SPACE OCCUPYING LESION

Presented by : Maria Margareta Hutajulu S.ked

Supervised by : dr. Riki Sukiandra, Sp.S
Clinical Clerkship of Neurology Departement
Faculty of Medicine University of Riau
Arifin Achmad General Hospital
Identity

Name : Ms. S
Age : 42 yo
Gender : Female
Address : Mandau
Religion : Islam
Marital’s Status : Married
Occupation : Housewife
Admitted to Hospital : January, 24th 2018
Medical Record : 9771**
Chief Complain

Loss of consciousness since 1 day

before admitted to the hospital.
Present illness
history

1 day 5 Month
Other complaints
were unknown.

Patient had loss of consciousness

The patient’s neighbours told that the patient
suddendly. No one knew other complain
complained headache. The headache getting
and patient’s activity before it happened.
worse by the time. Other specific of headache
Then patient’s neighbour took the patient
unknown. They told that the patient couldnt
to Permata Hati’s Hospital and diagnosed
walk normally and sometimes confused what
brain tumor by neurology specialist. While
she wanted to do. Her husband ever brough
at Permata Hati Hospital the patient has
the patient to alternative but there wasnt
seizure. The neighbour didnt know how
improvement.
many times the patient seizure.
Past illness
history Brain
Trauma

History of
last fever,
Tumor and
ear
malignancy
infection,
sinusitis
UNKNOWN

Hyperte Diabetic
nsion Mellitus
 Daily Routine Family Disease
History Jobs
History History
• Smoker (-) • Housewife • Unknown
• Alcoholism (-
)
 Summary

Patient Ms. S, 42 years old, admitted

to Arifin Achmad hospital with chief
complain lost of consciousness since 1 day
before admitted to the hospital. The
patient felt headache and getting worse by
the times. The patient also couldnt walk
normally and sometimes confused what she
wanted to do. She ever got seizure. Other
complains were unknown.
Physical Examination
(January, 25h 2018)

Generalized Condition Physical examination Neurological status

• Blood Pressure : 120/70 • Neck : no lymph node • Consciousness :

mmHg enlargement Somnolen
• HR : 90 bpm • Thorax : Normal • GCS : 12 (E3V4 M5)
• RR : 20 x/minute limit • Noble Function :
Type:Thoracoabdominal • Mammae : Normal limit Normal
• T : 36,9°C • Abdomen : Normal • Neck Rigidity : Negative
• Weight : 48 kg limit
• Height : 155 cm
• BMI : 20 kg/m2
(normoweight)
Cranial Nerves
N. I (Olfactorius )
Right Left Interpretation
Not Not
Sense of Smell applicable applicable
Not applicable

N.II (Opticus)
Right Left Interpretation
Not
Not
Visual Acuity applicable
applicable
Not Not
Visual Fields applicable applicable

Not applicable
Not Not
applicable applicable
Colour Recognition
Cranial Nerves

N.III (Oculomotorius)
Right Left Interpretation

Ptosis - -
Pupil
Shape Round Round
Doll eyes
Side Φ2mm Φ2mm
movement (+)
Extraoculer movement normal normal
Pupillary reaction to light
Direct + +
Indirect + +
Cranial Nerves
4. Cranial nerve IV (Trochlear)
Right Left Interpretation
Extraokuler Doll eyes
movement + + movement (+)

5. Cranial nerve V (Trigeminal)

Right Left Interpretation
Motor Not Not
applicable applicable
Corneal reflex
Sensory Not Not
applicable applicable positive
Corneal reflex + +

6. Cranial nerve VI (Abducens)

Right Left Interpretation
Eyes Movement + +
Doll eyes movement
Strabismus - -
-
(+)
Deviation -
Cranial Nerves
7. N. VII (Facialis)
Right Left Interpretation
Tic - -

Motoric N N
- corner of the mouth N N
- nasolabialis folds + + Normal except sense
-frowning + + of taste not applicable
-raise eyebrows + +
-closed eyes + +
Sense of taste Not Not
applicable applicable
Chovstek sign
- -

8. Cranial nerve VIII (Vestibulococlearis)

Right Left Interpretation
Hearing sense N N Normal
 9. Cranial nerve IX (Glossopharyngeal)
Interpretati
Right Left
on
Pharyngeal Arch
Pharyngeal Arch Normal Normal and gag reflex
are normal but
Sense of Taste Not applicable Not applicable flavor sense not
Gag Reflex (+) (+) applicable

10. Cranial nerve X (Vagus)

Right Left Interpretation
Cranial Nerves Pharyngeal Arch Normal Normal
Normal
Dysphonia - -

11. Cranial nerve XI (Accessory)

Right Left Interpretation
Motor Not Not
Trophy
Not applicable
applicable applicable

12. Cranial nerve XII (Hypoglossal)

Right Left Interpretation
Motor Not Applicable Not applicable
Trophy Eutrophy Eutrophy Motoric not applicable
-
Tremor -
- -
Dysarthria
Motoric

Right Left Interpretation

Upper Extremity
Strength
Distal Not applicable Not applicable
Proksimal Not applicable Not applicable
Tonus Hypertonus Normal
Trofi Eutrophy Eutrophy
Involunteer movement - -
Clonus - -
Fall Test Fall firstly Last fall
Stimulation pain Motion is less active Motion is more active
Lower Extremity
Strenght
Distal Not applicable Not applicable
Proksimal Not applicable Not applicable Lateralization to dextra
Tonus Hypertonus Normal
Trofi Eutrophy Eutrophy
Involunteer movement - -
Clonus - -
Fall Test Fall firstly Last fall
Stimulation pain Motion is less active Motion is more active

Body
Trofi Eutrophy Eutrophy
Involunteer movement - - Normal
Abdominal Reflex (+) (+)
 Interpretati
Right Left
on
Touch
Sensory System Pain
Temperature Not applicable Not applicable
Not
applicable
Proprioceptive

Right Left Interpretation

Physiologic
Biceps (+) (+)
Triceps (+) (+) Physiologic reflex (+)
Knee (+) (+)
Ankle (+) (+)
Reflex Pathologic
Babinsky (+) (-)
Chaddock (-) (-)
Hoffman Tromer (-) (-) Pathologic reflex (+)
Openheim (-) (-)
Schaefer (-) (-)
Primitive Reflex
Palmomental (-) (-) Reflex primitif (-)
Snout (-) (-)
 Coordination
Right Left Interpretation

Point to point movement

Walk heel to toe

Gait No No No appreciate
appreciate appreciate
Tandem

Romberg
Autonomy System Others Examination

Laseque : Limited in
Urinate : Normal
dextra <70o

Defecation : Normal Kernig : Limited in

dextra <130o

Patrick : (-)

Kontrapatrick : (-)

Valsava test : (-)

Brudzinsky : (-)
 • Increase Intracranial Pressure Syndrome
Clinical diagnose

WORKING Topical diagnose

• Cortex cerebri regio lobus frontoparietal sinistra

DIAGNOSE
• SOL ec suspect primary brain tumor
Etiological diagnose

Differential  SOL ec suspect tumor metastase

diagnose  SOL ec suspect cerebral abscess
 Suggestion
examination

• Blood routine • Electrocardiogram • Chest X-ray,

• blood chemistry Head CT-Scan
with contrast

Image
Lab Study
study
M
A • Head up 30o
Non
N pharmacologic • IVFD RL 20 dpm
A therapy
G
E
M • Anti-edemas drugs:
Pharmacologic Dexametason 4 x 4
E therapy mg IV
N
T
 Head CT-Scan without Contrast
Interpretation: (Mandau General Hospital)
Lab
There isn’t soft tissue swelling at extracranial
( January, 24th 2018 in Mandau General Hospital)

Study
Intact visualized bone structure
gray matter matter and white matter are not
firm
the lateral ventricle
Blood WBC narrowed
: 11.270 /ul
Routine
Midline shift to dextra
Jan, , 24
Visible
th Hb
inhomogen
: 11,6 g/dl hipodens –
lession
2018 in
Permata Hati’s
hiperdens, Ht
amorf : 33 %
shaped, borderless, irregular
Hospital
edge, size 40-60 PLT at the left frontal lobes.
: 174.000/ul

Blood
Impression: Mass apperance at lobus
Chemis
frontalis sinistra dd astrocytoma high grade
try Glucose : 121 mg/dL
dd/ (Oligodendroglioma
January, 24th Ureum : 25 :mg/dL
2018 in Suggested MRI
Permata Hati’s
Hospital Creatinin : 0,8 mg/dL

Multiple lession at intracranial suspect metastase.

Suggest MRI.
FINAL DIAGNOSE :
SOL ec suspect tumor metastase
FOLLOW UP

Follow up January, 26th 2018

S : Headache unknown, vomit (-), cough (- Motoric : Lateralization to dextra
), fever (-), seizure (-), limb dextra weakness Sensory : Difficult to Interprate
(+)
O Coordination : Difficult to asses
GCS 13 (E4M5V4)
Otonom : Normal
Blood Pressure : 110/80 mmHg
Heart Rate : 86 bpm Reflex physiology : Normal
Respiratory Rate : 20 x/min Reflex pathologic : Positive (babinsky)
Temperature : 36,7 °C A : SOL ec Suspect tumor metastase
P : :
Physical Examination
Thorax : Normal limit - IVFD RL 20 dpm
Abdomen : Normal limit - Dexametason 4 x 4 mg IV
Meningeal Sign : (-) - Consultation with neurosurgery specialist
Cranial Nerve : doll eyes movement (+), - Consultation with VCT
corneal reflex (+)
FOLLOW UP

Follow up January, 27th 2018 Motoric : Lateralization to dextra

Sensory : Difficult to Interprate
Coordination : Difficult to asses
Otonom : Normal
S : Headache unknown, vomit (-), fever (-), Reflex physiology : Normal
seizure (-), limb dextra weakness (+) Reflex pathologic : Positive (Babinsky)
O
GCS 13 (E4M5V4) Consult neurosurgery specialist : multiple
Blood Pressure : 120/70 mmHg lession at intracranial suspect metastase.
Heart Rate : 86 bpm Suggest MRI.
Respiratory Rate : 20 x/ min
Temperature : 36,7 °C Consult VCT : Focus non reactive

Physical Examination A : SOL ec suspect tumor

- Thorax : Normal limit metastase
- Abdomen : Normal limit P :
Meningeal Sign : (-) - IVFD RL 20 dpm
Cranial Nerve : doll eyes movement (+), - Dexametason 4 x 4 mg IV
corneal reflex (+) - Ranitidine inj 2 x 1 amp
- Check tumor marker
FOLLOW UP

Follow up January, 29th 2018

Motoric : Lateralization to dextra
S : Headache unknown, vomit (-), fever (-),
Sensory : Difficult to Interprate
seizure (-), limb dextra weakness
Coordination : Difficult to asses
Otonom : Normal
O : GCS 14 (E4M5V5)
Reflex physiology : Normal
Blood Pressure : 120/80 mmHg
Reflex pathologic : Positive
Heart Rate : 88 bpm
Respiratory Rate : 20 x/ min
A : SOL ec Suspect tumor metastase
Temperature : 36,9 °C
P :
- IVFD RL 20 dpm
Physical Examination
- Dexametason 4 x 4 mg IV
Thorax : Normal limit
Abdomen : Normal limit
Patient exit from hospital by request
Meningeal Sign : (-)
(PAPS)
Cranial Nerve : doll eyes movement (+),
corneal reflex (+)
DISCUSSION
 Case Report DISCUSSION

SOL is a extended lesion in brains

including tumor, hematoma and
abscesses.
 Case Report DISCUSSION

Brain Tumor

Classification

Primary Secondary
tumor tumor
Case Report DISCUSSION
 Case Report DISCUSSION

Metastase
Tumor
Cerebral metastases have spread to the brain from
cancer cells in other organs in the body.

 Lung cancer is 48%

 Breast cancer 21%
 Geniturinari 11%
 Skin cancer (melanoma) 9%,
 Gastrointestinal cancer 6%
 Head and neck cancer 5%.
 Case Report DISCUSSION

Changes in mental
Clinical status

Symptoms Headaches

Vomiting

Seizures
 Support
CT scan MRI
examination
Management

Anticonvulsi Cerebral edema

Radiotherapy Chemotherapy

Operation
BASIC DIAGNOSE
Basic clinical Basic
diagnoseclinical diagnose
Anamnesis
Lost of chronic Status mental
consciousness seizure change
Progressive Headache

Physical examination
Reflex Patologis (+)
Lateralization to dextra
babinsky

Increased intracranial pressure syndrome

This is in accordance with symptoms of increased intracranial pressure, there are Triassic of increased
intracranial pressure like headaches, vomiting and deficite neurology. Intracranial pressure is influenced
by three factors, namely the volume of brain tissue, cerebrospinal fluid and blood volume.
Basic topic diagnose

Lost of consciousness
Increased intracranial pressure syndrome
Seizure
Progressive Headache
Status mental change

The suspected topic diagnose in this case is in

cortex cerebri regio lobus frontoparietal sinistra.
Sign of brain tumor depends on true localizing sign
from that lession such as frontoparietal lobe will be
happen deficit neurology and contralateral
hemiparesis.
Basic etiological diagnose

SOL ec Suspect Confirmed by

Primary brain
tumor metastase
Tumor

- Deficit neurology
(+) Its proven by
radiology imagine
that there are MRI
- in physical multiple lession at Tumor Marker
examination there intracranial suspect
wasn’t find metastase
abnormalities
Basic differential diagnose

• Brain tumor • Patient didnt have

• Abscess sign of infection
• metastase such as fever or
focal infection, and
non reactive of HIV
Increase Brain abscess
intracranial may not
pressure suitable.
Basic of supportive examination

Labor • knowing risk factors whether infection exists, and knowing the general condition of the
atory patient.

Chest
X-ray to see the existence of a specific process, the primary tumor in the lung.

Head ct see a cross-section of the brain as whole which related to patient’s

scan complained

Knowing HIV status in this patient and if positive HIV, it could be

VCT
treated as soon as

MRI To know the location of tumor

Basic management

Non pharmacologic therapy: Pharmacologic therapy:

 Head up 30o : to prevent • Dexamethason 4 x 4 mg I.V

aspiration : to reduce brain edema.
 IVFD RL 20 dpm: to maintain the
state of euvolemic
Thank You