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Brain Mass

Detailed clinical case of a 69-year-old male presenting with weakness and visual symptoms, leading to a diagnosis of a glioblastoma multiforme. Includes history, examination findings, lab results, imaging, and differential diagnoses.

jerrymcbride
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Brain Mass

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  1. Brain Mass Student Name: Jack Li Period: 3 Date: 7/22/09

  2. History • 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

  3. Physical 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

  4. Findings • 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

  5. T1

  6. T2

  7. T2 FLAIR

  8. T1 Coronal

  9. T1 Sagittal

  10. Differential Diagnosis • Glioblastoma multiforme • Astrocytoma • Primary CNS Lymphoma

  11. Diagnosis Glioblastoma multiforme

  12. 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

  13. MRI • 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

  14. Post-Tumor Debulking T1

  15. References • 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

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