Brain MassBrain Mass

Student Name: Jack LiPeriod: 3 Date: 7/22/09

HistoryHistory• CC: “weakness”• HPI: 69 yo ♂ c/o worsening L upper and lower extremity

weakness x 2 mos, frequent falls to the left, persistent “travelling” black dot in L eye, Ø vertigo, nausea, vomiting, weight loss, F/C, but + night sweats x 2-3 yrs

• PMH: arthritis, ?steel fragment in L eye, self-limited hematuria x1yr

• FHx: +DM, emphysema, father died ~age 60 for unknown cause, no hx of cancers noted

• SHx: prior smoker 25+ pack-yrs, hx EtOH, no IVDU, +asbestos/lead exposure, lives at home w/ wife

• Meds: aleve, vitamin E, garlic pills• Allergies: NKDA• ROS: + urinary hesitancy, dribbling, chronic cough

Physical Exam and LabsPhysical Exam and Labs• Physical exam:

– Vitals: T 97.6 HR 67 RR 10 BP 154/92 97% RA– Neuro:

• CN 2-12: L facial droop, o/w grossly intact• Strength: 4/5 on L• Sensation: intact bilaterally• DTR: hyper-reflexia on L, 1+ R, beat L ankle clonus, Babinski

indeterminate• Cerebellar: sluggish on L

– No other significant findings• Labs:

– WBC: 6.7– Hgb: 14.3– Plts: 201– Na 140, K 3.6, Cl 107, bicarb 26, BUN 13, Cr 1.0, Gluc 106– protein 6.6, albumin 4.0– AST/ALT/alk. phos: 18/16/68– INR 1.1

FindingsFindings• MRI Brain

• Loss of normal gray white matter differentiation on R temporal lobe insula with hypoattenuation suggesting necrosis

• Mass measured to be 8.7 x 4.7 x 5.2 cm• Small focal high signal intensities in operculum and

lateral margins of basal ganglia suggesting microhemorrhages or calcifications

• Moderate mass effect with vasogenic edema and shift to the left by 1.3 cm with mild transfalcial herniation

• Well-defined neovascularity around periphery of tumor, suggesting aggressive behavior of disease process

T1T1

T2T2

T2 FLAIRT2 FLAIR

T1 CoronalT1 Coronal

T1 SagittalT1 Sagittal

Differential DiagnosisDifferential Diagnosis– Glioblastoma multiforme– Astrocytoma– Primary CNS Lymphoma

DiagnosisDiagnosis

Glioblastoma multiforme

Glioblastoma Multiforme• Epidemiology:

– Accounts for 70% of all brain tumors– Higher incidence in more developed nations

• Pathophysiology:– Arise from neural progenitor cells/multipotent stem cells

• Clinical sxs: – General: headaches, seizures, nausea/vomiting, syncope,

cognitive dysfunction– Focal: weakness, sensory loss, aphasia, visual-spatial

dysfunction• Diagnosis:

– MRI (functional, perfusion)– Magnetic resonance spectroscopy (MRS)– CT/PET/SPECT

MRIMRI

• Gadolinium-enhanced MRI usually only test needed to evaluate brain tumor

Advantages: • Superior evaluation of

surrounding soft tissue (meninges, subarachnoid space, posterior fossa)

• Can define vasculature distribution around abnormality

• No radiation

Disadvantages:• Expensive ($3000-$4000)• Difficult exam (motion

artifacts, claustrophobia)• Pacemakers are

contraindicated

Post-Tumor Debulking T1Post-Tumor Debulking T1

ReferencesReferences• Ohgaki H. Epidemiology of brain tumors. Methods Mol Biol.

2009;472:323-42.• Pathogenesis and biology of malignant gliomas. UptoDate 2009.• Gutin, PH, Posner, JB. Neuro-oncology: diagnosis and management

of cerebral gliomas--past, present, and future. Neurosurgery 2000; 47:1.

• Radiographic images obtained from VA CPRS/Stentor• Cost information from Complete Guide to Medical Tests by H. Winter

Griffin, MD