Atypical Presentation of Glioblastoma: A Case Report

This case report describes a patient who presented with devastating stroke-like symptoms secondary to a cystic brain lesion that was confirmed to be glioblastoma without significant symptomatology before her dramatic presentation. It further highlights the aggressive nature and the swift growth of the tumor in a short period of time. A 55-year-old female with no significant past medical history presented to the emergency department in a comatose state. The patient had experienced a week of worsening headaches and vomiting, self-medicating with Tylenol. Upon evaluation, she was noticed to have bilaterally dilated fixed pupils: R: 6 mm, L: 3 mm. The initial head CT revealed a right frontal cystic lesion associated with descending trans-tentorial brain herniation and brain-stem compression. Because of her relatively young age and sudden onset symptoms, the decision was made to take her urgently to the operating room. The patient underwent an emergency right frontal craniotomy, resection, and lobectomy. The patient was intubated and ventilated after surgery. The postoperative exam was significant for pupils ~2-3 mm and reactive to light. On postoperative day 1, the patient became very responsive and was eventually extubated. She was found to have a normal neurological examination after extubating her; despite the devastating presentation and extent of the tumor, the patient recovered well without significant motor or behavioral deficits. The surgical intervention prevented an impending brain death. A follow-up MRI after two weeks shows a substantial recurrence of the tumor as compared to imaging upon discharge. The patient was taken again to the operating room for a second surgery. She was discharged a few days after her second operation with follow-up recommendations with oncology. This case is among very few cases that highlight a swift and dramatic presentation of glioblastoma and isocitrate dehydrogenase-wild type grade IV in a patient without precipitating symptoms succeeding the main presentation. It also emphasizes rapid approaches to prevent a dreadful prognosis in this well-known aggressive type of brain tumor.