Neurology: Day 17-25

During my days on the Primary Neurology Inpatient service, I had the opportunity to care for this patient (information has been modified to protect patient privacy/confidentiality). She is a 64 year old right-handed female who presented to our emergency department with a complaint of a seizure-like episode. The episode began while she was reading a newspaper; her left hand began to shake, then her left arm, then her left leg, and then spread to all four extremities. During this episode, she was unaware of her surroundings and was unable to respond. This episode lasted for 4-5 minutes, followed by a period of confusion. She then came to our ED. *A seizure of this description can be classified as Complex Partial with Secondary Generalization (if interested in more information regarding seizures, see this blog post.) While at the ED, she noticed weakness of her entire left side, which quickly improved (possibly Todd's Paralysis - a weakness of one side of the body following a seizure).

New onset seizure in a patient can have many different causes. The 4 M's/4 I's: Metabolic, Mass, Missing drugs (alcohol withdrawal), Miscellaneous (Eclampsia, Hypertensive Emergency, Non-epileptic), Infection, Intoxication, Ischemia, or Increased ICP. In her age group, we were initially concerned of a stroke (Ischemia caused). So we ordered a CT and a complete stroke workup, which did not elicit any findings consistent with ischemia as a cause for her seizure. On CT, an area of suspicion was noticed in the right parietal region - what appeared to be edema in an area non-consistent with an arterial distribution. Thus, an MRI was ordered, which revealed a mass in that region. This mass was fairly well demarcated, and a dural tail could be appreciated. This led us to believe that the lesion could be one of two likely etiologies: a metastasis to the dura matter or a meningioma.

The CT-Scan: note the edema (hyperdensity) in the patient's right fronto-parietal region (not localized to an area of arterial distribution):

MRI-DWI (Diffusion-weighted image) - this image is used to investigate the possibility of a recent infarct. It is often used to diagnose a stroke. If a stroke had been present, there would be an area of hyper-intensity that would look bright white, and it would be in the area of an arterial distribution (like the ACA, MCA, or PCA). This MRI-DWI does not show evidence of a stroke:

(If a stroke is present, the MRI-DWI would look something like this:)

The MRI-T1 is used to look for any structural abnormalities.

This patient has hypertensity (on the left image) due to the edema.

On a sagittal section (right image), there is an area of suspician (can you spot it?!)

The MRI-T2 is used to look for areas of hyperintensity.

You can see the edema (left image) and the mass (right image):

The MRI-T2 FLAIR is used to look for regions of hyperintensity which are likely to be pathological.

The MRI-T1 Post-contrast helps to better visualize the pathological lesion. The lesion takes up the gadolinium contrast and enhances the visualization of the lesion.

Note the dural tail (circled in red in the middle image).

This patient subsequently underwent surgical excision of the mass, and pathology has revealed that it is, in fact, a meningioma.If all of the tumor was excised, the likelihood of recurrence is exceedingly low. Good news for this patient! She has done very well post-operatively and is likely to make a full recovery.



Most common primary malignant brain tumor in adults: astrocytoma. Most common primary brain tumor in adults: meningioma.