A case of glioblastoma associated with dissemination, secondary to intratumoral hemorrhage

The occasional occurrence of dissemination and tumor-associated hemorrhage from glioblastoma is well known and widely reported in the literature. The authors present a case of cerebral glioblastoma with dissemination possibly caused by intratumoral hemorrhage. Computed tomographic (CT) scan revealed a small hemorrhagic lesion in the right frontal lobe and a sylvian fissure in a 62-year-old man who complained of sudden headache. Four months later, he again presented with neck pain followed by weakness and numbness in the extremities. Magnetic resonance images (MRI) of the cervical spine demonstrated multiple enhanced tumors. After transfer to our institution, a large cystic tumor with ring-like enhancement was found in the right frontal lobe. Progressive neurological deficits prompted an operation on the cervical tumors and a pathological diagnosis of anaplastic astrocytoma with a negative reaction for glial fibrillary acidic protein (GFAP) was made. Intraoperative findings of the second operation for the cerebral tumor disclosed that the tumor extended outside the frontal lobe, growing substantially within the sylvian subarachnoid space and involving middle cerebral artery branches. The results of a pathological study were those consistent with glioblastoma having tumor cells with little positive reaction to GFAP staining. Craniospinal radiation was undertaken as a palliative treatment of the residual tumor. On MRI, multiple nodular dissemination in the lumbo-sacral region was diagnosed. Two months later, the patient suddenly lost consciousness and suffered eye deviation. A CT scan found a large tumor-associated hemorrhage in the right frontal lobe. Emergency evacuation of the hematoma with gross total removal of the residual tumor was performed. He temporarily returned to his preoperative neurological condition but died later due to the recurrent cervical tumor. Dissemination secondary to intratumoral hemorrhage in patients with glioblastoma has not been reported. This rare case shows that hemorrhagic glioblastoma is at risk for dissemination, especially when the hemorrhage occurs in or near the subarachnoid space and tumor cells have a less positive reaction for GFAP staining.