She works as a ticketing officer with an airline and lives in Lagos with her husband and her child. Since four months, she was troubled by persisting and rather worsening headache, left sided eye pain, photophobia and diplopia . Headache was worse in the morning and associated with vomiting. She was treated in various hospitals in Lagos for Malaria and Typhoid. She also visited eye clinics and had several treatments with little benefit. She was particularly worried about double and failing vision. Two weeks before presentation, she became increasingly lethargic, restless with progressive cognitive decline. MRI brain scan done in one of hospitals she visited in Lagos revealed a brain tumor and this necessitated her referral to this center.
Neurological examination on admission revealed a lethargic, restless and confused young lady with admitting GCS of 14 and and MMSE 20/30. Pupils were 2mm reactive but sluggish. Muscle power was grade 4/5 globally with increased reflexes on both lower and upper limbs. Sensory functions were completely intact.
Review of MRI brain revealed multiple (3) 1cm diameter contrast enhancing lesions situated on the right insula cortex and also on the right basal ganglia extending to the thalamus and upper mid-brain with associated central core of hypo intensities in all three lesions. Also noted was obstructive hydrocephalus as evidenced by dilated lateral and third ventricles.
Based on the above, a diagnosis of Intrinsic brain tumour on the right insula cortex and thalamus with associated obstructive hydrocephalus was made. This diagnosis was duly explained to her relations to their basic understanding, particularly the fact that headache was due to the acute obstructive hydrocephalus complicating this tumor. Surgical management strategies: 1- CSF diversion procedure (VP shunt) 2- Minimally invasive stealth guided neuro navigation biopsy of small mass lesions located deep in the insula cortex, basal ganglia and thalamus. The latter procedure was the main reason for their referral to the Wellington all the way from Lagos because we could biopsy those lesions with minimal upset to her.
Pre-op Management strategies: 1- Stealth MRI, which is basically a T1 weighted Gad+MRI with fiducials affixed on the patients head.2-FBC, Electrolyte, Urea and Creatinine to ascertain that blood levels and kidney functions were essentially normal. 3- Chest X-ray and ECG were also found to be normal.
Operative findings: 1-Tiny bits of mixed appearance taken on different points with a trucut brain biopsy needle. 2-Clear CSF with very high opening pressure more than 40cm of water
Details of operative procedure: Under General anesthesia, supine position, head pins, neuro navigation guided biopsy of the above mentioned lesion was performed. Insertion of left sided ventriculo peritoneal shunt in the standard way followed immediately. Operation was uneventful and post-op recovery was satisfactory and uneventful. Total operation time was 1hr 30 minutes and blood loss was less than 50mls.
Immediate Post op orders: 1-Neuro observation in the neuro ICU for 24 hrs including GCS, vital signs, urine output etc. 2-Analgesia with Paracetamol and Tramal. 3- I.V omeprazole 20mg daily x 72hrs. 4- IV ceftriaxone 1g 12hrly x 72hrs. 5- Seizure prophylaxis with IV Phenytoin 1g loading dose, then 300mg dly x 5days. 6-Dexamethasone to continue 4mg tds x 5days and step down to 2mg tds and finally tailed off.
A check brain scan was conducted 48hrs post op showed evidence of small hematoma track at the region of the tumor which confirmed target was definitely not missed. Ventricular end of the VP shunt was also noted on this scan to be well positioned.
It is reassuring to note that in the next few days she became less confused and less restless, and about the fifth day she regained near complete higher mental function. She was now able to make and receive call and chat freely and intelligently with the rest of the family. She was then beginning to get worried about getting back to work and home. GCS was 15 and MMSE was 30 and her request for discharge was granted.
Histology report was reviewed one week later and it confirmed a WHO Grade II Gemistocystic astrocytoma with eccentric nuclear and large cytoplasm, . There was no evidence of neovascularization or necrosis; all features are in keeping with Grade II astrocytoma. Tumor marker GFAP –( glial fibrilliary acidic protein) was found to be strongly positive in keeping with astrocytic tumors.
Subsequent management therefore involved a multidisciplinary team meeting with the Oncologist Dr Folusho Arewa a consultant Oncologist and Nuclear Medicine in attendance. Histology report and biological behaviour of this Grade II astrocytomas was discussed with the patient and her relations to their basic understanding. Natural history, biological behavior and overall prognosis of low grade gliomas was explained to the patient and her husband. Options of subsequent treatments including: 1- Watchful waiting with clinical and radiological follow ups. 2-immediate deployment of adjuvant treatment including chemotherapy (temozolamide) with concomitant radiotherapy (Stupp Regimen). They were to decide before the one month check MRI. They were happy to return to Lagos base much better than they came but with some take home drugs including Tab phenytoin 300mg daily x 1/12, Tab tramadol 100mg b d x5/7 (PRN), Tab dexamethasone 2mg daily x 1/52, Tab omeprazole 20mg daily x 1/52
Discussion- This case illustrates a typical presentation of brain tumors. It also illustrates how often such a potentially fatal condition is often misdiagnosed as malaria or typhoid headache in several clinics and hospitals. That headache may not just be an ordinary one as clearly confirmed on an MRI scan here. Our physicians must come to terms with the wide availability of both CT and MRI tools needed to establish an early diagnosis. The main issue in this report is to demystify the fear associated with surgery for brain tumors. The emergence and availability of neuro-navigation in Nigeria today and presently situated at the Wellington Abuja has not only helped this young lady but several others who have had successful brain operations since October 2016 when Medtronic USA installed this brain GPS machine. The referring physician from Lagos did realize that the best available local option should be explored. The beauty is surgical precision and accuracy, minimal post-surgical morbidity and ultra-short hospital stay. Furthermore early definition of tumor histology and immunohistochemistry dictates not only the biological behavior but also the adjuvant treatment options and overall prognosis. It would have been nearly impossible to safely access this mass lesion without the help of stealth and we would probably still be in the dark even when we succeed in addressing the obstructive hydrocephalus through a VP shunt. We should therefore embrace this technology and indeed make it widely available.
Multimedia
Pre-op Gad + MRI Brain
48 hours Post op check NCCT Brain
Histology/immunohistochemistry- WHO II Gemistocytic astrocytoma with GFAP expression
Charles Ugochukwu Ugwuanyi MD, FMCS, FNIMC is a Consultant Neurosurgeon, National Hospital Abuja& Wellington Neurosurgery Centre Abuja.
+234 7036842976, +2349051095645, +2348168704327, ugougwuanyi@yahoo.co.uk, ugougwuany@gmail.com