Case Presentation Intern 郭彥麟

Identifying Information Age: 59 y/o Gender: Woman Handedness: Right Education: College Occupation: Retired elementary school teacher

Chief Complaint Chief Complaints: subacute onset and rapidly progressive cognitive decline for 3-4 months

Summary of Her Disease Difficulty in Word-finding difficulty Reading Calculation Writing Naming Word-finding difficulty Poor recent memory Focal weakness (-), bulbar symptoms (-), fever (-), headache (-) Past history : liver cirrhosis (HBV carrier), depression

Neurological Examination Language: coherent and fluent Comprehension: 3-steps-> can Repetition: can Judgment, orientation: normal Memory: impaired recent memory in 3 objects, can’t still after hint Affect: anxious and depressed Calculation: 1+2=4, 2+4=4 Visual field: left hemianopia

Cortical Function R’t-L’t disorientation (+) Finger agnosia (+) Agraphia (+) Alexia (+) Hemineglect (-) Double stimulation test, line bisection Constructional apraxia (-)

Localization by History and NE, and Etiology Left parietal lobe Space occupying lesion Chronic SDH Neoplasm Primary Secondary Chronic CNS infection Brain abscess

3/31 NECT Left side T-P heterogenous mass No obvious calcification

3/31 NECT Suspect hemorrhage

4/3 MRI : STIR

4/3 MRI : FLAIR

4/3 MRI : DWI

4/3 MRI : T1 Coronal

4/3 MRI : T1 + GD

Conclusions from NECT and MRI Multiple left temporal-parietal lesions, containing cystic and solid components. Max diameter : 3.5cm Two solid nodules in the nearby area Suspected necrosis and hemorrhage No hydrocephalus No vein thrombosis

Adult Supratentorial Tumor High-grade astrocytoma (40%) Menigioma (15%) : benign looking Metastasis (12%) Low-grade astrocytoma (8%) : necrosis or hemorrhage less common Pituitary adenoma (4%) : exclude by symptom Craniophryngioma (1%) : most are benign, solid, in the sella turcica

Adult Supratentorial Tumor Oligodendroglioma (<1%): typically in the temporofrontal lobe, 50% mixed, 50% calcification Primary CNS lymphoma (<1%): usually 1 solid mass Others : CNS neurocytoma : typically in the frontal horn, lateral ventricles. Hyperdense on CT, 50% calcification

Differential Diagnosis Metastasis , origin ? Astrocytoma (low grade, anaplastic, GBM) Oligodendroglioma (anaplastic oligodendroglioma) CNS primary lymphoma

After Abdominal CT and CXR No obvious tumor was found, only some suspected hepatic cysts were noted No significant lymph node enlargement DDX : astrocytoma anaplastic oligodendroglioma metastasis

Pathology Pathology report : MICROSCOPIC FINDING: Section shows a highly cellular tumor comprising of hyperchromatic and pleomorphic, plump-spindle tumor cells with moderate amount of pale eosinophilic cytoplasm. There are some multinucleated tumor giant cells. Vascular proliferation and necrosis are noted. Glioblastoma multiforme.

hyperchromatic and pleomorphic, plump-spindle tumor cells

Pleomorphic nuclei, irregular arragement

Vascular proliferation, tumor cell bulging into the vessel

Necrosis?

GBM Highest grade of astrocytoma, the most common adult primary brain tumor Symptoms : epilepsy, IICP sign, focal neurologic deficits Treatment : surgery + radiotherapy ±chemotherapy Prognosis : mean survival length : 8~10 months

Pathology Gross : firm white area, yellow soft tissue, necrotic area, hemorrhage

Pathology Micro : necrosis, vascular proliferation, pseudopalisading around the necrosis, tumor cell bulging into the newly-formed vessel

Vascular proliferation

Pseudopalisading around a necrotic area