Post-Surgery Notes

DATE OF DISCHARGE: 05/05/2015

PCP: Nasima Vira, MD

DISCHARGE DIAGNOSIS:
Brain mass

CONSULTS COMPLETED:
Consulting services in CORES:
Nurse Care Coordinator
Rehabilitation Medicine
Neurosurgery
_

OPERATIONS/PROCEDURES:
Events/Procedures from CORES:
crani (05-01-2015)

PRINCIPAL DIAGNOSTIC STUDIES/RESULTS:
MRI Brain (05/02/2015 11:16)
~EXAMINATION:
MRI BRAIN WO/W CONT
CLINICAL INDICATION:
s/p crani for tumor rsxn, CN 6 palsy
TECHNIQUE:
MRI Head Cranial Nerve – Facial Nerve w contrast (B 21)
Non-contrast IAC/Parotid: Sagittal \T\ axial T1, axial BFFE, coronal T2 fat
saturation
Post-contrast IAC/Parotid: Sagittal \T\ coronal T1 fat saturation 3 mm.
MRI Head Extra-Axial Tumor (Mening/Schwann) B-2EA
Non-contrast Head: Axial T1, T2, FLAIR \T\ DWI
Post-contrast Head: Sagittal T1, Axial \T\ Coronal T1 FS
CONTRAST:
Prohance 15 ml 05/02/2015 10:57 AM INTRAVENOUS
COMPARISON:
CT head May 1, 2015 and MRI brain April 27, 2015 and March 9, 2015..
FINDINGS:
Patient is status post left frontotemporal craniotomy for resection of
suspected low-grade chondrosarcoma at the left petro clival synchondrosis.
Expected post surgical changes are identified including pneumocephalus and
trace extra-axial blood products. No large intracranial hemorrhage, midline
shift, herniation, or infarct is identified. A small extra-axial fluid
collection is identified overlying the left convexity, without significant
mass impression on the adjacent brain. A larger extra-axial fluid collection
is present within the left middle cranial fossa, best seen on coronal images,
measuring up to 11 mm in thickness and likely representing a postsurgical
blood products. Surgical changes are present involving the sphenoid bone and
clivus, and about the petro clival synchondrosis..
Fluid is present within the left mastoid air cells, presumably related to
recent surgery. Asymmetric signal alteration is present involving the left
foramen ovale and V3 segment, and portions of the left cavernous sinus. This
is nonspecific and may represent expected postsurgical changes. Signal
alteration is present involving the mesial left temporal lobe which may be
related to retraction injury.
Mildly thickened there are and soft tissue is identified in the ascending the
of the left cavernous sinus (see image 11 of series 501, 701, and 1601) which
may represent residual tumor versus postsurgical change. Mild signal
alteration is present involving the left occipital condyle, with associated
enhancement, concerning for residual tumor (see image 3 of series 701 and
1601). Otherwise, no definite abnormal enhancement is identified.
IMPRESSION:
1. Expected post surgical changes related to skull base tumor resection as
above described. No evidence of unsuspecting acute post surgical
complication. Scattered areas of residual signal alteration suggestive of
possible residual tumor. Attention to these regions on follow-up is advised.
ATTENDING RADIOLOGIST AND PAGER NUMBER
501322 Andre Jalal B MD
***RESULT DETAIL***
Ordering Provider:Ali Cyrus Ravanpay 260910
Diagnosis:s/p crani for tumor rsxn, CN 6 palsy
History:
Comment:From ORCA: Order CMT: Inpatients will not be scheduled until the
Safety Screen is completed and sent to MRI.
Assisting Radiologist(s):

CT Head (05/01/2015 20:10)
~AFTER HOURS PRELIMINARY REPORT
EXAMINATION:
CT HEAD WO CONT
CLINICAL INDICATION:
s/p crani, brain tumor
TECHNIQUE:
CT Head Routine wo contrast (N-1)
Non-contrast axial 5 mm contiguous sections were obtained through the head.
Patient age specific scan parameters were used for radiation exposure.
COMPARISON:
CT head dated 4/27/2015
PRELIMINARY FINDINGS:
Patient is status post left frontotemporal craniotomy for resection of tumor.
There is no midline shift.
The lateral, third and fourth ventricles are appropriate in size.
The basal cisterns are patent.
There is expected pneumocephalus as well as some blood products located
extra-axially by the craniotomy site.
No evidence of acute intracranial hemorrhage or territorial infarct.
PRELIMINARY IMPRESSION:
Patient is status post left frontotemporal craniotomy for tumor resection with
expected postoperative changes.
Preliminary results created by resident Xue Bai, MD, R3. A final report will
be available for review by 10am the following morning Monday through Friday or
after 3 pm Saturday, Sunday, and holidays.
Unless a final report appears below, the images have not been reviewed by the
attending radiologist.
Neuro fellow prelim: Agree.
FINDINGS (final):
I agree with the preliminary interpretation submitted by the on-call resident,
with the following additional findings:
Extruded postsurgical changes are identified within the left middle cranial
fossa and about the petroclival synchondrosis. Evaluation for possible
residual tumor would be best performed on MRI.
IMPRESSION:
1. Expected post surgical changes related to skull base tumor resection as
above described.No evidence of unsuspecting acute intracranial pathology.
ATTENDING RADIOLOGIST AND PAGER NUMBER
501322 Andre Jalal B MD
***RESULT DETAIL***
Ordering Provider:Ali Cyrus Ravanpay 260910
Diagnosis:s/p crani, brain tumor
History:
Comment:From ORCA:
Assisting Radiologist(s):Xue Bai 502450

CTA Head (04/27/2015 12:41)
~EXAMINATION:
CTA HEAD WO/W CONT
CLINICAL INDICATION:
CTA head W/WO Contrast,CTA of the head for itraoprative image guidance for
possible chrodrosarcoma. 42-year-old female.
TECHNIQUE:
CTA Head Intracranial hemorrhage Aneurysm AVM (N-47)
1. Axial 5 mm contiguous sections were obtained through the head without
contrast.
2. CTA Head: During contrast infusion of 150 mL of contrast, 0.625 mm sections
were obtained from the skull base to the vertex. Slab MIP reformatted images
of the neck and skull vessels were obtained in the axial, sagittal, and
coronal planes. 3-D rotated images of the vessels were reconstructed on an
independent workstation.
3. Post-contrast 5 mm sections were repeated through the brain. Patient age
specific scan parameters were used for radiation exposure.
Contrast: Omnipaque 350 mg-ml 80@3cc/sec ml 04/27/2015 12:42 PM INTRAVENOUS
COMPARISON:
MRI from March 9, 2015 from Virginia Mason Issaquah
FINDINGS:
NON-CONTRAST HEAD CT:
MASS EFFECT \T\ VENTRICLES: No shift. The lateral ventricles are symmetric.
The ventricles, sulci and cisterns are normal.
BRAIN: The brain parenchyma is normal. No acute infarct, hemorrhage or mass
lesion is seen.
VASCULAR: Cavernous carotids and vertebral vessels are normal.
EXTRA-AXIAL: Extra-axial spaces are normal.
EXTRA-CRANIAL: The skull base shows a lytic petro clival lesion involving the
clivus from the sella down to the left upper loss canal and petrous apex. It
measures approximately 3.4 x 2.6 x 3.9 cm. The matrix of the lesion has a few
specks of calcification and also has mild enhancement postcontrast. The
contrast enhancement is much better appreciated on the outside MRI study. It
extends up into the posterior aspect of the left cavernous sinus and displaces
and compresses Meckel’s cave. The margin of the involved bone shows sharply
marginated scalloped areas including involvement of the left horizontal
petrous carotid canal.. Sinuses and mastoids are clear. Orbits are normal.
POST-CONTRAST HEAD CT:
ENHANCEMENT: Normal intracranial enhancement except for the petro clival mass
which shows mild enhancement..
HEAD CTA:
ARTERIES: Normal intracranial arteries above the clinoids. However, the left
horizontal petrous carotid artery and the precavernous segment are displaced
slightly anteriorly, unroofed superiorly and narrowed by approximately 1 mm in
diameter compared with contralateral petrous carotid arteries which measures
4.1 mm versus 3.2 mm on the left. The ICA in the segment is approximately 3/4
encased by the petro clival mass.. No aneurysm, AVM, stenosis, vasospasm or
occlusion.
VARIANTS: Circle of Willis is normally developed. No other vascular anatomic
variants.
VEINS: Dural sinuses and deep venous structures are normal.
IMPRESSION:
1. Normal brain CT. No acute infarct, hemorrhage or mass effect.
2. Left petro clival mass with speckled calcification and slightly enhancing
matrix on CT most consistent with a chondroid lesion. This lesion encases the
horizontal left petrous and precavernous internal carotid artery by
approximate 75% through the segment and displaces the vessel anteriorly and
narrows it by approximately 20-30%. The CTA of the head is otherwise normal.
ATTENDING RADIOLOGIST AND PAGER NUMBER
007718 Dalley Roberta W MD
(206)991-3475
***RESULT DETAIL***
Ordering Provider:Olga Lucia Paredes 501306
Diagnosis:CTA head W/WO Contrast,CTA of the head for itraoprative image
guidance for possible chrodrosarcoma
History:
Comment:From Epic: Additional Clinical Info: CTA of the head for itraoprative
image guidance for possible chrodrosarcoma Referral for: Procedure or
ancillary service not done by the referring provider. PATIENT INSTRUCTIONS:
Please call the locatio SEE EPIC
Assisting Radiologist(s):

MRI Brain (04/27/2015 12:17)
~EXAMINATION:
MRI BRAIN W CONT
CLINICAL INDICATION:
MRI Brain W/Contrast,MRI of the brain with contrast for intraoprative image
guidance for neuronavigation. 42-year-old female with left petro clival tumor.
TECHNIQUE:
MRI Head 3D Stealth cranial navigation w contrast(B 19)
Post-contrast Head: Sagittal T1, 3D SPGR, 3D FLAIR with stealth fiducial
markers.
CONTRAST:
Prohance 15 ml 04/27/2015 12:02 PM INTRAVENOUS
COMPARISON:
MRI brain done March 9, 2015 from Virginia Mason Issaquah
FINDINGS:
MASS EFFECT \T\ VENTRICLES: No shift. The lateral ventricles are symmetric.
The ventricles, sulci and cisterns are normal, except for medial left temporal
lobe cisternal compression.
BRAIN: The brain parenchyma is normal. No hemorrhage or mass lesion is seen.
ENHANCEMENT: The left petro clival mass enhances moderately and homogeneously.
Otherwise normal enhancement of intracranial structures.
VASCULAR: Cavernous carotid, vertebral, and other intracranial vascular flow
voids are normal, but the left horizontal petrous segment of the carotid
artery shows some mild compression and three quarter encasement due to the
adjacent mass.
EXTRA-AXIAL: No extra axial fluid collections.
EXTRA-CRANIAL: The left petro clival mass measures 3.2 x 2.5 x 5.5 cm and
lies between the petrous apex and the clivus. It is diffusely enhancing post
gadolinium and shows very high T2 signal typical of a chondroid lesion. It has
well circumscribed margins with erosion of the bone of both the left clivus
extending all the way down to the level of the hypoglossal canal and the left
petrous apex all the way to the porus acusticus of the anterior internal
auditory canal. It minimally compresses the left and petrous carotid artery
and partially encases it and it also extends into Meckel’s cave and displaces
the dura of the cavernous sinus anterolaterally.l. Sinuses and mastoids are
clear. Orbits are normal.
IMPRESSION:
1. Stealth surgical planning study showing no change in the left petro clival
lesion which is most consistent with a chondroid tumor such as low-grade
chondrosarcoma. Very mild petrous carotid compression and three-quarter
circumferential encasement.
ATTENDING RADIOLOGIST AND PAGER NUMBER
007718 Dalley Roberta W MD
(206)991-3475
***RESULT DETAIL***
Ordering Provider:Olga Lucia Paredes 501306
Diagnosis:MRI Brain W/Contrast,MRI of the brain with contrast for
intraoprative image guidance for neuronavigation
History:
Comment:From Epic: Additional Clinical Info MRI of the brain with contrast for
interaoperative image guidance for neuronavigation Referral for: This
referral for consultation or procedure grants authorization to perform
diagnostic or other services r SEE EPIC
Assisting Radiologist(s):

REASON FOR ADMISSION:
From Dr Ferreira’s operative report:
The patient is a 42-year-old female who suffered a partial then near complete abducens palsy on the left. Imaging revealed the presence of a large tumor at the level of the skull base from the cavernous sinus distorting the medial left temporal lobe extending through the petrous bone clivus down the level of foramen magnum. I went over the risks and benefits of surgery with the patient and her husband and the differential diagnosis of which I favored chondrosarcoma versus chordoma. They understood that the role for a complete gross total resection in chordoma is quite different if this proved to be a chondrosarcoma. We talked about the possibility of staging this procedure or leaving the residual and either following this radiographically versus up-front radiation therapy. They understood that my formal recommendation should this prove to be a chordoma would be complete gross total resection of that tumor. We prepared for a left subtemporal transcavernous approach and a posterior fossa, posterior petrosal via anterior and posterior petrosectomies respectively. They understood the risks and benefits and opted to proceed.

HOSPITAL COURSE:
Ms Nichols underwent the above operation without complications. She was admitted to the ICU post-operatively for neurologic monitoring and was transferrred to the floor the next day. She was evaluated by rehab medicine, who recommended outpatient referrals to PT, OT, SLP and vocational rehab. On the day of discharge she was ambulating without difficulty, tolerating a diet and had her pain well-controlled on PO analgesics.

CONDITION:
Good

DISPOSITION:
[x] Home [_] Skilled Nursing Facility [_] Other: _

CLINICAL FOLLOW-UP, INCLUDING APPOINTMENTS:
UWMC Neurosurgery Clinic, 1-2 weeks
UWMC Rehab Medicine, 4-6 weeks
Outpatient referrals to PT, OT, SLP, vocational rehab

DIAGNOSTIC STUDIES RECOMMENDED:
_

PENDING RESULTS: (as of this summary)
_

THERAPEUTIC RECOMMENDATIONS:
Activity as tolerated
OK to wash hair. No scrubbing/soaking incision.