• HPI: A 45-year-old Hispanic right-handed female presents with a 1-week history of headaches on the right side of her head and some associated neck pain. She initially presented to her primary care physician who treated her for muscle spasms with muscle relaxants. She did not find any benefit from this treatment. On the morning prior to her admission to the hospital she awoke with a severe headache and had multiple bouts of emesis. She presented to her local emergency room where a CT of the head without contrast demonstrated a right frontotemporal mass with surrounding edema and midline shift (Figure 1). She is transferred to your facility for further evaluation and management. She denies any seizures or weakness. No recent travel or fevers. 

    PMH/PSH: None 

    SOCIAL HISTORY: Married with 3 healthy children. No tobacco, alcohol, or other illicit drug use. She has lived in the U.S. for the past 35 years. 

    CURRENT MEDICATIONS: Muscle relaxants (she cannot recall the name)
    Tylenol PRN 

    FAMILY HISTORY: Father with cardiac disease and lung cancer. “Several” people in her family with diabetes. 

    PHYSICAL EXAMINATION: 
    Vitals: BP 134/77, temp 37.7, pulse 68. 
    Pertinent findings: She has a completely normal physical examination. 

    LABS: all normal 

    Figure 2. (Below) MRI/MRA brain with and without contrast. There is a 5.7 cm (AP) x 4.0 cm (transverse) x 3.6 cm (SI) T2 hyperintense, predominantly peripherally enhancing mass centered within the right hippocampal gyrus with mass-effect upon the right temporal horn and mesencephalon. Abnormal enhancement is noted along the right occipital horn consistent with subependymal spread. Increased signal is noted within the optic chiasm and right optic tract raising concern for infiltration of those structures. A moderate amount of surrounding vasogenic edema is noted throughout the right anterior temporal lobe white matter as well as the right inferior frontal lobe. There is 1.4 cm of right-to-left midline shift.

    Figure 1. Head CT without contrast (non-serial sections).

    Figure 2. An MRI/MRA of the brain is obtained.

     

    1. What is your most likely diagnosis?

    2. What is the next step in your management?

    3. What is your surgical management?

    4. What would be your surgical plan for this patient?

    5. What is your surgical approach?

    6. Would you do a formal angiogram with endovascular occlusion of feeding vessels prior to surgery?

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

    This is an obvious glioblastoma multiforme with rapid growth indicated by the surrounding edema and necrotic center. There is no need for a biopsy stereotacticly. Endovascular occlusion is not necessary because, as demonstrated on the arteriogram, the tumor is relatively avascular. The purpose of the surgery is to reduce the tumor cell mass to give radiation and chemotherapy a chance to be more effective.

    The patient is taken to the OR and you find there is infiltration of the hippocampus and mesial temporal lobe with the majority of the tumor centered in the lateral ventricle. The surgery goes uneventfully you achieve gross-total resection of the intraventricular portion and medial temporal lobe. Final pathology reveals Grade IV Astrocytoma according to Ann-Mayo criteria. Follow-up MRI reveals continued subependymal spread and infiltration of the optic chiasm and right optic tract. Once she is stabilized and recovered from surgery she is placed on a protocol to undergo radiation and chemotherapy.

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