Background: Small cell neuroendocrine carcinomas (SCNECs) are highly aggressive malignancies with a marked propensity for early metastasis. Osteodural involvement is exceptionally rare and may present as acute intracranial hemorrhage, closely mimicking a traumatic extradural hematoma and generating significant diagnostic and medico legal uncertainty.

Case presentation: We report the case of a 69-year-old homeless woman with a history of chronic alcohol and tobacco use, found unconscious in a public street. Initial non-contrast CT imaging demonstrated a large right frontal heterogeneous extradural hematoma with significant mass effect, an associated subgaleal hematoma with intraorbital extension, and a non- displaced orbital wall fracture. Emergency decompressive craniotomy revealed an abnormal fibrotic extradural mass rather than a purely traumatic hematoma. Despite initial postoperative neurological improvement, the patient subsequently deteriorated and died seven days later. Autopsy and histopathological examination identified an osteodural metastasis of a poorly differentiated small cell neuroendocrine carcinoma, confirmed by immunohistochemical positivity for CK AE1/AE3, chromogranin A, synaptophysin, and TTF-1. No primary tumor site could be identified despite a complete post-mortem examination. Minor craniofacial traumatic lesions were present but were insufficient to account for death. An incidental mature ovarian teratoma was also noted.

Conclusion: Death resulted from acute intracranial hypertension secondary to hemorrhagic transformation of an osteodural metastatic SCNEC, with minor trauma considered contributory but non-lethal. This case highlights the potential for metastatic disease to masquerade as traumatic intracranial hemorrhage and underscores the indispensable role of histopathology and autopsy in resolving diagnostic ambiguity and ensuring accurate medico-legal determination of the cause of death, particularly in socially vulnerable individuals.

Related Papers: