Cerebral astrocytoma and cavernous angioma: A case report

British Journal of Neurosurgery (1994) 8, 607-6 10

SHORT REPORT

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Cerebral astrocytoma and cavernous angioma: a case report NICOLA ACCIARRI, ROBERTO PADOVANI, MARC0 GIULIONI & FEDERICO RONCAROLI' Department of Neurosurgey and 'Service of Pathology, Bellaria Hospital, Bologna, Italy

Abstract The authors report a case of cerebral astrocytoma associated with a cavernous angioma. The patient presented with seizures and progressive hemiparesis. Diagnostic studies suggested the presence of a cavernous malformation with signs of previous haemorrhage. Surgery disclosed a complex tumour, which on histological examination revealed to be an anaplastic astrocytoma associated with a cavernous angioma. Key words: Astrocytoma, brain neoplasm, cavernous angioma, computed tomography, magneric resonance imaging.

Introduction Co-existence of primary brain neoplasm and vascular malformation is an infrequent occurrence.'-13 The association of a cerebral glioma with a cavernous angioma is even more rare, only three cases having so far been reported in the literature. We report an additional such case, initially diagnosed and approached as a cavernous angioma, which at surgery proved to be an anaplastic astrocytoma co-existent with a cavernous malformation. The diagnostic difficulties and the possible aetiology of this unusual condition are discussed. 134~12

Case report

A 25-year-old woman had complained of two attacks of partial motor seizures, together with weakness of the leg and visual field disturbances on the right side. Cranial C T showed a deep-seated, left parietal lesion, with signs of a

previous haemorrhage (Fig. 1). Intravenous contrast medium did not alter the image. On examination the patient was found to have a right hemiparesis and a right homonymous hemianopia. Magnetic resonance imaging (MRI) confirmed a well defined, left parietal lesion, showing features consistent with a Cavernous angioma (Fig. 2). Angiography showed no vascular anomalies in the lesion. A left parietal craniotomy was performed and the deepseated lesion was exposed. It appeared as a greyish infiltrating tumour, without defined limits, resembling a typical glial neoplasm. Nevertheless, a vascular component resembling a cavernous angioma was present within the growth. As much infiltrating tumour as possible was removed, together with the whole vascular glomus. Histological examination revealed the tumour to be composed of two distinct parts: one showing true neoplastic features, made up of foci of astrocytic prolifera-

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FIG.1. Cerebral CT scan, showing a left parietal mass, with signs of previous haemorrhage.

FIG.2. Cerebral T2-weighted MRI shows a left parietal

tion, with increased pleomorphism and mitotic division, without necrosis (Fig. 3); another part having the characteristics of a vascular malformation, with clustered, thinwalled cavernous spaces of varying size, surrounded by reactive gliosis and haemosiderin-laden phagocytes (Fig. 4). A diagnosis of anaplastic astrocytoma associated with cavernous angioma was made. The postoperative course was uneventful. Radiation therapy was delivered, with a total dose of 3500 rad. Six months after surgery, the patient showed an improvement of the initial neurological deficit.

existent, but separate 1esions,3~5-8~10-12 contralateral in two cases,10-12and ipsilateral in the other six cases (Table I).395-8,11 The most unusual situation is that of combined, or contiguous, lesions (Table 1),1,2,419~'3 especially when these consist of a cerebral glioma and a cavernous a n g i ~ m a , ' >as~ in our patient. The development of a glial tumour at the same site as a vascular malformation has been reported in three other cases, described by

lesion, with typical features of a cavernous angioma.

Discussion

Cases of primary intra-axial brain tumour associated with a vascular malformation are rare, and a review of the literature dealing with this unusual condition disclosed only 13 previously reported cases.l-13The spectrum of neoplasms includes gliomas most often, while an arteriovenous malformation (AVM) is the most common among the tumour-associated a m ~ ~ ~ a l(Table i e s 1). Among these 13 reported cases, the majority (eight patients) had co-

FIG.3. Histological specimen of tumour, showing astrocytic cells with anaplastic features. Some vascular spaces are evident (H&E, X 59).

Cerebral glioma and cavernous angioma

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TABLE I. Simultaneously occurring primary brain turnours and vascular malformations (A) Separate, contralateral: White et al.

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Warren”

(B) Separate, ipsilateral: Fine et ab3 Welcher & Seidel” Hefher et al.’ Ho & Wolfe6 Licata etal.’ Martinez-Lage et al. (C) Combined or contiguous Raynor & ~ i n g m a n ’ Crowell et al. Zuccarello et a/. l3 Fischer et aL4 Chee et al.

Astrocytorna of the septum pellucidumleft temporal cavernous angioma Right temporal globlastoma-left cerebral AVM Right intraventricular oligodendroglioma-parietal AVM Astrocytoma and AVM in the same hemisphere Right frontal astrocytomadural AVM Left cingulate astrocytoma-thalamic AVM Left temporal glioma-occipital AVM Intraventricular oligodendroglioma-parietal AVM (collision tumours): Posterior fossa hemangioblastoma with vascular malformation Right temporal oligodendroglioma with AVM Left temporal malignant astrocytoma with AVM Frontal glial neoplasm with cavernous angioma Frontal oligodendroglioma-cavernous angioma

A quite different condition is that of abnorFischer et a1.: Licata et a1.I and Goodkin et al.14As these found the subsequent, and not mal proliferation of oligodendrocytes induced the contemporary, development of the tu- from chronic ischaemia in cerebral tissue mours at the site of a previously diagnosed within a true AVM, as reported by Nazek et vascular malformations, we have not included a1.I5 in three cases. Another group of vascular glial lesions is these three cases in the group under discussion of simultaneously occurring brain neoplasms that of the so-called “angiogliomas”, most of which are low-grade lesions.I6 Although these and vascular anomalies.

FIG.4. Vascular spaces, filled with thrombi, of the tumour-associated cavernous angioma (H&E,

X

87).

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ebral angioma and an intraventricular oligodenlesions are highly vascular tumours, their clinidroglioma. Scott Med J 1960; 5:342-346. copathological features, as well as the progFischer EG, Sotrel A, Welch K. Cerebral hemannosis, appear to be no different from those of gioma with glial neoplasia (angioglioma?). Report of two cases. J Neurosurg 1982; 56:430-4. similar gliomas without angioma-like vasculaHeffner RR, Porro RS, Deck MDF. Benign astroture.I6 cytoma associated with arteriovenous malformaFrom the radiological standpoint, the diagtion. Case report. J Neurosurg 1971; 35:229-33. 6 Ho KL, Wolfe DE. Concurrence of multiple scleronosis of gliomas associated with vascular malsis and primary intracranial neoplasms. Cancer formations may pose problems. On the CT 1981; 47~2913-19. scan, the vascular changes of a tumour can 7 Licata C, Pasqualin A, Freschini A, et al. Management of associated primary cerebral neoplasms and overlap with those of a vascular malformation, vascular malformations. 2. Intracranial arterio-vecausing diagnostic confusion. The neoplasm nous malformations. Acta Neurochir (Wien) 1986; may be overlooked on MRI, or may be angio83~38-46. 8 Martinez-Lage JF, Poza M, Esteban JA, et al. Subgraphically occult, if co-existent with cavernarachnoid hemorrhage in the presence of a cerebral ous angi~ma.’~~,’’-’~ AVM-associated tumours arteriovenous malformation and an introventricular are usually apparent on a n g i ~ g r a p h y . ~ ~ ~ - ” ~ ’ ~oligodendroglioma: case report. Neurosurgery 1986; 191125-8. There are various possible aetiologies of the 9 Raynor RB, Kingman AF Jr. Hemangioblastoma association of glial tumours and vascular maland vascular malformation as one lesion. Arch formations within the same patient. Fine et al. Neurol 1965; 12: 3 9 4 8 . and Martinez-Lage et aL8 suggested a fortu- 10 Warren GC. Intracranial arteriovenous malformation, pulmonary arteriovenous fistula, and maligitous association. A genetic predisposition was nant glioma in the same patienr. Case report. J proposed by White et al. while the possibility Neurosurg 1969; 30:618-21. of a common viral cause for both glioma and 11 Welcher ER, Seidel K. Kombination eines Angioma arteriovenosum aneurysmaticum mit einem vascular malformation has been discussed by Astrocytom. Dtsch Z Nervenheilk 1966; 189:231Fischer et aL4 9. Wood MW. A study of In conclusion, brain glioma associated with 12 White RJ, Kernohan JW, fifty intracranial vascular tumors found incidentally vascular malformation, particularly cavernous at necropsy. J Neuropathol Exp Neurol 1958; 17:392-8. angioma, is an uncommon occurrence, that may have no specific clinico-diagnostic 13 Zuccarello M, Giordano R, Scanarini M, et al. Malignant astrocytoma associated with arterifindings, presenting only features of one of ovenous malformation. Case report. Acta Neurochir (Wien) 1979; 17:392-8. coexistent lesions. This rare condition must not be confused with glial proliferative reac- 14 Goodkin R, Zaias B, Michelsen WJ. Arteriovenous malformation and glioma: coexistent or sequential? tion inside AVMs,” or with the relatively comJ Neurosurg 1990; 72:798-805. 15 Nazek M, Mandybur TI, Kashiwagi S. Oligodenmon angiogliomas.I6

Address for correspondence: Dr Nicola Acciarri, Department of Neurosurgery, Bellaria Hospital, Via Altura 3, Bologna 40139, Italy.

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