X-ray Case (3)

[Diagnostic]

35 year old woman from Africa presented with projectile vomiting preceded with headache. Nothing important in past medical history apart from chronic cough. Investigation: look at the attached Image Questions 1- What is your diagnosis? 2- What other important clinical presentation? 3- How to treat this patient?

Diagnostic

[Muna1]

happy new year for all inshall ah   .
i think the diagnosis is Subarachnoid Hemorrhage
clinically presentation :
acute onset of sever headache , nausea, vomiting,an altered level of consciousness , nick stiffness
 management of the patient :
1 admission in ICU
2 The head end of the bed should be kept elevated at 30°
3 Relief of associated vasospasm medically with calcium channel blockers
4   Urgent surgical removal of blood may be indicated and maintenance of cerebral perfusion
5   Early surgical clipping is used to prevent re bleeding
6   Control blood pressure , prevention of seizures, treatment of nausea, management of ICP,  control of pain.
 i hope it is correct.
.

[Diagnostic]

It's one of the differential diagnosis but try again!

[Mustafa]

assalam aleikum dear poster,

The clinical symptoms seem to be suggestive for an elavated intracranial pressure complicated by multiple brain lesions/metastasis. undermentioned an attempt for an explanation:
1. Headache ( 40 to 50 percent ) is a common manifestation of brain tumors and is the worst symptom in about one-half of patients. The headaches are usually dull and constant, but occasionally throbbing.
2. Brain tumors can cause nausea and/or vomiting by increasing the ICP at the area postrema of the medulla  ( the area in the floor of the fourth ventricle which contains a "chemoreceptor trigger zone" that is sensitive to many humoral factors, including neurotransmitters, peptides, drugs, and toxins. ).
Patients with primary or metastatic brain tumors may present with either generalized ( Headaches, seizure, nausea/vomiting, depressed level of consciousness and neurocognitive dysfunction ) or focal ( seizures, weakness, sensory loss, aphasia and visual spatial dysfunction).
treatment:
The management of patients with multiple brain metastases remains a difficult challenge for neurosurgeons. The KPS ( karnofsky Performance Scale ) score has been used as a major predictor of survival in patients with multiple brain metastases. It is generally accepted that patients with a KPS score of 70 or greater may benefit from either resection and/or radiosurgery, it has been shown that patients with higher KPS scores experienced prolonged survival compared with those with a score lower than 70. This patient has a poor prognosis when compared with those harboring a solitary brain metastasis, and historically treatment has generally consisted of administering whole-brain radiotherapy once the diagnosis of multiple brain metastases is made.
Besides,whole-brain radiation therapy is the standard therapy for brain metastasis, with an established body of literature supporting its use for multiple metastases. Moreover whole-brain irradiation has the ability to eradicate micrometastatic disease to delay recurrenceand is often used in conjunction with surgical resection or radiosurgery. It is tolerated fairly well and can be very effective for radiosensitive tumors such as metastases from small cell lung cancer.


wa assalam caleikum
Mustafa

[Diagnostic]

Dear Mustafa, you are so close
There is elevated intra cranial pressure with multiple brain lesions but it's not due to metastasis.
Try again
Diagnostic

[Mustafa]

salaam aleikum dear case poster,
1. motivation why I thought of metastasis in this case was: she might have had primary pulmonary carcinoma which possibly was undetected ( Since some types of carcinoma don't necessarily present with the classic symptoms such as caxhexia or haemoptoe ans so on.) and then later on presented with the symptoms you have mentioned in the case plus the multiple lesions intracranially.
to come up with the diagnosis of this disease, I believe it is of paramount importance to take a personal history of tuberculosis ( such as the whereabouts of the patient and her chronic cough ), past or present, as it is of course highly contributive for the diagnosis, as is the overall general physical examination . Therefore I think it is intracranial tuberculoma.
These are tumor-like masses of tuberculous granulation tissue, most often multiple ( hence why i thought of metastasis) and it is very rare in developed countires whereas in developing countries they constitute from 5 to 30 percent of all intracranial mass lesions ( the patient is in Africa ).
Except the abovementioned symptoms in the case other common complaints may include  seizures, epilepsy. Of course other neurological symptoms attributable to the location of the lesion may be seen.
The diagnosis of intracranial tuberculoma is often made on history and physical, suspicion, and diagnostic imaging though CSF when taken enough  provide the best information. therefore there is no definite diagnostic pathway but a work-up is a often a good start as this disease neuroradiologically mimics neoplasma.
CDC guidelines recommend a 9- to 12-month pharmacologic treatment regimen ( INH, rifampin (RIF), pyrazinamide, and ethambutol. Corticosteroids can be added to the regimen to decrease the elevated intracranial pressure as in this case though its value is still under investigation .

I hope that I have given enough arguments why I have come up with this diagnosis, keeping in mind that a differential diagnosis for this clinical presentation still remains for me a cerebral metastasis as a work-up.

wa asslaam aleikum

Mustafa

[Diagnostic]

Well done brother Mustafa
It's Intra cranial Tuberculoma.
Although Image wise it's difficult to tell professional diagnosis in this case but when you analyze the history, you see a middle aged patient from Africa with only chronic cough with no significant medical history.
As a doctor working in Africa, the intra cranial tuberculoma will pop up while you as a doctor practicing int Netherlands, brain metastasis will be the right guess!. but  I admit that this case needs more keywords to be added.
This is to compare the two images of (Intra caranial Tuberculoma VS Brain Metastasis)

There are multiple lesions of similar size scattered in both cerebral hemispheres, but more on the right side. There is marked oedema of the deep white matter associated with each focus, but without significant mass-effect. The lesions enhance after intravenous contrast.

The CT scan shows mass lesions in both cerebral hemispheres with a brightly enhancing rim. There is one in each frontal and parietal lobe. The right frontal lesion is parasaggital. A ring of density in the body of the right caudate nucleus may represent another lesion. There is an underlying pattern of large cerebral sulci and lateral ventricles.

There are other close differential diagnosis rather than brain metastasis such as:
Cysticercus granuloma, pyogenic abscess, fungal granuloma & glioma.
Diagnostic

[Admin]

Thanks for all those who participate this case & congratulation to dr.mustafa & 15 points of this case goes to him!
The case will be locked but if one of you "diagnostic" or "mustafa" needs more discussion on this case, please inform me to unlock it.
Thanks
Dr.Mahdi