Welcome to CNS Case of the Month Section. The purpose of this Web area is to provide a forum for discussion and debate regarding the management of both ordinary and extraordinary cases. There are no right or wrong answers, but rather, there are various opinions on what should be the "standard of care." The answers given will be collected anonymously, and be presented in a graphical format at the end of each month. We will then see the spectrum of thought regarding the management of these patients.
We are always open to suggestions, and if you have a case or questions that you would like to have presented, please submit them to: info@1cns.org
Ashok R. Asthagiri, MD National Institutes of Health
Cara Sedney, MD West Virginia University, Robert C. Byrd Health Sciences Center
Prashant Chittiboina, MD LSU Health Sciences Center
May 2012: Brainstem Mass
HPI: A 38 year-old male, visiting from Guatemala, presents with a several month history of progressive left sided weakness.
PMH: non contributory
Physical exam - Awake, alert, and appropriate
- CN: Left facial weakness (HB grade 3)
- Motor/sensory: LUE and LLE weakness (3/5) and decreased sensation to pinprick and soft touch.
Basic laboratory studies (CBC, Chem panel, Coagulation studies are WNL)
Figures
Figure 1: CT scan demonstrates a large, hypodense brain stem mass with calcifications.
Figure 2: MR-imaging demonstrates a very large mass. A distinct solid component is located ventrally and a large cystic or cavitary component located posteriorly. The solid component demonstrates contrast enhancement.
a. Associated with Neurofibromatosis type 1
b. Identified in children and appear as a diffuse pontine mass
c. Identified in young adults as a tectal mass presenting with hydrocephalus
d. Located in the cervicomedullary region
2. Which surgical approach would you recommend?
a. Retrosigmoid
b. Pre-sigmoid
c. Trans-oral
d. Subtemporal
e. Extended far lateral
3. Would lumbar drainage be safe and/or helpful in this case?
a. Although it would be safe, I do not feel that it would be helpful.
b. I believe that it would be both safe and helpful.
c. It would not be safe, and therefore not helpful.
4. Final pathology returns as an ependymoma with tanycytic features. Post-operative MR-imaging demonstrates a small residual anterior to the pons. What management paradigm would you recommend?
a. Second look surgery – as soon as possible
b. Stereotactic radiosurgery to residual tumor
c. Fractionated radiation to residual tumor
d. Chemotherapy
e. Close observation, but with no initial intervention
5. Which of the following describes you?
a. Resident/fellow
b. Private practice
c. Academics
6. I practice in one of the following locations.
a. I practice in one of the following states: WA, OR, CA, AK, HI
b. I practice in one of the following states: AZ, ID, NV, MT, WY, CO, NM, UT
c. I practice in one of the following states: ND, SD, NE, KS, OK, MN, IA, MO, WI, IL MI, IN, OH
d. I practice in one of the following states: TX, AR, AL, LA, KY, TN, MS, WV, NC, SC, GA, FL
e. I practice in one of the following states: ME, VT, NH, MA, RI, CT, NJ, NY, PA, DE, MD, DC, VA
f. I practice in Mexico or Canada
g. I practice in South America
h. I practice in Europe
i. I practice in Asia
j. I practice in Australia/Pacific Rim
k. I practice in Africa
7. Comments
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