Cerebellum Cavernous Hemangioma

*Rima Asmarani

**dr. Soetedjo, Sp. S(K)

ABSTRACT
CEREBELLUM CAVERNOUS HEMANGIOMA
Rima Asmarani* Soetedjo**
ABSTRACT
Background
Hemangiomasare benign tumorsorhamartomasthatoccurdue to interferenceon the
developmentandformation ofblood vessels and canoccurin allorganssuch as the liver,
spleen, brain, bone, andskin. The prevalence ofthe most commonin newbornswitha
percentageof 5-10% in childrenaged lessthanoneyear. Nevertheless, it is possible in
adults. The prognosis dependson thelocation, size, complication and management of
the tumor
Case Report
Reported man aged 25, a labour, came with 3 months of having a chronic
progressive head pain accompanied by projectile vomiting, and imbalance. Brain
MSCT scan imaging shows a hipodens and isodens mass in the cerebellum, after
contrast injection shows enhancement at isodens lesion, tend to be a cerebellum
astrocytoma. This patient treated with dexamethasone and tumor surgical
evacuation. The result of the anatomic pathology is cavernous hemangioma.

Conclusion
Cavernous Hemangioma is a benign neoplasma because of the disturbance of
angiogenes . Diagnosis is based on history, physical examination and imaging.
Definitive diagnosis established by anatomical pathology. The Prognosis of this tumor
depend on location, size, complication, and good management.

Keyword: microcystic meningioma, diagnosis, prognosis

*Resident of Departement of Neurology Medical Faculty of Diponegoro University /
Kariadi Hospital Semarang

Fossa posterior tumor prevalence

SOL prevalence in children

Cerebellum Anatomy

LCS Flow
Disturbance of LCS flow
hidrocephalus
peningkatan TIK

Cerebellum Disorder
HHipotonus
AAtaksia
NNistagmus
DDismetri
Intentional Tremor

HEMANGIOMA DEFINITION

Hemangiomas are benign tumors that caused

by disturbances in the development and
formation of blood vessels and can occur in any
organ such as the liver, spleen, brain, bone, and
skin
Hemangiomas are benign vascular tumor that is
common in infants and children. But did not rule
occur in adults. Hemangiomas are more common
in women than men by a ratio of 3: 1

EPIDEMIOLOGY
The prevalence of hemangiomas 1-3% in
neonates and 10% in infants up to 1 year of
age.
the most common sites of hemangioma is at the
head and neck (60%)
In areas of the oral cavity is often found on the
lips, tongue and buccal mucosa.
Approximately 80% of cases is single lesions, and
the of this lesions were multiple.

ETIOLOGY
&PATHOMECHANISME
The occurrence of hemangiomas is still unknown
(presumably from interruption angiogenesis
process with the mechanisme of increasing levels
of angiogenesis factor or reduced angiogenesis
inhibitors)
The cause is related with blood vessel growth
control mechanisms.

Hemangioma Classification

Capillary Hemangioma
Strawberry hemangioma
(hemangioma simplek)
Granuloma piogenik
Cavernosum hemangioma
Mix Hemangioma

The others....
1.
2.
3.
4.
5.
6.
7.

Intramuscular hemangioma
Synovial hemangioma
Osseus hemangioma
Choroidal hemangioma
Spindle cell hemangioma
Gorham disease
Kassabach-Merritt syndrome

DIAGNOSIS
Head CT Scan
MRI
MRI is very important and sensitive in detecting tumors in the posterior fossa.

Biopsy

MANAGEMENT
The management of hemangiomas :
Conservative
Active
Active Management of hemangioma:
A. Surgery
B. Radiotheraphy
C.Corticosteroid
D Sclerotic agent
E. Electrocoagulation
F. freezing
G. Antibiotic

Indication of active management:

grow on vital organs, such as the
eyes, ears, and throat
Bleeding hemangioma
Ulcerated hemangioma
Infected hemangioma
hemangioma with rapid growth and
cause deformity (abnormal) tissue

PROGNOSIS
In general, the prognosis depends on the
location of the tumor, complications and
good management
small or superficial hemangiomas may
disappear completely by itself. Large
cavernous hemangioma should be
evaluated and receive the proper
management.

CASE REPORT

Patient Identity
Name : Mr. W
Age : 25 years old
Sex : Laki-laki
Marriage status: unmarried
Last Education : SeniorHigh School
Occupation : labour
Address : Mawar Indah Purwodadi
Date of admission : 21 April 2015
Medical record : C526746

Anamnesis
Recent History
Chief complaint: headache
Onset
: 3 months ago, getting
worse
Quality
: throbbing pain
Quantity
: ADL helped by family

Chronology
3 months before hospital admission the patient complained
of throbbing pain in head, intermittently, especially when
straining to defecate, so patients are afraid to defecate.
Patient also complained of vomiting 5 times / day, nausea
(-). Patient's family brought him to the clinic and treated for
three days, given a pain-reducing medication then patient
getting better.
2 months before hospital admission headache was getting
worse. not relieved by taking medication, nausea (-), vomiting
(+), and the patient's gait was unsteady. Patients also felt
dizzy, continuously, and not influenced by the movement of
the head, aggravated when the patient opened his eyes and
walks, tinnitus (-), hearing loss (-). The patient felt weak and
had to be assisted when stand up. Seizures (-), loss of
consciousness (-), bowel and bladder no complaints.
The patient's family brought him to hospital in Purwodadi and
got a head scan. The Doctor said that there was a brain
tumor, then the patient was referred to Kariadi hospital

 Aggravating factor
: Attenuating factor
: Concomittant symptom : vomit,
dizziness

 Past Medical History

- a history of weight loss in short time (-)
- long history of cough (-)
- history of head trauma (-)
Family History
No family suffering like this, long cough, or
tumor
Socio-economy History
Patient is a labour, unmarried. Class III BPJS.
impression= low socio-economy status

CLINICAL FINDINGS
Status Presens
Level of Conscioussness : Compos mentis
: GCS : E4M6V5 = 15
Blood Pressure
: 130 / 80 mmHg
Heart Rate
: 84 x/ mnt
Respiratory Rate
: 20 x/ mnt
T
: 36,7 o C
VAS
:5
Height
: 166 cm,
Weight
: 50 kg
BMI
: 23,44 (normoweight)

Status Internus
Head
Eye
(-/-)
Neck
not
Thorax
Cor

: mesosefal, simetric
: conjungtiva anemis (-/-), ikterik sclera
: simetric, freely, enlargement of nnll(-), JVP
increase
: normal heart sound, murmur (-),gallop (-)

Paru
: normal breathing, Rh-/-, Wh -/- Abdomen
: supel, peristaltic (+) normal,
unpalpable liver
and spleen, ascites (-)

Neurologic State
Level of conscioussness : GCS E4 M6 V5 = 15
Head

: mesocephal, simetris

Eye

: pupil round, isocor 3/3

mm,light reflex +/+

Neck

: nuchal rigidity (-)

Cranial Nerves

: normal

 Motoric Superior Inferior

Movement +/ + +/ +
Strength 555/555 555/555
Tonus / /
TrophyE/ E E/ E
FR ++ / ++ ++ / ++
PR - / - - / Clonus - / Sensibility : normal
Vegetatif : normal

Coordination Tests
Past pointing test : Right dismetri
(+), Intensional Tremor(-)
Finger to nose test : Right dismetri
(+), Intensional Tremor (-)(-)
Rebound Phenomenon (-)
Right Disdiadokokinesia (+)
Gait Ataksia (+)

Laboratory
Examination

Result

Normal point

Hematologi
Hemoglobin

15,4

gr%

12.00-15.00

Hematrokrin

44.8

35-47.0

Eritrosit

4.92

million/mmk

3.90-5.60

MCH

31.4

Pg

27.00-32.00

MCV

91.2

Fl

76.00-96.00

MCHC

34.5

g/dl

29.00-36.00

Lekosit

11.0

thousand/mmk

4.00-10.60

Trombosit

256

thousand/mmk

150.0-400.0

RDW

13.1

11.60-14.80

MPV

4.72

Fl

4.00-11.00

Kimia Klinik
GDS

112

mg/dL

74-106

Ureum

19

mg/dL

15-39

Creatinin

0.79

mg/dL

0.60

Natrium

135

mmol/L

136-145

Kalium

4.2

mmol/L

3.5-5.1

Chlorida

105

mmol/L

98-107

Magnesium

0.99

mmol/L

0.74-0.99

Calcium

2.43

mmol/L

2.12-2.52

PPT

10.4

Detik

9.4-11.3

control

10.7

Detik

APTT

30.4

Detik

control

29.9

Detik

Elektrolit

Coagulation

23.4-36.8

Thorax X Ray
Impression: in normal state
theres no sign of
metastasis

Head CT Scan
non contrast

contrast

 Hipodens lesion with partly isodens on

cerebellum, enhancement on isodens lesion
with contrast injection
Narrowing of the sulci and cisterna around
the lesion
Narrowing of the 4th Ventricle
Midline shifting (-)
Pons was pushed to cranial because of
cerebellum lesion

Impression : Cerebellum SOL dd/

Astrocytoma

EKG normosinus rhythm

Neurologic Formulation
Patient, Mr. W,25 years old man, Javannesse, a labour, right
handed, unmarried, came with chief complaint a chronic
progressive headache, with vomiting, and impaired balance
since 3 months. The patient has no significant past medical
history.
On physical examination found vital signs, BP: 140/80, HR:
84x/mnt, RR;20x/mnt, t: 36,7. The neurological examination
level of conscioussness composmentis (GCS:E4M6V5),
headachache,with VAS=5, signs of the cerebellar syndrome (+).
On contrast head CT scan appeared SOL in Cerebellum and
Hydrocephalus. A collection of signs and symptoms consistent
leading to increased Intracranial Pressure due to Cerebellum
SOL.
The most likely diagnosis in this patient is Cerebellar
Astrocytoma

Diagnosis
Clinical Diagnosis:
- Chronic progressive headache, vomitus (signs of
ICP increasing)
- Ataksia,
- Right Dismetria,
- Right Disdiadokokinesia
- Hipotonus
- Central Vertigo
Topical Diagnosis : Cerebellum
Etiology : Hidrosephallus et causa Cerebellum SOL
dd/ Astrocytoma

Hidrosephallus et causa SOL Cerebellum SOL dd/

Astrocytoma

Px : Consult to ophtalmologist,
&neurosurgeon
Tx : - IVFD RL 20 dpm
- Inj Dexametason 10mg/6jam
(intravena)
- Inj Ranitidin 50mg/12jam (intravena)
- Na. Diclofenac 500mg/8jam (orally)
- Acetazolamide 500 mg/ 8 jam (orally)
Mx : Vital signs, GCS, and neurologic
deficits

Ophtalmologic consult result :

impression : there are signs of edem
papil, hipertension retinopathy (-),
DM retinopathy(-) increased ICP (+)
Neurosurgeon consult result:
Craniotomy on April 29th 2015

PROGRESS NOTE

HARI

24-04-2015
(day hospital treatment:4)

25-4-2014
(day hospital treatment:5)

29-4-2014
( day hospital treatment:8)

Throbbing headache, weakness

Throbbing headache, weakness

Throbbing headache, weakness

O GCS
BP
HR
RR
t
PE

E4 M6 V5, VAS: 4
130/80mmHg
80x/mnt
20x/mnt
36,1C
No changes

E4 M6 V5,VAS:4
120/80mmHg
100x/mnt
24x/mnt
36,8C
No changes

E4 M6 V5 , VAS :4
110/70mmHg
86x/mnt
20x/mnt
36,2C
No changes

Lab

A
P

Con Consult to anestesiologist

sult
Hidrosephallus et causa cerebellum Hidrosephallus et causa
SOL dd/ Astrocytoma
cerebellum SOL dd/ Astrocytoma

Hidrosephallus et causa cerebellum

SOL dd/ Astrocytoma

Dx
Tx

-IVFD RL 20 dpm
-Inj Dexametason 10mg/6jam
(intravena) day 4
-Inj Ranitidin 50mg/12jam
(intravena)
-Na. Diclofenac 500mg/8jam orally
-Acetazolamide 500mg/8jam orally

-IVFD RL 20 dpm
-Inj Dexametason 10mg/6jam
(intravena) day 5
-Inj Ranitidin 50mg/12jam
(intravena)
-Na. Diclofenac 500mg/8jam
orally
-Acetazolamide 500mg/8jam
orally

- IVFD RL 20 dpm
-Inj Dexametason 10mg/8 jam
(intravena) day 8 , tapp off day2
-Inj Ranitidin 50mg/12jam
(intravena)
-Na. Diclofenac 500mg/8jam orally
-Acetazolamide 500mg/8jam orally
-Craniotomy

Mx

Vital signs & neurologic deficits

Vital signs & neurologic deficits

Vital signs & neurologic deficits

Ex

No changes

No changes

No changes

Surgery report
1. Informed consent & profilactic antibiotic
2. The position of the patient is sleeping face down
3. Disinfection & cover with sterile doek
4. linea mediana posterior incission
5. Incission deepen to the periosteum
6. Set aside to lateral & plug retraktors
7. Burr hole 2 & craniotomy from inion to magnum foramen
8. Open duramater
9. Obtained redness and partially cystic mass, cystic pungtion
10.Separate the mass from the cerebellum
11.Feeding artery from the cerebellum
12.
Draining artery from the cerebellum
13. Lift tumor and manage bleeding
14.
Sewing duramater & manage bleeding
15.
Cut duramater & plug the drain

Post Surgery Instructions

- inj Paracetamol 1g/8jam (intravena)
- inj Omeprazole 40mg/12jam (intravena)
- Perdipin 5mg/jam syringe pump if TD>
140

Mx : Vital signs and neurologic deficit

Ex :Explain about patients condition and
management

HARI

30-04-2015
(day hospital treatment:9,
Day 1 post craniotomy in ICU)
Surgical wound pain

O GCS E4 M6 VET, VAS: difficult to

assessed
BP 160/100mmHg
HR 80x/mnt
RR 20x/mnt
t
36,1C
PE No changes, drain:100cc

01-5-2015
(day hospital
treatment:10,day 2 post
craniotomy in ward)

02-5-2015
day hospital treatment:11,
day 3 post craniotomy)

Surgical wound pain (reduced),

fever

Surgical wound pain (reduced), fever

E4 M6 V5,VAS:4

E4 M6 V5 , VAS:3

130/70mmHg
100x/mnt
24x/mnt
39,3C
No changes, drain:100cc

130/70mmHg
86x/mnt
20x/mnt
39C
No changes, drain:80 cc

Lab

Leukositosis 34.900, osm:290,55

Con sult
Cerebellum SOL dd/
astrocytoma, 1st day Post
craniotomy

Cerebellum SOL dd/

astrocytoma, 2nd day Post
craniotomy

Dx

Tx

-Post surgery instruction: analgetic

agent from anesthesi
- IVFD RL 500ml/24jam
- IVFD NaCl 0.9 % 1500 ml/24jam
- inj Paracetamol 1g/8jam
(intravena
- inj Omeprazole 40mg/12jam
(intravena)
- perdipin 5mg/jam syringe pump if
TD> 140

Wait for PA result

Cerebellum SOL dd/ astrocytoma,

3rd day Post craniotomy

septic

Wait PA result, Blood count

lab

IVFD RL 30 dpm +drink plenty of

water
- Inj. Tramadol 100mg/8jam
(intravena)
- Inj. Omeprazol 40mg/12jam
(intravena)
- Vit B1B6B12 1tab/8jam (orally)
-Miring kanan-kiri /2
-Inj. Paracetamol 1 gram/ 8 jam iv

Wait PA & culture rsult

IVFD RL 30 dpm +drink plenty of

water
- Inj. Tramadol 100mg/8jam (intravena)
- Inj. Omeprazol 40mg/12jam
(intravena)
- Vit B1,B6,B12 1tab/8jam (orally)
-Miring kanan-kiri /2jam
-Inj. Ceftriakson 2 grm/ 24 jam iv skin
test
--Inj. Paracetamol 1 grm/ 8 jam iv

HARI

03-05-2015
(day hospital treatment:-12,
day 4 post craniotomy)

04-5-2015
(day hospital treatment:13,
day 5 post craniotomy)

05-5-2015
(day hospital treatment:14, day
6 post craniotomy)

Surgical wound pain (reduced),

fever (-)

Surgical wound pain (reduced),

fever (-)

Surgical wound pain (reduced),

fever (-)

O GCS
BP
HR
RR
t
PF

E4 M6 V5, VAS: 3
130/70mmHg
80x/mnt
20x/mnt
36,5C
Gait ataksia (-), others No changes,
drain:70cc

E4 M6 V5,VAS:2
130/70mmHg
100x/mnt
24x/mnt
36,3C
No changes, drain:60 cc

E4 M6 V5, VAS:2
130/70mmHg
86x/mni
20x/mnt
36C
No changes, drain:25 cc

Cerebellum SOL dd/

astrocytoma, 5th day Post
craniotomy
Septic (getting better)

Cerebellum SOL dd/

astrocytoma, 6th day Post
craniotomy

Lab

Con sult
Cerebellum SOL dd/
astrocytoma, 4th day Post
craniotomy
Septic
Dx
Tx

Wait PA&culture result

- IVFD RL 30 dpm
- Inj. Tramadol 100mg/8jam
(intravena)
- Inj. Omeprazol 40mg/12jam
(intravena)
- Vit B1,B6,B12 1tab/8jam (orally)
-Miring kanan-kiri /2jam
-Inj. Ceftriakson 2 grm/ 24 jam iv
day 2
-Inj. Paracetamol 1 grm/ 8 jam iv

Wait PA & culture result

- IVFD RL 30 dpm
- Inj. Tramadol 100mg/8jam
(intravena)
- Inj. Omeprazol 40mg/12jam
(intravena)
- Vit B1,B6,B12 1tab/8jam (orally)
-Miring kanan-kiri /2jam
-Inj. Ceftriakson 2 grm/ 24 jam iv
day 3
-Paracetamol 500 mgrm/ 8 jam
orally, if t>37.5

Septic (getting better)

wait PA & culture result
- IVFD RL 30 dpm
- Inj. Tramadol 100mg/8jam
(intravena)
- Inj. Omeprazol 40mg/12jam
(intravena)
- Vit B1,B6,B12 1tab/8jam (orally)
-Miring kanan-kiri /2jam
-Inj. Ceftriakson 2 grm/ 24 jam iv
day 5
-Paracetamol 500 mg/ 8 jam orally if
t>37.5

HARI

06-05-2015
(day hospital treatment:15,
day 7 post craniotomy)

07-5-2015
(day hospital treatment:16,
day 8 post craniotomy)

08-5-2015
(day hospital treatment:17,
day 9 post craniotomy)

Surgical wound pain (reduced),

fever (-)

Surgical wound pain (reduced),

fever (-)

Surgical wound pain (reduced), fever

(-)

O GCS
BP
HR
RR
t
PE

E4 M6 V5, VAS: 2
120/80mmHg
80x/mnt
20x/mnt
36,5C
No changes, drain:25cc

E4 M6 V5,VAS:2
120/70mmHg
80x/mnt
20x/mnt
36,3C
No changes, drain:-

E4 M6 V5, VAS:1-2
120/70mmHg
86x/mnt
20x/mnt
36C
No changes

Lab

Blood&urine culture: no growth

of bactery

Con sult
Cerebellum SOL dd/
astrocytoma, 7th day Post
craniotomy

Septic (getting better)

P

Dx

Tx

- IVFD RL 30 dpm

Mx

Wait the result of culture &

PA

Cerebellum SOL dd/

astrocytoma, 8th day Post
craniotomy

Septic (getting better)

Wait PA result

-IVFD RL 30 dpm

- Inj. Omeprazol 40mg/12jam (intravena)

- Vit B1,B6,B12 1tab/8jam (orally)
-Miring kanan-kiri /2jam
-Inj. Ceftriakson 2 grm/ 24 jam iv day 7
- Paracetamol 500m grm/ 8 jam orally

- Vit B1,B6,B12 1tab/8jam (orally)

-Miring kanan-kiri /2jam
-Inj. Ceftriakson 2 grm/ 24 jam iv
day 8
- Paracetamol 500m grm/ 8 jam
orally
--aff drain

Vital signs& neurologic deficit

Vital signs & neurologic deficit

Cerebellum SOL dd/ astrocytoma,

9th day Post craniotomy

Septic (getting better)

wait PA resullt
IVFD RL 30 dpm
- Vit B1,B6,B12 1tab/8jam (orally)
-Miring kanan-kiri /2jam
-Inj. Ceftriakson 2 grm/ 24 jam iv stop
- Paracetamol 500m grm/ 8 jam orally

Vital signs and neurologic deficit

HARI

09-05-2015
(day hospital treatment:18,
day 10 post craniotomy)
Surgical wound pain (reduced)

O GCS E4 M6 V5, VAS: 1-2

BP
HR
RR
t
PE

120/80mmHg
80x/mnt
20x/mnt
36,5C
No changes

10-5-2015
(day hospital treatment:19,
day 11 post craniotomy)

11-5-2015
(day hospital treatment:20,
day 12 post craniotomy)

E4 M6 V5,

E4 M6 V5, VAS:1-2

120/70mmHg
80x/mnt
20x/mnt
36,3C
No changes

120/70mmHg
86x/mnt
20x/mnt
36C
No changes

Cerebellum SOL dd/

astrocytoma, 11th day Post
craniotomy

Cerebellum SOL dd/ astrocytoma,

12th day Post craniotomy

Lab
Con sult

Cerebellum SOL dd/

astrocytoma, 10th day Post
craniotomy

Septic (getting better)

P

Dx
Tx

Wait the result of PA

- IVFD RL 30 dpm

Septic (getting better)

Wait the result of PA

-IVFD RL 30 dpm aff

Septic (getting better

wait the result of PA,

-Vitamin B1, B6, B12 1 tab/ 8 jam orally
-outpatient

- Vit B1,B6,B12 1tab/8jam (orally)

- Paracetamol 500m grm/ 8 jam orally
-Walking exercise

- Vit B1,B6,B12 1tab/8jam (orally)

-FT
-outpatient plan tomorrow

Mx

Vital sign, neurologic deficit

Vital sign, neurologic deficit

Ex

No changes

No changes

Edukasi untuk kontrol

Outpatient

May 16 th 2015 (18 days post

craniotomy)
S : headache (-)
O : GCS : E4M6V5
wound post craniotomy surgery,
pus (-)
A : 19 days post craniotomy ec/
cavernosum hemangioma
P : wound care

Patologi Anatomi

 Makroscopis : 1 piece of tissue the size of

2 x 2 x 1 cm, off-white
Mikroscopis : Cerebellum tissue sections
showed coated vascular endothelial cells
and the tissues between cells in the brain
parenchyma tissue stroma containing
mass hyperemesis necrosis bleeding. Not
visible signs of bleeding.
Conclusion : Cavernous Hemangioma

DECISION MAKING

NO

Active Problem

Date

NO

Inactive
problem

1.

Chronic Progressive

21/04/2015

headache)since 3
months7
2.

Vomitus7

21/04/2015

3.

Hipotonus7

21/04/2015

4.

Dismetri7

21/04/2015

5.

Disdiadokokinesia7

21/04/2015

6.

Hidrocephalus7

21/04/2015

7.

Hemangioma cavernosum

21/04/2015

cerebellum

Date