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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 52  |  Issue : 3  |  Page : 99-102

Multiple massive intratumoral hemorrhages of metastatic brain melanoma after ventriculoperitoneal shunt


Department of Neurosurgery, Chung Shan Medical University Hospital; Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan

Date of Submission09-Oct-2018
Date of Decision08-Jan-2019
Date of Acceptance20-Mar-2019
Date of Web Publication17-Jun-2019

Correspondence Address:
Dr. Fook-How Chan
Department of Neurosurgery, Institute of Medicine, Chung Shan Medical University Hospital, No. 110, Sec. 1, Chien-Kuo North Road, Taichung 40201
Taiwan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/fjs.fjs_107_18

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  Abstract 


A 50-year-old male presented with sudden-onset headache, diplopia, and unsteadiness due to a posterior fossa hemorrhagic melanoma causing hydrocephalus. Computed tomography of the brain showed a 2.3 cm × 2.0 cm hemorrhagic tumor in the cerebellar vermis and a concomitant fourth ventricular hemorrhage. He underwent removal of the tumor and then ventriculoperitoneal shunt insertion for hydrocephalus. Because of his widespread disease, the patient died 2 weeks later from multiple massive intratumoral hemorrhages. To avoid this unfortunate consequence, we discuss the mechanism and suggest methods for treatment improvement. The variable we could control carefully was the opening pressure of the shunt and the flow of cerebrospinal fluid drainage. Setting a higher opening pressure and changing the pressure more slowly should be considered. To achieve this goal, the use of a programmable valve and anti-siphon system should strongly be recommended in these high-risk populations with extremely high bleeding tendency.

Keywords: Cerebral hemorrhage, melanoma, ventriculoperitoneal shunt


How to cite this article:
Yang TH, Liu JT, Chan FH. Multiple massive intratumoral hemorrhages of metastatic brain melanoma after ventriculoperitoneal shunt. Formos J Surg 2019;52:99-102

How to cite this URL:
Yang TH, Liu JT, Chan FH. Multiple massive intratumoral hemorrhages of metastatic brain melanoma after ventriculoperitoneal shunt. Formos J Surg [serial online] 2019 [cited 2019 Oct 19];52:99-102. Available from: http://www.e-fjs.org/text.asp?2019/52/3/99/260435




  Introduction Top


Ventriculoperitoneal (VP) shunting has been accepted as a safe and useful procedure for brain tumors that produce obstructive hydrocephalus. Some complications, such as subdural hematomas, infections, shunt malfunction, tube kinking, and seizures, have been reported for cerebrospinal fluid (CSF) ventricular shunts, but intratumoral hemorrhage is an uncommon complication of a VP shunt insertion. Several case reports have described brain tumor bleeding after VP shunt implantation, but no bleeding from a brain metastatic melanoma has yet been reported. In the present study, we report a case of multiple massive hemorrhagic melanomas after the placement of a VP shunt. The hemorrhaging caused the patient's poor clinical condition to lead rapidly to death.


  Case Report Top


A 50-year-old male was admitted because of a sudden-onset headache, rotatory vertigo, vomiting, loss of balance, and poor coordination. A physical examination revealed a Glasgow Coma Scale (GCS) of E4V5M6, but the patient was mentally slow and disoriented. He had marked truncal ataxia and dysdiadochokinesis in both the hands. His muscle strength, deep tendon reflexes, and sensation were preserved. He had no Babinski's sign. A 2 cm × 2 cm black nevus with irregular margins was found on the left plantar surface [Figure 1].
Figure 1: A black, border irregularity melanoma on the left lateral plantar area

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Computed tomography (CT) of the brain demonstrated a 2.3 cm × 2.0 cm hemorrhagic tumor mass with a high-density lesion in the midline of the cerebellar vermis and the left parasagittal region of the cerebellum [Figure 2]a and [Figure 2]b. Brain magnetic resonance imaging showed a short T1 with contrast-enhancing nodules over the left cerebellar peduncle, left cerebellopontine angle, and left frontal and temporal regions. Multiple ill-defined lower density lesions were found in the subcortical region of the bilateral parietal white matter [Figure 3]. Laboratory data showed no bleeding tendency (prothrombin time: 9.6 s; activated partial thromboplastin time: 24.8 s; and platelets: 146000/μL).
Figure 2: (a) A 2.3-cm ovoid high-density lesion in the midline of the cerebellar vermis and the left parasagittal region of the cerebellum. (b) A contrast enhancement lesion surrounded by a hematoma

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Figure 3: (a-c) A short T1 with contrast-enhancing nodules over the left frontal and left temporal regions, left cerebellar peduncle, left cerebellopontine angle, and multiple ill-defined lower density lesions in the subcortical region of the bilateral parietal white matter

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The patient underwent a cerebellar tumor resection for biopsy and decompression via a suboccipital craniotomy. Histopathologic examination revealed a metastatic brain melanoma. Postoperatively, the patient's GCS was 15, with a relatively slow response. A brain CT image obtained 21 days after the operation revealed hydrocephalus [Figure 4]a and [Figure 4]b. Symptoms of hydrocephalus, including headache, nausea, vomiting, and unsteady gait, were also noted. The standard VP shunting procedures (Medtronic PS valve, high pressure; opening pressure: 14.5 cmH2O) were performed to control the hydrocephalus.
Figure 4: (a and b) Diffuse ventricular dilatation demonstrating communicating hydrocephalus. (c) Brain computed tomography scans 10 days after the shunt procedure, when the patient became drowsy, showing a massive intratumoral hemorrhage and swelling in the left parietal lobe. (d) Multiple malignant melanoma-related intracerebral hemorrhages over the right occipital lobe and the right head of the caudate nucleus

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After the surgery, the patient's response and symptoms improved rapidly. Unfortunately, 10 days after the VP shunt implantation, the patient developed progressive drowsiness, severe posterior neck pain, and headache. A physical examination revealed weaker muscle power on the right limbs, with a score of 3/5 on the British Medical Research Council strength scale, and an increase in the deep tendon reflex. A brain CT scan showed multiple melanoma-related intracerebral hemorrhages (ICHs) over the left parietal lobe, right occipital lobe, and head of the caudate nucleus [Figure 4]c and [Figure 4]d. The rapid worsening of subfalcine herniation with massive intratumoral hemorrhages necessitated an emergency surgery for removal of the ICH with shunt ligation. Seven days later, the CT showed more ICH and severe brain swelling. The patient's poor neurological state and absent brainstem reflexes precluded any contemplation of reoperation, and the patient died 3 days later.


  Discussion Top


Melanoma is one of the most common tumors to metastasize to the brain, ranking the 5th after carcinomas of the lung, breast, kidney, and gastrointestinal tract. A high incidence of male predominance (79%) has been noted for all thin metastatic melanomas. The autopsy incidence of cerebral metastasis for a primary melanoma at the Sloan-Kettering Cancer Center is 40%. Even with advanced treatments, such as surgical intervention, radiation therapy, and chemotherapy, the median surgical time of a metastatic melanoma patient is only 6–9 months, and only 15% of these patients live for >3 years.[1] Several studies have reported the detection of brain metastases in 10%–70% of patients with metastatic melanoma, and autopsies confirm that 70%–90% of these patients died from melanoma. Once a diagnosis of cerebral metastasis of melanoma is confirmed, the median survival is under 6 months, and metastasis causes death in 94% of these cases.[2] The prognosis for patients with metastatic melanoma is particularly poor if cerebral metastases are present.

Treatments for brain melanoma metastasis include local control with surgery and stereotactic radiosurgery, as well as systemic treatments with chemotherapy, immunotherapy, and target therapy. Numerous antitumor agents have been identified in the current era, but melanoma tends to be refractory to both radiotherapy and chemotherapy. Standard chemotherapy has shown only limited responses in the treatment of melanoma brain metastases. The factors associated with longer survival and better prognosis of brain metastasis for surgical resection include the absence of preoperative neurological deficits, single cerebral metastasis, and no lung or visceral metastasis.[3]

Hydrocephalus is a common complication caused by brain metastasis, and a VP shunt is one efficient and typical surgical option for treatment. Many complications of CSF ventricular shunting, such as infections, shunt malfunction, subdural hematomas, seizures, migrating catheters, and tube kinking, have been reported. By contrast, intratumoral hemorrhage is an uncommon complication of VP shunt insertion and is almost always reported in the pediatric population.[4],[5],[6] A search for previous articles via MEDLINE and PubMed revealed only a few case reports regarding intratumoral hemorrhage after shunting. The literatures about VP shunts with tumor bleeding are presented in [Table 1].
Table 1: Published case reports of intratumoral bleeding following ventriculoperitoneal shunt insertion in the past 30 years

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ICH after shunt insertion can arise via many mechanisms, including coexistent bleeding disorder, shunt-induced disseminated intravascular coagulation, disruption of an intracerebral vessel by the catheter, hemorrhage into intracerebral tumors, hemorrhage from an occult vascular malformation, and head trauma occurring shortly after shunt placement.[7] Hemorrhage might occur in a variety of cerebral tumors, but the more common primary tumors are medulloblastoma, glioblastoma multiforme, pituitary adenoma, and oligodendroglioma. Of the different metastases, malignant melanomas are the most commonly observed and hemorrhage has been observed in approximately 50% of these cases.[8] However, despite the high incidence of brain melanoma bleeding, no study has indicated bleeding after VP shunting. Elgamal et al., in 2006, reported a case of fatal hemorrhage in a medulloblastoma following ventricular drainage. The mechanism of hemorrhage, in that case, was attributed to the immaturity, fragility, and structural abnormality of the tumor vessels, as well as necrotic changes.[6] Harada et al., in 1993, and Matsumoto et al., in 1997, both reported cases of pineocytoma with intratumoral hemorrhage after VP shunts. The proposed mechanism was a shift of the tumor away from the surrounding structures following the reduction in the volume of the ventricle, and this caused a change in the venous circulation, resulting in a tumor hemorrhage.[5],[9] Waga et al., in 1981, mentioned that ventricular decompression resulted in rapid motion and distortion of the intracranial structures and disrupted the balance between the intracranial and intratumoral pressures, thereby causing vascular insufficiency, congestion, and subsequent intratumoral hemorrhage.[4] Khalatbari et al., in 2014, proposed two passible mechanisms: (1) a rapid reduction in intracranial pressure following VP shunt insertion or increased transmural pressure due to CSF drainage, where the pressure exceeds the strength of the tumor blood vessel wall and causes intratumoral bleeding and (2) the swift decreases in the CSF volume and pressure after VP shunting, which disrupts the balance between the different intracranial compartments, resulting in a rise in the cerebral blood flow and causing vascular congestion, with a subsequent intratumoral hemorrhage.[10]

Taking these mechanisms into consideration, the variables we could control are the opening pressure of the shunt and the flow of the CSF drainage. Setting a higher opening pressure and changing the pressure more slowly should be considered. This goal could be achieved using a programmable valve and an anti-siphon system in these high-risk populations. In our case, multiple massive intratumoral hemorrhages happened even when we set the Medtronic PS valve at its highest pressure, which is 14.5 cm H2O for the fixed-pressure Medtronic PS valve. However, the programmable Medtronic Strata NSC valve has the highest pressure of 21 cmH2O, so perhaps, this programmable valve should be used because of its higher opening pressure. Unfortunately, this valve has the disadvantage of a higher self-pay price (the Medtronic PS valve is covered by health insurance). Nevertheless, based on our experience, the programmable VP shunt valve should be strongly recommended in cases of multiple brain melanoma metastases with previous intratumoral hemorrhage since these metastases have an extremely high bleeding tendency that can cause fatal complications.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Gugger A, Barnhill RL, Seifert B, Dehler S, Moch H, Lugassy C, et al. Cutaneous melanoma with brain metastasis: Report of 193 patients with new observations. PLoS One 2016;11:e0156115.  Back to cited text no. 1
    
2.
Zakrzewski J, Geraghty LN, Rose AE, Christos PJ, Mazumdar M, Polsky D, et al. Clinical variables and primary tumor characteristics predictive of the development of melanoma brain metastases and post-brain metastases survival. Cancer 2011;117:1711-20.  Back to cited text no. 2
    
3.
Zacest AC, Besser M, Stevens G, Thompson JF, McCarthy WH, Culjak G. Surgical management of cerebral metastases from melanoma: Outcome in 147 patients treated at a single institution over two decades. J Neurosurg 2002;96:552-8.  Back to cited text no. 3
    
4.
Waga S, Shimizu T, Shimosaka S, Tochio H. Intratumoral hemorrhage after a ventriculoperitoneal shunting procedure. Neurosurgery 1981;9:249-52.  Back to cited text no. 4
    
5.
Harada K, Hayashi T, Anegawa S, Torigoe R, Maeda K, Toda K, et al. Pineocytoma with intratumoral hemorrhage following ventriculoperitoneal shunt – Case report. Neurol Med Chir (Tokyo) 1993;33:836-8.  Back to cited text no. 5
    
6.
Elgamal EA, Richards PG, Patel UJ. Fatal haemorrhage in medulloblastoma following ventricular drainage. Case report and review of the literature. Pediatr Neurosurg 2006;42:45-8.  Back to cited text no. 6
    
7.
Alcázar L, Alfaro R, Tamarit M, Gómez-Angulo JC, Ortega JM, Aragonés P, et al. Delayed intracerebral hemorrhage after ventriculoperitoneal shunt insertion. Case report and literature review. Neurocirugia (Astur) 2007;18:128-33.  Back to cited text no. 7
    
8.
Yoo H, Jung E, Gwak HS, Shin SH, Lee SH. Surgical outcomes of hemorrhagic metastatic brain tumors. Cancer Res Treat 2011;43:102-7.  Back to cited text no. 8
    
9.
Matsumoto K, Imaoka T, Tomita S, Ohmoto T. Pineocytoma with massive intratumoral hemorrhage after ventriculoperitoneal shunt-case report. Neurologia Medico-Chirurgica 1997;37:911-5.  Back to cited text no. 9
    
10.
Khalatbari MR, Khalatbari S, Moharamzad Y. Fatal intratumoral hemorrhage in tectal plate glioblastoma multiforme following ventriculoperitoneal shunt. Journal of Pediatric Neurosciences 2014;9:192-5.  Back to cited text no. 10
    


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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
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