‫بسم الل ہ الّرح ٰمن الرحیم‬

A case of intracranial mass

Zafar Iqbal
R.M.O.
Neurosurgery
Abbasi Shaheed Hospital Karachi
General Profile

 Aftab Khan
 35y married
 60 kg 5.8'height
 Rt. Handed
 Vehicle driver
 Korangi
 D.O.A.: 19.11.2008
 Referred from Medicine with the

complaints
 H/A 4M
 Vomiting 3M
 Altered sensorium 1M
 Dysphasia 1M
 Ataxia 1M
 Urinary incontinence 15 d
 HOPC
 Had persistent generalized H/A more pronounced at
morning, progressive, later associated with
 Vomiting
 Started staggering 1 m back and later progressed to
the walk with support and then was grossly
 Ataxic and unable to walk.
 Mental deterioration was slowly progressive and was
initially (1m back) inattentive and later on
 Progressed to disorientation
 Started slurring of speech 1 m back, later the content
of the speech was difficult to Interpret...both the
content and word pronunciation
 His visits to the physician for poor
mentation lead to the workup for
metabolic and toxic Encephalopathy
(hepatic, uremia, copper) and later on
the MRI. of brain revealed the
intracranial lesion.
 No H/O: Trauma, febrile illness, fits, ENT
infection
 PAST

 No H/O major medical illness

 Personal

 No addiction, non smoker, normal habits

 Vaccination: +ve
GENERAL EXAMINATION

 Bed ridden
 No anemia, jaundice, abnormal
pigmentation, lymphadenopathy,
oedema
 No ear nose discharge,
 No scalp/skull shape abnormality
 Communicates poorly… in a drowsy
state.
 VITAL SIGNS

 B.P:120/70
 Pulse:70/m
 Temp: 98.6 degree F
SYSTEMIC
Respiratory System

 Rate:14/m
 N.V.B no abnormal sounds
 C.V.S

 S1+S2+0
Abdomen

 Normal
 Soft
 No visceromegaly
 No mass
 No tenderness
 No fluid
Neurological Examination
Higher mental functions

 Communicates poorly… in a drowsy

state
 slurred speech
 G.C.S:12/15 (3+5+4)
 Cranial Nerves

 Vision:Recognizes people by face…

unable to check the acuity
 Fundus: bilateral papilloedema
 Cranial Nerves

 Other cranial nerves: intact

 Motor

 Bulk: normal bilaterally

 Tone: increased on Rt. side
 U/L: Rt: grade 4+ LT: GRADE 5
 LL: Rt: GRADE 4+ LT:GRADE 5
 Reflexes:Brisk all over
 Plantars: bilateral up going
 Pronator Drift: +ve on Rt. side
 Sensory

 Notable to be checked accurately due to

decreased mentation
Investigations
 Hematology/Biochemistry
 C.B.C:
 Hb: 12.3gm %
 T.L.C:10,000/ul
 Platelets: 154,000/ul
 B.S.R:89 mg%
 Urea: 30
 Creatinine: 1.2
 Electrolytes: within normal limits
 L.F.T.'s, S.Copper,S.Ammonia: within normal
limits
 General radiology

 Chest X-Ray :Normal

 M.R.I (22.11.2008)
 Lt. Parietal lesion of 5+5 cm with decreased
intensity on T1 weighted and increased
intensity on T2 weighted images.
 Small portion anteriorly of mixed intensity
 Few signal voids anteriorly
 Fluid/fluid level
 Mild enlargement of ventricles.
 Significant mass effect with midline shift.
 DIAGNOSIS

 :?????????
 Cystic Astrocytoma
 Oligodendroglioma
 Treatment

 STEROIDS
 MANNITOL
 PREOOP PREP
 ANAESTHESIA EVALUATION
 SURGERY

 Lt.PARIETAL CRANIOTOMY
25.11.2009
 Cystic Fluid aspirated, Excision of wall of
cyst, No solid nodular mass seen.
 Wall of cyst sent for histopathology
 Fluid sent for D/R and cytology
Post operative

 Pt.
improved post operatively
 Was at GCS 15 after 3days post op.
 Histopathology
 Neoplasm composed of sheets of small to
round cells having peri-nuclear halo present
against fibrillary background. Mild nuclear
atypia and pleomorphism is appreciated. No
significant necrosis or endothelial proliferation
is identified. The tumor cells stain positive for
IHC stain GFAP. The staining pattern of GFAP
favors neoplastic process.
Conclusion:
Oligodendroglioma grade
2(WHO Grading)
 Fluid

 Fluidcytology: malignant cells not seen

 Thick viscid fluid
 Gram stain: no organism seen
 Z.N. Stain: negative for AFB
Post op

 Post
op scan on 3rd post op day
showed: no residual mass
Radiotherapy

 PT was advised for radiotherapy which

the attendants did not opt to.
 After 20 days

 After 20 days pt came again with LOC

AND TACHYPNOEA
 C.T showed cyst with significant mass
effect
 Options

 ?????????
 Taping

 resulted in improvement
 intra cystic catheter

 After 3 tapings on alternate days decided

for Placement of subcutaneous reservoir
connected with intra cystic catheter for
repeated per cutaneous taping.
 Weekly taping resulted in improvement and
progressive decrease in quantity of fluid
tapped from the Reservoir (40~10).
 BUT STILL IT NEEDS TAPPING
 Q,s

 Radiotherapy .......... yes/no

 Cysto-Peritoneal Shunt .........yes/no
Discussion
 Oligodendroglioma

 approximately 5% of all gliomas

 Occur throughout the adult age group
with a maximal incidence in the 5th
decade.
 The tumor is rare in children.
 Pathology

 Nearly all oligodendrogliomas occur

above the Tentorium
 most are located in the cerebral
hemispheres and
 about half of these are in the frontal
lobes.
 Oligodendrogliomas may project into
either the 3rd or lateral ventricles.
 Histopathology

 the same spectrum of histological

appearance as astrocytomas
 Ranging from very slow growing, benign
tumors to a
 more rapidly growing, malignant variety
with abundant mitotic figures, endothelial
proliferation and foci of necrosis.
 Histopathology

 Calcium deposits in up to 90%

 Unlike the astrocyte group,most
oligodendrogliomas are well differentiated.
 Not infrequently tumors have mixed histology,
 with both oligodendroglial and astroglial
features.
 Clinical presentation

 The presenting features are essentially

the same as for the astrocyte group
 but, as these tumours are more likely to
be slow growing,
 epilepsy is common, occurring in 80%
of patients and
 seen as an initial symptom in 50%.
 Clinical presentation

 The features of raised intracranial

pressure and focal neurological deficits
are each present in approximately one-
third of patients.
Radiological investigation
 CT scanning and MRI are the
fundamental investigations.
 They will confirm the diagnosis of an
intracranial tumour and in many cases
the diagnosis will be highly probable.
 Calcification will be present in 90% of
cases
 and over half show contrast
enhancement
 Treatment and results

Treatment options:
 surgical resection
 radiotherapy
 other adjuvant treatments.
 standard treatment

 has been an aggressive resection

 followed by radiation therapy
 Radiotherapy

 although radiotherapy would now not be

given to low-grade tumors
 and utilized only for the intermediate- or
high-grade tumors.
 chemotherapy

 have been shown to be more sensitive

to chemotherapy than the astrocytomas
 especially if the oligodendrogliomas
belong to the group with loss of
heterozygosity OF chromosome 1p or
19q
In the patients reported by Olson et
al
 36% of patients who had been treated
with radiotherapy developed dementia,
 20% treated with chemotherapy suffered
toxicity, and
 6% of those undergoing surgery
suffered permanent neurological
impairment.
 survival

depends on the
 degree of histological malignancy.
 Five-year survival rates are between 30
and 50% with a
 small number of patients living for many
years (up to 5% for 20 years)
 astrocyte-derived cells

 many tumors with histological features of

oligodendroglioma also have a
component of astrocyte-derived cells,
usually
 anaplastic astrocytoma, and
 the tumor behaves biologically and
clinically as an anaplastic astrocytoma
rather than an oligodendroglioma.
References
 Ino Y, Betensky RA, Zlatescu MC, Sasaki H, Macdonald DR,
Stemmer-Rachamimov AO et al. Molecular subtypes of anaplastic
oligodendroglioma: implications for patient management at diagnosis.
Clin Cancer Res 2001;7(4):839–45.
 Bigner SH, Matthews MR, Rasheed BK, Wiltshire RN, Friedman HS,
Friedman AH et al. Molecular genetic aspects of oligodendrogliomas
including analysis by comparative genomic hybridization. Am J Pathol
1999;155(2):375–86.
 Paleologos NA, G CJ. Treatment of oligodendroglioma an update.
Neuro-oncology 1999;1(1):61–8. Cairncross G, Macdonald D, Ludwin
S et al. Chemotherapy for anaplastic oligodendroglioma. J Clin Oncol
1994;12(10):2013–21.
 Mork SJ, Lindegaard K-F, Halvorsen TB, Lehmann EH, Solgaard T,
Hatlevoli R et al. Oligodendroglioma: incidence and biological
behavior in a defined population. J Neurosurg 1985;63:881–9.