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CASE REPORT July, 2014

Wahidin Sudirohusodo Hospital


CEREBELLOPONTIN ANGLE TUMOR



By :

WIDYAWAN SYAHPUTRA
Supervisor : dr. Abdul Muis, Sp.S (K)


DEPARTMENT OF NEUROLOGY
FACULTY OF MEDICINE
HASANUDDIN UNIVERSITY
2014

1


CASE REPORT
By : Widyawan Syahputra
Supervisor : dr.Abdul Muis, Sp.S (K)

I. REGISTRATION
Name : Mr. J
Age : 57 years-old
Address : Toli - Toli
Registration number : 66 59 77
Admission date : June 2
nd
, 2014

II. ANAMNESIS
Chief complaint : Severe headache (NPRS 7-8)
It occurred since 2 years ago and worsened recently in 2 months. The pain was felt like
throbbing starting at the back of head and then radiating to all region of head. The pain was
intermittent. The pain wasnt aggravated by activities and could appear anytime but more
often in the morning. The pain was reduced by taking medicine. Sometimes he vomited when
he got headache. He also complaint dizziness everytime he did activities and he was difficult
to take goods and focused with left extremities. Sometimes he felt as if he would have felt
down. Last 1 year, he also complaint buzzing voice together with hearing loss at the left ear.
There was history of hypertension and there was no history of fever, head trauma, diabetic
and heart disease.

III. PHYSICAL EXAMINATION
General status : Looks moderate to severe
Vital sign :
BP : 160/90 mmHg RR : 20 x/minute, thoraco abdominal
HR : 86 beats per minute, regular T : 36,8
0
C
Head : Within normal limit
Eyes : Anemic conjunctiva (-), icteric sclera (-)
Thorax : Lungs : Vesiculer, ronchi -/- wheezing -/-
2

Heart : Regular, sinus rhytm, no murmur
Abdomen : liver and spleen were not palpable

Neurological status:
GCS : E4M6V5
Higher CF : Within normal limit
Meningeal sign : Neck stiffness (-), Kernigs sign -/-
Cranial nerves : Pupils are round isocor 2,5/2,5 mm, Direct Light
Reflex +/+, Undirect Light Reflex +/+
Other cranial nerves: Left nerve VII paresis
Motoric function:
Movement N N Strength 5 5 Muscle tone N N
N N 5 5 N N
BPR

TPR
N N KPR

APR
N N PR HT

B
_ _
N N N N _ _

Dismetria : - / + Romberg test : Difficult to evaluate
Figer to nose : - / + Stepping test : Difficult to evaluate
Finger nose finger : - / +
Disdiadokokinesis : - / +
Heel to toe : - / +

Sensoric function : Within normal limit
Otonomic function : Urinating and defecating are within normal limit

IV. WORKING DIAGNOSIS
Clinical : Chronic headache, vertigo, tinnitus, hearing loss, left ataxia
Topical : Left cerebellar
Ethiological : Susp left cerebellar tumor
3

V. TREATMENT
IVFD RL : 20 drops/minute
Neuroprotector : Citicholin 1 amp/12 hours/IV
Anti oedema : 2 amp 1 amp/6 hours/IV (tapering off)
H2RA : Ranitidin 1 amp/12 hours/IV
Neurotropic : Mecobalamin 1 amp/24 hours/IM
Anti hypertension : Amlodipin 1x5mg

VI. SUGGESTION
Routine blood examination
EKG
AP Chest X-ray
CT Scan kontras & non contrast

VII. SUPPORTING EXAMINATION
Laboratory findings ( January 13
th
, 2014)
Routine blood examination Blood chemistry examination
WBC : 10,21.10
3
/mm3 Glucose ad random : 90 mg/dl
RBC : 5,06. 10
6
/ul Ureum : 17 mg/dl
HGB : 14,0 g/dl Creatinin : 0,70 mg/dl
HCT : 41,0% Uric acid : 3,2 mg/dl
PLT : 370. 10
3
/ul Total Cholesterol : 138 mg/dl
Trigliserida : 139 mg/dl
SGOT : 17 u/l
SGPT : 21 u/l
LDL : 183 mg/dl
HDL : 15 mg/dl


4

Chest X- ray (June 2
nd
, 2014)






























Bronchovasculer is within normal limit
There was no active specific process on both lungs field
Enlarged cor with CTI : 0,58. Elongation and dilatation of aorta
Both sinuses and left diaphragm is good, right diaphragm is at high position
Looks old fracture at right back of costa IV-VI and left back of costa IV,
other bones are intact
Impression : - Cardiomegaly with dilatation et elongation of aorta
- Elevation of right diaphragm
- Old fracture of right back costa IV-VI and left back costa
IV



5

Non contrast CT scan (June 2
nd
, 2014)






















o Looks slight hiperdense mass (40,14 HU) with firm relative boundaries, round shape with
surrounding perifocal oedema at left cerebellar region that suppresses fourth ventricle
and causing dilatation of other ventricular systems
o Sulci and gyri are within normal limit
o No midline shift
o Scanned paranasalis sinus and aircell mastoid are within normal limit
o Scanned Bulbus oculi and retroorbita space are within normal limit
o Bones are intact

Impression : Left intracerebral mass sugestif cerebellar astrocytoma with ventriculomegaly
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Contrast CT scan (June 4
th
, 2014)




















7










VIII. FOLLOW UP
June 3
rd
, 2014 (2
nd
day of treatment)
S : Headache (NPRS 6-7)
Left hearing loss
O Vital sign :
BP : 150/90 mmHg RR : 20 x/minute, thoraco abdominal
HR : 76 beats/minute , regular T : 36,8
0
C
Neurological status:
GCS : E4M6V5
Higher CF : Within normal limit
Meningeal sign : Neck stiffness (-), Kernigs sign -/-
Cranial nerves : Pupils are round isocor 2,5/2,5 mm, Direct Light
Reflex +/+, Undirect Light Reflex +/+
Other cranial nerves: Left nerve VII paresis

o Looks slight hiperdense mass (40,14 HU) with firm relative boundaries, round
shape with cystic lesion inside it. Enhancing post contrast (67 HU) with
enlargement of left internus acusticus canalis, and surrounding perifocal
oedema at left CPA region that suppressed fourth ventricle and causing
dilatation of other ventricular systems
o Sulci and gyri are within normal limit
o No midline shift
o Scanned paranasalis sinus and aircell mastoid are within normal limit
o Scanned Bulbus oculi and retroorbita space are within normal limit
o Bones are intact
Impression : - CPA mass sugestif acoustic neuroma
- Ventriculomegaly

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Motoric function:
Movement N N Strength 5 5 Muscle tone N N
N N 5 5 N N
BPR

TPR
N N KPR

APR
N N PR HT

B
_ _
N N N N _ _

Dismetria : - / + Romberg test : Difficult to evaluate
Figer to nose : - / + Stepping test : Difficult to evaluate
Finger nose finger : - / +
Disdiadokokinesis : - / +
Heel to toe : - / +

Sensoric function : Within normal limit
Otonomic function : Urinating and defecating are within normal limit

Therapy:
IVFD RL : 20 drops/minute
Neuroprotector : Citicholin 1 amp/12 hours/IV
Anti oedema : Dexamethason 1 amp/6 hours/IV
H2RA : Ranitidin 1 amp/12 hours/IV
Neurotropic : Mecobalamin 1 amp/24 hours/IM
Anti hypertension : Amlodipin 1x5mg




9

June 7
th
, 2014 (2
nd
day post VP shunt)
S : Headache reduced (NPRS 2-3)
Left hearing loss
O Vital sign :
BP : 140/90 mmHg RR : 18 x/minute, thoraco abdominal
HR : 88 beats/minute , regular T : 36,8
0
C
Neurological status:
GCS : E4M6V5
Higher CF : Within normal limit
Meningeal sign : Neck stiffness (-), Kernigs sign -/-
Cranial nerves : Pupils are round isocor 2,5/2,5 mm, Direct Light
Reflex +/+, Undirect Light Reflex +/+
Other cranial nerves: Left nerve VII paresis
Motoric function:
Movement N N Strength 5 5 Muscle tone N N
N N 5 5 N N
BPR

TPR
N N KPR

APR
N N PR HT

B
_ _
N N N N _ _

Dismetria : - / + Romberg test : Difficult to evaluate
Figer to nose : - / + Stepping test : Difficult to evaluate
Finger nose finger : - / +
Disdiadokokinesis : - / +
Heel to toe : - / +

Sensoric function : Within normal limit
Otonomic function : Urinating and defecating are within normal limit
10

Therapy:
IVFD RL : 20 drops/minute
Neuroprotector : Citicholin 1 amp/12 hours/IV
Anti oedema : Dexamethason 1 amp/12 hours/IV
H2RA : Ranitidin 1 amp/12 hours/IV
Neurotropic : Mecobalamin 1 amp/24 hours/IM
Anti hypertension : Amlodipin 1x5mg

IX. FINAL DIAGNOSIS
Clinical : Chronic headache, vertigo, tinnitus, hearing loss, left ataxia
Topical : Left CPA
Ethiological : Left CPA tumor (suggestive acoustic neuroma)

X. DISCUSSION

A 57- year-old man was admitted to Wahidin Sudirohusodo hospital with severe headache
that occurred since 2 years ago intermittently and worsened recently in 2 months. The pain was
felt like throbbing starting at the back of head and then radiating to all region of head. The pain
wasnt aggravated by activities and could appear anytime but more often in the morning and
reduced by taking medicine. Sometimes he vomited when he got headache. He also complaint
dizziness everytime he did activities and he was difficult to take goods and focus with left
extremities. Sometimes he felt as if he would have felt down. Last 1 year, he also complaint
buzzing voice together with hearing loss at the left ear. There was history of hypertension and
there was no history of fever, head trauma, diabetic and heart disease. Based on anamnesis and
physical examination, we made diagnosis of this patient with acoustic neuroma.
Acoustic neuroma, also known as vestibular schwannoma, is a benign, slow-growing tumor
affecting Schwann cells of the eighth cranial nerve. It comprises approximately 8%10% of all
intracranial tumors. Schwann cells are peripheral nervous system cells that produce a myelin
sheath around neuronal axons.
1
As this tumor derives from Schwann cells, which lines the vestibular portion of the VIII
nerve. But because of nerve VIII has two parts, namely the acoustic (hearing) and vestibular part
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(balance) as well as the types of benign tumors (neuromas), then the term is more commonly used
acoustic neuroma. Acoustic neuromas grow in the internal auditory canal which then extends to the
cerebellopontine angle (CPA) so that involves nerve 8
th
). The most common symptom is the loss
of hearing in one ear. With increasing size of the tumor, the tumor can cause symptoms due to
compression another important structure in the vicinity, such as the adjacent cranial nerves,
cerebellum and brain stem.
2,3,4,5



Axial slice, internal auditory canal level and cerebellopontin angle. 5=trigeminal nerve,
7=facial nerve, 8=vestibulocochlear nerve, PA=petrosa apex, I AC=internal auditory
canal, CO=cochlea, GG=Ganglion facial nerve geniculatum, ME=middle ear,
EAC=external auditory canal, M= air mastoid cell, SCC=semicircularis canal,
CPA=cerebellopontine angle, SS=sigmoid sinus, 4V=fourth ventricle, Cl=clivus, P=pons,
Cb=cerebellum
3

Clinical symptoms arising in acoustic neuroma is caused due to compression of nerve VIII
cochlear component that goes slowly progressive. There are 3 typical symptoms of acoustic
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neuroma, namely ipsilateral sensorineural hearing loss, tinnitus and balancing disorder. In 95% of
patients showed initial symptoms such as unilateral hearing loss on the lesion side, Cerebellar
symptoms such as ataxia and gait disturbances may occur in the size of large tumors that
encourages the cerebellum. Symptoms can also appear due to compression of a nerve V and give
manifestasion such as face hipestesion and decrease corneal reflex. If the tumor is large enough
occupying the area cerebellopontine angle, it will cause the blocks of liquor flow causing high
intracranial pressure including headache, vomiting and papilledema. Because the location is
adjacent to N.VII it can also give clinical symptom such as facial muscles weakness and tastation
impairment at two thirds of the anterior tongue, but this is rare.
2,3,6
There are 4 stadium of acoustic neuroma :
8



A. Intracanalicular stadium B. Cisternal stadium

C.Compressive stadium D. hydrocephalus stadium
13

In this patient the clinical symptoms are chronic headache, vertigo, tinnitus, hearing loss and
left ataxia. Chronic headache happened due the compression of tumor whereby the tumor is getting
bigger. The growth of tumor also clog the fourth brain ventricle and causing hydrocephalus. This
condition will aggravate headache in this patient because of high intracranial pressure. Vertigo in
this patient happened because of disturbance in vestibular system, tinnitus and hearing loss in this
patient is caused by cochlear component compression of nerve VIII. As we know nerve VIII has
two function, vestibular system for controlling balance and cochlear for hearing system. Cerebellar
symptom such as ataxia gait disturbance in this patient is caused by size of tumor that compress the
cerebellar system.
Management of acoustic neuroma depends on several factors: tumor size, symptoms, patient
age and life expectancy. The ultimate goal is to control the growth of tumor. Secondary treatment
aims to reduce symptoms and minimize complications. The desired outcome is to save hearing
function and fasialis nerve. Acoustic neuroma is a slow-growing tumor; so that conservative
management with periodic MRI is acceptable. In a meta-analysis study, the mean tumor growth
obtained 1.9 mm per year. Unfortunately in some cases the growth of tumor is unpredictable.
Some may shrink spontaneously, while others may grow uncontrolled.
7
In this case, due to continuous severe headache experienced by the patients, we consulted
this patient to neurosurgery department for management of hydrocephalus. After VP shunt, there
was significant reduction of headache in this patient. this condition will also reduce the intracranial
pressure. Neurosurgery planned to remove the tumor soon after the general condition of the patient
getting better. Although definite diagnosis of this patient is from histopathology result, we
convinced with our final diagnosis. We analyzed this patient from anamnesis, physical
examination and supporting examination. The most common tumor in CPA is Acoustic neuroma
(probability 85%) and our analysis support an acoustic neuroma.




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REFERENCES
1. Palmisano S, Schwartzbaum J, Feychting M. Role of tobacco use in the etiology of
acoustic neuroma. American journal of epidemiology; Oxford University Press. June
15, 2012; 175(12): 1243-1251
2. Arthurs B J et al. Gamma Knife radiosurgery for Vestibular Schwannoma: case
report and review of the literature. World Journal of Surgical Oncology 2009, 7:100
3. British Association of Otorhinolaryngologists Head and Neck Surgeon. Clinical
Effectiveness Guidelines Acoustic Neuroma (Vestibular Schwannoma). Spring 2002,
1-21
4. Labuguen RH. 2006. Initial Evaluation of Vertigo in Journal American Family
Physician January 15, 2006 :Volume 73, Number 2
5. Agrawal SK MD, Blevins N H MD, Jackler R K MD. Vestibular Schwannoma and
Other Skull Base Neoplasms In: Otorhinolaryngology 17 Head and Neck Surgery
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Other Skull Base Neoplasms In: Otorhinolaryngology 17 Head and Neck Surgery
Centennial Edition. Bc Decker Inc.2009: 418-426