A case of bilateral visual loss

Posted by Dr. Thamburaj Dr. Thamburaj
A 38 years old right handed Bangladeshi lady came to us with the complaints of
1. Sudden  diminution  of vision in both  eyes, since last  6 months.
2. Difficulty in balancing while walking and tendency to fall towards left side, since last 6 months.
3. Numbness over left half of face  since 4 months.  
4. Heaviness of head on and off.
Patient was apparently alright 6 months ago. In the 3rd trimester of her last  pregnancy about 6 months back she had sudden deterioration of her vision in both eyes and also developed unsteadiness of  gait  which was gradual  in  onset. After  the delivery  she  didn't  improve vision wise.
There was no history of any redness, excessive lacrimation, abnormal protrusion of the eyes or retro orbital pain, double vision, headache, swelling of extremities altered sensorium or seizures.
However, her hospital records revealed that she has had antihypertensive medications (?pre eclampsia) in the past.
She noticed imbalance while walking with a tendency to fall towards the left side, which was gradual in onset and progressive in course. There was no associated with any giddiness or vertigo.
She was able to appreciate the texture of the floor.
There was no difficulty in walking in low light.
She was able to take her food to the mouth.
There was no history of any change in voice or cough during drinking liquids.
The  numbness over the left half of face started about 4 months ago.  It was gradually worsening.
It was constant, and not precipitated by cold air, water or touch.
It was not associated with facial weakness or difficulty in closing the eye or pain.
She was able to appreciate heat and cold, but not as much  as  on right half of face.
There was no difficulty in chewing the food.
Her hearing in the left ear started reducing at the same time. No history of any ringing sensation in the ear.
On and off, she used to complain of heaviness of head.
There was no  history of vomiting, seizure, loss of conscious, or weakness or sensory blunting in the limbs.
There was no speech  dysfunction or sphincteric dysfunction.
She was not a known diabetic or asthmatic. There was no history of any other major systemic  illness.
There was no history of such complaints in her near relatives.
On examination, she was conscious, alert and oriented, with normal higher intellectual functions.
Her pupills were equal and reacting to light, and ocular movements were full.
Her fundi revealed blurred disc margins bilaterally.
Visual acuity was 2/36 bilaterally.
Reduced sensation in all the 3 divisions of left fifth nerve, with no motor involvement.
There was sensorineural deafness in left ear.
Other cranial nerve functions were normal.
Long tract signs were normal with normal DTRs, and down going plantars bilaterally.
Cerebellar signs - Minimal finger nose in-coordination on  left side.
Gait - Sways towards left side while walking.
Rombergs sign - Negative.
There was no neck stiffness.
Skull and spine - NAD.

MRI brain (plain and contrast.)  revealed thickening of the intracranial portion  of both optic nerves and chaisma.
Two enhancing  lesionin  the cerebellum, one in the left cerebellar vermis and pons junction.
The  left  cerebellar hemispheric lesion was predominantly cystic.
Routine ultrasound abdomen had revealed a mass lesion in the head of pancreas. So a diagnosis of possible carcinoma  of the head of pancreas with metastasis to  brain  was thought of CT guided biopsy of the lesion done. This came as non contributory.
At this stage patient was referred to us.
We  had  the  following differential diagnosis in our mind at that stage
1. Carcinoma pancreas with multiple brain metastases.
2. Multifocal tuberculosis with infiltrative optic neuropathy.
3. Lymphoma
4. Multicentric glioma
5. Neurofibromatosis-optic Nerve glioma with cerebellar astrocytoma
6. Multiple infarcts as a complication of pre eclampsia.

As her neurological status was deteriorating rapidly, a biopsy of the brain lesions was planned for further management.

She  underwent a left suboccipital craniectomy.  The dura was lax.  
The  peripheral  lesion  of the left  cerebellar  hemisphere  was tapped. Thick dirty yellow colored fluid came out. The  solid portion of  the  tumor was  soft  and   relatively vascular.
Macrosopic total excision of the lesion done.
The histopathologic report was as grade III - Grade IV astrocytoma.

Multifocal gliomas can be categorized as
   'Connected' (microscopic parenchymal connection or satellite lesions) or
   'Disconnected' (no detectable microscopic connection)' and as
   'Synchronous' (if present on initial presentation) or
   'Metachronous' (if developed during follow-up).
They are termed
   'multiple', if present at the same time but are separate spatially, and
   'multicentric', if they are independent spatially as well as temporarily.

Although multiple astrocytomas may arise independently within a single patient, the majority are probably represent the presence of a single neoplastic disease. Reportedly, the multifocality occurs in 2.3% bto 9.1% of cases.


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Adrian  Mattes, M.D. Adrian Mattes, M.D.
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Re: A case of bilateral visual loss

    A very nice, interesting case indeed. There may be a lot of things that can be done, like to research, study the reason of the multifocal astrocytomaIII-IV; also why same patients have the tendency to have multiple tumors(pancreas , and cerebellar, etc), is this related to Genetics ?, Imunologic deficiencies ?, etc, etc.
   Maybe when they diagnosed her before the Pancres tumor, they could did her a "screening", and find out the cerebellar lesions before.  Would be possible in the future to have a test to screen for future tumors of the Brain, etc ?
Dr. Thamburaj Dr. Thamburaj
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Re: A case of bilateral visual loss

In reply to this post by Dr. Thamburaj
thanks for your input