Vol. 9, No. 4. SINGAPORE MEDICAL JOURNAL December, 1968. 280 THE DIAGNOSIS OF TUMOUR

By Lee Suan Yew and Gwee Ah Leng (Med. Unit III, General Hospital, Singapore)

It has been long realised that the diagnosis In all neurological clinics, the common techni- of an intra -cerebral tumour is a very difficult ques in use are air and contrast studies. (Dandy one from the point of exact localisation. In 1918; Moniz, 1927). Air studies have now been fact, Cushing mentions specifically that to rely in use for a period of well over 30 years, and on clinical examination alone, the localisation they have proved to be of consistent value both of a cerebral tumour would be erroneous in in showing the midline shifts and in localising about half of the cases. That this is so is because pressure effects that lead to the deformation of of the fact, that an intra -cerebral tumour is one or more of the ventricular chambers the capable of of producing three kinds of effects: brain. It is also of some value in cases of super- firstly the local effect where the tumour by ficial atrophies, and also in showing up the infiltration and destruction, or by pressure and presence of abnormal spaces in the brain, nutritional where deprivation causes some neurologi- air may gain entrance such as in porencephaly cal deficit incidentally indicating the site of the where the cystic lesions are in communication primary lesion; secondly, the tumour may by with the ventricles. However, this has certain its presence occupy space meriting the name, limitations in that it is not without danger if space -occupying lesion in the head, leading to it is done thoroughly, and a thorough air increased intra study -cranial pressure, resulting in will require almost the complete replacement what is known very well as the triad of increased of the cerebral spinal fluid with air. This com- intra -cranial pressure, namely papilloedema, plete replacement with air particularly in the headache, and vomiting: and, thirdly, the presence of increased intra -cranial pressure, tumor may by its presence produce shift and inter- and when done by the lumbar route, is in fact ference with the circulatory dynamics in the a very hazardous procedure. On the other hand, brain of the blood and CSF, resulting in complete replacement with air through the what is known as false localising signs, best ventricular route at an operation is not illustrated by the frequent presence of pyramidal entirely satisfactory, because of the leakage of release, and by sixth nerve palsy. Whereas air, and the difficulty in positioning. In addition, it is common knowledge that there can be three it requires a surgical operation, and is therefore different kinds of aetiologies of neurological not a routine investigation or procedure. Partial deficit following the presence of a tumour, it replacement by air is safer, but is not as in- is however extremely difficult when dealing formative, and attempts have been made to with a case to differentiate one from the other, introduce small quantities of radio -opaque and frequently localisation of a tumour depend- substances together with air in order to obviate ing on clinical examination alone comes to this difficulty, and also to help to outline the grief because of this difficulty. However, it is smaller passages in the such essential that for the purpose of treatment as the aqueduct, where the small amount of air especially of a definitive nature, exact localisa- will sometimes make it difficult to be visualised tion is necessary. This is so because it is known in xray film. to be a very dangerous procedure to open the Dye studies on the other hand has a more on the side opposite to the tumour, and recent history, but it has definite advantages also it is not really possible to have very large in that it displays the arterial and the venous exposures in the skull and hence, to have an system effectively in good inexact localisation will quality arteriograms. render operation or This will mean that any treatment by deep xrays displacement of vessels irradiation extremely or abnormal vascularity hazardous and ineffective. inside the skull will be easily displayed. Since most intra -cranial tu- The advent of new diagnostic techniques mours will do one or the other, then the display has been of considerable importance to the of the presence of a tumour by dye studies can neurologists in that, whereas, clinical local- be very satisfactory indeed. Further, the exact isation is difficult even to the expert, with the anatomy of intra -cranial vessels has been studied use of these new techniques, the localisation very intensively, so much so that it is now can be exact and in fact very frequently accurate. known that the variations of these vessels are 281 SINGAPORE MEDICAL JOURNAL much less than in fact the variations of the being a summation effect of the voltage changes ventricular system as far as asymmetry between of many active foci within the skull. Radio- the two sides is concerned. It means that from isotopic studies on the other hand seem to be the point of localisation, especially in smaller simpler to apply, but the safety from radiation lesions, dye studies will be superior to ventri- is still to be evaluated, and its value is just culogram. On the other hand, certain lesions beginning to be reported and assessed. Thus may display no displacement of blood vessels it seems generally accepted, that it is useful such as an intra -ventricular space occupying if there is a change in the vascularity of the lesion e.g. papilloma of the choroid plexus, or tumour area or if there is abnormal take up areas where there are no big vessels either in of the radio-isotope by the tumour tissue, and the way of arteries and veins, since the capillary that the lesion is at least two centimetres in formation of the brain is such that it is not diameter, and also not near the base of the possible to tell from the general appearence of skull where there are many structures so as to capillaries whether it is normal or abnormal, produce confusion in scanning. especially when the definitions of capillary These considerations will in fact vary with phase in most cerebral arteriograms are such the position of the tumour inside the head, as not to have distinctive features. Dye studies and by and large, it is accepted that for supra- are however, infinitely superior to ventricu- tentorial tumours, air and dye studies are of lography when one comes to study blood vessel great value, EEG is of little value other than malformations, and vascular tumours, because helping in deciding the laterality of the tumour the localisation will be extremely accurate and much as the echo -encephalogram, and radio the nature of the lesion sometimes definitive. isotope investigation is of value in some cases Hence it is that these two techniques constitute but not in others. The following case is reported the sheet anchor of neurological diagnosis, and because it shows an exception to the rule in with their combination, the diagnosis of intra - that the case was clinically suspected to have cranial tumour has become a matter of every a tumour and the air and dye studies were unable day routine, so much so that many neurosurgeons, to substantiate the clinical impression, but the and in fact, even general surgeons, resort to electro -encephalogram was indicative of a neuro -surgical work without having to seek definite lesion at a definite site, and subsequently the assistance of the neurologists. at post-mortem, it was found that the EEG Other techniques include electro -encepha- indication was correct. logram, ultra -sonic echo -encephalography and The patient was a Chinese merchant 52 radio-isotope scanning of the brain. It has been years of age admitted on 21.6.66. He had a a general impression that the echograph is of history of epigastric discomfort for 8 years value only in displaying the shift of midline and was taking alkalis regularly. For two structures and as such, its value in exact dia- months prior to admission, he felt unsteady gnosis is limited. However, it has the distinctive with no definite vertigo, or incoordination, value in that it is non -traumatizing as far as and a month later, he also noted some episodic we know of the intensity of ultra -sonic waves frontal headache, which was constrictive in that we use in diagnosis; and it is easy to carry nature but not disabling, and usually relieved out, hence repeated examinations can be done. by massaging the head. He also noticed that Because of these points, echo -encephalogram his tongue felt stiff and clumsy, and he could will definitely have value in that it can be used not talk well, and his memory for recent events as a screening method in diagnosis prior to the showed deterioration to such an extent that are employment of other techniques which he frequently misplaced articles. not without danger and difficulty. Electro- history of mental and encephalogram has the same advantage as the There was no past physical illness, or trauma to the head, and echo -encephalogram in that it is also non - family history was not traumatic and capable of indefinite repetition, all his personal and but however it is handicapped in that it is more relevant. time consuming, is difficult to do in a restless Examination showed that he had a B.P. of patient, and also the interpretation of electro - 140/80, and was physically normal except in encephalography is much more difficult for the nervous system. He had bilateral early many reasons amongst which may be mentioned papilloedema, no visual field defect. and no the presence of more than one discharging other cranial nerve disturbance that was detect- foci in the brain, and secondly, the picture able. There was a generalised increase of reflexes DECEMBER, 1968 282 r

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which were however equal on both sides. Vertebral Arteriogram: Direct right vertebral Babinski responses downgoing, and abdominal artery puncture. The right posterior cerebral reflexes were present. He had, however, a mild and superior cerebeller arteries are rather impairment of coordination in the right upper narrowed, and appear somewhat straightened limb, but his gait was normal. There was no although this may be within limits of normality. nystagmus. The speech showed a marked naming aphasia. The signs showed rapid deterioration and CONCLUSION within a fortnight, he was hemplegic and bed- There is no obvious space -occupying lesion. ridden. with akinesia, and lethargy. The pa- Appearance of arterio-sclerotic narrowing of pilloedema remained much the same. From posterior cerebral and superior cerebellar arte- then on, he deteriorated steadily until 3 months ries on the right. later, he was tremulous all over, mute and akinetic, conscious but unable to respond to Dr. Yin J. spoken words. He assumed an attitude of flexion in the upper limbs and extension in the lower Lumbar air encephalogram: U.38573. Easy flow limbs in a posture of decerebrate rigidity. of air into the ventricular system. The size and Babinski sign was positive on both sides, and position of the ventricles are normal. The there was an impairment of convergence position of the aqueduct is normal. Size of the with a rotatatory nystagmus in both eyes. The sulci and cisterns are also normal. pupillary reflexes were normal, and the papil- Normal air encephalogram. loedema resolved. He remained in this state till death occurred on 14.1.67-six months Dr. Yu S. F. from time of admission. A premortem diagnosis was made of a Investigation at the time of onset showed progressive parieto-temporal lesion the following: with brain stem involvement-- ?glioma,secondary deposit? Hb, TW, LP - normal encephalitis. The neuro -surgeon was not pre- Chest and skull films normal pared to explore him just for a brain , EEG-high voltage slow waves 3-4/pc bi- and it was thought that in the absence of posi- laterally with right focal discharge tive proof, it would be unreasonable to submit Carotid arteriogram normal the case to deep xray. Vertebral arteriogram normal - After death, post-mortem permission was Lumbar air encephalogram - normal not given, and a brain biopsy was done through C.S.F. enzymes - glutathione the right orbit. The biopsy specimen was re- Reductase normal. LDH 21. - normal. ported by the pathologist as follows: Section Xrays showed gemistocytic astroctoma (Dr. Lee Swee Kok). Skull: B.35760 No radiological evidence of raised intra - SUMMARY cranial pressure, no abnormal calcifica- tion and the pituitary fossa looks normal A brief discussion of the diagnostic aspects --Dr. Boey H.K. of intra -cranial space -occupying lesions was made, and it was recapitulated that the relia- Chest: Normal bility of air and dye studies was usually better Y.40388 than that of electro -encephalogram from the --Dr. Yin J. point of the exact localisation of a lesion. A case was reported however, to show that in Left Carotid Arteriogram: Normal position of the presence of an infiltration tumour, the EEG the anterior and middle cerebral arteries. No was the only abnormality other than clinical avascular areas seen. No areas of abnormal signs, and that air and dye studies both failed vascularity. to demonstrate the lesion.