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Management of patients suffering from hemorrhagic intracranial metastases: Propositions to help the neurosurgeon in emergencies situations based on a literature review - 21/11/20

Doi : 10.1016/j.neuchi.2020.11.005 
S. Boissonneau, MD MSc 1, 2, , T. Graillon 1, 3, A. Rolland 4, C. Botella 5, J. Pallud 5, 6, H. Dufour 1, 3
1 Aix-Marseille Université, APHM, CHU Timone, Department of Neurosurgery, Marseille, France 
2 Inserm, INS, Institute of Neurosciences of Systems, Aix Marseille Univ, Marseille, France 
3 Aix-Marseille Université, INSERM, MMG, Marseille, France 
4 Department of Neurosurgery, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France 
5 Department of Neurosurgery, Centre Hospitalier Saint Anne, Paris, France 
6 UMR 1266 INSERM, IMA-BRAIN, Institute of Psychiatry and Neurosciences of Paris, Paris, France 

Corresponding author: Neurosurgery Department – Pr Dufour, La Timone– Assistance Publique Hôpitaux de Marseille, 264 Rue Saint-Pierre, 13385 Marseille, FranceNeurosurgery Department – Pr Dufour, La Timone– Assistance Publique Hôpitaux de Marseille264 Rue Saint-PierreMarseille13385France
Sous presse. Manuscrit accepté. Disponible en ligne depuis le Saturday 21 November 2020

Abstract

Introduction: Brain metastases are the most common intracranial neoplasm in adult patients, and one of the fearsome complications proves to be intratumoral hemorrhage. The neurosurgical management of patients harboring a bleeding brain metastasis is not fully established and there is still today an ongoing debate on the optimal management of these patients. The aim of this article is to provide the neurosurgeons with practical tools to assist in their decision-making process in the management of BMs.

Methods: We conducted a literature review of the relevant Pubmed, Cochrane, and Google scholar-indexed articles published between 2000 and 2019. The following keywords were entered in the Pubmed search engine: [metastasis], [metastases], [brain metastases], [brain metastasis], [hemorrhage], [hematoma], [blood clot], [intracerebral hemorrhage], [intracranial hemorrhage]. The review was performed in accordance with the PRISMA recommendations.

Results: Based on PubMed, Cochrane, and Google scholar, 459 articles were retained, 392 were then removed because of their non-adequacy with the topic and, 9 articles were removed because they were not written in English language. So, 58 articles were analyzed. Radiological evaluation is crucial, but few traps exist. The frequency of overall brain tumor-related with intracranial hematoma is 7.2%, with a higher frequency for secondary tumors.

The local recurrence rate after resection of a hemorrhagic metastasis seems to be better probably because of an easier “en bloc” resection thanks to the hematoma.

An atypical presentation is reported in up to 4% in patients with chronic or acute subdural hematoma. Patients with subarachnoid hemorrhage and epidural hematoma are rare.

A clear-cut correlation between the incidence of bleeding event in brain mets and prior stereotactic radiosurgery was not established

Conclusion: The current literature pertaining to the neurosurgical management of acute bleeding in brain metastasis is scant and the level of evidence remains low (experts ‘opinions; class C). Herein we suggest a flowchart to assist in dealing with those difficult patients.

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© 2020  Publié par Elsevier Masson SAS.
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