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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Patients with intracerebral tumors mostly present with slowly progressive neurological deficits or symptoms associated with increased intracranial pressure&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">1&#8211;3</span></a> Occasionally&#44; patients may present with acute neurological decline secondary to spontaneous intracranial hemorrhages &#40;ICHs&#41;&#46; In such cases&#44; delayed diagnosis is not uncommon given that the initial radiological evaluation may not reliably discriminate between neoplastic and vascular etiologies in cases with extensive hemorrhages&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">1&#44;4&#44;5</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In previous studies&#44; the incidence of spontaneous ICH owing to brain tumors &#40;BTs&#41; ranges from 1&#46;4&#37; to 10&#37;&#44; with an average of around 2&#37;&#8211;3&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">1&#44;6</span></a> As a general rule&#44; any type of BT can bleed&#59; however&#44; the frequency of bleeding varies widely across tumor types&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">1&#44;7&#8211;9</span></a> Expectedly&#44; fast-growing and highly vascularized neoplasms with irregular and fragile vasculature have been found to be most frequently associated with ICH&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">1&#44;10</span></a> Although such cases have been widely reported&#44; their clinical features are yet to be fully reviewed&#46; Thus&#44; the purpose of the current study was to elucidate clinical characteristics of previously silent BTs that initially manifest with spontaneous ICH by retrospectively reviewing our experiences in a series of 55 patients&#46; By this way&#44; we aimed to determine which tumor types bleed more often and to determine the relationship between the tumor type and the type of the hemorrhage while describing our series&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Materials and methods</span><p id="par0015" class="elsevierStylePara elsevierViewall">After obtaining approval from the local institutional review board&#44; we retrospectively examined patients who were surgically treated by the senior author of this manuscript between January 2003 and December 2021&#46; Patients &#62;17 years of age who clinically presented initially with ICH owing to a BT were included in the study&#44; whereas those with features that could predispose themselves to ICHs&#44; such as the use of anti-aggregants or anticoagulants or decreased platelet count&#44; were excluded&#46; Patient records&#44; including hospital progress notes&#44; operation notes&#44; and preoperative and postoperative neuroimaging&#44; radiology&#44; and pathology reports&#44; were then analyzed&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Demographical and clinical data were obtained upon admission&#46; Patients were further divided into the following subgroups according to their levels of consciousness &#40;LOCs&#41; based on the Glasgow coma score &#40;GCS&#41;&#58; &#40;1&#41; mildly affected &#40;13&#8211;15&#41;&#44; &#40;2&#41; moderately affected &#40;9&#8211;12&#41;&#44; and &#40;3&#41; severely affected &#40;3&#8211;8&#41;&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">All patients underwent cranial computed tomography &#40;CT&#41;&#46; Patients whose initial cranial CT scan findings indicated the presence of a BT as the underlying cause for the ICH underwent magnetic resonance imaging &#40;MRI&#41; for further evaluation&#46; Based on this&#44; the distribution of the hemorrhage was classified as &#40;1&#41; ICHs within the confines of the tumor &#40;HCTs&#41;&#44; &#40;2&#41; extensive intracerebral hemorrhages with&#47;without expansion into the ventricles &#40;EIHs&#41;&#44; &#40;3&#41; acute subdural hemorrhage &#40;ASH&#41;&#44; or &#40;4&#41; acute epidural hemorrhage &#40;AEH&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Depending on their clinical condition&#44; patients underwent either emergency or elective open microneurosurgical resection of the tumor and evacuation of the hematomas&#46; The tumors were then classified as &#40;1&#41; high-grade glial tumors &#40;HGGTs&#41; &#91;World Health Organization &#40;WHO&#41; grades III and IV&#93;&#44; &#40;2&#41; low-grade glial tumors &#40;LGGTs&#41; &#40;WHO grades I and II&#41;&#44; &#40;3&#41; metastatic BTs &#40;MBTs&#41;&#44; &#40;4&#41; meningiomas and &#40;5&#41; other tumors &#40;those responsible for &#60;5&#37; of the cases&#44; i&#46;e&#46;&#44; pituitary adenoma&#44; ependymoma&#44; epidermoid tumor&#44; schwannoma&#44; etc&#46;&#41; based on the final pathology reports&#46; Functional outcome was assessed based on the Glasgow outcome score &#40;GOS&#41; at discharge&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Continuous variables were expressed in terms of mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>standard deviation&#46; Independent samples <span class="elsevierStyleItalic">t</span>-test was used for comparisons between the two groups according to normality test results&#46; Categorical variables were presented as frequency and percentage values &#91;<span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&#93; and compared using the Pearson Chi-square test&#46; Statistical analysis was performed using SPSS &#40;IBM Corp&#46; Released 2012&#44; IBM-SPSS Statistics for Windows&#44; Version 21&#46;0&#44; Armonk&#44; NY&#41;&#46; A <span class="elsevierStyleItalic">p</span> value of &#60;0&#46;05 indicated statistical significance&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Results</span><p id="par0040" class="elsevierStylePara elsevierViewall">Among a total of 1893 patients with BTs treated surgically between January 2003 and December 2021&#44; 55 patients with spontaneous ICH were identified&#46; Therefore&#44; 2&#46;9&#37; &#40;55&#47;1893&#41; of patients in our series had BTs presenting with ICH as their initial manifestation&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">A total of 31 &#40;56&#46;4&#37;&#41; patients with hemorrhagic BTs &#40;HBTs&#41; were male and 24 &#40;43&#46;6&#37;&#41; were female&#44; with an average age of 53<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12&#46;6 years &#40;range&#44; 21&#8211;76 years&#41;&#46; All patients suffered from an abrupt onset of severe headache &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>55&#44; 100&#37;&#41; in addition to other signs and symptoms of increased intracranial pressure&#44; such as nausea and vomiting &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>26&#44; 47&#46;3&#37;&#41;&#46; These were accompanied by the signs and symptoms of space-occupying lesions of particular brain areas&#44; such as extremity weakness &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>25&#44; 45&#46;4&#37;&#41;&#44; speech disorders &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>24&#44; 43&#46;6&#37;&#41;&#44; and seizures &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>20&#44; 36&#46;3&#37;&#41;&#46; Upon admission&#44; 39 &#40;70&#46;9&#37;&#41; patients had mildly affected LOCs&#44; whereas 11 &#40;20&#37;&#41; and 5 &#40;9&#46;1&#37;&#41; patients had moderately and severely affected LOCs&#44; respectively&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Among the patients with HBTs&#44; 11 &#40;20&#37;&#41; had infratentorial and 44 &#40;80&#37;&#41; had supratentorial lesions&#46; The temporal lobe was the most common site of origin for supratentorial HBTs &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>22&#44; 40&#37;&#41;&#46; Thirty-four &#40;61&#46;8&#37;&#41; patients presented with intraparenchymal HCTs&#44; whereas 16 &#40;29&#46;1&#37;&#41; presented with EIHs&#46; ASH and AEH were observed in 3 &#40;5&#46;5&#37;&#41; and 2 &#40;3&#46;6&#37;&#41; patients&#44; respectively&#46; The demographics&#44; clinical presentation&#44; and general information of patients with HBTs are presented in <a class="elsevierStyleCrossRefs" href="#tbl0005">Tables 1 and 2</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Patients with HCTs mainly presented with mildly affected LOCs &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>33&#44; 97&#46;1&#37;&#41;&#44; except for 1 &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#44; 2&#46;9&#37;&#41; who presented with moderately affected LOCs&#46; In contrast&#44; all but one patient &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#47;16&#44; 6&#46;25&#37;&#41; with EIHs presented with either moderately &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>10&#47;16&#44; 62&#46;5&#37;&#41; or severely &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>5&#47;16&#44; 31&#46;25&#37;&#41; affected LOCs&#46; All cases of tumor-associated AEH &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#47;2&#44; 100&#37;&#41; and ASH &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3&#47;3&#44; 100&#37;&#41; had mildly effected LOC&#46; Either moderately or severely decreased LOCs were significantly more common with EIHs than with HCTs&#44; which was almost always associated with mildly affected LOCs &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;00001&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">All patients in the reported series underwent microsurgical tumor resection as well as hematoma evacuation in cases where the hemorrhage extended beyond the mass&#44; such as the epidural or subdural compartments&#46; In cases where the EIH extending to the ventricles&#44; external ventricular drainage was performed when necessary&#46; During the perioperative stage&#44; 53 cases &#40;96&#46;4&#37;&#41; were cured or showed improvement&#44; whereas 2 &#40;2&#46;6&#37;&#41; died&#46; HGGT &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>25&#47;55&#44; 45&#46;4&#37;&#41; was the leading pathological diagnosis in this series of HBTs followed by MBTs &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>16&#47;55&#44; 29&#37;&#41;&#44; whereas relatively few cases were diagnosed as LGGTs &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>7&#47;55&#44; 12&#46;7&#37;&#41;&#44; &#8220;others&#8221; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#47;55&#44; 7&#46;3&#37;&#41;&#44; and meningiomas &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3&#47;55&#44; 5&#46;5&#37;&#41;&#46; Initial presentation with ICH was observed in 4&#46;8&#37; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>16&#47;335&#41; and 3&#46;74&#37; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>25&#47;668&#41; of all MBTs and HGGTs&#44; respectively&#44; but in only 2&#46;5&#37; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>7&#47;279&#41;&#44; 2&#46;2&#37; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#47;184&#41;&#44; and 0&#46;7&#37; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3&#47;427&#41; of LGGTs&#44; others&#44; and meningiomas&#44; respectively&#46; No significant difference in the frequency of hemorrhagic manifestation was observed between MBTs and HGGTs &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;4026&#41;&#46; Among all hemorrhagic MBTs&#44; lung and bronchial carcinomas &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>5&#47;16&#44; 31&#46;3&#37;&#41; represented the majority of the cases&#44; followed by malignant melanomas &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#47;16&#44; 25&#37;&#41;&#46; Importantly&#44; the frequency of hemorrhagic manifestations of MBTs was the highest for sarcomas &#40;2&#47;8&#44; 25&#37;&#41; and malignant melanomas &#40;4&#47;18&#44; 22&#46;2&#37;&#41;&#46; The distribution of patients with various types of BTs based on clinical presentation&#44; regardless of hemorrhagic status&#44; is presented in <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#46; Hemorrhagic HGGTs mainly presented with HCTs &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>19&#47;25&#44; 76&#46;0&#37;&#41;&#46; The LOCs were mildly affected in all patients with HGGT-associated HCTs &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>19&#47;19&#44; 100&#37;&#41;&#46; However&#44; 80&#37; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#41; of the patients with EIH presented with moderately affected consciousness&#44; except for 1 &#40;20&#37;&#41; who presented with severely affected consciousness&#46; Upon discharge&#44; the overall GOS of patients with hemorrhagic HGGTs ranged from 3 to 5 &#40;mean 3&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;69&#41;&#46; Specifically&#44; patients with HGGT-associated HCTs had a mean GOS of 4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;64 &#40;range&#44; 3&#8211;5&#41;&#44; whereas those with EIHs had a GOS score of 3 upon discharge&#46; MBTs predominantly caused HCTs &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>9&#44; 56&#46;3&#37;&#41;&#44; whereas 4 &#40;25&#46;0&#37;&#41; cases presented with EIHs&#44; 2 &#40;12&#46;5&#37;&#41; with AEH&#44; and 1 &#40;6&#46;2&#37;&#41; with ASH&#46; Except for 1 &#40;11&#46;1&#37;&#41; case with a moderately affected LOC&#44; all patients with HCTs &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>8&#44; 88&#46;9&#37;&#41; displayed mildly affected LOC upon presentation&#46; One patient with EIH owing to a metastatic malignant melanoma&#44; who initially presented with a GCS of 4&#44; died 4 days after surgical resection&#46; Upon discharge&#44; the GOS of the remaining patients with hemorrhagic MBTs ranged from 3 to 5 &#40;mean 4&#46;33<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;7&#41;&#46; Furthermore&#44; patients with HCTs of the MBTs had a mean GOS of 4&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;5 &#40;range 4&#8211;5&#41;&#44; whereas those with EIH had a mean GOS of 3&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;5 &#40;range 3&#8211;4&#44; deceased patient excluded&#41; upon discharge&#46; The patient with ASH had a discharge GOS of 4&#44; whereas both patients with tumor-associated AEH had a GOS of 5&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Six of the patients in the LGGT group had EIH &#40;85&#46;7&#37;&#41; whereas the remaining one patient &#40;14&#46;3&#37;&#41; demonstrated HCT&#46; The difference between the groups was significant &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;00043&#41;&#46; The LOC was severely affected in 2 &#40;33&#46;3&#37;&#41; patients with EIH but only moderately affected in the others &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#44; 66&#46;6&#37;&#41;&#46; The patient with HCT presented with mildly affected LOC&#46; One patient with EIH owing to an LGGT&#44; with an initial GCS of 5&#44; died 11 days after surgical resection of the mass&#46; Upon discharge&#44; the GOS of the remaining patients with hemorrhagic LGGTs ranged from 2 to 4 &#40;mean&#44; 3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;57&#41;&#46; Only one patient with a discharge GOS of 4 presented with a mildly affected LOC owing to an HCT&#46; Those with LGGT-associated EIHs had a mean discharge GOS of 2&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;4 &#40;range 2&#8211;3&#44; deceased patient excluded&#41;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">EIH was not observed in patients with hemorrhagic meningiomas throughout the present series given that all of them presented with mildly affected consciousness &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3&#44; 100&#37;&#41; owing to AEH &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#44; 33&#46;3&#37;&#41;&#44; ASH &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#44; 33&#46;3&#37;&#41;&#44; or HCT &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#44; 33&#46;3&#37;&#41;&#46; Upon discharge&#44; the mean GOS of these patients was 4&#46;33<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;47&#46; Specifically&#44; the patient with HCT had a GOS of 5&#44; whereas the remaining two patients had a GOS of 4 each&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">All patients with tumors classified as &#8220;others&#8221; in this report presented with mildly affected LOC owing to HCTs and a discharge GOS of 5&#46; The distribution of hemorrhage types based on pathological diagnosis of HBTs is presented in <a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Discussion</span><p id="par0080" class="elsevierStylePara elsevierViewall">ICH has been reported in up to 10&#37; of cases with BTs&#44;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">1&#44;6&#44;11&#44;12</span></a> whereas various clinicopathologic series have reported that 0&#46;8&#37;&#8211;7&#46;4&#37; of BTs present with spontaneous ICH&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">12&#44;13</span></a> Given that the hemorrhagic presentation of a previously silent BT is even rarer&#44; current evidence regarding this matter is limited&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The present study showed that among all patients who underwent surgery&#44; 2&#46;9&#37; had previously silent BTs presenting acutely with ICH&#44; which falls within the previously reported range for HBTs&#46; The most common symptoms of HBTs include sudden onset of headache and vomiting&#46; The hemorrhagic event often presents acutely with an abrupt onset&#44; thereby leading to a relatively short symptom duration ranging from a few days to weeks&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">12</span></a> Nonetheless&#44; symptoms may develop more gradually in some cases&#44; before sudden deterioration occurs&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">14&#44;15</span></a> Notably&#44; most patients may also experience new symptoms upon hemorrhaging&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">12&#44;16</span></a> Consistent with previous reports&#44; the present study showed that headache&#44; the most common symptom&#44; was present in all patients&#44; followed by nausea and vomiting&#46; Alterations in the LOCs resulting from the acute increase in intracranial pressure had been observed in majority of the patients&#46; Seizures&#44; a common feature of lobar tumors&#44; were noted in 36&#46;3&#37; of our cases&#46; The rate of dysfunction of the affected brain regions leading to focal deficits depending on its location&#44; such as limb paresis and aphasia&#44; was also consistent with that presented in a previous report&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">16</span></a> Several factors predisposing to tumoral hemorrhage&#44; such as a history of head injury&#44; hypertension&#44; and shunt procedures as well as the use of anticoagulants&#44; have been reported&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">9</span></a> All patients included in the present study were asymptomatic prior to the acute episode experienced&#44; indicating sudden intracranial bleeding owing to the tumor itself&#46; Importantly&#44; none of our patients had a history of recent trauma&#44; vascular disorders&#44; and hematologic&#47;coagulopathic predisposing factors or malignant hypertensive crisis&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Symptomatic tumoral hemorrhage should be suspected in patients with previously known BTs who present with sudden clinical symptoms&#46; Naturally&#44; one should also exclude ICH attributable to other causes&#46; Importantly&#44; although CT is extremely useful for detecting ICH&#44; using only CT to determine the underlying cause of the hemorrhage may be difficult&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">9&#44;17&#44;18</span></a> This can be explained by the similarity between the CT images of tumor-related ICH and spontaneous ICH with vascular causes&#44; such as hypertensive cerebrovascular disease&#44; intracranial aneurysms&#44; and vascular malformations&#46;<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">19&#8211;21</span></a> Moreover&#44; in cases with severe intratumoral bleeding filling the entire lesion&#44; radiological findings would be similar to those of spontaneous ICH owing to other causes&#44; hindering radiologic identification of a BT&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">11&#44;22</span></a> In milder cases of tumoral hemorrhage filling only a portion of the lesion&#44; findings such as a heterogeneous mass lesion with&#47;without a mural nodule and enhancement may be observed&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">11&#44;22&#44;23</span></a> Of note&#44; radiological findings of HBTs are non-specific&#46; However&#44; several hemorrhagic features may indicate BTs as the underlying cause&#44; such as an irregular shape&#44; atypical hemorrhage location&#44;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">1</span></a> solid blood areas or multiple hemorrhages with a heterogeneous appearance&#44;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">24</span></a> and the presence of perihematomal edema&#44; which is a common sign of space-occupying lesions including BTs&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">25</span></a> Notably&#44; conducting a thorough anamnesis of the patients is of immense importance given that tumoral hemorrhage may potentially be the underlying reason for deterioration in the health of young patients with ICH who also have a history of a malignant tumor but no history of hypertension&#46; Therefore&#44; cranial CT followed by postcontrast MRI should be performed in cases suspected as having tumoral hemorrhage&#46; Moreover&#44; in the absence of abnormal initial radiologic findings&#44; cerebral angiography should be considered to rule out a potential underlying vascular pathology&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">In the present series&#44; majority of the cases presenting with tumoral hemorrhage had supratentorial lesions which were most commonly located in the temporal&#44; parietal and frontal lobes&#46; On the other hand&#44; only a handful of the cases presented with hemorrhagic infratentorial lesions&#46; This difference was attributable to the predominance of supratentorial localization of BTs in adult patients&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">26</span></a> Our results were consistent with those presented previously by Wakai et al&#46; and Schrader et al&#46;&#44; who reported that among patients with HBTs&#44; 80&#37; and 76&#37; of supratentorial lesions were predominantly located on the parietal and frontal lobes&#44; respectively&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">1&#44;6</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">In the present series&#44; majority of patients with HBTs presented with HCTs followed by EIH whereas extra-axial hemorrhages&#44; including ASH and AEH&#44; were much less common&#46; A similar classification of the type of hemorrhages had been presented in a previous series&#44; which reported that HCT was the most common type &#40;30&#47;45&#41; of tumor-related hemorrhage followed by intraparenchymal hemorrhage&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">6&#44;27</span></a> Expectedly&#44; HCT primarily resulted in mildly affected LOCs&#44; whereas EIHs were associated with more severely affected LOCs in our series&#46; In other words&#44; although rare&#44; patients with hemorrhagic LGGTs presented with a more severe clinical condition compared to those with hemorrhagic HGGTs and MBTs given that they were primarily associated with extensive parenchymal destruction&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Previously&#44; MBTs have been highlighted as the most common cause of tumor-related ICH&#44; followed by HGGTs<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">28</span></a> and gliomas and certain metastatic tumors&#44; such as malignant melanomas&#44; have been reported to be more frequently associated with ICH compared to benign tumors&#44;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">24</span></a> which may be explained by the characteristic differences of the tumors&#46; In the current study&#44; 5&#37; of the MBT cases but only 3&#46;9&#37; of HGGT cases presented with hemorrhage&#46; However&#44; we found that the majority of the cases that presented with tumoral hemorrhage harbored HGGTs followed by MBTs&#46; In other words&#44; metastatic tumors were more commonly associated with tumoral hemorrhage in our series&#44; consistent with previous reports&#46; Importantly&#44; however&#44; this difference did not reach statistical significance&#46; Majority of cases with hemorrhagic MBTs had lung and bronchial carcinomas&#44; followed by malignant melanomas&#46; These results were comparable with those presented in previous reports&#44; which suggested that lung cancers and malignant melanomas were the most common causes for hemorrhagic MBTs&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">1&#44;27</span></a> Notably&#44; the present series showed that among all MBTs&#44; sarcomas and lymphomas displayed the highest association with hemorrhage&#44; followed by malignant melanomas&#46; The frequency of hemorrhagic manifestations of LGGTs in the present series was greater than that previously reported &#40;i&#46;e&#46;&#44; &#60;1&#37; of all HBTs&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">11&#44;28</span></a> Moreover&#44; our series of HBTs showed that meningiomas were far less common&#46; Although previous studies had reported that up to 14&#37; of meningioma cases presented with tumoral hemorrhage&#44;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">1&#44;27</span></a> low rates&#44; such as that presented herein&#44; have also been reported in other studies&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">6</span></a> Nonetheless&#44; the aforementioned discrepancies between studies in terms of the frequencies of certain pathological diagnoses of HBTs have been basically attributed to differences between the type of tumors dealt with&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Currently&#44; the pathophysiology of intratumoral hemorrhage remains unclear&#46; The presence of immature blood vessels with weak and thin walls<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">6&#44;13</span></a> as well as subdural veins that easily rupture after exposure to factors such as trauma&#44; hypertensive attacks&#44; or coagulopathy<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">9&#44;18&#8211;20</span></a> or spontaneous rupture due to the stretching effect of the rapidly growing tumor leading to necrosis have been proposed as mechanisms for intracranial tumoral hemorrhage&#46; Moreover&#44; the invasion of previously healthy peritumoral vessels may promote tumoral hemorrhage&#46; In LGGTs&#44; the reason behind tumoral hemorrhage is even more inexplicable given the lack of either tumor necrosis or abnormal vessels in this type of tumors&#46; However&#44; the presence of abnormal vessels and endothelial proliferation have been previously suggested as possible reasons for tumoral hemorrhage in LGGTs&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">13&#44;29&#8211;31</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Although previously types of tumor related ICHs were differentiated&#44;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">6&#44;27</span></a> to the best of our knowledge&#44; an association between the tumor type and the hemorrhage type was not questioned before in detail&#46; Interestingly&#44; the present study observed that the type of hemorrhage was associated with the type of tumor&#59; such that HGGTs and MBTs mainly caused HCTs&#44; whereas LGGTs were more commonly associated with EIHs&#46; Current literature shows that the LGGTs as well as HGGTs display diverse biological characteristics depending on their genetic information of subtypes&#44; which is also used for survival prediction&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">32</span></a> Today&#44; it is believed that this may influence the angiogenesis in LGGTs&#44; as well&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">33</span></a> Based on this&#44; although higher grades of gliomas display excessive vascularization with more prevalent angiogenesis compared to LGGT&#44; microvascular proliferation characteristics have gained importance for grading and subtype of LGGTs&#46; It is also well known that LGGTs generally display ill-defined margins of diffuse infiltration areas&#46; Even though offering a well-built hypothesis based on our current knowledge is extremely difficult&#44; we affirm that diffuse infiltrative nature of LGGTs leading to their ill-defined margins together with the presence of weak tumor-associated vessels&#44; which are not adequately supported with the surrounding supportive glial tissue&#44; might be the reason behind their predilection to cause EIHs once they bleed&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">All patients in the present series had undergone emergency or elective microsurgical resection of the hemorrhagic masses and evacuation of the extratumoral hematomas whenever necessary&#46; Except for the two patients who unfortunately died during the postoperative period&#44; the health status of the majority of our patients &#40;96&#46;4&#37;&#41; eventually improved or the patients were cured&#46; Based on this experience&#44; we highlight the importance of surgical resection of the hemorrhagic tumor along with hematoma evacuation given the possibility of tumors with potentially more benign courses causing ICH&#44; such as LGGTs or benign meningiomas&#46; This assertion has been supported by previous studies&#44; emphasizing the importance of the complete surgical resection of hemorrhagic tumors&#44; a significant portion of which consisted of prognostically favorable neoplasms&#44; to eliminate the risk of recurrent tumoral hemorrhage or further tumor growth&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">1&#44;21</span></a> On the other side&#44; our results also stated that almost half of all patients with HBTs harbor HGGT whereas one-third of them harbor MBTs&#46; Although the number cases of the present work is small to make certain conclusions&#44; it should be noted that there is not enough number of studies in the current available literature to draw conclusions on HBTs as well&#46; On this regard&#44; our purpose was to determine the tumor types that may be associated with ICH more commonly and the relationship between the tumor type and the type of the hemorrhage while describing our series&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conclusions</span><p id="par0125" class="elsevierStylePara elsevierViewall">The acute hemorrhagic presentation of a previously silent BT is a rare occurrence&#46; Although any type of tumor can bleed&#44; metastatic tumors and malignant glial tumors&#44; which mainly cause HCTs&#44; have been responsible for the majority of the ICH cases&#46; Nonetheless&#44; despite the benign characteristics of LGGTs&#44; these tumors may result in extensive parenchymal destruction once they bleed&#46; Surgical resection of the hemorrhagic tumor and decompression of the affected brain regions followed by histological confirmation of the pathological diagnosis should be the main goals of treatment in HBT cases&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Author contributions</span><p id="par0130" class="elsevierStylePara elsevierViewall">AT and MKK performed data analysis and wrote the initial draft of the article&#46; PEO performed the statistical analysis&#44; prepared the figures&#44; and revised the paper critically&#46; TK obtained the data&#46; ST performed pathological evaluation and supervised the pathological analysis&#46; AB conceived the study&#44; supervised the data analysis&#44; and critically revised the paper&#46; All authors approved publication and agreed to be accountable for all aspects of the work&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Funding</span><p id="par0135" class="elsevierStylePara elsevierViewall">This research did not receive any specific grant from funding agencies in the public&#44; commercial&#44; or not-for-profit sectors&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conflicts of interest</span><p id="par0140" class="elsevierStylePara elsevierViewall">None&#46;</p></span></span>"
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          "identificador" => "xres1935632"
          "titulo" => "Abstract"
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              "titulo" => "Introduction and objectives"
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          "titulo" => "Abbreviations"
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          "titulo" => "Resumen"
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    "fechaRecibido" => "2022-03-02"
    "fechaAceptado" => "2022-06-12"
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1668181"
          "palabras" => array:5 [
            0 => "Hemorrhagic brain tumor"
            1 => "High-grade glial tumor"
            2 => "Intracranial hemorrhage"
            3 => "Metastatic brain tumor"
            4 => "Low-grade glial tumor"
          ]
        ]
        1 => array:4 [
          "clase" => "abr"
          "titulo" => "Abbreviations"
          "identificador" => "xpalclavsec1668183"
          "palabras" => array:8 [
            0 => "AEH"
            1 => "ASH"
            2 => "BT"
            3 => "CT"
            4 => "EIH"
            5 => "GCS"
            6 => "GOS"
            7 => "HBT"
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          "palabras" => array:5 [
            0 => "Tumor cerebral hemorr&#225;gico"
            1 => "Tumor glial de alto grado"
            2 => "Hemorragia intracraneal"
            3 => "Tumor cerebral metast&#225;sico"
            4 => "Tumor glial de bajo grado"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction and objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Acute presentation with intracranial hemorrhage owing to a previously silent brain tumor &#40;BT&#41; is rare&#46; Although any BT can bleed&#44; the frequency and type of bleeding varies across tumor types&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Materials and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We aimed to retrospectively review our experience with 55 patients with BTs presenting with ICH&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Signs of increased intracranial pressure were the most common symptoms&#46; The temporal lobe was the most common lesion site &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>22&#41;&#46; Hemorrhages were mainly confined to the tumor margins &#40;HCTs&#41; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>34&#41;&#46; Extensive intraparenchymal hemorrhages &#40;EIHs&#41; were mainly associated with moderately&#47;severely decreased levels of consciousness &#40;LOCs&#41; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>15&#47;16&#41;&#46; High-grade glioma &#40;HGGT&#41; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>25&#41; was the leading pathological diagnosis followed by metastasis &#40;MBT&#41; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>16&#47;55&#41;&#46; The hemorrhage type was associated with the pathological diagnosis of the tumor&#46; Patients with HGGT &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>19&#47;25&#41; and MBT &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>9&#47;16&#41; mainly presented with HCTs&#44; whereas low-grade gliomas &#40;LGGT&#41; primarily caused EIHs &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>6&#47;7&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Hemorrhagic presentation is a rare occurrence in BTs&#46; Among all&#44; MBT and HGGT are responsible for majority of the cases&#46; Importantly&#44; despite their relatively benign characteristics&#44; LGGTs mainly result in extensive parenchymal destruction once they bleed&#46; Maximum surgical resection of hemorrhagic BTs and decompression of the affected brain regions followed by histological confirmation of the diagnosis should be the main goals of treatment in cases with hemorrhagic BTs&#46;</p></span>"
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          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Introduction and objectives"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Materials and methods"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n y objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La presentaci&#243;n aguda con hemorragia intracraneal debida a un tumor cerebral &#40;BT&#41; anteriormente silencioso es rara&#46; A pesar de que cualquier BT puede sangrar&#44; la frecuencia y el tipo de sangrado var&#237;an seg&#250;n el tipo de tumor&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Materiales y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Nuestro objetivo fue reexaminar retrospectivamente nuestra experiencia con 55 pacientes con los BT que presentaban HIC&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Los s&#237;ntomas m&#225;s comunes fueron signos de aumento de la presi&#243;n intracraneal&#46; El l&#243;bulo temporal fue el sitio de lesi&#243;n m&#225;s com&#250;n &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>22&#41;&#46; Las hemorragias se limitaron especialmente a los m&#225;rgenes tumorales &#40;HCT&#41; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>34&#41;&#46; Las hemorragias intraparenquimatosas extensas &#40;HIE&#41; se asociaron mayormente con niveles de conciencia moderada&#47;severamente disminuidos &#40;LOC&#41; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>15&#47;16&#41;&#46; El glioma de alto grado &#40;HGGT&#41; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>25&#41; fue el principal diagn&#243;stico patol&#243;gico despu&#233;s de la met&#225;stasis &#40;MBT&#41; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>16&#47;55&#41;&#46; El tipo de hemorragia se asoci&#243; con el diagn&#243;stico patol&#243;gico del tumor&#46; Los pacientes con HGGT &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>19&#47;25&#41; y MBT &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>9&#47;16&#41; presentaron mayormente con HCT&#44; mientras que los gliomas de bajo grado &#40;LGGT&#41; causaron principalmente HIE &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>6&#47;7&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La presentaci&#243;n hemorr&#225;gica es una ocurrencia rara en los BT&#46; Entre todos&#44; MBT y HGGT son responsables de la mayor&#237;a de los casos&#46; M&#225;s importante a&#250;n&#44; pese a sus caracter&#237;sticas relativamente benignas&#44; los LGGT resultan mayormente una destrucci&#243;n extensa del par&#233;nquima una vez que sangran&#46; La resecci&#243;n quir&#250;rgica m&#225;xima de BT hemorr&#225;gicos y la descompresi&#243;n de las regiones cerebrales afectadas con la confirmaci&#243;n histol&#243;gica del diagn&#243;stico deben ser los objetivos principales del tratamiento en casos con BT hemorr&#225;gicos&#46;</p></span>"
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            "titulo" => "Materiales y m&#233;todos"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Axial unenhanced CT scan of the head in a 67-year-old female who presented with sudden severe headache followed by loss of consciousness &#40;GCS&#58; 7&#41;&#46; A left frontal hemorrhagic lesion causing severe midline shift is evident&#46; She was intubated immediately and underwent emergent decompression and resection of the mass&#46; Pathology revealed the diagnosis as metastatic undifferentiated sarcoma&#46; &#40;B&#41; Axial unenhanced CT scan of the head in a 52-year-old male who presented with severe headache&#44; drowsiness&#44; and weakness in the left half of the body &#40;GCS&#58; 15&#41; revealed a right frontal hemorrhagic mass lesion causing significant midline shift and perilesional edema&#46; He underwent urgent excision of the mass&#46; Pathology revealed the diagnosis as anaplastic oligodendroglioma &#40;WHO grade III&#41;&#46; &#40;C&#41; Axial unenhanced CT scan of the head in a 47-year-old woman who presented with headache and sleepiness&#46; Neurological examination revealed decreased level of consciousness and left hemiparesis &#40;GCS&#58; 13&#41;&#46; Her imagings demonstrated a right thalamic lesion with perilesional edema and hemorrhage within the subdural space causing severe midline shift&#46; She underwent emergent evacuation of the mass as well as the hematoma&#46; Pathology confirmed the diagnosis as metastatic over cancer&#46; &#40;D&#41; Axial unenhanced CT scan of the head in a 73-year-old woman who presented with one week of dizziness&#44; headache&#44; and nausea&#46; Neurological examination revealed distortion of the cerebellar tests on the left &#40;GCS&#58; 15&#41;&#46; Her imagings revealed a left cerebellar hemorrhagic lesion compressing the 4th ventricle&#46; She underwent emergent evacuation of the mass&#46; Pathology confirmed the diagnosis as metastatic lesion &#40;primary unknown&#41;&#46;</p>"
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            "Ancho" => 2175
            "Tamanyo" => 152113
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Bar graph showing the distribution of patients with various types of brain tumors based on clinical presentation&#46; Hemorrhagic presentation is indicated in &#8220;blue&#44;&#8221; whereas nonhemorrhagic presentation is indicated in &#8220;red&#46;&#8221; HGGT&#58; high-grade glial tumor&#44; LGGT&#58; low-grade glial tumor&#44; and MBT&#58; metastatic brain tumor&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Fig&#46; 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr3.jpeg"
            "Alto" => 1080
            "Ancho" => 2091
            "Tamanyo" => 108386
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Bar graph showing the distribution of the tumor types based on the pathological diagnosis of the hemorrhagic brain tumors&#46; AEH&#58; acute epidural hemorrhage&#44; ASH&#58; acute subdural hemorrhage&#44; EIH&#58; extensive intraparenchymal hemorrhage&#44; HCT&#58; hemorrhage confined to the tumor&#44; HGGT&#58; high-grade glial tumor&#44; LGGT&#58; low-grade glial tumor&#44; MBT&#58; metastatic brain tumor&#46;</p>"
        ]
      ]
      3 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
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        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at1"
            "detalle" => "Table "
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        "tabla" => array:2 [
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            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Variables&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Number of cases with hemorrhagic brain tumors &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Mean age &#40;range&#41;&#44; years</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">53<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Sex</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Male</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">31 &#40;56&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Female</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24 &#40;43&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">LOC</span><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a><span class="elsevierStyleBold">at presentation</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Mildly affected &#40;GCS</span><a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a><span class="elsevierStyleItalic">13&#8211;15&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">39 &#40;70&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Moderately affected &#40;GCS</span><a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a><span class="elsevierStyleItalic">9&#8211;12&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11 &#40;20&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Severely affected &#40;GCS</span><a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a><span class="elsevierStyleItalic">3&#8211;8&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;9&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Supratentorial</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">44 &#40;80&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Temporal&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22 &#40;40&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Parietal&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">15 &#40;27&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Frontal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 &#40;12&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Infratentorial</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11 &#40;20&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Hemorrhage type</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Confined to the tumor</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">34 &#40;61&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Extensive intraparenchymal hemorrhage</span><span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">expansion into the ventricles</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16 &#40;29&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Acute subdural hemorrhage</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;5&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Acute epidural hemorrhage</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;3&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Pathological diagnosis</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">High-grade glial tumor</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25 &#40;45&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Metastatic tumors</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16 &#40;29&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Low-grade glial tumors</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 &#40;12&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Others</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4 &#40;7&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Meningiomas</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;5&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                  \t\t\t\t">55 &#40;100&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">26 &#40;47&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">24 &#40;43&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">33 &#40;97&#46;2&#41;<a class="elsevierStyleCrossRef" href="#tblfn0015">&#42;</a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1 &#40;2&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Extensive intraparenchymal hemorrhage&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">10 &#40;62&#46;5&#41;<a class="elsevierStyleCrossRef" href="#tblfn0015">&#42;</a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">5 &#40;31&#46;25&#41;<a class="elsevierStyleCrossRef" href="#tblfn0015">&#42;</a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Acute subdural hemorrhage&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3 &#40;100&#41;&nbsp;\t\t\t\t\t\t\n
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                    0 => array:2 [
                      "titulo" => "Spontaneous intracranial haematomas caused by neoplasms"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "B&#46; Schrader"
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                            2 => "E&#46;W&#46; Lang"
                            3 => "R&#46; Buhl"
                            4 => "H&#46;H&#46; Hugo"
                            5 => "J&#46; Biederer"
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                        "tituloSerie" => "Acta Neurochir"
                        "fecha" => "2000"
                        "volumen" => "142"
                        "paginaInicial" => "979"
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11086806"
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                      "titulo" => "Neurinomas presenting as spontaneous intratumoral hemorrhage"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "S&#46; Asari"
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                            2 => "T&#46; Itoh"
                            3 => "S&#46; Tsuchida"
                            4 => "T&#46; Furuta"
                            5 => "T&#46; Ohmoto"
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                      "titulo" => "Tumor hemorrhage in intracranial tumors"
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                        "tituloSerie" => "Neurochirurgia &#40;Stuttg&#41;"
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                      "titulo" => "Intracerebral tumor-associated hemorrhage caused by overexpression of the vascular endothelial growth factor isoforms VEGF121 and VEGF165 but not VEGF189"
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                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Acta Neurol Belg"
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