Table of Contents
Washington University Experience | NEOPLASMS (GLIAL) | Astrocytoma, pilocytic - Gross Pathology | 1A0 Case 1 History
Case 1 History ---- This 4.5 year old female was first seen at SLCH in January 1980 for evaluation of a mild right hemiparesis and right arm tremor. She was the product of a normal pregnancy, labor and delivery without complications in early development. At the age of 6 months, the patient was noted to have a tremor of the right hand when she reached for objects. This persisted over the following several years although she otherwise had normal developmental milestones. In September 1979, she started preschool and tremor in the right hand increased markedly. In December 1979, her family noted decreased use of the right arm. She complained of generalized throbbing headaches lasting two minutes to two days. She was uncoordinated and had frequent falls. The patient was alert, slightly obese, and had a normal general examination. Pupils were 3/3, round and reactive to light; visual fields were full, and fundi were benign. Extra ocular movements were full without nystagmus. There was a right central seventh nerve dysfunction. The remainder of the cranial nerves were normal. Strength was 4/5 in the right upper extremity, but motor function was otherwise normal elsewhere. There was no clonus and tone was normal. There was an intention tremor of the right upper extremity; otherwise, coordination testing was normal. Station, gait, and running were normal. Sensory was intact to pinprick in all extremities. Deep tendon reflexes were 2+ in the upper extremities, 3+ in the lower extremities, and plantar reflexes were down going bilaterally. A CT scan showed a contrast enhancing tumor in the region of the left thalamus extending to the midbrain and pons. The lesion was 3 cm in diameter at each level with pressure on the third ventricle, quadrigeminal cistern and the fourth ventricle. There was slight lateral ventricular dilatation. An angiogram showed a thalamic mass which extended to the temporal notch and into the midbrain. Clinical impression was an inoperable glial tumor, and the patient was discharged for an outpatient course of radiation therapy which was to be completed over a 6 week period. The patient was seen in April 1980 for a repeat CT scan under general anesthesia. Exam at that time showed a mild residual hemiparesis. In May 1980, her parents noted increasing hemiparesis and tremor. Later she was irritable and suddenly became stiff and unresponsive with opisthotonic posturing. In the ER her pupils were pinpoint and unreactive and she did not react to painful stimuli. Plantar reflexes were extensor bilaterally. Heart rate was regular and blood pressure 110/70. Fundi showed bilateral papilledema with retinal hemorrhages. Over approximately 20 minutes, she became arousable and talked to her parents. She then became stiff with generalized extensor tone and became unresponsive. Pupils were dilated and unreactive to light. Extra ocular movements were absent to Doll's eye maneuver. There were no corneal or gag reflexes or facial movement. Deep tendon reflexes were absent. Respirations and pulse gradually weakened and the patient was pronounced dead.
