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| CASE REPORT |
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| Year : 2020 | Volume
: 58
| Issue : 2 | Page : 122-124 |
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Fleeting nerve palsy and foster–Kennedy syndrome in frontal lobe tumor
Savithiri Visvanathan, Thendral Velmurugan
Department of Ophthalmology, Tirunelveli Medical College Hospital, Tirunelveli, Tamil Nadu, India
| Date of Submission | 08-Feb-2020 |
| Date of Acceptance | 01-May-2020 |
| Date of Web Publication | 17-Jun-2020 |
Correspondence Address:
Dr. Thendral Velmurugan
Department of Ophthalmology, Tirunelveli Medical College Hospital, Tirunelveli, Tamil Nadu
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/tjosr.tjosr_7_20
Glioblastoma multiforme, also referred to as grade IV astrocytoma, is the most aggressive form of glioma and incredibly a fast-growing tumor. The typical presentation of the frontal lobe tumors includes difficulty in attention and concentration, urinary incontinence, problems in memory and learning, and difficulties in impulse control, reasoning, planning, decision-making, control, and coordination of movement. Frontal lobe tumors can become very large before they manifest clinically, and their symptoms may be trivial. We report here a case of Foster–Kennedy syndrome presenting as depression as the first symptom along with the rare finding of “Transient Oculomotor Nerve palsy” during the seizure episode.
Keywords: Depression, Foster Kennedy syndrome, glioblastoma multiforme, transient oculomotor nerve palsy
How to cite this article:
Visvanathan S, Velmurugan T. Fleeting nerve palsy and foster–Kennedy syndrome in frontal lobe tumor. TNOA J Ophthalmic Sci Res 2020;58:122-4 |
| Introduction | |  |
Foster–Kennedy syndrome (FKS) is characterized by an anterior intracranial mass which directly compresses the ipsilateral optic nerve causing optic atrophy and increasing intracranial tension which then causes contralateral papilledema. The three major causes of FKS are frontal lobe meningioma, olfactory groove meningioma, and sphenoid wing meningioma. About 50% of the patients with primary brain tumor presents with ocular manifestation as the first complaint. Gliomas are central nervous system tumors which arise from glial cells such as astrocytes and oligodendrocytes. There are four grades of glioma, glioblastoma multiforme (GBM) being the fourth grade. GBM, also referred to as grade IV astrocytoma, is the most aggressive form of glioma and incredibly a fast-growing tumor. For adults, it most commonly occurs in the frontal or temporal lobe. It accounts for 52% of primary brain tumors and 17% of both primary and metastatic brain tumors.[1] It can either arise from “de novo” which constitutes 90% of the tumor, or from low-grade astrocytoma constituting 10%.[2] We report here a case of FKS presenting with depression as the first symptom. A rare occurrence of transient oculomotor nerve palsy during the seizure episode has also been reported in our patient.
| Case Report | | |
A 31 years old male patient r eferred from the psychiatric department with chief complaints of defective vision in his right eye for the past 1 year. The defective vision was insidious in the onset, and gradually progressive. There were no aggravating or relieving factors. In addition, a history of involuntary movements has been present for 20 days, along with a history of a loss of interest in work, excessive sleep, slowness in activity, and a motivation for 1 year. These symptoms initially led him to seek multiple psychiatric consultations. There is no other systemic or ocular history. The patient was admitted and diagnosed with acute transient depression and was treated with Fluoxetine tablets, following which he developed involuntary movements. The psychiatrist made a provisional diagnosis of Fluoxetine-induced dystonia and mood disorder. The Fluoxetine tablet was stopped; however, it was later found that what was initially interpreted as Fluoxetine-induced dystonia was actually a series of atypical frontal lobe seizures. On examination, the patient was conscious and oriented to the time, place, and person. No pallor, clubbing, pedal edema, or lymphadenopathy. Blood pressure was 140/90 mm hg, and the pulse rate was 72/min. Examination of the cardiovascular system, respiratory system and abdomen was normal. Neurological examinations showed the positive findings of the absence of smell, relative afferent pupillary defect (RAPD), and partial ptosis with restricted adduction, elevation, and depression in the right eye. Extraocular movements in the left eye were normal. All other cranial nerve examinations were normal. Motor system examinations, sensory system examinations, and cerebellar function test were normal. Plantar reflex was flexor. On initial ocular examination, the best-corrected visual acuity, the patient could count fingers close to his face using the right eye, and the vision in his left eye was 6/6. The color vison in the right eye could not be elicited, but the color vision in his left eye was normal. Examinations of the right eye showed RAPD, and the fundus showed a disc of chalky white pallor, suggesting primary optic atrophy. His left eye showed the presence of established papilledema [Figure 1]. Extraocular movements were full. Field testing was unreliable because of poor cooperation. Differential diagnoses of FKS, Pseudo FKS, AION, and asymmetric NAION were made. An urgent magnetic resonance imaging of the brain scan with magnetic resonance angiography and magnetic resonance venography was ordered [Figure 2], which shows T1 hyperintense lesion of 6 cm × 5 cm × 6 cm in the frontotemporal lobe, the rostrum of the callosum with surrounding diffuse edema and a mass effect over the frontal horn of the right ventricle with midline shift toward the left. The aforementioned lesion was in the right frontotemporal lobe and extended along the corpus callosum frontal lobe with poorly defined infiltrating borders. On the 2nd day of the examination, the patient had one seizure episode followed by the complete ptosis of the right eye with restricted elevation, adduction, and depression [Figure 3]. The ptosis and the third nerve palsy were resolved spontaneously after a few minutes. The development of the third nerve palsy during the seizure episode is explained by irritative focus, which causes functional interruption of corticofugal fibers from the prefrontal region to the midbrain.[3] The patient has been planned for the surgery followed by chemotherapy and radiotherapy. | Figure 1: Color fundus photograph of the right eye showing temporal pallor (a) and the left eye showing established papilledema (b)
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 | Figure 2: Magnetic resonance imaging showing frontotemporal mass with midline shift toward left
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 | Figure 3: Clinical picture showing complete ptosis (a), which resolved spontaneously after a few minutes (b), Third nerve palsy with restricted elevation, depression, and adduction (c), Resolved third nerve palsy with good improvement in extraocular movements within few minutes (d)
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| Discussion | | |
The three most common neuro ophthalmological symptoms of brain tumor are defective vision, headache, and photophobia.[4] The most common signs in descending order are defective color vision, optic atrophy, hemianopia, and RAPD. Depression was reported in 2.5%–15.4% of patients with primary brain tumors[5] and was more commonly found in patients with frontal lobe tumors.[6] Patients may also present with apathy, which is a state of motivation and chronic fatigue due to functional interruption between the frontal lobe and the paralimbic area caused by the frontal lobe tumors.
A study by Keschner et al. examined 530 patients with brain tumors and reported that 78% of those patients had psychiatric symptoms; however, only 18% of the patients presented these psychiatric symptoms as the first clinical manifestation of a brain tumor.[7] GBM, which is a heterogeneous group of tumors usually presents with ataxia, syncope, and seizures. It may also occur in genetic disorders such as tuberous Sclerosis, turcot syndrome, MEN Type II-A, and neurofibromatosis Type I.
FKS accounts for 1%–2.5% of all intracranial masses.[8] The typical presentation of frontal lobe tumors includes difficulty in attention and concentration, urinary incontinence, problems in memory and learning, and difficulties in impulse control, reasoning, planning, decision making, control, and coordination of movement. Frontal lobe tumors can become very large before they manifest clinically, and their symptoms may be trivial.
| Conclusion | | |
This case of FKS is particularly peculiar for two essential reasons. First, the primary manifestations of brain tumors are rarely defective vision and depression. Second, for the “transient oculomotor nerve palsy” during the seizure episodes, which was rarely reported in the literature.
The detailed neuro-ophthalmic examination conducted by the ophthalmologist played a crucial role in the early diagnosis and timely referral to neurosurgeons for the proper treatment. Thus, this case represents the importance of thorough examination in cases of behavior disorders which are not respondent to treatment or in cases of sudden onset of behavioral changes.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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| 8. | von Wowern F. The Foster Kennedy syndrome an evaluation of its diagnostic value. Acta Neurol Scand 1967;43:205-14. |
[Figure 1], [Figure 2], [Figure 3]
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