MEDICAL
REPORT
A.R, 74YEARS, FEMALE,
WCA/6033/2023
Diagnosis: Right sided
posterior frontal SOL/ High grade glioma r/o High grade meningioma
Operation- Stealth guided resection of intrinsic right
posterior frontal tumor
Date of Admission- 15/02/2023
Date of Operation- 21/02/2023
Reason for delay (need to stay off clopidrogel for
at least five days)
Background
Information- A 74yr old
woman who presented today on account of 3months history of recurrent seizures.
Eight days history of slurring of speech. She was in her usual state of health
until three months ago when she suddenly had seizures which was characterized
by abnormal jerking and gnashing of teeth, However, no loss of consciousness,
no foaming in the mouth, no incontinence, nor involvement of the limb. About
eight days ago, her quality of speech changed (deteriorated) to a slurred
state. There is also associated left upper limb weakness. No visual impairment,
anosmia, memory charges, no history of trauma, swelling in any part of the
body. A known hypertensive on medications. Not a known diabetic. No previous
history surgery.
On examination:- an elderly woman, not pale,
anicteric , afebrile, acyanosed.
Neurological
Examination GCS =15/15
Pupils=3mm, reactive
Ambulates with supports
Left upper limb: hypertonia, power= 4/6 and
hypereflexia
Right upper limb = NAD
Right lower limb = NAD
Patchy areas of patchy hyperesthesia
On account of above presentation, and on clinical suspicion of space occupying lesion in the brain, Gadolinium enhanced Brain MRI (below) already done before presentation was reviewed and it showed a dura based in-homogenous contrast enhancing mass situated on the right posterior frontal lobe, with significant peri-lesional edema.
A diagnosis of intrinsic brain tumor was made with a
strong differential diagnosis of durally based high grade Meningioma was made.
This diagnosis was explained to the basic understanding of the patient as well
as the treatment options especially the need t proceed with image guided
surgical excision of the tumor. This will not unly provide tissue diagnosis but
also achieve cytoreduction and set the stage for necessary oncology referrals
and adjuvant treatments.
And following informed consent, she was prepared and
underwent surgery as outlined above.
Management:
·
Counsel patient
on findings.
·
Admit in work up
for tumor excision.
·
I.V
Dexamethasone 4mg 12hrly
·
I.V Omeprazole
40mg daily
·
Metastatic work
up, Chest CT, Abdominal pelvic CT.
·
FBC, EUCR, ECG,
Clotting profile, Serology, Clotting profile, Group and Cross match two units
of blood
Update
(16/02/2023)
Review of CT abdomen shows a ?pelvic mass with both solid and cystic
components
Liver, Spleen and Kidneys appear normal.
INR, Platelets – normal but Clopidogrel only stopped
this morning.
Plan: Delay surgery for five days
Perform abdominal examination.
17/02/2023
Scheduled for craniotomy/excision of a brain tumor.
Pre-op workup shows suspicious pelvic mass on CT
Abdomen/Pelvic/Chest
This is important in view of possible metastatic
lesion, kidneys, lungs, liver due however clear.
Meanwhile, D/C Clopidogrel until after surgery.
Abdominopelvic USS was also conducted Further reviews, there was no convincing
evidence of any primary mass lesions in the chest abdomen and pelvis from both
CT and US scans.
Update (21/02/2023)
Scheduled and had successfully stealth guided craniotomy for excision of
brain mass done.
Plan: prepare theater.
Update (22/02/2023)
First day post stealth guided craniotomy for excision of
right intrinsic frontal of intrinsic brain tumor.
She has being sedated and ventilated all through the night.
Current neurology she is fully awake, endotracheal tube has
been removed. Moving all limbs but much weaker on the left side
HR- 80BPM, BP- 140/70mmHg, RR- 18cpm, SP02- 98%
She is sedated this morning after giving 200mg of
hydrocortisone.
Wound drain insitu drain 150mls serosanginous fluid.
Plan: continue NG tube feeding
Early physiotherapy.
Continue
other post op management.
Expecting
the histology report for further management.
Update 23/02/2023 (
48hrs post op)
Post op CT scan done , showed minimal hematoma at the tumour
bed , which was debulked significantly with restitution of previously
compressed brain tissue and restoration of midline structures. See image below.
.
Other Post op investigations FBC: PCV; 44.62, WBC;10.15 PLT;
162
E/U/CR: NA;140.8 K;3.99 UR;20.37 CR; 0.57, were essentially normal
Update 25-02.2023
– five days post op-
She was completely off all ICU support, alert and
neurologically stable and was stepped down to the HDU and subsequently to the
ward.
Histology report
shows a biphasic tumour composed of glial component and transforming vascular
component into sarcoma consistent with gliosarcoma.
Basic Histology slides above show evidence of gliosarcoma and IHC was recommended, result of which is detailed in the slides and report below attached.
Update- 27/02/2023
Stable, sitting out of bed and tolerating oral feeds.
Awaiting labs and preps for discharge. She complained of constipations and
currently waiting neuro- oncology review. FBC done was essentially normal. EUCR
showed hypernatremia.
O/E: General condition satisfactory
Vital signs: BP- 160/90mmHg, PR- 74bpm,
Plan:
·
Reduce salt intake
·
Tabs PCM 1g tds x5/7
·
Syrup lactulose 10ml tds
·
Tabs valsatan 80mg daily
·
For oncology review
·
For physiotherapy
Update 02/03/2023
(ONCOLOGIST REVIEW)
Patient is conscious, alert, and oriented, GCS (E=4,
M=6, V=5), wound is clean, dry and well apposed.
Plan: discharge patient home
·
To start
Radiotherapy in NHA 6 weeks post-surgery
·
To have an MRI
done prior to Radiotherapy
·
Continue
physiotherapy
·
Continue tabs
dexamethasone 2mg bd
·
Continue tabs
carbamazepine 200mg bd
·
Continue on
antihypertensives
Discharge Instructions:
·
To start
Radiotherapy in NHA 6 weeks post-surgery
·
To have an MRI
done prior to Radiotherapy
·
To remove
staples after one week
Discharge Medications:
·
Tabs Omeprazole 20mg bd
·
Tabs Dexamethasone 2mg tds
·
Tabs Carbamazepine 200mg bd
·
Tabs Amlodipine 10mg dly
·
Tabs Clopidogrel 75mg dly
·
Tabs Valsartan 80mg dly
Next appointment is in 2 weeks
following discharge (18th of March 2023) but can present earlier if
need be.
Kindly revert for further
clarifications if need be.
Sincerely yours,
Dr.
Halima Ibrahim
For
Team Wellington Clinics