Cerebellar Hemorrhage Secondary to Cerebellopontine Angle Metastasis From Thyroid Papillary Carcinoma

Abstract

A 63-year-old woman presented with a metastatic focus of papillary thyroid carcinoma in the cerebellopontine angle manifesting as lateral gazing nystagmus and slurred speech. Computed tomography demonstrated massive hemorrhage in the left cerebellar hemisphere. She was treated conservatively. Her symptoms resolved completely, but she experienced progressive deterioration in auditory acuity and ataxia over the next 6 months. Magnetic resonance imaging with gadolinium demonstrated an enhanced mass in the left cerebellopontine angle, and she was scheduled for elective resection of the tumor. Left retrosigmoid craniotomy was performed, and the tumor was subtotally removed except for a small amount at the junction of the trigeminal nerve and the pons. Histological examination confirmed a diagnosis of metastatic papillary thyroid carcinoma. The patient then underwent adjuvant gamma knife radiosurgery. Her clinical course was unremarkable, and her hypoacusis and ataxia resolved completely. Postoperative gallium scintigraphy revealed no residual tumor and no other systemic metastases. Hemorrhagic cerebellar metastasis from papillary thyroid carcinoma is extremely rare, but early recognition of metastatic cerebellar tumor should prompt immediate treatment to avoid the development of hearing loss, ataxia, and tonsillar herniation.

Brain Metastasis From Papillary Thyroid Carcinoma in a Seventy-Three-Year-Old Man

“…Acute and severe spontaneous cerebral hemorrhage is a life threatening complication that can lead to abrupt onset of neurologic symptoms and rapid death due to intratumoral hemorrhage. Hemorrhagic intracranial metastases represent 3% to 14% of all cerebral metastases and they classically originate from renal cell carcinoma, melanoma, choriocarcinoma, bronchogenic carcinoma, and hepatocellular carcinoma (11)(12)(13). The presented case and sporadic cases of hemorrhagic brain metastases caused by PTC, demonstrate that PTC should be considered in the differential diagnosis of hemorrhagic intracranial metastases (11,(13)(14)(15).…”

“…Hemorrhagic intracranial metastases represent 3% to 14% of all cerebral metastases and they classically originate from renal cell carcinoma, melanoma, choriocarcinoma, bronchogenic carcinoma, and hepatocellular carcinoma (11)(12)(13). The presented case and sporadic cases of hemorrhagic brain metastases caused by PTC, demonstrate that PTC should be considered in the differential diagnosis of hemorrhagic intracranial metastases (11,(13)(14)(15). Some risk factors for distant metastasis of PTC include male sex, advanced age, histologic grade, extrathyroidal invasion at initial examination, and multiple organs involvement (16,17).…”

“…Several treatment modalities with varying results, e.g. surgical resection, gamma knife radiosurgery, whole brain radiation therapy, radioiodine therapy, and chemotherapy, have been used in the limited number of intracranial metastatic PTCs (13,(24)(25)(26)(27). Although the presence of a brain metastasis is an overall negative prognostic indicator, surgical resection of brain metastases might help to significantly prolong survival in patients with differentiated thyroid carcinoma, especially in solitary or oligometastatic lesions (13,(24)(25)(26).…”

“…Although the presence of a brain metastasis is an overall negative prognostic indicator, surgical resection of brain metastases might help to significantly prolong survival in patients with differentiated thyroid carcinoma, especially in solitary or oligometastatic lesions (13,(24)(25)(26). In life-threatening complications such as refractory intracranial hypertension, severe brain edema, tonsillar herniation, and intracranial hemorrhage, surgery is also the treatment of choice (13,24). However, if a patient is at high risk for surgery or surgery is impossible and in the case of incomplete resection of metastatic lesions or diagnostic biopsy, adjuvant therapy such as whole brain radiotherapy or radiosurgery might be the best therapeutic choice.…”

“…Gamma knife radiosurgery certainly is an attractive option for the local control of a solitary lesions or a few smaller ones because it is less invasive than craniotomy; it is especially important in patients who might have a limited survival time (24). Patients treated with SRS (stereotactic radio surgery) for brain metastases from primary thyroid cancer have a favorable prognosis with an expected median survival of longer than three years (13,29). Radioiodine treatment would be a reasonable treatment option if findings of the I 131 whole body scan were positive.…”