A 13-year-old girl is brought to the clinic due to frequent headaches. She first developed mild headaches a year ago, which were treated intermittently with ibuprofen. Over the last 3 months, the headaches have progressively worsened in severity and now occur almost daily. The pain has awakened the patient from sleep multiple times. She has no chronic medical conditions and takes no additional medications. The patient's growth chart shows that height tracked along the 50th percentile until age 11; today it is at the 5th percentile. Weight remains stable at the 75th percentile. Temperature is 37.2 C (99 F), blood pressure is 110/70 mm Hg, and pulse is 90/min. Examination shows mild optic disc edema. The neck is supple. Cardiopulmonary examination is normal. Strength is 5/5 in the bilateral upper and lower extremities. Sensation is intact. Reflexes are 2+ bilaterally. Finger-nose-finger testing shows no dysmetria. The patient has a normal gait. Sexual maturity rating (Tanner) is stage 1. Skin examination is normal. MRI of the brain for this patient would most likely show which of the following?

Question

A 13-year-old girl is brought to the clinic due to frequent headaches.  She first developed mild headaches a year ago, which were treated intermittently with ibuprofen.  Over the last 3 months, the headaches have progressively worsened in severity and now occur almost daily.  The pain has awakened the patient from sleep multiple times.  She has no chronic medical conditions and takes no additional medications.  The patient's growth chart shows that height tracked along the 50th percentile until age 11; today it is at the 5th percentile.  Weight remains stable at the 75th percentile.  Temperature is 37.2 C (99 F), blood pressure is 110/70 mm Hg, and pulse is 90/min.  Examination shows mild optic disc edema.  The neck is supple.  Cardiopulmonary examination is normal.  Strength is 5/5 in the bilateral upper and lower extremities.  Sensation is intact.  Reflexes are 2+ bilaterally.  Finger-nose-finger testing shows no dysmetria.  The patient has a normal gait.  Sexual maturity rating (Tanner) is stage 1.  Skin examination is normal.  MRI of the brain for this patient would most likely show which of the following?

Quizplus · Accepted Answer

11ec25c8_d6e7_dff7_bc81_a7320b5eb1cb_MD0003_00 This patient has poor linear growth, pubertal delay, and worsening headaches with papilledema, findings concerning for craniopharyngioma. Craniopharyngioma is a benign tumor derived from epithelial remnants of Rathke pouch (within the pituitary stalk) and is found in the suprasellar region adjacent to the optic chiasm. The main complications result from compression of the pituitary stalk and optic chiasm. Due to their slow growth, craniopharyngiomas often cause subtle symptoms for years prior to diagnosis. Pituitary stalk compression often causes panhypopituitarism, which most commonly manifests as growth failure due to TSH or growth hormone deficiency. In addition, hypogonadism from LH and FSH deficiency may cause pubertal delay (eg, no breast development by age 12 in girls). Diabetes insipidus due to antidiuretic hormone deficiency and adrenal insufficiency due to corticotropin deficiency may also occur. Tumor compression of the optic chiasm can cause visual field deficits (ie, bitemporal hemianopsia). In addition, craniopharyngiomas may cause headache from compression of nearby structures or obstructive hydrocephalus. Obstructive hydrocephalus can also cause papilledema (eg, optic disc edema), as seen in this patient. bitemporal hemianopsia On diagnostic MRI, craniopharyngioma classically presents as a cystic or calcified, suprasellar mass. (Choice A) Acoustic neuroma is a benign tumor of the vestibular nerve. On imaging, it appears as an enhancing lesion in the internal auditory canal. Patients are usually adults with hearing loss, tinnitus, and mild ataxia (due to vestibular dysfunction). (Choice B) Brain abscess appears as an intraparenchymal lesion with air-fluid levels and a hyperdense rim on imaging. Patients typically have an acute headache, focal neurologic findings (eg, sensorimotor deficits), and often fever. This patient has chronic headaches with no focal findings, making an abscess unlikely. (Choice C) Patients with tuberous sclerosis complex (TSC) may have subependymal nodules in the lateral ventricles. These nodules can increase intracranial pressure due to obstructive hydrocephalus. However, this patient has no cutaneous features of TSC (eg, ash leaf spot, angiofibroma). (Choice E) Medulloblastoma arises from the cerebellar vermis and presents with vomiting, headache, and cerebellar dysfunction (eg, ataxia, dysmetria). This patient has a normal gait with no dysmetria. Educational objective: Craniopharyngiomas are benign, slow-growing, calcified tumors within the suprasellar region. Tumor compression of the optic chiasm can result in bitemporal hemianopsia, and pituitary stalk compression can cause panhypopituitarism (eg, growth failure, pubertal delay). References: Craniopharyngioma. (http://www.ncbi.nlm.nih.gov/pubmed/24467716) Craniopharyngioma. (http://www.ncbi.nlm.nih.gov/pubmed/21819881)

A 13-Year-Old Girl Is Brought to the Clinic Due to Frequent