Department of Neurosurgery, Second Affiliated = Hospital,=20 College of Medicine, Zhejiang University, # 88 Jiefang Road, = Hangzhou=20 City, 310009, PR China

Abstract

We report one case of brain glioma that developed in the scar = of an old=20 brain trauma. A 45-year-old man who presented with seizures; MRI = showed a=20 large mass in the right temporal region. Surgical biopsy showed a=20 glioblastoma multiforme. The patient had suffered a cranial trauma = in a=20 road accident 10 years previously with an intracerebral hematoma = in the=20 right temporal region. This case fulfills the established criteria = for a=20 traumatic origin of brain tumors and adds further support to the=20 relationship between cranial trauma and the onset of glioma. As = stated by=20 other authors, an association between head trauma and brain tumor = risk=20 cannot be ruled out and should be studied further.

1. Introduction

Until now, there are only a few cases in which the relationship = between=20 a previous traumatic event and the occurrence of a brain glioma is = unequivocally demonstrated on the basis of well accepted criteria. = Recently, Elisa Anselmi et al. ^{1 =}reported two=20 patients who developed brain gliomas in the scar of an old brain = injury=20 meet all the criteria for a causal relationship between head = trauma and=20 glioma; these cases did support the theory of a causal = relationship=20 between trauma and gliomas. Here we report one case of glioma that = developed in a patient with a previous head trauma, which adds = further=20 support to the causal relationship between brain trauma and = gliomas.

2. Case report

A previously healthy 45-year-old man presented with seizures = and=20 expressive aphasia. He was admitted to our hospital. Magnetic = resonance=20 imaging (MRI) documented a large contrast-enhancing lesion in the = right=20 temporal region (Fig. 1). The mass = histological=20 examination revealed a glioblastoma multiforme. About 10 years = earlier the=20 patient had suffered a cranial trauma in a road accident when he = traveled=20 in another city. After the trauma he had been unconscious for 3 = days and=20 CT scan demonstrated an intracranial hematoma in the right = temporal lobe=20 at the site of the subsequent glioblastoma. The intracranial = hematoma was=20 treated conservatively at that time. After the diagnosis of the=20 glioblastoma multiforme the patient was treated with radiotherapy = and=20 chemotherapy, but he died seven months later.

3. Discussion

Top =
1.=20 Introduction
2. Case=20 report
3.=20 Discussion
4.=20 Conclusion
References

Although epidemiological studies do not support a definitive = connection=20 between head injury and intracranial glioma², there = have been=20 a few case reports of post-traumatic gliomas. As has been reported = recently¹,=20 it must be emphasized that some of the described cases with = post-traumatic=20 glioma did not fulfill the criteria suggested by zulch³for a=20 relationship between trauma and tumor, only a few authors have = provided=20 definite evidence of the causative role of trauma ⁴.

Zulch ³=20 in 1965 suggested the following criteria for the acceptance of a = causal=20 relationship between trauma and the onset of cerebral tumors:

The patient must have been in good health before suffering = the head=20 injury.
The below must be severe enough to cause brain contusion and = a=20 secondary reparative process.
The location of the impact and the tumor should correspond = exactly=20 one to the other.
There should be a time interval between trauma and the = appearance of=20 the tumor of at least 1 year, a longer latent period increasing = the=20 likelihood of a causal relationship.
The presence of the tumor must be proved histologically.
Trauma should consist of an external force.

Manuelidis ⁵⁼²⁰in 1972 added three more criteria:

The traumatized brain must also be proved histologically.
Bleeding, scars and edema secondary to the presence of the = tumor=20 must be clearly differentiated from that caused by trauma.
Tumor tissue should be in direct continuity with the = traumatic scar,=20 not merely in its vicinity or separated by a narrow zone of = healthy or=20 slightly altered brain tissue.

The stringent criteria for diagnosing a posttraumatic glioma = proposed=20 by Zulch et al. ³⁼²⁰and Manuelidis et al. ⁵ require = histopathological confirmation. These criteria were established in = the=20 pre-CT (computed tomography) era. The recent cases of = posttraumatic glioma=20 that have been reported show CT scans at the time of the trauma=20 demonstrating significant injury and the follow-up scans = demonstrating=20 tumor at the same site⁴. With = the routine=20 use of CT and magnetic resonance imaging (MRI), some of the = pathologic=20 criteria can be replaced or supplemented by imaging criteria. = CT/MRI,=20 which elegantly reveal the severity and location of the traumatic = brain=20 injury and the subsequent formation of a neoplasm at the same = site, can=20 provide convincing evidence for the traumatic causation of a brain = tumor.

Our case fulfill all the criteria defined by Zulch and two of = the three=20 criteria of Manuelidis because the intracerebral hematoma = secondary to=20 trauma was not histologically verified; it must be emphasized, = however,=20 that CT scan documented the absence of tumor at the time of the = brain=20 injury.

We suggest that these conditions for the acceptance of a causal = relationship between cranial trauma and brain tumor study are the=20 following: (1) the patient had been in good health before = suffering the=20 head injury, and early brain CT was negative; (2) the blow was = severe and=20 caused brain contusion or intracranial hematoma with a secondary=20 reparative process; (3) the location of the impact and the = occurrence of=20 the tumor corresponded exactly one to the other; and (4) there was = a more=20 than one year interval between trauma and the appearance of the = tumor.

As regards the pathogenesis of post-traumatic glioma, the = regenerative=20 and scarring processes secondary to the trauma may in some rare = instances=20 stimulate neoplastic proliferation; for these reasons it is = important that=20 the tumor arises at the site of the old scar to demonstrate a = relationship=20 between trauma and tumor⁶. If the = tumor=20 arises at different site of the old lesion, should be = coincidence⁷. The = fact that=20 epidemiological studies have not shown marked increase of the = relative=20 risk may reflect the fact that the association, if it exists, is = not a=20 direct one. The mechanism of post-traumatic brain cancer is = unclear.=20 Experimental data have shown that trauma can act as a cocarcinogen = in the=20 presence of an initiating carcinogen ². It was = hypothesized that cells damaged by the initiating carcinogen = proliferated=20 as a natural result of the trauma, leading to tumor formation. = Trauma=20 probably acts as a cocarcinogen in the presence of an initiating=20 carcinogen, i.e. it may induce the proliferation of = =E2=80=9Cinitiated =E2=80=9D=20 cells.

Figure 1 =20

MRI scan of the head show a large temporal mass secondary to = the=20 glioblastoma at the site of the previous intracerebral = hematoma.

(Click on the image to enlarge.)

4. Conclusion

An association between head trauma and brain tumor risk cannot = be ruled=20 out and should therefore be studied further. Post-CT/MRI era = should have=20 more convenient conditions to study. Large study populations are=20 imperative because of the relatively low prevalence of head = injuries and=20 the low incidence of brain tumors.

Conflict of Interest

The authors have declared that no conflict of interest = exists.

References

Top =
1.=20 Introduction
2. Case=20 report
3.=20 Discussion
4.=20 Conclusion
References

1. Anselmi E, Vallisa D, Berte R. = et al.=20 Post-traumatic glioma: Report of two cases. Tumori.=20 2006;92:175-7

2. Preston-Martin S, Pogoda JM, = Schlehofer B.=20 et al. An international case-control study of adult = glioma and=20 meningioma: the role of head trauma. Int J Epidemiol.=20 1998;27:579-586

3. Zulch KJ. Brain tumors: Their = biology and=20 pathology, 2^nd edition. New York, USA: = Springer-Verlag=20 Publisher. 1965:51-58

4. Henry PT, Rajshekhar V. = Post-traumatic=20 malignant glioma: case report and review of the literature. = Br J=20 Neurosurgery. 2000;14:64-7

5. Manuelidis EH. Glioma in = trauma. In:=20 (ed.) Minckler J. Pathology of the Nervous System. New = York, USA:=20 McGraw Hill Publisher. 1972

6. Di Trapani G, Carnevale A, = Scerrati M. et=20 al. Post traumatic malignant glioma. Report of a case. = Ital=20 J Neurol Sci. 1996;17:283-286

7. Hu XW, Zhang YH, Wang JJ. et = al.=20 Angiocentric glioma with rich blood supply. J Clin = Neurosci.=20 2010;17(7):917-8

Author contact

3D"Corresponding =20 Corresponding author: Tel./fax: +86 15157161309. E-mail: = liuweiguo618 com

Received 2010-6-26
Accepted 2010-7-23=20
Published 2010-7-29