Glioblastoma
Patient Presentation:
C.O., a 56 year old male patient presented via EMS to the ED with a new onset of a full tonic-clonic seizure lasting about one minute as witnessed per wife. The patient was intubated in the field for airway protection and brought in. A CT scan was ordered immediately. He is an obese male with a past medical history of hypertension, hyperlipidemia, hypogonadism, obstructive sleep apnea and diabetes mellitus. The patient presents postictal, and is not responding to any painful stimulus. The CT shows a large frontal hypodensity with mass effect and shift. The patient is sent to the neuroscience intensive care unit for further evaluation.
Differential List:
Because on CT scan the lesion reported was hypodense we can rule out new hemorrhage. Current diagnosis could be a tumor, a large ischemic stroke, or cyst.
Diagnosis:
C.O. was sent for an MRI/MRA with brain lab protocol where they could map the mass, which was then deemed to be a tumor. Because the mass reached across hemispheres it was suspicious for a high grade astrocytoma or glioblastoma. Further differentiation would have to done by the pathologist once the tumor was resected. A right frontal craniotomy was scheduled for the following day. The patient was started on 3% sodium chloride for a sodium goal of 150-155 to help control cerebral edema. The patient had 2 more seizures that evening. A Keppra® 1 gram bolus was given intravenously and 1.5 grams scheduled b.i.d.. High doses of dexamethasone are given to help decrease swelling.
Treatment:
The immediate treatment for the patient was to remove the tumor via craniotomy and precise excision using brain lab, a mapping system that allows edges of tumors to be mapped while in surgery, assuring that all tumor tissue is taken out. Antiepileptic medications will be continued throughout the patients stay, and can possibly be weaned during recovery months later. If more cerebral edema is expected, the 3% sodium chloride IV will be continued and monitored under an ICU setting. Mechanical ventilation will be weaned after the surgery as the patient becomes more alert. The patient will be placed on a dexamethasone taper over several weeks to continue to manage postoperative swelling.
Outcome:
The immediate frozen pathology came back during surgery as a high grade glioblastoma. While in the post anesthesia care unit, the patient had a 6-minute seizure that was only broken by high doses of lorazepam. Mechanical ventilation remained necessary. Continuous EEG was ordered immediately to help to monitor any seizure activity that the patient might have. Sedation was continued during the night and ordered to not be weaned for accurate neurological checks until further notice. The patient was seizure free for 24 hours, and sedation and mechanical ventilation were weaned with time. Once the patient progressed to following commands briskly, moving all extremities and had no seizure, the oral endotracheal tube was removed, and the patient stepped down. It is important that these patients start their radiation and chemotherapy soon after their surgery, and radiation/oncology referrals are made while they are an inpatient before discharge. Due to the glioblastomas cell origin, the astrocyte, the tumor is hard to completely excise, and is rapidly growing. Further management becomes treatment of their symptoms. Many patients go through "de-bulking" or a craniotomy where tumor mass is taken without intention of excising the whole tumor. Currently the median prognosis for an adult patient diagnosed with a glioblastoma is about 12 months after initial diagnosis.
Case created by Courtney Oliver, 2012.