Low-grade gliomas presenting with hemorrhage: Are intratumoral blood products associated with malignant transformation?

Objective

Gliomas are the most common primary tumor in the central nervous system (CNS), with low-grade gliomas (LGG) comprising more than 5 percent of all adult primary CNS tumors. While glioblastoma, the most malignant glioma subtype, is known to present with hemorrhage, LGGs rarely present with hemorrhage. This systematic review investigates LGGs that present as hemorrhage and provides an illustrative case presentation in order to evaluate trends and outcomes for this pathology.

Methods

A systematic review of the literature was performed to evaluate presentation, treatment, and outcomes for patients with LGG that present as intracranial hemorrhage. Articles included were case series describing surgical approach; literature reviews were excluded. Variables evaluated included presenting symptoms, imaging results, and postoperative outcomes.

Results

The initial screen yielded 1373 articles. Fourteen articles, published between 1977 and 2023, met inclusion criteria. Sixteen (16) patients were identified with LGG that presented initially as hemorrhage. The most common tumors were pilocytic astrocytoma (6/16), subependymoma (4/16), and ependymoma (2/16). The most common presenting symptoms were headaches (9/11) and impaired consciousness (9/11). Eleven patients underwent gross total resection of the tumor, while four patients received partial resection. Outcomes included two mortalities and one recurrence after six months; the thirteen remaining patients had no recurrence at final reported follow-up.

Conclusion

LGGs presenting with hemorrhage are associated with more severe initial symptoms. Though very uncommon, it is imperative to recognize the possibility of an underlying low-grade neoplasm in the setting of hemorrhage. Such early identification can lead to expeditious surgical intervention which can alleviate symptoms, lead to diagnosis, and ultimately trigger adjuvant treatment that has the potential to prolong survival. Continued research on the underlying pathophysiology of these hemorrhagic low-grade tumors is needed to further stratify risk in these populations.