Case: 40-year-old Woman with Headache

by Roy Strowd, MD

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    00:00 In this lecture we're going to talk about meningiomas.

    00:03 The most common primary brain tumor that we see a really neat tumor and something that I want you to understand.

    00:11 Let's start with a case.

    00:13 40-year-old woman who presents with headache.

    00:15 40-year-old woman presents with six months of progressive headache.

    00:19 Now, new right-sided hemibody numbness and some mild weakness with gait stumbling over the past one month.

    00:26 So this has been going on for a little while.

    00:28 She was seen in a local emergency department where a CT of the head showed a left-convexity lesion.

    00:35 And MRI the brain was requested and performed also showing a homogeneously enhancing left-convexity lesion.

    00:43 Examination shows right-sided drift and pronation which is where the arm pronate, it turns and drifts down, indicating subtle right-sided and right arm weakness.

    00:53 So what's the diagnosis? Well, how do we think about this case? There's a few key features that I want you to pick up on.

    01:00 First, the onset of this process is slow.

    01:03 This took six months to develop.

    01:05 So whatever is occurring in the brain is developing slowly, and maybe a benign tumor.

    01:11 The second is the right hemibody symptoms, which point to a left hemibrain or left-brain problem and that's where we're going to go looking.

    01:20 And then last is imaging showed an extra-axial lesion, or something that is concerning for an extra-axial lesion in the left-convexity.

    01:28 And we'll look more at that.

    01:30 And here we see this patient's imaging.

    01:33 So when we're looking at MRIs, this is a T1 post-contrast gadolinium enhanced contrast enhanced imaging.

    01:40 The left side of the patient is actually on the right side things are opposite. So this is a left-convexity lesion.

    01:46 And we see it's homogeneously enhancing.

    01:48 It's white all the way through it.

    01:50 Actually, it with some of that contrast extending out on either side of this lesion.

    01:56 So what's the diagnosis? Is this a brain metastasis, meningioma, pituitary adenoma, glioma, or vestibular schwannoma? What doesn't look like a brain metastasis, we can see dural metastasis, but this patient has no known cancer, and this has been going on for a while without concern for growth pattern that would suggest a brain metastasis.

    02:19 It's not in the right location for a pituitary adenoma, which occurs in the sella turcica, that midline structure in the middle of the brain.

    02:27 This is not typical for what we see with gliomas.

    02:31 Glial tumors and glial cells, glial tumors arise from the brain parenchyma.

    02:35 This looks on the outside of the brain, on the covering around the brain.

    02:39 This is nowhere near that vestibulocochlear nerve, so we don't think that this is a vestibular schwannoma, which typically presents with hearing loss.

    02:47 So this is a classic presentation for a meningioma.

    02:51 Typically a benign slow-growing tumor that's located in the cerebral convexity.

    About the Lecture

    The lecture Case: 40-year-old Woman with Headache by Roy Strowd, MD is from the course CNS Tumors.

    Included Quiz Questions

    1. Extra-axial lesion
    2. Lesion localized to CN VIII
    3. Frontal lobe lesion
    4. Infratentorial lesion
    5. Lesion localized to the fourth ventricle
    1. Pituitary adenoma
    2. Glioma
    3. Meningioma
    4. Vestibular schwannoma
    5. Oligodendroglioma

    Author of lecture Case: 40-year-old Woman with Headache

     Roy Strowd, MD

    Roy Strowd, MD

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