HPI: A 10 y/o boy falls off his bicycle and hits his head on the concrete sidewalk. Although he was wearing a helmet he has a brief loss of consciousness (the episode was witnessed). He was somewhat confused after the incident and therefore taken to the hospital for evaluation where a head CT demonstrated a midline lesion with no mass effect. He was subsequently transferred to your institution for further evaluation and management.
ROS: The patient denies any headaches, weakness, numbness, dysarthria, dysphagia, diplopia, history of seizures, or other neurological complaints.
PMH: He has followed all of his developmental milestones according to the family. He has no physical limitations. He had been hospitalized for two pneumonias when he was younger. No prior surgeries.
FAMILY HISTORY: Significant for headaches in the patient's mother with an abnormal EEG (treated with Dilantin). No other neurological disorders.
SOCIAL HISTORY: He is in the 3rd grade and doing well in school. He has no siblings.
PE: Vitals: normal.
A healthy-looking boy in no apparent distress. He follows commands well. He has normal speech and mental status. His pupils are equal and reactive to light. His extraocular movements are intact. Faces are symmetric. His tongue is midline with no atrophy or fasciculations. He has sharp disk margins on funduscopic examination; the optic disks are somewhat unusual but not characterizable Normal tone, strength and reflexes in all 4 extremities with downgoing toes. Gait is normal and he has no cutaneous anomalies or dysmorphic features. He is normocephalic.
RADIOLOGY: MRI scan shows a mass involving the septum pellucidum measuring 1.5 to 2 cm and adjacent to the fornices. There is no obvious obstruction of the foramen of Monro, although the mass is very close to the foramen. There is no hydrocephalus or other abnormalities.
Figure 1. Axial T2 FLAIR (+C)
Figure 2. Sagittal T1 FLAIR (-C)
Figure 3. Coronal T2 FLAIR (+C)
1. What is the most likely diagnosis for this lesion?
2. Is any other work-up warranted?
3. If yes, what other work-up would you perform?
4. Would you LP the patient to obtain CSF for tumor markers?
5. Would you obtain an Ophthamology consult to evaluate for papilledema or visual field deficits?
6. What is your next step in management?
7. After talking to the patient’s parents you all decide for surgical intervention. What is your approach?
8. Please add any suggestions or comments regarding this case:
A similiar case had been treated in my practice. The patient, 65 ys old, has been followed in out-patient service. The serials of MRI scans indicated no progress of the lesion for 3 years.
The patient underwent endoscopic resection of the lesion. Final pathology revealed Central Neurocytoma.