f*********1
发帖数: 189 | 1 old patient presents with fatigue, sleep 20 hours per day:), and left side
weakness.
1. Brain MRI
2. CT head and neck
3. CT Chest
我打算一个一个的发，有奖竞猜，嗬嗬，对了得，版大可能会给发包子：）
1. Brain MRI
What do you think the patient may have? |
A*******s
发帖数: 9638 | 2 This is T1 with Gad.
Why do CT of head and neck after MRI?
I am more interested in CT of the chest. |
z****o
发帖数: 368 | 3 Thx for the case. It seems to be a solitary enhancing mass located near the
amygdala or hypothalamus. Since circadian cycle is controlled by the
hypothalamus("suprachiasmatic nucleus", according to wiki), it is likely
that the pt. is suffering from hypothalamus dysfunction due to the brain
mass. It could also compress the internal capsule or along the pathway,
causing the left side weakness.
Without further info, most possible reason for the mass is brain tumor. At
this age, it is more likely a metastasis tumor rather than a primary one.
Wait to see more images, like the chest CT to rule in/out lung tumor. |
z****o
发帖数: 368 | 4 head CT to look for tumor calcification? or to rule out hemorrhage?
【在 A*******s 的大作中提到】
: This is T1 with Gad.
: Why do CT of head and neck after MRI?
: I am more interested in CT of the chest.
|
f*********1
发帖数: 189 | |
A*******s
发帖数: 9638 | 6 你可以点【回复】来回答上面任何一个帖子， 包括你原文在内，就会看到【附件】这
个选项。
【在 f*********1 的大作中提到】
: 请问，怎末在回文中贴图片，谢谢！
|
f*********1
发帖数: 189 | 7 Here is the CT head:)
Compared to the MRI brain, what do you think now? |
A*******s
发帖数: 9638 | 8 A heterogeneous mass lesion involving right BG, thalamus and superior
cerebellar peduncle/midbrain with surrounding edema and mild midline shift.
MRI would be better than CT though. |
f*********1
发帖数: 189 | 9 版大应该给自己发包子，嗬嗬，您的神经解剖学的真好：）
你现在觉得这个lesion 是啥？
【在 A*******s 的大作中提到】
: A heterogeneous mass lesion involving right BG, thalamus and superior
: cerebellar peduncle/midbrain with surrounding edema and mild midline shift.
: MRI would be better than CT though.
|
A*******s
发帖数: 9638 | 10 Lung Ca with brain mets， you leaked the info， lol
【在 f*********1 的大作中提到】
: 版大应该给自己发包子，嗬嗬，您的神经解剖学的真好：）
: 你现在觉得这个lesion 是啥？
|
|
|
R*******t
发帖数: 367 | 11 Hyper dense masses with avid homogeneous enhancement, ddx include small blue
cell tumors, and lymphoma should be excluded first. |
f*********1
发帖数: 189 | 12 Brian meta usually are multiple, so brain meta is ruled out:)
【在 A*******s 的大作中提到】
: Lung Ca with brain mets， you leaked the info， lol
|
f*********1
发帖数: 189 | 13 Ruby, you have great points!
1.Intially the concern had been for CNS lymphoma given the appearance of the
lesion on imaging, however 3 LPs were negative for flow and cytology.
2. Other differentials include GBM, HIV encephalopathy, or granuloma disease
.
Neuroradiologists said that it is not GBM, as GBM should be hypodensity, not
hyperdensity on CT head.
Patient's Oncologist and Neurologist want to do biopsy. Oncologist insisted
that biopsy should be done, since GBM would progress quickly and kill the
patient without immediate treatment.
blue
【在 R*******t 的大作中提到】
: Hyper dense masses with avid homogeneous enhancement, ddx include small blue
: cell tumors, and lymphoma should be excluded first.
|
f*********1
发帖数: 189 | 14 Surgeons do not want to do biopsy due to the location of the CNS lesion:)
So no one knows what the CNS lesion would be at that point:) |
f*********1
发帖数: 189 | 15 The patient is HIV negative, and is a wealthy VIP from outer state, and the
patient's family also refused biopsy of the CNS lesion.
So it is less likely a primary CNS lymphoma or HIV encephalopathy at the
point.
I am going to post the CT chest later today:) |
R*******t
发帖数: 367 | 16 Does the patient has any risk factors for TB? CNS TB is a great mimicker for
lots of stuff. However, the usual work up is usually head CT first, then
MRI, then CT body |
A*******s
发帖数: 9638 | 17 No, you can not r/o mets just because of a single lesion.
【在 f*********1 的大作中提到】
: Brian meta usually are multiple, so brain meta is ruled out:)
|
A*******s
发帖数: 9638 | 18 Without a biopsy, everything is possible at present.
I would tell family this lesion could be a demyelinating lesion as well,
like Tumefactive multiple sclerosis, which is highly treatable.
How about neurosarcoids?
However, I would do a CT of chest w/wo contrast prior to any biopsy. |
f*********1
发帖数: 189 | 19 what is the major presentation of neuro-sarcoidosis? Is it usual to see
neurosarcoidosis at an age of 80?
what is the etiology of neurosarcoidosis?
【在 A*******s 的大作中提到】
: Without a biopsy, everything is possible at present.
: I would tell family this lesion could be a demyelinating lesion as well,
: like Tumefactive multiple sclerosis, which is highly treatable.
: How about neurosarcoids?
: However, I would do a CT of chest w/wo contrast prior to any biopsy.
|
f*********1
发帖数: 189 | 20 How would CNS TB present clinically? Could CNS TB grow so big?
Another question is why the patient had symptoms at the time, instead of at
an earlier time?
The patient's family wants brain MRI first instead of CT head due to
radiation exposure:)
for
【在 R*******t 的大作中提到】
: Does the patient has any risk factors for TB? CNS TB is a great mimicker for
: lots of stuff. However, the usual work up is usually head CT first, then
: MRI, then CT body
|
|
|
A*******s
发帖数: 9638 | 21 Inflammatory process, but a Neurosarcoid is very unusual for a 80 years old
man.
【在 f*********1 的大作中提到】
: what is the major presentation of neuro-sarcoidosis? Is it usual to see
: neurosarcoidosis at an age of 80?
: what is the etiology of neurosarcoidosis?
|
A*******s
发帖数: 9638 | 22 Could you post some MRI axial views, like FLARE and T1 with Gad?
at
【在 f*********1 的大作中提到】
: How would CNS TB present clinically? Could CNS TB grow so big?
: Another question is why the patient had symptoms at the time, instead of at
: an earlier time?
: The patient's family wants brain MRI first instead of CT head due to
: radiation exposure:)
:
: for
|
f*********1
发帖数: 189 | 23 Here you go.
【在 A*******s 的大作中提到】
: Could you post some MRI axial views, like FLARE and T1 with Gad?
:
: at
|
A*******s
发帖数: 9638 | 24 Thanks. It looks like a heterogeneous enhanced mass lesion.
I would bet on mets first then primary CNS tumor. Given his advanced age, I
would accept his family's decision.
【在 f*********1 的大作中提到】
: Here you go.
|
f*********1
发帖数: 189 | 25 CT chest showed mediastinal lymphadenopathy without pulmonary nodules, what
would you do next?:) |
A*******s
发帖数: 9638 | 26 lymph node biopsy.
what
【在 f*********1 的大作中提到】
: CT chest showed mediastinal lymphadenopathy without pulmonary nodules, what
: would you do next?:)
|
R*******t
发帖数: 367 | 27 To worry about radiation in an 80 yo is really not necessary. But I
understand he is a VIP, and they get what they want. :)
at
【在 f*********1 的大作中提到】
: How would CNS TB present clinically? Could CNS TB grow so big?
: Another question is why the patient had symptoms at the time, instead of at
: an earlier time?
: The patient's family wants brain MRI first instead of CT head due to
: radiation exposure:)
:
: for
|
R*******t
发帖数: 367 | 28 He needs CT of whole body including neck, abdomen and pelvis to evaluate
extent of disease. He can have a PET/CT too, if family insists. We can
finish the imaging before sticking a needle in him or mediastinoscopy.
what
【在 f*********1 的大作中提到】
: CT chest showed mediastinal lymphadenopathy without pulmonary nodules, what
: would you do next?:)
|
z*****2
发帖数: 498 | 29 Plusplus, 真棒！在国内我是干神经解剖的，后来完成了了神经外科的住院医。来美后
又改了电脑，但每每看到神经解剖的内容，总是勾起我青年时的回忆。
【在 A*******s 的大作中提到】
: A heterogeneous mass lesion involving right BG, thalamus and superior
: cerebellar peduncle/midbrain with surrounding edema and mild midline shift.
: MRI would be better than CT though.
|
A*******s
发帖数: 9638 | 30 过奖了， 没想到Roy是神经外科， 不出国就应该是“心术”里的老大了吧？
【在 z*****2 的大作中提到】
: Plusplus, 真棒！在国内我是干神经解剖的，后来完成了了神经外科的住院医。来美后
: 又改了电脑，但每每看到神经解剖的内容，总是勾起我青年时的回忆。
|
|
|
z*****2
发帖数: 498 | 31 是啊， 我有20多年没有听到 BG, thalamus and superior cerebellar peduncle/
midbrain 这样的名词了，真是亲切。在国内我主要做stereotactic neurosurgery, 来
美国做Gamma unit的fellowship. 后来遇到另外一个CMG电脑高手教我，于是就改了行
了。提到”心术“， 最近我刚刚贴在我新开的网站上，刚看两集：
http://social.cmgforum.net/blog/view/656/--
【在 A*******s 的大作中提到】
: 过奖了， 没想到Roy是神经外科， 不出国就应该是“心术”里的老大了吧？
|
f*********1
发帖数: 189 | 32 Great points:)
【在 R*******t 的大作中提到】
: He needs CT of whole body including neck, abdomen and pelvis to evaluate
: extent of disease. He can have a PET/CT too, if family insists. We can
: finish the imaging before sticking a needle in him or mediastinoscopy.
:
: what
|
f*********1
发帖数: 189 | 33 Thanks for the good points!
【在 z****o 的大作中提到】
: head CT to look for tumor calcification? or to rule out hemorrhage?
|
f*********1
发帖数: 189 | 34 mediastinoscopy showed sarcoidosis in the mediastinal LNs:) What is your
next step management?
【在 A*******s 的大作中提到】
: lymph node biopsy.
:
: what
|
A*******s
发帖数: 9638 | 35 IV steroids.
But wait, you could diagnose sarcoidosis based on LN biopsy?
Chiusmd, can you help me? :)
【在 f*********1 的大作中提到】
: mediastinoscopy showed sarcoidosis in the mediastinal LNs:) What is your
: next step management?
|
A*******s
发帖数: 9638 | 36 I don't believe the neurosarcoid is the answer, even if he has a lung
sarcoidosis. It could be just coincident. Biopsy is the only way to tell. |
f*********1
发帖数: 189 | 37 Rheumatologist was consulted, and said it looked like sarcoidosis:)
Patient was treated with steriod, and symptoms get better:) We were
joked at for telling them that the imaging findings are most consistent
with CNS lymphoma, and the brain and mediastinum were separate
processes:)
However, according to Icetea
"Corticosteroid has no direct anti tumor activity towards GBM however it
is
very helpful reducing edema and inflammation, this is also true for
metastatic brain lesions. Regarding edema caused by bleeding/abscess, I
guess it is not very clear, it depends on each patient's clinical
situation.
For CNS lymphoma, corticosteroid does have substantial anti tumor
activity.
You would want to talk to hem/onc before you give steroid for somebody
whom
you suspect CNS lymphoma because it will substantially lower the
positive
biopsy yield."
Can the patient get better clinically on steroid itself prove that the
patient has neurosarcoidosis? They did LP three times, and all were
negative for malignant cells. |
A*******s
发帖数: 9638 | 38 The improvement is because the edema related to the tumor is very responsive
to steroids treatment. It does not matter whether it is a GBM, a sarcoid
or a lymphoma.
【在 f*********1 的大作中提到】
: Rheumatologist was consulted, and said it looked like sarcoidosis:)
: Patient was treated with steriod, and symptoms get better:) We were
: joked at for telling them that the imaging findings are most consistent
: with CNS lymphoma, and the brain and mediastinum were separate
: processes:)
: However, according to Icetea
: "Corticosteroid has no direct anti tumor activity towards GBM however it
: is
: very helpful reducing edema and inflammation, this is also true for
: metastatic brain lesions. Regarding edema caused by bleeding/abscess, I
|
f*********1
发帖数: 189 | 39 The patient is discharged, and in their discharge note, the discharge
diagnosis is sarcoidosis:)
why more sarcoidosis cases in USA? What are the etilogies of non-
infectious inflammatory disease? When I was in China, I rarely
saw sarcoidosis, actually I never saw one case of sarcoidosis when I was
in China:) |
A*******s
发帖数: 9638 | 40 A good case discussion, thank you, forestpark1.
But the diagnosis is dubious. :) |
