Brain Mass
Student Name: Jack Li
Period: 3
Date: 7/22/09
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
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
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
T1
T2
T2 FLAIR
T1 Coronal
T1 Sagittal
Differential Diagnosis
– Glioblastoma multiforme
– Astrocytoma
– Primary CNS Lymphoma
Diagnosis
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
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
Post-Tumor Debulking T1
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