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.
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.