2019 Research Forum

Applicant: Sarah El-Halees MS IV Principal Investigator & Faculty Sponsor: David Aguirre MD A Case of Gliomatosis Cerebri

David Aguirre MD, Nosheen Hasan MD R3

INTRODUCTION Glioblastoma cerebri is an extremely rare and aggressive brain tumor with resistance to therapy. Its incidence is reported to be less than 100 cases each year in the United States. PURPOSE 49-year-old male with a history of IV crystal meth abuse, ETOH abuse and seizure disorder on Keppra 750mg BID presented to the emergency department for increasing frequency of seizures. DISCUSSION Patient reported having at least 5 episodes daily of seizures that involved upper extremity clenching with subsequent loss of consciousness and urinary incontinence. Seizures were typically followed by 4-5 minute post ictal period. Per patient sister, he was also having daily visual hallucinations for the past 2-3 weeks described to be as patient talking, yelling, and fighting with nonexistent people in an empty room. Medical records were obtained from previous neurological evaluation one-month prior which indicated an unremarkable CT and MRI brain, no epileptiform activity on EEG monitoring and negative CSF fluid analysis for acute infections All labs including urine toxicology were unremarkable on presentation. Overnight, EEG monitoring also indicated no epileptic activity. MRI brain was performed and was notable for multiple areas of subtle white and gray matter T2 and Flair abnormalities in the bilateral frontotemporal lobes, edema appearing in the bilateral frontotemporal areas and basal ganglion, with one discrete small 7 mm enhancing ring lesions in the left temporal area, highly suspicious gliomatosis cerebri type 2. Neurosurgery was consulted for brain biopsy and pathology of the right temporal lobe was positive for diffuse astrocytoma (WHO grade II/IV). Patient was started on Depakote for seizures as well as chemotherapy and radiation for four months. Post radiation treatment MRI brain was repeated but was notable for worsening bilateral frontotemporal hyperintensities, and an enlarging left temporal lesion with three new left frontal enhancing lesions. Oncology referred the patient to neurosurgery for consideration of resection of the astrocytoma, however were unfortunately notified that patient had already deceased. CONCLUSION Gliomatosis cerebri is a rare infiltrating glioma involving multiple contiguous lobes of the brain. Main presenting symptoms are dementia, seizures, and hemiparesis. Diagnosis is made primarily with MRI and histopathologic confirmation of an astrocytic process. Prognosis is poor despite aggressive treatment with 26-52% surviving less than one year. Surgical resection is generally not an option due to multiple lobe involvement, radiation has an unclear benefit, and chemotherapy has no proven efficacy,

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