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Puremotor Hemiplegia Secondaryto Brain-Stemtumour

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Puremotor Hemiplegia Secondaryto Brain-Stemtumour J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.38.12.1240 on 1 December 1975. Downloaded from Journal of Neurology, Neurosurgery, and Psychiatry, 38, 1240-1243 Pure motor hemiplegia secondary to brain-stem tumour LAWRENCE P. LEVITT,' DENNIS J. SELKOE, BRUCE FRANKENFIELD, AND WILLIAM SCHOENE From the Divisions of Neurology and Internal Medicine, Sacred Heart Hospital, Allentown, Pa., and the Departments of Pathology and Neurology, Peter Bent Brigham Hospital, Boston, Massachusetts, U.S.A. SYNOPSIS 'Pure motor hemiplegia' is a common stroke syndrome defined by Fisher as paralysis of face, arm, and leg on one side, unaccompanied by sensory signs, visual field defect, aphasia, or apractognosia. It occurs almost exclusively in hypertensive patients and carries a good prognosis. We report a case of a normotensive patient in whom pure motor hemiplegia was the presenting feature, not of a cerebrovascular syndrome, but of a pontine glioblastoma. We note that brain-stem tumours may masquerade as brain-stem strokes. 'Pure motor hemiplegia' is a common stroke Visual fields were full. There was left facial weakness, syndrome defined by Fisher and Curry (1965) as left hemiparesis, left hyperreflexia, and a left Bab- guest. Protected by copyright. paralysis of face, arm, and leg on one side, un- inski sign. Sensory examination was normal to pin, accompanied by sensory signs, visual field de- touch, position, and stereognosis. fect, aphasia, or apractognosia. It occurs almost Complete blood count, urinalysis, and electrolytes were normal except for 10,800 leucocytes/mm3. exclusively in hypertensive patients, and carries a Lumbar puncture showed opening pressure of good prognosis. It is usually secondary to an 300 mm water, closing pressure of 180 mm with infarct in the pons or internal capsule of the 1,952 leucocytes/mm3 (58% polymorphonuclear brain. cells, 42% mononuclear cells), protein 0.74 g/l, and glucose 4.11 mmol/l. Gram stain and India ink CASE REPORT preparations were negative; bacterial, fungal, and tuberculosis cultures showed no growth. EEG, skull R.M., a 60 year old married woman with no pre- radiograph, and brain isotope scan were normal. ceding history of hypertension, was admitted to The patient was treated with intravenous ampi- Sacred Heart Hospital because of the sudden onset, cillin, and what had been assumed to be a meningitis over a one-hour period, of weakness of her left arm cleared. Repeat lumbar puncture one week later and left leg. During the preceding month she had showed only 9 lymphocytes/mm3; protein and sugar complained of sore throat and fever, and was treated were normal. She was discharged and remained with oral tetracycline for pharyngitis by her local stable for the next two months, when she had a physician. Two weeks before admission, she had sudden onset of diplopia and was found to have a http://jnnp.bmj.com/ shaking chills, myalgias, and headaches. The anti- left sixth nerve palsy. Over the next two months she biotic was changed from tetracycline to cephalo- developed progressive ataxia of gait, dysarthria, and sporin, but the chills, fever, and headache persisted. further weakness of her left limbs. Vertical nystag- On admission, blood pressure was 160/80 mmHg; mus appeared and a diminished gag reflex and dys- pulse 90 per minute; respirations 22 per minute, and phagia. A four-vessel cerebral angiogram was per- temperature 383°C. General physical examination formed and was normal. She continued to deteri- was normal except for a basal systolic ejection mur- orate and died six months after her initial admission. mur and pain on neck flexion. Neurological exam- ination showed a normal mental status without on September 29, 2021 by denial or impersistence. Language function, memory, NECROPSY Findings at necropsy included a large judgement, and calculation ability were intact. pulmonary embolus which was considered to be the immediate cause of death. The basis pontis, sur- 1 Address for reprint requests: Dr Levitt, Division of Neurology, Sacred Heart Hospital, 4th and Chew Streets, Allentown, Pa. U.S.A. rounding structures, and meninges were replaced (Accepted 16 July 1975.) and infiltrated by a diffuse, focally necrotic mass 1240 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.38.12.1240 on 1 December 1975. Downloaded from Puire motor hemiplegia secondary to brain-stem tumolur 1241 r .:.~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~........~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~... guest. Protected by copyright. FIG. 1 Glioblastoma multiforme ofthe basis pontis with area ofold necrosis on the right side (arrow). The basilar artery (B) is surrounded but not occluded by tumour. http://jnnp.bmj.com/ on September 29, 2021 by FIG. 2 High power view of section taken from the right basis pontis showing tumour cells (above) and necrosis and fibrosis within the glioblastoma (below). Haematoxylin and eosin, x130. J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.38.12.1240 on 1 December 1975. Downloaded from 1242 Lawrence P. Levitt, Dennis J. Selkoe, Bruce Frankenfield, and William Schoene which compressed the fourth ventricle and encased McLaurin and Helmer (1962) reported 22 cases the basilar artery (Fig. 1). of brain tumours misdiagnosed during life, in- Microscopic sections showed pseudo-palisading, cluding two primary brain-stem gliomas clini- hypercellularity, pleomorphism of giant cells, and cally diagnosed as basilar artery occlusions. The endothelial proliferation which was diagnostic of authors described several cases in which cerebral glioblastoma multiforme (Fig. 2). Regions ofnecrosis thromboses were incorrectly diagnosed and the and fibrosis were most prominent in the right basis patients were anticoagulants in the absence pontis, within the tumour mass (Figs 1 and 2). The giv-n basilar artery, though surrounded by tumour, was of arteriography with resultant fatal complica- not occluded. In the medulla, the right pyramidal tions. tract showed a loss of myelin and also some infiltra- In an angiographic series reported by Silver- tion of tumour. Examination of the cerebral and stein (1965), the clinical histories of 280 patients cerebellar hemispheres and remaining brain-stem with presumed occlusive cerebrovascular disease showed no infarct or tumour. The meninges over the were carefully analysed before angiography and cerebral hemispheres were thin without inflamma- any cases felt to have signs of subacutely pro- tion. Slight atherosclerosis was seen. gressive or non-vascular disease were removed from the series. Nonetheless, 5%o of the patients DISCUSSION were discovered at angiography to have mass lesions as the explanation of their symptoms. Fisher and Curry (1965) noted that pure motor Progression of signs after 'stroke' is usually the hemiplegia, involving face, arm, and leg, is the clue to the mistaken diagnosis. Failure of the result of contralateral infarction of either the process to respect vascular territory may be guest. Protected by copyright. posterior limb of the internal capsule or the another clue to the presence of brain tumour basis pontis. In both places, the motor fibres to rather than stroke. these body parts are closely grouped together and Intramedullary tumours of the brain-stem are amenable to interruption without other clinical most commonly encountered in childhood but signs. Fisher and Curry (1965) indicated that are well known in adults as noted by Barnett thrombosis is probably the responsible vascular and Hyland (1952) and White (1963). Involve- process. The present case illustrates that a patient ment of the pons with glioblastoma multiforme with glioblastoma of the pons with necrosis pre- in adults, though rare, has been previously re- dominantly on one side can present as a 'pure ported by Masucci et al. (1966). The occurrence motor hemiplegia' without a history of hyper- of a brain-stem neoplasm simulating one of the tension. It seems reasonable to assume in our lacunar stroke syndromes has not been, to our case that the necrosis in the pons was secondary knowledge, reported previously. The importance to the glioblastoma, especially since neither in- of this potential diagnostic error is heightened farcts nor lacunes were found in the cerebral or by the good prognosis usually given for patients cerebellar hemispheres. with lacunar strokes, and the tendency not to The similarity of our patient's presentation to perform angiography in these cases. The de- that of the vascular pure motor syndrome led to velopment of computerized transaxial tomo- an error in initial diagnosis. It was not until the graphy may provide a safe, non-invasive method http://jnnp.bmj.com/ progression of cranial nerve signs that it was to assist in correctly diagnosing similar cases. realized that the process was neoplastic. Confu- With this case, we note that 'pure motor' hemi- sion of brain tumours with cerebrovascular plegia need not be a 'pure' vascular syndrome disease has been described and cautioned against and that brain-stem tumours may masquerade in the past. Elsberg and Globus (1929) reported as brain-stem strokes. 37 cases of 'acute brain tumor' in which patients experienced a sudden neurological deficit, usually REFERENCES on September 29, 2021 by cent of a hemiparesis or aphasia. Eighty per Barnett, H. J., and Hyland, H. H. (1952). Tumours in- their patients had glioblastoma multiforme at volving the brainstem. Quarterly Journal of Medicine, 21, necropsy. Moersch et al. (1941), noted that one- 265-284. Elsberg, C., and Globus, J. H. (1929). Tumors of the brain third of their patients with necropsy proved with acute onset and rapidly progressive course. Archives glioblastoma were diagnosed clinically as strokes. ofNeurology and Psychiatry, 21, 1044-1078. J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.38.12.1240 on 1 December 1975. Downloaded from Pure motor hemiplegia secondary to brain-stem tumour 1243 Fisher, C. M., and Curry, H. G. (1965). Pure motor hemi- Moersch, F. P., Craig, W. M., and Kernohan, J. W. (1941). plegia of vascular origin. Archives ofNeurology, 13, 30-44. Tumors of brain in aged persons. Archives of Neurology McLaurin, R.
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