Case: 49-year-old Man with Headache

by Roy Strowd, MD

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    00:01 In this lecture, we're going to talk about gliomas, or that most common type of malignant brain tumor.

    00:08 We're going to follow a patient's course through diagnosis and treatment, and learn about how we both approach patients in clinical vignettes for this common and complex type of brain tumor.

    00:20 Let's start with a case.

    00:22 This is a 49-year-old man who presented with headache.

    00:25 He presented with six month history of cognitive complaints, which culminated in persistent dull headaches, and intermittent episodes of word-finding difficulty, possible seizure.

    00:37 After presenting to the emergency department with an episode of more prolonged aphasia, a CT scan showed left brain lesions or a left brain lesion.

    00:46 and he was admitted to the hospital for MRI of the brain with and without gadolinium contrast.

    00:52 Ultimately, the MRI showed a non-enhancing lesion in the left temporal lobe.

    00:57 So what's the diagnosis? Well, let's think about some of the features of this case.

    01:02 First of all, this patient presents with headache and some type of paroxysmal episode.

    01:08 When we think about paroxysmal episodes, episodes that have the same thing every single time, make us concern for a seizure.

    01:16 And this sounds concerning for a seizure.

    01:19 The second is the imaging. We have a parenchyma lesion, a lesion that appears to be inside the brain, where we think about the cell types that are in the brain in terms of an imaging differential, and this is a non-enhancing lesion, suggesting that it may be lower-grade, which is consistent with the six month history of presentation.

    01:38 Here's the imaging for this patient.

    01:40 And we're looking at two types of scans here.

    01:43 On the left, we see a T2 image that shows us swelling and gliosis anything that's abnormal around this lesion.

    01:50 And on the right we see a T1 post-contrast image with gadolinium in the veins but not in this lesion.

    01:58 This is a non-enhancing lesion.

    02:00 So in summary, this is a lesion in the left temporal lobe without enhancement.

    02:05 And this makes us concerned for a low-grade lesion, a low-grade tumor.

    02:12 So what's the diagnosis? Is this a brain metastasis, a meningioma, a pituitary adenomas, a glioma, or a vestibular schwannoma? Brain metastasis could be the case but this patient's history is quite long and no systemic malignancy to suggest a clinical history suggestive or consistent with brain metastasis.

    02:32 The patient doesn't present with symptoms of a vestibular schwannoma and imaging is not consistent with that.

    02:38 The lesion is not in the pituitary or the sella turcica, to suggest a pituitary adenoma.

    02:44 This lesion looks to be inside the brain as opposed to developing from the dural surface.

    02:49 And imaging would be inconsistent with a dural base lesion like a meningioma.

    02:53 This is a glioma.

    02:55 And this is the typical a classic presentation for a patient with a low-grade glioma.

    03:01 Let's take a different case.

    03:03 The same 49-year-old man, but this gentleman presents with a one-month history of cognitive complaints, a shorter time course of presentation that culminated in severe headaches, gait dysfunction and falls and right-sided weakness.

    03:18 We don't see a history suggestive of seizure.

    03:21 This patient has a focal neurologic deficit, suggesting that this lesion, this mass, maybe this tumor is growing more rapidly.

    03:28 Again, after presenting to the emergency department, a CT scan shows multi-focal brain lesions and he's admitted the hospital for an MRI, which shows a ring-enhancing mass involving the corpus callosum.

    03:41 So again, the time course is suggestive of more rapid growth.

    03:45 We see focal neurologic deficits, which means this patient needs imaging.

    03:49 And on imaging, we see a ring-enhancing lesion, which could conjure up an important differential diagnosis for this patient.

    03:56 Let's look at this patient's imaging.

    03:58 Here again, we're looking at T1 post-contrast imaging on the left, and on the right, the T2 imaging showing this area of edema or swelling, abnormal finding around this tumor.

    04:10 This enhancement pattern, the ring of enhancement is concerning for a higher-grade lesion, and a possible tumor.

    04:18 So what's the tumor? Is this a brain metastasis, a lymphoma, a low-grade glioma, a high-grade glioma? Or could this be multiple sclerosis? Well, low-grade glioma, we just saw what that looks like.

    04:30 and that's typically a nonenhancing or tumor without enhancement, and this one prominently enhances.

    04:36 We don't like low-grade glioma.

    04:38 Could it be a brain metastasis? It could be, but we've seen in brain metastases that those tumors like the gray-white junction, that area between the cortical gray matter and the subcortical white matter.

    04:50 This lesion is in the white matter.

    04:51 It's along the corpus callosum, the white matter tracks and actually has a butterfly appearance spreading and emanating from the corpus callosum.

    05:00 Could this be lymphoma? It could be. Lymphomas can look tricky.

    05:04 But typically lymphomas are homogeneously enhancing.

    05:07 And this has a ring-enhancing pattern that really favors an alternative diagnosis.

    05:13 What about inflammation? Could this be multiple sclerosis? There's this a type of multiple sclerosis that can cause a tumor like lesion it's called tumefactive MS or tumefactive multiple sclerosis but typically inflammatory lesions don't have a complete ring of enhancement.

    05:30 There's an incomplete ring of enhancement.

    05:32 And so here the imaging features in clinical presentation favor a high-grade glioma or glioblastoma.

    About the Lecture

    The lecture Case: 49-year-old Man with Headache by Roy Strowd, MD is from the course CNS Tumors.

    Included Quiz Questions

    1. Seizures
    2. History of systemic malignancy
    3. Hearing loss
    4. Lesions within the sella turcica
    5. Dural-based lesions
    1. A ring-enhancing lesion
    2. A non-enhancing lesion
    3. A lesion at the gray–white matter junction
    4. Incomplete ring enhancement due to inflammation
    5. Diffuse hyperintense lesions
    1. Gadolinium-enhanced MRI
    2. Non-contrast-enhanced CT
    3. Contrast-enhanced CT
    4. Non-enhanced MRI
    5. CT angiogram

    Author of lecture Case: 49-year-old Man with Headache

     Roy Strowd, MD

    Roy Strowd, MD

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