Miss S. is a 21-year-old who recently emigrated from a foreign country with a complex geopolitical history and ongoing socioeconomic problems, including widespread poverty and rampant corruption. She came to Canada, like so many others, in search of a better life. She’s now a university student and has a boyfriend.
For several weeks, though, she’s been having a nagging headache and some nausea. She attributes this to her menstrual period and various personal stresses in her life. Her family and friends note that she seems a little down — she’s more moody and irritable than usual, and can burst into tears for no apparent reason.
She called her family physician who accommodated her quickly. On examination, she was a healthy-looking young woman with no external signs of disease. Her vital signs were stable, and general physical examination was normal. Likewise, her neurological exam was unremarkable, with no focal deficits. Routine blood work was normal. A tentative diagnosis of depression was made and she was given a prescription for an antidepressant with arrangements for follow-up with the family physician a few weeks later.
Her symptoms escalated and 10 days later she presented herself to a local emergency room. Her headaches were worse and were now accompanied by vomiting. She also had subtle trouble finding the occasional word, more pronounced in English than in her native language. She felt that this had happened to her before whenever she got over-tired. Neurological examination again revealed no hard focal deficits. Brain imaging was done. What’s wrong with Miss S.?
Imaging
Magnetic resonance imaging (MRI) is the brain imaging modality of choice. It clearly revealed the cause of Miss S.’s problems — a large cystic lesion with an enhancing wall, and a lot of perilesional edema, located deep in her left thalamus. Diagnostic considerations included a neoplastic process such as a primary or metastatic tumour, and an infectious process such as an abscess. A resolving hematoma (for example, resulting from a cavernoma or arteriovenous malformation) can also have this appearance on MRI.
Management
Histological diagnosis must be obtained in order to guide subsequent appropriate treatment. Given the tumour’s deep and eloquent location, surgical resection was not feasible because the risks of permanent neurological injury would be too high (i.e. 100%). In this situation we performed an awake craniotomy with brain mapping for an image-guided biopsy of the cyst wall and drainage of the liquid contents. She tolerated the procedure very well and went home the following day.
Pathological examination of the lesion revealed it to be an uncommon primary malignant brain tumour called a primitive neuroectodermal tumour (PNET). It’s more familiarly known as a medulloblastoma, when it occurs in the cerebellum of children. The patient was quickly referred to a team of radiation and medical oncologists for treatment with craniospinal radiation and chemotherapy. Her prognosis is very guarded, with a poor chance of cure and life expectancy measurable in terms of a few years.
The message
For family physicians, patients with brain tumours represent an uncommon but frightening occurrence and pose a really difficult diagnostic challenge because the symptoms can mirror those seen in patients with everyday conditions like stress, depression, anxiety, fatigue, and tension or migraine headaches. Not every brain tumour patient presents with a seizure or significant neurological deficit, both of which quickly raise a red flag. Any new personality change in an adult should raise the possibility of a structural lesion in the brain like a brain tumour, and brain imaging (CT or MRI) should be ordered.
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