Meningioma

A 43-year-old man was admitted to the hospital with a 2-day history of nausea and vomiting. He vomited about 6 times each day. Cerebral palsy had been diagnosed in childhood; the patient used a wheelchair.

The patient had been evaluated for persistent vomiting a few years earlier at another hospital. At that time, the results of an upper and lower GI tract endoscopic examination were unremarkable. The patient continued to have intermittent episodes of vomiting.

Physical examination was notable for quadriparesis. The patient's motor power was 4/5 in the right upper extremity, 2/5 in the right lower extremity, 3/5 in the left upper extremity, and 1/5 in the left lower extremity. The abdominal examination was unrevealing. White blood cell count; serum electrolyte, amylase, and lipase levels; and renal and liver function test results were normal.

Intravenous fluids were initiated; the patient was given nothing by mouth. Upper GI tract endoscopy was scheduled.

The day after he was admitted, somnolence-which had been attributed to promethazine given for vomiting-developed; it improved somewhat toward the end of the day. There was no electrolyte or acid-base imbalance. An abdominal ultrasound scan was normal.

On the third day, the patient was again somnolent and complained of headache. Because of further weakening in the left arm, he was unable to reach his hand to point to the site of the headache. Upper GI tract endoscopy was postponed.

A CT scan of the brain and subsequent T1- and T2-weighted MRIs revealed a large mass measuring 9.5 × 7.2 cm in the right frontal lobe.

This mass produced uncal and subfalcine herniation with midline shift to the left. It demonstrated uniform intense contrast enhancement after gadolinium administration. The left lateral ventricle was markedly dilated because of an outlet obstruction at the foramen of Monro. A meningioma was suspected.

Drs KoKo Aung and Thwe T. Htay of Texas Tech University Health Sciences Center, Odessa, Tex, write that a central cause of vomiting must be considered, particularly when the evaluation for intra-abdominal pathology is unrevealing. Neurologic examination of a new patient with chronic neurologic deficits is challenging, especially if a detailed description of previous findings is absent. To readily detect new deficits, repeat the neurologic examination and carefully document existing deficits.

The patient successfully underwent surgical resection of the frontal lobe tumor; pathologic examination of the resected mass confirmed the tumor was a meningioma. After the operation, the patient became very alert, the left-sided weakness markedly improved, and the episodes of vomiting ceased.