Case Report

SPACE OCCUPYING LESION

By:
MARIA MARGARETA HUTAJULU
1608437629

Supervisor:
dr. Riki Sukiandra, Sp.S

DEPARTMENT OF NEUROLOGY
MEDICAL SCHOOL RIAU UNIVERSITY
RSUD ARIFIN ACHMAD
PEKANBARU
2018
 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. Patient’s Identity

Name Ms. S
Age 42 yo
Gender Female
Address Mandau
Religion Islam
Marital’s Status Married
Occupation Housewife
Admitted to Hospital January, 24th 2018
Medical Record 9771**

II. ANAMNESIS :

Alloanamnesis with patient’s neighbour January, 25th 2018)

Chief Complain

Lost of consciousness since 1 day before admitted to the hospital.

Present illness history

1 day before admitted to the hospital, patient had loss consciousness. Patient

lost consciousness suddendly. No one knew other complain and patient’s activity

before it happened. Then patient’s neighbour took the patient to Permata Hati’s

Hospital and diagnosed brain tumor by neurology specialist. While at Permata Hati

Hospital the patient has seizure. The neighbour didnt know how many times the

patient seizure.

1
 5 Months before admitted to the hospital, the patient’s neighbours told that

the patient complained headache. The headache getting worse by the time. Other

specific of headache unknown. They told that the patient couldnt walk normally

and sometimes confused what she wanted to do. Her husband ever brough the

patient to alternative but there wasnt improvement. Other complains such as weight

lost, cough for three months or longer, breast tumor and abnormal vaginal bleeding

were unknown. The patients husband left the patient.

Past Illness history

 History of brain trauma unknown

 History of last fever, ear infections, teeth infections, sinusitis unknown

 History of stroke unknown

 Diabetes Mellitus unknown

 Hypertension unknown

 History of the tumor and malignancy unknown

Daily routine history

Smoker (-), Alcoholism (-)

History Jobs

Housewife

The Family Disease History

History of hypertension, diabetes mellitus, and stroke unknown.

2
Summary of anamneis
Patient Ms. S, 42 years old, admitted to Arifin Achmad hospital with chief complain

lost of consciousness since 1 day before admitted to the hospital. The patient felt

headache and getting worse by the times. The patient also couldnt walk normally

and sometimes confused what she wanted to do. She ever got seizure. Other

complains were unknown.

III. Physical Examination (January, 25h 2017)

A. Generalized Condition

Blood Presure : 110/70 mmHg

Heart Rate : 88 bpm

Respiratory rate : 20 x/mnt Type : Thoracoabdominal

Temperature : 36,9°C

Weight : 48 kg Height : 155 cm

BMI : 20 kg/m2 (normoweight)

B. Physical examination

 Neck : No lymph node enlargement

 Mammae : Normal limit

 Thorax : Normal limit

 Abdomen : Normal limit

C. Neurological status

1) Consciousness : Somnolen GCS : 12 (E3V4 M5)

2) Noble Function : Normal

3
3) Neck Rigidity : Negative

Cranial Nerves

1. N. I (Olfactorius )

Right Left Interpretation

Not Not
Sense of Smell applicable applicable
Not applicable

2. N.II (Opticus)

Right Left Interpretation

Not Not
Visual Acuity applicable applicable
Visual Fields
Not Not Not applicable
applicable applicable
Not Not
Colour Recognition applicable applicable

3. N.III (Oculomotorius)

Right Left Interpretation

Ptosis - -
Pupil
Shape Round Round Doll eyes
Side Φ2mm Φ2mm movement
Extraoculer movement + + (+)
Pupillary reaction to light
Direct + +
Indirect + +

4. N. IV (Trokhlearis)

Right Left Interpretation

Extraocular movement + + Doll eyes movement (+)

5. N. V (Trigeminus)

Right Left Interpretation

Motoric
Not Not Corneal reflex normal
applicable applicable
Sensory

4
 Not Not
Corneal reflex applicable applicable
+ +

6. N. VI (Abduscens)

Right Left Interpretation

Eyes movement + +
Strabismus - - Doll eyes movement (+)
Deviation - -

7. N. VII (Facialis)

Right Left Interpretation

Tic - -

Motoric N N
- corner of the mouth N N
- nasolabialis folds + + Normal except sense of
-frowning + + taste not applicable
-raise eyebrows + +
-closed eyes + +
Sense of taste Not Not
Chovstek sign applicable applicable
- -

8. N. VIII (Akustikus)

Right Left Interpretation

Hearing sense N N Normal

9. N. IX (Glossofaringeus)

Right Left Interpretation

Pharyngeal Arch N N Pharyngeal Arch

not not and gag reflex are
Flavour sense applicable applicable normal but flavor
Gag Reflex + + sense not applicable

5
 10. N. X (Vagus)

Right Left Interpretation

Pharyngeal Arch N N
Normal
Dysfonia - -

11.N. XI (Assesorius)

Right Left Interpretation

Motoric Not Not
Trofi applicable applicable
Not Not Not applicable
applicable applicable

12.N. XII (Hypoglossus)

Right Left Interpretation

Motoric Not Not
Applicable applicable Motoric not applicable
Trofi Eutrophy Eutrophy
Tremor - -
Disartria - -

IV. Motoric

Right Left Interpretation

Upper Extremity
Strength
Not applicable Not applicable
Distal Not applicable Not applicable
Proksimal Hypertonus Normal
Tonus Eutrophy Eutrophy
Trofi - -
Involunteer movement - -
Clonus Fall firstly Last fall
Fall Test Motion is Motion is
Stimulation pain less active more active
Lower Extremity
Strenght Lateralization to
Distal Not applicable Not applicable dextra
Proksimal Not applicable Not applicable
Tonus Hypertonus Normal
Trofi Eutrophy Eutrophy
Involunteer movement - -
Clonus - -

6
 Fall Test Fall firstly Last fall
Stimulation pain Motion is Motion is
less active more active

Body
Trofi Eutrophy Eutrophy
Involunteer movement - - Normal
Abdominal Reflex (+) (+)

V. SENSORY

Right Left Interpretation

Touch
Not Not
Pain applicable applicable
Not applicable
Temperatur
Propioseptif

VI . REFLEX

Right Left Interpretation

Physiologic
Biseps (+) (+)
Physiologic reflex
Triseps (+) (+)
normal
Patella (+) (+)
Achilles (+) (+)

7
 Patologic
(+) (-)
Babinski
(-) (-) Patologic reflex (+)
Chaddock
(-) (-)
Hoffman Tromer
(-) (-)
Openheim
(-) (-)
Schaefer

Primitive Reflex
(-) (-) No primitive reflex
Palmomental
(-) (-)
Snout

VII. COORDINATION

Right Left Interpretation

Point to point movement
Walk heel to toe
No No
Gait Appreciate appreciate No Appreciate
Tandem
Romberg

VIII. Otonom

Urinate : Normal

Defecate : Normal

IX. Others Examination

a. Laseque : Limited in dextra <70o

b. Kernig : Limited in dextra <130o

c. Patrick : -/-

d. Kontrapatrick : -/-

e. Valsava test : -/-

f. Brudzinski : -/-

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IV. Summary
General Status

Blood Presure : 110/70 mmHg

Heart Rate : 88 bpm

Respiratory rate : 20 x/mnt Type : Thoracoabdominal

Temperature : 36,9°C

Weight : 48 kg Height : 155 cm

BMI : 20 kg/m2 (normoweight)

Thorax : Normal

Abdomen : Normal

Noble Function : Normal

Meningeal Sign : (-)

Cranial Nerve : Doll eyes movement (+), corneal reflex (+)

Motoric : Lateralization to dextra

Sensory : Not applicable

Coordination : Difficult to asses

Otonom : Normal

Fisiologis reflex : Positive

Pathologic reflex : positive (Babinsky)

WORKING DIAGNOSE

Clinical Diagnose : Increased Intracranial Pressure Syndrome

Topical Diagnose : Cortex cerebri regio lobus frontoparietal sinistra

Etiological Diagnose : SOL ec suspect primary brain tumor

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Differential Diagnose : SOL ec suspect tumor metastase
SOL ec suspect cerebral abscess

SUGGESTION EXAMINATION:

1. Lab study :

(Blood routine, blood chemistry)

2. Electrocardiogram

3. Imaging study :

(Chest X-ray, Head CT-Scan with contrast)

MANAGEMENT

Non pharmacologic therapy:

 Head up 30o

 IVFD RL 20 dpm

Pharmacologic therapy:

 Anti-edemas drugs:

Dexametason 4 x 4 mg IV

LABORATORY FINDING :

1. Lab study

a. Blood Routine ( January, 24th 2018 in Permata Hati’s Hospital)

WBC : 11.270 /ul

Hb : 11,6 g/dl

Ht : 33 %

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 PLT : 174.000/ul

b. Blood Chemistry ( January, 24th 2018 in Permata Hati’s Hospital)

Glucose : 121 mg/dL

Ureum : 25 mg/dL

Creatinin : 0,8 mg/dL

2. Head CT-Scan without Contrast ( January, 24th 2018 in Mandau General

Hospital)

Interpretation:

There isn’t soft tissue swelling at extracranial

Intact visualized bone structure

gray matter matter and white matter are not firm

the lateral ventricle narrowed

Midline shift to dextra

Visible inhomogen lession hipodens – hiperdens, amorf shaped, borderless,

irregular edge, size 40-60 at the left frontal lobes.

10
Impression: Mass apperance at lobus frontalis sinistra dd astrocytoma high grade

dd/ Oligodendroglioma

Suggested : MRI

Other Interpretation

Multiple lession at intracranial suspect metastase.

Suggest : MRI

FINAL DIAGNOSE :

SOL ec suspect tumor metastase

Follow up January, 26th 2018

S : Headache unknown, vomit (-), cough (-), fever (-), seizure one times (+)
nobody knows the type of seizure , limb dextra weakness (+)
O :
GCS 13 (E4M5V4)
Blood Pressure :110/80 mmHg
Heart Rate : 86 bpm
Respiratory Rate : 20 x/min
Temperature : 36,7 °C
Physical Examination
- Thorax : Normal limit
- Abdomen : Normal limit
Meningeal Sign : (-)
Cranial Nerve : Doll eyes movement (+), corneal reflex (+)

Motoric : Lateralization to dextra

Sensory : Difficult to Interprate

Coordination : Difficult to asses

Otonom : Normal

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Reflex physiology : Positive
Reflex pathologic : Positive (Babinsky)
A : SOL ec Suspect tumor metastase

P :
 Head up 30o

 IVFD RL 20 dpm

 Dexametason 4 x 4 mg IV

 Consultation with neurosurgery specialist

 Consultation with VCT

Follow up January, 27th 2018

S : Headache unknown , vomit (-), fever (-), seizure (-), limb dextra
weakness
O :
GCS 13 (E4M5V4)
Blood Pressure :120/70 mmHg
Heart Rate : 86 bpm
Respiratory Rate : 20 x/ min
Temperature : 36,7 °C
Physical Examination
- Thorax : Normal limit
- Abdomen : Normal limit
- Meningeal Sign : (-)
- Cranial Nerve : Doll eyes movement (+), N. V corneal reflex (+)

- Motoric : Lateralization to dextra

- Sensory : Difficult to Interprate

- Coordination : Difficult to asses

- Otonom : Normal

- Reflex physiology : Normal

12
 - Reflex pathologic : Positive (Babinsky)
Consult neurosurgery specialist : multiple lession at intracranial suspect
metastase. Suggest MRI.
Consult VCT : Focus non reactive

A : SOL ec suspect tumor metastase

P :
 Head up 30o

 IVFD RL 20 dpm

 Dexametason 4 x 4 mg IV

 Check tumor marker

Follow up January, 29th 2018

S : Headache unknown, vomit (-), fever (-), seizure (-), limb dextra
weakness
O :
GCS 14 (E4M5V5)
Blood Pressure :120/80 mmHg
Heart Rate : 88 bpm
Respiratory Rate : 20 x/ min
Temperature : 36,9 °C
Physical Examination
- Thorax : Normal limit
- Abdomen : Normal limit
- Meningeal Sign : (-)
- Cranial Nerve : Doll eyes movement (+), corneal reflex (+)

- Motoric : Lateralization to dextra

- Sensory : Difficult to Interprate

- Coordination : Difficult to asses

- Otonom : Normal

13
 - Reflex physiology : Positive
- Reflex pathologic : Positive (Babinsky)
A : SOL ec Suspect tumor metastase
P :
 Head up 30o

 IVFD RL 20 dpm

 Dexametason 4 x 4 mg IV

 Patient exit from hospital by request ( PAPS )

14
 DISCUSSION

1. 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 braincirculation 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

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, makethe

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 complain. 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 diagnose.

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2. BRAIN TUMOR

2.1 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 itscover,

8% are located in intracranial space and 2% in canalis spinalis. The process of

neoplasm in nerves include two types: 2

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 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. 2

In order to discover the exact pathology underlying a brain tumor, it is

essential that it is biopsied and sent for analysis to an experienced neuropathologist.

This biopsy can be done via a stereotactic technique, which allows tissue to be

sampled from the lesion in a relatively safe way. This deploys a co‐ordinate system

based on scans, which allows the surgeon to access the tumor for biopsy in a

16
minimally invasive approach. The other alternative is that a biopsy is performed as

part of the debulking or excision of a tumor.

Broadly speaking, brain tumors can be classified as either gliomas or non‐

gliomas. These are either tumors of the glial cells of the brain or tumors of the other

intracranial cells. The vast majority of lesions in adults tend to be supratentorial

(above the tentorium cerebelli) and 86% of these falls into the category of

gliomas.This includes astrocytomas, oligodendrogliomas and ependymomas.

1. Gliomas

Astrocytomas are the most common type of glioma and are graded

according to the WHO scale of grades one to four. Grade 1 astrocytomas include

pilocytic astrocytomas which are benign. Grade 2 astrocytomas are low grade

infiltrating tumors. Grade 3 anaplastic astrocytomas exhibit mitoses. Finally, the

grade 4 glioblastoma multiforme (GBM)3 is the most aggressive primary brain

tumor in humans and has a median survival of 14 months following diagnose even

if given optimal therapy.4,5 GBM can arise as a first presentation or a secondary

presentation to a lower grade astrocytoma. The gliomas most commonly

encountered in adults are neoplasms of astrocytic or oligodenrocytic lineage. Mixed

tumors also occur, the most common of which is termed anaplastic

oligoastrocytoma.10 In US studies, glioblastomas formed around 50% of these

tumors. This was followed by oligodendrogliomas (9.2%), other astrocytomas

(9.1%) and ependymomas (5.6%).6

2. Non‐Gliomas

Non‐gliomas form the remainder of brain tumors. This includes

meningiomas, which arise from the meninges and compress the brain thereby

17
creating a mass effect. With an incidence of around 2 per 100,000,8 over 90% of

these tumors are benign and are therefore potentially curable through resection.

Loss of chromosome 22 is a characteristic genetic feature of these tumors.6 Pituitary

adenomas also fall into the category of non‐gliomas and are eitherfunctioning or

non‐functioning. If functioning, they may secrete hormones causing endocrine

disturbance.

The clinical manifestation of the tumor depends on the hormone secretion.

Sexual dysfunction and galactorrhoea occur in prolactinoma. A “buffalo hump”,

“moon face”, acne, weight gain, hypertension and diabetes mellitus occur in

Cushing’s disease (ACTH hypersecretion). Acromegaly can result from an over‐

secretion of growth hormone with the typical changes that occurs with soft tissue

growth in adult sufferers. Rarely, other secreting pituitary tumors such as TSHomas

occur. Non‐functioning pituitary tumors may exert a mass effect due to their

proximity to the optic chiasm and can cause visual disturbance such as bitemporal

hemianopia.7

Medulloblastomas are primitive neuroectodermal tumors which are rare in

adulthood but much more common in children, accounting for 20% of childhood

brain tumors.8 These tumors are generally located in the cerebellum and therefore

present with signs of cerebellar dysfunction. They can involve the 4th ventricle and

lead to the development of hydrocephalus.9

With the correct initial treatment of medulloblastoma, long‐term survival

may be achieved in around 40‐60% of all patients.10 These tumors can however

spread in the subarachnoid space to involve other parts of the CNS. Primary CNS

lymphoma is another tumor within the grouping of non‐gliomas. These constitute

18
2‐3% of total brain tumors in people of normal immunity. Patients with

immunodeficiency are at an increased risk of developing this form of cancer.

2.2 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.10

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. 10

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 diagnose 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. 10

19
2.3 Clinical Symptoms

There are 4 common clinical symptoms associated with brain tumors, like

mental status changes, headaches, vomiting, and seizures. 9

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 complain often made by cancer patients with a

variety of forms, ranging from mild memory dysfunction and difficulties

concentrating until disorientation, hallucinations, or lethargy. 11

b. Headaches

Headaches is an early symptom of intracranial tumors on 20% of sufferers.

The character of the headache felt like being pressedor 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.11

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.11

20
 d. Seizures

Focal seizure is another manifestation that is commonly found in the 14-

15% 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.11 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 secondary, while

local seizures occurring if the tumor is widespread on both hemisphere serebri. 12

2.4 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.12

2.5 Management

Treatment of patients with SOL include: 11,12

 Symptomatic.

a. Antikonvulsi

21
 Controlling epilepsy is an important part of the treatment patients

with a brain tumor.

b. Cerebral edema

If patients with increased intracranial pressure and the description of

Radiology showed cerebral edema, then dexametason can be used

reduce the edema.

c. 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.

d. 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

22
 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. 12

e. 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 11,12

2.6 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. 11,12

23
3. BASIC DIAGNOSE

3.1 Basic clinical diagnose

From the anamnesis the patients complain loss of consciousness. The

neighbour told that the patient often felt severe headache. Headache start more than

5 month. The pain was mild for the first times and getting worse by time. The patient

ever got seizure and also got hemiparese dextra.

These symptomps is suitable with symptoms of increased intracranial

pressure, where there are main symptoms of increased intracranial pressure like loss

of consciousness, headache, vomiting, and neurological deficit . Intracranial

pressure is influenced by three factors, namely the volume of brain tissue,

cerebrospinal fluid and blood volume.

3.2 Basic topic diagnose

From this patient symptoms and sign there were found a loss of consciousness,

chronic progressive headache, change status mental and hemiparese dextra, then

the suspected topic diagnose in this case is in cortex cerebri regio lobus

frontoparietal sinistra. Sign of brain tumor depends on true localizing sign from that

lession such as frontoparietal lobe will be happen deficit neurology and

contralateral hemiparesis.

3.3 Basic etiological diagnose

Patient had loss of consciousness and ever felt severe headache. The pain

was mild for the first times and getting worse by the time. The symptomps is

suitable with clinical symptomps of primary brain tumor, like mental status change,

headache, vomiting and seizure. But in physical examination there wasn’t find

abnormalities.

24
 Its proven by radiology imagine that there’s multiple lession at intracranial

suspect metastase. Therefore final diagnose for this patient is SOL ec suspect tumor

metastase but much better confirmed with Magnetic Resonance Imaging (MRI) and

check tumor marker.

3.4 Basic differential diagnose

Patient’s neurological deficit occur slowly and feels increasingly worse,

such as loss of conscious, severe headache progressively, and hemiparese. The

symptomps are caused by increased intracranial pressure. Increase intracranial

pressure can be found in cerebral abscess, brain tumor or metastase. Patient didnt

have sign of infection such as fever or focal infection, and non reactive of HIV,

therefore brain abscess may not suitable.

3.5 Basic of supportive examination

a. Laboratory: knowing risk factors a loss consciousness and knowing the

general condition of the patient.

b. Thoracic x-rays: to see the existence of a specific process, to see metastasis

or originate tumor

c. Head CT-scan: to see a cross-sectional view of the brain as whole, which

related to patient’s complained.

d. VCT : Knowing HIV status in this patient and if positive HIV, it could be

treated as soon as

e. MRI : To know the specific location of tumor

3.6 Basic management

- IVFD RL 20 dpm : to maintain the state of euvolemic.

- Dexametason: to reduce the brain edema.

25
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