Case Report

SPACE OCCUPYING LESION

By:
SHERLY NURFADHILA
1508434457

Supervisor:
dr.Riki Sukiandra, Sp.S

DEPARTMENT OF NEUROLOGY
MEDICAL SCHOOL RIAU UNIVERSITY
RSUD ARIFIN ACHMAD
PEKANBARU
2017
 KEMENTRIAN PENDIDIKAN DAN KEBUDAYAAN
FAKULTAS KEDOKTERAN UNIVERSITAS RIAU
SMF/ BAGIAN SARAF
Sekretariat : Gedung Kelas 03, RSUD Arifin Achmad Lantai 04
Jl. Mustika, Telp. 0761-7894000
E-mail : saraffkur@gmail.com
PEKANBARU

I. Patient’s Identity

Name Ms. N
Age 18 yo
Gender Female
Address Tembilahan
Religion Islam
Marital’s Status Single
Occupation Student
Admitted to Hospital May, 13th 2017
Medical Record 9554**

II. ANAMNESIS :

Autoanamnesis and alloanamnesis (May, 17th 2017)

Chief Complain

Vision loss since 1 months before admitted to the hospital.

Present illness history

One months before admitted to the hospital, patient complained lost of

vision and limb weakness suddenly. Patient hospitalized at Tembilahan Hospital for

several days and suggested to be referred to Pekanbaru Hospital because there was

no CT-scan there, but she refused to be referred because financial problem and she

went home. At home she could walk with someone help slowly at the beginning,

but now she need assisted to get up.

1
 Four months before admitted to the hospital, patient complained of

headache, pulsated in forehead. Headache came suddenly without trigger, and

disappear by itself without taking medicine. Headache accompanied by projectile

vomiting. During headache patient also suffer loss of vision then recover when

headache disappear. The symptoms least in 30 minutes, it happened for several

times. Day by day patient feels blurred of vision. She went to ophtalmologist and

get glasses for treatment, but her sight didn’t get better.

Patient had no fever before, no reduced appetite and weight loss, no

unconsciousness and seizure history, nor urinary and intestinal disorder.

Past Illness history

 History of brain trauma (-)

 History of last fever (-), ear infections (-), teeth infections (-), sinusitis (-)

 History of stroke (-)

 Diabetes Mellitus (-)

 Hypertension (-)

 History of the tumor and malignancy (-)

Daily routine history

Smoker (-), Alcoholism (-)

History Jobs

Student

The Family Disease History

a. No family had the same complaint

b. A history of cancer or tumors (-)

2
Summary of anamneis
Patient Ms. N, 18 years old, admitted to Arifin Achmad hospital with chief

complaint vision loss and limb weakness since one months ago. In four months

before she complained of recurrent headache with vomiting, and temporary vision

loss.

III. Physical Examination (May, 17th 2017)

A. Generalized Condition

Blood Presure : 110/70 mmHg

Heart Rate : 88 bpm

Respiratory rate : 18 x/mnt Type : Thoracoabdominal

Temperature : 36,9°C

Weight : 48 kg Height : 155 cm

BMI : 20 kg/m2 (normoweight)

B. Physical examination

 Thorax : Normal limit

 Abdomen : Normal limit

C. Neurological status

1) Consciousness : Composmentis GCS : 15 (E4V5 M6)

2) Noble Function : Normal

3) Neck Rigidity : Negative

3
Cranial Nerves

1. N. I (Olfactorius )

Right Left Interpretation

Sense of Smell N N Normal

2. N.II (Opticus)

Right Left Interpretation

Visual Acuity 0 0
Visual Fields - -
Colour Recognition - -
Funduscopic; blind
Fundus reflex + +
Papill atrophy + +

3. N.III (Oculomotorius)

Right Left Interpretation

Ptosis - -
Pupil
Shape Round Round
Side Φ4mm Φ6mm
N. III parese
Extraoculer movement normal normal
Pupillary reaction to light
Direct - -
Indirect - -
Deviation + +

4. N. IV (Trokhlearis)

Right Left Interpretation

Extraocular movement N N normal

5. N. V (Trigeminus)

Right Left Interpretation

Motoric N N
Sensory N N Normal
Corneal reflex + +

4
6. N. VI (Abduscens)

Right Left Interpretation

Extraocular movement + + normal

7. N. VII (Facialis)

Right Left Interpretation

Tic - -

Motoric N N
- corner of the mouth N N
- nasolabialis folds + + Normal
-frowning + +
-raise eyebrows + +
-closed eyes + +
Sense of taste N N
Chovstek sign - -

8. N. VIII (Akustikus)

Right Left Interpretation

Hearing sense N N Normal

9. N. IX (Glossofaringeus)

Right Left Interpretation

Arkus farings N N
Flavour sense N N Normal
Gag Reflex + +

10. N. X (Vagus)

Right Left Interpretation

Arcus farings N N
Normal
Dysfonia - -

11.N. XI (Assesorius)

Right Left Interpretation

Motoric N N Normal

5
 Trofi Eutrophy Eutrophy

12.N. XII (Hypoglossus)

Right Left Interpretation

Motoric N N
Trofi Eutrophy Eutrophy Normal
Tremor - -
Disartria - -

IV. Motoric

Right Left Interpretation

Upper Extremity
Strength
Distal 4 4
Proksimal 4 4
Tonus Normal Normal
Trofi Eutrophy Eutrophy
Involunteer movement - -
Clonus - -
tetraparese
Lower Extremity
Strenght
Distal 4 4
Proksimal 4 4
Tonus Normal Normal
Trofi Eutrophy Eutrophy
Involunteer movement - -
Clonus - -

Body
Trofi Eutrophy
Eutrophy -
Involunteer movement - Normal
(+)
Abdominal Reflex (+)

V. SENSORY

Right Left Interpretation

Touch N N
Normal
Pain N N

6
 Temperatur N N
Propioseptif N N

VI . REFLEX

Right Left Interpretation

Physiologic
Biseps (+) (+)
Triseps (+) (+) Normal
Patella (+) (+)
Achilles (+) (+)

Patologic
(-) (-)
Babinski
(-) (-)
Chaddock
(-) (-)
Hoffman Tromer
(-) (-) Patologic reflex (-)
Openheim
(-) (-)
Schaefer

VII. COORDINATION

Right Left Interpretation

Point to point movement
Walk heel to toe
Gait No test No test Difficult to asses
Tandem
Romberg

VIII. Otonom

Urinate : Normal

Defecate : Normal

7
IX. Others Examination

a. Laseque : Unlimited

b. Kernig : Unlimited

c. Patrick : -/-

d. Kontrapatrick : -/-

e. Valsava test : -/-

f. Brudzinski : -

IV. Summary
General Status

Blood Presure : 110/70 mmHg

Heart Rate : 88 bpm

Respiratory rate : 18 x/mnt Type : Thoracoabdominal

Temperature : 36,9°C

Weight : 48 kg Height : 155 cm

BMI : 20 kg/m2 (normoweight)

Thorax : Normal

Abdomen : Normal

Noble Function : Normal

Meningeal Sign : (-)

Cranial Nerve : blind, N. III paresis

Motoric : tetra parese

Sensory : Normal

Coordination : Difficult to asses

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Otonom : Normal

Fisiologis reflex : Positive

Pathologic reflex: Negativ

WORKING DIAGNOSE

Clinic Diagnose : Increased Intracranial Pressure Syndrome

N. III paresis

Tetraparese

Topic Diagnose : Brainstem

Etiologic Diagnose : SOL ec susp brainstem tumor

Differential Diagnose : brain abscess

SUGGESTION EXAMINATION:

1. Lab study :

(Blood routine, blood chemistry)

2. Imaging study :

(Chest X-ray, Head CT-Scan with contrast)

MANAGEMENT

Non pharmacologic therapy:

 Head up 30o

 IVFD RL 20 dpm

9
Pharmacologic therapy:

 Anti-edemas drugs:

Dexametason 4 x 4 mg IV

 Ranitidine inj 2 x 1 amp

LABORATORY FINDING :

1. Lab study

a. Blood Routine (May, 13th 2017)

WBC : 11.470 /ul

Hb : 12,4 g/dl

Ht : 37,2 %

PLT : 362.000/ul

b. Blood Chemistry (May, 13th 2017)

Ureum : 29 mg/dL Crea : 0,65 mg/dL

10
 2. Head CT-Scan with and with Contrast (May, 16th 2017)

Interpretation:

Mass with mixed density (hyperdense and isodens), round form, firm, size 3,28 x

2,68 x 2,41 cm at mesencephalon.

With contrast: enhanced (+) inhomogen

Mass extends aquaduct aqueductus sylvii, that made 3rd ventricle and lateral

ventricle widen

Sulci narrowed.

No deviation of midline structures.

Cerebellum normal.

Impression: obstruction hydrocephalus

Causation: mesencephalic tumor

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 5.Chest X-Ray

Impression (Chest X-Ray May, 15th 2017):

Heart: within normal limits

Lung: within normal limits

FINAL DIAGNOSE :

SOL ec mesencephalic tumor

Non communicant Hydrocephalus

Follow up May, 18th 2017

S : Headache (-), vomit (-), fever (-), seizure (-), limb weakness, blindness
O :
GCS 15 (E4M6V5)
Blood Pressure :110/80 mmHg
Heart Rate : 86 bpm
Respiratory Rate : 20 x/min
Temperature : 36,7 °C
Physical Examination
- Thorax : Normal limit
- Abdomen : Normal limit

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Meningeal Sign : (-)
Cranial Nerves : blind, n III palsy
Motoric : tetraparese
Sensory :Normal
Coordination :Normal
Autonomy :Normal
Reflex
Pathologic (-)
Physiology : Normal

A : SOL ec mesencephalon tumor

Non communican Hidrocephalus
P :
 IVFD RL 20 dpm

 Dexametason 4 x 4 mg IV

 Ranitidine inj 2 x 1 amp

 Consultation with neurologysurgery specialist  pro vp shunt

Follow up May, 19th 2017

S : Headache (-), vomit (-), fever (-), seizure (-), limb weakness, blindness
O :
GCS 15 (E4M6V5)
Blood Pressure :120/70 mmHg
Heart Rate : 86 bpm
Respiratory Rate : 20 x/ min
Temperature : 36,7 °C
Physical Examination
- Thorax : Normal limit
- Abdomen : Normal limit
Meningeal Sign : (-)
Cranial Nerves : blind, n III palsy

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Motoric : tetraparese
Sensory :Normal
Coordination :Normal
Autonomy :Normal
Reflex
Pathologic (-)
Physiology : Normal
Pathologic : (-)

A : SOL ec mesencephalon tumor

Non communican Hidrocephalus
P :
 IVFD RL 20 dpm

 Dexametason 4 x 4 mg IV

 Ranitidine inj 2 x 1 amp

Follow up May, 20th 2017

S : Headache (+), vomit (-), fever (-), seizure (-), limb weakness, blindness
O :
GCS 15 (E4M6V5)
Blood Pressure :110/80 mmHg
Heart Rate : 86 bpm
Respiratory Rate : 20 x/ min
Temperature : 36,7 °C
Physical Examination
- Thorax : Normal limit
- Abdomen : Normal limit
Meningeal Sign : (-)
Cranial Nerves : blind, n III palsy
Motoric : tetraparese

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Sensory :Normal
Coordination :Normal
Autonomy :Normal
Reflex
Pathologic (-)
Physiology : Normal
Pathologic : (-)

A : SOL ec mesencephalon tumor

Non communican Hidrocephalus
P :
 IVFD RL 20 dpm

 Dexametason 4 x 4 mg IV

 Ranitidine inj 2 x 1 amp

15
 DISCUSSION

1. Headache

1.2 Definition

Headache is pain or discomfort on whole area of the head. headache is most

commonly subjective chief complaints as reported.1.2

1.3 Classification

Based on international headache classification 2rd edition from the

International Headache Society (IHS)

Primary headache is headache with no underlying disease. The primary

headache, such as:2,3

 Migraine

Periodic disorder with unilateral or bilateral headache and can be following

with vomiting and visual disturbances. This condition occurs frequently, more than

10% of the population are experiencing at least one migraine attack in her life.

Migraine can occur at all of ages, but generally the onset occurs on teenage or

twenties and female more often than male. There is family history of migraines on

commonly patient.

 Tension-type headache (TTH) 2,3

This headache is frequenly occurs with unknown etiology, although had

been accepted that the contraction of the head and neck muscles is a mechanism

causes pain. Muscle contraction can be triggered by psychogenic factors such as

anxiety or depression or by local disease on head and neck.

16
 Patients commonly experienced headache that can be settled for a few days,

months or years. headache can worsen in the afternoon and generally not responsive

with analgesic drugs. This headache had a variative pain. Headache starts from the

blunt pain in various places until a thorough pressure sensation to the feeling of the

head tight-tied/tense.

 Cluster Headache2, 3

This syndrome are different from migraine, both marked by

unilateral headache, both can occur at the same time, but the very distinct

of the two is red eye. Histaminergic and humoral mechanisms underlying

the autonomous symptoms is estimated to occur in conjunction with this

head pain.

Patients usually are men, aged 20 to 60 years. Patients feel great pain

around one eye (always on the same side) for 20 to 120 minutes, can be

repeated several times a day, and patient often woke up more than one time

in the middle of the night. Alcohol can also trigger an attack. This pattern

lasted for days, weeks and even for months.

The secondary headache :

 Headache attributed to head and/or neck trauma and cranial or cervical vascular

disorder

 Headache attributed to non-vascular intracranial disorder

 Headache attributed to a substance or its withdrawal and infection

 Headache attributed to disorder of homeoeostasis

 Headache or facial pain attributed to disorder of cranium, neck, eyes, ears, nose,

sinuses, teeth,mouth, or other facial or cranial structures.

17
 Headache attributed to psychiatric disorder

 Cranial neuralgias and facial pains

 Cranial neuralgias and central causes of facial pain

 Other headache, cranial neuralgia central, or primary facial pain.

2. Space occupying lesion (SOL)

SOL is a extended lesion in brains including tumor, hematoma and

abscesses. Because the cranium is stiff with a fixed volume,then the lesions will

increase the intracranial pressure. A lesion that extends first will be accommodated

by removing the cerebrospinal fluid from the cavity of the cranium. Eventually

venous will compression and disorders braincirculation and cerebrospinal fluid will

appears, so the intracranial pressure will increase. Venosa congestion gives rise to

increased production and decreased absorption of cerebrospinal fluid and increase

the volume and going back to things like above.1

The position of the lesion in the brain space urges can have a dramatic

influence on the signs and symptoms. For example a lesion can clog the spaces flow

urges out of cerebrospinal fluid or directly pressing on a large vein, makethe

intracranial pressure increased rapidly. Signs and symptoms allows doctors to

localize the lesion will depend on the occurrence of a disorder in the brain as well

as the degree of tissue damage caused by nerve lesion. Great head pain, possibly

due to stretching durameter and vomiting due to pressure on the brain stem is a

common complaint. A lumbar pungsi should not be performed on patients

suspected intracranial tumors. Spending on the cerebrospinal fluid will lead to the

onset of sudden shifts hemispherium cerebri through notch into posterior fossa

18
cranii cerebelli or herniation of the medulla oblongata and serebellum through the

foramen magnum. At this time the CT-scan and MRI is used to enforce a diagnose

3. BRAIN TUMOR

3.1 Introduction

Brain tumor in a general sense means lumps, in terms of radiology known

as Space Occupying Lesion (SOL). Central nervous system neoplasm is generally

progressive neurological dysfunction which causing damage. Symptoms caused by

slow growing tumor give you symptoms that slowly emerging, while the tumor lies

on a vital position will give you symptoms that appear quickly. Approximately 10%

of all of neoplasm process in the rest of the body found in the nerves and itscover,

8% are located in intracranial space and 2% in canalis spinalis. The process of

neoplasm in nerves include two types: 11

a. The primary Tumor, a tumor originating from the brain tissue itself that tend

to develop in certain places. Like ependimoma which located near the walls

of the ventricles or canalis centralis of medulla spinalis, glioblastoma

multiforme is mostly found on parietal lobe, frontal lobe and

spongioblastoma in corpus calosum or pons.

b. Secondary Tumor (metastasis), a tumor originating from metastatic

carcinoma from other parts of the body. The most frequent metastatic

carcinoma found in bronchus and prostate in men as well as Carcinoma of

the mammae in women. 11

In order to discover the exact pathology underlying a brain tumor, it is

essential that it is biopsied and sent for analysis to an experienced neuropathologist.

19
This biopsy can be done via a stereotactic technique, which allows tissue to be

sampled from the lesion in a relatively safe way. This deploys a co‐ordinate system

based on scans, which allows the surgeon to access the tumor for biopsy in a

minimally invasive approach. The other alternative is that a biopsy is performed as

part of the debulking or excision of a tumor.

Broadly speaking, brain tumors can be classified as either gliomas or non‐

gliomas. These are either tumors of the glial cells of the brain or tumors of the other

intracranial cells. The vast majority of lesions in adults tend to be supratentorial

(above the tentorium cerebelli) and 86% of these falls into the category of

gliomas.This includes astrocytomas, oligodendrogliomas and ependymomas.

1. Gliomas

Astrocytomas are the most common type of glioma and are graded

according to the WHO scale of grades one to four. Grade 1 astrocytomas include

pilocytic astrocytomas which are benign. Grade 2 astrocytomas are low grade

infiltrating tumors. Grade 3 anaplastic astrocytomas exhibit mitoses. Finally, the

grade 4 glioblastoma multiforme (GBM)6 is the most aggressive primary brain

tumor in humans and has a median survival of 14 months following diagnose even

if given optimal therapy.4,5 GBM can arise as a first presentation or a secondary

presentation to a lower grade astrocytoma. The gliomas most commonly

encountered in adults are neoplasms of astrocytic or oligodenrocytic lineage. Mixed

tumors also occur, the most common of which is termed anaplastic

oligoastrocytoma.10 In US studies, glioblastomas formed around 50% of these

20
tumors. This was followed by oligodendrogliomas (9.2%), other astrocytomas

(9.1%) and ependymomas (5.6%).7

2. Non‐Gliomas

Non‐gliomas form the remainder of brain tumors. This includes

meningiomas, which arise from the meninges and compress the brain thereby

creating a mass effect. With an incidence of around 2 per 100,000,8 over 90% of

these tumors are benign and are therefore potentially curable through resection.

Loss of chromosome 22 is a characteristic genetic feature of these tumors.7 Pituitary

adenomas also fall into the category of non‐gliomas and are eitherfunctioning or

non‐functioning. If functioning, they may secrete hormones causing endocrine

disturbance.

The clinical manifestation of the tumor depends on the hormone secretion.

Sexual dysfunction and galactorrhoea occur in prolactinoma. A “buffalo hump”,

“moon face”, acne, weight gain, hypertension and diabetes mellitus occur in

Cushing’s disease (ACTH hypersecretion). Acromegaly can result from an over‐

secretion of growth hormone with the typical changes that occurs with soft tissue

growth in adult sufferers. Rarely, other secreting pituitary tumors such as TSHomas

occur. Non‐functioning pituitary tumors may exert a mass effect due to their

proximity to the optic chiasm and can cause visual disturbance such as bitemporal

hemianopia.9

Medulloblastomas are primitive neuroectodermal tumors which are rare in

adulthood but much more common in children, accounting for 20% of childhood

brain tumors.10 These tumors are generally located in the cerebellum and therefore

21
present with signs of cerebellar dysfunction. They can involve the 4th ventricle and

lead to the development of hydrocephalus.11

With the correct initial treatment of medulloblastoma, long‐term survival

may be achieved in around 40‐60% of all patients.12These tumors can however

spread in the subarachnoid space to involve other parts of the CNS. Primary CNS

lymphoma is another tumor within the grouping of non‐gliomas. These constitute

2‐3% of total brain tumors in people of normal immunity. Patients with

immunodeficiency are at an increased risk of developing this form of cancer.

3.2 Cerebral metastases

Cancer cells of cerebral metastases have spread to the brain from cancer

cells in other organs in the body. The most frequent cause of lung cancer is 48%,

breast cancer 21%, cancer geniturinari 11%, skin cancer (melanoma) 9%, as many

as 6% of gastrointestinal, head and neck cancer 5%. Such organs the primary cancer

spreading through the bloodstream to spread to the brain so called secondary

tumors. Most brain metastases have occurred in the cerebrum, the cerebellum 80%

16%, and 4% of the brainstem, the incidence of occurrence of metastases to the

brain is 20%-40% of all cancer patients, as much as 70% had multiple lesions.12

Cancer cells that develop in the brain can suppress, irritating and or destroy

normal brain tissue, so that it will give rise to a progressive headache, vomiting,

seizures, impaired verbal symptoms, weakness of the limbs, paralysis,

unconsciousness, and even death.This occurs if the size of the tumor already

causing damage in the brain. But not everyone complained about it, even a third of

sufferers are tumor metastases have no symptoms at all. 12

22
 Generally ypes of cancer can spread to the brain, so it's important for the

doctor to determine the cause of the primary sources of the metastases tumor of

brain. So that it can determine and implement for the effective option treatment.

Early diagnose and treatment of brain metastases tumor can cause remission or

recovery of symptoms of disorders of the brain and may improve the patient's

quality of life and prolonging survival. 12

3.3 Clinical Symptoms

There are 4 common clinical symptoms associated with brain tumors, like

mental status changes, headaches, vomiting, and seizures. 11

a. Changes in mental status

Early symptoms can be vague. The inability of the execution of daily tasks,

irritability, labile emotions, mental inertia, impaired concentration, even

psychosis.2 Cognitive function is a complaint often made by cancer patients with a

variety of forms, ranging from mild memory dysfunction and difficulties

concentrating until disorientation, hallucinations, or lethargy. 13

b. Headaches

Headaches is an early symptom of intracranial tumors on 20% of sufferers.

The character of the headache felt like being pressedor full flavor on the head as if

willing to explode 2 Initially pain can be mild, episodic and dull, and then gain

weight, blunt or sharp and also intermittent. Pain can also be caused by the side

effects of chemotherapy drugs. This pain is more excellent in the morning and can

be diperberat by coughing, tilt your head or physical activity.3 The location of the

pain that can be unilaterally in accordance with location of tumor. Tumors in the

23
posterior fossa kranii head pain usually leads to ipsilateral retroaurikuler.

Supratentorial tumors in pain cause head on the side of the tumor, in a frontal or

parietal, temporal orbita.13

c. Vomiting

Vomiting is also often arise in the morning and not food-related. Where

vomiting is typical projectiles and not preceded by nausea. This situation is often

found in the posterior fossa of tumor.13

d. Seizures

Focal seizure is another manifestation that is commonly found in the 14-

15% of sufferers of brain tumor, 20-50% of patients brain tumor showed symptoms

of seizures. Seizures arising first on age of consent indicating the presence of a

tumor in the brain. Seizure related brain tumor was originally a form of focal

seizures (focal damage indicative of serebri) as in meningiomas, can then become

a public seizure is mainly a manifestation of glioblastoma multiforme.13 Seizures

usually paroxysmal, a result of the cortex in neurological serebri. Partial seizures

due to focal areas of emphasis on the brain and menifestasi on the secondary, while

local seizures occurring if the tumor is widespread on both hemisphere serebri. 14

3.4 Support examination

A brain tumor can be detected with a CT-scan or MRI. The choice depends

on the availability of facilities at each hospital. CT-scan cheaper than an MRI,

commonly available in hospital and when you use the contrast can detect the

majority of brain tumors. More specialized MRI to detect tumors with small size,

tumors at the base of the skull and bones in the posterior fossa. In addition, MRI

24
can also help the surgeon to plan the surgery because it showed tumors in a number

of areas.14

3.5 Management

Treatment of patients with SOL include: 13.14

 Symptomatic.

a. Antikonvulsi

Controlling epilepsy is an important part of the treatment patients

with a brain tumor.

b. Cerebral edema

If patients with increased intracranial pressure and the description of

Radiology showed cerebral edema, then dexametason can be used

reduce the edema.

c. Radiotherapy

Radiotherapy played an important role in the treatment of brain

metastases, and includes entirely namely irradiation, radiotherapy

and radiosurgery. For decades, whole brain irradiation has been

recommended for patients with multiple lesions, the life expectancy

of less than three months, or the value of the performance of

Karnofsky is low. However it should be noted often cause severe

side effects, including radiation necrosis, dementia, nausea,

headaches, and sore. In children who get this treatment can cause

mental retardation, psychiatric disorders and other neuropsychiatric

effects.

25
 d. Chemotherapy

Chemotherapy is rarely used for the treatment of brain metastases,

as chemotherapeutic agents penetrate the blood-brain barrier very

badly. However, some types of cancer such as lymphoma,

carcinoma small cell lung and breast cancer is a very chemosensitive

and chemotherapy can be used to treat extracranial to metastatic

disease cancer. Experimental treatment for brain metastases is

intrathecal chemotherapy, a technique in which chemotherapy drugs

delivered through intralumbar injection into the cerebrospinal fluid.

However, it was not approved by the u.s. Food and Drug

Administration (FDA) for the treatment of brain metastases. 14

e. Operation

Brain metastasis frequently managed surgically, with a maximum of

surgical resection followed by stereotactic radiosurgery or whole

brain irradiation provides more benefits to patient survival compared

with whole brain irradiation method using 13,14

3.6 Prognosis

The prognosis for metastatic brain is variable. This depends on the type of

primary cancer, the patient's age, the absence or presence of extracranial metastases

metastatic and amounts in the brain. For all patients an average of average survival

is only 2-3 months. However, in some patients, such as those with extracranial

metastasis, those who are younger than 65, and those with one site of metastases in

the brain, the prognosis is much better, with a survival rate of an average of up to

13 months. 13.14

26
4. BASIC DIAGNOSE

4.1 Basic clinical diagnose

From the anamnesis, the patients first complained was vision loss and limb

weakness. There was also a history of recurrent headache with vomiting and

transient vision loss. Her sight getting worst by time that didn’t treated with glasses.

Patient's neurological deficits occur slowly and getting worser, such as lost

of vision and body weakness.

These symptomps is suitable with symptoms of increased intracranial

pressure, where there are main symptoms of increased intracranial pressure like

headache, vomiting, blindness, and there’s also another neurological deficit such as

palsy of cranial nerve III

5.2 Basic topic diagnose

From patients symptom and sign there were found a headache, lost of vision

and cranial nerve palsy, which suggested there was any intracranial process. Then

tetraparese occurred with bilateral cranial nerve III palsy indicated there’s a lesion

within brainstem.

5.3 Basic etiological diagnose

From the anamnesis, patient’s neurological deficits occur slowly and

increasingly worse such as loss of vision. Presence of headache with projectile

vomiting history and neurological deficits shows sign of increased intracranial

pressure which can caused by tumor. Physical examination show there’s N III

paresis. Therefore etiological diagnosis of this patient is SOL ec suspect brainstem

tumor.

27
 Its proven by radiology imagine that there’s extended mass lession at

mesencephalon and non communican hidrocephalus. Therefore final diagnose of

this patient is SOL ec Mesenchepalon Mass and Non communican Hidrocephalus.

5.4 Basic differential diagnose

Patient had symptoms of nerve palsy due to increased intracranial pressure,

increased intracranial pressure can also be found in abscess, that also had the same

characteristic: sub-acute/cronic.

5.5 Basic of supportive examination

a. Laboratory: knowing risk factors whether infection exists, and knowing the

general condition of the patient.

b. Thoracic x-rays: to see the existence of a specific process, to see metastasis

or originate tumor/infections in the lung

c. Head CT-scan: to see a cross-sectional view of the brain as whole, which

related to patient’s complained.

5.6 Basic management

- IVFD RL 20 dpm : to maintain the state of euvolemic.

- Dexametason: to reduce the brain edema.

- Ranitidine : to inhibit excessive stomach acid production

28
 References

Price SA, Wilson ML. Patofiologi konsep klinis proses-proses penyakit. Ed 6.

Jakarta : EGC 2005. h. 1021-2024

Sherwood L. Fisiologi manusia dari sel ke sistem. Ed 6. Jakarta : EGC 2011. h.

151-154

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