A 55-year-old woman is brought to the emergency department due to worsening headaches and right-sided weakness. The patient developed these headaches a month ago and since then has had continuous throbbing pain over the left side of her head that is associated with nausea. More recently, she has noticed increasing difficulty using her right arm and leg. The patient has had no trauma, neck stiffness, fever, double or blurry vision, or photophobia. She recently emigrated from Mexico with her family. She is a retired seamstress and admits to chronic tobacco use for many years. Her temperature is 36.7 C (98 F), blood pressure is 150/90 mm Hg, pulse is 84/min, and respirations are 14/min. Neurologic examination is significant for right-sided pronator drift. A non-contrast head CT scan reveals a partially calcified round extra-axial mass compressing the left frontal lobe, as shown in this exhibit. The mass appears dural-based and homogeneously enhances on post-gadolinium MRI. Which of the following is the most appropriate next course of action in management of this patient?

Question

A 55-year-old woman is brought to the emergency department due to worsening headaches and right-sided weakness.  The patient developed these headaches a month ago and since then has had continuous throbbing pain over the left side of her head that is associated with nausea.  More recently, she has noticed increasing difficulty using her right arm and leg.  The patient has had no trauma, neck stiffness, fever, double or blurry vision, or photophobia.  She recently emigrated from Mexico with her family.  She is a retired seamstress and admits to chronic tobacco use for many years.  Her temperature is 36.7 C (98 F), blood pressure is 150/90 mm Hg, pulse is 84/min, and respirations are 14/min.  Neurologic examination is significant for right-sided pronator drift.  A non-contrast head CT scan reveals a partially calcified round extra-axial mass compressing the left frontal lobe, as shown in this exhibit.  The mass appears dural-based and homogeneously enhances on post-gadolinium MRI.  Which of the following is the most appropriate next course of action in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d92e_e9e6_bc81_a1de8af1a363_MD0003_00 This patient's presenting symptoms and imaging findings are consistent with an expanding intracranial neoplasm. The presence of an extra-axial well-circumscribed or round homogenously enhancing dural-based mass on MRI is strongly suggestive of a meningioma. These tumors usually undergo calcification and can appear hyperdense on non-contrast head CT scan. MRI Meningiomas are considered to be benign primary brain tumors arising from meningothelial cells and are more commonly found in middle-age to elderly women. They can cause significant neurologic symptoms (eg, headache, seizure, focal weakness/numbness) if they become large enough to cause mass effect on critical neurovascular structures. The diagnosis of meningioma is confirmed intraoperatively and the treatment of choice in symptomatic patients is typically complete resection as this leads to a cure in most individuals. (Choice A) Chemotherapy is not considered first-line treatment for meningioma. Chemotherapy may be coupled with surgical resection and radiation in patients with highly malignant primary brain tumors (eg, glioblastoma multiforme, medulloblastoma). It can also be considered in patients with highly chemosensitive metastatic brain disease (eg, due to testicular germ cell tumor). (Choice B) Isoniazid, rifampin, pyrazinamide, and ethambutol may be used to treat tuberculosis, which can cause meningitis and rarely intracerebral tuberculoma in patients from endemic areas (eg, Mexico and other developing countries). Tuberculosis is less likely in this patient given the absence of systemic symptoms (eg, fever, weight loss, night sweats) or chronic cough. (Choice C) CT scan of the chest, abdomen, and pelvis is usually done to look for a primary visceral malignancy in patients suspected of having metastatic brain disease. Brain metastasis, which is more common than primary brain tumor, typically appears as multiple ring-enhancing lesions at the grey-white junction (intra-axial). (Choice E) Whole brain radiation is not indicated for the treatment of meningioma; rather, it is usually considered for the treatment of diffuse metastatic brain disease. Focused tumor radiation (stereotactic radiosurgery) may be considered for partially resected or unresectable meningiomas. Educational objective: The presence of an extra-axial well-circumscribed dural-based mass that is partially calcified on neuroimaging is strongly suggestive of a meningioma. Meningiomas are considered benign primary brain tumors; however, they can present with headache, seizure, and focal neurologic deficits due to mass effect. In such cases, complete surgical resection is recommended. References: Management of meningiomas. (http://www.ncbi.nlm.nih.gov/pubmed/20056312)

A 55-Year-Old Woman Is Brought to the Emergency Department Due