Case 7: multiple brain lesions

posted: August 5, 1996

Resident: Ian Angel, MD
Attending Staff: Robert Tiel, MD

PRESENTATION: This 65 year old black man was brought to the ER by his family for "change in mental status"- patient was becoming increasingly apathetic and indifferent). The patient also gives a 1 month history of headaches (global) without associated neurological deficits; nauasea/ vomiting; stiff neck, or photophobia. the patient has history of hypertension treated with medications; he denies any history of seizures or trauma. Social history is significant for tobacco use for many years.

EXAMINATION: Vital signs: BP 180/90; P72; R16; afebrile
Patient was awake and alert and oriented. He had a paucity of speech, but was able to understand speech as well as name objects. Cranial nerves were intact bilaterally. No papilledema or optic atrophy. Pupils equal and reactive. No focal motor or sensory deficits. Reflexes normal; no pathological reflexes. Cerebellar exam normal. No Romberg sign. Shuffling gait.

DIAGNOSTIC STUDIES: Initial study was a CT scan without (left) and with (right) contrast:

The above scans show two lesions: one right frontal (homogenously enhancing) and other right parietal and deeper (hemorrhagic lesion with no enhancement)

MRI scan with and without contrast was obtained next- select views are shown below:

Coronal T1WI with contrast- note the homogenously enhancing frontal lesion

Sagittal T1WI without contrast- note the two lesions: hypointense frontal lesion and hyperintense posterior parietal lesion

Axial T1WI without contrast showing the frontal lesion.

How would you proceed at this stage? Would you biopsy or resect these lesions- which one? If biopsy- open or stereotactic?

Please comment: dawast@lsuhsc.edu

STEPS TAKEN AT LSU: We felt that the frontal lesion was the most accessible and most likely an extra-axial lesion, thus we elected to perform a right frontal craniotomy. Intraoperatively, the lesion was extra-axial, dural-based and soft yellowish-orange. It was fully resected. Postoperatively, the patient did well. He continued to remain awake and alert with no focal neurological deficits except the frontal lobe emotional changes. It is our thinking that the 2nd lesion (posterior parietal) probably represents a hypertensive bleed- however we will follow this man with serial MRI scans to assess the nature of this lesion. The frontal lesion turned out to be a MENINGIOMA.

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