1. Donna M. Struck, Philadelphia College of Osteopathic Medicine; Thomas G. Bowers, Penn State Harrisburg; Lawrence McCloskey, Hershey Medical Center Abstract A 41 year-old college student, referred for a psychoeducational assessment to rule out attention and learning difficulties, revealed a pattern of inconsistent test results, indicating significant cognitive impairment. Subsequent neuropsychological evaluation and neurological follow-up confirmed cerebral impairment, and a MRI scan confirmed a neoplasm in the left frontal cortex, which was treated surgically. This paper reviews three serial assessment batteries, and treatment summaries as the individual progressed over a three year period. He has been free of cancer of eighteen months, but the neurologists had warned that the tumor was one a rapid and aggressive growth and reoccurrence. He is active in a support group but he continues to experience tension and anxiety. In addition, the deleterious effects of radiation treatment are often delayed by more than a year. He also participated in psychotherapy sessions reevaluating his achievements, difficulties and future goals. In general, he demonstrated improved neuropsychological functioning on post- surgery assessment, with improved scores noted on the Category Test, the Tactual Performance Test, the Seashore Rhythm Test and Trails A. Category Test results were in the mildly impaired range, however, and TPT scores were weak on nondominant (left) hand and both handed performance. TPT Localization score remained weak. His finger tapping speed slowed, although not in the impaired range, and he continued to have significant difficulty with Trails B. His memory abilities largely improved into the average range, but working memory scores remained very low. Conclusions The finding of a glioblastoma multiforme frontal tumor with an individual presenting as an individual with a specific learning disorder is certainly unusual. Nevertheless, these findings indicate that practitioners need to consider the possibility of significant serious and severe cerebral factors impacting on learning in the course of psychoeducational assessment. At a minimum, it is argued the psychoeducational evaluations need to include assessment of memory functions and the use of screening instruments for brain-behavioral compromise. Findings of impairment in memory or signs of brain-behavioral impairment should dictate more comprehensive follow-up with neuropsychological tests and neurological consultation. A 41 year-old male non-traditional student was initially referred for an evaluation of this intellectual and academic functioning because of concerns about his academic performance. While his demeanor was pleasant, he was also anxious, and he complained of “extreme test anxiety.” His mood and affect was normal, but thinking and mentation was slow. His speech was difficult and marked by extreme word-finding difficulty, and aphasic production was noted on intake. Initial assessment indicated functioning in the low average range, but with a significant difference between his Verbal and Performance IQ, favoring his Verbal IQ score. He demonstrated a significant and severe elevation on a deterioration index of.43. He demonstrated significantly strong abilities on verbal comprehension scores, relative to significantly weaker scores on perceptual organization and working memory abilities. He performed poorly on tasks which required him to assemble abstract stimulus materials. He performed atypically on the Conner’s Continuous Performance Test (CPT), as well demonstrating difficulty with age-level tasks in reading and language. He also performed poorly on assessment of visual memory by the Benton Visual Retention Test. The pattern of results implicated right –hemisphere type dysfunction, with left-hemisphere processing deficits in expressive and receptive aphasia. He was evaluated on neuropsychological functioning and those results indicated a high likelihood of acquired cerebral impairment, with problems in construction apraxia, spelling apraxia, acalculia, and alexia. It was also noted that there were left-sided sensory perceptual errors and his visual fields were compromised. He had a great deal of difficulty with abstract thinking and executive functioning, and milder but still significant difficulty with central auditory processing. Remarkably, his simple psychomotor speed was actually above average. Figure 1. This example of a glioblastoma multiforme tumor here was provided by the Penn State Hershey Medical Center's Neuropathology Laboratory, Hershey, PA, operated under the direction of Dr. Jay Towfighi. Table 1. Initial Psychoeducational Assessment Pre-Surgery Wechsler Adult Intelligence Scale – Revised (WAIS-R) Results Verbal Scaled ScoresPerformance Scaled Scores Information11Picture Completion5 Digit Span 7Picture Arrangement8 Vocabulary10Block Design 4 Arithmetic 4Object Assembly9 Comprehension 8Digit Symbol5 Similarities11 Verbal IQ 91 Performance IQ79 Full Scale IQ84 Woodcock-Johnson – Revised (WJ-R) Results ScaleSSPercentile Broad Reading 95 37 Broad Wrtn Lang76 5 LW Ident98 44 Pass Comp91 28 Calculation81 11 Dictation78 7 Writing Samples78 7 Verbal Memory (MAS)84 14 Table 2. Halstead-Reitan Neuropsychological Battery Results Pre-Surgery TestRaw ScoreSignificant Category Test95 errors * Tactual Performance Test18.64’ * -Dominant Hand 9.30’ * -Nondominant Hand 6.17’ * -Both Hands 3.17’ * -Memory 6 -Localization 4 * Finger Tapping Test -Dominant Hand 61.0 -Nondominant Hand 54.2 Speech Sounds Test 4 errors Seashore Rhythm Test 9 errors * Trails A 51” * Trails B 199” * Table 3. Neuropsychological Results Post-Surgery 1. Wechsler Adult Intelligence Scale – Revised (WAIS-R) Results Verbal Scaled ScoresPerformance Scaled Scores Information10Picture Completion5 Digit Span 7Picture Arrangement5 Vocabulary 9Block Design 5 Arithmetic 6Object Assembly 10 Comprehension 7Digit Symbol5 Similarities 8 Verbal IQ 89 Performance IQ81 Full Scale IQ84 2. Woodcock-Johnson – Revised (WJ-R) Results ScaleSSPercentile Broad Reading 92 30 Broad Wrtn Lang85 16 LW Ident98 45 Pass Comp84 14 Calculation80 9 Dictation85 16 Writing Samples92 30 3. Wechsler Memory Scale - III ScaleSSPercentile Auditory Immediate92 30 Visual Immediate94 34 Immediate Memory91 27 Auditory Delayed97 42 Visual Delayed88 21 Aud Recogn Delayed 100 50 General Memory92 30 Working Memory66 1 4. Halstead-Reitan Battery Raw ScoreSignificant Category Test69 errors * Tactual Performance Test 16.80’ * -Dominant Hand 6.52’ -Nondominant Hand 5.72’ * -Both Hands 4.65’ * -Memory 7 -Localization 3 * Finger Tapping Test -Dominant Hand 49.0 -Nondominant Hand 47.6 Speech Sounds Test 3 errors Seashore Rhythm Test 6 errors Trails A 35” Trails B 237” * Because of the severity of his difficulties, a neurological follow-up was arranged for him. At the time he presented to the neurologist’s office, approximately two weeks later, there were persistent headaches, lethargy, and right arm weakness. Speech and cognitive abilities had diminished even further. The results of a MRI scan revealed a roughly 5 x 5 x 5 cm cystic neoplasm in the posterior left frontal lobe, producing vasogenic edema. Neurological evaluation indicated right hemiparesis, dysarthia, ataxia, and impairment in memory and concentration. After a left frontal craniotomy for a gross total resection of a glioblastoma multiforme his neurological deficits improved. He also received a course of whole – brain radiation. Follow-up MRI scans detected a roughly 3 x 3 cm hematoma at the surgical site, showing the expected evolution. Six months later, the postoperative cyst had decreased to two cm. in size. One year follow-up indicated psychomotor speed had declined mildly, but scores were still in or near the normal range. There were inconsistent indications of impairment in attention and concentration, but formerly poor memory and concept formation skills had normalized, and tactile problem solving skills remained broadly normal. His intellectual and achievement remained the low average range, but the spread between his verbal and performance abilities had decreased [1][1] The authors are grateful to Family Development Services for providing the opportunity to review this case and support for this paper. Frontal Glioblastoma Multiforme Tumor: Presentation as a Specific Learning Disorder[1][1]