Metastatic gestational trophoblastic neoplasia presenting initially as intraparenchymal and subdural hematoma: a case report

BACKGROUND: Gestational trophoblastic neoplasia is a rare but highly chemosensitive pregnancy-related malignancy with a strong tendency for hematogenous spread and hemorrhagic metastasis. Brain involvement occurs in a minority of patients and may present as life-threatening intracranial hemorrhage. CASE PRESENTATION: A 40-year-old Ethiopian woman presented with a sudden-onset severe headache, focal seizures, vomiting, and progressive right-sided weakness. She had a history of spontaneous abortion five months prior. Neuroimaging revealed a left frontoparietal intraparenchymal hemorrhagic mass with surrounding edema and a concomitant holohemispheric subacute subdural hematoma causing mass effect. Serum β-human chorionic gonadotropin (β-hCG) levels were elevated to 1500 IU/L. Although lower than the levels typically observed in disseminated choriocarcinoma, modest β-hCG elevations may occur in partially regressed primary lesions or in isolated metastatic disease. The patient underwent urgent craniotomy with evacuation of the subdural hematoma and resection of a hemorrhagic intraparenchymal metastatic lesion. Histopathological examination confirmed a diagnosis of metastatic choriocarcinoma. Staging evaluation revealed pulmonary and uterine involvement, consistent with International Federation of Gynecology and Obstetrics (FIGO) stage IV disease, with a World Health Organization prognostic score of 11. She received multi-agent chemotherapy with progressive neurological recovery and normalization of β-hCG levels during follow-up. CONCLUSION: Simultaneous intraparenchymal and subdural hemorrhages can represent a rare initial presentation of metastatic gestational trophoblastic neoplasia, even in the absence of gynecologic symptoms. Prompt measurement of serum β-hCG levels is essential for early diagnosis of unexplained intracranial hemorrhage in women of reproductive age. Early neurosurgical intervention combined with timely multi-agent chemotherapy can result in favorable outcomes, even in high-risk stage IV disease with brain metastasis.