Expert: Claes-Gustaf Nordquist, M.D. - 7/2/2009

Question
QUESTION: can a lession of 3.6CMx3.7CMx4.1CM in the brainstem cause
ONLY a little double vision in a 6 yrs girl.
she is a very healthy girl, only a little double vision,absolutly no other sysmptoms

Regards

ANSWER: It may cause double vision but there probably should be other symptoms as well. Please copy her MRI & CT brain scan reports here! You should discuss her case very thoroughly with her neurologist! What kind of lesion is it?


---------- FOLLOW-UP ----------

QUESTION: no other symptoms.

Resultats:
fosse  posterieure:   presence  d’un  processus  expansif  heterogene  et  infiltrant  de  4.1CM d’axe transverse  de 3.7CM de hauteur et de 3.1CM d’axe  antero-posterieur  accupant  le tronc cerebral  avec un aspect  exophytique  de la calotte protuberantielle  nottament  en  para-sagital gauche  encastrant  le  tronc  basilaire  qui reste permeable. Cette  lesion  ne  semble  pas s’etendre  vers  les  pedoncules  cerebelleux  moyens  ni  superieurs. Absence d’extension mesencephalique  identifialble. La masse deforme  et  aplatie le plancher du quatrieme ventricule  sans dilatation de l’aqueduc  de silvius. Une  prise  de contraste  ovalaire  irreguliere de 1.3x1CM  est  visible dans la partie anterieure  et  lateral  gauche  de  ce  processus. La  prise de contraste  parait en cocarde irreguliere  et  pourrait  comporter  des residus  hemorragiques en  hyposignal  sur les sequences T2  s’accentuant  sur les sequences  en  diffusion protonique. Une  invagination de la masse exophytique  est  visible  en avant  de l’olive  bulbaire au dessus et en avant de l’abouchement  du segment  V4  de  la  vertebrale  gauche  au tronc  basilaire sans engagement  des  amygdales  cerebelleuses  dans  les  trous  accipitales. Absence  de rehaussement  duro-meninge  pathologique  identifiable par ailleurs.
Etage sus-tentoriel : expansion  normale  et  symetrique  des  ventricules  lateraux sans deplacement  des  structures  medians. Absence d ’anomalie  majeure  du  signal  de la substance  blanche  peri-ventriculaire  sous-corticale.  Integrite  des  noyaux  gris  centraux, du calleva  et du revetement  cortical. Le  sinus sagital  superieur  et permeable.
Conclusion : L’IRM  cerebrale  realisee  avant  et puis  après  injection du produit  de contraste releve  la  presence  d’un  large processus  expansif  et  infiltrant  du  tronc cerebral  deformant le  quatrieme  ventricule  sans dilatation des  cavites  ventriculaire  a l’etage  sus-tentoriel. La masse  comporte  une zone de  rehaussement  heterogene  en cocarde  irreguliere. L’hypothese d’une  lesion  neuro-gliale  et a  soulever  en premier


ANSWER: My French is today rather rusty due to very limited use. However after reading the report I can only say that even in the absence of more symptoms - which at present I can not explain - this is a VERY serious case and you MUST discuss it with a neurosurgeon (which I'm not, I'm a medical oncologist & radiation therapist). The position of the tumor will however probably make any surgical intervention at least very tricky. The tumor is most probably too big for radiological treatment with the GammaKnife and conventional radiation can not cure it - certainly not alone. Please do keep me posted!


---------- FOLLOW-UP ----------

QUESTION: Dear,

when we first discover her little double vision,
the examination of her eyes is perfect,am MRI is requested.
the neurologist read the report, and did not believe that
my daughter is healthy and suggest raditherapy.
the oncologist also dit not believe that little double vision is the only sysmptom. when the oncologist see my daughter he say : let do the radiation therapy to reduce the symptom and we will see. what symptoms i ask?, no response.
we start the radiotherapy with 3 week of decadron.
after taking decadron the double vision is very little and
sometimes cannot be seen. after stopping decadron a little
double vision reoccurs.
today i read that the Epidermoid cysts can exist in the brain stem, and decadron alone is excellent if surgery is unavailable.
Epidermoid cysts can be treated with radiotherapy??
can the result of RMI be wrong??
can the RMI itself be wrong??


i am confused, my girl is now in a dance school,
she go for swimming, she play as normal.

many thanks,


Answer
Thanks! I do understand your concern! This must be terrible for you! It is normal that the double vision should be reduced by Decadron as that medication will reduce any brain swelling. That is also supported by the fact that more double vision returned after reduction of the Decadron dosage. What is described in her MRI report is NOT an epidermoid cyst. No, epidermoid cysts are not treated with radiation therapy - except if small enough (less than 4 cm) they may be treated with the GammaKnife. In the report it is stated - if I read its French text correctly - that her lesion is an infiltrating process and probably a gliomal process. That does NOT fit with an epidermoid cyst - just as I stated above! It does fit however with a malignant brain tumor. I can not guarantee that the report fits what is actually seen in her MRI scans but I find it very improbable that there should be any mistake there. And if there is no mistake there then this can not be an epidermoid cyst! Please do keep me posted and have a new MRI brain scan done after her treatment!