1. Case Presentation
Intern
郭彥麟

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

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

4. 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

5. 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

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

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

8. 3/31 NECT
Left side T-P heterogenous mass
No obvious calcification

9. 3/31 NECT
Suspect hemorrhage

10. 4/3 MRI : STIR

11. 4/3 MRI : FLAIR

12. 4/3 MRI : DWI

13. 4/3 MRI : T1 Coronal

14. 4/3 MRI : T1 + GD

15. 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

16. 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

17. 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

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

19. 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

20. 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.

21. hyperchromatic and pleomorphic, plump-spindle tumor cells

22. Pleomorphic nuclei, irregular arragement

23. Vascular proliferation, tumor cell bulging into the vessel

24. Necrosis?

25. 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

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

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

28. Vascular proliferation

29. Pseudopalisading around a necrotic area