Tectal Plate Glioma Presenting With Intratumoral Hemorrhage

Abstract

Tectal gliomas are rare brainstem tumors. These tumors typically cause obstructive hydrocephalus due to mass effect on the cerebral aqueduct; however, intratumoral hemorrhage is exceedingly rare, with only one previously documented case to our knowledge. Patients typically present with symptoms of hydrocephalus, including headaches, nausea, and visual disturbances. We report the case of a 43-year-old man with a known tectal plate glioma who presented with acute obstructive hydrocephalus secondary to intratumoral hemorrhage. Following the patient's rapid neurological decline, computed tomography (CT) and magnetic resonance imaging (MRI) confirmed the diagnosis. The patient underwent an endoscopic third ventriculocisternostomy (ETV) for cerebrospinal fluid diversion, along with an endoscopic biopsy of the tectal mass. The patient's postoperative course was favorable, with gradual resolution of symptoms, including diplopia and headaches. A follow-up MRI revealed reduced tumor size and stable ventriculomegaly. Histopathological analysis suggested the tumor to be of glial origin and low-grade in nature, based on its contrast enhancement on MRI and the patient's clinical trajectory. This case illustrates a rare presentation of intratumoral hemorrhage in tectal gliomas, emphasizing the need for heightened clinical suspicion in such cases. ETV remains an effective treatment for obstructive hydrocephalus, though the potential for hemorrhagic complications warrants close monitoring.

Keywords: case report; intracranial hemorrhage; midbrain tumor; midbrain tumor hemorrhage; tectal glioma.

Figure 1. (A) Axial T2-weighted MRI of the brain with FLAIR at initial presentation to the neurosurgical oncology clinic. (B) Sagittal T1-weighted MRI of the brain post-contrast. Sagittal T1-weighted and axial T2-weighted FLAIR MRI reveal a T2 hyperintense lesion centered in the midbrain tectum with extension into the right thalamus, producing a mild mass effect on the third ventricle and compressing the aqueduct of Sylvius, leading to mild hydrocephalus. There is no abnormal restricted diffusion, midline shift, intracranial hemorrhage, or extra-axial collection. Major arteries in the circle of Willis show normal flow voids, and no significant abnormalities are noted in the pituitary gland, orbits, or paranasal sinuses. This lesion likely represents a glioma, and further evaluation with contrast-enhanced imaging is advised for better characterization.

FLAIR: fluid-attenuated inversion recovery.

Figure 2. (A) Sagittal non-contrast CT head at ED presentation for decreased level of consciousness. (B) Axial non-contrast CT head at ED presentation for decreased level of consciousness. Acute intracranial hemorrhage appears centered in the tectum, measuring up to 2.1 × 1.6 × 1.7 cm, extending into the third ventricle and dependent on bilateral lateral ventricles. A right frontal approach ventricular catheter terminating in the midline frontal horn of the right lateral ventricle is seen. Mild diffuse ventriculomegaly is compatible with hydrocephalus. Effacement of convexity sulci may reflect diffuse cerebral edema.

ED: emergency department.

Figure 3. T1-weighted MRI of the brain with FLAIR showing an evolving hemorrhage at the midbrain/tectum, measuring approximately 1.9 × 1.5 × 2.2 cm (axial × sagittal × craniocaudal), and in the lateral and third ventricles, with corresponding T1 hyperintensity. Interval increase in patchy foci of restricted diffusion with FLAIR hyperintensity at the bilateral frontal vertices suggests possible small thromboembolic infarctions. A stable right frontal ventriculostomy catheter is present.

FLAIR: fluid-attenuated inversion recovery.

Figure 4. (A) Sagittal T2-weighted MRI of the brain with FLAIR 1.5 years post-ETV. (B) Sagittal MRI of the brain with 3D FIESTA, 1.5 years post-ETV. A stable T1 hypointense, T2 hyperintense, and heterogeneous hemorrhagic lesion is present in the tectum with associated FLAIR hyperintensity in the bilateral thalami, more prominent on the right, where a 0.9 × 0.9 × 0.7 cm lesion shows susceptibility consistent with chronic blood products. There is no CSF flow through the cerebral aqueduct; however, a patent third ventriculostomy demonstrates expected CSF flow dynamics. A mild interval increase in lateral and third ventricular size is noted, with no evidence of acute hemorrhage.

CSF: cerebrospinal fluid, ETV: endoscopic third ventriculostomy, FLAIR: fluid-attenuated inversion recovery, FIESTA: fast imaging employing steady-state acquisition, MRI: magnetic resonance imaging.