Case Report

SPACE OCCUPYING LESION

(TUBERCULOMA)

By:
Definov Tacsa Meta

1408465572

Supervisor:
dr.Enny Lestari, Sp.S
DEPARTMENT OF NEUROLOGY
MEDICAL SCHOOL RIAU UNIVERSITY
RSUD ARIFIN ACHMAD
PEKANBARU
2015

KEMENTRIAN PENDIDIKAN DAN KEBUDAYAAN

FAKULTAS KEDOKTERAN UNIVERSITAS RIAU
SMF/ BAGIAN SARAF
Sekretariat : Gedung Kelas 03, RSUD Arifin Achmad Lantai 04
Jl. Mustika, Telp. 0761-7894000
E-mail : saraffkur@gmail.com
PEKANBARU

I.

II.

Patients Identity

Name

Mr. R

Age

38 years

Gender

Male

Address

Tapung, kabupaten kampar

Religion

Islam

Maritals Status

Married

Occupation

Farmer

Entry Hospital

20 November 2015

Medical Record

907857

ANAMNESIS :

Autoanamnesis (23 August 2015)

Chief Complain
Severe Headache
Present illness history
2 weeks before admitted to hospital, patient complained of headache, headache
felt like being pressed and felt dominantly on the right side of the head, headche
felt continously, and did not disappear by taking medicines like bodrex migrain,
the pain was getting worser day by day, and increased during activities, cough and
did not reduce while resting, headache was not accompaniedby red eyes, tense
shoulder, neck stiffness, fever, blurred vision, speaking difficulty, oblique mouth,
faint, seizure. Patient complained vomitting, projectile vomitting, reduced apptite
and body weight, and difficult to do daily activities. Patient also felt much sweat
on the night without clear reason.

2 months before admitted to hospital, patient complained of right limbs

weaknesses, appeared gradually, began by numbness, worser until the patient
difficult to stand.
Past Illness history

History of brain and spine trauma (-)

History of last fever (+)

History of stroke (-)

Diabetes Mellitus (-)

Hypertensi(-)

History of contact with TB patients: patient has never contacted neither short
nor long term with people around who felt chronic cough, bloody cough, 6
months medical taking (antituberculosis drugs), contact to skin disease patient,
and also to broken watery neck glands (-).

Ear infections (-)

History of the disease malignancy (-)
a.Lung cancer (-): the patient did not complain about the presence of cough,
coughing up blood, chest pain, shortness of breath, hoarseness, difficult
swallowing, pain/fever lost arising
b.Colon Cancer (-): Patient did not complain of any change in bowel
movements (constipation, bloody and slimy, diarea or slimy), such as goat
droppings
c.Prostate cancer (-): Patient did not complain of the existence of difficulties
urinating, bloody urine, painful urination, urinary choked up.
d.Kidney cancer (-): the patient did not complain of pain in the waist, the
presence of a lump in the abdomen, and bloody urine.

Custom history

He is a Smoker since 20 years ago

History of sexual before married (+)
Free drugs injection history (-)
Long Drug Consumption (-)
History Jobs

Farmers: often the kind of Gramoxone for cleanup land

The Family Disease History

No family complain that same complaint
A history of cancer or tumors (-)
RESUME ANAMNESIS
Patient Mr. R, 38 years of age, entered to RSUD Arifin Achmad main complaint
with headache, headache felt like being pressed and felt dominantly on the right
side of the head, headche felt continously, the pain was getting worser day by day,
and increased during activities, cough and did not reduce while resting, Patient
complained vomitting, projectile vomitting, reduced apptite and body weight, and
difficult to do daily activities. Patient also felt much sweat on the night without
clear reason. Right limbs weaknesses, appeared gradually, began by numbness,
worser until the patient difficult to stand.
III. Physical Examination
A. Generalized Condition
Blood Presure : Right: 120/80 mmHg

Left: 120/80 mmHg

Heart Rate

: 86 bpm

Respiratory

: Respiratory rate : 20 x/mnt Type : abdominotorakal

Temperature : 37C
Weight : 70

Height : 165 cm

B. Neurological status
1) Consciousness

: Composmentis GCS : 15 (E4 V5 M6)

2) Noble Function

: Normal

3) Neck Rigidity

: Negatif

Cranial Nerves
1. N. I (Olfactorius )
Sense of Smell

Right
Normal

Left
Normal

Interpretation
Normal

2. N.II (Opticus)
Visual Acuity
Visual Fields
Colour Recognition

Right
Normal
Normal
Normal

Left
Normal
Normal
Normal

Interpretation
Normal

3. N.III (Oculomotorius)
Interpretatio

Right

Left

(-)

(-)

Shape

Round

Round

Side

3mm

3mm

Normal

Normal

direct

Indirect

Ptosis

Pupil

Extraocular movement

Normal

Pupillary reaction to light

4. N. IV (Trokhlearis)
Extraocular movement

Right
Normal

Left
Normal

Interpretation
Normal

5. N. V (Trigeminus)
Left
Normal

Interpretation

Motoric

Right
Normal

Sensory

Normal

Normal

Normal

(+)

(+)

Right
Normal

Left
Normal

Interpretation

Strabismus

(-)

(-)

Normal

Deviation

(-)

(-)

Corneal reflex
6. N. VI (Abduscens)
Extraocular movement

7. N. VII (Facialis)
Right

Left

Interpretation

Tic

(-)

(-)

Motoric

Normal

Normal

Flavour Sense

Normal

Normal

Tanda chvostek

Right

Left

Interpretation

Normal

Normal

Normal

Left
Normal

Interpretation

Arkus farings

Right
Normal

Flavour sense

Normal

Normal

Normal

(+)

(+)

Right
Normal

Left
Normal

(-)

(-)

Motoric

Right
Normal

Left
Normal

Trofi

Eutrofi

Eutrofi

Right
Normal

Left
Normal

Interpretation

Motoric
Trofi

Eutrofi

Eutrofi

Normal

Tremor

(-)

(-)

Disartria

(-)

(-)

Right

Left

Normal

8. N. VIII (Akustikus)

Hearing sense

9. N. IX (Glossofaringeus)

Gag Reflex
10.N. X (Vagus)
Arcus farings
Dysfonia

Interpretation
Normal

11.N. XI (Assesorius)
Interpretation
Normal

12.N. XII (Hipoglossus)

IV. Motoric
Upper Extremity

Interpretation
Normal

Strength
Distal

Normal

Proksimal

Normal

Tonus

Normal

Normal

Trofi

Eutrofi

Eutrofi

Involunteer movement

(-)

(-)

(-)

(-)

Distal

Normal

Proksimal

Normal

Tonus

Normal

Normal

Trofi

Eutrofi

Eutrofi

Involunteer movement

(-)

(-)

Clonus

(-)

(-)

Clonus
Lower Extremity
Strenght

Hemiparese Dextra

Body
Trofi

Eutrofi

Eutrofi

Involunteer movement

Abdominal Reflex

(-)

(-)

Normal

V. SENSORY
Touch
Pain
Temperatur
Propioseptif

VI. REFLEX

Right

Left

(+)

(+)

(+)

(+)

(+)

(+)

(+)

(+)

Interpretation

Normal

Right

Left

Interpretation

Fisiologic

Normal

Biseps

Normal

Triseps

Hiperefle

Normal

reflex of lower right

Patella

Normal

extremity

Achilles

Hiperefle

Normal

Normal

Increas fisiologic

x
Patologic
Babinski
Chaddock
Hoffman Tromer
Openheim
Schaefer

(-)

(-)

(-)

(-)

(-)

(-)

(-)

(-)

(-)

(-)

No Patologic Reflex

VII. Coordination

Point to point movement

Right
Normal

Left
Normal

Walk heel to toe

Normal

Normal

Drop foot

Normal

Tandem

Normal

Normal

Romberg

Not Test

Not Test

Gait

VIII. Otonom
Urinate

: Normal

Defecate

: Normal

IX. Others Examination

a. Laseque

: Negatif

b. Kernig

: Negatif

c. Patrick

: Negatif

d. Valsava test

: Negatif
8

Interpretation

Drop foot

e. Brudzinski

: Negatif

IV. EXAMINATION RESUME

Generalized Condition
Blood Presure : 120/80 mmHg
Heart Rate
: 96 bpm
Respiratory

: Respiratory rate : 20 x/mnt Type : abdominotorakal

Temperature
Weight
Noble Function
Meningeal Sign
Cranial Nerve
Motoric
Sensory
Coordination
Otonom
Reflex

: 37C
: 70 kg
Height : 165 cm
:Normal
:(-)
: Normal
: Hemiparese dextra UMN
: Normal
: Normal
: Norrmal

Fisiologis

: Increase fisiologic reflex of right extremity

Patologic

: Negative

WORKING DIAGNOSA
Clinic Diagnosa: SOL
Topic Diagnosa: Intracranial
Etiologic Diagnosa: Brain tumor
SUGGESTION EXAMINATION :
1. Blood Routine
2. Blood Chemistry
3. Electrolit
4. X-Ray Rontgen Thoraks
5. Head CT-Scan without contras

6. VCT
LABORATORIUM FINDING :
1. Blood Routine (20 November 2015)
-

Hemoglobin : 13,7 gr%

Leukosit

: 10.000/mm3

Trombosit

: 477.000/mm3

Hematocrit : 39,5 %

2. Blood Chemistry (20 November 2015)

-

Glucose

: 140 mg/dl

Cholesterole : 199 mg/dl

Ureum

: 20,8 mg/dl (10 - 50)

Creatinin

: 1,22 mg/dl ( 0,6 1,3)

AST

: 31 U/L (14 50)

ALT

: 11 U/L (11 60)

Alb

: 4,05

3. Electrolit (20 November 2015)

-

Na+

: 136, 5mmol/L (135 145)

K+

: 3,17 mmol/L (3,5 4,5)

Cl

: 108,3 mmol/L (97-107)

4. ThoraksX- Ray Rontgen ( 20 November 2015)

10

Interpretation: Normal

CT-Scan without contras (20 November 2015)

11

Interpretation: Visible hypodense lesion, tentacles from both hemisphares (Suspec

SOL intracerebri)
VCT consultation
Non-Reaktif
Follow up 24 November 2015
S

: Headache (+), Weakness of the left extremity, nausea (-), vomit (-),

GCS 15
Blood Pressure

:120/80 mmHg

Heart Rate

: 86 bpm

Respiratory Rate

: 20 x/i

Temperature

: 36,7 C

Cognitive Function

: Normal

Meningeal Sign

: Negatif

Cranial Nerves

: Normal

Motoric

: Hemiparese dextra, Motoric right extremity (4)

Sensory

: Normal

12

Coordination

: Normal

Autonomy

: Normal

Reflex

: Pathologic (-), Physiology (+)

: SOL

IVFD RL 20 dpm

Citikolin inj 2 x 250 mg

Ranitidine inj 2 x 150 mg

Dexametason inj 3 x 5 mg

Planing for MRI

Follow up 27 November 2015

S

: Decrease of Headache, Weakness of the left extremity, nausea (-), vomit

(-),

GCS 15
Blood Pressure

:110/80 mmHg

Heart Rate

: 88 bpm

Respiratory Rate

: 22 x/i

Temperature

: 36,8 C

Cognitive Function

: Normal

Meningeal Sign

: Negatif

Cranial Nerves

: Normal

Motoric

: Hemiparese dextra, Motoric right extremity (4)

Sensory

: Normal

Coordination

: Normal

Autonomy

: Normal

Reflex

: Pathologic (-), Physiology (+)

MRI

13

Head MRI with contrast (27 November, 2015)

It appears multiple lesions scattered evenly throughout the second lobe
serebri hemisphere, second hemisphere serebeli both sides of the brain stem. The
lesions varied-sized spherical accompanied perifocal edem. Hipointens lesions on
T1 and T2 on hiperintens, ring-shaped enchanchent post contrast. Invisible
restrikted area on a DWI. The ventricular system and cannot widen sisterna. Sella
turcica good.Sulcy and good gyri.Good bone and scalp. Invisible hydrocephalus.
Interpretation:
SOL intraaksial multiple on both hemisphere serebri, serebelli and brain stem fits
tuberkuloma
A

: SOL ( Suspec Tuberculoma) DD: Metastase tumor

IVFD RL 20 dpm
14

Citikolin inj 2 x 250 mg

Ranitidine inj 2 x 150 mg

Dexametason inj 3 x 5 mg

Planing for complete the peripheral Blood and blood creep mean, Anti-TB
IgG Serology and Tumor marker: CEA and PSA

Follow up 30 November 2015

S

: Headache (-), Weakness of the left extremity, nausea (-), vomit (-),

GCS 15
Blood Pressure

:120/80 mmHg

Heart Rate

: 78 bpm

Respiratory Rate

: 20 x/i

Temperature

: 37 C

Cognitive Function

: Normal

Meningeal Sign

: Negatif

Cranial Nerves

: Normal

Motoric

: Normal

Sensory

: Normal

Coordination

: Normal

Autonomy

: Normal

Reflex

: Pathologic (-), Physiology (+)

Anti TB

: Reaktif

CEA

:<0,50 ng/ul

TPSA

: 2,32 ng/ul

BCM

: 12/hour

: Tuberculoma

: Rifamfisin 600 mg 1x1

Isoniazide 300 mg 1x1
Pirazinamide 500 mg 1x3
Etambutol 500 mg 1x3
Pyridoxine 10 mg 1x1
Metyl predinisolon 4 mg 2x1

15

FINAL DIAGNOSA
Clinic Diagnosa: SOL
Topic Diagnosa: Intracranial
Etiologic Diagnosa: Tuberkuloma Serebri

DISCUSSION
1. Headache
1.2 Definition

16

Headache is pain or discomfort on whole area of the head. headache is

most commonly subjective chief complaints as reported.1.2
1.3 Classification
Based on international headache classification 2rd edition from the
International Headache Society (IHS)
Primary headache is headache with no underlying disease. The primary
headache, such as:2,3
a. Migraine
Periodic disorder with unilateral or bilateral headache and can be
following with vomiting and visual disturbances. This condition occurs
frequently, more than 10% of the population are experiencing at least one
migraine attack in her life. Migraine can occur at all of ages, but generally
the onset occurs on teenage or twenties and female more often than male.
There is family history of migraines on commonly patient.
b. Tension-type headache (TTH) 2,3
This headache is frequenly occurs with unknown etiology, although had
been accepted that the contraction of the head and neck muscles is a
mechanism causes pain. Muscle contraction can be triggered by
psychogenic factors such as anxiety or depression or by local disease on
head and neck.
Patients commonly experienced headache that can be settled for a
few days, months or years. headache can worsen in the afternoon and
generally not responsive with analgesic drugs. This headache had a
variative pain. Headache starts from the blunt pain in various places until a
thorough pressure sensation to the feeling of the head tight-tied/tense.
c. Cluster Headache 2, 3
This syndrome are different from migraine, both marked by unilateral
headache, both can occur at the same time, but the very distinct of the two
is red eye. Histaminergic and humoral mechanisms underlying the
autonomous symptoms is estimated to occur in conjunction with this head
pain.
Patients usually are men, aged 20 to 60 years. Patients feel great pain
around one eye (always on the same side) for 20 to 120 minutes, can be
repeated several times a day, and patient often woke up more than one
17

time in the middle of the night. Alcohol can also trigger an attack. This
pattern lasted for days, weeks and even for months.
The secondary headache :
a. Headache attributed to head and/or neck trauma and cranial or cervical
b.
c.
d.
e.

vascular disorder
Headache attributed to non-vascular intracranial disorder
Headache attributed to a substance or its withdrawal and infection
Headache attributed to disorder of homeoeostasis
Headache or facial pain attributed to disorder of cranium, neck, eyes, ears,

f.
g.
h.
i.

nose, sinuses, teeth,mouth, or other facial or cranial structures.

Headache attributed to psychiatric disorder
Cranial Neuralgias and facial pains
Cranial neuralgias and central causes of facial pain
Other headache, cranial neuralgia central, or primary facial pain.

2. Space occupying lesion (SOL)

SOL is a extended lesion in brains including tumor, hematoma and
abscesses. Because the cranium is stiff with a fixed volume,then the lesions will
increase the intracranial pressure. A lesion that extends first will be
accommodated by removing the cerebrospinal fluid from the cavity of the
cranium. Eventually venous will compression and disorders brain circulation and
cerebrospinal fluid will appears, so the intracranial pressure will increase. Venosa
congestion gives rise to increased production and decreased absorption of
cerebrospinal fluid and increase the volume and going back to things like above.1
18

The position of the lesion in the brain space urges can have a dramatic
influence on the signs and symptoms. For example a lesion can clog the spaces
flow urges out of cerebrospinal fluid or directly pressing on a large vein, make the
intracranial pressure increased rapidly. Signs and symptoms allows doctors to
localize the lesion will depend on the occurrence of a disorder in the brain as well
as the degree of tissue damage caused by nerve lesion. Great head pain, possibly
due to stretching durameter and vomiting due to pressure on the brain stem is a
common complaint. A lumbar pungsi should not be performed on patients
suspected intracranial tumors. Spending on the cerebrospinal fluid will lead to the
onset of sudden shifts hemispherium cerebri through notch into posterior fossa
cranii cerebelli or herniation of the medulla oblongata and serebellum through the
foramen magnum. At this time the CT-scan and MRI is used to enforce a
diagnosis
3. Cerebral Tuberculoma
3.1 Definition
Intracranial tuberkuloma is a mass like a tumor derived from dispersion
hematogen tuberkulosa lesions in other parts of the body especially of the lung.
Tuberkuloma often as a multiple and located in the posterior fossa in children and
adults but can also in the cerebri hemisphere.3
Appearenced image on CT scan tuberkulosa granuloma is a low
attenuation with increased contrast on the capsule. Usually surrounded by edema
and the lesions may be multiple. On tuberkuloma there is the occasional
calcification. Preoperatif diagnosis usually enforced only after the introduction of
tuberkulosa focus on other places of body. 4
3.2 Etiology
Tuberculosis is caused by Mycobacterium Tuberculosis, a type of bacteria
that shaped rods with length 1-4 m thick and 0.3-0.6 m and is classed in the
acid-resistant bacilli.
3.3 Epidemiology

19

CNS involvement based on frequency of literature organized from 0.5%

until 5% and many found in developing countries. The manifestations are often
from tuberculosis on SSP is meningitis tuberkulosa followed by tuberkuloma.
Tuberkuloma found only 15% to 30% of tuberculosis cases of CNS and most
occurred on the hemisphere. Although tuberkuloma is usually more on the
developing world, tuberkuloma may also be increased in developed countries in
regard to the effects of HIV infection from the view of clinical tuberculosis.
Tuberkuloma CNS very high morbidity and mortality will be, although there are
detection methods as well as modern medicine. 5.6
3.4 Pathogenesis
The most way of transmission of Tuberculosis is through the breath, even
though other means is still possible. Tuberculosis bacteria that enter the alveoli
will be caught and ingested by macrophages. When bacteria virulent, it will thrive
and damaging the macrophages. The damage macrophage will produce a
chemotaxis materials that attracts monocytes (macrophages) from circulation and
forming small tubercles. Activation of macrophages that derived from blood and
form these tubercles stimulated by limfokin is generated from the T cell
lymphocytes. The bacteria that reside in the alveoli made the Ghon focus, through
the lymph channels, the bacteria will reach the hilar lymph nodes and form
another

focus

(Lymphadenopathy).

Ghon

focus

along

with

hilar

Lymphadenopathy is called primary complex. Furthermore, the bacteria spread

through the lymph ducts and blood vessels and colonize in various organs of the
body. So the primary tuberculosis is an sistemic infectious. At the time of the
occurrence of bakteremia derived from focus of infection, tuberculosis primary
form several small tubercles on the medulla spinalis or meningen. Tubercles can
rupture and the liquid enters the brain in the subarachnoid space and the
ventricular system causing meningitis.
The clinical picture of sufferers is divided into 3 phases. In the beginning
of the symptoms are not typical, such as apathy, anorexia, malaise, fever,
headache. After the second week, the phase of meningitis with headache, nausea,
vomiting, and drownsiness. Cranial nerve paralysis and hydrocephalus occured
because exudate that experienced organisations, and which causes a hemiparesis

20

vaskulitis or convulsions which can also be caused by intracranial tuberkuloma

process. In the third phase is marked by a progressive sleepy to comatose and
focal damage more heavily.7
Tuberculosis is an airborne disease caused by the bacteria Mycobacterium
tuberculosis two pathogenic process of tuberculosis on the CNS is formation of
granuloma and meningoencephalitis (tubercles). Tubercles can grow, urging the
surrounding tissue and cause symptoms depending on the location in the brain
affected. 6.7
3.5 Clinical Symptoms
The clinical symptoms similar to intracranial tumors, within an increased
of intracranial pressure, focal neurological signs, and seizures, epileptic symptom
of systemic tuberculosis such as fever, lethargy, excessive sweating, and happens
less than 50% of the cases.
On intracranial tuberkuloma there is some addition to the symptoms of
intracranial rise in intracranial pressure due to process urges space also gives rise
to the symptoms of meningitis. Clinical Menifestation of tuberkuloma is the
process of intracranial urges space (20% of space caused by tuberkuloma urges
intracranial). Symptoms that occur due to edema of the brain is an indication for
giving of corticosteroids.
Granting of anti tuberculosis should be given to sufferers of suspected TB milier
without having to wait for the discovery of the bacteria. The use of corticosteroids
in TB milier may cause the tubercles become smaller and are very effective for
reducing shortness of breath which is sometimes found in TB milier, as well as to
control the brain edema. 7
3.6 Diagnosis
The discovery of the systemic infection and common laboratory-related
infection can not be found, because tuberculosis bacil not always evident on the
CSF and even at mass are taken, negative results from the examination of bacteria
did not rule out the possibility of infection with tuberculosis. Neuroradiological
imaging with CT and MRI has high sensitivity to tuberkuloma, but the low
definitive specificity diagnose.

21

On a CT Scan, after the awarding of the contrast, tuberkuloma gives an

overview of the following:
a. Ring-shaped Lesion with a hipodens or isodens in the middle and walls
that absorb the contrast
b. Lesion shaped nodules/plaque that absorbs the contrast.
Without contrast, lesions are generally hipodens or isodens, in some cases
obtained calcification. The image of tuberculoma CT Scan is difficult to different
with the tumor, abscess or granuloma Chronicle. MRI has an important role in the
diagnosis of intracranial tuberkuloma. On MRI, TI-Weighted MR images can
show areas of hipointens or isointens and T2-weighted images may show
hypointense or isointense central, hyperintense zone surrounded hypointense rim.
Then usually misdiagnosis with meningiomas, neurinoma, even with metastases.
When it was reported that the proton magnetic resonance spectroscopy can
distinguish tuberkuloma from other intracranial disorder. 3 nonetheless tumor
metastases have malignant glioma, such as meningiomas, and neurocysticercosis
can show a similar picture on a CT Scan or an MRI. 6
Some writers argue that tuberkuloma can be ensured when on serial CT
scans or Serial Magnetic Resonance Imaging (MRI) lesions disappear after got
antituberkulosis therapy.7 Tuberculosis infection initials CNS activation generally
arises after a few years. Then the visible lesions on chest radiography is devoted
to tuberculosis and sequelae result serologis required on suspicion of tuberkuloma
in the preoperatif period. If the suspicion is strong diagnosanya is tuberkuloma,
treatment with antituberkulosis can be used for surgical intervention and
regression on the lesion followed on a regular basis can mengkorfimasi the results
of the diagnosis. But in some special cases, a biopsy can prevent fault diagnosis in
lesion (example: meningiomas) and prevent patients from the harmful effects of
unnecessary treatment (Radiotherapy). The definite diagnosis tuberkuloma
enforced by surgery. Histology examination will reveal a tuberkuloma.5,8
2.7 Management
The surgical treatment on intracranial tuberculoma is not recommended in
most cases because long-term treatment with drugs and corticosteroids are usually

22

effective for healing. Despite surgery is needed to decompress immediately or

biopsy for definitive diagnosis enforcement. 7
CDC guideline recommends pharmacology treatment for 9-12 months for
CNS Tuberculosis with 4 regiment drugs. Initial phase of treatment in the first 2
months consist of Isoniazide, Rifampicin, Pirazinamide, and Etambutol. The
medicines given each day in the first phase. The second phase consist isoniazide
and rifamficin for 7-10 months, and can be extended if the patient has a slow
response to the treatment. When patients with intracranial tuberkuloma show signs
of increased intracranial pressure or neurological signs, corticosteroids may be
added in the treatment 9.
The addition of corticosteroids into the regiment of the drug shows good
results in healing and considered able to prevent surgery. Developments or
additions of the intracranial tuberculosis lesions in the treatment of tuberculosis
do not indicate a failure in treatment, it shows the need in addition for treatment
period and the addition of high doses corticosteroids into the regimen. Repeat
MRI and CT Scan with contrast in a few months to evaluate the lesion. Liver
function can be done because the side effects of anti tuberculosis medicines
against liver remain high. If you already found the elevation of liver function,
alternative replacement regimen can be taken.9
4. BRAIN TUMOR
4.1 Introduction
Brain tumor in a general sense means lumps, in terms of radiology known
as Space Occupying Lesion (SOL). Central nervous system neoplasm is generally
progressive neurological dysfunction which causing damage. Symptoms caused
by slow growing tumor give you symptoms that slowly emerging, while the tumor
lies on a vital position will give you symptoms that appear quickly. Approximately
10% of all of neoplasm process in the rest of the body found in the nerves and its
cover, 8% are located in intracranial space and 2% in canalis spinalis. The process
of neoplasm in nerves include two types: 11
a. The primary Tumor, a tumor originating from the brain tissue itself that
tend to develop in certain places. Like ependimoma which located near the

23

walls of the ventricles or canalis centralis of medulla spinalis,

glioblastoma multiforme is mostly found on parietal lobe, frontal lobe and
spongioblastoma in corpus calosum or pons.
b. Secondary Tumor (metastasis), a tumor originating from metastatic
carcinoma from other parts of the body. The most frequent metastatic
carcinoma found in bronchus and prostate in men as well as Carcinoma of
the mammae in women. 11
4.2 Cerebral metastases
Cancer cells of cerebral metastases have spread to the brain from cancer
cells in other organs in the body. The most frequent cause of lung cancer is 48%,
breast cancer 21%, cancer geniturinari 11%, skin cancer (melanoma) 9%, as
many as 6% of gastrointestinal, head and neck cancer 5%. Such organs the
primary cancer spreading through the bloodstream to spread to the brain so called
secondary tumors. Most brain metastases have occurred in the cerebrum, the
cerebellum 80% 16%, and 4% of the brainstem, the incidence of occurrence of
metastases to the brain is 20%-40% of all cancer patients, as much as 70% had
multiple lesions.12
Cancer cells that develop in the brain can suppress, irritating and or
destroy normal brain tissue, so that it will give rise to a progressive headache,
vomiting, seizures, impaired verbal symptoms, weakness of the limbs, paralysis,
unconsciousness, and even death. This occurs if the size of the tumor already
causing damage in the brain. But not everyone complained about it, even a third
of sufferers are tumor metastases have no symptoms at all. 12
Generally ypes of cancer can spread to the brain, so it's important for the
doctor to determine the cause of the primary sources of the metastases tumor of
brain. So that it can determine and implement for the effective option treatment.
Early diagnosis and treatment of brain metastases tumor can cause remission or
recovery of symptoms of disorders of the brain and may improve the patient's
quality of life and prolonging survival. 12
4.3 Clinical Symptoms

24

There are 4 common clinical symptoms associated with brain tumors, like
mental status changes, headaches, vomiting, and seizures. 11
a. Changes in mental status
Early symptoms can be vague. The inability of the execution of daily
tasks, irritability, labile emotions, mental inertia, impaired concentration, even
psychosis.2 Cognitive function is a complaint often made by cancer patients with a
variety of forms, ranging from mild memory dysfunction and difficulties
concentrating until disorientation, hallucinations, or lethargy. 13
b. Headaches
Headaches is an early symptom of intracranial tumors on 20% of sufferers.
The character of the headache felt like being pressed or full flavor on the head as
if willing to explode 2 Initially pain can be mild, episodic and dull, and then gain
weight, blunt or sharp and also intermittent. Pain can also be caused by the side
effects of chemotherapy drugs. This pain is more excellent in the morning and can
be diperberat by coughing, tilt your head or physical activity.3 The location of the
pain that can be unilaterally in accordance with location of tumor. Tumors in the
posterior fossa kranii head pain usually leads to ipsilateral retroaurikuler.
Supratentorial tumors in pain cause head on the side of the tumor, in a frontal or
parietal, temporal orbita.13
c. Vomiting
Vomiting is also often arise in the morning and not food-related. Where
vomiting is typical projectiles and not preceded by nausea. This situation is often
found in the posterior fossa of tumor.13
d. Seizures
Focal seizure is another manifestation that is commonly found in the 1415% of sufferers of brain tumor, 20-50% of patients brain tumor showed
symptoms of seizures. Seizures arising first on age of consent indicating the
presence of a tumor in the brain. Seizure related brain tumor was originally a form
of focal seizures (focal damage indicative of serebri) as in meningiomas, can then
become a public seizure is mainly a manifestation of glioblastoma multiforme. 13
Seizures usually paroxysmal, a result of the cortex in neurological serebri. Partial
seizures due to focal areas of emphasis on the brain and menifestasi on the

25

secondary, while local seizures occurring if the tumor is widespread on both

hemisphere serebri. 14
4.4 Support examination
A brain tumor can be detected with a CT-scan or MRI. The choice depends
on the availability of facilities at each hospital. CT-scan cheaper than an MRI,
commonly available in hospital and when you use the contrast can detect the
majority of brain tumors. More specialized MRI to detect tumors with small size,
tumors at the base of the skull and bones in the posterior fossa. In addition, MRI
can also help the surgeon to plan the surgery because it showed tumors in a
number of areas.14
If on examination of MRI found the presence of the lesion ring
enchanment to determine comparison diagnosis then used the term MAGIC DR.
M: Metastase, A: Abces, G : Glyoblastoma, I : infeksi, C : Contussio, D :
Dimyelinisasi, R : Radiasi nekrosis

The algorithm to differentiate the multiple ring enhancing lesson in HIV

negative and positive patient.

26

Picture 1. The algorithm in HIV negative patient

Picture 2. The algorithm in HIV positive patient

4.5 Management

27

Treatment of patients with SOL include: 13.14

a. Symptomatic.
Antikonvulsi
Controlling epilepsy is an important part of the treatment patients
with a brain tumor.

Edema serebri
If patients with increased intracranial pressure and the description
of Radiology showed edema serebri, then dexametason can be used
reduce the edema.

Radiotherapy
Radiotherapy played an important role in the treatment of brain
metastases, and includes entirely namely irradiation, radiotherapy
and radiosurgery. For decades, whole brain irradiation has been
recommended for patients with multiple lesions, the life
expectancy of less than three months, or the value of the
performance of Karnofsky is low. However it should be noted often
cause severe side effects, including radiation necrosis, dementia,
nausea, headaches, and sore. In children who get this treatment can
cause

mental retardation,

psychiatric disorders

and

other

neuropsychiatric effects.

Chemotherapy
Chemotherapy is rarely used for the treatment of brain metastases,
as chemotherapeutic agents penetrate the blood-brain barrier very
badly. However, some types of cancer such as lymphoma,
carcinoma small cell lung and breast cancer is a very
chemosensitive and chemotherapy can be used to treat extracranial
to metastatic disease cancer. Experimental treatment for brain
metastases is intrathecal chemotherapy, a technique in which
chemotherapy drugs delivered through intralumbar injection into
the cerebrospinal fluid. However, it was not approved by the u.s.
Food and Drug Administration (FDA) for the treatment of brain
metastases. 14

28

Operation
Brain metastasis frequently managed surgically, with a maximum
of surgical resection followed by stereotactic radiosurgery or whole
brain irradiation provides more benefits to patient survival
compared with whole brain irradiation method using 13,14

4.6 Prognosis
The prognosis for metastatic brain is variable. This depends on the type of
primary cancer, the patient's age, the absence or presence of extracranial
metastases metastatic and amounts in the brain. For all patients an average of
average survival is only 2-3 months. However, in some patients, such as those
with extracranial metastasis, those who are younger than 65, and those with one
site of metastases in the brain, the prognosis is much better, with a survival rate of
an average of up to 13 months. 13.14
5. BASIC DIAGNOSIS
5.1Basic clinical diagnosis
From the anamnesis, patient's neurological deficits occur slowly and
getting worser, such as:
a. Severe headache, progressive
b. Projectile vomitting
c. The weakness of limbs (hemipharese dextra)
This is in accordance with symptoms of increased intracranial pressure,
where there are Triassic of increased intracranial pressure like headaches,
vomiting and deficite neurology. In addition, there are other clinical symptoms
that support the increased intracranial pressure which is motoric change to be
weak. Intracranial pressure is influenced by three factors, namely the volume of
brain tissue, cerebrospinal fluid and blood volume. When there is an increase in
one of these factors, then it would increase intracranial pressure.

In this patient, there found signs of the "headaches" red flag, namely:
a. Worser frequency and intensity
b. Constant Pain in 72 hours.
c. Neurological deficits such as weakness of the limbs

29

5.2 Basic topic diagnosis

From anamnesis there are obtained a progressive headache, and projectile
vomitting, and also complaint about the presence of limbs weaknesses, then
suspected diagnosis of the topic in this case is intracranial process.
5.3 Basic etiological diagnosis
From anamnesis there are obtained headache that getting worser
progressively, projectile vomiting, and also complained about the existence of the
weakness of the limbs, the patient complains of the existence of a history of night
sweats without a clear cause, decreased appetite, and weight loss. Based on the
MRI examination multiple lesions are visible with ring enchancement post
contrast alleged as cerebral tuberculoma with the differential diagnosis of tumor
metastases have appeal, but from the results of laboratory examination of anti TB
acquired reactive and CEA tumor marker obtained in normal limits and PSA
increase above normal limit but not signignificant as well, so the diagnosis of
definite etiology in this patient is caused by the mycobacterium tuberculosis
which attack brain.
5.4 Basic differential diagnosis
From the anamnesis, patient's neurological deficits occur slowly and
feels increasingly worse, such as:
a. Severe headache
b. Projectile vomitting
c. The weakness of limbs (hemipharese dextra)
This is in accordance with symptoms of increased intracranial pressure,
where there are Triassic of increased intracranial pressure i.e. headaches,
vomiting. One of the causes of increased intracranial pressure is the presence of a
tumor mass which pressing the space.
5.5 Basic of supportive examination

Laboratory: knowing risk factors whether infection exists, and knowing

the general condition of the patient.

Thoracic x-rays: to see the existence of a specific process, the primary
tumor in the lung.
30

VCT consultation: there is risk of exposed to HIV virus which is obtained

from anamnesa.
Head CT-scan: to see a cross-section of the brain as whole which related

to patients complains.
Head MRI: to see a clear picture of the cross-sectional CT scan that is
associated with patients complains.

5.6 Basic management

Infusion RL 16 drops/minute to maintain the State of euvolumik.

Dexametason to reduce the brain edema.
Citikolin: neuroprotector.
Ranitidine: to inhibit excessive stomach acid production.
Anti tuberculosis drugs : Specific antibiotics for tuberculosis

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3. Shams, Shahzad. 2011. Intracranial Tuberculoma. Omar Hospital, Jail Road,
Lahore: Pakistan.

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4. Kumar, Ravindra. 1996. Diagnosis Intracranial Tuberculoma. Lucknow:

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