Lion in Sheep’s Clothing: Glioblastoma Mimicking Intracranial Hemorrhage

Intracranial hemorrhage (ICH) as a unique image finding, is a rare presentation of glioblastoma (GBM), and can pose a diagnostic challenge. Hypertensive vascular changes are responsible for the majority of the ICH cases, where hemorrhage from brain tumors account only for 5.1% to 7.2% of cases and, the etiology seems to be multifactorial. We present a clinical case of a 70-year-old male who came to the emergency department after a syncopal episode at the workplace, associated with nausea and vomiting. Computed tomography scan and magnetic resonance imaging showed intracranial subdural hematoma, subarachnoidal and interventricular hemorrhage without any underlying lesion. Follow-up imaging in one month showed a new ICH with a thick peripheral mass concerning an underlying neoplasm. The patient underwent tumor resection and immunohistochemical staining confirmed glioblastoma. Despite a multiapproach treatment, including, chemotherapy, radiotherapy, and follow-up surgery, the outcome was poor. GBM is a great mimicker and may initially present with unassuming intracranial hemorrhage with a much more sinister hidden diagnosis. A high index of suspicion on initial imaging based on the patient’s demographics with early tissue diagnosis is crucial in arriving at the correct diagnosis. This case reinforces the importance of close interval follow-up in patients with spontaneous ICH, maintaining a high suspicion for brain tumors. To date, GBM remains a poor prognosis despite combined surgery, chemotherapy, and radiotherapy treatment.