A Case of Recurrent Hemorrhages due to a Chronic Expanding Encapsulated Intracranial Hematoma

Abstract

Few case reports of encapsulated intracranial hematoma (EIH) exist, and the mechanisms underlying the onset and enlargement of EIH remain unclear. Here, we report on a 39-year-old woman with an EIH that repeatedly hemorrhaged and swelled and was ultimately surgically removed. In June 2012, the patient visited her local doctor, complaining of headaches. A magnetic resonance imaging (MRI) scan identified a small hemorrhage of approximately 7 mm in her right basal ganglia, and a wait-and-see approach was adopted. Six months later, her headaches recurred. She was admitted to our department after MRI showed tumor lesions accompanying the intermittent hemorrhaging in the right basal ganglia. After admission, hemorrhaging was again observed, with symptoms progressing to left-sided hemiplegia and fluctuating consciousness; thus, a craniotomy was performed. No obvious abnormal blood vessels were observed on the preoperative cerebral angiography. We accessed the lesion using a transcortical approach via a right frontotemporal craniotomy and removed the subacute hematoma by extracting the encapsulated tumor as a single mass. Subsequent pathological examinations showed that the hematoma exhibited abnormal internal vascularization and was covered with a capsule formed from growing capillaries and accumulating collagen fibers, suggesting that it was an EIH. No lingering neurological symptoms were noted upon postoperative follow-up. This type of hematoma expands slowly and is asymptomatic, with reported cases consisting of patients that already have neurological deficits due to progressive hematoma growth. Our report is one of a few to provide a clinical picture of the initial stages that occur prior to hematoma encapsulation.

Encapsulated Intracerebral Hematoma Presenting as Cerebral Abscess

“…CEIH remains rare, and due to its variable radiographic appearance, may be mistaken for a tumor or a brain lesion [1][2][3][4][5][6][7][8][9][10][11]. Recent case reports have shown CEIH occurrences as a late complication of AVM radiosurgery, with 37 cases described as of 2020 [5,10].…”

“…Chronic encapsulated intracerebral hematoma (CEIH) is difficult to diagnose because of its tendency to mimic other brain lesions [1][2][3][4]. Patients may develop CEIH after spontaneous intracerebral hemorrhage (ICH), and in more recent years, CEIH has been reported after radiosurgery for arteriovenous malformations (AVMs) [4][5][6][7][8][9][10][11].…”

Imaging Diagnosis of Chronic Encapsulated Intracerebral Hematoma, a Comparison of Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) characteristics

“…Cerebral hemorrhage in CEICH is a slow and continuous process that is characterized by small amounts of bleeding in the initial stage [ 1 ]. Early symptoms are relatively mild and are often not noticed or misdiagnosed due to the lack of initial CT or MRI data.…”

“…Chronic encapsulated intracerebral hematoma (CEICH) is a rare type of intra-cerebral hematoma. The main clinical symptoms of CEICH include a chronic, progressive development and progressive intracranial hypertension in most cases [ 1 ]. Brain imaging shows lesions of chronic scalability because of a slow clinical course and atypical clinical and imaging findings.…”

Chronic encapsulated intraventricular hematoma in a pediatric patient: case report

“…21,28 The friable vasculature of the hematoma capsule wall can rehemorrhage, further adding to the volume of the hematoma core. 4,[15][16][17]24 It is important to note that the fibroblastic capsule is critical to the definition of CEIH and CEIVH, and in the absence of this capsule a lesion is not considered as such. 20 It has been postulated that one-half of all CEIHs first form due to a vascular malformation or microaneurysm.…”