Case Report

SPACE OCCUPYING LESION

By:
Gilang Pradigdo
1408465702

Supervisor:
dr.Riki Sukiandra, Sp.S
DEPARTMENT OF NEUROLOGY
MEDICAL SCHOOL RIAU UNIVERSITY
RSUD ARIFIN ACHMAD
PEKANBARU
2016
1

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.

Patients Identity

Name

Mr. TB

Age

53 years

Gender

Male

Address

Jl AMD Gg AMD IV Tanjung Rhu

Religion

Kristen Protestan

Maritals Status

Married

Occupation

Unemployment

Admitted to Hospital

June, 12th 2016

Medical Record

926xxx

II ANAMNESIS :
Alloanamnesis (June, 12th 2016)
Chief Complain
Loss of consciousness since one day before admitted to the hospital
Present illness history
One days before admitted to hospital, patient had a loss of consciouness.
At the time patient was lying in bed. His family invited him for dinner. But when
called, patients difficult to wake. Patient only respond by moved his hand when
his arm was pinched. Then, the family brought patient to the Petala Bumi Hospital
and the patient treated for half day, and she get refered to Arifin Ahmad Hospital
because the limitation of facility. Patient didnt complained about seizure, fever,
cough and breathless.

One year before admitted to the hospital, the patient complained of

headache, pulsated in all part of head. The pain didnt spread to other part of body.
The patient took some pain killer from the shop but the pain didnt disappear. The
pain got worst day by day. It can appear when the patient rest or in activity. The
pain had no any trigger. There were no red eyes, watery eyes, neck stiffness, fever,
oblique mouth, faint or seizure.
Three weeks before admitted to the hospital, the patient complained about
weakness of entire body especially his limb. Appeared gradually, began by
numbness and pins needles sensation, worser until the patient difficult to stand.
Two weeks before admitted to the hospital, the weakness had worsened.
Especially his limb. The patient was more often sat and did daily activity on his
bed. The headache complaint was still felt more often.
One week before admitted to the hospital, the patient body gotten
imbalance and cant stood even for a moment. He still did daily activity on his
bed. The mactutition activity was helped by his wife with bolstered him. The
headache had gotten worsened even when he slept. He took some pain killer but
there was nothing changed.
Two days before admitted to the hospital, the patient looked sleepy and
always closed his eye. But still responded to sound. Patient also complained
difficult to talk, difficult to eat and start to feel blurred vision.
Past Illness history
History of brain trauma (-)
History of last fever (-)
History of stroke (-)
History of TB infection (-)
Patient has never contacted neither short nor long term with people around who
felt chronic cough, bloody cough, 6 months medical taking (antituberculosis
drugs)
Ear infections (-)
History
Diabetes Mellitus (-)

 Hypertension(+)
Patient knew that he suffered with hypertension since 2011, but he didnt
controlled it routinely.
History of the disease malignancy (-)
a. Lung cancer (-): He didnt complained about the presence of cough, chest
pain, shortness of breath, hoarseness, difficult swallowing, pain/fever lost
arising.
b. Colon Cancer (-): He didnt complained there was bowel disorders
(constipation, bloody and slimy, diarea or slimy), such as goat droppings.
c. Prostat cancer (-): He didnt complained there was micturition problem.
There is no history of micturition pain, micturition drip or discontentment on
peeing.
d. Kidney cancer (-): He didnt complained of pain in the waist, the presence
of a lump in the abdomen, and bloody urine.
Daily routine history
a.
Smoker (+)
Patient smoked since 1972 until 1983 with 10 cigerettes per day
Long Drug Consumption (+)
Patient took amlodipine to control his hypertension, but he didnt consumpted it
routinely.
Alkoholism (-)
History Jobs
Construction workers (1990-2002)
Mechanic (2005-2014)
The Family Disease History
No family complain that same complaint
A history of cancer or tumors (-)

Summary
Patient Mrs. M, 53 years old, admitted to RSUD Arifin Achmad with
chief complaint loss of consciousness. Patient didnt complained about seizure,

fever, cough and breathless. Patient complained about severe headache and
progressive about one year. Patient also complained weakness of entire body,
difficult to talk, difficult to eat, vomitting and blurred vision.
III. Physical Examination
A. Generalized Condition
Blood Presure : Right: 180/110 mmHg

Left: 150/80 mmHg

Heart Rate

: 83 bpm

Respiratory

: Respiratory rate : 21 x/mnt

Type : Abdominothoracal

Temperature : 37,1C
Weight
BMI

: 63 kg
: 24,6 kg/m2 (overweight)

Height : 160 cm

B. Physical examination

Thorax

: Normal limit

Abdomen
Opthalmoscopy

: Normal limit
:

C. Neurological status
1)

Consciousness

: Stupor

GCS : 7 (E2V1 M4)

2)

Noble Function

: Difficult to asses

3)

Neck Rigidity

: Negative

Cranial Nerves
1. N. I (Olfactorius )
Sense of Smell

Right
Difficult
to asses

Left
Difficult
to asses

Interpretation

Right

Left

Interpretation

Difficult
to asses

Difficult
to asses

Difficult to asses

Difficult to asses

2. N.II (Opticus)
Visual Acuity
Visual Fields
Colour Recognition

3. N.III (Oculomotorius)
Right

Left

(-)

(-)

Round

Round

4mm

2mm

Difficult
to asses

Difficult
to asses

Ptosis

Interpretation

Pupil
Shape
Side
Extraokuler movement

Pupil
anisokor,
Pupillary
Reflex (+/+)

Pupillary reaction to light

direct
Indirect
4. N. IV (Trokhlearis)
Extraocular movement

Right
Difficult
to asses

Left
Difficult
to asses

Right

Left

Interpretation
Difficult to asses

5. N. V (Trigeminus)
Motoric
Sensory
Corneal reflex

Difficult Difficult
to asses to asses
+
+

Interpretation
Difficult to asses,
Corneal reflex (+/+)

6. N. VI (Abduscens)
Extraocular movement
Strabismus
Deviation

Right
Left
Difficult Difficult
to asses to asses
(-)
(-)
(-)
(-)

Interpretation
Difficult to asses

7. N. VII (Facialis)
Tic

Right
(-)

Left
(-)

Difficult
to asses

Difficult
to asses

Motoric
Flavour Sense

Interpretation
Difficult to asses

Tanda chvostek
8. N. VIII (Akustikus)

Hearing sense

Right
Difficult
to asses

Left
Difficult
to asses

Interpretation

Right

Left

Interpretation

Difficult
to asses

Difficult
to asses

Difficult to asses

Right
Difficult
to asses

Left
Difficult
to asses

Right
Difficult
to asses
Eutrofi

Left
Difficult
to asses
Eutrofi

Right
Difficult
to asses
Eutrofi

Left
Difficult
to asses
Eutrofi
-

Difficult to asses

9. N. IX (Glossofaringeus)
Arkus farings
Flavour sense
Gag Reflex
10. N. X (Vagus)
Arcus farings
Dysfonia

Interpretation
Difficult to asses

11.N. XI (Assesorius)
Motoric
Trofi

Interpretation
Difficult to asses

12.N. XII (Hipoglossus)

Motoric
Trofi
Tremor
Disartria

Interpretation
Difficult to asses

IV. Motoric
Right

Left

Interpretation

Upper Extremity
Strength

With fall down

Distal

Difficult to

Proksimal

asses

Difficult to
asses

Tonus

Normotonus Normotonus

Trofi

Eutrophy

Eutrophy

Involunteer movement

(-)

(-)

Clonus
Lower Extremity

(-)

(-)
test, there is no

Strenght
Distal
Proksimal
Tonus
Trofi
Involunteer movement
Clonus

lateralization
Difficult to

Difficult to

asses

asses

Normotonus Normotonus
Eutrophy

Eutrophy

(-)

(-)

(-)

(-)

Eutrofi

Eutrofi

(-)

(-)

Body
Trofi
Involunteer movement
Abdominal Reflex

Normal

V. SENSORY
Right

Left

Interpretation

Touch
Pain
Temperatur

Difficult to
asses

Propioseptif

VI. REFLEX
8

Difficult
to asses

Difficult to
asses

Right

Left

Biseps

(+)

(+)

Triseps

(+)

(+)

Patella

(+)

(+)

Achilles

(+)

(+)

Babinski

(-)

(-)

Chaddock

(-)

(-)

Hoffman Tromer

(-)

(-)

Openheim

(-)

(-)

Schaefer

(-)

(-)

Interpretation

Physiologic
Physiologic Reflex
(+/+)

Patologic

Patologic Reflex (-/-)

VII. Coordination
Right

Left

Difficult

Difficult

to asses

to asses

Interpretation

Point to point movement

Walk heel to toe
Gait
Tandem
Romberg
VIII. Otonom
Urinate

: Urine cathetherized

Defecate

: No defecate

IX. Others Examination

a. Laseque

: Unlimited

b. Kernig

: Unlimited

c. Patrick

: -/-

d. Kontrapatrick

: -/-

e. Valsava test

: -/-

f. Brudzinski

: 9

Difficult to asses

IV. Summary
General Status
Blood Presure : 180/110 mmHg
Heart Rate
: 83 bpm
Respiratory

: Respiratory rate : 21 x/mnt Type : abdominothorakal

Temperature

: 37,1C

Weight
BMI

: 63 kg
: 24,6 kg/m2 (overweight)

Thorax

Height : 160 cm

: Normal

Abdomen : Normal
Noble Function : Difficult to asses
Meningeal Sign : (-)
Cranial Nerve : Pupil anisokor
Motoric
: Difficult to asses
Sensory
: Difficult to asses
Coordination : Difficult to asses
Otonom
: Abnormal urination and defecation
Reflex Fisiologis: Positive
Refleks Patologic: Negatif
WORKING DIAGNOSA
Clinic Diagnosis: Increased Intracranial Pressure Syndrome
Topic Diagnosis: The right side hemisphere of the cerebri
Etiologic Diagnosis: SOL ec Primary Brain Tumor
Differential Diagnosis: Brain abscess
Secondary diagnosis: Hypertension Grade II
SUGGESTION EXAMINATION :
1. Blood Routine

4. Electrolyte test

2. Blood Chemistry

5. Head CT-Scan with contrast

3. Arterial Blood Gas

MANAGEMENT

IVFD NaCl 0,9% 20 tpm

10

NGT

DC

Ranitidine inj 2 x 1 amp

Dexametason inj 3 x 10 mg

Amlodipine 1 x 10 mg

LABORATORY FINDING :
1. Blood Routine (June, 12th 2016)
WBC

: 9,100 /ul

Hb

: 13,5 g/dl

Ht

: 39,4 %

PLT

: 173.000/ul

2. Blood Chemistry (June, 12th 2016)

Ureum : 29 mg/dl
Crea

: 0,71 mg/dl

3. Blood Chemistry (June, 12th 2016)

pH

: 7,47 (7,35 7,45)

pCO2 : 41 mmHg (35-45 mmHg)

pO2

: 123 mmol/L (80-100 mmol/L)

HCO3 : 29,8 mmol/L (22-26 mmol/L)

4. Electrolyte test (June, 12th 2016)
Na+

: 136 mmol/L (135-145 mmol/L)

K+

: 3,1 mmol/L (3,5-5,5 mmol/L)

Ca ++ : 1,1 mmol/L (0,9-1,08 mmol/L)

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5. Head CT-Scan without Contrast (June, 14th 2016)

6. Head CT-Scan with Contrast (June, 14th 2016)

12

CT-Scan Reading :
Show images of isodens perifokal mass with round shape with edema, size 6x5cm
in fronto-parietal region dextra convexity.
Ventrikel lateral dextra is pressed by mass
Midline shift to the left
Interpretation :
SOL appearance at fronto-parietal region dextra convexity.
ec : suspect Meningioma

Follow up June, 13th 2016

13

: Loss of consciouness (-), Weakness of the extremity (-), Headache (+),

nausea (-), vomit (-), seizzures (-)

: GCS 14 (E3M6V5)

Blood Pressure

:170/100 mmHg

Heart Rate

: 78 bpm

Respiratory Rate
Temperature

: 20 x/i
: 36,9 C

Physical Examination
Thorax

: Normal limit

Abdomen : Normal limit

Cognitive Function

: Normal

Meningeal Sign

: Normal

Cranial Nerves

: Blurred vision (N II)

Motoric

: Normal

Sensory

: Normal

Coordination

: Normal

Autonomy

: Normal

Reflex
Pathologic : Negative
Physiology : Positive
A

: SOL ec primary brain tumor

IVFD NaCl 0,9% 20 tpm

NGT

DC

Ranitidine inj 2 x 1 amp

Dexametason inj 3 x 10 mg

Amlodipine 1 x 10 mg

14

Follow up June, 14th 2016

S

: Loss of consciouness (-), Weakness of the extremity (-), Headache (-),

nausea (-), vomit (-), seizzures (-)

: GCS 14 (E3M6V5)

Blood Pressure

:160/90 mmHg

Heart Rate

: 81 bpm

Respiratory Rate
Temperature

: 18 x/i
: 36,5 C

Physical Examination
Thorax

: Normal limit

Abdomen : Normal limit

Cognitive Function

: Normal

Meningeal Sign

: Normal

Cranial Nerves

: Blurred vision (N II)

Motoric

: Normal

Sensory

: Normal

Coordination

: Normal

Autonomy

: Normal

Reflex
Pathologic : Negative
Physiology : Positive
A

: SOL ec primary brain tumor

IVFD NaCl 0,9% 20 tpm

NGT

DC

Ranitidine inj 2 x 1 amp

Dexametason inj 3 x 10 mg

Amlodipine 1 x 10 mg

15

Follow up June, 15th 2016

S

: Loss of consciouness (-), Weakness of the extremity (-), Headache (-),

nausea (-), vomit (-), seizzures (-)

: GCS 14 (E3M6V5)

Blood Pressure

:160/90 mmHg

Heart Rate

: 76 bpm

Respiratory Rate
Temperature

: 19 x/i
: 36,8 C

Physical Examination
Thorax

: Normal limit

Abdomen : Normal limit

Cognitive Function

: Normal

Meningeal Sign

: Normal

Cranial Nerves

: Blurred vision (N II)

Motoric

: Normal

Sensory

: Normal

Coordination

: Normal

Autonomy

: Normal

Reflex
Pathologic : Negative
Physiology : Positive
A

: SOL ec primary brain tumor

IVFD NaCl 0,9% 20 tpm

NGT

DC

Ranitidine inj 2 x 1 amp

Dexametason inj 3 x 10 mg

Amlodipine 1 x 10 mg

16

FINAL DIAGNOSA : Suspect Meningioma + Hypertension Grade II

DISCUSSION
1. Headache
1.2

Definition
Headache is pain or discomfort on whole area of the head. headache is

most commonly subjective chief complaints as reported.1.2

1.3 Classification
Based on international headache classification 2rd edition from the
International Headache Society (IHS)
Primary headache is headache with no underlying disease. The primary
headache, such as:2,3

Migraine
Periodic disorder with unilateral or bilateral headache and can be
following with vomiting and visual disturbances. This condition occurs
frequently, more than 10% of the population are experiencing at least one
migraine attack in her life. Migraine can occur at all of ages, but generally
the onset occurs on teenage or twenties and female more often than male.

There is family history of migraines on commonly patient.

Tension-type headache (TTH) 2,3
This headache is frequenly occurs with unknown etiology, although
had been accepted that the contraction of the head and neck muscles is a
mechanism causes pain. Muscle contraction can be triggered by
psychogenic factors such as anxiety or depression or by local disease on
head and neck.
Patients commonly experienced headache that can be settled for a
few days, months or years. headache can worsen in the afternoon and
generally not responsive with analgesic drugs. This headache had a
variative pain. Headache starts from the blunt pain in various places until a

thorough pressure sensation to the feeling of the head tight-tied/tense.

Cluster Headache2, 3

17

This syndrome are different from migraine, both marked by

unilateral headache, both can occur at the same time, but the very distinct
of the two is red eye. Histaminergic and humoral mechanisms underlying
the autonomous symptoms is estimated to occur in conjunction with this
head pain.
Patients usually are men, aged 20 to 60 years. Patients feel great
pain around one eye (always on the same side) for 20 to 120 minutes, can
be repeated several times a day, and patient often woke up more than one
time in the middle of the night. Alcohol can also trigger an attack. This
pattern lasted for days, weeks and even for months.
The secondary headache :

Headache attributed to head and/or neck trauma and

cranial or cervical

vascular disorder
Headache attributed to non-vascular intracranial disorder
Headache attributed to a substance or its withdrawal and infection
Headache attributed to disorder of homeoeostasis
Headache or facial pain attributed to disorder of cranium, neck, eyes, ears,

nose, sinuses, teeth,mouth, or other facial or cranial structures.

Headache attributed to psychiatric disorder
Cranial Neuralgias and facial pains
Cranial neuralgias and central causes of facial pain
Other headache, cranial neuralgia central, or primary facial pain.

2. Space occupying lesion (SOL)

SOL is a extended lesion in brainsincluding 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
18

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 complaint. 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
diagnosis
3. BRAIN TUMOR
3.1 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 growingtumor 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: 11
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. 11
In order to discover the exact pathology underlying a brain tumour, 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
19

allows tissue to be sampled from the lesion in a relatively safe way. This deploys a
coordinate system based on scans, which allows the surgeon to access the tumour
for biopsy in a minimally invasive approach. The other alternative is that a biopsy
is performed as part of the debulking or excision of a tumour.
Broadly speaking, brain tumours can be classified as either gliomas or
nongliomas. These are either tumours of the glial cells of the brain or tumours 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 tumours. Grade 3 anaplastic astrocytomas exhibit mitoses. Finally, the
grade 4 glioblastoma multiforme (GBM)6 is the most aggressive primary brain
tumour in humans and has a median survival of 14 months following diagnosis
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 tumours also occur, the most common of which is termed
anaplastic oligoastrocytoma.10 In US studies, glioblastomas formed around 50%
of these tumours. This was followed by oligodendrogliomas (9.2%), other
astrocytomas (9.1%) and ependymomas (5.6%).7

2. NonGliomas
Nongliomas form the remainder of brain tumours. This includes
meningiomas, which arise from the meninges and compress the brain thereby
creating a mass effect. With an incidence of around 2 per 100,000,8 over 90% of
these tumours are benign and are therefore potentially curable through resection.
Loss of chromosome 22 is a characteristic genetic feature of these tumours. 7

20

Pituitary adenomas also fall into the category of nongliomas and are
eitherfunctioning or nonfunctioning. If functioning, they may secrete hormones
causing endocrine disturbance.
The clinical manifestation of the tumour 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 Cushings disease (ACTH hypersecretion). Acromegaly can result from an
oversecretion of growth hormone with the typical changes that occurs with soft
tissue growth in adult sufferers. Rarely, other secreting pituitary tumours such as
TSHomas occur. Nonfunctioning pituitary tumours may exert a mass effect due
to their proximity to the optic chiasm and can cause visual disturbance such as
bitemporal hemianopia.9
Medulloblastomas are primitive neuroectodermal tumours which are rare
in adulthood but much more common in children, accounting for 20% of
childhood brain tumours.10These tumours 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.11
With the correct initial treatment of medulloblastoma, longterm survival
may be achieved in around 4060% of all patients.12These tumours can however
spread in the subarachnoid space to involve other parts of the CNS. Primary CNS
lymphoma is another tumour within the grouping of nongliomas. These
constitute 23% of total brain tumours in people of normal immunity. Patients
with immunodeficiency are at an increased risk of developing this form of cancer.

3.2 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

21

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.12
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. 12
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 diagnosis 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. 12
3.3 Clinical Symptoms
There are 4 common clinical symptoms associated with brain tumors, like
mental status changes, headaches, vomiting, and seizures. 11
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 complaint often made by cancer patients with a
variety of forms, ranging from mild memory dysfunction and difficulties
concentrating until disorientation, hallucinations, or lethargy. 13
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

22

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.13
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.13
d. Seizures
Focal seizure is another manifestation that is commonly found in the 1415% 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. 13
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. 14
3.4 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.14
3.5 Management
Treatment of patients with SOL include: 13.14
Symptomatic.
a. Antikonvulsi
23

Controlling epilepsy is an important part of the treatment patients

with a brain tumor.
b. Edema serebri
If patients with increased intracranial pressure and the description
of Radiology showed edema serebri, 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 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. 14
e. Operation
Brain metastasis frequently managed surgically, with a maximum
of surgical resection followed by stereotactic radiosurgery or whole

24

brain irradiation provides more benefits to patient survival

compared with whole brain irradiation method using 13,14
3.6 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. 13.14
4. BASIC DIAGNOSIS
4.1 Basic clinical diagnosis
From the anamnesis, patient's neurological deficits occur slowly and
getting worser, such as:
a.Loss of consciousness
b.
c.
d.
e.

Severe headache, progressive

Projectile vomiting
Blurred vision
Body wasnt balanced
This is in accordance with symptoms of increased intracranial pressure,

where there are Triassic of increased intracranial pressure like headache,

vomiting, blurred vision and body wasnt balanced. In addition, there were other
clinical symptoms that support the increased intracranial pressure which is
motoric change to be weak. Intracranial pressure is influenced by three factors,
namely the volume of brain tissue, cerebrospinal fluid and blood volume. When
there is an increase in one of these factors, then it would increase intracranial
pressure.
In this patient, there found signs of the "headaches" red flag, namely:
3. Worser frequency and intensity
4. Constant Pain in 72 hours.
5. Neurological deficits such as weakness of the limbs
5.2 Basic topic diagnosis

25

From anamnesis there were obtained a Loss of consciousness, progressive

headache, vomitting, then suspected diagnosis of the topic in this case is
intracranial process.
5.3 Basic etiological diagnosis
From the anamnesis, patient's neurological deficits occur slowly and feels
increasingly worse, such as:
21.Loss of consciousness
22. Severe headache
23. Vomiting
24. The weakness of limbs
This is in accordance with symptoms of increased intracranial pressure,
where there are Triassic of increased intracranial pressure i.e. headaches,
vomiting. One of the causes of increased intracranial pressure is the presence of a
tumor mass which pressing the space.
From radiology Appear hiperdense lessions at right temporoparietal lobes
hemispheres. Therefore etiologic diagnosis of this patient is primary brain tumor.
5.4 Basic differential diagnosis
Because this patient didnt found cancer from the other organ, we should
consider intracranial mass on this patient also could be caused by primary tumor
from brain.
5.5 Basic of supportive examination
f. Laboratory: knowing risk factors whether infection exists, and knowing
the general condition of the patient.
g. Thoracic x-rays: to see the existence of a specific process, the primary
tumor in the lung.
h. Head CT-scan: to see a cross-section of the brain as whole which related
to patients complained.
5.6 Basic management
-

Infusion NaCl 0,9% 20 drops/minute to maintain the State of euvolumik.

Dexametason to reduce the brain edema.
Ranitidine: to inhibit excessive stomach acid production.
Amlodipine: to controlled the hypertension

26

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