurai Y, Ogasawara K,
Niizuma H, Wada T, et al. [Encapsulated chronic
intracerebral hematoma caused by venous angioma at
basal ganglia: a case report.] No Shinkei Geka
1990;18 :735± 9. (In Japanese.)
12 Chan S, Tse CH C. Chronic encapsulated intracerebral hem atom a in young Chinese adult: case report.
Nurosurgery 1987;20 :639± 41.
13 Fiumara E, Gambacorta M , D’ Angelo V, Ferrara
M , Corona C. Chronic encapsulated intracerebral
haem atom a: pathogenetic and diagnostic considerations. J Neurol Neurosurg Psychiatry 1989;52 :1296± 9.
14 Lin SZ, Shih C J, Wang YC, Tsai SH. Intracerebral
hematom a simulating a new growth. Surg N eurol
1984;21 :459± 64.
15 Terada T, Okuno T, Moriwaki H, Nakai E, Komai N.
Chronic encapsulated intracerebral hematoma during
infancy: case report. N eurosurgery 1985;16 :833± 5.
16 Aoki N, M izuguchi K. Chronic encapsulated intracerebellar hem atom a in infancy: case report. Neurosurgery 1984;14:594± 7.
17 Aoki N, M izugichi K. Expanding intracerebral
hematom a: a possible clinicopathological entity. N eurosurgery 1986;18 :94± 6.
18 M atsum oto K, Asari S, Nishimoto A, Namba S.
[Chronic encapsulated intracerebral hematoma due to
metastatic brain tum or: a case report.] No Shinkei
G eka 1988;16:327± 31. (In Japanese.)
19 Cohen D, Zubay GP, Goodman RR. Seizure outcome
after lesionectomy for cavernous malformations. J
Neurosurg 1995;83:237± 42.
20 Rigamonti D, Drayer BP, Johnson PC, Hadley M N,
Zabramski J, Spetzler RF. The MRI appearance of
cavernous malform ations (angiomas). J N eurosurg
1987;67 :518± 24.