Chronic Encapsulated Hematoma Domenico d'Avella, M .D ., Antonino Germano, M .D., Alberto Romano, M .D ., Emanuele Cardia, M .D., Francesco Tomasello, M .D. Neurosurgical Clinic, University of Messina School of Medicine, Messina, Italy OBJECTIVE AND IM PO R TA N CE: Chronic encapsulated intracerebral hematoma is a fairly rare clinical entity. This unique lesion is peculiar for its clinical onset, formation of a capsule, and progressive enlargement. The mechanism for capsule formation and self-perpetuating expansion still re­ mains uncertain, as well as the causal relationship with vascular malforma­ tions. Because of their pseudotumoral course and misleading neuroradiologi­ cal features, these lesions can be misdiagnosed preoperatively as cerebral neoplasms. CLINICAL PRESENTATION: A 62-year-old man was referred with a 2-month history of generalized tonicoclonic seizures. There was no history of head injury or arterial hypertension. The results of a neurological examination were normal. Computed tomographic scans revealed a slightly hyperdense roundish area in the right parietotemporal region with ring-like enhancement after contrast medium injection, moderate mass effect, and perifocal low attenuation. With the provisional diagnosis of astrocytoma, the patient was admitted for a craniotomy. Before surgery, a thallium-201 single photon emission computed tomographic study was performed, which showed no abnormal uptake of the tracer, raising significant doubt regarding the presumptive diagnosis of a tumor. INTERVENTION: Intraoperative findings revealed a hematoma, with a welldemarcated, thick, fibrous-elastic capsule. There was evidence of re­ peated intracapsular hemorrhages. The lesion was totally removed, and the patient recovered fully. No other pathological findings, including vascular malformations, were noted. CONCLUSION: Chronic encapsulated intracerebral hematomas probably occur more frequently than the limited number of reported cases would indicate. This case represents a realistic clinical problem-solving setting in which thallium-201 single photon emission computed tomography was used because of its capacity for functional tumor detection and differen­ tial diagnosis. (Neurosurgery 4 1 :6 7 7 -6 8 0 , 1997) Keywords: Chronic encapsulated hematoma, Differential diagnosis, SPECT, Thallium-201 hronic encapsulated intracerebral hem atom a (EIH) is a rare, although w ell defined, clinical entity. Since the first description presented by Hirsh et al. (7) in 1981, 29 cases have been re­ ported in the literature (8 ). U nlike the typical intracerebral hem atom as, EIHs have a slo w ly progressive clinical pre­ sentation, are frequently observed in young norm otensive patients, and show, at surgery, a w ell-defined capsule. A p­ proximately one-half of the reported cases were associated w ith vascular malforma­ tions (9, 11); no apparent cause w as evi­ denced in the others (13). Because of their clinical behavior of slow ly expanding lesions w ith progres­ sive neurological deficits and the nonspe­ cific, som etim es equivocal, neuroradio­ logical features, encapsulated hematomas are frequently m isdiagnosed as cerebral neoplasm s (12). Thallium-201 single pho­ ton em ission tomography (SPECT) has re­ cently been proposed to be a useful diag­ nostic tool in the preoperative imaging assessment of patients with brain tumors (10, 14). We report a n ew case of chronic en cap su lated hem atom a and describe the crucial contribution of thallium -201 SPECT in su ggestin g a preoperative dif­ ferential diagnosis of EIH. C CASE REPORT A 62-year-old man presented in June 1994 w ith a 2-m onth history of general­ ized tonicoclonic seizu res. There w a s n o h istory of head injury or arterial h yperten sion . Examination Plain com puted tom ography d em on ­ strated a slightly hyperdense roundish area adjacent to the inner table in the right parietotem poral region. This w as accom panied by m oderate m ass effect to the surrounding structures and peri­ focal low attenuation. After contrast m e­ dium injection, a 3-cm diam eter ring­ like enhancem ent w as clearly evident. A m arginal zone of the lesion w as also partially enhanced by contrast material (Fig. 1). The lesion w as initially judged by the neuroradiologist to be consistent with a brain tumor. With a provisional Neurosurgery , Vol. 41, No. 3, September 1997 Downloaded from https://academic.oup.com/neurosurgery/article-abstract/41/3/677/2843665 by EKU Libraries user on 23 January 2019 Chronic Encapsulated Intracerebral Hematoma: Contribution of Thallium-201 Single Photon Emission Computed Tomography in Preoperative Diagnosis: Case Report 677 678 d'Avella et al. toma cavity or in the brain tissue around the capsule. A m yloid angiopathy was not a feature of the pathological speci­ men. The patient had an excellent post­ o p era tiv e cou rse. H e w as discharged w ith no n eu ro lo g ica l deficit 1 week postoperatively. F IG U R E 1. Preoperative com puted tom ographic scans show ing a slightly hyperdense roundish area in the right parietotem poral region w ith ring-like F IG U R E 2. Planar (A) and axial (B) enhancem ent after contrast medium thallium -201 SPEC T images show ing no injection. Note m oderate mass effect abnorm al uptake of the tracer. and perifocal low attenuation. diagnosis of astrocytoma, the patient w as admitted for a right temporoparietal cra­ niotomy. The results of a neurological exam in ation w ere norm al. Before su r­ gery, thallium-201 SPECT w as performed, w hich revealed no abnormal uptake of the tracer (Fig. 2), raising significant doubt regarding the presum ptive diagnosis of a tumor. Thallium-201 imaging There is little uptake of thallium-201 in the normal brain. Thallium-201 uptake by brain tumoral tissue is principally re­ lated to cell grow rates (3). In a recent stu d y , the se n sitiv ity of th alliu m -201 SPECT for supratentorial brain tumors w as 71.7% and specificity w as 80.9% (5). According to our protocol for routine thallium -201 SPECT (2), tw o different m ethods for determining the thallium -201 uptake index were used in evaluating this patient, including axial SPECT and planar imaging. The thallium-201 average counts-per-pixel lesion uptake w as re­ lated to the average counts per pixel of the hom ologous contralateral cerebral region uptake on the planar images. It w as also related, with the use of a tumor-to-cardiac (T/C ) ratio thallium-201 uptake, to the background thallium -201 brain uptake, norm alized to cardiac blood p ool u p ­ take, on the sin g le p h oton em issio n com puted tom ographic axial im ages. A m arked difference w as observed b e­ tw een the thallium -201 uptake indices in the lesion (SPECT 1.0; T /C ratio, 0.06) and the reference valu es obtained at our institution in low -grade tum ors (SPECT 1.37; T /C ratio, 0.1) and high-grade tu­ m ors (SPECT 2.51; T /C ratio, 0.53). Therefore, in this case, thallium -201 SPECT w as crucial in h elp in g to distin ­ gu ish an EIH from a tumor. Surgical procedures At surgery, a right tem poroparietal craniotom y w a s perform ed. The cortex revealed a brownish yellow discolora­ tion. Through a microsurgical trans-sulcal approach, the lesion w as observed at a depth of approximately 10 m m from the cortex. A well-demarcated, greenish, thick, fibrous-elastic capsule w as identi­ fied. Incision of the capsule revealed its content to be a hematoma, w hich show ed variations in its nature, including brown liquid hematoma and deeply black, solid hematoma. These findings suggested re­ peated hemorrhages inside the capsule. The lesion w as totally removed. N o other pathological findings, including vascular malformations, were noted in the hem a­ Downloaded from https://academic.oup.com/neurosurgery/article-abstract/41/3/677/2843665 by EKU Libraries user on 23 January 2019 D ISCU SSIO N The peculiar clinical behavior of some intracerebral hem atom as has recently led to the identification of a new clinical entity, EIH, defined by common charac­ teristics that differ from those of typical intracerebral hem atom as (15). Most of the 29 cases described in the literature had tum or-like onsets (slow ly progres­ sive neurological deficits, increased in­ tracranial pressure, or seizures). Thev occurred in relatively you ng normotensive patients w ith an evident male pre­ dom inance, and a w ell-defined fibrous capsule w ith a rich neovascularity was observed in each case (12). Vascular m alform ations w ere observed to be re­ sp onsible for the hem atom as in approx­ im ately one-half of the cases, including that reported by Kurita et al. (8 ), which d ev elo p ed at the site of partially oblit­ erated arteriovenous malformations af­ ter radiosurgery. It is very likely that hem atom as for w hich the causes remain u nk now n w ere also caused by vascular m alform ations that w ere destroyed or thrombosed by the hemorrhage. Unfortu­ nately, neither magnetic resonance (MR) im aging nor angiography were per­ formed for this patient. Therefore, al­ though pathological examination failed to reveal vascular anomalies, w e cannot con­ fidently rule out the causative role of small vascular malformations. Different pathophysiological mecha­ nism s have been proposed to explain w h y these hem atom as produce a cap­ su le and increase their size over tune instead of resorbing spontaneous!' Fiumara et al. (6 ) observed that most encapsulated hem atom as reported by the literature w ere located close to the arachnoidal spaces, hypothesizing that a proliferative reaction of arachnoid h broblasts stim ulated by the initial bleed ing w as responsible for the formation ot the capsule. A m ore convincing hypoth­ esis su g g ests sin gle or multiple m stances of m inor bleeding from vascular Neurosurgery, Vol. 41, No. 3, September 1997 Chronic Encapsulated Hematoma w hen clinical questions, including atypi­ cal sym ptom atology and radiological findings, m ight arise. It should also be noted that, in this era of cost containment, both low cost of the radiopharmaceutical agent and easy clinical access to SPECT facilities contribute to the attractiveness of thallium -201 functional studies. It has been su ggested that EIHs prob­ ably occur m ore frequently than the lim ­ ited num ber of reported cases indicate (12). The occurrence of EIHs has been recently associated w ith radiosurgery for obliteration of arteriovenous m alfor­ m ations (8 ). With the grow in g num ber of such radiosurgical procedures, it is also likely that neurosurgeons w ill be in­ creasingly faced w ith EIH diagnostic work-up and surgical management. In this respect, the case reported here repre­ sents a realistic clinical problem-solving setting in w hich thallium-201 SPECT w as used because of its capacity for functional tum or detection and differen­ tial diagnosis. 8. K u rita H , S a sa k i T, K a w a m o to S , T a n ig u c h i M , K ita n a k a C , N a k a g u ch i H , K irin o T: C h ro n ic en ca p su la ted ex p a n d in g h em a to m a in a sso cia ­ tio n w ith g a m m a k n ife s tereo ta ctic ra d io su r­ gery for a ce re b ra l a rterio v en o u s m a lfo rm a tio n : C a se rep o rt. J N eu ro su rg 8 4 :8 7 4 -8 7 8 , 1996. 9. M o n m a S, O hno K, H ata H , K o m a tsu K, Ich im u ra K , H ira k a w a K : C a v ern o u s a n g io m a w ith e n ca p su la ted in tra cere b ra l h em a to m a : R e­ p o rt o f tw o cases. S u rg N e u ro l 3 4 :2 4 5 -2 4 9 , 1990. 10. M o u n tz JM , S ta ttfo rd -S ch u ck K , M cK ee v er PE, T a ren J, B e ierw a ltes W H : T h a lliu m -2 0 1 tu m or/ ca rd ia c ra tio e stim a tio n o f re sid u a l a stro cy ­ to m a. J N e u ro su rg 6 8 :7 0 5 -7 0 9 , 1988. 11. M u ra k a m i S , S o tsu M , M o ro o k a S , S u z u k i T: C h ro n ic e n ca p su la ted in tra cere b ra l h em a to m a a sso cia ted w ith ca v e rn o u s a n g io m a : A ca se re ­ port. N e u ro su rg e ry 2 6 :7 0 0 -7 0 2 , 1990. 12. P o z z a ti E , G iu lia n i G , G a ist G , P ia z z a G , V erg o n i G : C h ro n ic ex p a n d in g in tra cere b ra l h e m a ­ to m a. J N e u ro su rg 6 5 :6 1 1 -6 1 4 , 1986. 13. R o d a JM , C a rc elle r F , P e re z -H ig u era s A , M o ­ ra les C : E n ca p su la ted in tra cere b ra l h em a to m a s: A d efin ed en tity. J N e u ro su rg 7 8 :8 2 9 -8 3 3 , 1993. 14. R o llin s N K , L o w ry P A , S h a p iro K N : C o m p a ri­ so n o f g a d o lin iu m -e n h a n ced M R an d th a lliu m 201 sin gle photon em ission com puted tom ogra­ phy in pediatric brain tum ors. P ed iatr N eu rosu rg 22 :8 -1 4 , 1995. 15. T era d a T, O k u n o T , M o rik a w i H , N a k a i E, K o m a i N: C h ro n ic en ca p su la ted in tra cere b ra l R e c e i v e d , S e p tem b e r 24, 1996. h em a to m a d u rin g in fan cy : C a se rep o rt. N e u ro ­ A c c e p t e d , M arch 21, 1997. su rg e ry 1 6 :8 3 3 -8 3 5 , 1985. R e p r i n t r e q u e s t s : D om enico d 'A v e lla , M .D., 16. Y a m a sh im a T , Y a m a m o to S , F rie d e R L: T h e ro le N e u ro su rg ic a l C linic, P oliclinico U n iv ersitario, U n iv e rsity of M essina School of M ed i­ cine, 98100 M essina, Italy. o f e n d o th e lia l g ap ju n c tio n s in th e en la rg e m en t REFERENCES 1. A o k i N , M izu g u ch i K: E x p a n d in g in tra cere b ra l h em ato m a: A p o ssib le clin ico p a th o lo g ica l e n ­ tity. N eu ro su rg ery 1 8 :9 4 -9 6 , 1986. 2. B ald ari S, G erm an d A , C a ccio la F, B o n a n n o N: T h alliu m -201 S P E C T an d p la n a r im a g in g in the p re-o p era tiv e assessm en t o f bra in tu m o rs. A cta N eu rol B e lg 95[S u p p l l] :7 7 - 7 8 , 1995. 3. B lack K L, H aw k in s RA , K im K T, B eck er D P, L e m e r C , M arcia n o D: U se o f T h alliu m -201 S P E C T to q u an tita te m a lig n a n cy g ra d e o f g lio ­ m as. J N eu ro su rg 7 1 :3 4 2 -3 4 6 , 1989. 4. C h a n S, T se C: C h ro n ic e n ca p su la ted in tra c ere­ b ral h em ato m a in a y o u n g C h in ese a d u lt: C a se rep o rt. N eu ro su rg ery 2 0 :6 3 9 -6 4 1 , 1987. 5. D ierck x R A , M a rtin JJ, D o b b e leir A , C ro ls R, N ee ten s 1, D e D ey n PP: S en sitiv ity an d s p ecific­ ity o f th alliu m -201 sin g le -p h o to n em issio n to­ o f ch ro n ic su b d u ra l h em a to m a s. J N eu ro su rg 5 9 :2 9 8 -3 0 3 , 1983. COMMENTS This report m akes a case for the u se of thallium -201 single photon em ission com ­ puted tomography (SPECT) in cases in which the distinction between an intrace­ rebral tumor and a hematoma is unclear. At our institution, magnetic resonance spectroscopy is also being evaluated for this purpose. In their present state of de­ velopm ent, these studies are helpful but not diagnostic; therefore, surgical confir­ mation remains essential. It is conceivable that in the not-too-distant future, one may be able to confidently establish the nature of such lesions without surgical excision. m o g ra p h y in the fu n ctio n a l d e tectio n and d if­ Raj K. N aray an feren tial d iag n o sis o f bra in tu m o rs. E u r J N ucl P h ila d elp h ia , P en n sy lv an ia M ed 2 1 :6 2 1 -6 3 3 , 1994. 6. F iu m ara E, G am b a co rta M , D 'A n g e lo V , F errara M , C o ro n a C: C h ro n ic e n ca p su la ted in tra cere­ b ral h em ato m a: P a th o g en e tic and d ia g n o stic co n sid eratio n s. J N eu rol N eu ro su rg P sy ch ia try 5 2 :1 2 9 6 -1 2 9 9 , 1989. 7. H irsh LF, S p e cto r H B, B o g d a n o ff BM : C h ro n ic e n cap su lated in tra cereb ra l h em ato m a. N eu ro ­ su rg e ry 9 :1 6 9 -1 7 2 , 1981. This is an interesting case report d e­ scribing chronic encapsulated intracere­ bral hem orrhages. The authors clearly indicate the usefulness of thallium w ith SPECT. It is likely, how ever, that m ost patients w ith such lesions w ould be op ­ Neurosurgery, Vol. 41, No. 3, September 1997 Downloaded from https://academic.oup.com/neurosurgery/article-abstract/41/3/677/2843665 by EKU Libraries user on 23 January 2019 malformations to be responsible for the growth of granulation tissue. Fibro­ blasts then organize a fibrous m em ­ brane with a rich vascularity that can be responsible for su ccessive instances of bleeding w ithin the hem atom a cavity. The presence in the capsule of m acro­ capillaries w ith altered perm eability al­ lows water and blood products to leak into the hematoma, further increasing its size with a mechanism similar to that of chronic subdural hem atom as (1 ,4,13,16). These pathophysiological m echanism(s) provide an explanation for the tumor-like behavior of EIH, i.e. gradual onset, slow ly progressive neurological deficits, or seizures. This clinical picture, associated w ith the com p uted tom o­ graphic findings of a ring-like enhance­ ment surrounding an area of variable density w ith m ass effect and perilesional edem a, m ay lead to the w rong initial diagnosis of a brain tumor. The diagnostic im portance of MR stud ies of EIHs remains to be determ ined. MR findings of EIHs w ere described for the first time by Roda et al. (13) in 1993. However, as recently em p hasized by Kurita el al. (8 ), MR im ages of EIHs do not exhibit characteristic differentiating features and can be m isleading. Again, the lack of an MR exam ination d oes not allow us to add further insight regard­ ing its diagnostic role. In this case, h o w ­ ever, preoperative thallium -201 SPECT, revealing no tracer uptake, ruled out the possibility that the lesion could be a high-cellularity m alignant m ass, raising the preoperative suspicion of EIH, sub­ sequently confirm ed at surgery and by pathological exam ination. Thallium-201 SPECT has been recently proposed as a useful diagnostic tool in the preoperative imaging assessm ent of pa­ tients with brain tumors (10, 14). Thus technique can predict tumoral grading and clinical aggressiveness, differentiat­ ing high- from low-grade malignant brain tumors based on the relative thallium up­ take in tumors compared to normal brain (5). Although the need for direct histolog­ ical confirmation of all intracranial mass lesions cannot be questioned, our experi­ ence demonstrates, in keeping with prior work (2-3,5), that this radionuclide im ag­ ing modality may offer clinically relevant information with important prognostic and therapeutic implications, particularly 679 680 d'Avella et al. the m echanism of expansion of these lesions, w hich is sim ilar to that p o stu ­ lated for subdural hem atom as. W hether changes in coagulation param eters also play a role, as they do in subdural h e­ m atom as, is not know n. In sum m ary, d'A vella et al. present a very interesting case report of chronic encapsulated intracerebral hem atom as. The use of SPECT to identify these le­ Traumatic Bilateral Jugular Vein Thrombosis: Case Report and Review of the Literature Bryan J. Duke, M .D ., Robert K. Ryu, M .D., Kerry E. Brega, M .D ., Douglas M. Coldwell, M .D ., Ph.D. D ivisio n of N eurosurgery (BJD , KEB) and Departm ent of Radiology (R KR , D M C ), U niversity of C olorado Health Sciences Center and D enver Health M edical Center, sions is the uniq ue feature of this article SPECT is a tool w ith w hich to determine the locations of these lesions in the deep structures to avoid craniotomy or even biopsy. The m echanism s leading to hem­ orrhage need to be identified, and diag­ nostic studies should not be omitted. Law rence F. Marshall S an D iego, California ugular vein throm bosis (JVT) has pre­ v io u sly been reported in association w ith central v en o u s catheterization, rad­ ical neck dissection, head and neck in­ fection, intravenous drug abuse, and the hypercoagulable state associated with m alignancy (2^4). W e present a case of bilateral JVT that occurred secondary to n o n p en etra tin g neck injury, re­ su lted in elev a ted intracranial pres­ sure (ICP), and w a s treated with an en d o v a scu la r stent. J CASE REPORT D en ver, C olorado OBJECTIVE AND IM PORTANCE: Thrombosis of the internal jugular vein (IJV) with associated elevated intracranial pressure (ICP) is a rare com­ plication of central venous catheterization but has not been reported as a result of blunt trauma. CLIN ICA L PRESENTATION: An 18-year-old male patient was observed to be obtunded after an assault. The initial examination was remarkable for somnolence, bruising of the anterior neck, and diffuse, edematous swell­ ing of the face and scalp. The results of computed tomography of the brain were normal. An angiogram obtained on the 2nd hospital day to rule out carotid injury revealed bilateral IJV thromboses to the cranial base. An ICP monitor was placed with an opening pressure of 33 mm Hg. The central venous pressure was measured to be 9 mm Hg. A catheter was passed through the left IJV thrombus and into the sigmoid sinus, where the pressure was 17 mm Hg. IN TERVENTION: An intravascular stent was deployed in the left IJV. ICP rapidly normalized. A regimen of coumadin was administered to the patient for 6 weeks, at which time the stent remained patent. C O N C LU S IO N : We conclude that traumatic jugular vein thrombosis can be associated with significant elevation in ICP and that treatment with an endovascular stent can affect the rapid correction of intracranial hyper­ tension in patients who are candidates for anticoagulation. (Neurosurgery 4 1 :6 8 0 -6 8 3 , 1997) Key w o rds: Inju ry, Jugular vein , Stent, Throm bosis Downloaded from https://academic.oup.com/neurosurgery/article-abstract/41/3/677/2843665 by EKU Libraries user on 23 January 2019 erated on because of m ass effect and that the procedure w o u ld be perform ed in a sim ilar fashion, m inim izing the d am age to norm al tissue. N evertheless, the availability of SPECT to identify these lesion s is im portant and m ight lead occasionally to observation in pa­ tients for w h om SPECT sh ow s no ev i­ dence of activity. The authors present a w ell-articulated d iscussion regarding An 18-year-old Caucasian male pa­ tient suffered a w itnessed assault by four other y o u n g men. Paramedics ob­ served the patient to be unresponsive w ith a G lasgow C om a Scale score of 3, a blood pressure of 140 /9 0 mm Hg, a heart rate of 88 beats per minute, and a respiratory rate of 6 breaths per minute H e w as nasotracheally intubated and transported to the em ergency depart­ m ent, w here he w a s noted to have linear ecch ym oses across the neck extending onto both m astoid processes with asso­ ciated diffuse sw ellin g of the face and scalp (F ig. 1). In the em ergency depart m ent, the patient w as able to be aroused by the sou nd of a voice, intermittent!' follow ed com m ands, withdrew briskly in response to pain to all four extremi­ ties, had equal and reactive pupils, and w as noted to have spontaneous respira­ tory activity. The results of computed tom ography (CT) of the head and com­ puted tom ographic carotid angiograpb' perform ed at that tim e were normal w ith the exception of extensive soft tis sue sw ellin g of the face and scalp The results of the rem ainder of the patient- Neurosurgery, Vol. 41, No. 3, September 1997