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Surgical treatment of brain tumor coexisted with intracranial aneurysm—case series and review of the literature

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Abstract

Coexistence of brain tumor and intracranial aneurysm was previously considered as an uncommon phenomenon. Actually it is not rare in neurosurgical procedures, and its incidence rate may be underestimated. Furthermore, there remains a lack of consensus regarding numerous aspects of its clinical management. We performed a retrospective study of 12 cases of coexistent brain tumor and intracranial aneurysm in our database. Then a systematic PubMed search of English-language literature published between 1970 and 2012 was carried out using the keywords: “brain tumor” and “intracranial aneurysm” in combination with “associate” or “coexist.” A consensus panel of neurosurgeons, anesthetists, interventional neurologists, and intensivests reviewed this information and proposed a treatment strategy. In the majority of patients, clinical symptoms were caused by tumor growth, whereas aneurysm rupture was seen only in a few cases. Meningioma was the commonest tumor associated with aneurysm. In most patients, both lesions occurred within the adjacent area. Treatment of both pathologies in one session was performed in most patients. All of our patients were alive within the period of follow-up. Coexistence of brain tumor and intracranial aneurysm may be a coincidence. The treatment strategy should be designed according to the conditions of tumor and aneurysm, locations of both lesions, and pathologic nature of tumor.

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Acknowledgments

This research was supported by a grant from the National Natural Science Foundation of China (81270856) and grants of Shanghai Committee of Science and Technology: 10JC1410700, 10411954200, and 12JC1406201.

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The author reports no conflict of interest.

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  1. Department of Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, 197, Rui Jin Er Road, Shanghai, 200025, China

    Zhihong Zhong, Yuhao Sun, Dong Lin, Qingfang Sun & Liuguan Bian

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  1. Zhihong Zhong
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Comments

Yavor Enchev, Varna, Bulgaria

Zhong et al. presented a relatively numerous series of 12 cases with coexistence of brain tumours and intracranial aneurysms and an extensive review of the literature. On this basis, they try to define evidence-based suggestions for the clinical management of such complicated patients.

The keywords-based PubMed literature search found out altogether of 54 comprehensive studies (out of initial result of 262 papers, not fulfilling the prefixed inclusion criteria) comprising 108 patients with the coexistence of brain tumours and intracranial aneurysms. Interestingly, all the studies were retrospective. The patients in these series were analyzed in the same way as the cases in the authors’ study. A multidisciplinary team of four neurosurgeons, two interventional neurologists, anesthetist, and intensivist, analyzed the presented series and the relevant literature in attempt to achieve consensus for the optimal treatment strategy as well as for the best risk of complications management.

In most of the cases, clinical symptoms were due to tumour evolution, whereas aneurysm bleeding was documented rarely. Meningiomas were the commonest tumours coexisted with intracranial aneurysm, followed by pituitary adenomas, neuroepithelial tumours and metastases. Most frequently both lesions were adjacently located. Significant sex discrepancy was found out as the coexistence of meningiomas, and intracranial aneurysms was four times more frequent in females than in males in contrast to the incidence rate of neuroepithelial tumors coexisted with aneurysms which was twice higher in males than in females. In the majority of patients with the coexistence of brain tumours and intracranial aneurysms, the lesions were solitary.

According to the literature, the incidence of coexistence of brain tumours and intracranial aneurysms is about 0.7–5.4 % and in no way is negligible. The intraoperative or postoperative rupture of a non-diagnosed aneurysm could be devastating. Thus, the authors suggest that cerebral angiography should be performed preoperatively in patients with brain tumours as far as possible not only to demonstrate neoplastic vascularization but also to verify any eventual incidental aneurysm.

Up to date, despite of the numerous existing hypotheses, no any proof exists to confirm the eventual casual relationship for the coexistence of brain tumours and intracranial aneurysms. Zhong et al. summarized that this coexistence could be even only an ordinary coincidence.

One stage treatment of both pathologies was undergone in most patients.

Based on their experience, extensive literature review and multidisciplinary team analysis, Zhong et al. proposed clear treatment strategy or algorithm for patients with coexistence of brain tumours and intracranial aneurysms. In my opinion, the proposed treatment strategy is clinically valuable because of its simplicity and comprehensiveness

Bernhard R Fischer, Bochum, Germany

Zhong et al. describe in their article the co-existence of intracranial tumors and aneurysms. Each of these pathologies on its own can produce difficulties in diagnostic, treatment and follow-up. The co-occurrence of aneurysm and brain tumors can multiply these difficulties. Questions arising in the face of this special kind of illness concern a possible causal or co-incidental relationship, the necessity of angiography in every patient with intracranial tumor, different treatment strategies and so on. The so long published data are all results of retrospective studies and mostly of the pre-magnetic resonance imaging area, so nobody knows something about the incidence of this co-existing pathologies. In this article, the authors analyze data of 12 own patients and data of 108 patients published up to now. They well describe the differences of the co-occurred pathologies, e.g. localization, cause of symptoms, kind of treatment and outcome of the 120 patients. Due to the results of their analysis, they develop a treatment algorism as a good orientation for daily clinical practice.

As one main result the authors concluded that the mechanism for the co-occurrence of intracranial tumors and aneurysms mostly remains unexplained.

The concept of wait-and-see-strategy in patients with small and asymptomatic aneurysms and/or small and asymptomatic tumors may help in the future to answer the question of co-incidence or a specific causality of the co-occurrence of these pathologies.

I finally fully agree with the authors’ conclusion concerning the necessity of individual and interdisciplinary treatment.

Keyvan Mostofi, Hannover, Germany

As Zhong et al. noted in their paper, coexistence of intracranial aneurysm (IA) and brain tumour (BT) are more frequent than estimated. The majority of papers on this subject is after the 1970 and have increased in number until now. Among other things, one reason for this increase is development of modern brain imaging such as CT and MRI and brain angiography. These imaging give opportunities of earlier diagnosis of diseases which remained for a long time unnoticed.

Underestimated for the reasons mentioned, the incidence of coexistence of IA and BT is difficult to estimate correctly at present, as a result of insufficient data in the literature

Recently, coexistence of IA in patients with pituitary adenoma was estimated about 2.3 % [1]

Literature database are generally about coexistence of IA and meningioma and reports regarding other brain tumours like gliomas are almost non-existent.

Zhong et al. have taken in their paper a good initiative to conduct a review of the literature on this subject. The manuscript represents an interesting retrospective experience of management of brain tumour coexisted with intracranial aneurysm and an extensive review of the literature

The proposed treatment strategy by Zhong et al. has the advantage to be simple and based on experience so practical but unfortunately they give sometimes arbitrary suggestion owing to lack of sufficient literature data and the lack of prospective study; for an example, it is not possible to obtain validated conclusions about different strategies and they cannot provide any evidence proof to confirm the eventual causal relationship between coexistence of brain tumours and intracranial aneurysms. Despite these items, I believe that the experience of Zhong et al. could be interesting for the neurosurgical and neuroradiological communities.

Reference

1. Oh MC, Kim EH, Kim SH. Coexistence of intracranial aneurysm in 800 patients with surgically confirmed pituitary adenoma. J Neurosurg. 2012 May;116(5):942–7

Zhihong Zhong and Yuhao Sun contributed equally to this work.

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Zhong, Z., Sun, Y., Lin, D. et al. Surgical treatment of brain tumor coexisted with intracranial aneurysm—case series and review of the literature. Neurosurg Rev 36, 645–656 (2013). https://doi.org/10.1007/s10143-013-0477-7

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