Neurosurgery Department, University General Hospital of Alicante, Foundation for the Promotion of Health and Biomedical Research in the Valencian Region (FISABIO), Alicante, Spain

Highly-vascularized, primary malignant brain tumors (BTs), including glioblastoma, oligodendroglioma and metastatic BT, tend to bleed spontaneously and should always be included in the differential diagnosis of non traumatic intracerebral hemorrhage 1).

Clinical and autopsy studies have identified that brain tumors represent 0.9–11% of spontaneous ICH 2) 3) 4) 5) 6) 7) 8) 9) 10) 11).

Up to 10% of patients with BTs may experience a diagnostic delay if CT is the only imaging modality that is used 12).

Dual-energy CT may be useful in detecting underlying tumors in patients with an ICH of unknown origin, and is a useful tool in differentiating between tumor bleeding and pure ICH in patients with acute ICH of an unclear origin 13).

Using MRI with gadolinium early in the post-operative period is likely to lead to an earlier detection of the BT. A previous study showed that the use of MR angiography (MRA) aided the disclosure of the development of an intratumoral aneurysm on a dilated feeding artery, the rupture of which led to intratumoral bleeding 14).

The standard treatment of a BT manifesting as an ICH is the surgical removal of the hematoma and the tumor 15) 16).

However, the optimal timing of the therapeutic intervention is poorly defined, particularly when the neurological status of the patient is stable following admission and there is only a minimal or no mass effect on the CT scan 17)

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Kim SJ, Lim HK, Lee HY, Choi CG, Lee DH, Suh DC, Kim SM, Kim JK, Krauss B. Dual-energy CT in the evaluation of intracerebral hemorrhage of unknown origin: differentiation between tumor bleeding and pure hemorrhage. AJNR Am J Neuroradiol. 2012;33:865–872.
Hashiguchi A, Morioka M, Ichimura H, Mimata C, Kuratsu J. Glioblastoma with an intratumoral feeding-artery aneurysm. Clin Neurol Neurosurg. 2007;109:302–304.
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Inamasu J, Nakamura Y, Saito R, Kuroshima Y, Mayanagi K, Ichikizaki K. Rebleeding from a primary brain tumor manifesting as intracerebral hemorrhage (CNN 04/077, revised version) Clin Neurol Neurosurg. 2005;108:105–108.
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