title: Acute spontaneous subdural hematoma caused by skull metastasis of hepatocellular carcinoma: case report.
abstract: BACKGROUND
  Skull and intracranial metastases from hepatocellular carcinoma (HCC) have seldom been reported. A skull metastasis of HCC with a tumor bleeding resulting in spontaneous subdural hematoma (SDH) is extremely unusual. We report the first case of acute spontaneous SDH in a 69-year-old woman who presented with acute onset of headache, because of tumor bleeding caused by skull metastasis of HCC.
  
  
  METHODS
  A 69-year-old woman was referred to our hospital because of progressive headache, nausea, and vomiting for 3 days. Brain computed tomography (CT) performed in the emergency department (ED) revealed a left temporal SDH with a slight mass effect and a small left temporal bone erosion. Tri-phasic abdominal CT demonstrated a large right lobe liver tumor compatible with HCC. She experienced progressive deterioration of consciousness in the intensive care unit. Follow-up CT showed an enlargement of the SDH. An emergency craniotomy for hematoma evacuation and removal of skull tumor was performed. She regained consciousness and had no neurological deficits during the postoperative course. Pathological examination of the skull specimen indicated metastasis of a HCC.
  
  
  CONCLUSIONS
  Patients with acute SDH without a history of head injury are rarely encountered in the ED. Metastatic carcinoma with bleeding should be included as a differential diagnosis for acute spontaneous SDH. Before an operation for SDH, the possibility of metastatic lesion of the skull should be considered in the surgical planning and the origin of malignancy should be sought.
authors.affiliation: Department of Neurosurgery, E-Da Hospital, School of Medicine, I-Shou University, 1 E-Da Rd., Yan-Chau Dist, 824, Kaohsiung City, Taiwan.
authors.forename: Cien-Leong
authors.initials: CL
authors.lastname: Chye
authors.affiliation: Department of Emergency Medicine, E-Da Hospital, School of Medicine, I-Shou University, Kaohsiung, Taiwan.
authors.forename: Kuo-Hsuan
authors.initials: KH
authors.lastname: Lin
authors.affiliation: Department of Diagnostic Radiology, E-Da Hospital, Kaohsiung, Taiwan.
authors.forename: Chang-Hsien
authors.initials: CH
authors.lastname: Ou
authors.affiliation: Department of Emergency Medicine, E-Da Hospital, School of Medicine, I-Shou University, Kaohsiung, Taiwan.
authors.forename: Cheuk-Kwan
authors.initials: CK
authors.lastname: Sun
authors.affiliation: Department of Pathology, E-Da Hospital, Kaohsiung, Taiwan.
authors.forename: I-Wei
authors.initials: IW
authors.lastname: Chang
authors.affiliation: Department of Neurosurgery, E-Da Hospital, School of Medicine, I-Shou University, 1 E-Da Rd., Yan-Chau Dist, 824, Kaohsiung City, Taiwan. ed100183@edah.org.tw.
authors.forename: Cheng-Loong
authors.initials: CL
authors.lastname: Liang
mesh_terms: D000368:Aged; D006528:Carcinoma, Hepatocellular / Q000150:complications / Q000175:diagnosis / Q000556:secondary*; D005260:Female; D020199:Hematoma, Subdural, Acute / Q000000981:diagnostic imaging / Q000209:etiology*; D006801:Humans; D008113:Liver Neoplasms / Q000473:pathology*; D012888:Skull Neoplasms / Q000150:complications / Q000175:diagnosis / Q000556:secondary*; D014057:Tomography, X-Ray Computed