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Quick Consult: Symptoms Headache, Blurry Vision, Tinnitus, Photophobia

Bergamo, Cara MD; Wiler, Jennifer L. MD, MBA

doi: 10.1097/01.EEM.0000459011.90859.39
Quick Consult

Dr. Bergamois second-year emergency medicine resident at Denver Health Medical Center. Dr. Wileris an associate professor of emergency medicine and the vice chair of the department of emergency medicine at the University of Colorado School of Medicine. Read her past columns athttp://bit.ly/WilerConsult.

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A 57-year-old man presents with three weeks of severe, constant right-sided headache with associated right-sided blurry vision, tinnitus, and photophobia.

A CT head without contrast is shown.

What diagnoses are you considering, and what is the next step in evaluation and management?

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Glioblastoma multiforme (GBM) is the most common primary central nervous system tumor, with an average incidence of 3.19 per 100,000 people. (Cancer Epidemiol Biomarkers Prev 2014;23[10]:1985.) GBM is also one of the most lethal central brain tumors, and is classified as a grade IV glioma (the most aggressive and anaplastic grade) with a one-year survival rate of 35.7 percent and five-year survival rate of 4.7 percent. (Neuro Oncol 2012;14[Suppl 5]:v1.)

Glioblastoma is a heterogeneous malignancy without a specific molecular pathway or environmental factor associated with its development. Epidemiologically, the average age of diagnosis is 64 years, and men are predominantly affected. (Cancer Epidemiol Biomarkers Prev 2014;23[10]:1985.) Positive prognostic factors are diagnosis at a younger age, location in the cerebellum, high performance status, and maximal resection.

Patients usually present with symptoms indicative of increased intracranial pressure, which is attributed to the rapid growth of GBM. These chief complaints can range from headaches, nausea, and vomiting to personality changes, gait imbalance, urinary incontinence, visual changes, or unilateral weakness. (American Brain Tumor Association, 2014; http://bit.ly/1rZ36i5; JAMA 2013;310:1842.)

Symptoms are vast, with no pathognomonic physical exam findings for GBM. A thorough neurological exam, however, is important to establish the extent of neurological deficit prior to resection.

Magnetic resonance imaging with and without contrast is the best way to diagnose a central brain tumor such as GBM. (JAMA 2013;310[17]:1842.) CT scans can identify a mass, but the gadolinium contrast used in MRIs can identify central areas of necrosis with surrounding white matter edema, a characteristic consistent with GBM. Once a brain tumor is suspected, the definitive diagnosis is brain biopsy during surgical resection.

Treatment for GBM begins with maximal tumor resection that is safe for the patient. That is followed by concurrent radiation and chemotherapy, usually with temozolomide (TMZ). The patient then undergoes adjuvant chemotherapy with TMZ. The median survival with surgery alone is six months, which increases to 12.1 months with radiation therapy and chemotherapy. Median survival increases to 14.6 months if the patient is able to undergo adjuvant TMZ. (Surg Neurol Int 2014;5:64.) The heterogeneity of GBM has made developing effective molecular and immunological therapies difficult.

This patient was diagnosed with glioblastoma multiforme, as shown in the MRI, and underwent successful maximal safe resection. He received radiation therapy and chemotherapy with TMZ.

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