Case report
An 18 year-old man presented with a headache for 1 month and limb weakness for 10 days. He also had slurring of speech and purposeless laughing while talking over the same duration. On examination, motor power in the lower limb was 4/5 in all limbs, with increased tone and exaggerated deep tendon reflexes. Ankle clonus was present. Hand grip was weak in both hands (Right > Left). A sensory exam appeared to be intact.
Magnetic resonance imaging (MRI) showed diffuse altered signal intensity area involving the pons with its asymetrical expansion predominantly on the left aspect measuring 29 x 32 x 39 mm (Figure 1A-1B). The lesion was causing dorsal displacement of the floor of the fourth ventricle, with compression of the middle cerebellar peduncle. This was towards the left side, was abutting both the basilar artery and its anterior displacement with normal flow voids. The post contrast image showed thick, irregular, and heterogeneous enhancement within the expanded pons (Figure 2 A-2B). Magnetic resonace spectroscopy showed a decrease in NAA and an elevated choline/ creatinine ratio. The patient was diagnosed with pontine tumor and underwent a left retrosigmoid craniectomy, and gross total excision of the tumor was achieved. Postoperative imaging showed complete resection of the tumor. Histopathological examination was suggestive of glioblastoma (Figure 3). A customized immunohistochemistry panel was advised, which revealed immunoreactive Olig-2, Ki-67,ATRX, P53 and H3K27M.
The patient’s postoperative recovery was uneventful with mild hemiparesis and facial palsy. The patient was discharged on tenth postoperative day with satisfactory outcomes and a Karnofsky performance score (KPS) of 50%. Postoperatively, the patient was then scheduled for referral to a cancer center for further treatment. However, he unfortunately passed away in a local hospital while receiving treatment for pneumonia.