A 77-year-old male patient was admitted to the emergency department with dysarthria, expressive dysphasia, right hemiparesis and progressive deterioration of consciousness.
The patient was informed by family members of a history of essential hypertension treated with 50 milligrams of captopryl every 12 hours and aspirin 100 milligrams daily.
In addition, they reported that two weeks before admission, he had blunt occipital trauma with transient loss of consciousness after stumbling and falling; however, at that time he did not seek medical attention.
On admission he presented intense motor agitation, with blood pressure 175/98 mm Hg, heart rate of 96 beats per minute, respiratory rate of 20/minute and temperature of 36.4 degrees centigrade.
A small superficial excoriation in healing phase was found in the left parieto-occipital region.
Pupils were the same and reacted symmetrically to direct and consensual photomotor reflex.
When performing painful stimuli, he performed ocular opening, emitted words and located the stimulated site, however, with right hemiparesis (Glasgow Coma Scale: 10/15).
Babinski's sign was present bilaterally.
An emergency brain scan was performed after haloperidol administration to reduce agitation, which had poor technical quality due to the persistence of patient movements.
In this study, an extra-axial, hyperdense image in the parenchyma of the brain appeared, with a semi-occurrence of a medial hematoma of 17 millimeters, located in the frontal, parietal and parietal areas.
The disproportionate magnitude of the mass effect and edema adjacent to the lesion alerted about the possible characteristics of the lesion.
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Contrast-enhanced brain tomography showed an image, extra-axial, hyperdense in relation to the cerebral parenchyma, occupying the dorsal-lateral surface frontotemporal-parietal left, with intense frontal contrast uptake.
Additionally, the bone window showed a thinning of the skull in the left temporoparietal region due to the lesion.
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A left frontoparietal craniotomy was carried out during which the eroded bone was found and infiltrated by a more deep temporal thinning lesion, very vascularized, which extended through the frontal cortex, reaching the partom.
Partial resection was performed, leaving abnormal material adhered to the brain surface.
The patient presented improvement of consciousness, becoming alert, with significant improvement of muscle strength on the right side, although with persistence of congenital dysphasia.
The clinical impression of a meningeal metastasis of an unknown primary tumor was requested CT with contrast of thorax, abdomen and pelvis, in which only an increase in prostate size was documented.
Rectal examination revealed a prostatic pink nodule with undefined edges to palpation.
Prostate specific antigen serum obtained was 588 ng/dL, so a prostate biopsy was performed which showed a poorly differentiated adenocarcinoma.
The histopathological study of the intracranial lesion also corresponded to a poorly differentiated metastatic adenocarcinoma.
As the relatives wished, the patient was not submitted to any oncological treatment and was discharged with palliative outpatient care.
