Case report
An 18 year-old man presented with a headache for 1 month and limb
weakness for 10 days. He also had slurring of speech and purposeless
laughing while talking over the same duration. On examination, motor
power in the lower limb was 4/5 in all limbs, with increased tone and
exaggerated deep tendon reflexes. Ankle clonus was present. Hand grip
was weak in both hands (Right > Left). A sensory exam
appeared to be intact.
Magnetic resonance imaging (MRI) showed diffuse altered signal intensity
area involving the pons with its asymetrical expansion predominantly on
the left aspect measuring 29 x 32 x 39 mm (Figure 1A-1B). The lesion was
causing dorsal displacement of the floor of the fourth ventricle, with
compression of the middle cerebellar peduncle. This was towards the left
side, was abutting both the basilar artery and its anterior displacement
with normal flow voids. The post contrast image showed thick, irregular,
and heterogeneous enhancement within the expanded pons (Figure 2 A-2B).
Magnetic resonace spectroscopy showed a decrease in NAA and an elevated
choline/ creatinine ratio. The patient was diagnosed with pontine tumor
and underwent a left retrosigmoid craniectomy, and gross total excision
of the tumor was achieved. Postoperative imaging showed complete
resection of the tumor. Histopathological examination was suggestive of
glioblastoma (Figure 3). A customized immunohistochemistry panel was
advised, which revealed immunoreactive Olig-2, Ki-67,ATRX, P53 and
H3K27M.
The patient’s postoperative recovery was uneventful with mild
hemiparesis and facial palsy. The patient was discharged on tenth
postoperative day with satisfactory outcomes and a Karnofsky performance
score (KPS) of 50%. Postoperatively, the patient was then scheduled for
referral to a cancer center for further treatment. However, he
unfortunately passed away in a local hospital while receiving treatment
for pneumonia.