case_images: PMC10695471_01
case_images: (a) Initial head CT showing a 5.7 cm left frontal hypervascular tumor with significant edema. (b) Pre- and (c) post-contrast T1-weighted MRI showing a 5.8 cm enhancing extra-axial left parafalcine hemorrhagic mass crossing midline. (d) T2-FLAIR MRI shows extensive surrounding vasogenic edema. CT: Computed tomography, MRI: Magnetic resonance imaging, FLAIR: Fluid-attenuated inversion recovery.
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case_images: PMC10695471_01_SNI-14-398-g001.jpg
case_images: F1
case_images: The patient's initial examination was notable for the left gaze preference, global aphasia, and right hemiparesis, with head CT showing a large hypervascular 5.7 cm tumor with surrounding edema [Figure 1a]. Brain magnetic resonance imaging (MRI) revealed a 5.8 cm enhancing left dural parafalcine hemorrhagic mass extending across the midline with significant vasogenic edema [Figures 1b-d].
case_images: Cerebral angiography showing (a) left ACA pseudoaneurysm, and tumor contrast blush with additional supply from the (b) left meningeal branch of the left ophthalmic artery (red arrows) and the (c) right middle meningeal artery (blue arrows). (d) Post-embolization of the ACA pseudoaneurysm. ACA: Anterior cerebral artery.
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case_images: PMC10695471_01_SNI-14-398-g002.jpg
case_images: F2
case_images: A diagnostic cerebral angiogram demonstrated a distal left anterior cerebral artery (ACA) pseudoaneurysm within the hemorrhagic mass, with additional inputs from the left ophthalmic artery and right middle meningeal artery [Figures 2a-c]. The patient underwent successful endovascular embolization of the pseudoaneurysm, which was deemed the source of hemorrhage [Figure 2d].
case_images: Postoperative (a) pre- and (b) post-contrast T1-weighted MRI with no evidence of residual enhancing tumor. MRI: Magnetic resonance imaging.
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case_images: PMC10695471_01_SNI-14-398-g003.jpg
case_images: F3
case_images: Following a discussion with the family, who agreed with said recommendations, the patient underwent an uncomplicated bicoronal frontal craniotomy for falcine tumor resection [Figures 3a and b].
case_images: Prepared slides of the dural-based tumor stained with hematoxylin and eosin showing (a) viable tumor (left) and necrotic tumor (right), (b) cohesive nests of tumor cells with a fair amount of eosinophilic cytoplasm, and (c) atypical tumor cells with brisk mitotic activity, nuclear pleomorphism, and prominent nucleoli. Immunohistochemical examination showing (d) markedly elevated ki-67 index of 25%, supporting the malignant nature of the tumor. (e) The tumor was diffusely positive for epithelial markers (cytokeratin AE1/AE3) and negative for hepatocellular markers (HepPar1, glypican 3), though albumin in situ hybridization was positive in a large subset of tumor cells. These findings in a patient with a history of liver cirrhosis were consistent with metastatic hepatocellular carcinoma.
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case_images: PMC10695471_01_SNI-14-398-g004.jpg
case_images: F4
case_images: Histopathological findings of the dural-based tumor returned following the patient's passing, revealing a poorly differentiated carcinoma with positive epithelial markers and in situ hybridization staining for albumin [Figures 4a-e].