PMC3385075_01
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
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This was confirmed on a computed tomography (CT) scan [Figure 1a]. Four weeks later, he had worsening confusion and a repeat CT scan [Figure 1b] showed that the left-sided chronic subdural hematoma was now larger and causing significant mass effect and midline shift. Postoperative CT [Figure 1c] showed satisfactory evacuation of the subdural hematoma and resolution of the midline shift. Repeat CT [Figure 1d] showed that there was a significant recurrent left-sided chronic subdural hematoma with mass effect and midline shift. A review of the original MRI [Figure 1e] performed at his local hospital showed that despite the initial report, there was infact, evidence of dural enhancement suggestive of dural metastases.
Histology slides. (a) Low-power (x10 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 (x10). (c) Higher magnification (x40) 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 (x40). (e) There is intense immunoreactivity for prostate-specific acid phosphatase (PSAP, x40). (f) In contrast, no staining is seen for cytokeratin 7 (x40)
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The pathology [Figure 2] report showed that he had dural metastases and malignant cells in the subdural fluid.