Headache case 3

Headache case 3

A 69-year-old man presents to the emergency department with a headache. He states that the headache is the worst headache he has ever had and has been constant for the past three hours. The patient has a past medical history of hypertension and benign prostate hypertrophy.
Review of systems reveals a possible seizure two months ago. Medications include atenolol and occasional ibuprofen. Vital signs are normal.
Physical examination is notable for papilledema bilaterally and a clumsy gait.
Question 1 of 4
Which of the following is the most likely diagnosis?
/ A. Arteriovenous malformation
/ B. Ganglioglioma
/ C. Glioblastoma multiforme
/ D. Meningococcal meningitis
/ E. Metastatic renal cell carcinoma

Q 2
A CT scan with intravenous contrast shows a large, enhancing mass of the left temporal, frontal and parietal lobes. Biopsy of this lesion would
most likely show which of the following?
/ A. Atypical astrocytes with mild pleomorphism
/ B. BIepharoplasts in a sheet configuration
/ C. Normal astrocytes
/ D. Pseudopalisading astrocytes with necrosis
/ E. Tubules and rosettes of blepharoplasts



Q3
Besides surgery, which of the following would be the most appropriate pharmacotherapy in this patient?
/ A. Aspirin
/ B. Coumadin
/ C. Dexamethasone
/ D. Doxycycline
/ E. Heparin


Q 4
If this patient was left untreated for six months, what would be the most likely new presenting symptom?
/ A. Anosmia
/ B. Cardiac arrhythmias
/ C. Left hemiparesis
/ D. Right hemiparesis
/ E. Sudden death

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Headache case 3 answers

A1
The correct answer is C. Glioblastoma multiforme is the most common brain tumor in adults. In adults, glioblastomas are noted most frequently in the frontal lobe with the temporal lobe second in frequency. Childhood glioblastomas of the cerebral hemispheres are also located most often in the frontal lobe; with the second most frequent site being the parietal lobe. Glioblastomas account for 50% of all gliomas and arise after age 50 in most patients. Younger patients tend to have a better prognosis than the elderly. Radiation and chemotherapy appear to extend the life of the patient.
Glioblastoma multiforme is the highest grade of astrocytoma, and may present with papilledema, headaches, seizure, or personality changes. The next step is to obtain diagnostic imaging studies such as a computed tomography (CT) scan or magnetic resonance imaging (MRI) scan. The tumor would typically be a large, irregular, necrotic, enhancing mass within the brain parenchyma.
Arteriovenous malformations (choice A) are relatively uncommon brain lesions that often present with seizures in patients less than forty years of age.
Gangliogliomas (choice B) are rare, benign brain tumors that present with seizures in patients less than forty years of age.
Meningitis (choice D) usually presents with photophobia, fever, and headache. Meningitis would be on the differential diagnosis in this case.
Metastatic disease (choice E) is common in this older age group. Usually there are signs or symptoms from the primary neoplasm first, but an isolated brain metastasis may be the initial presentation. Renal cell carcinoma is a much less common cause of a brain mass than glioblastoma multiforme.

A2
The correct answer is D. Markedly pleomorphic astrocytes in a pseudopalisading configuration with necrosis is a classic appearance for glioblastoma multiforme. There are often multiple gemistocytes (large astrocytes) present as well.
Atypical astrocytes with mild pleomorphism (choice A) are characteristic of a low grade astrocytoma, not a high grade astrocytoma, like glioblastoma multiforme.
Blepharoplasts (choice B and E) are the key cells seen in ependymoma, a less aggressive tumor of the ependyma, which lines the ventricles. Typically, blepharoplasts are arranged in tubules and rosettes around blood vessels.
Astrocytes (choice C) are the most common cell in the normal brain. Normal astrocytes make up only a small portion of the cells in a glioma

A3
The correct answer is C. A high potency steroid like dexamethasone or prednisolone is indicated to lower intracranial pressure on the brain. A low potency steroid like cortisone would not be effective. Steroids interrupt the normal inflammatory cascade of the body, and thus reduce brain swelling from causes such as a tumor or trauma. A low potency nonsteroidal anti-inflammatory agent like aspirin or ibuprofen would not reduce intracranial pressure to any measurable extent.
Aspirin (choice A) is a low potency anti-inflammatory agent that also has an effect on platelets. It might help with headache, but would not relieve symptoms of increased intracranial pressure.
Coumadin (choice B) is an oral anticoagulant that is contraindicated in a patient with a brain tumor because of the risk of potentially fatal intracranial hemorrhage within the tumor.
Doxycycline (choice D) is an antibiotic with no known role in the treatment of brain tumors.
Heparin (choice E) is an intravenous anticoagulant that is contraindicated in a patient with a brain tumor because of the risk of potentially fatal intracranial hemorrhage within the tumor.

A4
The correct answer is D. Right hemiparesis is the most likely outcome, because a frontoparietal lesion on the left would likely affect the motor strip controlling the entire right side of the body. Specific body parts affected would depend on the exact neural circuits damaged. The patient would likely also experience sensory deficits on the right side of the body.
Anosmia (choice A) is characteristic of lesions in the inferior frontal lobes or the bones of the anterior cranial fossa interfering with the first cranial nerves, which convey the sense of smell.
Lesions affecting the autonomic centers of the medulla, or a lesion of the pituitary causing an electrolyte imbalance, could conceivably cause an arrhythmia, but cardiac arrhythmias (choice B) are most commonly caused by primary dysfunction of the cardiac conduction system or electrolyte imbalances, rather than brain lesions.
Left hemiparesis (choice C) would arise from a lesion of the right frontal region.
Sudden death (choice E) is a rare effect of brain tumors. A tumor would have to compress the medulla (directly, or via a mass effect) to stop respiration or cardiac activity. A posterior cranial fossa mass lesion could cause sudden death from cerebral herniation.