Abstract
BACKGROUND
Metastatic cerebral aneurysms are an extremely rare complication of cancer. We present a case of an intracerebral hemorrhage (ICH) secondary to a neoplastic aneurysm as the initial manifestation of lung cancer. CASE REPORT: A 63-year-old man presented with acute aphasia and was found to have a left parieto-temporal ICH on brain imaging. Angiography demonstrated a fusiform dilation of the distal left middle cerebral artery suspicious for a mycotic aneurysm. Patient underwent hematoma evacuation and aneurysmal clipping; pathology showed intravascular atypical cells determined by immunohistochemistry to be an embolus from a primary lung cancer. Chest imaging revealed a previously undiagnosed lung nodule with hilar adenopathies. Needle biopsy of one of the lymph nodes demonstrated neoplastic cells identical to those visualized in the aneurysm, with final pathology consistent with poorly differentiated lung adenocarcinoma (EGFR, ALK and KRAS negative). Patient subsequently received Gamma Knife radiosurgery to the surgical bed, followed by carboplatin, pemetrexed and pembrolizumab for treatment of his systemic disease.
DISCUSSION
Tumoral intracerebral aneurysms are rare, with about 100 cases published in the literature, the majority of them arising from cardiac myxoma or choriocarcinoma. Only six cases of neoplastic cerebral aneurysms from metastatic lung cancer have been reported, all presenting as ICH. Four of them died as a result of the hemorrhage, and the remaining two had complications that precluded the administration of further therapy, making ours the first case to receive cancer-directed treatment aimed at the aneurysmal metastatic lesion.
CONCLUSION
Neoplastic cerebral aneurysms are rare, but should be considered in patients with malignancy presenting with a pattern of ICH suspicious for aneurysmal origin. There are no guidelines regarding the treatment of these uncommon aneurysms, but based on our case, we suggest approaching them as any other cerebral metastasis, with complete resection whenever possible, followed by stereotactic radiosurgery.