A 22-year-old, right-handed housewife presented to the hospital with complaints of headache of 15 days duration. Headache was generalized, intermittent in duration, aching in nature, associated with vomiting and visual obscurations, especially while changing positions. These symptoms aggravated in morning hours. There was also history of single episode of generalized tonic-clonic seizure 10 days back, after which the patient was started on anticonvulsants and there were no further episodes. Patient also noticed weakness of the right upper limb since last 8 days, which was gradual in onset and progressive in nature. Weakness was more significant in the left hand as compared to the left shoulder. There was also history of drowsiness since last 2 days.
On neurological examination, the patient was conscious, cooperative, and well oriented in time, place, and person with normal higher mental functions. Visual acuity was 6/9 in both eyes. Fundus was showing grade 1 papilledema on both sides. The rest of the cranial nerves' examination was normal. Nutrition and bulk was normal in all four limbs. Tone was increased on the right side. Power was 4+/5 in the right shoulder and 4/5 in the right elbow and right wrist. Grip was weaker on the right side as compared to the left side. Rest of the limbs had normal power. Sensory examination did not reveal any abnormality. Reflexes were brisk in the right upper limb, rest were normal. Gait was normal. Plain radiograph of the skull was normal.
Computed tomography (CT) scan [Figure 1] showed a lesion of 3.4 cm x 2.4 cm in size with well-defined margins and multiple foci of calcification in the left fronto-parietal region. The lesion was strongly enhancing inhomogenously on contrast administration with surrounding perifocal edema and mass effect suggestive of glioma or tuberculoma.
Magnetic resonance imaging (MRI) [Figure 2] scan was suggestive of a thick ring-enhancing lesion seen in the left high parietal region with perifocal edema with mass effect suggestive of granulomatous lesion, most likely tuberculosis.
CT angiography [Figure 3] showed a small lesion in the left high parietal region with increased vascularity.
Patient was operated with left parietal craniotomy with total excision of lesion. The tumor was adhered to the undersurface of dura. The tumor was dark brown in color, necrotic, and solid with increased vascularity. There were feeders from the periphery. The brain was edematous and pulsating well. Lax duraplasty was done using pericranium. Tumor was excised in toto.
Postoperatively, the patient recovered well. She was relieved of headache completely and there were no further episodes of vomiting or seizures. The right upper limb weakness improved to 4+/5. The blurring of vision also improved gradually. There was no new neurological deficit postoperatively.
Postoperative CT scan [Figure 4] showed complete excision of the lesion.
The patient was discharged on 10th postoperative day without any neurological deficit.
Neuropathological [Figure 5] examination showed a tumor composed of peripherally arranged tumor cell in sheets and syncytium. These were large cells having moderate eosinophilic to clear cytoplasm with dense hyperchromatic nuclei and increased nucleocytoplasmic ratio and prominent macronucleoli. The tumor showed mitotic activity of about 1-2/high power field, and extensive areas of necrosis and hemorrhage suggestive of primary choriocarcinoma of the left parietal lobe.
In view of the diagnosis of choriocarcinoma, the patient was investigated extensively for the detection of the primary lesion. b-Human chorionic gonadotropin (b-HCG) was 20,000 IU. Gynecology opinion was taken Patient was pregnant once and had delivered full-term baby vaginally 2 years back without complications. Past and present menstrual history was normal. Transvaginal ultrasound was normal. X-ray chest was normal. CT scan abdomen and pelvis did not reveal any abnormality.
The patient has been referred to another specialized institute for adjunctive treatment. She has been following up regularly with evidence of widespread metastasis over a period of 6 months.