A hemorrhagic vestibular schwannoma presenting with rapid neurologic decline: A case report

Introduction: Vestibular schwannomas (VS) account for approximately 8% of all intracranial neoplasms and nearly 80% of all cerebellopontine angle tumors. Spontaneous intratumoral hemorrhage (ITH) remains a rare entity with only 10 published reports existing in the international literature. In the present case, we discuss the clinical presentation, radiographic evaluation and management of a 66-year-old male with a histologically confirmed spontaneous hemorrhagic VS. Study Design: Case Report Setting: Tertiary Referral Center Results: A 66-year-old male with a history of prodromal left sided sensorineural hearing loss presented for evaluation after experiencing a rapid onset severe left sided headache, projectile vomiting and vertigo that woke him from sleep. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed a left sided 2X2 cm cerebellopontine angle mass consistent with a VS. Local mass effect resulted in 4th ventricle effacement and hydrocephalus. Areas of T2 hypointensity and corresponding increased attenuation on CT confirmed an acute ITH. Hematology and coagulation laboratory studies were normal. The patient subsequently underwent a left suboccipital craniotomy with complete resection of a histologically confirmed hemorrhagic VS. Conclusion: Spontaneous hemorrhage into a VS is an extremely rare event. In contrast to the insidious progression typified by nonhemorrhagic VSs, those with gross intratumoral bleeding most often present with acute cranial neuropathies and symptoms of subarachnoid hemorrhage. In surgically fit patients, we advocate urgent microsurgical resection. Simple observation with serial radiography may risk repeated hemorrhage while the role of radiosurgery is not yet defined.