Pitfalls in diagnosis Te two cases presented here highlight some of the pitfalls in the diagnosis of brain tumours.
Case 1 A 54-year-old woman had been attending her GP for over 10 years and periodically pointed out a lump on her head which was increasing in size. She was reassured and told it was a lipoma despite being hard. Te lump increased in size and over a period of three months she started to develop progressive weakness of her leſt leg. She mentioned this to a general surgeon who was seeing her for an unrelated problem and he found a bony lump in the parietal region. An MRI scan was organised which showed a large parasagittal meningioma associated with a large overlying bony exostosis (Fig. 1). Following neurosurgical referral, the lesion was excised and she made a good recovery.
Learning points:
• Lesions of the skull may be associated with underlying intracranial pathology.
•
Investigation or referral should occur in the face of a lesion which is changing in size.
Fig. 1 A coronal MRI scan which shows a large mass lesion aris- ing from the skull vault which is associated with an underlying parasagittal menin- gioma.
• Earlier referral would have resulted in the lesion being detected before it had started to cause neurological deficit.
Case 2 A 72-year-old man presented with a two-week history of headache and had a grand mal fit which brought him to hospital. A CT scan was performed which showed a mass lesion with irregular ring enhancement (Fig. 2). His case was discussed at the local neuro-oncology MDTmeeting where it was held that the radiological appearances were more in favour of an abscess than a malignant tumour and immediate transfer for biopsy
Fig. 2 A contrast-en- hanced CT brain scan showing an irregular ring-enhancing mass le- sion in the frontal re- gion which turned out to be an abscess rather than a high-grade glioma.
DIAGNOSIS When to consider the diagnosis of intracranial tumour
• Headache arising in a person with no history of headache that persists especially if associated with
• Progressive neurological deficit. nausea.
• New onset of epilepsy or alteration of pre-existing epilepsy.
• Visual disturbance not explained by refractive error.
was recommended. Unfortunately, due to problems with communication this did not occur and he remained at the local hospital where it was assumed that no action was advocated as the lesion was a malignant brain tumour with a hopeless prognosis. He deteriorated and died four days aſter the MDT meeting and at autopsy, a brain abscess which had terminally ruptured into the right lateral ventricle was found.
Learning points:
• Neither CT nor MRI scanning is tissue specific. • Communication between clinicians managing patients is vital especially when different institutions are involved.
• Te prognosis of a cerebral abscess and a malignant brain tumour are entirely different and would have been distinguished by biopsy.
Conclusions It is always difficult to provide advice on uncommon conditions, especially when they present in an unusual or atypical manner. Headache is a very common symptom in general practice but brain tumours are rare. It would be completely inappropriate to refer every patient who presents with headache for a specialist opinion on the basis that they might harbour serious intracranial pathology. Are there any pointers or “red flags” which should
arouse suspicion of intracranial tumour and prompt investigation or referral? Remember if you don’t consider the diagnosis you
will not make it! Despite modern imaging techniques, the era of clinical methods is not yet dead. Tere is no substitute for taking a detailed history and performing a thorough physical examination. Persistent or progressive symptoms should always raise suspicion of serious underlying pathology and prompt referral to a neurologist or neurosurgeon.
n Professor Paul Marks is a consultant neurosurgeon at Leeds General Infirmary and Visiting Fellow in Law, St Chad’s College, University of Durham.He also serves as HM Deputy Coroner, West Yorkshire (Western District)
• Symptoms of raised intracranial pressure in a person with a past history of malignant disease.
WINTER 2012
* Te 2007 WHO classification of tumours of the central nervous system. Louis DN et al. Acta Neuropathol (2007):114;97-109
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