Neurology · Year 3 · from Neurology

Case 1: Glioblastoma Multiforme

Patient Demographics

  • Age: 62 years
  • Sex: Male
  • Occupation: Retired accountant

Chief Complaint

"Progressive headaches and weakness in my left arm for 3 weeks."

History of Present Illness

The patient presents with a 3-week history of progressively worsening headaches, initially intermittent but now constant. The headaches are worse in the morning and improve somewhat as the day progresses. He has noted nausea, particularly in the morning, and vomited twice last week. Over the past 2 weeks, his wife has noticed weakness in his left arm - he has difficulty buttoning his shirt and dropped a coffee mug. She also reports subtle personality changes: he has become apathetic, less engaged in conversation, and has made poor financial decisions recently. Three days ago, he had a witnessed generalized tonic-clonic seizure lasting approximately 2 minutes, which prompted this emergency department visit. No prior history of seizures, no significant medical history, non-smoker.

Neurological Examination Findings

Vital Signs:

  • BP: 142/88, HR: 78, RR: 14, Temp: 36.8C

Mental Status Examination:

  • Alert and oriented to person, place; disoriented to date
  • Flat affect, reduced spontaneity of speech
  • MMSE: 24/30 (impaired recall, attention)
  • Impaired executive function on frontal testing

Cranial Nerves:

  • Pupils: 3mm, equal, reactive
  • Papilledema present bilaterally - blurred disc margins
  • Visual fields: Left homonymous hemianopia (incomplete)
  • Facial sensation intact
  • Mild left central facial droop

Motor Examination:

  • Right side: 5/5 throughout
  • Left upper extremity: 3/5 (deltoid through hand intrinsics)
  • Left lower extremity: 4+/5
  • Left-sided pronator drift present
  • Mildly increased tone on left

Sensory Examination:

  • Decreased sensation to light touch, left arm and face
  • Extinction to double simultaneous stimulation on left

Reflexes:

  • Right: 2+
  • Left: 3+ (hyperreflexia)
  • Left Babinski: Extensor

Coordination:

  • Right: Normal
  • Left: Limited by weakness

Gait:

  • Left hemiparetic gait with circumduction

Localization

  • Right frontal-parietal lesion (contralateral motor and sensory deficits, personality changes, left homonymous hemianopia from involvement of optic radiation)

Neuro Workup

CT Head without Contrast (Emergency):

  • Large heterogeneous mass in right frontal-parietal region
  • Surrounding hypodense edema
  • Mass effect with 8mm midline shift to left
  • Effacement of right lateral ventricle

MRI Brain with and without Contrast:

  • 5.2 cm heterogeneous mass in right frontal-parietal lobe
  • Ring enhancement with irregular, thick walls
  • Central necrosis (T1 hypointense, T2 hyperintense)
  • Extensive surrounding vasogenic edema (T2/FLAIR hyperintensity)
  • Mass effect with subfalcine herniation
  • No restricted diffusion in center (unlike abscess)
  • Involvement of corpus callosum ("butterfly pattern" early)

MR Spectroscopy:

  • Elevated choline (cell membrane turnover)
  • Decreased N-acetylaspartate (neuronal loss)
  • Elevated choline/NAA ratio
  • Lipid/lactate peak (necrosis)

Laboratory Studies:

  • CBC, CMP, coagulation: Normal
  • No evidence of systemic malignancy on initial screening

Diagnosis

Suspected High-Grade Glioma (Glioblastoma)

  • Final diagnosis requires tissue confirmation and molecular profiling

Surgical Management

Preoperative Management:

  1. Dexamethasone 10mg IV load, then 4mg q6h - reduce peritumoral edema
  2. Levetiracetam 500mg BID - seizure prophylaxis
  3. Neurosurgery consultation

Surgical Resection:

  • Maximal safe resection performed with:
  • Intraoperative neuronavigation
  • Motor mapping/cortical stimulation (preserve motor cortex)
  • Awake craniotomy considered given proximity to eloquent cortex
  • Gross total resection achieved based on post-operative MRI

Pathology Results:

  • Glioblastoma, IDH-wildtype, WHO Grade 4
  • Histology: High cellularity, nuclear atypia, mitotic figures, microvascular proliferation, necrosis with pseudopalisading
  • IDH1/2 mutation: Negative (wildtype - worse prognosis)
  • MGMT promoter methylation: Present (favorable - better response to temozolomide)
  • EGFR amplification: Present
  • TERT promoter mutation: Present

Adjuvant Treatment (Stupp Protocol)

Concurrent Chemoradiation:

  1. Radiation therapy: 60 Gy in 30 fractions (2 Gy/day x 6 weeks)
  2. Temozolomide: 75 mg/m2 daily during radiation

Adjuvant Chemotherapy:

  1. Temozolomide: 150-200 mg/m2 x 5 days every 28 days x 6 cycles
  2. Tumor-treating fields (TTFields): Considered for maintenance

Supportive Care:

  • Continue dexamethasone, taper as tolerated
  • PCP prophylaxis (TMP-SMX) while on temozolomide + steroids
  • Antiemetics for temozolomide
  • VTE prophylaxis (high risk in GBM)
  • Physical/occupational therapy for left-sided weakness
  • Driving restriction given seizure history

Prognosis Discussion

With Standard Treatment:

  • Median overall survival: ~15-18 months
  • 2-year survival: ~25-30%
  • 5-year survival: <10%

Favorable Prognostic Factors in This Patient:

  • MGMT methylation present (better temozolomide response)
  • Achieved gross total resection
  • Good performance status at diagnosis

Unfavorable Factors:

  • IDH-wildtype (compared to IDH-mutant gliomas)
  • Age >60 years

Clinical Image

Image Description: Sagittal T1-weighted MRI with contrast showing a glioblastoma multiforme with characteristic ring enhancement, central necrosis, and surrounding vasogenic edema.

Attribution: Image from Wikimedia Commons. Public domain. Source: https://commons.wikimedia.org/wiki/File:Glioblastoma_-_MR_sagittal_with_contrast.jpg

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