Department of Neurosurgery

Vicente Sotto Memorial Medical Center

Neurosurgery
Case Presentation

Group 6 Team C:
Adraincem | Avila | Kaibing | Pepito
 Filipino

Married

Roman Catholic

E.J. DOB: March 28, 1966

Kabuhi, Mahayag, Zamboanga del Sur

57/M

Date and Time of Admission:

August 12, 2023 2:00PM
Muscle Weakness of
Lower Extremities
History of Present Illness
1 year PTA, patient noted onset of muscle weakness on lower extremities. No other
associated symptoms. Tolerated the condition, no consult done.

In the interim, no progression or improvement of condition noted. The patient

tolerated his condition without seeking consultation or taking any medications.

2 weeks PTA, patient noted gait disturbance associated with numbness of both lower
extremities. Brought to a private AP, imaging was done revealing a cerebellar mass with
calcifications. Patient was then referred to our institution for further evaluation and
management.
Past Medical History
(+) HPN
non compliant to medication (Telmisartan/Amlodipine)

(-) DM
(-) BA

Fistulotomy (Igano Hospital, 2021)

Family History

No heredofamilial diseases on maternal and paternal sides.

Personal and Social History
Smoker for 5 pack years

Occasional alcoholic drinker

No history of illicit drug use

No food and drug allergies

Physical Examination
BP: 150/100 PR: 85 O2: 97% at RA Wt: 96 kg
Temp: 36.3 RR: 21 Ht: 166 cm BMI: 34.8 (Obese I, WHO-Asia
Pacific)
SKIN: Warm to touch, good skin turgor
HEENT: anicteric sclerae, pink palpebral conjunctiva
NECK/LYMPH NODES: No lymphadenopathy
CHEST/LUNGS: Equal chest expansion, Clear breath sounds
CARDIOVASCULAR: Distinct heart sounds, (-) murmurs
Physical Examination
ABDOMEN: Flat, normoactive bowel sounds, soft, non-tender on light and deep palpation
MUSCULOSKELETAL: Full range of motion
EXTREMITIES: strong peripheral pulses, CRT < 2 seconds
CENTRAL NERVOUS SYSTEM: GCS 15 (E4V5M6)
Neurologic Examination
Cerebral: awake, coherent, responsive, cooperative, oriented to time, place, and person
Cranial Nerves:
CN I: Able to smell coffee and citrus zest
CN II, III: (+) PLR, direct and consensual
CN III, IV, VI: full EOM by finger following test
CN V: , VII facial sensations intact; symmetric facial expressions
CN VIII: able hear spoken voice from 2 feet away
CN IX, X: (+) gag reflex, (+) swallow reflex, uvula at midline
CN XI: able to turn head and shrug shoulders against resistance
CN XII: tongue midline at rest and protrusion, no wrinkling or fasciculations
Neurologic Examination
Cerebellar: (+) Truncal Ataxia, wide-stance unstable gait
Motor: no atrophy or involuntary movements, no tremors, good muscle tone
Muscle strength: 5/5 5/5
5/5 5/5
Sensory: intact light touch and pain senses
Reflexes: 2+ DTR all extremities
Diagnostic Labs
Complete Blood Count 08/12/2023 08/19/2023 09/06/2023

WBC 4.63 18.95 23.87

RBC 4.80 4.94 4.95

Hemoglobin 137.00 143.00 147.00

Hematocrit 42.10 42.20 43.40

MCV 87.70 85.40 87.70

MCH 28.50 28.90 29.70

MCHC 32.50 33.90 33.90

RDW-CV 12.70 12.70 14.70

Platelet count 256.00 431.00 300.00

Neutrophil 42.00 88.80 92.50

Lymphocyte 47.90 6.80 2.60

Monocyte 7.10 4.30 4.70

Eosinophil 2.60 0.00 0.00

Basophil 0.40 0.10 0.20

Diagnostic Labs
Complete Blood Count 08/12/2023 08/19/2023 09/06/2023

WBC 4.63 18.95 23.87

RBC 4.80 4.94 4.95

Hemoglobin 137.00 143.00 147.00

Hematocrit 42.10 42.20 43.40

MCV 87.70 85.40 87.70

MCH 28.50 28.90 29.70

MCHC 32.50 33.90 33.90

RDW-CV 12.70 12.70 14.70

Platelet count 256.00 431.00 300.00

Neutrophil 42.00 88.80 92.50

Lymphocyte 47.90 6.80 2.60

Monocyte 7.10 4.30 4.70

Eosinophil 2.60 0.00 0.00

Basophil 0.40 0.10 0.20

Diagnostic Imaging
Diagnostic Imaging
Intraoperative Findings
Intraoperative Findings
Primary Impression

Cerebellar mass, Low-grade astrocytoma, Pilocytic

Differential Diagnoses

● Hemangioblastoma
○ Headaches
○ Focal Neurological deficit
○ Cystic imaging feature
● Glioblastoma multiforme
○ Highest incidence in the fifth and sixth decade of life
○ Most of the time, focal neurological deficit is the presenting sign
● Oligodendroglioma
○ Headache and visual disturbance
○ Focal neurological deficit
○ Highest incidence in between 40-50 years of age
Case Discussion
 Neuroglial Neoplasms
● Tumors of neuroglia account for 40% to 50% of intracranial tumors.
● Tumors of astrocytes are those most commonly encountered and include astrocytomas and
glioblastomas.
● Tumors of the neuroglia are highly invasive.
● These tumors infiltrate, they often do so without interfering with the function of neighboring
neurons.
 Astrocytoma
● Primary intracranial tumors derived from astrocytes cells of the brain.
● Largest subgroup of gliomas (about 20% to 30% of all gliomas)
● Histology into 4 grades: pilocytic astrocytoma, diffuse astrocytoma, anaplastic astrocytoma and
glioblastoma multiforme.
● The histologic subtypes of astrocytomas cannot be distinguished on MRI.
○ Cystic Pilocytic Astrocytomas and Subependymal giant cell astrocytomas may be
diagnosed pre-operatively on MRI due to their typical appearance, location, and clinical
features.
Pathophysiology
● The exact pathogenesis of astrocytoma is not completely understood, believed that this tumor
has a close association with genetic mutations.
● Astrocytomas of all grades have been associated with cranial therapeutic irradiation
● People who have certain rare genetic conditions such as neurofibromatosis or Li-Fraumeni
syndrome
● People over the age of 65 are diagnosed at a rate four times higher than younger people
Mutations affecting p53 and overexpression of platelet-derived growth factor alpha
(PDGF-A) and its receptor- most common in the low grade astrocytomas

Disruption of tumor suppressors gene ( RB and p16/CDKNaA and tumor suppressor on

chromosome 19q)- transition to higher grade astrocytoma
Epidemiology
● May occur at any age
● The low-grade type is often found in children or young adults, while the high-grade
type is more prevalent in adults.
● Pilocytic astrocytomas are tumors of young, approximately 70% occur in children,
with a mean age at diagnosis of 7 years.
● In general, there is an equal male-to-female distribution.
Risk factors
● Environmental exposure to:
○ Phenols
○ Organic solvents
○ Formaldehydes
○ Pesticides
● Radiation exposure to the brain
● Genetic risk factors:
○ Neurofibromatosis
○ Tuberculosis-sclerosis
○ Li-Fraumeni Syndrome
○ Turcot syndrome
Risk factors
● Previous head trauma
● History of meningitis
● History of epilepsy
Anatomy
● Pilocytic astrocytomas preferentially affect the cerebellum, brainstem, optic nerves,
and third ventricular region.
● The tumor often manifests as a mural nodule within a cyst
● Invasion of the overlying leptomeninges is common, but this feature does not
constitute a negative prognostic factor.
Clinical Presentation
● Increased intracranial pressure:
○ Headache
○ Nausea or Vomiting
○ Changes in behaviour
○ Unusual sleeping pattern
● Cerebellar:
○ Hypotonia
○ Postural changes or alterations in gait
○ Ataxia
○ Dysdiadochokinesia
○ Nystagmus
○ Dysarthria
Clinical Presentation
● Pons involvement results in ipsilateral CN paralysis and contralateral hemiparesis:
○ Weakness and asymmetry of facial muscles
○ Weakness of lateral rectus muscle
○ Nystagmus
○ Weakness of jaw muscles
○ Hearing impairment
○ Contralateral hemiparesis
○ Anesthesia to light tough
○ Contralateral sensory defects of trunks and limbs
Diagnosis
Laboratories Imaging

- for general metabolic surveillance MRI- considered the standard imaging study
and preoperative assessment CT scan

Basic metabolic profile, CBC, PT/aPTT Advanced MRI techniques

Advanced Positron Emission Tomography (PET)

Functional MRI (fMRI)

Therapeutics
● In extremis, management of airway and addressing hydrocephalus is first priority
● Surgery is always the first-line therapy because gross total resection is the most important
determinant of outcome for low-grade gliomas
○ Intracranial low-grade gliomas, cerebellar astrocytomas are the most amenable to complete resection,
which can be curative.
○ Observation after complete resection
○ Imaging monitoring every 4 months
● Postoperative adjuvant therapy with radiotherapy or chemotherapy is not indicated
because it has not been shown to delay progression or improve survival, even with WHO
grade II tumors.
Prognosis and Complications
● Cerebellar mutism (posterior fossa syndrome):
○ Ataxia
○ Hypotonia
○ Cranial nerve palsies
○ Hemiparesis
○ Emotional lability
○ Severe dysarthria
● Risk for recurrence:
○ 10% to 20% after total resection
○ 50% to 80% after subtotal resection
○ Late recurrences have been reported as late as 15 years post-oparatively
Prognosis and Complications
● Low-grade astrocytomas (grade I [pilocytic] and grade II) have a relatively favorable
prognosis
○ particularly for circumscribed, grade I lesions where complete excision is possible
● Unfavorable prognostic features:
○ Young age
○ Fibrillary histology
○ Inability to obtain a complete resection
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