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Washington University Experience | VASCULAR | Herniation, uncal | 9A0 Case 9 History
Case 9 History ---- The patient was a 54 year old woman admitted to BJH on 7 /16 for evaluation of papilledema and multiple intracranial masses. Her past medical history was significant only for a reduction mammoplasty, drainage of a benign breast cyst and mild high blood pressure. One month prior to admission while playing tennis she noticed that she was having some transient difficulty using her right arm. Approximately 2 wks prior to admission she had the onset of bifrontal headache. In the ER on 7/I4 she was noted to have blurred discs. Workup included a CT scan which showed 3 contrast enhancing mass lesions in the right frontal area, right parietal area, and left parieto-occipital area. Her neurologic exam was remarkably benign. An angiogram performed on 7/17 showed 2 large vascular tumor masses, one in the right mid-frontoparietal area, and the second one in the interhemispheric fissure. On 7 /18 the patient had a needle biopsy performed under CT scan guidance of the right frontal tumor mass. A frozen section showed hemorrhage without tumor. Shortly after the needle biopsy the patient rapidly developed nausea and sweating, left hemiparesis, and within a period of minutes became hypertensive with a blood pressure of 210/120, dilated her right pupil with her left pupil being sluggish, and became unresponsive. She was given mannitol and steroids and taken to the operating room (immediately) for decompression, with a presumed diagnosis of herniation secondary to tumor hemorrhage. Frozen section at the time of surgery showed GBM with anaplasia and the lesion was debulked. Postoperatively the patient was comatose with bilateral upgoing toes. Pupils were sluggishly reactive, with no doll’s eyes and decorticate posture. There was no improvement in her neurological status until the time of death two weeks later on 7 /31.
