Case presentation

Mohammed Al Sakiti

Outlines

• Case presentation

• Discussion

31 Y F referred from privet clinic to neuro OPD with 3 weeks h/o episodes of headache.

• OPD was closed

• Pain score 3/10

• BP 140/80 mmHg, PR 87/min , Spo2 100% in room air , T 36.7 c

• Triage staff ??

History H.A 31 Y Omani F K/D/O HTN on medications,

3/3/2009 Bell’s palsy.

She presented to the ED with 3 weeks H/O frequent episodes of sever throbbing left sided mainly occipital headache associated with blurred vision , reduced visual acuity , photophobia and redness with excessive tearing of the left eye. Disturbing her sleep.

History

No history of fever, nausea , vomiting.

Systematic review was unremarkable.

She denies family history of chronic headache.

.She is a bank cashier, married with two children .No history of travel .she is on OCP.

Examination

• Pain score 3/10

• BP 140/80 mmHg, PR 87/min , Spo2 100% in room air , T 36.7 c

• General examination unremarkable

• GCS 15/15

• Fundoscopy.

• No other neurological deficit could be detected in neurological examination.

Rt & Lt eye

DD

Invx

CT with out contrast

• 3 cm hyperdense mass in the midline cerebellum with focal oval shaped cystic area.

• Mass effect on 4th ventricle resulting in acute obstructive hydrocephalous.

• DD : cystic medulloblastoma , density astrocytoma.

MRI

Disposition

• Neurosurgery KH .

Principles of Disease

“Headache is the most common

presenting complaint with brain tumor, being reported by approximately 50% of the patients.”

Forsyth PA, Posner JB: Headaches in patients with brain tumors: A study of 111 patients.  Neurology  1993; 43:1678.

“The pain patterns produced are highly variable, depending on the location of the mass and the structures involved”

Newman LC, Lipton RB: Emergency department evaluation of headache.  Neurol Clin  1998; 16:285

Clinical Presentation

The classic triad of brain tumor headache: sleep disturbances, severe pain, and nausea and vomiting—is seen in only one third of patients

Patchell RA, Posner JB: Neurologic complications of systemic cancer.  Neurol Clin  1985; 3:729.

Diagnostic Evaluation

• Contrast enhancement on CT often improves the identification of the underlying mass lesion 

• MRI

Treatment

• urgent referral to neurosurgery • acute complications:  symptoms suggestive of increased 

ICP →10 mg IV, followed by 4 mg every 6hs. seizures → anticonvulsant therapy

      Empirical or prophylactic treatment .

Newton HB, et al: Clinical presentation, diagnosis, and pharmacotherapy of patients with primary brain tumors.  Ann Pharmacother  1999; 33:816.

Thank you