This patient is an engineer by profession. He was working as an electric engineer in gulf countries for about three decades. After retirement he has settled down in Tellichery. Ever since he has been my patient for the treatment of DM and HT. He has not complained of symptoms suggestive of neurological problems until recently. About two years ago one morning he came with a complaint of severe vertigo and nausea. I examined him fully. No altered sensorium. No visual problem. . His gait was normal. No pyramidal or cerebellar involvement noted clinically. After routine investigations I gave him some symptomatic treatment with the advice to take complete rest for a week. After a week he came back fully normal. After examining him again I could not find any abnormality. There was a lurking feeling in me that if he had a small size cerebellar lesion there may not be much elicitable signs. When I suggested for a CT scan brain he immediately agreed to have one. It was a startling revelation. There was an extra axial mass lesion measuring 6.9×6.1×1.9 cm in the right high parietal convexity region extending to the left parietal convexity, extending to both side of the falx cerebri and casing the superior sagittal sinus. Both parietal lobes are compressed and displaced inferiorly.
With this huge lesion he has no symptoms or elicitable signs. What to do with the patient? I put him on phenytoin sodium 100 mg at night purely for prophylactic purpose in addition to the antivertigal medicines which he was already taking from me and referred him to a local neurosurgeon. After seeing these pictures he advised immediate surgery. Then he went to Calicut and consulted another surgeon who also advised surgery. Again the patient came back to me asking my advice. I was in a dilemma. Though anyone who looks at these pictures naturally would advise surgery only, I had my own reservations regarding surgery. Most importantly for a lesion of this size, he has none of lesion-specific symptoms. He is related to my wife through his marriage and lives in our neighbourhood. I used to see him often walking on the road with absolutely normal gait, sometimes even carrying provisions in both his hands. Even the vertigo episode he recently experienced cannot be attributed to this lesion because he has completely recovered from it now.
This lesion is a massive one. No doubt. But what will happen if you remove it. Even in the best centres, the postoperative complications after craniotomy such as infection, bleeding, hematoma and unexpected development of hemiplegia and paraplegias should be expected. After removal of such a big lesion from one side of the cranial cavity, the remaining brain part may be sucked into the vacuum area and a shift of the midbrain may take place with unpredictable catastrophe. Should this man who at present does not have any disability as such, be subjected to these likely complications? My usual dictum is that not to subject any one to a radical intervention unless the clinical picture warrants such a course. Now more than two years since we first detected this lesion in his brain. A CT scan done a few days ago does not show any worsening. In fact the size of the swelling seems to be a little less than the previous pictures. This is a true case presently under my care. I am enclosing the pictures and the reports below. I want valued opinions from my colleagues as to the next course of action in the management of this case.
UA Mohammed