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: Pathogenesis and biology of malignant gliomas. UptoDate 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