Intracerebral Hemorrhage due to Metastasis of Ovarian Granulosa Cell Carcinoma 36 Years after Initial Diagnosis

mission until the occurrence of the cerebral hemorrhage. A 69-year-old woman reported acute headache, vomiting and blurred vision. Clinical examination showed a homonymous hemianopia to the right side and somnolence. At this time, cranial computed tomography demonstrated an atypically located intracranial hemorrhage in the left parieto-occipital region ( fig. 1 ). As somnolence rapidly progressed, intubation and mechanical ventilation were initiated and surgical treatment performed. The lesion was completely resected. Microscopic investigation revealed a malignant epitheloid tumor with a hepatiform growth pattern and the presence of so-called ‘coffee-bean’ nuclei. Immunoreactivity for inhibin and CD99 in the majority of tumor cells confirmed the diagnosis of granulosa cell carcinoma ( fig. 2 ). The postoperative course was uneventful. Additional gynecological examination showed no further local recurrence of granulosa cell carcinoma. PET examination, performed to detect neoplastic tissue, was unremarkable except for a diminished allocation of the nuclide in the left parietooccipital brain region. Whole brain radiation therapy with 40 Gy was performed. Clinical and neuroradiological followup 6 months after diagnosis showed no signs of cranial and extracranial tumor recurrence. Dear Sir, Ovarian cancer is the fifth most frequent cancer in women, with poor prognosis if diagnosed at an advanced stage [1] . Metastasis to the central nervous system is a rare condition (0.5–0.9%) that is ascribed to the double capillary filter of the liver and lung [1–4] . Granulosa cell tumors are malignant sex-cord-stromal tumors and account for 2–3% of all ovarian tumors. Their natural history is characterized by slow growth and late recurrence occurring at a mean interval of 6 years after the initial diagnosis [5] . In the etiology of spontaneous intracerebral hemorrhages (ICHs), intracranial tumors play a not negligible role. In a large analysis from a single center, 4.4% of intracerebral hematomas were related to intracranial tumors, mostly glioblastoma, metastases, anaplastic and low-grade glioma, and meningiomas [6] . In other cohorts, 1.4–15% of spontaneous ICHs are tumorassociated depending on the age of patients and the different diagnostic procedures [7] . We report a patient with acute ICH due to metastasis of a granulosa cell carcinoma with symptomatic bleeding. Hitherto, in the literature there have been descriptions of 3 patients with solitary intracranial metastases of a granulosa cell carcinoma [4, 8] . In our patient, the primary manifestation of the ovarian granulosa cell carcinoma had been surgically treated 36 years earlier. The patient remained in a state of complete clinical reReceived: November 8, 2006 Accepted: December 28, 2006 Published online: June 13, 2007