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Grand Ward Rounds - 20/3/2008 -

Grand Ward Rounds - 20/3/2008 -. - Dr Angeline Yong. Case 1. 46/Chinese/Female Factory worker No PMHx of note Presented on 25/2/2008 with C/o: Intermittent BOV over LE x 6/12 - generalised darkening of vision during attacks lasting a few seconds - no neurological deficits

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Grand Ward Rounds - 20/3/2008 -

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  1. Grand Ward Rounds - 20/3/2008 - - Dr Angeline Yong

  2. Case 1 • 46/Chinese/Female • Factory worker • No PMHx of note • Presented on 25/2/2008 with • C/o: Intermittent BOV over LE x 6/12 • - generalised darkening of vision during attacks lasting a few seconds • - no neurological deficits • - no headache/nausea and vomitting

  3. Case 1 • O/e: • VA - OD: 6/7.5-1 • OS: 6/15 --> 6/12 • IOP - OD: 14 mmHg • OS: 17 mmHg • Left RAPD • Left red desaturation and decrease in light sensitivity (40% of right eye) • Ishihara color vision - OD: 13/15 OS: 15/15 • EOM full

  4. Case 1 • HVF - OD: normal OS: Patchy non-specific losses, enlarged blind spot

  5. Case 1 • Anterior segment: • Early cataracts R/L - NS + • Cornea clear • AC D&Q

  6. Case 1 Posterior segment: • OD: Optic disc normal in appearance - pink and healthy • OS: Swollen left optic disc - ?chronic in appearance. No Haemorrhage/CWS. Macula/Retina - NAD

  7. Case 1 • Bp checked - 144/96 mmHg, HR 66 bpm • Imp - Left chronic swollen disc • ??cause

  8. Case 1 • Patient referred to neuro-ophthalmology and underwent MRI Brain in the meantime

  9. Case 1 -MRI

  10. Case 1 -MRI

  11. Case 1 -MRI

  12. Case 1 • MRI Brain (with contrast) - Diffuse thickening of left orbital nerve sheath which also shows homogenous contrast enhancement. Two lobulated enhancing mass lesions noted in the left anterior paraclinoid region, measuring 6 mm and 8 mm in diameter and appear to be in continuity with the thickened nerve sheath. • Both globes and bilateral ocular muscles unremarkable. Pituitary gland and stalk are normal in appearance.

  13. Case 1 • MRI is the preferred imaging method because it can show the dural origin of the tumor in most cases. The typical meningioma is isointense or hypointense to gray matter on T1 with strong homogeneous enhancement with gadolinium.

  14. Case 1 • Diagnosis - Left paraclinoid meningioma with extension along left orbital nerve sheath.

  15. Case 1 • Differentials? Several other disease processes have a propensity for involving the dura or subdural space resulting in an appearance that may suggest meningioma. These include: • 1. Lymphoma • 2. Metastatic carcinoma • 3. Inflammatory lesion such as sarcoidosis and Wegener’s granulomatosis • 4. Infections such as tuberculosis.

  16. Case 1 • Further Mx - • Patient was subsequently referred to neurosurgery and was seen on 29/2/2008 by Prof Ong Peck Leong • Dx and option of surgery was discussed with patient • Meningioma - benign tumour, but if continues to grow will lead to blindness. • Prognosis of surgery- 90% maintain vision of which 50% will improvement. 10% risk of blindness • Other risks of surgery - stroke - 5% (because of ICA invasion) pituitary dysfunction - 1% death - 1% Major complications incl infection/ bleeding = 15%

  17. Case 1 • Patient decided for excision of left paraclinoid meningioma • Admitted on 2/3/2008 for surgery on 3/3/2008 • Intra-op findings: Soft pinkish moderately vascular tumor encasing around both the optic nerves and the left ICA. • Histology: Meningioma, WHO grade II • Patient discharged well on 10/3/2008 (POD 7)

  18. Case 1- Discussion • Meningiomas arise from the arachnoid cap cells of the arachnoid villi of the meninges; 90% of which are benign

  19. Case 1 - Discussion Epidemiology --- • In a 1995 analysis of data from the Surveillance, Epidemiology and End Rsults (SEER) program of the National Cancer Institute, meningioma was the second most frequent primary brain tumor.1 • Overall the incidence is approximately 6 per 100,000 and meningiomas account for 13 to 26 percent of primary intracranial tumors.1-3 • Meningiomas are common between the ages of 40 to 70 and are 2 to 3 x more prevalent in females than in males. 2 1. Radhakrishnan, D, Mokri, et al. The trends in incidence of primary brain tuors in the population of Rochester, minnesota. Ann. Neurol 1995; 37:67 2. Longstreth, WTJr, et al. epidemiology of intracranial meningioma. Cancer 1993; 72:639. 3. Whittle, IR, Smith, et al. Meningiomas. Lancet 2004; 363:1535.

  20. Case 1 - Discussion • Meningiomas can arise from the dura at any site, most commonly the skull vault and at sites of dural reflection (eg falx cerebri, tentorium cerebelli, dura of adjacent venous sinuses). • Less common sites include the optic nerve sheath and choroid plexus.

  21. Case 1 - Discussion • Clinical presentation - • Many meningiomas are asymptomatic and discovered incidentally on a neuroimaging study or at atopsy where incidence rates are 1 to 2 percent. • Symptomatic intracranial meningiomas on the other hand present commonly with a focal or generalised seizureor a gradually worsening neurologic deficit.

  22. Case 1 - Discussion Focal findings - Characteristic focal deficits are caused by tumors in specific locations: • Visual changes - though often unrecognised, are common in meningiomas. 2. Hearing loss - cerebellopontine angle meningiomas can produce SNHL. 3. Mental status changes - neglect/inattention may result from large subfrontal/sphenoid ridge meningiomas. 4. Extremity weakness - parasagittal meningiomas growing on the falx against the motor strip can lead to bilat. Leg weakness. 5. Obstructive hydrocephalus - Large tumors in the posterior cranial fossa can cause obstructive hydrocephalus and present with papilledema and early morning headache

  23. Case 1 - Discussion In one series of 80 patients, approximately 1/3 had ophthalmologic symptoms including visual field loss, field defects, and diplopia.4 • Visual field defects in particular may be caused by parasellar meningiomas. • Progressive unilateral visual loss which may be mistaken for optic neuritis (like our patient), may be caused by optic nerve sheath meningiomas. • Mild extraocular movement weakness by cavernous sinus meningiomas. • Foster-Kennedy sydrome - which is optic atrophy in one eye and papilledema in the other, may be produced by parasellar or subfrontal meningiomas. 4. Anderson, D, Khalil, M. Meningioma and the ophthalmologist. A review of 80 cases. Ophtahalmology 1981; 88:1004

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