An Autopsy Case of Intracranial and Intraspinal Hematoma due to Widespread Metastasis of Adenocarcinoma

Abstract

An autopsy case of intracranial and intraspinal subdural hematomas secondary to invasion of the dural and epidural vessels by a metastatic adenocarcinoma was presented. The extremely rare occurrence of such lesions was reviewed in the literature and the mechanism of hematoma formation was discussed.A 45-year-old woman, who had a partial gastrectomy for adenocarcinoma of the stomach 12 years previously, showed increased serum alkaline phosphatase level and multiple high uptake areas on a radioisotope bone scan. Physical and neurological examination on admission showed no definite abnormalities. Ten weeks later, she complained of double vision and became semicomatose within a few days. Brain CT showed the presence of subdural hematoma in the right parietal region. Laboratory examinations, suggested the presence of disseminated intravascular coagulation (DIC). A burrhole was placed and bloody fluid was evacuated from the subdural space. The level of consciousness gradually improved, but again deteriorated progressively into a comatose state. Brain CT showed bilateral subdural hematomes. She died on the 7th postoperative day.
Autopsy revealed metastatic adenocarcinoma foci in various tissues such as the lungs, left retroperitoneal space, lymphnodes, and bones, although no evidence of local recurrence was found in the stomach. In the lungs and the bone marrow of the skull and vertebrae, many tumor cell nests were found only within the dilated vessels. Subdural blood clots were found bilaterally over the frontoparietal lobes and around the lower thoracic and lumbar segments of the spinal cord. Histologicaly, an extensive permeation of tumor cells into the lumina of the vessels was observed in the cranial dura over the subdural hematoma. The spinal dura covering the subdural hematoma contained a large number of engorged vessels without tumor cells. Veins in the spinal epidural tissue were distended and filled with tumor cells. Therefore, both intracranial and intraspinal subdural hematomas were assumed to be the result of obstruction of the dural or epidural veins by the tumor cells and of the subsequent bleeding from the capillaries of the inner vascular or areolar layer of the dura. In addition, the coagulation defect, or DIC, may have played a significant role in the development of the subdural hematomas.