Neurology

Cases
Saima Usmani
Case #1
GBMor is it?
 History
74-year-old female with history of HTN, DM II,
HLD presents with several days of recurrent
falls and generalized weakness.
She also has had difficulty sleeping at night
and weight loss, and is forgetful at baseline
She denies previous history of stroke/TIA or
seizure. She is on ASA/Plavix at home
Daughter states that mother is very active and
has had no changes in her personality
 Relevant Exam Findings
Vital signs normal

Oriented x3, flat affect

Mild left facial weakness, 4+/5 LUE and LLE
weakness. + pronator drift of left arm
Rest of exam is negative

Labs: Cr .9/ WBC 8.3/Hbg 10.4/ Plts 273/ Trop .01

 Discussion
Worried about: Old stroke/TIA (considering risk
factors of HLD and HTN)
Malignancy (considering age and weight loss)
Autoimmune/inflammatory process (unlikely if
this is the first time at her age without
instigation)

Non-contrast CT head was done: Right basal

ganglia hypodensity causing edema, mass effect,
midline shift, hemorrhagic conversion of an
infarct vs. neoplasm
Plan: Further imaging required to narrow
differential
 MRI

This FLAIR image shows

heterogenous mass
approximately 2 cm with
surrounding edema, and some
midline shift and mass effect
across the falx
 Interpretation
Impression: Enhancing hypercellular mass
centered in the right lentiform nucleus and
extending into the internal capsule, anterior
thalamus, subthalamic nucleus, and cerebral
peduncle. The findings are most compatible with
high-grade glial neoplasm versus lymphoma.
 Brain Neoplasms in
Adults
Primary tumors:
o Meninges Meningiomas (common, usually slow growing)
o Glial cells Gliomas (defined by and prognosis determined by
molecular mutation pathways)
Astrocytomas
Oligodendromas
Glioblastoma (common, aggressive and malignant)
Ependymomas (aggressive)
o Other Epithelial, Pituitary tumors, and CNS Lymphomas

Secondary tumors:
o Metastases (most common are melanoma, breast, lung and prostate)
 GBM vs Lymphoma
Glioblastoma multiform
Arises from glial cells, via PTEN/CDK
mutations (more aggressive) or IDH
mutations (better prognosis)
Appearance: enhancement on MRI, can cross
corpus callosum, prefers deep nuclei
Risk factors: prior radiation, NF1, ?
Accounts for 15% of brain tumors,
usually ages 45-70, 90% 2-year survival
Treatment: surgical debulking, palliative
CNS lymphoma
Arises from aberrant neoplastic CNS
lymphocytes
Appearance: periventricular, solitary, can
cross corpus callosum
Risk factors: immunodeficiency
Accounts for 4% of brain tumors, ages 45-
65, 30% 5 year survival
Treatment: radiation, methotrexate
 Decision Making
Patient and her family is informed that patient likely
has GBM, an aggressive form of brain cancer arising
from glial cells that has essentially no cure, and that
the recommendation would be palliative care.
However, there is a small chance that this lesion
may be a CNS Lymphoma, which is significantly less
common. Lymphomas are treatable.

Patient and her family are hesitant for a biopsy, and

are almost prepared to accept the GBM diagnosis.
However, after careful counseling and allowing them
to deliberate, they consent for a brain biopsy, and
patient is transferred to neurosurgery.
 Biopsy

Pathology results: Large b-cell lymphoma,

consistent with diffuse large b-cell lymphoma
(dlbcl) primary of the central nervous system
 Hospital course
Patient was started on steroids, Keppra for seizure
prophylaxis, and was transferred to hematology
She started chemotherapy on MTX
She was discharged to rehab with persistent left
hemiparesis
 references
Appin CL, Brat DJ. Molecular pathways in gliomagenesis and their
relevance to neuropathologic diagnosis. Adv Anat Pathol. 2015
Jan;22(1):50-8. doi: 10.1097/PAP.0000000000000048. Review. PubMed
PMID: 25461780.
Eric T Wong, MD, Julian K Wu, MD. Clinical presentation and diagnosis
of brain tumors. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA.
Tracy Batchelor, MD, MPH, Jay S Loeffler, MD. Clinical presentation,
pathologic features, and diagnosis of primary central nervous system
lymphoma. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA.
Nelson, James S. et al. Potential Risk Factors for Incident
Glioblastoma Multiforme: The Honolulu Heart Program and Honolulu-
Asia Aging Study. Journal of neuro-oncology 109.2 (2012): 315321.
PMC. Web. 7 May 2017.
Jeffrey N Bruce, MD. Glioblastoma MultiformeTreatment &
Management. Medscape. May 4 2017
 Case #2
Cardioembolic Strokes
 Patient history
95-year-old male with history of coronary artery
disease s/p CABG 30 years ago, on full dose ASA,
presents with fall 1 day ago and found this
morning to be confused, pale, and unable to get
up.
Stat head CT in the ER is negative for hemorrhage
or ischemia
On second day of admission, a second head CT
revealed acute right-sided caudate infarct and
chronic left cerebellar stroke
Stroke team is called to evaluate the patient
 Acute R caudate
ischemic infarct
(area of hypodensity)
No evidence of
hemorrhage
(hyperdense on CT)
Old cerebellar stroke
not visualized on this
slice

Non-contrast CT
 Relevant exam findings
Vitals: Temp 97.2 HR 61-76 BP 134-196/52-96 O2
94%
Mental Status: arousable to voice, oriented to
person, limited speech (1-2 words with effort),
unable to recognize family
CN: no deficits
Motor, sensation, reflexes intact
Echo results: LVEF 45%, inferior wall hypokinetic
A1c 7.5%, Cr 1.1, WBC 8.1, Hgb 14.6, Plts 140,
Trop .04
 MRI (diffusion-weighted shown)

Acute right lateral lenticulostriate territory infarct involving

corpus callosum with some petechial hemorrhage
Small, late subacute bilateral white matter infarcts
Small, chronic left basal ganglia and left cerebellar infarcts
 Ischemic Stroke Risk
Factors
Age (After age 55, each successive 10 years
stroke rate more than doubles)
Hypertension
Cardiogenic risk factors (arrhythmias, congenital
defects)
Diabetes/metabolic disorders
Hyperlipidemia
Genetic tendencies in families
Smoking, illicit drugs
Lifestyle factors
Ischemic Strokes: Etiology
Cardioembolic: cardiogenic source of emboli (ex,
atrial fibrillation)
Large Vessel atherosclerosis: thrombosis of large
named arteries, or emboli from large plaques
shoot into anterior circulation (carotid stenosis)
Small Vessel occlusion: local processes cause
blockages in small, unnamed deep vessels
(lipohyalinosis)
Other causes: dissection, moyamoya, anti-
phospholipid, Binswangers disease
Cryptogenic
 Cardioembolic Strokes
Clots for due to some cardiac dysfunction and are
shot into brain circulation
Precipitating factors include: atrial fibrillation,
atrial dilation,
Patterns seen: multiple ischemic strokes in a
variety of territories, could be anterior, middle or
posterior circulation, in either hemisphere,
because such a proximal source (heart) does little
to discriminate the destination of its emboli
Prevention: anticoagulation
 tPA candidacy?
IV alteplase (tissue plasminogen activator/tPA) is a
thrombolytic used for acute ischemic strokes
Benefits of administration only within 4.5 hours of
symptom onset has been shown to outweigh risk of
bleeding
Exclusion criteria include:
o Younger than18 years of age
o Evidence of intracranial hemorrhage (or history of one)
o Active bleeding
o Serum glucose <50
o INR >1/7 or PT>15 seconds
Our patient was not eligible, considering his
symptoms begin more than 24 hours ago
 Hospital Course
Patient was on full dose ASA and HTN Rx
(amlodipine, lisinopril, carvedilol, furosemide)
before coming to hospital
Patient was started on statins, SC heparin, and
ASA was continued. Patient was not started on
anticoagulation considering small petechial
hemorrhage noted on MRI
Over stay, patients mental status continued to
show improvement
Patient was discharged on low-dose ASA and
lovenox, to be discontinued and replaced with
apixaban for stroke prevention
Patient was discharged to HJD Rehab
 references
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ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of
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Ralph L. Sacco, Emelia J. Benjamin, Joseph P. Broderick, Mark Dyken, J. Donald
Easton, William M. Feinberg, Larry B. Goldstein, Philip B. Gorelick, George Howard,
Steven J. Kittner, Teri A. Manolio, Jack P. Whisnant, Philip A. Wolf. Stroke: Risk
factors. http://stroke.ahajournals.org/content/28/7/1507.full
Louis R Caplan, MD. Etiology, classification, and epidemiology of stroke.
UpToDate. March 14, 2017.
National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group.
Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 1995;
333:1581.
Hart RG, Pearce LA, Koudstaal PJ. Transient ischemic attacks in patients with atrial
fibrillation: implications for secondary prevention: the European Atrial Fibrillation
Trial and Stroke Prevention in Atrial Fibrillation III trial. Stroke 2004; 35:948.
Jauch EC, Saver JL, Adams HP Jr, et al. Guidelines for the early management of
patients with acute ischemic stroke: a guideline for healthcare professionals from
the American Heart Association/American Stroke Association. Stroke 2013;
44:870.