Clinical History:

This 50-year-old woman was in her normal state of good health when she began to notice a funny feeling in her left hand. Over the ensuing weeks she began to notice a continual nagging headache which was partially relieved with acetaminophen. On the morning of admission she had a grand mal seizure witnessed by her husband. Upon arrival at the emergency room she was awake and slightly disoriented but could give a good history. On physical examination there was mild weakness of the left arm and leg with paresthesias of the left hand.

Image 6.1:

This is an enhanced MRI scan of the right hemisphere as seen sagittally. Describe the findings and give possible etiologies for the lesion seen.

There is a large mass in the right hemisphere. This is most likely tumor because of the irregular shape. Abscesses tend to be rounded and have an even ring enhancing edge. Tumors can have a ring enhancing edge with a lucent center, but the ring enhancement tends to be irregular. A bleed would have to be ruled out with an unenhanced scan.

Image 6.2:

This is an H&E stained microscopic section of the biopsy taken from the lesion. Describe the changes. What is the diagnosis? What is the treatment for this lesion?

This is a cellular tumor with pleomorphic nuclei infiltrating brain. There is an area of necrosis in the center of the section and mitoses are found. The diagnosis is glioblastoma. The treatment is radiation and chemotherapy.

Image 6.3:

This is a gross photograph of a similar lesion from an elderly man who died. Describe the gross changes. What is the usual age at presentation for patients with this lesion?

This photograph shows a horizontal section of brain with a hemorrhagic yellowish mass involving the corpus callosum posteriorly and both sides of the brain adjacent to the corpus callosum. The usual age at presentation of patients is the 50's to 60's.

Answers:

1. What are possible causes for these symptoms?

Since the symptoms progressed over weeks, tumor or abscess should be considered. A chronic subdural is another possibility.

2. What would be part of your workup on this patient?

A radiographic scan can aid in diagnosis if a localized lesion is suspected. CT scans are better at identifying intracranial hemorrhages, while MRI scans are better at identifying neoplasms. A stereotactic biopsy can be done to confirm the diagnosis.