J Neurosurg 66:609-610, 1987

Cerebral endometriosis

Case report

LEE L. THIBODEAU, M.D., GEORGE R. PRIOLEAU, M.D., ELIAS E. MANUELIDIS, M.D.,

MARIA J. MERINO, M.D., AND MICHAEL D. HEAFNER, M.D.
Sections of Neurosurgery, Neuropathology, and Neurology, Department of Surgery, Yale University
School of Medicine, New Haven, Connecticut, and Laboratory of Pathology, National Cancer Institute,
Bethesda, Maryland

v, A 20-year-old woman presented with a 3-year history of intermittent focal headaches and a generalized
seizure. Computerized tomography demonstrated a hypodense ring-enhancing cystic right parietal lobe le-
sion. At operation, a chocolate-colored cyst was excised which on histological examination proved to be endo-
metriosis.

KEY WORDS 9 endometriosis cerebral endometrial tissue

E
NDOMETRIOSIS is a condition in which function-
al endometrial tissue is located at extrauterine
sites. It is most c o m m o n l y seen in the pelvis and
is rarely found in the abdominal cavity above the um-
bilicus. Endometrial tissue has been found in the thorax,
the extremities, the vertebral column, the spinal canal,
and the sciatic nerve, e-7 A case of cerebral endometri-
osis is presented.
Case Report
This 20-year-old w o m a n was admitted to the Yale-
New Haven Hospital because of a generalized sei-
zure that had been preceded by a severe fight occipital
headache. She gave a 3-year history of episodic, pul-
satile right occipital headaches that characteristically
lasted 4 to 5 minutes and occurred once or twice each
month. These headaches usually developed in the eve-
ning and were unrelated to menstrual cycle phase,
activity, or diet. She denied any history of seizures,
migraine headaches, other neurological symptoms, drug
abuse, trauma, recent illness, or infections. H e r men-
strual history was normal. H e r medical history was
relevant only for two therapeutic abortions, one at 16
and one at 17 years of age. She took no prescribed
medications and had not previously been hospitalized.
A detailed review of systems was otherwise negative.
Her family history was negative for migraine headaches,
seizures, or other neurological or gynecological dis-
orders.
Examination. At the time of admission, the pa-
tient's neurological, gynecological, and general physical
examinations were normal. Laboratory studies of blood
and urine, an electrocardiogram, and chest x-ray films
were normal. An electroencephalogram revealed mod-
erate generalized slowing, most prominent over the
right temporal area. Computerized tomography (CT)
with and without intravenous contrast m e d i u m dem-
onstrated a hypodense ring-enhancing well-circum-
scribed lesion, located peripherally in the right poster-
oinferior parietal region. There was no significant mass
effect or edema. A C T scan using bone windows and
plain radiographs of the skull revealed scalloping of the
adjacent calvaria. Cerebral angiography demonstrated
an avascular parietal lobe mass. Preoperatively, the
patient was given phenytoin and remained neurologi-
cally normal without additional seizures.
Operation. The patient underwent a right parieto-
occipital craniotomy. Calvarial thinning was noted over
the lesion. When the dura was opened, a greenish-
brown cystic lesion was seen on the surface of the
posteroinferior parietal lobe. Aspiration of the cyst
yielded thick chocolate-brown fluid with no odor. The
cyst walls were smooth and hemosiderin-stained except
for a 5-ram reddish-brown nodule. The entire cystic
lesion was excised.
Postoperative Course. The patient tolerated the
procedure well, and had an uneventful postoperative
course without neurological deficit. She was treated

J. Neurosurg. / Volume 66/April, 1987 609


FIG. 1. Low-power photomicrograph showing endometrial epithelium and hemorrhagic endometrial stroma
with adjacent brain tissue containing scattered reactive gemistocytic astrocytes. H & E, • 150.
with danazol, 400 mg twice daily for 6 months. She has
had no subsequent seizures or menstrual irregularity
and her neurological and gynecological examinations
were normal 1 year after her operation.
Pathological E x a m i n a t i o n . Histological evaluation
of the lesion showed endometrial epithelium and hem-
orrhagic endometrial stroma (Fig. 1). The epithelial cells
were cuboidal and had dark pyknotic nuclei and abun-
dant cytoplasm. The stroma was composed of spindle-
shaped cells and contained variable amounts of pig-
mented macrophages. The lining mucosa was focally
denuded and replaced by iron-laden macrophages in-
terspersed in endometrial stroma. Mature brain show-
ing reactive gliosis was seen adjacent to the lesion. The
pathological diagnosis was benign endometriosis.
Discussion
It is of interest that, despite the histological evidence
of endometrial tissue, there were no symptoms relating
to the patient's menstrual cycle. Hematogenous implan-
tation would seem to be the most likely pathogenic
mechanism. The history o f two therapeutic abortions
and the absence o f demonstrable endometriosis at other
sites suggests that endometrial cells spread hematoge-
nously to the brain through the vertebral venous sys-
tem, ~ an undetected partially patent foramen ovale, or
a pulmonary arteriovenous shunt.
610
L. L. Thibodeau, et al.
Acknowledgments
The authors wish to thank Dr. Jung H. Kim and D. J.
Mulqueen for their help in preparing this report.
References
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2. Blaustein A: Pelvic endometriosis, in Blaustein A (ed):
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3. Duncan C, Pitney WR: Endometrial tumours in the
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Manuscript received January 2, 1986.
Accepted in final form August 11, 1986
Address reprint requests to: Lee L. Thibodeau, M.D.,
Section of Neurosurgery, Department of Surgery, Yale Uni-
versity School of Medicine, 333 Cedar Street, New Haven,
Connecticut, 06510.
J. Neurosurg. / Volume 66/April, 1987