An Interesting intracranial lesion

[uamohammed]

This patient is an engineer by profession. He was working as an electric engineer in gulf countries for about three decades. After retirement he has settled down in Tellichery. Ever since he has been my patient for the treatment of DM and HT. He has not complained of symptoms suggestive of neurological problems until recently. About two years ago one morning he came with a complaint of severe vertigo and nausea. I examined him fully. No altered sensorium. No visual problem. . His gait was normal. No pyramidal or cerebellar involvement noted clinically. After routine investigations I gave him some symptomatic treatment with the advice to take complete rest for a week. After a week he came back fully normal. After examining him again I could not find any abnormality. There was a lurking feeling in me that if he had a small size cerebellar lesion there may not be much elicitable signs. When I suggested for a CT scan brain he immediately agreed to have one. It was a startling revelation. There was an extra axial mass lesion measuring 6.9x6.1x1.9 cm in the right high parietal convexity region extending to the left parietal convexity, extending to both side of the falx cerebri and casing the superior sagittal sinus. Both parietal lobes are compressed and displaced inferiorly.
With this huge lesion he has no symptoms or elicitable signs. What to do with the patient? I put him on phenytoin sodium 100 mg at night purely for prophylactic purpose in addition to the antivertigal medicines which he was already taking from me and referred him to a local neurosurgeon. After seeing these pictures he advised immediate surgery. Then he went to Calicut and consulted another surgeon who also advised surgery. Again the patient came back to me asking my advice. I was in a dilemma. Though anyone who looks at these pictures naturally would advise surgery only, I had my own reservations regarding surgery. Most importantly for a lesion of this size, he has none of lesion-specific symptoms. He is related to my wife through his marriage and lives in our neighbourhood. I used to see him often walking on the road with absolutely normal gait, sometimes even carrying provisions in both his hands. Even the vertigo episode he recently experienced cannot be attributed to this lesion because he has completely recovered from it now.
This lesion is a massive one. No doubt. But what will happen if you remove it. Even in the best centres, the postoperative complications after craniotomy such as infection, bleeding, hematoma and unexpected development of hemiplegia and paraplegias should be expected. After removal of such a big lesion from one side of the cranial cavity, the remaining brain part may be sucked into the vacuum area and a shift of the midbrain may take place with unpredictable catastrophe. Should this man who at present does not have any disability as such, be subjected to these likely complications? My usual dictum is that not to subject any one to a radical intervention unless the clinical picture warrants such a course. Now more than two years since we first detected this lesion in his brain. A CT scan done a few days ago does not show any worsening. In fact the size of the swelling seems to be a little less than the previous pictures. This is a true case presently under my care. I am enclosing the pictures and the reports below. I want valued opinions from my colleagues as to the next course of action in the management of this case.
UA Mohammed

[uamohammed]

A year later CT taken again ; Reports are attached below

UA Mohammed

[uamohammed]

This year also scan repeated and enclosed below

UA Mohammed

[Badri]

Dear Mohammed,

A very interesting but worrying finding on the scan. Your patient will need an experienced neurosurgeon to assess this lesion. As you mention it will be difficult for the patient to decide what he should do. As the lesion appears to be increasing, a decision on management must be made urgently. I will try and get a senior neurosurgeon's opinion as soon as possible. In the mean time if you can post better pictures of the scan it would help.

Badri.

[Badri]

Dear Mohammed,

I have discussed your patient with Dr. G N Narayana Reddy, who was head of the department of Neurosurgery and Director of NIMHANS, Bangalore. I am enclosing his comments:

The tumour is likely to be a benign meningioma arising from the dural part of Falx. As the tumour has been present for over 2 years (on the scan) it indicates that it is growing slowly and hence no significant symptoms or clinical signs have been noted so far. None the less it is likely to progress and serious symptoms are likely to appear in the future. It is difficult to give you a time frame.

It is best to operate now when no significant symptoms or signs are present. Although there is always a risk of causing some neurological deficit through surgery, the risk will be much less now than when surgery is attempted when patient starts developing neurological complications as a result of the tumour increasing in size.

I think Dr Reddy's comments are clear. You have to discuss this with your patient and only he can decide whether to go ahead with surgery.

( I have attached enhanced pictures of the scan you posted)

[uamohammed]

Hi Badri
I have gone through the note by the noted neurosurgeon, Dr Narayana Reddy which is a sound advice considering the size of the tumour and the likely complications he might encounter in future. I will put forward this advice to his family members and himself. It is up to them to decide. But one important point in his past history is exercising my mind. After the first CT scan and after he met the local neurosurgeon advised him immediate surgery he came to me. As I was talking with him I gathered another important past history from him. About two to three decades ago he was in Saudi Arabia. Once he and a few of his colleagues were travelling in an open van through the desert. While on their way there was a head on collision with another vehicle when both the vehicles were at great speed. This engineer friend was thrown out of the van and he landed on his head and he was unconscious for some time and was taken to a nearby hospital. Those were the days when there were not much medical facilities in Saudi and after a few days treatment he was discharged and he did not have any problem since then. He had literally forgotten about the incident. Now when I was repeatedly probing him about his past medical history, he suddenly recollected this incident. Could this lesion which looks like a space occupying one, be an organised hematoma over a period of many years, as a result of this accident, lying dormant? If that is so, it may not be malignant. If that is the case this lesion may not grow further and he can live the rest of his life with this lesion as he had lived with this for more than 2 decades.
Incidentally I have attached a photograph of the staircase which he is climbing many times to reach his office where he is helping his sons to run a printing press in his retired life. Even I find it difficult to negotiate this passage which is in a pathetic condition with not much hand support.
Below I have given a link to my dropbox from where you can get all the pictures of his CT and MRI taken during these years. I think these are quite clear now. I used the CamScan from my mobile.
Another link I have given is about a lady’s story with a brain-tumour which she left untouched for some years. I am not trying to combine these two cases.

https://www.dropbox.com/sh/nvnygbe6tnk4 ... qQsZa?dl=0

http://www.stuff.co.nz/life-style/well- ... r-10-years

UA Mohammed

[uamohammed]

Hi friends
This is about ten months ago I had posted this interesting case in this forum. This engineer is regularly consulting me for his diabetes and hypertension and he is in a fine shape now. In between about a fortnight ago he had upper respiratory tract infection when he had fever and headache with stuffy nose. After a few days symptomatic treatment he has come back to his former self. He is moving about as before without any specific change in the gait or any other signs and symptoms of intracranial lesion. His son wanted a fresh CT scan to assess his present condition. I am enclosing the picture and the report along with this. The report says there is no significant enlargement when compared to the previous one.

UA Mohammed.

[Badri]

Hi Mohammed,

A very brave patient indeed to opt out of surgery. He has been lucky so far. It was pointed out that it is a slow growing lesion. Perhaps it has not altered very much in size but it is showing signs of collapse with cystic changes. I do not know what complications this will lead to. Let us ask the neurosurgeons for their opinion.

[uamohammed]

Hi Badri
As you have mentioned he is a brave man and so far he is lucky. But you should not forget that even the best of the surgeons cannot foresee what would happen to him in case of intervention. His stance is that at least he is able to move about normally without any difficulty. To be honest, I am also inclined to side with him!

UA Mohammed.

[Badri]

Dear Mohammed,

I had an email from our friend Dr Murali from USA. He apologises for the delayed response as he had not been to the "Forum" for a long time. I enclose his response to the problem that you had listed in your post.

"I read all the emails and until today had difficulty in being able to open the actual scans. Today, I managed to see them in a drop box link. I read the history provided by our dear colleague, Dr. U. Mohammed. This is a very large, slow growing benign meningioma that has been there for years and years. It is a formidable tumor mainly because it has involved so many important veins on the brain surface and also the SSS. If this tumor is removed, it is unlikely that he would have a smooth postoperative recovery. Given how asymptomatic he is, I would recommend a conservative approach and not subject him to surgery. I would recommend annual scans for surveillance. This may be a case where discretion is the better part of valour! Can you please forward this email to Dr. UM and please also convey him my kindest regards? About 54 years ago, I remember seeing him in the special wards of GH when he was having some investigations for some headaches under BRM! Thank you very much and once again sorry for this delay in replying.

Best regards,

R. Murali".