History and Physical
A 10-year-old boy presented with sudden-onset seizures, characterized by staring and right-hand twitching. After the seizures, he was sleepy but otherwise neurologically intact. He had experienced headaches for several days before. Prior medical history included absence seizures without convulsive features at 2 years of age, controlled with sodium valproate. He had a normal birth history and was otherwise well.
The patient developed several additional episodes of seizures, upon which he was intubated and transferred to the intensive care unit for stabilization. Following extubation, his clinical examination was normal including cranial nerve examination and fundoscopy, and he was discharged.
Several weeks later, he returned with worsening seizures, now with an aura of epigastric discomfort and postictal confusion and short-term memory dysfunction.
Diagnostic Workup
EEG indicated seizures arising from the left temporal lobe. Empiric IV acyclovir was started without clinical response and with increasing seizure burden.
Lumbar puncture demonstrated acellular sterile CSF. Herpes virus (HSV) polymerase chain reaction (PCR) and antibody panel were negative.
Head CT at presentation showed subtle hypodensity in the left temporal lobe ( Fig. 45.1a ). MRI 6 days later ( Fig. 45.1b ) showed expansile T2 hyperintense signal in the left anterior temporal lobe cortex and white matter without enhancement, restricted diffusion, or hemorrhage.
Diffuse astrocytoma. (A) Head CT demonstrates subtle expansile hypodensity in the left anterior temporal lobe ( arrows ). (B) Brain MRI, axial T2 shows expansile hyperintensity involving left temporal cortex and subcortical white matter ( arrow ). (C) Follow-up 2 months later shows tumor progression with greater mass effect and extent ( arrows ).
