Abstract | November 17, 2023
Repeated Intracranial Hemorrhage as a Presenting Feature of Metastatic Melanoma
Learning Objectives
- Upon completion of this lecture, learners should be better prepared to remain cognizant of the diverse presentations of melanoma, extending beyond typical cutaneous manifestations. Melanoma is ranked as the fifth most prevalent cancer in the United States and one of the most frequent cancers to metastasize to the brain, potentially leading to multiple episodes of brain hemorrhage. This case report describes a patient without a history of melanoma who presented with increased confusion caused by recurrent brain hemorrhages, ultimately identified as a manifestation of metastatic melanoma.
- Upon completion of this lecture, learners should be better prepared to examine patients cautiously when faced with multiple instances of brain hemorrhage, particularly if they repeatedly occur at the same site, as this may signify an underlying malignancy, such as metastatic melanoma. Intracranial hemorrhage typically associates with stroke or vascular anomalies. Nevertheless, physicians should be able to consider alternative diagnoses when encountering atypical bleeding patterns, as illustrated in this case.
Introduction:
Melanoma is the third most common skin malignancy. It is also well known for its high propensity to metastasize to the brain; when it does, it can cause intracerebral hemorrhage. This case report describes a patient without a history of melanoma who exhibited repeated occurrences of intracranial hemorrhage in the same area as the primary presentation of metastatic melanoma.
Case presentation:
A 75-year-old male, with a documented history of intracerebral hemorrhagic stroke at the left parieto-occipital junction presumably from repetitive falls one month prior to this admission, presented to the emergency department due to a progressive decline in mental status. The patient denied experiencing fever, headache, neck stiffness, or trauma. Upon initial evaluation, his vital signs were normal, and laboratory results yielded unremarkable results. Physical examinations revealed confusion and agitation, but no obvious neurological impairments were observed.
Several differential diagnoses were taken into consideration, including the possibility of recurrent stroke. A CT brain revealed a minor increase in the size of the prior left parieto-occipital junction hemorrhage, accompanied by surrounding edema. Subsequent brain MRI showed no evidence of restricted diffusion concerning for ischemia. However, it revealed a uniformly enhanced 1.7 x 1.6 cm mass in the left occipital lobe, associated with hemorrhage.
Based on these imaging findings, an emerging possibility of hemorrhagic metastasis was identified, while the likelihood of an atypical cavernous hemangioma was observed but considered to be lower. As a result, a metastatic workup was initiated.
Final diagnosis:
A CT of the chest identified a 20.4 x 17 mm nodule in the left upper pulmonary lobe. Subsequent abdominal/pelvic CT showed multiple enhancing masses in the left retroperitoneum and a right adrenal mass. A needle biopsy of the retroperitoneal mass was done and confirmed metastatic melanoma. Further molecular studies detected BRAF G466E mutation.
Management and Follow-up:
The patient was referred to the departments of hematology/oncology and radiation oncology for further treatment planning. Palliative whole-brain radiation therapy was initiated during the hospitalization. Subsequently, the patient was discharged to the rehabilitation facility for optimized care. Systemic immunotherapy was scheduled as an outpatient.
References and Resources
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- Wang, J., Guo, Z. Z., Wang, Y. J., Zhang, S. G., Xing, D. G. (2014). Microsurgery for the Treatment of Primary Malignant Intracranial Melanoma: A Surgical Series and Literature Review. Eur J Surg Oncol, 9, 1062-1071.
