Case Report

SPACE OCCUPYING LESION ec Suspect Primary

Brain Tumor

By:
Diadema Al Arif
1508437946

Supervisor:
Dr. Enny Lestari, 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 Mr. Z
Age 23 yo
Gender Male
Address Simalinyang
Religion Islam
Marital’s Status Single
Occupation Teacher
Admitted to Hospital July, 04th 2017
Medical Record 9593**

II. ANAMNESIS :

Autoanamnesis and alloanamnesis with patient’s sister(July, 05th 2017)

Chief Complain

Loss of conciousness since 4 hours before admitted to the hospital.

Present illness history

Four hours before admitted to hospital, patient complaint loss of

conciousness. Patient could open his eyes when someone call him. One week

before admitted to the hospital, patient complaint that his headache was heavier.

The pain felt like thickening, the pain was mild for the first time and getting worse

by time, pain didn’t disappear with pain killer. Headache getting worse especially

1
when he did activity. The duration of headache was ±5 minutes and recurrent.

The headache began 1 year before at the back of the head. Nausea and vomitus

(+), fever (+), convulsion (-). One month before admitted to the hospital, patient

complaint weakness of his right extremity, but at that time patient still could walk.

Patient did CT Scan at Eka Hospital one week ago and the doctor said that

there is swelling at his brain. There is no history of weight loss, no history of mass

in his body area.

Past Illness history

 History of brain trauma (-)

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

 History of the malignancy (-)

 History of hypertension (+), since 1 year ago (no daily antihypertension drugs)

Daily routine history

Smoker (-), Alcoholism (-)

The Family Disease History

a. No family has the same complaint

b. History of cancer or tumors in family (-)

Summary
Patient Mr. Z, 23 years old, admitted to RSUD ArifinAchmad with chief

complaint loss of conciousness since 4 hours ago. Right extremity weakness since

1 week ago. Headache was severe since 1 week ago especially in his back of head,

it started more than 1 year. Patient also complaint nausea and vomitus (+), fever

(+). 1 week ago patient did CT Scan and doctor said there is swelling at his brain.

2
III. Physical Examination(July, 05th 2017)

A. Generalized Condition

Blood Presure : 160/100 mmHg

Heart Rate : 74 bpm

Respiratory : Respiratory rate : 21 x/mnt Type :Thoracoabdominal

Temperature : 36,5°C

Weight :55kg

Height : 160 cm

BMI : 21,5 kg/m2 (normoweight)

B. Physical examination

 Neck:no lymph node enlargement

 Thorax: Normal limit

 Abdomen: Normal limit

C. Neurological status

1) Consciousness : Somnolen GCS : 14 (E4V5M5)

2) Noble Function : Normal

3) Neck Rigidity : Negative

Cranial Nerves

1. N. I (Olfactorius )

Right Left Interpretation

Sense of Smell N N Normal

3
2. N.II (Opticus)

Right Left Interpretation

Visual Acuity N N
Visual Fields N N Normal
Colour Recognition N N

3. N.III (Oculomotorius)

Right Left Interpretation

Ptosis (-) (-)
Pupil
Shape Round Round
Side Φ2mm Φ2mm Normal
Extraoculer movement + +
Pupillary reaction to light
Direct + +
Indirect + +

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 + +

6. N. VI (Abduscens)

Right Left Interpretation

Extraocular movement + +
Strabismus - - Normal
Deviation - -

7. N. VII (Facialis)

Right Left Interpretation

Tic - - Normal

4
 Motoric N N
- corner of the mouth N N
- nasolabialisfolds + +
-frowning + +
-raise eyebrows + +
-closed eyes + +
Sense of taste - -
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
Trofi Eutrofi Eutrofi

12.N. XII (Hypoglossus)

Right Left Interpretation

Motoric Parese N
Trofi Eutrofi Eutrofi Parese dextra
Tremor - -
Disartria + +

5
IV. Motoric

Right Left Interpretation

Upper Extremity
Strength
Distal 0 5
Proksimal 0 5
Tonus Normal Normal
Trofi Eutrofi Eutrofi
Involunteer movement - -
Clonus - -

Lower Extremity
Strenght
Distal 0 5 Hemiplegi of right
Proksimal 0 5 extremity
Tonus Normal Normal
Trofi Eutrophy Eutrophy
Involunteer movement - -
Clonus - -

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

V. SENSORY

Right Left Interpretation

Touch (↓) (+)
Pain (↓) (+)
Temperature (↓) (+)
Hypestesia
Proprioceptive
right
 Position (+) (+)
extremity
 Two point
discrimination (+) (+)
 Stereognosis (+) (+)
 Graphestesia (+) (+)

6
  Vibration (+) (+)

VI. REFLEX

Right Left Interpretation

Physiologic
Biseps (↑) (+)
Hyperreflex dextra
Triseps (↑) (+)
(UMN lesion)
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 - - Difficult to assess
Tandem - -
Romberg - -

Ringer to nose test + +

Nose finger nose test + + Normal
Finger to finger test + +
Disdiadokonesia + +

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 : 160/100 mmHg

Heart Rate : 74 bpm

Respiratory : Respiratory rate : 24x/mnt Type : thorakobdominal

Temperature : 36,5°C

Weight : 55 kg Height: 160 cm IMT: 21,5 (overweight)

Neck : no lymph node enlargement

Thorax : Normal

Abdomen : Normal

Noble Function:Normal

Meningeal Sign : (-)

Cranial Nerve : Parese N VII dextra

Motoric : Pareseright extremity

Sensory : Normal

Coordination : Normal

Otonom : Normal

8
Fisiologis reflex : Positive

Pathologic reflex: Negative

WORKING DIAGNOSE

Clinic Diagnose: Increased Intracranial Pressure Syndrome

Topic Diagnose: Intracranial

Etiologic Diagnose: SOL ec Suspect Primary Brain Tumor

Differential Diagnose: SOL ec Cerebral Abscess

Secondary Diagnose: Hypertension

SUGGESTION EXAMINATION:

1. Lab study :

(Blood routine, blood chemistry)

2. Imaging study :

(ChestX-ray, Head CT-Scan with and without contrast)

3. Tumor marker

MANAGEMENT

Non pharmacologic therapy: Pharmacologic therapy:

 Head up 30o  Anti-edemas drugs:

 IVFD NaCl 0,9% 20 dpm Dexametason 3 x 10 mg IV

9
LABORATORY FINDING :

1. Lab study

a. Blood Routine (July, 04th 2017)

WBC : 7.510/ul

Hb : 12,8g/dl

Ht :37,2 %

PLT : 381.000/ul

b. Blood Chemistry

(July, 04th 2017)

Glucose : 114 mg/dL Ureum: 20mg/dL Creatinin : 0,67 mg/dL

AST : 28 U/L ALT : 46 U/L

(July, 05th 2017)

Glucose : 73 mg/dL

CHOL : 183 mg/dL LDL : 121,8 mg/dL HDL : 35 mg/dL

TGL : 131 mg/dL Urin Acid : 4,9 mg/dL

c. Electrolit

Na+ : 142 mmol/L

K+ : 4,7 mmol/L

Cl- : 106 mmol/L

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 2. Head CT-Scan without Contrast(July, 04th 2017)

Interpretation :

Hhypodens lesion at temporoparietalis sinistra with midline shift

Sulci and gyrus cotricalis, fissure Sylvii bilateral and fissure interhemisphere are

within normal

Enlargement of lateral ventricle dextra

Subarachnoid space within normal

Sisterna ambiense and basalis within normal

Selatursika and jukstastella and cerebello-pontin angle within normal

12
Impression :

Hypodence lesion at temporoparietalis sinistra region with midline shift ec.

Sugestif SOL

FINAL DIAGNOSE : SOL ec Suspect Primary Brain Tumor

Follow up July, 06th 2017

S:headache (+),right extremity weakness (+), nausea and vomitus (-)

O: GCS 14 (E3M6V5)

Blood Pressure :140/90 mmHg

Heart Rate : 84 bpm

Respiratory Rate : 20x/i

Temperature : 36,7 °C

Physical Examination

Neck : normal

Thorax and abdomen : normal limit

Cognitive Function : Normal

Meningeal Sign :-

Cranial Nerves : parese N XII dextra

Motoric : Hemiplegi of right extremity

Sensory : Hypesthesia of right extremity

Coordination : normal

Otonom : normal

ReflexPathologic: Negative

Reflex Physiology: Positive

13
A : SOL ec Suspect Primary Brain Tumor

P :IVFD NaCl 0,9% 20 dpm

Dexametason 3 x 5 mg iv

Head CT Scan with contrast

Consult to Neurologyst Surgeon

Follow up July, 07h 2017

S:headache (+),right extremity weakness (+),

O: GCS 15 (E4M6V5)

Blood Pressure :150/90 mmHg

Heart Rate : 78 bpm

Respiratory Rate : 20x/i

Temperature : 36,7 °C

Physical Examination

Neck : normal

Thorax and abdomen : normal limit

Cognitive Function : Normal

Meningeal Sign :-

Cranial Nerves : parese N XII dextra

Motoric : Hemiplegi of right extremity

Sensory : Hypesthesia of right extremity

Coordination : normal

Otonom : normal

ReflexPathologic: Negative

Reflex Physiology: Positive

14
A : SOL ec Suspect Primary Brain Tumor

P :IVFD NaCl 0,9% 20 dpm

Dexametason 3 x 5 mg iv

Head CT Scan with contrast

Consult to Neurologyst Surgeon (Consult to VCT : Suspect HIV infection)

Follow up July, 08th 2017

S:headache (+),right extremity weakness (+),

O: GCS 15 (E4M6V5)

Blood Pressure :140/80 mmHg

Heart Rate : 82 bpm

Respiratory Rate : 20x/i

Temperature : 36,7 °C

Physical Examination

Neck : normal

Thorax and abdomen : normal limit

Cognitive Function : Normal

Meningeal Sign :-

Cranial Nerves : parese N XII dextra

Motoric : Hemiplegi of right extremity

Sensory : Hypesthesia of right extremity

Coordination : normal

Otonom : normal

Reflex Pathologic: Negative

Reflex Physiology: Positive

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VCT consultation (July, 08th 2017) : HIV Reactive

A : SOL ec Suspect Primary Brain Tumor + HIV

P :IVFD NaCl 0,9% 20 dpm

Dexametason 2 x 5 mg iv

Head CT Scan with contrast

Follow up July, 10th 2017

S:headache (-),right extremity weakness (+),

O: GCS 15 (E4M6V5)

Blood Pressure :130/90 mmHg

Heart Rate : 84 bpm

Respiratory Rate : 20x/i

Temperature : 36,7 °C

Physical Examination

Neck : normal

Thorax and abdomen : normal limit

Cognitive Function : Normal

Meningeal Sign :-

Cranial Nerves : parese N XII dextra

Motoric : Hemiparesis of right extremity

Sensory : Hypesthesia of right extremity

Coordination : normal

Otonom : normal

Reflex Pathologic: Negative

Reflex Physiology: Positive

16
VCT consultation (July, 08th 2017) : HIV Reactive

A : SOL ec Suspect Primary Brain Tumor + HIV

P :IVFD NaCl 0,9% 20 dpm

Dexametason 1 x 5 mg iv

17
 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.

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 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.

19
 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 brainsincluding 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

20
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

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

progressive neurological dysfunction which causing damage. Symptoms caused

by slow growingtumor 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: 8

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

metastaticcarcinoma found in bronchus and prostate in men as well as

Carcinoma of the mammae in women. 8

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

essential thatit is biopsied and sent for analysis to an experienced

21
neuropathologist. 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 debulkingor 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 theWHO scale of grades one to four. Grade 1 astrocytomas include

pilocyticastrocytomaswhich are benign. Grade 2 astrocytomas are low grade

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

grade 4 glioblastomamultiforme(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.4,5GBM 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.9 In US studies, glioblastomas formed around 50% of these

22
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, whicharise 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

causingendocrine disturbance.

The clinical manifestation of the tumor depends on thehormone secretion.

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

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

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

anover‐secretion of growth hormone with the typical changes that occurs with

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

as TSHomas occur. Non‐functioning pituitary tumors may exert a mass effect due

totheir proximity to the optic chiasm and can cause visual disturbance such

asbitemporal hemianopia.6

Medulloblastomas are primitive neuroectodermaltumors which are rare

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

childhood brain tumors. These tumors are generally located in the cerebellum and

23
therefore present with signs of cerebellar dysfunction. They can involve the 4th

ventricle and lead to the development of hydrocephalus.6

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

may be achieved in around 40‐60% of all patients.7These 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.7

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

24
causing damage in the brain. But not everyone complained about it, even a third

of sufferers are tumor metastases have no symptoms at all. 6

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. 6

3.3 Clinical Symptoms

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

mental status changes, headaches, vomiting, and seizures. 7

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. 8

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

25
could be heavier 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 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.8

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.9

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. 9

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

26
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

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

number of areas.9

3.5 Management

Treatment of patients with SOL include: 8,9

 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,

27
 dementia, nausea, headaches, and sore. In children who get this

treatment can cause mental retardation, psychiatric disorders and

other neuropsychiatric effects.

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. 9

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 8,9

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

28
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. 9,10

29
 THE BASIC DIAGNOSE

1. Basic clinical diagnose

From the anamnesis, the patients complaint loss of conciousness. Right

extremity weakness since 1 week ago. Headache was severe since 1 week ago

especially in his back of head, it started more than 1 year. Patient also complaint

nausea and vomitus (+), fever (+).

These symptomps is suitable with symptoms of increased intracranial

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

loss of consciousness, headache, vomiting and neurological deficit (Cranial nerve

: parese N XII dextra , motoric: parese of right extremity, sensory: hypesthesia of

right extremity).

2. Basic topic diagnose

From patients symptom and sign there were found a severe headache,

neurological deficit, then the suspected topic diagnose in this case is in

intracranial process.

3. Basic etiological diagnose

Patient complaint loss of conciousness since 4 hours before admitted to

hospital. Right extremity weakness since 1 week ago. Headache was severe since

1 week ago especially in his back of head, it started more than 1 year. Patient also

complaint nausea and vomitus (+), fever (+). 1 week ago patient did CT Scan and

doctor said there is swelling at his brain. These symptomps is suitable with

clinical symptoms of brain tumor, like headaches, vomiting and seizures.

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 4. Basic differential diagnose

Patient had symptoms of neurological deficit due to increased intracranial

pressure, increased intracranial pressure can also be found in cerebral abscess, that

also had the same characteristic: sub-acute/cronic.

4.5 Basic of supportive examination

a. Laboratory: to know 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.

4.6 Basic management

- IVFD NaCl 0,9% 20 dpm: to maintain the state of euvolemic.

- Dexametason: to reduce the brain edema.

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 References

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

Ed 6. Jakarta : EGC 2005. h. 1021-2024

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

2011. h. 151-154

3. Ropper AH. Adam and Victor’s Principle of Neurology. Ed 10.

Massachusetts: McGraw Hill. p 168-96.

4. Shams, Shahzad. 2011.SOL . Omar Hospital, Jail Road, Lahore: Pakistan.

5. Adamson, C, et al. "Glioblastomamultiforme: a review of where we have

been and where we are going." Expert opinion on investigational drugs

18.8 (2009): 1061‐1083.

6. Suslu, Hikmet Turan, Mustafa Bozbuga, Cicek Bayindir. 2010. SOL .

JTN: 21(3): 427-429.

7. Buckner, J C, et al. "Central nervous system tumors." Mayo Clinic

proceedings 82.10 (2007): 1271‐1286.

8. Ropper AH, Brown RH. Intracranial Neoplasms and Paraneoplastic

Disorders in Adams and Victor’s Principles of Neurology. 8th edition.

USA: Mc Graw Hill, 2005. 546-88

9. Kleinberg LR. Brain Metastasis A multidisiplinary Approach. New York:

Demos Medical.

10. Patil CG, Pricola K, Garg SK, Bryant A, Black KL. Whole brain radiation

therapy (WBRT) alone versus WBRT and radiosurgery for the treatment

of brain metastases. Cochrane Database Syst Rev. 2010 Jun

16;(6):CD006121. Review. PMID 20556764

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