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Case Report

A rare case of infantile cerebellar pilocytic

astrocytoma and thrombocytopenia
presenting with intratumoral hemorrhage
Shashank R. Ramdurg, Jaybrata Maitra
Department of Neurosurgery, MR Medical College, Gulbarga, Karnataka, India

Address for correspondence: Dr. Shashank R. Ramdurg, Department of Neurosurgery, MR Medical College, Gulbarga ‑ 585 105,
Karnataka, India. E‑mail: shashank.ramdurg@gmail.com

ABSTRACT
Incidence of gliomas presenting with hemorrhage is around 3.7–7.2%. Low‑grade gliomas account for
<1% tumor with hemorrhage. Infants presenting with cerebellar pilocytic astrocytomas (PAs) and hemorrhage
with thrombocytopenia have not been reported. We report an interesting case of a 9‑month‑old infant who
presented to the emergency department in a drowsy state with recurrent vomiting. Laboratory investigations
showed anemia, thrombocytopenia, and coagulopathy. Radiological evaluation showed a large PA with
bleed. The patient was treated with retromastoid suboccipital craniotomy and tumor excision and improved
postoperatively. Cerebellar PA with bleed and coagulopathy in infants has not been reported in literature till
date. Their presentation seems to be acute in nature, and high index of suspicion is required for the diagnosis
of these posterior fossa tumors, which can deteriorate rapidly in infants.

Key words: Astrocytoma, gliomas, hemorrhage, infant, pilocytic

Introduction Case Report

Spontaneous intracerebral hemorrhage is an uncommon
but recognized initial presenting sign of both primary
and metastatic brain tumors. The rate of tumor‑related
intracranial hemorrhage is variably reported from <1%
to 14.6%. [1] Hemorrhage in primary gliomas occurs in
3.7–7.2% of gliomas, mainly in glioblastoma multiforme
and oligodendroglioma with low‑grade astrocytomas
accounting for <1%. Hemorrhage associated with pilocytic
astrocytomas (PAs) is only sporadically reported.[2] It is
even rarer in infants. Here, we report an interesting case of
hemorrhage in cerebellar region in infants’ PA with associated
low platelet counts and coagulopathy.
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A 9‑month‑ old infant presented to the emergency
department in a drowsy state. The child improved
following the administration of cerebral decongestants.
Routine blood tests revealed thrombocytopenia and
deranged prothrombin time. Computed tomography (CT)
[Figure 1a and b] of the head demonstrated right cerebellar
nonenhancing solid cystic mass lesion with hemorrhage,
midline shift with obstructive hydrocephalus. Magnetic
resonance imaging plain and contrast [Figure 2a‑ d]
confirmed the CT findings and the lesion was not
enhancing on contrast.
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DOI: Cite this article as: Ramdurg SR, Maitra J. A rare case of infantile cerebellar
10.4103/1817-1745.193366 pilocytic astrocytoma and thrombocytopenia presenting with intratumoral
hemorrhage. J Pediatr Neurosci 2016;11:249-51.

© 2016 Journal of Pediatric Neurosciences | Published by Wolters Kluwer - Medknow / 249

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Ramdurg and Maitra: Infantile pilocytic astrocytoma with hemorrhage
Under fresh frozen plasma, platelet-rich plasma cover, retromastoid
craniotomy was performed and tumor decompression done. At
surgery, there was a solid‑cystic right cerebellar tumor with an
abnormal leash of blood vessels. Cystic component was filled
with blood. Gross total excision of tumor was done.
Histopathology [Figure 3a‑d] revealed PA with hemorrhage.
Interspersed in the cells was hemorrhagic component. The
a b
Figure 1: Plain computed tomography images demonstrating cerebellar
tumor with bleeding. (a) Computed tomography axial view (b) computed
tomography coronal view
a b
c d
Figure 2: Magnetic resonance imaging of the brain demonstrating right
cerebellar tumor with bleeding. (a) Magnetic resonance imaging T1‑weighted
image, (b) magnetic resonance imaging T2‑weighted image, (c) apparent
diffusion coefficient image, (d) contrast image
a b
c d
Figure 3: Histopathology images demonstrating sheets of pilocytic cells and
blood vessels and hemorrhage. (a and b) Dense sheets of elongated bipolar
cells with fibrillary process, (c and d) neoplastic astrocytes with foci of bleeding
250 / Journal of Pediatric Neurosciences / Volume 11 / Jul-Sep / 2016
child recovered well postoperatively without the need for any
cerebrospinal fluid diversionary procedure.
Discussion
The reported rate of hemorrhage in primary gliomas
has been around 3.7–7.2% (mainly in glioblastoma and
oligodendroglioma) while the low‑grade astrocytomas account
for <1% of cases.[2] White et al.[1] reported that the rate of
spontaneous hemorrhages in histologically proven cases of
PAs was 8%. They concluded that there was no particular
location susceptible for hemorrhage; however, no bleeding
occurred in cerebellum in their series. The symptomatic
hemorrhages associated with cerebellar PAs are extremely
rare.[3‑5]
The etiology of intratumoral hemorrhage in PAs is
unclear. Endothelial proliferation, rupture of an encased
aneurysm, and dysplastic capillary beds have been factors
hypothesized as potential causes for bleeding.[6,7] In our case,
an abnormal leash of blood vessels was seen at the surgery.
Contributing to this was the deranged coagulation profile
and thrombocytopenia (whether cause or effect could not be
ascertained) which could have led to a vicious cycle leading
to symptomatic hemorrhage.
In all the above series, the association of infantile cerebellar
PAs with symptomatic hemorrhage with association of
thrombocytopenia and deranged coagulation profile has not
been reported, making this case a rare and interesting one.
Conclusion
PAs, although benign, can present with hemorrhage.
Cerebellar PA with bleeding and coagulopathy in infants has
not been reported in literature. Their presentation seems to
be acute in nature, and high index of suspicion is required
for the diagnosis of these posterior fossa tumors, which can
deteriorate rapidly in infants.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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2. Kumar A, Deopujari CE, Biyani N, Mhatre MV. Pediatric cerebellar
pilocytic astrocytoma presenting with hemorrhage. Neurol India
2010;58:972‑4.
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Ramdurg and Maitra: Infantile pilocytic astrocytoma with hemorrhage

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