Metastatic coagulopathic subdural hematoma: A dismal prognosis

Abstract

Background: Dural metastases have been found in about 8-9% of patients who died of cancer, in most autopsy series. Dural metastases presenting with chronic subdural hematoma are rare, with only about 55 cases reported in the literature.

Case description: We discuss the case of a 72 year old gentleman with prostate cancer who presented with a chronic subdural hematoma which was drained surgically. He was found to have disseminated intravascular coagulation (DIC) and recurrence of the subdural hematoma for which further drainage was required. After the second drainage of the chronic subdural hematoma, dural metastases were diagnosed from the pathology specimens.

Conclusion: On reviewing the literature, 25 cases of dural metastases with chronic subdural hematoma and coagulopathy were found. These cases were characterized by the fact that they had a very poor clinical outcome in spite of surgical drainage. This combination could be a distinct entity and its recognition is important to guide management of this rare condition.

Keywords: Coagulopathy; disseminated intravascular coagulation; dural metastases; subdural hematoma.

Figure 1

CT and MRI images. (a) Initial CT with a small left-sided chronic subdural hematoma. (b) CT prior to the first surgery which shows the subdural hematoma has expanded. (c) CT after the first surgery with good evacuation of the subdural hematoma. (d) CT prior to the second surgery where the subdural hematoma has recollected. (e) MRI. This was initially reported as showing only a small left-sided subdural hematoma and ruled out any intracranial metastases. However, on closer inspection, the dural enhancement is evident, especially on the right side. On the left side, the subdural hematoma is masking this

Figure 2

Histology slides. (a) Low-power (×10 magnification) view shows typical subdural hematoma with ectatic blood vessels, mixed inflammation, and fibroblasts. (b) In addition, there is a widely infiltrating carcinoma that grows in nodules (×10). (c) Higher magnification (×40) shows pleomorphic, often round nuclei with prominent single nucleoli and brisk mitotic activity. (d) Immunohistochemistry for prostate-specific antigen (PSA) shows mild positivity in the carcinoma but not anywhere else (×40). (e) There is intense immunoreactivity for prostate-specific acid phosphatase (PSAP, ×40). (f) In contrast, no staining is seen for cytokeratin 7 (×40)