MILD COGNITIVE IMPAIRMENT IN SUPRASELLAR MENINGIOMA WITH BILATERAL NO-LIGHT-PERCEPTION

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NEUROLOGY | CASE REPORT

MILD COGNITIVE IMPAIRMENT IN SUPRASELLAR MENINGIOMA WITH BILATERAL NO-LIGHT-PERCEPTION

Dico Gunawijaya^∗,1and Anak Agung Ayu Putri Laksmidewi^∗∗

∗Neurology Resident, Faculty of Medicine, Udayana Univesity / Sanglah General Hospital Bali Indonesia.,^∗∗Neurology Specialist, Consultant of Neurobehavior, Department of Neurology Faculty of Medicine, Udayana Univesity/Sanglah General Hospital Bali Indonesia.

ABSTRACT Background: The examination of cognitive function in individuals with disabilities is still a challenge for neurobehavior practitioners. The lack of sensory impulses causes it, and it is also related to individual responses and the interpretation of the examination. Cognitive examination for visual impairment is still developing at this moment.Case Report:A 34-year-old woman complained of a progressive chronic headache for two years before her visit. She also complained of a blurred vision that deteriorated to blindness. The patient was currently on her fourth pregnancy with a nine-month gestational age. On neurological examination were found bilateral anosmia, visual acuity of no-light-perception on both eyes with papillary atrophy. Head MRI with contrast showed an extra-axial mass in suprasellar. Tumour biopsy showed a WHO grade I fibrous meningioma. The value of MoCA-Blind in the patient was 16 (cognitive impairment), while MMSE for Sensory Deficit was 22 (mild cognitive impairment). Impairment in more than one cognitive domain was also found in this case.Discussion:Cerebral tumours can affect cognitive function through various mechanisms. One study found that the majority of patients with cerebral tumours had impaired at least one area of cognitive function. Cases of cerebral tumours with blindness sometimes were found in daily practice. Cognitive testing ideally requires a normal vision, so we need an adjusted instrument, such as MoCA-Blind and MMSE for Sensory Deficit.Conclusion:Cognitive function needs to be evaluated in cases of cerebral tumours, especially if accompanied by disabilities. Further studies on adjusting the total value and interpretation of examinations are required to determine the instrument’s validity.

KEYWORDSmeningioma, cerebral tumour, blindness, cognitive, MoCA-Blind, MMSE

Introduction

Cognition is one of several complex functions carried out by the cerebral hemisphere. The limbic system and its relationship to other hemisphere areas and the brain stem play a vital role in the cognitive function of individuals.[1] The main areas of

Accepted: May 15, 2020 Associate Editor: Ivan Inkov (BG);

1Neurology Resident, Faculty of Medicine, Udayana Univesity / Sanglah General Hospital Bali Indonesia; E-mail: [email protected]

cognitive function are attention, language, memory, visuospatial, as well as the function of exclusion.[2,3,4] Examination of neuro-behaviour is a part of the neurological examination that focuses on cognitive and mental functions. Ideally, the individual examined should have adequate contact, cooperative, and good general conditions.[5,6]

Examination of cognitive function in individuals with disabilities, whether in the form of physical, visual, or hearing disabilities, is a challenge. Some problems can be found in assessing the cognitive function of individuals with disabilities, mainly due to the lack of incoming sensory impulses and the mo- tor responses needed in interpretation.[7] Cognitive examination on the patient with visual impairment or blindness is currently under development.[8,9] MoCA-Blind, which is a modification

Dico Gunawijaya et al./ International Journal of Medical Reviews and Case Reports (2020) 4(11):11-14

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of the MoCA, as well as the MMSE for Sensory Deficit, are modified instruments which are used to assess cognitive functions for individuals with visual impairment, and both examinations are currently in the stage of developing and validating the total score interpretation.[10,11,12,13]

Figure 1:Head MRI with contrast.

Figure 2a and b:Histopathology of fibrous meningioma.

Case presentation

A 34-year-old female, admitted to the hospital, complaining headache for two years before admitted—the headache de- scribed as throbbing all over the head all day long, especially in the morning. The last five months, the headache had gotten worse and not improved with medication, patient’s daily activities were disrupted. A week before, the patient was complaining projectile vomit. Blurred vision in both eyes has been felt for four months. The patient was given eyeglasses, but the visual acuity did not improve. Blurred vision worsened until she could not see at all for the past month. The patient’s family also said that the patient often looked depressed, rarely spoke, and had less appetite since the complaint appeared. The patient was currently on her fourth pregnancy with a nine-month gestational age. Be- fore this pregnancy, patients used three-month birth control shot for two years. On examination, vital signs were normal, numeric pain rating scale of 3. The patient was conscious, with bilateral anosmia, visual acuity of no-light-perception on both eyes with papillary atrophy and non-reactive pupillary mydriasis, also with progressive chronic vascular type cephalgia. Motoric,

sensory and autonomic functions were within normal limits.

Pathological reflex was not found. Laboratory tests were normal.

Head MRI with contrast showed an extra-axial lobulated mass in the suprasellar, pressing the optic chiasm, bilateral frontal lobes, third ventricle, and bilateral lateral ventricles. There was a midline shift in the anterior cerebral interhemispheric fissure 0.99 cm to the left, suggesting a suprasellar meningioma.

The examiner used the MoCA-Blind instrument and MMSE for Sensory Deficit to assess cognitive function. During the examination, the patient showed depressive affect but was able to follow the examiner’s instructions properly. The total score of MoCA-Blind was 16 (cognitive impairment), with an addi- tional one point score due to the patient’s formal education≤12 years. MMSE for Sensory Deficit obtained a score of 22 (mild cognitive impairment), with an adjustment score for the vision- independent cognitive domain. A summary of the results of cognitive function tests is shown in table 1.

The patient underwent tumour resection surgery accompanied by histopathological biopsy as soon as the result of head MRI with contrast was available. Biopsy result showed neoplas- tic meningothelial cell proliferation which formed a short and whorled fasciculus structure, without the presence of nuclear atypia, mitosis or necrosis—Histomorphology of this tumour in accordance with WHO is a grade I fibrous meningioma. After surgery, the patient was treated in the intensive care unit. Phar- macological therapies were administered, including steroids, opioid analgesics, and proton-pump inhibitors.

Discussion

A 34-year-old woman complained of progressive chronic headache with projectile vomiting and blindness. The symptoms showed an increase in intracranial pressure, with blindness as a sign that the pressure is chronically rising. On physical examination found anosmia, visual acuity of no-light-perception, and non-reactive pupillary mydriasis indicating a space-occupying lesion at the anterior cranial base. In this case, sensitive brain imaging was needed to make a differential diagnosis, which was the head MRI. The picture of the extra-axial primary cerebral tumour supported radiological results, with the main suspect of a meningioma. Risk factors that can be identified were the use of hormonal contraception and pregnancy, in which estrogen acts as a promoter of cell proliferation.[14] The definitive diagnosis of meningioma was established through histopathological features with the WHO grading system.[15] Apart from surgery, other treatments include steroids to treat vasogenic oedema, analgesic and monitoring for signs and symptoms of increasing intracranial pressure.[14]

Cerebral tumours are found to interfere with cognitive function through various mechanisms, whether due to the destruc- tion or suppression of the tumour itself, treatment of tumour- related epilepsy, and emotional stress.[16] At least one of the domains of cognitive function was found to be impaired in the majority of patients with cerebral tumours. One study found that 53.75% of patients had multiple domain disorders, 16.25% language disorders, 13.75% amnesia, 8.75% concentration problems [5], 6.25% apraxia, and 1.25% deficit in visuospatial understand- ing.[17]

Cognitive function of patients was examined by MMSE and MoCA, which is adapted for blind subjects. The examination results showed mild cognitive impairment on the total MMSE score and cognitive impairment on the total MoCA score. In both examinations, the patient experienced multiple domain

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Table 1The Result of Cognitive Function Examination.

Examination Cognitive Area Score Max Score

MoCA-Blind Language 2 3

Abstract 2 2

Recall 3 5

Orientation 4 6

Total score (+1) 16 22

Interpretation Cognitive Impairment

MMSEfor Sensory

Deficit Orientation 7 10

Registration 3 3

Atention/Calculation 2 5

Recall 3 3

Language 3 4 (for

vision-independent)

Total score 18 25 (for

vision-independent)

Score adjustment 22

Interpretation Mild Cognitive Impairment

disorders, namely orientation, language, attention, and recall.

Factors causing cognitive and mental disorders, in this case, can be explained anatomically and emotionally. Anatomically, suppressing tumours in the pars dorsomedial pre-frontal lobes can cause low motivation, which can lead to depression. In addi- tion, executive function is also regulated by the involvement of the prefrontal lobe. The connection of the prefrontal lobe to the hippocampus and limbic system can disrupt various cognitive domains, such as memory and learning, encouragement, and language.[1,3] From an emotional standpoint, chronic pain is said to be one of the triggers of emotional stress in patients with cerebral tumours.[16] Not only chronic pain, visual disturbances, even blindness, will significantly affect the patient’s learning function. All these cognitive impairments can reduce the quantity and quality of daily activities.[7,8] MoCA and MMSE are often chosen to be used for assessing cognitive function in individuals with visual impairments because they are concise and covering all cognitive domains.[9] Further studies on adjustments of total scores and interpretation of examinations are needed to avoid over- or underdiagnosed of cognitive impairment accompanied by sensory impairment.

Conclusion

Comprehensive neurological examination, including cognitive function, is needed in evaluating cerebral tumours. Some cases of cerebral tumours can be accompanied with significant disabilities that can affect the patient’s cognition, for example, vision and hearing disorders. Several examination instruments that have been modified for people with disabilities can be used, such as MoCA-Blind and MMSE for Sensory Deficit. However, further studies are needed regarding the validity of this examination.

Patient informed consent

Written informed consent obtained from the patient to publish this case report and any accompanying images.

Ethics committee approval

This case report has ethical clearance issued by the Ethic Com- mission of Faculty of Medicine, Udayana University, Sanglah General Hospital Denpasar.

Funding

There was no funding applied for this article.

Conflict of interest

Author declare no conflict of interests.

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