PROF.DR.K.H.NOORUL AMEEN R.Pandi chelvan M6
<ul><li>16 yr old boy admitted in imcu for </li></ul><ul><li>c/o fever  -  2 days </li></ul><ul><li>c/o seizure – 1 day  <...
<ul><li>involving all four limbs </li></ul><ul><li>tonic – clonic in nature </li></ul><ul><li>asso with impaired conscious...
<ul><li>Past history: </li></ul><ul><li>known case of seizure disorder- GTCS  for last 5 yrs  on regular  treatment </li><...
CT PICTURE TAKEN 5 YRS BEFORE
<ul><li>On examination </li></ul><ul><li>unconscious </li></ul><ul><li>not obeying oral command </li></ul><ul><li>no respo...
<ul><li>Vitals  PR 98/min </li></ul><ul><li>BP 140/90mmhg </li></ul><ul><li>RR  28/min </li></ul><ul><li>CVS  -S1,S2 heard...
<ul><li>CNS examination on the day of admission  pt is unconscious </li></ul><ul><li>E1 V1 M1  GCS 3/15 </li></ul><ul><li>...
<ul><li>PROVISIONAL DIAGNOSIS </li></ul><ul><li>Seizure disorder-Status epilepticus </li></ul><ul><li>Raised ICT-?  CAUSE ...
16 YR OLD BOY WITH PAPILLOEDEMA AND SEIZURE <ul><li>Differential diagnosis: </li></ul><ul><li>1.CNS infection-acute/chroni...
pt treated  in imcu with  Nasal o2;  Inj. Diazepam  100 mg iv  Inj. Phenytoin 600mg iv infusion Inj .Cefotoxime 1g iv bd I...
<ul><li>Subsequent neurological examination in general medical ward </li></ul><ul><li>HMF –  normal </li></ul><ul><li>Cran...
16 YR BOY SEIZURE AND HEMIPARESIS <ul><li>DIFFERENTIAL DIAGNOSIS </li></ul>
16 YR OLD BOY SEIZURE AND HEMIPARESIS <ul><li>DIFFERENTIAL DIAGNOSIS </li></ul><ul><li>1.POST ICTAL </li></ul><ul><li>2.SP...
<ul><li>Investigations  : </li></ul><ul><li>Urine R/E: </li></ul><ul><li>Albumin- nil </li></ul><ul><li>Sugar  -nil </li><...
<ul><li>LFT: </li></ul><ul><li>Total bilirubin 1 mg </li></ul><ul><li>Direct bilirubin 0.2mg </li></ul><ul><li>SGOT  39 </...
 
RECENT CT BRAIN PLAIN
<ul><li>Hetero dense lesion in right fronto parietal region </li></ul>Hetero dense lesion in right fronto parietal region
MRI BRAIN T1 IMAGE
 
MRI BRAIN T1 CONTRAST
MRI BRAIN T2 IMAGE
 
 
<ul><li>Well defined T1,T2 mixed intensity cortical lesions in right fronto parietal region </li></ul><ul><li>Both cystic ...
Radiological differential diagnosis <ul><li>Astroblastoma </li></ul><ul><li>Pilocytic astrocytoma </li></ul><ul><li>Pleomo...
<ul><li>Pt transferred to neurosurgery department and operated </li></ul><ul><li>procedure : fronto parietal  craniotomy <...
<ul><li>CYTOLOGY REPORT </li></ul><ul><li>Eosinophilic proteinaceous material </li></ul><ul><li>HISTOPATHOLOGY REPORT </li...
SEIZURES ,PAPILLODEMA & CEREBRAL SOL <ul><li>A. Primary tumour </li></ul><ul><li>1.Gliomas-Astrocytomas </li></ul><ul><li>...
SEIZURES IN TUMOUR <ul><li>1.Vasogenic odema </li></ul><ul><li>2.Raised intracranial tension </li></ul><ul><li>3.tumour wi...
<ul><li>Convulsion seen in 20-50% of pts with cerebral tumour </li></ul><ul><li>Reported in 60-70%of supratentorial glioma...
STATUS EPILEPTICUS <ul><li>continuous seziure </li></ul><ul><li>repetitive discrete seizure </li></ul><ul><li>imparied con...
CAUSES <ul><li>Anticonvulsant withdrawal </li></ul><ul><li>Noncompliance </li></ul><ul><li>Metabolic disturbance  </li></u...
 
REFRACTORY EPILEPSY  <ul><li>1/3 rd of pt not respond to treatment with single drug </li></ul><ul><li>--focal epilepsy wit...
<ul><li>Surgical treatment : </li></ul><ul><li>approximately 20-30% epilepsy resistant to medical therapy </li></ul><ul><l...
 
<ul><li>Seziures occuring for the 1 st  time in adult life/old age </li></ul><ul><li>Asso. With signs and symptom of raise...
SCHWANNOMAS <ul><li>Neuromas, Neurinomas,Neurolemmomas </li></ul><ul><li>Arise from schwann cells of nerve roots </li></ul...
 
INTRA CEREBRAL SCHWANNOMA <ul><li>Rare </li></ul><ul><li>Fewer than 40 cases were reported since  1965 </li></ul><ul><li>U...
<ul><li>On MRI </li></ul><ul><li>T1w images- hypo/iso intense lesions </li></ul><ul><li>cystic and solid components </li><...
<ul><li>Most frequently –Frontal or Temporal region </li></ul><ul><li>occur any where </li></ul><ul><li>D/D </li></ul><ul>...
<ul><li>Origin remain unsettled </li></ul><ul><li>Several hypothesis say </li></ul><ul><li>Perivascular nervi plexi </li><...
 
 
<ul><li>After surgery  </li></ul><ul><li>seizures free </li></ul><ul><li>papilloedema subside </li></ul><ul><li>residual n...
 
 
<ul><li>Carry home message </li></ul><ul><li>1.pt known epileptic  more than 5yr with reccurent  </li></ul><ul><li>seizure...
REFERRANCE:  API MEDICINE ADAMS-NEUROLOGY HARRISON
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A Case of Cerebral Schwannoma

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A Case of Cerebral Schwannoma

  1. 1. PROF.DR.K.H.NOORUL AMEEN R.Pandi chelvan M6
  2. 2. <ul><li>16 yr old boy admitted in imcu for </li></ul><ul><li>c/o fever - 2 days </li></ul><ul><li>c/o seizure – 1 day </li></ul><ul><li>Presenting illness </li></ul><ul><li>h/o fever -2 days </li></ul><ul><li>intermittent fever </li></ul><ul><li>low grade </li></ul><ul><li>not asso. With chills and rigor </li></ul><ul><li>h/o seizure –on the day of admission </li></ul><ul><li>15 episodes </li></ul><ul><li>each episode last for 1 min </li></ul>
  3. 3. <ul><li>involving all four limbs </li></ul><ul><li>tonic – clonic in nature </li></ul><ul><li>asso with impaired consciousness </li></ul><ul><li>asso with urinary incontinence </li></ul><ul><li>asso with frothing from mouth </li></ul><ul><li>h/o vomiting </li></ul><ul><li>No h/o trauma </li></ul><ul><li>No h/o tongue bite </li></ul>
  4. 4. <ul><li>Past history: </li></ul><ul><li>known case of seizure disorder- GTCS for last 5 yrs on regular treatment </li></ul><ul><li>Tab. Phenytoin 100mg bd </li></ul><ul><li>Tab. Carbamazepine 200mg tds </li></ul><ul><li>Tab. Phenobarbitone 100mg 2od.. Tab.Sodium valproate 2oomg tds </li></ul><ul><li>Family history : </li></ul><ul><li>his brother suffering from seizure disorder since his 7 yrs of age </li></ul>
  5. 5. CT PICTURE TAKEN 5 YRS BEFORE
  6. 6. <ul><li>On examination </li></ul><ul><li>unconscious </li></ul><ul><li>not obeying oral command </li></ul><ul><li>no response to painful stimuli </li></ul><ul><li>dyspneic </li></ul><ul><li>febrile </li></ul><ul><li>no icterus </li></ul><ul><li>no pallor </li></ul><ul><li>no cyanosis </li></ul><ul><li>no clubbing </li></ul><ul><li>no lymphnode enlargement </li></ul><ul><li>febrile </li></ul>
  7. 7. <ul><li>Vitals PR 98/min </li></ul><ul><li>BP 140/90mmhg </li></ul><ul><li>RR 28/min </li></ul><ul><li>CVS -S1,S2 heard </li></ul><ul><li>no murmurs. </li></ul><ul><li>RS NVBS </li></ul><ul><li>no added sounds. </li></ul><ul><li>P/A soft </li></ul><ul><li>no organomegaly </li></ul>
  8. 8. <ul><li>CNS examination on the day of admission pt is unconscious </li></ul><ul><li>E1 V1 M1 GCS 3/15 </li></ul><ul><li>B/L pupil 4mm equal reacting to light </li></ul><ul><li>B/L plantar extensor </li></ul><ul><li>Fundus- B/L papilloedema </li></ul><ul><li>No neck stiffness </li></ul><ul><li>Oculocephalic reflex intact </li></ul>
  9. 9. <ul><li>PROVISIONAL DIAGNOSIS </li></ul><ul><li>Seizure disorder-Status epilepticus </li></ul><ul><li>Raised ICT-? CAUSE </li></ul>
  10. 10. 16 YR OLD BOY WITH PAPILLOEDEMA AND SEIZURE <ul><li>Differential diagnosis: </li></ul><ul><li>1.CNS infection-acute/chronic </li></ul><ul><li>2.SOL </li></ul><ul><li>3.Cerebrovascular disease </li></ul><ul><li>4.Cerebral venous sinus thrombosis </li></ul><ul><li>5.Hypertensive encephalopathy </li></ul>
  11. 11. pt treated in imcu with Nasal o2; Inj. Diazepam 100 mg iv Inj. Phenytoin 600mg iv infusion Inj .Cefotoxime 1g iv bd Inj. Mannitol 175 mg iv bd Inj .Lasix 20mg Patient had status epilepticus in imcu treated with continuous Midazolam infusion After controlling the status epilepticus patient transferred to general medical ward
  12. 12. <ul><li>Subsequent neurological examination in general medical ward </li></ul><ul><li>HMF – normal </li></ul><ul><li>Cranial nerves- Fundus B/L Papilloedema </li></ul><ul><li>Left facial muscle weakness </li></ul><ul><li>Tone B/L normal </li></ul><ul><li>Power R ight Left </li></ul><ul><li>UL 5 4- </li></ul><ul><li>LL 5 4- </li></ul><ul><li>DTR + + </li></ul><ul><li>Plantar extensor extensor </li></ul><ul><li>Hand grip 100% 50% </li></ul>
  13. 13. 16 YR BOY SEIZURE AND HEMIPARESIS <ul><li>DIFFERENTIAL DIAGNOSIS </li></ul>
  14. 14. 16 YR OLD BOY SEIZURE AND HEMIPARESIS <ul><li>DIFFERENTIAL DIAGNOSIS </li></ul><ul><li>1.POST ICTAL </li></ul><ul><li>2.SPACE OCCUPYING LESION </li></ul><ul><li>3.INFANTILE DISORDER </li></ul><ul><li>-HEMIPLEGIA HEMISEIZURE EPILEPSY(HHE) SYNDROME </li></ul><ul><li>-RASMUSSEN’S ENCEPHALITIS </li></ul><ul><li>-STURGE WEBER SYNDROME </li></ul><ul><li>4.VASCULAR DISORDER </li></ul><ul><li>-ANTIPHOSPHOLIPID AB SYNDROME </li></ul><ul><li>-CEREBRAL VENOUS SINUS THROMBOSIS </li></ul><ul><li>-CEREBROVASCULAR DISEASE </li></ul><ul><li>-CNS VASCULITIS </li></ul><ul><li>5.METABOLIC -HYPOGLYCEMIA </li></ul>
  15. 15. <ul><li>Investigations : </li></ul><ul><li>Urine R/E: </li></ul><ul><li>Albumin- nil </li></ul><ul><li>Sugar -nil </li></ul><ul><li>Deposits- 1 -2 pus cells /hpf </li></ul><ul><li>CBC: </li></ul><ul><li>TC -9800 </li></ul><ul><li>DC P60;L37;E3 ESR 6/15 </li></ul><ul><li>Hb 13 </li></ul><ul><li>PCV42 </li></ul><ul><li>MCV81.6 </li></ul><ul><li>MCHC33.9 </li></ul><ul><li>MCH27.6 </li></ul><ul><li>PLC1.9 lac </li></ul>
  16. 16. <ul><li>LFT: </li></ul><ul><li>Total bilirubin 1 mg </li></ul><ul><li>Direct bilirubin 0.2mg </li></ul><ul><li>SGOT 39 </li></ul><ul><li>SGPT 59 </li></ul><ul><li>In view of papilloedema lumbar puncture not done </li></ul><ul><li>Neuromedicine opinion </li></ul><ul><li>Seizure disorder/ recurrent seizure/A/c febrile illness </li></ul><ul><li>suggested </li></ul><ul><li>MRI brain </li></ul><ul><li>continue the same </li></ul>
  17. 18. RECENT CT BRAIN PLAIN
  18. 19. <ul><li>Hetero dense lesion in right fronto parietal region </li></ul>Hetero dense lesion in right fronto parietal region
  19. 20. MRI BRAIN T1 IMAGE
  20. 22. MRI BRAIN T1 CONTRAST
  21. 23. MRI BRAIN T2 IMAGE
  22. 26. <ul><li>Well defined T1,T2 mixed intensity cortical lesions in right fronto parietal region </li></ul><ul><li>Both cystic and solid areas </li></ul><ul><li>. </li></ul><ul><li>Mass effect on the ipsilateral lateral ventricle with subfascial herniation to left side </li></ul><ul><li>. </li></ul><ul><li>No surrounding edema. </li></ul><ul><li>Cystic areas on contrast shows rim enhancement. </li></ul><ul><li>Solid areas shows moderate enhancement with some non enhancement. </li></ul><ul><li>Abnormal parenchymal enhancement on post contrast study. </li></ul>
  23. 27. Radiological differential diagnosis <ul><li>Astroblastoma </li></ul><ul><li>Pilocytic astrocytoma </li></ul><ul><li>Pleomorphic xantho astrocytoma </li></ul><ul><li>Intra axial schwannnoma. </li></ul>
  24. 28. <ul><li>Pt transferred to neurosurgery department and operated </li></ul><ul><li>procedure : fronto parietal craniotomy </li></ul><ul><li>tumour decompression </li></ul><ul><li>cyst aspiration </li></ul><ul><li>biopsy taken </li></ul>
  25. 29. <ul><li>CYTOLOGY REPORT </li></ul><ul><li>Eosinophilic proteinaceous material </li></ul><ul><li>HISTOPATHOLOGY REPORT </li></ul><ul><li>Macro: multiple grey brown soft tissue </li></ul><ul><li>Micro: multiple fragments of brain parenchyma with adjoining neoplasm composed of spindle cells arranged in fascicles and bundles disclosing hypocellular area with peripheral nuclear palisading, interspered vascular areas and areas of haemorrhage </li></ul><ul><li>feature suggesstive of schwannoma </li></ul>
  26. 30. SEIZURES ,PAPILLODEMA & CEREBRAL SOL <ul><li>A. Primary tumour </li></ul><ul><li>1.Gliomas-Astrocytomas </li></ul><ul><li>Oligodendroglioma </li></ul><ul><li>2.Medulloblastoma </li></ul><ul><li>3.Schwannoma </li></ul><ul><li>4.Cns lymphoma-primary/secondary </li></ul><ul><li>5.Haemangioma </li></ul><ul><li>B.Secondaries </li></ul><ul><li>CNS Infection- TB,Cysticercosis, Toxoplamosis, Fungal infection, Hytadid cyst </li></ul>
  27. 31. SEIZURES IN TUMOUR <ul><li>1.Vasogenic odema </li></ul><ul><li>2.Raised intracranial tension </li></ul><ul><li>3.tumour with bleed </li></ul><ul><li>4.Malignant transformation </li></ul><ul><li>5.secondary infection </li></ul><ul><li>6.Irritative focus </li></ul><ul><li>7.chemotherapeutic drugs </li></ul><ul><li>8.meningeal infiltration </li></ul>
  28. 32. <ul><li>Convulsion seen in 20-50% of pts with cerebral tumour </li></ul><ul><li>Reported in 60-70%of supratentorial gliomas and parasagittal meningiomas </li></ul><ul><li>Rare in cases of base of the skull and posterior fossa tumours </li></ul><ul><li>Focal seizures helps clinical localisation </li></ul><ul><li>Generalised seizure- no localisation value </li></ul>
  29. 33. STATUS EPILEPTICUS <ul><li>continuous seziure </li></ul><ul><li>repetitive discrete seizure </li></ul><ul><li>imparied consciousness in the inter ictal period. </li></ul><ul><li>Subtypes: </li></ul><ul><li>generalized convulsive </li></ul><ul><li>generalised nonconvulsive </li></ul><ul><li>Duration to meet the definition of status epilepticus is about 15 – 30 min. </li></ul><ul><li>Practically seizure prompts the acute use of anticonvulsant therapy. </li></ul>
  30. 34. CAUSES <ul><li>Anticonvulsant withdrawal </li></ul><ul><li>Noncompliance </li></ul><ul><li>Metabolic disturbance </li></ul><ul><li>Drug toxicity </li></ul><ul><li>Cns infection </li></ul><ul><li>Cns tumour </li></ul><ul><li>Refractory epilepsy </li></ul><ul><li>Head trauma </li></ul>
  31. 36. REFRACTORY EPILEPSY <ul><li>1/3 rd of pt not respond to treatment with single drug </li></ul><ul><li>--focal epilepsy with structural lesion </li></ul><ul><li>--multiple seizure types </li></ul><ul><li>--developmental delay require multiple drugs </li></ul><ul><li>Combine first line drugs i.e, carbamazepine,phenytoin,valporic acid,lamotrigine </li></ul><ul><li>If not controlled add topiramate,levetiracetam </li></ul>
  32. 37. <ul><li>Surgical treatment : </li></ul><ul><li>approximately 20-30% epilepsy resistant to medical therapy </li></ul><ul><li>temporal lobectomy </li></ul><ul><li>amygdalohippocampectomy </li></ul><ul><li>lesionectomy </li></ul><ul><li>multiple subpial transection </li></ul><ul><li>hemisperectomy or multilobar resection </li></ul><ul><li>corus callosotomy </li></ul>
  33. 39. <ul><li>Seziures occuring for the 1 st time in adult life/old age </li></ul><ul><li>Asso. With signs and symptom of raised intra cranial pressure or focal neurological deficit </li></ul><ul><li>The changing character/types over a period of time </li></ul><ul><li>Those have prolonged postictal paralysis </li></ul><ul><li>Those asso. With poor response to therapy </li></ul><ul><li>those have status epilepticus </li></ul>SUSPECT NEOPLASTIC AETIOLOGY
  34. 40. SCHWANNOMAS <ul><li>Neuromas, Neurinomas,Neurolemmomas </li></ul><ul><li>Arise from schwann cells of nerve roots </li></ul><ul><li>Mostly from 8 th cn; 5 th cn is 2 nd most common </li></ul><ul><li>Arise from any CN except 1 st n 2 nd CN </li></ul><ul><li>NF2 strongly predispose to vestibular schwannoma </li></ul><ul><li>Schwannoma of spinal roots occur in NF2and NF1 also </li></ul>
  35. 42. INTRA CEREBRAL SCHWANNOMA <ul><li>Rare </li></ul><ul><li>Fewer than 40 cases were reported since 1965 </li></ul><ul><li>Unlike vestibular schwannoma mostly seen young people </li></ul><ul><li>80% were under 30 yrs </li></ul><ul><li>Asso. With NF in 4 cases </li></ul>
  36. 43. <ul><li>On MRI </li></ul><ul><li>T1w images- hypo/iso intense lesions </li></ul><ul><li>cystic and solid components </li></ul><ul><li>unlike vestibular schwannoma calcification quite characterstic </li></ul><ul><li>surrounded by hypersignal on T2w images due to edema or gliosis </li></ul>
  37. 44. <ul><li>Most frequently –Frontal or Temporal region </li></ul><ul><li>occur any where </li></ul><ul><li>D/D </li></ul><ul><li>-Pilocytic astrocytoma </li></ul><ul><li>-Meningioma </li></ul><ul><li>-Metastatic tumour </li></ul>
  38. 45. <ul><li>Origin remain unsettled </li></ul><ul><li>Several hypothesis say </li></ul><ul><li>Perivascular nervi plexi </li></ul><ul><li>Multipotential mesenchymal cells </li></ul><ul><li>Ectopic schwann cell </li></ul><ul><li>Pial cell converted into schwann cell </li></ul><ul><li>Mostly benign cells </li></ul><ul><li>4 cases reported as malignant </li></ul><ul><li>Treatment complete excision </li></ul>
  39. 48. <ul><li>After surgery </li></ul><ul><li>seizures free </li></ul><ul><li>papilloedema subside </li></ul><ul><li>residual neurologigal deficit improved </li></ul>
  40. 51. <ul><li>Carry home message </li></ul><ul><li>1.pt known epileptic more than 5yr with reccurent </li></ul><ul><li>seizure with poly therpy –not investigated </li></ul><ul><li>2.only after status admitted and investigated found to have SOL </li></ul><ul><li>3.causes of seizures in SOL understood </li></ul><ul><li>4.type and rarity of this case evaluated </li></ul><ul><li>5.further course of treatment planned </li></ul>
  41. 52. REFERRANCE: API MEDICINE ADAMS-NEUROLOGY HARRISON

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