Case of the Month

Case of the Month

Welcome to CNS' Case of the Month Section.
The purpose of this Web area is to provide a forum for discussion and debate regarding the management of both ordinary and extraordinary cases. There are no right or wrong answers, but rather, there are various opinions on what should be the "standard of care." The answers given will be collected anonymously, and be presented in a graphical format at the end of each month. We will then see the spectrum of thought regarding the management of these patients.

We are always open to suggestions, and if you have a case and questions that you would like to have presented, please submit them to: info@1cns.org

Andrew M. Bauer MD
University of Wisconsin Hospital

Sharad Rajpal, MD
University of Wisconsin

Joe Cheng, MD
Vanderbilt University

Monthly Message

Case of the Month Archive

July/September 2008: Woman with Intraventricular Lesion

HPI: A 31-year old woman presents for admission to a psychiatric hospital for acute bipolar exacerbation and psychotic episode. Imaging during her work-up demonstrates an intraventricular lesion and she, therefore, undergoes an MRI during that admission (Figure 1). She denies any headache complaints and ROS is essentially negative.

PMH:
1. Bipolar disorder.
2. Intermittent psychotic episodes.

Meds:
1. Risperdal.
2. Cogentin.
3. Abilify.
4. Claritin.

Social Hx: Pt is divorced and has no children. She is a PhD student at the local university but is currently on medical leave. Denies any tobacco, alcohol or
illicit drug use.

Family Hx: Unremarkable.

Physical exam: Vital signs are normal. Memory is intact. Speech is fluent. Affect is flat. Cranial nerves are intact. Strength and sensation are full. Reflexes, gait, and cerebellar function are normal.

Figure 1. Axial T1 post-contrast MRI (left), axial T2 MRI (middle); axial diffusion weighted MRI (right).

Figure 1. Coronal T1 post-contrast MRI (left), sagittal T1 pre-contrast MRI (right).

She underwent MR-angiography but no distinct vascular abnormalities were demonstrated.

1. What is the most likely diagnosis?

a. Meningioma

b. Choroid plexus papilloma

c. Central neurocytoma

d. Choroids plexus carcinoma

e. Metastatic lesion

f. Glioma

2. What is your next step in management?

a. Conservative management with observation and serial imaging

b. Stereotactic biopsy (transcortical)

c. Endoscopic biopsy

d. Biopsy (open or endoscopic) with potential resection

3. What is your surgical approach?

a. Endoscopic resection

b. Transcortical resection

c. Transcallosal approach

d. Combined approach

4. You decide to take her to the OR for an endoscopic biopsy and resection. Where would you place your entry point/burr hole? Over the:

a Frontal lobe

b Parietal lobe

c. Occipital Lobe

d. Other

5. Comments

The patient is taken to the OR for endoscopic biopsy and planned resection. Intraoperative biopsy demonstrates central neurocytoma. She undergoes complete resection without complication and she is discharged from the hospital after 4 days.