A solitary hypothalamic metastasis from prostatic cancer mimicking a giant thrombotic aneurysm and presenting with intraventricular hemorrhage and acute hydrocephalus: a case report

Abstract

Background Despite the high prevalence of prostate cancer, its brain parenchymal metastasis is not common and intracranial hemorrhage due to such a metastasis is even less common. This report presents a challenging case of solitary brain metastasis secondary to prostate cancer that gave rise to intraventricular hemorrhage and acute hydrocephalus mimicking a giant aneurysm. Case presentation A 77-year-old man with a history of prostate cancer, hypertension, and morbid obesity presented to the emergency room with a severe headache. He was afebrile with a blood pressure of 144/79 mmHg, alert, without any sign of sensory or motor deficit. Shortly after admission, he became unresponsive and was immediately intubated. His blood tests revealed hypernatremia at 154 mmol/L; otherwise, the lab data including the COVID-19 screening proved normal. The cerebral CT and MR images, with and without contrast, were interpreted as a giant thrombotic aneurysm extending to the suprasellar region by the emergency radiologist. Also, moderate intraventricular hemorrhage, acute hydrocephalus, and sub-ependymal interstitial edema were observed. Upon further evaluation of the images, the lesion was determined to be an exophytic hemorrhagic hypothalamic mass, and the subsequent biopsy was consistent with prostate cancer metastasis. Conclusions The exophytic hemorrhagic hypothalamic metastasis can mimic a ruptured aneurysm on imaging. Given the improved survival of patients with prostate cancer, radiologists may encounter such unusual cerebral metastases from prostate cancers more frequently in the future.

The Clinical, Diagnostic, Therapeutic, and Prognostic Characteristics of Brain Metastases in Prostate Cancer: A Systematic Review

“…Fifty-seven [ 9 , 10 , 13 – 24 , 26 – 30 , 32 , 36 – 39 , 41 , 43 – 74 ] out of the 59 studies including 852 patients had reported BMs in PCa patients presenting with several clinical manifestations ranging from general symptoms such as hematuria, increased urinary frequency, and weakness to neurologic signs and symptoms such as aphasia, dysphasia, dysarthria, hemiplegia, headache, dizziness, confusion, double vision, visual field cut, ataxia, seizures, delirium, dementia, loss of appetite, and even behavioral changes. Moreover, different diagnostic methods including prostate-specific antigen (PSA), brain computed tomography (CT), brain magnetic resonance imaging (MRI), bone scan, multispectral immunofluorescence, immunohistochemistry (IHC), DNA sequencing, positron emission tomography (PET), prostate biopsy, and CSF analysis were used to diagnose BM in patients with PCa.…”

“…As described in Table 2 , these include symptoms such as headache, nausea, vomiting, seizures, confusion, weakness, aphasia, visual disturbances, ataxia, motor dysfunction, mono/hemiparesis, mental status or behavioral changes, cranial nerve dysfunction, and delirium. It was also demonstrated that patients can be asymptomatic, and the diagnosis of BMs in PCa may be an incidental finding during other investigations [ 9 , 10 , 13 – 24 , 26 – 30 , 32 , 36 – 39 , 41 , 43 – 74 , 76 , 77 ].…”

“…PCa patients with BMs are often in the end stages of the disease, or they may also have other accompanying chronic illnesses such as atherosclerosis, which may hide their CNS involvement and make the diagnosis even more challenging. Due to these multiple factors, cranial nerve and pituitary tumor spread, tumor mass effect, and meningeal involvement with hemorrhage of the contiguous brain tissue are frequently missed in these patients [ 9 , 10 , 13 – 24 , 26 – 30 , 32 , 36 – 39 , 41 , 43 – 74 , 76 , 77 , 80 – 83 ].…”

“…Hence, the necessity is for early diagnosis and management, especially in patients with high clinical suspicion for metastases [ 36 – 40 , 82 , 84 ]. As shown in Table 2 , several diagnostic approaches were used in BMs of PCa [ 9 , 10 , 13 – 24 , 26 – 30 , 32 , 36 – 39 , 41 , 43 – 74 ]. Herein, we categorized and discussed them separately based on the nature of the diagnostic approach.…”

“…As illustrated in the results, the first line imaging modality to detect BMs in PCa is a noncontrast CT scan which identifies lethal neurological conditions including hemorrhage, hydrocephaly, or massive compressive lesions [ 9 , 29 , 30 , 38 , 41 , 44 , 87 ]. Before using MRI as a diagnostic tool for detecting CNS metastases, imaging modalities lack the sensitivity to identify multiple intraparenchymal metastatic lesions.…”