Abstract
The following case involves an adult with left temporal lobe tumor. A tumor in the temporal lobe will affect the memory, emotions, sounds and the spoken word. Epileptic symptoms such as seizures are common in such situations. The tumor is a pilocytic astrocytoma, a condition that is more common in children and young adults. This is interesting because the patient is in his middle ages. The pilocytic astrocytomas are treated well with surgery, although chemotherapy and radiotherapy are sometimes used. Pilocytic astrocytomas are Grade I gliomas. They are usually benign and they rarely spread. PM appeared healthy after checking all his vital signs. He however did not remember what had happened to him.
Case Number:
Patient Initials: PM
Initial Date of Patient Consult/Treatment: March 12, 2007
Patient Age: 58 Gender: Male Occupation: Bus Driver
Introduction
A tumor in the temporal lobe will affect the memory, emotions, sounds and the spoken word. Epileptic symptoms such as seizures are common in such situations. The tumor is a pilocytic astrocytoma, a condition that is more common in children and young adults. This is interesting because the patient is in his middle ages. The pilocytic astrocytomas are treated well with surgery, although chemotherapy and radiotherapy are sometimes used. Pilocytic astrocytomas are Grade I gliomas. They are usually benign and they rarely spread. PM appeared healthy after checking all his vital signs. He however did not remember what had happened to him.
Summary of content
PM is a 58-year-old male who was brought to the A&E on March 12, 2007, by his wife, after he stopped talking and started to smack his lips in an unusual manner. PM did not remember any of the events that happened. He reported that he had increasingly become irritated with his wife and he had trouble sleeping in recent months. PM was diagnosed with haemorrhoidectomy when he was 52 years old and he has had hypertension for the last three years. His father suffers from COPD and his mother died of Cerebral Haemorrhage when she was 73. One of his uncles had scarlet fever and he later became epileptic when he was a teenager. He had to use anti-epilepsy medication all his life and he died when he was 55 years old after respiratory failure. PM does not control his hypertension well, and his blood pressure was 148/96 when he was last measured two months ago. He is currently taking bisorprolol and amitriptyline 75 mg nocte, 2/12. He reported that he does not smoke, and he does not take more than ten units of alcohol per week.
Assessment
PM appeared healthy after checking all his vital signs. He however did not remember what had happened to him. He did not remember an incident that had happened five days earlier, where he had insulted a police officer. His fundoscopy revealed early papillioedema in both optic disks. PM developed another seizure when waiting to undergo neurological tests. He later vomited and complained that he had a headache. An EEG test revealed that his left temporal lobe had slow wave activity, and he had epileptiform discharges. He also underwent an MRI. The T1-weighted gadolinium-enhanced MRI revealed that he had a left frontotemporal tumor. The signal intensity of the cortex sylvian fissure and insula had decreased on the left side. The T2-weighted MRI showed increased signal intensity in the temporal lobe and the lateral insula.
I had a chance to observe PM when he had a seizure as he was waiting to take a neurological exam. I suspected that the papilloedema was probably due to cerebral oedema or a tumor based on the family history. Later EEG and MRI tests confirmed my suspicions as they showed evidence of a tumor in the left temporal lobe and signs of focal epilepsy. PM was given 10 mg dexamethasone phosphate i.v. to treat the cerebral oedema. He stopped taking the dexanethasone after 5-7 days. He was then given 4 mg i.v. qds, which he was to take 2-4 days. PM took a biopsy, which revealed that he had pilocytic astrocytoma. His tumor was removed and he underwent radiotherapy. There was no tumor after the surgery and radiation. He took sodium valporate for three months and he did not report having any seizures during this time. He also took ramipril and amlodipine to control his blood pressure.
Discussion
Pilocytic astrocytoma occurs mostly in children and young adults. It accounts for 40% of all childhood tumors (Ishkanian 4070). It grows slowly mostly in the cerebrum, cerebellum, optic nerve, and brain stem. It is classified as Grade 1 or low-grade tumor. Most people with neurofibromatosis type 1 are usually at a greater risk of developing pilocytic astrocytomas especially in the optic pathways. Most of the pilocytic astrocytoma is found in the cerebellum and the deep midline structures (Stuer 2799). This means that patients who have been diagnosed with this type of tumor have difficulties in coordination and balance. Pilocytic astrocytomas usually occur in the cerebellum especially in the temporal and parietal lobes. Pilocytic astrocytomas are usually benign and they do not spread to other regions. Although they are slow growing, they can become very large. Patients often develop symptoms, which include seizures, headaches and visual disturbances. Patients with tumors on the frontal lobe usually have partial complex seizures. Some tumors affect the sensory and motor cortices, and they usually cause simple partial seizures. The intracranial pressure usually causes some of the symptoms such as headaches, nausea and emesis. Most patients usually undergo neurological tests, which show signs such as papillioedema and dysmetria. Many of the brain tumors are found in the temporal lobe (Pathol 557). Both the right and the left temporal lobes contribute to the semantic memory, and a patient’s memory is therefore affected when something is wrong in the lobes (Lambon et al., 3243)
Pilocytic astrocytoma in the brainstem rarely occurs in adults. Common symptoms include cranial nerve dysfunction and cerebellar abnormalities. Patients also exhibit symptoms of high intracranial pressure, pyramidal tract dysfunction, personality changes and sensory deficits. The pilocytic astrocytoma in the cerebellar is a cystic mass in the hemisphere. The pilocytic astrocytoma in the optic pathway usually occurs in the tract and the chiasm. They are not common in adults, and when they do, they have a less favorable outcome. They are usually accompanied by visual loss, which is mainly caused by the intracranial tumors in the optic nerve and chiasm. Common symptoms include headaches, papilloedema, optic atrophy and strabismus. In most cases, the tumors infiltrate to the midbrain, brainstem and hypothalamus. Gliomas on the optic pathway are usually not resected fully because of their location. They therefore have a less favorable outcome than tumors in other regions.
Pilocytic asstrocytoma can be examined on MRI. It can appear as a hypointense or hyperintense mass to the brain on T1-weighted MRI. However, it only appears as a hyperintense mass on brain on T2-weighted MRI. These tumors are often removed by surgery, and the patients have a high rate of survival. It is easy to resect the tumors fully because they are well circumscribed, and they do not usually infiltrate. Sometimes, the surgery can be combined with chemotherapy or radiotherapy, especially incases of subtotal resect. Radiotherapy is often used on adult patients when the whole tumor has not been removed. However, chemotherapy is often used on children since radiotherapy would destroy their cells. Radiation and/or chemotherapy are often recommended when the tumor is on the optic pathway or brainstem. The tumor is however, curable and total resection is usually the recommended option. Tumors can recur in patients who have heard subtotal resect, and in such cases, observation is usually required after surgery. Seizures can sometimes recur when the pilocytic astrocytomas recur even in patients who have not had seizures for a while (Nishimoto et al., 45).
PM had subtotal resection, and this was combined with radiotherapy. At the end of his treatment, he underwent another MRI test, and it showed that there was no tumor. He was given medication for his seizures and he has not reported any seizures for three months. His personality has become more stable since the treatments started taking effect. PM cannot return to his current job as a bus driver because of his seizures. The DVLA regulations require that a person who has a history of seizures should not drive until he has been free of seizures for ten years. PM is more worried that he will be labeled epileptic. He saw how his uncle suffered because of the labeling and he does not want to go through the same situation. With the treatment he has received for his seizures, I do not think that he will have to worry about that for long.
Works Cited
Ishkanian, A., Laperriere NJ, Xu W, Millar BA, Payne D, Mason W and Sahgal A. “Upfront Observation Versus Radiation for Adult Pilocytic Astrocytoma.” Cancer 117.17 (2009) 4070-9
Lambon Ralph MA, Cipolotti L, Manes F, Patterson K. “Taking Both Sides: Do Unilateral Anterior Temporal Lobe Lesions Disrupt Semantic Memory?” Brain 133.11 (2010) 3243-55
Nishimoto T, Iida K, Kagawa K, Watanabe Y, Kiura Y, Hashizume A, Sugiyama K, Kurisu K. “Late Recurrence of Intractable Epilepsy Associated with MRI-Occult Pilocytic Astrocytoma in the Temporal Lobe Nine Years after Initial Removal: A Case Report with Surgical and Late-Seizure Recurrence Observations.” Hiroshima J Med Sci 60.2 (2011) 45-9
Prayson A. Richard. “Brain Tumors in Adults with Medically Intractable Epilepsy.” Am J Clin Pathol 136.4 (2011) 557-63
Stüer C, Vilz B, Majores M, Becker A, Schramm J and Simon M. “Frequent Recurrence and Progression in Pilocytic Astrocytoma in Adults.” Cancer 110.12 (2007) 2799-808
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