Grand Ward Rounds 2032008

1
Grand Ward Rounds - 20/3/2008 -

• - Dr Angeline Yong

2
Case 1

• 46/Chinese/Female
• Factory worker
• No PMHx of note
• Presented on 25/2/2008 with
• C/o Intermittent BOV over LE x 6/12
• - generalised darkening of vision during attacks
  lasting a few seconds
• - no neurological deficits
• - no headache/nausea and vomitting

3
Case 1

• O/e
• VA - OD 6/7.5-1
• OS 6/15 --gt 6/12
• IOP - OD 14 mmHg
• OS 17 mmHg
• Left RAPD
• Left red desaturation and decrease in light
  sensitivity (40 of right eye)
• Ishihara color vision - OD 13/15
• OS 15/15
• EOM full

4
Case 1

• HVF - OD normal
• OS Patchy non-specific losses,
• enlarged blind spot

5
(No Transcript)
6

7
Case 1

• Anterior segment
• Early cataracts R/L - NS
• Cornea clear
• AC DQ

8
(No Transcript)
9
(No Transcript)
10
Case 1

• Posterior segment
• OD Optic disc normal in appearance - pink and
  healthy
• OS Swollen left optic disc - ?chronic in
  appearance. No Haemorrhage/CWS. Macula/Retina -
  NAD

11
Case 1

• Bp checked - 144/96 mmHg, HR 66 bpm
• Imp - Left chronic swollen disc
• ??cause

12
Case 1
13
Case 1

• Patient referred to neuro-ophthalmology and
  underwent MRI Brain in the meantime

14
Case 1 -MRI
15
Case 1 -MRI
16
Case 1 -MRI
17
Case 1

• MRI Brain (with contrast) - Diffuse thickening of
  left orbital nerve sheath which also shows
  homogenous contrast enhancement. Two lobulated
  enhancing mass lesions noted in the left anterior
  paraclinoid region, measuring 6 mm and 8 mm in
  diameter and appear to be in continuity with the
  thickened nerve sheath.
• Both globes and bilateral ocular muscles
  unremarkable. Pituitary gland and stalk are
  normal in appearance.

18
REASON FOR EXAM Intermittent blurring of
vision in the left eye for 6 months. Left
afferent pupillary defect and swollen disc. To
exclude optic neuritis and compressive lesions.
REPORT Pre and post contrast MRI of the brain
was performed. No prior studies for comparison
was available. There is diffuse thickening of
the left orbital nerve sheath which also shows
homogenous contrast enhancement. Two lobulated
enhancing mass lesions are also noted in the left
anterior paraclinoid region, measuring 6 mm and 8
mm in diameter and appear to be in continuity
with the thickened nerve sheath (Se 801 Im 17).
Both globes and bilateral ocular muscles are
unremarkable. The pituitary gland and stalk are
normal in appearance.   No acute intracranial
haemorrhage or infarct is detected. No midline
shift, hydrocephalus or effacement of the basal
cisterns is seen. The grey-white matter
differentiation is preserved. Few subcortical and
deep white matter foci of T2 prolongation are
noted, which may represent chronic microvascular
ischemic changes. Normal large vessel flow voids
are demonstrated. The major dural venous sinuses
demonstrate normal signal voids.
COMMENTS Thickened and enhancing left orbital
nerve sheath with also enhancing lesions noted in
the left anterior paraclinoid region are highly
suggestive of a paraclinoid meningioma that may
have extended along the left orbital nerve
sheath. Remote possibility of lymphoma.
Correlation with histological findings is
recommended.   The doctor in charge was informed
of above findings at time of reporting.
      REPORTED BY DR LIM WEI YANG On
25/02/2008 1818hrs APPROVED BY DR WICKLY LEE
On 26/02/2008 1059hrs   THIS REPORT HAS BEEN
APPROVED. NO SIGNATURE IS NEEDED.    



19
Case 1

• MRI is the preferred imaging method because it
  can show the dural origin of the tumor in most
  cases. The typical meningioma is isointense or
  hypointense to gray matter on T1 with strong
  homogeneous enhancement with gadolinium.

20
Case 1

• Diagnosis - Left paraclinoid meningioma with
  extension along left orbital nerve sheath.

21
Case 1

• Differentials?
• Several other disease processes have a
  propensity for involving the dura or subdural
  space resulting in an appearance that may suggest
  meningioma. These include
• 1. Lymphoma
• 2. Metastatic carcinoma
• 3. Inflammatory lesion such as sarcoidosis and
  Wegeners granulomatosis
• 4. Infections such as tuberculosis.

22
Case 1

• Further Mx -
• Patient was subsequently referred to neurosurgery
  and was seen on 29/2/2008 by Prof Ong Peck Leong
• Dx and option of surgery was discussed with
  patient
• Meningioma - benign tumour, but if continues to
  grow will lead to blindness.
• Prognosis of surgery- 90 maintain vision of
  which 50 will improvement. 10 risk of blindness
• Other risks of surgery -
• stroke - 5 (because of ICA invasion)
• pituitary dysfunction - 1
• death - 1
• Major complications incl infection/ bleeding
  15

23
Case 1

• Patient decided for excision of left paraclinoid
  meningioma
• Admitted on 2/3/2008 for surgery on 3/3/2008
• Intra-op findings Soft pinkish moderately
  vascular tumor encasing around both the optic
  nerves and the left ICA.
• Histology Meningioma, WHO grade II
• Patient discharged well on 10/3/2008 (POD 7)

24
Case 1

• Operative findings -
• Pinkish vascular tumor encasing the left as
  well as right optic nerves and also adherent to
  the left ICA. The tumor was removed in
  piece-meals, freeing both the optic nerves as
  well as left ICA from the tumor. Tumors between
  the bony clinoidal edge and the nerves was also
  removed. However a small remnant tumor between
  the left optic nerve and ICA was not possible to
  remove as the view was obstructed by the optic
  nerve and further dissection deemed unsafe.

25
Case 1- Discussion

• Meningiomas arise from the arachnoid cap cells of
  the arachnoid villi of the meninges 90 of which
  are benign

26
Case 1 - Discussion

• Epidemiology ---
• In a 1995 analysis of data from the Surveillance,
  Epidemiology and End Rsults (SEER) program of the
  National Cancer Institute, meningioma was the
  second most frequent primary brain tumor.1
• Overall the incidence is approximately 6 per
  100,000 and meningiomas account for 13 to 26
  percent of primary intracranial tumors.1-3
• Meningiomas are common between the ages of 40 to
  70 and are 2 to 3 x more prevalent in females
  than in males. 2
• 1. Radhakrishnan, D, Mokri, et al. The trends
  in incidence of primary brain tuors in the
  population of Rochester, minnesota. Ann. Neurol
  1995 3767
• 2. Longstreth, WTJr, et al. epidemiology of
  intracranial meningioma. Cancer 1993 72639.
• 3. Whittle, IR, Smith, et al. Meningiomas.
  Lancet 2004 3631535.

27
Case 1 - Discussion

• Meningiomas can arise from the dura at any site,
  most commonly the skull vault and at sites of
  dural reflection (eg falx cerebri, tentorium
  cerebelli, dura of adjacent venous sinuses).
• Less common sites include the optic nerve sheath
  and choroid plexus.

28
Case 1 - Discussion

• Clinical presentation -
• Many meningiomas are asymptomatic and discovered
  incidentally on a neuroimaging study or at atopsy
  where incidence rates are 1 to 2 percent.
• Symptomatic intracranial meningiomas on the other
  hand present commonly with a focal or generalised
  seizure or a gradually worsening neurologic
  deficit.

29
Case 1 - Discussion

• Focal findings -
• Characteristic focal deficits are caused by
  tumors in
• specific locations
• Visual changes -
• though often unrecognised, are common in
  meningiomas.
• 2. Hearing loss -
• cerebellopontine angle meningiomas can
  produce SNHL.
• 3. Mental status changes -
• neglect/inattention may result from large
  subfrontal/sphenoid
• ridge meningiomas.
• 4. Extremity weakness -
• parasagittal meningiomas growing on the
  falx against the motor
• strip can lead to bilat. Leg weakness.
• 5. Obstructive hydrocephalus -
• Large tumors in the posterior cranial fossa
  can cause
• obstructive hydrocephalus and present with
  papilledema and
• early morning headache

30
Case 1 - Discussion

• In one series of 80 patients, approximately
  1/3 had ophthalmologic symptoms including visual
  field loss, field defects, and diplopia.4
• Visual field defects in particular may be caused
  by parasellar meningiomas.
• Progressive unilateral visual loss which may be
  mistaken for optic neuritis (like our patient),
  may be caused by optic nerve sheath meningiomas.
• Mild extraocular movement weakness by cavernous
  sinus meningiomas.
• Foster-Kennedy sydrome - which is optic atrophy
  in one eye and papilledema in the other, may be
  produced by parasellar or subfrontal meningiomas.
• 4. Anderson, D, Khalil, M. Meningioma and the
  ophthalmologist. A review of 80 cases.
  Ophtahalmology 1981 881004