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Título

Unresectable high-grade pontine glioma in an adolescent: a case-based update

RESUMO

CASE PRESENTATION: A 14-years-old female has presented a history of sporadic, frontal headache, triggered by movements, associated with vomiting, photophobia and osmophobia for 3 years. There are no reports of similar illnesses in the family and her parents are not consanguineous. The patient developed a visual clouding 7 months ago, which evolved to persistent diplopia and macular edema 2 months after. The symptoms had important intensification 4 months ago, requiring hospitalization. On admission, she had an episode of convulsive crisis and sensorium lowering, so orotracheal intubation was performed. Skull Magnetic Resonance Imaging (MRI) showed an expansive, infiltrative lesion with imprecise limits, with an epicenter in the pons and extension to the midbrain, medulla and cerebellar peduncles, with a compressive effect on the fourth ventricle and involvement of the basilar artery. In the evolution, convulsive episodes were installed again for a week, and the neurosurgical evaluation did not indicate the possibility of surgical resection or biopsy, thus being transferred to the palliative radiotherapy unit.

DISCUSSION: Gliomas represent about 24% of primary tumors of the central nervous system, 80% of which are malignant. In general, they are histologically classified into low grade (I and II) and high grade (III - anaplastic astrocytomas/anaplastic oligodendrogliomas and IV - glioblastoma), in addition to molecular criteria. Clinical aspects depend on tumor location or compressive effect and may include focal neurological deficit, headache, nausea, vomiting, seizures, intracranial hypertension and visual changes. Contrast-enhanced MRI is the imaging exam of choice, showing heterogeneous gadolinium enhancement, with non-enhanced signal changes in the T2 images (infiltrative tumor), in addition to edema. Evidence of hemorrhage or restricted diffusion may also be seen. Confirmation comes from the pathological examination of the resection or biopsy. Treatment depends on the degree of cancer, ranging from chemotherapy, radiotherapy and surgical resection. Cases where the brainstem is largely involved are rare and unfeasible for resection, remaining palliative care.

FINAL COMMENTS: Early diagnosis and treatment of high-grade gliomas remains a challenge, especially in centers with limited financial resources. Being aware of the presentations of these tumors is necessary for proper and rapid management.

Palavras Chave

high-grade glioma, pontine glioma, adolescent