• History & Physical: This is a 46-year-old female who became progressively lethargic and bedridden, brought to the hospital by her family. On arrival, the patient was noted to be arousable to voice and oriented to person only. She denied any nausea, vomiting, headaches, fevers or chills, or other neurologic symptoms. Her past medical history noted hypertension and non-insulin dependent diabetes mellitus. Physical examination noted a lethargic patient following simple commands with motor strength of 4/5 bilaterally and sensory intact to light touch/pin prick in all extremities.

    Imaging: CT of the head was obtained showing a large left frontal lesion with 1.5 cm mid-line shift. MRI follow-up noted a 7x7x7 cm lesion that enhanced with contrast.

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    1. The diagnosis of this lesion is most likely:

    2. The treatment option of choice in this patient is:

    3. The optimal option offered to this patient would be:

    4. The optimal surgical approach to this lesion would be:

    5. Adjunctive treatments offered based on presumptive diagnosis (Question 1) would include:

    6. Please provide any comments or suggestions regarding management of this case:

    "If GBM would do Gliadel wafers at first operation."

    "Obviously a very aggressive tumor in the dominant hemisphere..likely GBM which precludes frontal lobectomy. I would debulk aggressively with speech mapping if needed..followed by whole brain radiation and if residual is less than 4 cm consider stereotactic radiosurgery boost"

    "Preoperative steroids, anticonvulsants, Radical excision, use image guidance and intraop ultrasound"

    "despite absence of a tail this still could be a meningioma vs glioma or highgrade oligo. 2 day of steroids then Radical resection c image guidance would be my choice in this young patient"

    "Fundoscopy?? R/O Foster Kenedy syndrome"

    "Appears extra axial but could be a glioma"

    "1-Right hemispher's (convexity)image is not better. May be there is a hyperintense lesion? (Coranal image?) 2-Right occipital lesion may be ischemic lesion?"

    "A meningioma is vascular in nature. I will try to reduce the flow of blood to the region and bypass the flow to other region. Maybe this will reduce the size of the lesion."

    "pre op steroid treatment"

    "preoperative emboliztion of the vascular supply give the appearence of flow voids on the MRI"

    "Pre-op embolization"

    "I think this case is a glioma and an oligodendroglioma is more effectiveness, despite that there is no epilepsy in the story of the patient. it is infiltrating the cerebral matter,some kystic formations or necrotic lesion inside ,it take contrast with gadolinium.this tumor can be all removed by transulcal approach. if the histological diagnosis confirmated our presomption of an oligodendroglioma the following treatement is a radiotherapy."

    "surgery post decadron and dilantin load unless there is clinical deterioration"

    "Unable to magnify the images, therefore not well visualized..."

    "operation at once"

    "In addition to the diagnoses listed I would add a few more in light of its unusual signal characteristics on the MRI. These would include gliosarcoma, meningioma (malignant), hemangiopericytoma and with the patient's history of diabetes consider mucormycosis. I would favor in this case a large metastasis."

    "In addition to the diagnoses listed I would add a few more in light of its unusual signal characteristics on the MRI. These would include gliosarcoma, meningioma (malignant), hemangiopericytoma and with the patient's history of diabetes consider mucormycosis. I would favor in this case a large metastasis."

    "Pay attention to laguage and QOL"

    "Emergency situation. Surgery is important"

    "- Where's the axial post-gadolinium? - Send pat. to the neuroICU, start dexamethasone and possibly manitol. - If it's really a meningioma and the resection is complete there is no immediate need for adjuvant chemo/radiotherapy."

    "gentile delivery of the mass, be carful about cortical vesseles, intense measurgers to decrease ICP,postoperative hyperventilation."

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