Virtual patient example
An intracranial mass lesion
www.ebrainJNC.com
Instructions
Slides must all have a title, content and branches.
Title
Should be brief and unique within this presentation
Content
Can include text, images, audio, video etc.
Try to keep it to one slide and avoid overcrowding – if essential a second slide can be
used.
Please use red text to give instructions to editors
Branches
The branch options should be a question followed by a number of answers
For each answer give the title of the destination slide to link to
Maximum of four answers, minimum of two
Alternatively just put “next” and give destination if there is only one route from that
slide
Presentation
A 55 year old male patient presents to you in
outpatients with a 3 week history of progressive
right sided hemiparesis. They were previously fit
and well. They have smoked for 20 years. There
is a cough that has been a bit worse over the last
few months. There is 2 stone of weight loss.
Please insert
suitable stock
image – male
patient with a
cough perhaps
Question text: What investigations would you arrange?
Answer 1: Chest x-ray
Link to page: Chest x-ray
Answer 2: CT scan brain
Link to page: CT Brain
Answer 3: Blood tests
Link to page: Bloods
Answer 4: No more of these tests - move on
Link to page: second line tests
Here is the chest x-ray.
Question text:
Chest x-ray
What does the x-ray show?
Answer 1: Lung mass
Link to page: CXR answer
Answer 2: Normal
Link to page: CXR answer
Answer 3: Return to previous slide
Link to page: Presentation
Answer 4:
Link to page
The chest x-ray is normal
CXR answer
Question text:
Answer 1: Next
Link to page: Presentation
Answer 2:
Link to page:
Answer 3:
Link to page:
Answer 4:
Link to page
CT Brain
This is the contrast enhanced CT scan of the brain.
What is the most likely diagnosis?
Question text: what does the scan show?
Answer 1: An Abscess
Link to page: CT brain answer
Answer 2: A primary brain tumour
Link to page: CT brain answer
Answer 3: A secondary brain tumour
Link to page: CT brain answer
Answer 4:
Link to page
CT brain answer
The scan shows a left sided 2.5cm lesion.
Note
1. The dark core - this is either cystic fluid or necrosis.
2. The bright rim - this is the active tumour or infection.
When compared to the precontrast scan there was
a brighter appearance - this is called “ring
enhancement”.
3. The peritumoural odoema - here it is not severe.
Peritumoural odoema is more marked in
metastases than primary tumours.
Whilst this could be a primary tumour, metastatic
tumour or abscess, with these appearances it is
probably most likely to be a primary tumour
Question text:
Answer 1: Next
Link to page: Presentation
Answer 2:
Link to page
Answer 3:
Link to page
Answer 4:
Link to page
Bloods
Which of the following blood tests would you organise
and why?
Please insert
suitable stock
image – blood
tubes, blood test
image or the like
Full blood count
U&E
CRP / ESR
Blood cultures
Blood gases
PSA / CEA or other tumour markers
Question text:
Answer 1: Next
Link to page: Bloods answers
Answer 2:
Link to page
Answer 3:
Link to page
Answer 4:
Link to page
Bloods answers
The blood results are shown opposite.
Here are the blood results
Full blood count - certainly relevant but note that the
white cell count is frequently normal even in
patients with a cerebral abscess. Remember
dexamethasone pushes up the white cell count.
U&E - certainly relevant
CRP / ESR - these are sometimes useful to monitor
change especially in abscesses but a one off
measurement is difficult to interpret.
Blood cultures - perhaps if you think this is an abscess
Blood gases - surely not
PSA / CEA or other tumour markers - advocated by
some but prostate very rarely metastasises to the
brain and tumour markers are rarely helpful.
Hb
WCC
Plts
12.6
9.2
198
Na+
K+
Urea
139
4.2
4.0
CRP
4
Question text:
Answer 1: Return to presentation
Link to page: Presentation
Answer 2:
Link to page
Answer 3:
Link to page
Answer 4:
Link to page
Second line tests
So we now know that we have a man with a cerebral
lesion, probably a primary but could also be a
metastasis or an abscess. What other tests might
be relevant?
Question text:
Answer 1: CT chest abdo pelvis
Link to page: CT Chest abdo pelvis
Answer 2: MRI brain
Link to page: MRI brain
Answer 3: Echo
Link to page: Echo wait
Answer 4: Move on to management
Link to page: Management
CT Chest abdo pelvis
A representative slice from the CT of the chest
abdomen and pelvis is shown opposite - the scan
was normal.
This investigation is essential if (as here) there is a
possibility that this is a metastasis.
However in patients with an obvious primary brain
tumour on brain imaging a normal chest x-ray is
probably adequate.
Question text:
Answer 1: Next
Link to page: Second line tests
Answer 2:
Link to page:
Answer 3:
Link to page:
Answer 4:
Link to page:
MRI brain
A representative slice of the MR is shown opposite this is a T1, gadolinium enhanced sequence - it
shows the single lesion, demonstrates that it is
premotor (frontal) and whilst not shown on this
slice also showed that the core is cystic.
An MRI of the brain is essential in metastatic disease 50% of patients with a single metastasis on CT
will be shown to have multiple metastases on
MRI.
An MRI of the brain has also become a standard
investigation for most patients with primary brain
tumours as well.
Question text:
Answer 1: Next
Link to page: Next
Answer 2:
Link to page:
Answer 3:
Link to page:
Answer 4:
Link to page:
Echo wait
The echo will take a week - do you want to wait?
Question text:
Answer 1: wait
Link to page: dead
Answer 2: don’t wait
Link to page: echo answer
Answer 3:
Link to page:
Answer 4:
Link to page:
Echo still wait
Two days later the patient’s hemiplegia is a bit worse they seem a bit more confused. You give them
some dexamethasone.
Are you still going to wait for the Echo?
Question text:
Answer 1: wait
Link to page: dead
Answer 2: don’t wait
Link to page: echo answer
Answer 3:
Link to page:
Answer 4:
Link to page:
Dead
4 days later the patient has a seizure, fails to regain
consciousness and is ventilated. A repeat CT
scan shows extensive enlargement of the mass
lesion and severe cerebral odoema.
The patient dies
Please insert
suitable stock
image – coffin
perhaps?
At post mortem the lesion is found to be a cerebral
abscess, it has enlarged, burst into the ventricle
and the patient has died from ventriculitis.
There was no endocarditis - there was a tooth
abscess.
Question text:
Answer 1: Restart
Link to page: presentation
Answer 2:
Link to page:
Answer 3:
Link to page:
Answer 4:
Link to page:
Echo answer
An Echo to rule out bacterial endocarditis is relevant if
this is a cerebral abscess but don’t let it delay
treatment.
It would therefore be quite uncommon to organise this
at this stage.
Question text:
Answer 1: Next
Link to page: second line tests
Answer 2:
Link to page:
Answer 3:
Link to page:
Answer 4:
Link to page:
Management
So we now know that we have a man with a cerebral
lesion, probably a primary but could also be a
metastasis or an abscess.
This is an isolated lesion - there is no disease on the
CT of the chest abdomen and pelvis or elsewhere
in the brain on MR.
How do you want to manage this patient?
Question text:
Answer 1: Dexamethasone
Link to page: Dexamethasone
Answer 2: Biopsy
Link to page: Biopsy
Answer 3: Whole brain radiotherapy
Link to page: Whole brain radiotherapy
Answer 4: Watch and wait
Link to page: dead
Dexamethasone
What dose of dexamethasone would you use?
What other drugs should be prescribed at the same
time?
The 1/2 life of dexamethasone is 48 hours - what are
the implications of this?
Do we have a
picture of
dexamethasone
tablets or the
bottle
Question text:
Answer 1: 4mgs qds
Link to page: Dexamethasone answer
Answer 2: 16mgs od
Link to page: Dexamethasone answer
Answer 3: 2 mgs qds
Link to page: Dexamethasone answer
Answer 4:
Link to page:
Dexamethasone answer
The traditional dexamethasone dose of 4mgs qds is
now outdated. It should be given once a day in
the morning. This way the insomnia can be
minimised.
It should always be prescribed with a proton pump
inhibitor or other medication to protect the gastric
mucosa. Nystatin lozenges can also be
considered as oral thrush is common.
Do we have a
picture of
dexamethasone
tablets or the
bottle
The long half life means that the drug accumulates
and does not reach steady state until about 5 days
after a change of dose.
Question text:
Answer 1: Next
Link to page: Management
Answer 2:
Link to page:
Answer 3:
Link to page:
Answer 4:
Link to page:
Biopsy
The patient has an image guided biopsy.
Pus is found and microbiology confirms that this is a
staph aureus abscess.
The patient is treated with antibiotics for six weeks.
Subsequently a tooth abscess is found. The
patient makes a full recovery.
Well done!
Question text:
Answer 1: Summary slide
Link to page: summary slide
Answer 2:
Link to page:
Answer 3:
Link to page:
Answer 4:
Link to page:
Radiotherapy
Radiotherapy options here would include stereotactic
radiosurgery, fractionated radiotherapy (whole
brain or focused on mass).
The oncology team rather reluctantly agree to proceed
with radiotherapy after an MDT confirms that this
is thought to be a cerebral primary brain tumour.
Suitable stock
radiotherapy
image perhaps
Question text:
Answer 1: Next
Link to page: Dead
Answer 2:
Link to page:
Answer 3:
Link to page:
Answer 4:
Link to page:
Summary slide
These are the main learning points:
1. It is not possible to distinguish reliably between primary
tumours, secondary tumours and abscesses on scans.
2. A CT of chest abdomen and pelvis and an MRI scan of the
brain are essential if there is a suspicion of metastatic
disease.
3. Don’t delay management of these patients - fast treatment
has been shown to improve outcomes in tumours and can
be life saving in abscesses.
4. Dexamethasone has a long half life - it can be given once a
day and takes a long time to reach a steady state. A
proton pump inhibitor should be prescribed concurrently.
5. Don’t give radiotherapy without a histological diagnosis
CXR answer
Chest x-ray
Start
Presentation
CT Brain
CT brain answer
Bloods
Bloods answer
CT Chest abdo pelvis
MRI brain
Echo answer
2nd line tests
Echo wait
Echo still wait
Dead
Watch and wait
Management
Radiotherapy
Dexamethasone
Biopsy
Summary slide
Dexamethasone
answer