• HPI: A 35-year-old right-handed man who underwent surgical resection of an epidermoid tumor within the left temporal lobe 12 years ago at an outside hospital. His initial presentation at that time were seizures with an aura of smell. He was followed for several years with brain MRIs but no recurrence; he did not undergo any chemotherapy or radiation therapy. Eight years ago he developed his first grand mal seizure. Over the past several years these have been increasing. He has been on many antiepileptics with varying doses but feels his seizure frequency is possibly increasing. His neurologist ordered an MRI of the brain (see below) and refers the patient to your clinic for further evaluation and management recommendations. He denies any recent fevers, chills, weight loss or other constitutional symptoms. 

    PMH: 
    1. Orchiectomy 10 years ago for an undescended right testicle 
    2. Diabetes 

    SOCIAL HISTORY: The patient works as a computer animator. He is married and has two children. (+) tobacco history of 1 pack per year X 15 years. Social alcohol use. 

    FAMILY HISTORY: His mother has CLL in his mother. 

    CURRENT MEDICATIONS: 
    1. Lamictal 200 mg p.o. every morning, 300 mg p.o. every evening. 
    2. Dilantin 200 mg p.o. every morning and 300 mg p.o. every evening. 

    ALLERGIES/MEDICATIONS: Contrast dye. 

    PHYSICAL EXAMINATION: Afebrile. BP 124/70. Neurological examination is completely normal with a well-healed, left-sided pterional craniotomy incision. 

    RADIOGRAPHICAL IMAGING: A brain MRI scan three years ago was negative. 

    Figure 4. The original patient images from the patient’s first surgery were not present. The Diffusion Weighted Images (DWI) from his most recent MRI of the brain showed the following (Below).

    Figure 1. Current brain MRI. Left: axial T1 with contrast. Right: axial T2 flair.

    Figure 2. Left: axial T1 with contrast. Right: axial T2 flair.

    Figure 3. Left: sagittal T1. Right: coronal T2 flair.

    Figure 4. Pathology demonstrated Epidermoid Tumor.

    1. Is any further diagnosic testing warranted?

    2. What is the next best step in management?

    3. If surgery is warranted, what would you surgical plan be?

    4. Would you use intra-operative monitoring?

    5. Please add any suggestions or comments regarding this case:

    + restriction of diffusion + PMH of epidermoid tumor = Epidermoid Kyst

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