Neurol Med Chir (Tokyo) 44, 646¿649, 2004

Chronic Subdural Hematoma Following Dural Metastasis
of Gastric Cancer: Measurement of Pre- and
Postoperative Cerebral Blood Flow With
N-isopropyl-p-[123I]iodoamphetamine
—Case Report—
Koichi FUKINO, Takeshi TERAO, Toyoyuki KOJIMA, Koji ADACHI,
and Akira TERAMOTO
Department of Neurosurgery, Nippon Medical School, Tokyo

Abstract
A 58-year-old female with gastric cancer presented with left chronic subdural hematoma (CSH) without
history of head injury. Magnetic resonance imaging revealed left CSH with atypical findings such as abnormal dural enhancement and swelling of the left cerebral hemisphere. One month after gastrectomy,
motor aphasia and right hemiparesis developed. Irrigation of the left CSH was performed. The hematoma was abnormally mucinous and became solid immediately after irrigation. Histological examination
showed that adenocarcinoma cells had metastasized to the dura mater and the outer membrane of the
hematoma. The preoperative cerebral blood flow (CBF) in the affected cerebral hemisphere, measured
by single photon emission computed tomography using N-isopropyl-p-[123I]iodoamphetamine, was
much higher than that in the opposite hemisphere, whereas the postoperative CBF was almost equal in
both hemispheres. Subdural hematomas secondary to dural metastases of extraneuronal malignancies
are rare, and are usually the chronic type. Measurement of the pre- and postoperative CBF in the present
patient with CSH following dural metastasis of the malignant tumor showed that preoperative hyperemia in the affected hemisphere may result from dilation of the cerebral vessels caused by the effects of
the CSH.
Key words: magnetic resonance imaging, N-isopropyl-p-[123I]iodoamphetamine single photon emission
computed tomography, chronic subdural hematoma, dural metastasis, malignant tumor,
cerebral blood flow

Introduction

ated with meningeal carcinomatosis.
The present study measured both preoperative
and postoperative CBF by N-isopropyl-p-[123I]iodoamphetamine single photon emission computed
tomography (IMP-SPECT) in a 58-year-old female
with CSH secondary to dural metastasis from gastric
cancer.

Non-traumatic subdural hematomas have various
causes, including vascular disorders, coagulopathies, intracranial hypotension, meningitis, and
dural metastases of malignant tumors.2) Subdural
hematomas secondary to dural metastases of extraneuronal malignancies are rare, and are usually
the chronic type.1) The common primary sites include the stomach, breast, lung, and prostate.12)
Cerebral blood flow (CBF) has been examined in the
patients with non-tumoral chronic subdural hematomas (CSHs), but not in patients with CSHs associ-

Case Report
A 58-year-old female underwent total gastrectomy
because of gastric cancer (type 4). She suffered from
loss of appetite and headache. Magnetic resonance

Received July 10, 2003;
Accepted June 18, 2004
Author's present address: K. Fukino, M.D., Division of Human Cancer Genetics, The Ohio State University Tzagournis
Medical Research Facility, Columbus, Ohio, U.S.A.

646

CSH Following Dural Carcinomatosis

Fig. 1

Fig. 2

Preoperative
N-isopropyl-p-[123I]iodoamphetamine single photon emission computed tomography (IMP-SPECT) scans revealing that the cerebral blood flow (CBF) was
much higher in the left cerebral hemisphere
than in the right (upper row). Postoperative
IMP-SPECT scans showing that the CBF
in the left hemisphere was almost equal to
that in the right (lower row). The preoperative scans showed the CBF of the contralateral cerebellar hemisphere was not
elevated compared to that of the ipsilateral
hemisphere, suggesting absence of remote
effect.

Fig. 3

Photomicrographs of the dura mater showing perivascular infiltration of atypical
cells (left: hematoxylin-eosin stain, ×20),
containing cytoplasm positive for periodic
acid-Schiff stain (right: ×20).

Preoperative
T1-weighted
magnetic
resonance (MR) images with gadolinium
demonstrating left chronic subdural hematoma associated with abnormal dural
enhancement, manifestation of the vessels
in the left hemisphere, and swelling of the
left hemisphere (left column). Postoperative
T1-weighted MR images with gadolinium
showing that the subdural hematoma had
completely disappeared and the vessels in
the left hemisphere were less visible,
whereas the dural enhancement persisted
(right column).

(MR) imaging with contrast enhancement revealed
left CSH with atypical findings, such as abnormal
enhancement of the dura mater, manifestation of
the vessels in the left cerebral hemisphere, and
swelling of the involved hemisphere (Fig. 1 left
column). These findings corresponded to group 2 of
the MR imaging classification of meningeal carcinomatosis.15) One month after gastrectomy, motor
aphasia and right hemiparesis occurred in the night.
Computed tomography (CT) showed slight increase
of the subdural hematoma and deterioration of the
swelling of the left cerebral white matter. IMPSPECT of the head, performed 6 days after the onset,
showed that the CBF of the left cerebral hemisphere
was much higher than that of the right (Fig. 2 upper
row). The CBF of the ipsilateral and contralateral
cerebellar hemispheres were similar.

Neurol Med Chir (Tokyo) 44, December, 2004

647

K. Fukino et al.

648

Administration of mannitol only transiently and
slightly improved her aphasia and right hemiparesis.
One and a half months after gastrectomy, irrigation
of the CSH was performed together with biopsy of
the dura mater and the outer membrane of the hematoma. The dura mater was rather thickened, and the
hematoma was abnormally mucinous and became
solid immediately after irrigation. Histological
examination of the dura mater and the outer membrane revealed perivascular infiltration of atypical
cells, which contained cytoplasm positive for
periodic acid-Schiff stain (Fig. 3). These histological
findings were compatible with dural metastasis of
adenocarcinoma.
Immediately after the operation, her headache
and nausea disappeared, and aphasia and motor
weakness of the right limbs improved. Postoperative
head CT showed that the CSH had almost completely disappeared. The vessels in the left hemisphere,
prominent on the preoperative MR image, had
become inconspicuous on the postoperative MR
image, whereas the dura mater was still enhanced as
strongly as before (Fig. 1 right column). Postoperative IMP-SPECT showed that the CBF of the left and
right cerebral hemispheres had become almost equal
(Fig. 2 lower row).
Her general condition and neurological findings
transiently improved. However, she soon developed
visual disturbance, probably due to thickening of the
dura mater in the optic canals, and she died of
disseminated intravascular coagulation one and a
half months after irrigation of the CSH. Autopsy was
not permitted.

Discussion
Several mechanisms of CSH formation associated
with dural metastasis have been postulated. Obstruction of the dural veins by tumor cells would cause
dilation of the capillaries in the inner areolar layer,
followed by rupture and subdural hemorrhage.13)
Hyperplasia of the inner areolar layer is an angiodesmoplastic response to the tumor invading the
meninges.10) Therefore, hematoma could result from
separation and hemorrhage into the highly vascular
abnormal areolar layer of the dura mater.1) The combined effect of metastases in dural vessels with a
coagulation defect could lead to large subdural
hematomas.1) Secretion by the mucin-producing
carcinoma was the proposed pathogenic mechanism
in a case of dural metastasis from an adenocarcinoma of the pancreas.3) The abnormally mucinous
hematoma in our case suggests that secretion by the
carcinoma cells could be a pathogenic mechanism.
CBF is not necessarily correlated with the type of

lesion, but can be affected by arteriovenous shunts,
blood-brain barrier dysfunction, and blood vessels
lacking autoregulation in or around the lesion.9) CBF
depression occurs in the hemisphere under CSH,
but the reported degree and/or the localization of the
CBF depression differ.5–7,11,14) In the present case,
IMP-SPECT showed much higher preoperative
uptake on the lesion side than that on the non-lesion
side, whereas the abnormally higher uptake diminished after irrigation of the CSH. A previous case of
adenocarcinoma of the stomach also demonstrated
higher IMP uptake.4) However, the higher uptake of
IMP in the present case could not be attributed to
the factors of adenocarcinoma cells, because simple
irrigation of the hematoma might have little effect
on the number and the metabolic activities of tumor
cells. The vessels under subdural hematomas are
pathologically dilated in patients with head injury,
and the dilation is reduced after removal of the
hematomas.8) In the present case, the preoperative
increased uptake on IMP-SPECT may be due to
dilation of the vessels, possibly caused by the
reduced venous return due to compression to the
cerebral veins by the CSH. Otherwise, mechanical
compression or chemical stimulation by the CSH
may have damaged the autoregulation of the vessels.
Irrigation of the CSH might remove or decrease such
harmful effects. Preoperative SPECT showed no
remote-effect signs suggesting the metabolic
coupling accompanying seizures. The hyperemia
together with compression by the hematoma might
have caused the swelling of the left hemisphere.
The etiology of the neurological symptoms was
unclear. Compression by the CSH, hyperemia
associated with brain swelling, and seizure are all
possible causes. The rather long duration of the
neurological deficits and the sudden improvement
immediately after irrigation tend to exclude seizure.
The combination of compression by the CSH and
deterioration of brain swelling is the most likely
cause, because the neurological deficits were transiently improved by the mannitol administration
and irrigation of the CSH.
Measurement of CBF in the present patient with
CSH associated with dural metastasis of malignant
tumor found abnormally high preoperative uptake
in the affected hemisphere which normalized after
irrigation of the CSH. Patients with dural metastases
of malignant tumors may experience transient
improvement of the neurological conditions by
irrigation of the hematoma, but many of them will
have very poor outcomes. Histological examination
of the dura mater and the outer membrane are very
important in patients with CSH and histories of
malignant tumors.

Neurol Med Chir (Tokyo) 44, December, 2004

CSH Following Dural Carcinomatosis

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Address reprint requests to: K. Fukino, M.D., Department
of Neurosurgery, Nippon Medical School, 1–1–5
Sendagi, Bunkyo–ku, Tokyo 113–8602, Japan.
e-mail: koichifukino＠aol.com