Case 19: left periSylvian mass

posted: May 12, 1997

resident: Ian Angel, MD
attending: Robert Tiel, MD

CLINICAL PRESENTATION: This 34 Jordanian man presented to the ER with new onset seizures (described as right-sided shaking episodes with episodic loss of consciousness). Patient described three such events over the course of 2 months. Patient seeked attention at an outside institution and a cranial CT scan was done- on the basis of this CT scan the patient was told to go the ER. Patient is otherwise healthy- no history seizure disorder, motor weakness, sensory impairment, visual problems, no auras, no history of hypertension, heart disease or diabets mellitus; no history of cigarette smoking or illicit drug abuse. Patient has been in the US for several years. No family history of neurological disorders

On examination- no focal neurological abnormalities; normal general examination; vital signs normal; no skin lesions

Initial diagnostic study was a cranial CT scan with and without contrast which the patient brought to the ER. Select axial views are shown below:

Left: without contrast; Right: with contrast. These images reveal a non-enhancing hypodense mass in the left periSylvian region.

What is differential diagnosis? What additional studies will you order?

Please comment: dawast@lsuhsc.edu

STEPS TAKEN AT LSU: Our differential diagnosis was either a primary low-grade neoplasm or possibly a vascular lesion (CVA, vsaculitis).

A MRI scan of the brain was obtained. Select views are shown below:

These images reveal a hypodense non-enhancing mass in the left frontotemporal region (periSylvian).

Sagittal view of the mass.

What is your differential diagnosis now? What additional steps will you take- biopsy, resection, follow-up?

Please comment: dawast@lsuhsc.edu

We felt the MRI represented a neoplasm (most likley primary).
A stereotactic biopsy of the mass was performed- this revealed a low-grade glioma.

Surgical resection was offered to the patient and the risks of speech difficulties and hemiparesis were explained. The patient chose for surgical resection.

A frontotemporal craniotomy was performed with significant debulking of the tumor (trans-Sylvian approach).

Postoperatively, the patient did well- no focal neurological deficits. No further therapy is currently planned for this grade 1 astrocytoma.

Would anyone opt for radiation therapy?

Please comment: dawast@lsuhsc.edu

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