This 75-year-old man was admitted with progressive weakness of the right side of his body. He had been bed bound for 2 months prior to admission. The reason the family brought him was because for the past 3 days, he has been unable to tolerate orally and was semi-conscious. There is no history of fever. He does not smoke or consume alcohol.
He has history of NPC a few years back for which he completed a course of radiotherapy and chemotherapy afterwhich his doctors proclaimed him disease free.
On examination, he is noted to be stuporous and could barely obey simple commands. The power on his right side is 0/5.
This is a slice of the CT brain film:
Questions:
1. Comment on the film.
2. What could be the cause of his condition?
3. What is the next step of management?
Mon, 050109 @ 0800
Thanks for the detail answer.
Embarassing of the typo
Answers:
1. A slice of a contrasted CT brain showing multiple irregular and heterogenous contrast enhancing lesions in the left basal ganglia area. The masses have invaded the posterior (and a bit of the anterior) horn of the left lateral ventricle causing a slight midline shift to the right. Surrounding the masses are hypodense areas indicating perilesional oedema. There is bilateral frontal lobes atrophy.
2. Given the history and the location of the masses, these masses are most likely extension of the NPC superiorly into the brain. Alternatively, they may be secondaries from the NPC.
3. After taking care of the ABC of resuscitation, the immediate step would be to relieve the intense cerebral oedema. Usually iv dexamethasone is given. As for diagnosis, the definitive procedure would be to perform an invasive brain biopsy.
Most of you have answered well, correctly identifying the lesions as well as the diagnosis. When it comes to management. There are 2 ways to look at it. The academic way, like most of you did ~ such as dexa, referral to neuro and ENT, chemo and radiotherapy, etc etc. The other is from a human and realistic point of view such as highlighted by TFTD.
In view of the age of the patient and the extend of his lesions as well as the moribund state of his physical condition, I would be, as TFTD suggested be inclined to explain the grave prognosis to the family members (btw, the correct word is ‘counsel’ and not ‘council’) while attempting to relieve the patient of his cerebral oedema ~ if there is improvement in, say 24 hours, perhaps the next steps of management could then be explored.
Under no circumstances should an LP be performed when there is evidence of midline shift, so iriqci, I’m afraid your answer has cost you a kudo this week! And peanut, CK has a point because if there is hemorrhage, the blood would act as a natural contrast agent on CT scan and hence the use of a contrast agent is not necessary.
Kudos for this week goes to peanut, CK, TFTD & oyy(well done both of you for thinking out of the box), w1, and pian. Well done.
Tomorrow, you will have a postgraduate level case.
1.Enchanced CT of the brain shows well demarcated hyperdense lesion encircling the normal dense area around the internal capsule, obliterating the third ventricle as well. Mild line is slightly shifted.
2. NPC with mets to the brain
3.
Dexamethasone to reduce cerebral edema
Multidisplinary apporach.
Suspect raised ICP- refer to neuro team for further review.
Lastly, palliative care is more important for his quality of life than to do any other invasive management.
1. Contrast CT of the brain shows multiple well-demarcated hyperdense lesion at the central midline of the left hemisphere. The lesion extends to obliterated the third ventricle. There is no midline shift.
2. Metastatic brain tumour secondary to NPC.
3. Explain and council family members. Palliative care with symptomatic treatment.
Since his condition is deteriorating badly, is there a role to start chemo/radiotherapy? In my opinion, I don’t think it is beneficial to the patient. Eager to know about the answer.
1. Contrast CT of the head showing an ill-defined mass in the left temporal-parietal lobe with peripheral hyperdensity and central non-enhancement.
Surrounding hypodensed area are due to edema. Lateral horn is partially obliterated. Midline deviation to right.
2. This lesion might be 1′ tumor or mets
3.Nasopharynx endoscopy. Orogastric intubation
Restart chemo. Palliative treatment.
1. Hyperdense mass on the left hemisphere of brain at the area of internal capsule and lateral ventricle. Compression occurs at the anterior and posterior horn of lateral ventricle (left side) leading to its displacement. Ischemic or edema also occur at the area surrounding the mass, maybe due to destruction of vascular component.
2. Tumor relapse. Maybe stage T3, M1. Most probably tumor at the pure motor area of internal capsule, that is why he had paresis of contralateral side of his body as well as dysarthria and dysphagia.
3. Refer the patient to neuro department. Prescribe IV steroid, antitumoral and antiepileptic drugs before surgery. Perform angiography on the patient and finally surgery.
Maybe perform LP also to determine whether there is hemorrhage of brain caused by the tumor.
Intracranial bleeding should not have a history of progressive weakness of body part. Blood in CT contrast should be homogenous hyperdense.
1. this is a CT brain in axial view with contrast showing a heterogenous hyperdense lesion at left thalamus region extends to left internal capsule with irregular margin. it appears nodular. there is surrounding edematous with compression at ipsilateral lateral ventricle and midline shift. there is narrowing of sulci and flattening of gyri.
there is no bleeding into the lesion.
Brain atropy prominent at bilateral frontal lobe noted which is a normal degenerative condition in elderly.
2. recurrence of NPC with brain metastases. As there is a history of NPC and recurrence of NPC is high within 5 years post chemotherapy.
3. With a CT brain suggestive a space occupying lesion with clinically semiconscious, increase intracranial pressure should be suspected. He should be referred immediately to neurosurgeon.
His condition should be assessed for surgical intervention which includes comorbidities. He should be consented for emergency craniotomy and VP shunt. Meanwhile he can be given IV steroid to decrease the cerebral edema.
For the definite diagnosis, excisional biopsy and histopathology can be done. Treat accordingly.
Oops… forgot to describe it is roundish in shape. LOL!
1. Multiple large hyperdense lesions seen in the CT scan of the brain with IV contrast, located at the left internal capsule, caudate nucleus, putamen, globus pallidus & thalamus near the midline consistsent with history of right sided weakness. There is significant midline shift to the right due to the space occupying lesions at the left side of the brain. The lateral ventricle at the left side is also compressed. The surrounding area of the lesions is hypodense indicative of cerebral edema.
2. The most likely cause of his condition could be metastases of the NPC tumor to the brain in view of the history of treated NPC, presence of multiple lesions together with progressive weakness of the right side of the body. However, recurrence of the tumor with intracranial extension of the old nasopharyngeal carcinoma could not be excluded.
3. Palliative care with radiotherapy & chemotherapy with cisplatinum & 5-fluororuracil (most likely resistant) for the patient can be tried. Steroid therapy (dexamethasone) could be offered to the patient to reduce cerebral edema & improve his general condition.
*If intracerebral hemorrhage, no need for IV contrast CT scan of the brain. Can see the lesion straight without contrast.
1. CT scan of brain. Hyperdense structure on the left hemisphere occupying structures like capsula interna, thalamus and posterior part of left ventricle. Midline slightly deviated to the right.
2. If understood correctly. NPC = nasopharyngeal carcinoma (not good with abbreviations) then I would say that this is a metastatic brain tumour secondary to NPC.
3. Next step of management should be a CT guided biopsy to confirm the diagnosis? Need to differiente from hemorrhagic stroke. After that, remove the tumour.