Altered Mental Status, Fever After Resection of Glioblastoma
Altered Mental Status, Fever After Resection of Glioblastoma
A 54-year-old man with a medical history of hypertension presented to the emergency room after a single, generalized tonic-clonic seizure in August 2002. Work-up at the time included an MRI of the brain that revealed a 3.4 x 3.5 x 3.7 cm, heterogeneous mass with central necrosis in the right frontal lobe and extension into the corpus callosum. No other masses, hemorrhages, or infarctions were identified. The patient received phenobarbital for seizure prophylaxis at that time and experienced no further seizure activity.
He underwent biopsy of the right frontal-lobe lesion in October, and the pathology was compatible with glioblastoma multiforme. Following the biopsy, the patient developed a left hemiplegia and required inpatient rehabilitation. According to his wife, the patient's strength improved significantly during rehabilitation, such that he could walk and had full use of his left arm by the time of discharge.
Of note, during his stay in the rehabilitation hospital, the patient suffered acute shortness of breath, a pulmonary embolus, and associated right lower-extremity, deep vein thrombosis. He underwent inferior vena cava filter placement without difficulty and experienced no further events. In November, he was referred to Johns Hopkins Hospital for tumor resection and further management.
After resection of the right frontal mass, the patient spent an uneventful postoperative night in the neurologic critical care unit (NCCU). He was transferred to the general neurosurgery ward the following day in stable condition and did well upon transfer. However, 2 days later he was found acutely unresponsive and was readmitted to the NCCU. He was afebrile and had normal respirations and oxygenation as well as stable blood pressure. All laboratory values were normal (including cardiac enzymes and coagulation studies), and his echocardiogram revealed no new changes. An emergency head computed tomographic (CT) scan (Figure 1) showed hemorrhage into the resection cavity.
(Enlarge Image)
Head CT shows hemorrhage into resection cavity and ventriculomegaly.
The patient underwent emergency evacuation of the hemorrhage. He tolerated this procedure well and experienced another uneventful and rapid recovery in the NCCU. Two days later he recovered to his preoperative baseline.
The patient was subsequently discharged from the NCCU in stable condition and continued to improve; however, 4 days later he again became acutely unresponsive to verbal stimuli. He grimaced and localized painful stimuli with his right side, had minimal withdrawal to pain in the left upper extremity, and had flexion posturing of the left lower extremity. His temperature was 38.4°C. He was transferred emergently to the NCCU for further evaluation and management.
A 54-year-old man with a medical history of hypertension presented to the emergency room after a single, generalized tonic-clonic seizure in August 2002. Work-up at the time included an MRI of the brain that revealed a 3.4 x 3.5 x 3.7 cm, heterogeneous mass with central necrosis in the right frontal lobe and extension into the corpus callosum. No other masses, hemorrhages, or infarctions were identified. The patient received phenobarbital for seizure prophylaxis at that time and experienced no further seizure activity.
He underwent biopsy of the right frontal-lobe lesion in October, and the pathology was compatible with glioblastoma multiforme. Following the biopsy, the patient developed a left hemiplegia and required inpatient rehabilitation. According to his wife, the patient's strength improved significantly during rehabilitation, such that he could walk and had full use of his left arm by the time of discharge.
Of note, during his stay in the rehabilitation hospital, the patient suffered acute shortness of breath, a pulmonary embolus, and associated right lower-extremity, deep vein thrombosis. He underwent inferior vena cava filter placement without difficulty and experienced no further events. In November, he was referred to Johns Hopkins Hospital for tumor resection and further management.
After resection of the right frontal mass, the patient spent an uneventful postoperative night in the neurologic critical care unit (NCCU). He was transferred to the general neurosurgery ward the following day in stable condition and did well upon transfer. However, 2 days later he was found acutely unresponsive and was readmitted to the NCCU. He was afebrile and had normal respirations and oxygenation as well as stable blood pressure. All laboratory values were normal (including cardiac enzymes and coagulation studies), and his echocardiogram revealed no new changes. An emergency head computed tomographic (CT) scan (Figure 1) showed hemorrhage into the resection cavity.
(Enlarge Image)
Head CT shows hemorrhage into resection cavity and ventriculomegaly.
The patient underwent emergency evacuation of the hemorrhage. He tolerated this procedure well and experienced another uneventful and rapid recovery in the NCCU. Two days later he recovered to his preoperative baseline.
The patient was subsequently discharged from the NCCU in stable condition and continued to improve; however, 4 days later he again became acutely unresponsive to verbal stimuli. He grimaced and localized painful stimuli with his right side, had minimal withdrawal to pain in the left upper extremity, and had flexion posturing of the left lower extremity. His temperature was 38.4°C. He was transferred emergently to the NCCU for further evaluation and management.
