A CASE REPORT FROM WAHIDIN SUDIROHUSODO

Thursday, September 12th 2013

PRESENTED BY : APRIYANTI PURWANINGSIH

SUPERVISOR : Dr.Cahyono Kaelan, Ph.D,Sp.PA(K),Sp.S

I.

II.

REGISTRASION
Name
: Mr.J
Age
: 45 years old

Admission date
Registration no.

: 16th July 2013

: 612514

ANAMNESIS
Chief complaint

: Headache

It occurred about one year ago, but it got worse in last two months, and the pain felt
specially on the right side of the head area and it was spreading to the back of the head. The
headache often felt in the morning and it became heavy with activity, but it reduced if he
taking analgetik (paramex). He also complained that have a double vision. He felt weakness
on the left side of the body progress since 6 months ago. He was treated in Sinjai hospital
two days before he was taken to Wahidin Sudirohusodo Hospital with headache, vomiting
about three times, decreased of consciousness and seizures. The seizures was experienced
two times during two minutes and throughout the body. There were no history of head
trauma and fever. There were no history of hypertension, chest pain and diabetes mellitus.
History in the family with the same disease has denied.
PHYSICAL EXAMINATION
Vital Signs
BP : 130/70 mmHg

RR : 20 x/minute, thoracoabdominal

HR : 60 x/minute,regularly

BT : 36,5oC,axillary

Internal Status
Head

: anemia (-), icteric (-), cyanotic (-)

Thorax

: Cor and pulmo were within normal limit

Neurological Status
1

- GCS

: E4M6V5

- VAS

: 7-8

- Higher cortical function : within normal limit

- Meningeal sign

: No Neck stiffness, Kernigs sign were absent

- Cranial nerves

: ODS : Pupil were round isocor 2,5 mm

Direct and Indirect light reflexes were normal
Funduscopi ODS : papil edema +/+

- Other Cranial nerves

: - Right CN.VI parese (diplopia)

- Left CN.III parese

- Motor function : Movement

Muscles strength

N
Tones

5 4+
5 4+

BPR N

KPR N

TPR N

APR N

- Sensory function

: within normal limit

- Autonomic function

: Micturation : within normal limit

Defecation

PR _

+ +

: within normal limit

III. WORKING DIAGNOSIS

Clinical

: Chronic Headache + Left Hemiparesis + Multiple cranial nerves palsy +

Diplopia

Topical

: Right Cerebral Hemisphere

Ethiological : Suspect SOL Intracranial

IV. TREATMENT
2

- Head up 20o- 30o

- IVFD RL 20 drops/minute
- Corticosteroid

: Dexamethason 10 mg/iv and then followed 5 mg/6 hours /iv

- Neuroprotector

: Piracetam 3 gram/6 hours/iv

- Neurotropic

: B1 B6 B12 1 amp/ 24 hours/im

- Analgesic

: Ketorolac 30 mg/8 hours / iv

- H2 receptor antagonist : Ranitidin 50 mg /12 hours /iv

V. SUGGESTIONS
-

Complete blood count

Blood chemistry examination

Chest X-Ray AP

Head CT Scan

ECG

VI. FOLLOW UP
17th July 2013 (2nd day care)
- Complaint

: Headache + double vision

- GCS

: E4M6V5

- VAS

: 5-6

- Higher cortical function : within normal limit

- Meningeal sign

: No Neck stiffness, Kernigs sign were absent

- Cranial nerves

: ODS : Pupil were round isocor 2,5 mm

3

Direct and Indirect light reflexes were normal

Funduskopi ODS : papil edema +/+
- Other cranial nerves

: Right CN.VI parese (diplopia) , Left CN.VI parese

- Motor function

: Movement N

muscles strength 5

BPR N

APR N

PR _

TPR

KPR N

- Sensory function

: Within normal limit

- Autonomic function

: within normal limit

Diagnosis

4+ Tones N
4+

_
+

: Chronic Headache + Left Hemiparesis + Multiple Cranial Nerves

Palsy + Diplopia ec Susp. Astrocytoma

Laboratory Finding On 16th July 2013

WBC

11,93 x103/mm3

HGB

11,1 g/dl RBC

Creatinin 0,30 mg/dl (N = <1,3 mg/dl)

RBC

5,47 x 106/UL

Ureum 30 mg/dL

HCT

33,4 %

PLT

243 x 103/mm3

MCV

81,3 fl

Total Choles 312 mg/dl (N = 200 mg/dl)

MCH

27,0 pg

HDL Choles 45 mg/dl (N = > 55 mg/dl)

Glucose at random 120 mg/dl (N = 140 mg/dl)

SGOT 25 u/l (N = < 38 u/L)

SGPT 23 u/l (N = < 41 u/L)

MCHC 33,2 g/dl

LDL Choles 247 mg/dl (N = < 130 mg/dl)

Na 143 mmol/l (N=136-145 mmol/l)

Trigliserida 125 mg/dl (N = 200 mg/dl)

K 4,2 mmol/l (N=3,5-5,1 mmol/l)

Cl 103 mmol/l (N=97-111 mmol/l)

INR

1,03

Radiology : Head CT Scan without contrast on 16th July 2013

Visible heterogenous mass density 48 HU with unclear boundary. Edema

perifocal size 6.8 x 6.1 which constrict the right lateral ventricle and
causing midline shift to the left as far as 2 cm in the right frontoparietal
region.
Obliteration of sulci and gyri
Visible physiological calcification in the pineal body and choroideus
plexus.
Ventricular system and subarachnoid space within normal limits.
Water cell mastoids and sinuses paranasalis within normal limits.
Bulbus oculi and retrobulber space within normal limits.
The bones are intact.

IMPRESSION : Intracranial mass susp.astrocytoma

CHEST X-RAY AP Result on 16th July 2013
-

Bronchovasculer pattern within

normal limit.
- There is no specific process both the
lungs.
- Both sinuses and diaphragms within
normal limit
- Cor within normal limit.
- The bones are intact.
Impression : Within normal limit

ECG : Within normal limit

5

Treatment
- Head up 20o- 30o
- IVFD RL 20 drops/minute
- Corticosteroid

: Dexsametason 5 mg/6 hours/iv

- Neuroprotector

: Piracetam 3 gr/8 hours/iv

- Neurotropic

: B1 B6 B12 1 amp/ 24 hours/im

- Analgesic

: Paracetamol 3 x 500 mg

- H2 receptor antagonis : Ranitidin 50 mg/12 hours /iv

- Antibiotic

: Ceftriaxon 1 gr/12 hours/iv (skin test)

- Antidislipidemia

: Simvastatin 20 mg 0-0-1

Suggestions : -

Head CT Scan with contrast examination

Consultation to Neurosurgery after get the result of Head CT Scan with
contrast examination.

20th July 2013 (5th day care)

- Complaint

: Headache

- GCS

: E4M6V5

- VAS

: 4-5

- Higher cortical function

: Within normal limit

- Meningeal Sign

: No Neck stiffness, Kernigs sign were absent

- Cranial nerves

: ODS Pupil were round isocor 2,5 mm

Direct and Indirect light reflexes were normal
Funduscopi ODS : papil edema +/+

- Other cranial nerves

: - Left CN.III parese

6

- Right CN.VI parese (diplopia)

- Motor function

: Movement N

muscles strength 5

4+

TPR N

KPR N

PR _

BPR N

APR N

- Sensory function

: Within normal limit

- Autonomic function

: Micturation : within normal limit

Defecation

Diagnosis

4+ Tones N
N

: within normal limit

: Chronic Headache + Left Hemiparesis + Multiple Cranial Nerves Palsy +

diplopia ec Glioblastoma Multiforme

Head CT Scan With Contrast On 18th July 2013

Visible heterogenous mass density 48 HU with unclear boundary. Edema perifocal

size 6.8 x 6.1 which constrict the right lateral ventricle and causing midline shift to the
left as far as 2 cm in the right frontoparietal region. The heterogenous enhancement
mass in giving contrast
Obliteration of sulci and gyri
Visible physiological calcification in the pineal body and choroideus plexus.
Ventricular system and subarachnoid space within normal limits.
Water cell mastoids and sinuses paranasalis within normal limits.
Bulbus oculi and retrobulber space within normal limits.
The bones are intact.

IMPRESSION : Featuring of Glioblastoma Multiforme

TREATMENT
- Head up 20o- 30o
- IVFD RL 20 drops/menit
- Corticosteroid

: Dexamethason 5 mg/24 hours/iv

- Neuroprotector

: Piracetam 3 gr/8 hours/iv

- Neurotropic

: B1 B6 B12 1 amp/ 24 hours/im

- Analgesic

: Paracetamol 3x500 mg

- H2 receptor antagonist : Ranitidin 50 mg/12 hours /iv

- Antidislipidemia

: Simvastatin 20 mg 0-0-1

The answer consult from neurosurgery : got any advice for craniotomy to partial
removal tumor that can helps relieve symptoms by reducing pressure on the brain but the family
and himself refused to do the operation.

27th July 2013 (12th day care) : The patient forced to go home by himself.
8

VII. FINAL DIAGNOSIS

Clinical

: Chronic Headache + Left Hemiparesis + Multiple cranial nerves palsy +

diplopia

Topical

: Right Cerebral Hemisphere, right frontoparietal region

Ethiological : Glioblastoma Multiforme

VIII. PROGNOSIS
Quo ad vitam

: poorly

Quo ad sanationam

: poorly

IX. DISCUSSION
A male 45 years old came to the hospital with headache. It occurred about one year ago,
but it got worse in last two months, the pain felt specially on the right side of the head area
and it was spreading to the back of the head. The headache was more often felt in the
morning and it became heavy with activity, but it reduced if he taking analgetic (paramex).
He also have a double vision. He felt weakness on the left side of the body progress since 6
months ago. He was treated in Sinjai hospital two days before he was taken to Wahidin
Sudirohusodo Hospital with headache, vomiting about three times, decreased of
consciousness and seizures. The seizures was experienced two times during two minutes
and throughout the body.. From the physical examinations we found GCS E4M6V5, there
were left hemiparesis extremity with decreasead of tonus and physiological reflexes, parese
of left third nerve and right sixth nerve. There was babinski bilateral. The supporting
examinations were laboratory tests, ECG, Chest X-Ray AP, Head CT Scan without and with
contrast. The result of Head CT Scan without contrast was astrocytoma suspected
intracranial mass, and Head CT Scan with contrast was commensurate with Glioblastoma
Multiforme. The Chest X-Ray was within normal limits. Based on history, physical
examination and supporting examination it was diagnosed chronic headache + Left
Hemiparesis + Multiple cranial nerves palsy + diplopia ec Glioblastoma Multiforme.

Glioblastoma multiforme (GBM, malignant glioma) is a malignant primary brain tumor

is the most common and most aggressive in humans (in adults), involving glial cells.
Glioblastoma multiforme is the highest grade astrocytoma, which occurred about two thirds
of all cases of astrocytoma. Astrocytoma is a brain primary tumors derived from brain glial
cells. Astrocytoma accounted for 75% of all gliomas. Astrocytoma classified by WHO into 4
grades based histologiknya picture, grade I (pilocytic astrocytoma) to grade IV
(glioblastoma multiforme). (1,2,3,)
Glioblastoma multiforme (GBM) is the most malignant brain tumor and is most
common in adults, which is about 33-45% of all primary brain tumors, more common in
men than women (3: 2), and usually occurs in patients aged more than 50 years. Whereas
low-grade astrocytoma usually occur in young people, the average age was 35 years.
Although this tumour can occur in all age groups, including children, the average age at
which it is diagnosed is 55 years.(1,4,7)
For unknown reasons, GBM occurs more commonly in males. Most glioblastoma
tumors appear to be sporadic, without any genetic predisposition. Consumption of the
artificial sweetener aspartame causes brain tumors in rats and its increasing prevalence in
diet sodas parallels the increasing prevalence of glioblastoma in western cultures. No links
have been found between glioblastoma and smoking, consumption of cured meat, or
electromagnetic fields. Alcohol consumption may be a possible risk factor.
Clinical symptoms and signs that can be found in patients with astrocytoma (including
GBM), among others: (1.2.5)
1.

Signs of increased intracranial pressure with clinical symptoms and signs include
headache, nausea and vomiting, loss of consciousness, edema and papilledema.
Increased intracranial pressure due to a tumor and edema perifocal (mass effect)
may result in herniation of the brain that can lead to death. Mass effect can also

2.

result in hydrocephalus.
Focal neurologic deficits such as seizures, paralysis of cranial nerves, motor and
sensory disorders, cognitive disorders, behavioral disorders, ataxia, aphasia,
impaired vision loss even when the lesion occurs in the optic pathway, and

diplopia. (1,2,5)
For this patient almost to have all the symptoms and signs above. The signs and
symptomps are directly dependent on the localization of the tumor in the cerebral tissue.(7)
10

GBM is usually located in the cerebral hemispheres, with a predilection for the white
matter on the centrum semiovale and corpus callosum. There is relative sparing of the
basal ganglia and grey matter. Posterior fossa and brain stem gliomas are seen in a
younger age group. Location of the tumor for this patient in the right frontoparietal region.
Diagnosis can be established by supporting examination are Head CT Scan and MRI. The
Head CT Scan and MRI showed all of intracranial tumor and be a first investigation
procedure when the patient showed the progressive signs, the diffuse or focal cranial
disease symptomps, or one of specific signs from tumors syndrome. Sometimes difficult
to differentiated the tumor from abcess or others process. Some type of tumor will seems
real in the Head CT Scan with contrast.(9,10)

Head CT scan without contrast findings may

include :
-A heterogeneous poorly marginated mass
-Irregularity
-Midline shift
And for this patient we found a
heterogenous
mass
with
unclear boundary, perifocal
edema, and midline shift.

-Perifocal edema
-Hipodens, hyperdense or both, calsification and
haemorrhage(10,11)

11

Head CT scan with contrast include :

1.
Significant enhancement

of

findings such as irregularity and inhomogeneity

2.
Possible ring enhancement;
possible,

but

uncommon,

solid

enhancement;

possible little enhancement possible in diffuse forms.

We found ring enhancement for this patient.

MRI findings demonstrate :

- A heterogeneous with clearly marginated mass
-There are internal cystic areas, internal flow voids
representing prominent vessels, internal areas of high
signal intensity on T1 (hemorrhagic foci), neovascularity,
necrotic foci, significant peritumoral vasogenic edema, and
significant mass effect.
-Irregularity
-Midline shift

The treatment in GBM are steroid therapy, palliative therapy, radiotherapy, chemotherapy,
radio-chemotherapy combination.
Steroid Therapy
Dexamethasone is useful to reduce edema around the tumor, so it can reduce the
symptoms and can be prepared operation. Subsequent intravenous dose of 10 mg 4 mg 4
times per day. Analgesics such as acetaminophen can be used to control headache. (1,2,6,10)
PalliativeTherapy
Surgery is the treatment of GBM patients with histopathological confirmation of the
diagnosis. Total excision generally improve neurological function, reduce edema and can
increase the survival rate. Some tumours can be removed completely; others can be removed
only partially or not at all. Partial removal helps relieve symptoms by reducing pressure on
the brain, reducing the size of the tumour to be treated by radiation or chemotherapy and
12

prolonging survival. Of the study, GBM patients who had total resection 2 year survival rate
is about 19%.(1.6,7)
Radiotherapy
Radiotherapy after surgery can reduce the tumour size. Tumors treated by conventional
radiotherapy with a total of 5000-6000 cGy of radiation each fraction in several directions.
(7,10)

Chemotherapy
Temozolamide. Studies have proven that the combination of a small daily dose of
temozolomide, a chemotherapeutic drug, first together with radiotherapy and then on its own
produced a modest improvement in the survival of patients with minimal additional toxicity .
Temozolomide is also indicated for the treatment of people with malignant glioma showing
recurrence or progression after standard therapy.
Carmustine Wafers. Wafer implants are a new way of giving chemotherapy for brain
tumours. The wafer is made of gel that contains a chemotherapy drug. During brain surgery
to remove some or all of a tumour, the surgeon places up to 8 wafers in the space where the
tumour was. Some clinical trials have shown that using chemotherapy wafers as well as
surgery and radiotherapy helps people with glioma live longer.(7)
We just gave to this patient symptomatic therapy was steroid therapy. There was planned
craniotomy from neurosurgery to this patient for partial removal tumour, but the family and
himself refused to do operation.
GBM prognosis is determined by the aggressiveness of therapy and quality of life of
patients after treatment. Usually patients can live only 1 year. Based on the data in developed
countries, with early diagnosis and appropriate treatment through surgery followed by
radiotherapy, 5-year survival rate (5 years survival) ranged from 50-60% and a survival rate of
10 years survival ranged from 30 -40%. Brain tumor therapy in Indonesia in general the
prognosis is still poor, based on operative measures conducted in several hospitals in Jakarta.
(1,2,7)

. For this patient the prognosis is bad and on the 12th day care patients forced to go home by

himself.

13

Treatment
Grade

Palliative

Radiotherapy

Chemotherapy

Survival Rate

5 years survival

II

45-54
Gy, Temozolomide
75
2
delivered in 1.8 to mg/m /day on days 12.0 Gy fractions
21 of 28-d cycl

rate was 85%

5 years survival
rate was 50%, a
survival rate of
10

years

survival ranged
III

60 Gy in 30-35
fractions
and
adjuvant
emozolomide 75
mg/m2/day,
usually
1-1.5h
before radiation.
Postradiation
therapy: continue
temozolomide at
higher doses of
150-200
mg/m2/day PO for
5d every 28d

IV

60 Gy in 30-35
fractions
and
adjuvant
emozolomide 75
mg/m2/day,
usually
1-1.5h
before radiation.
Postradiation
therapy: continue
temozolomide at
higher doses of
150-200
mg/m2/day PO for
5d every 28d

PCV(procarbazine,
lomustine,vincristine)
: lomustine (CCNU)
130 mg/m2 on day 1
plus procarbazine 75
mg/m2 on days 8-21
plus vincristine 1.4
mg/m2 on days 8 and
29; administer every
6wk for up to 4 cycles
with
deferred
radiation therapy

PCV(procarbazine,
lomustine,vincristine)
: lomustine (CCNU)
130 mg/m2 on day 1
plus procarbazine 75
mg/m2 on days 8-21
plus vincristine 1.4
mg/m2 on days 8 and
29; administer every
6wk for up to 4 cycles
with
deferred
radiation therapy

from 30 -40%
5-year survival
rate (5 years
survival) ranged
from 50-60%

Two
year
survival rate was
in 6.66%, three
year survival (the
long
term
survival) was
only 4.8 % and
only one patient
lived longer than

14

DAFTAR PUSTAKA

1. Kolegium Neurologi Indonesia., Astrositoma in Modul Neuro-Onkologi, Perhimpunan

Dokter Spesialis Saraf Indonesia, 2008,. Hal : 11 12
2. Lopa R, Referet Glioblastoma, Bagian Radiologi FKUNHAS,2012
3. Stephen J.McPhee, Intracranial and Spinal Tumor in Large 2008 Current Medical Diagnosis
and Treathment, 2008, Page 860 865
4. Terra Kusuma, M.Saiful Islam Bagian Neurologi, FK Unair RSU Dr.Soetomo,Surabaya
5. Perdossi Bekerjasama dengan Gajah Mada University Press, Buku Ajar Neurologi

Klinis,Jakarta 1996, Hal 201

6. Ropper AH, Brown RH. Glioblastoma Multiforme in Intracranial Neoplasma. Adams and

Victor Principles of Neurology. 8th Ed. 2005. P : 546 556

7. Epitopoietic Research Corporation. Glioblastoma Multiforme (GBM) : the disease ERC

Belgium. Available at: ercbelgium.com/main/glioblastoma-multiforme-gbm-the-desease/

8. Weerakkody Y, Gaillard F. Glioblastoma multiforme. Available at : Radiopaodia .org
9. Robert MC, Wastie ML. Glioblastoma Multiforme : a rare manifestation of extensive liver
and bone metastase. Available at: Biomedical Imaging and Intervention Journal.
10. Kumpulan Refrat dan Presus serta catatan kuliah. Available at: Refrat Presus B4703L.
11. Lobera A, Naul GL. Imaging in Glioblastoma Multiforme. Available at: Medscape

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