Working Diagnosis:
Ganglioglioma

Treatment:
Surgical resection of tumor and prophylactic anti-seizure medication for 6 months

Outcome:
The patient is now one month since resection of his benign ganglioglioma. He is doing well, with resolved dizziness and improved alterations in mood. He remains on Keppra for seizure prophylaxis. His neurosurgeon plans to clear him for return to baseball in 6 months but states that return to football next year is unlikely.

Author's Comments:
Gangliogliomas are generally benign central nervous system tumors composed of both neuronal and glial elements. Gangliogliomas account for approximately 1% of all adult CNS tumors and 10% of pediatric CNS tumors. They are most commonly diagnosed in children and young adults, with the average age at diagnosis being 20 years old. Most often, these slow growing tumors are located in the temporal lobe and are frequently associated with intractable epilepsy (approximately 50% of cases). Gangliogliomas tend to be well circumscribed and thus amenable to complete resection. The five year survival rate is greater than 90% after resection. Total surgical resection is the treatment mainstay, while radiation therapy and chemotherapy are reserved for an unresectable recurrence. While fewer than 10% of gangliogliomas undergo anaplastic transformation, these cases are usually fatal.

According to the Third International Conference Consensus Statement on Concussion in Sport, conventional structural neuroimaging will “contribute little to concussion evaluation but should be employed whenever suspicion of an intracerebral structural lesion exists.� Although this patient had a normal neurological exam with no focal findings, his history could not be explained with a diagnosis of concussion alone. In addition to dizziness, he presented with mood swings and discrete episodes of abnormally oppositional behavior, nonsensical and slurred speech, and tonic-clonic posturing. Although the patient and his parents felt that his symptoms were the sequelae of a “hard hit� during football practice, a prudent sports medicine physician must note the chronology of these symptoms (the dizziness and mood swings were present prior to the “hard hit�) and discern that these symptoms are concerning for structural brain pathology and not just transient functional impairment as seen in concussion. This patient’s symptoms warranted the need for neuroimaging, showing that not all who cry dizzy are concussed.

Editor's Comments:
With the recent attention on concussions, the author makes a good point of not categorizing all athletes with neuropsychologic symptoms as having concussions. There are validated clinical decision rules, such as the New Orleans Criteria and the Canadian CT Head Rule, for head CT after acute closed head injury. However, there are no clearly established guidelines for imaging in the setting of a concussion. Generally, if the player has prolonged or worsening headache, intractable vomiting, or seizure-like activity, one should consider obtaining a CT head. Also, if the symptoms do not fit the diagnosis, consider expanding your differential and work-up.

References:
References:
- Bristol R. Low-Grade Glial Tumors: Are They All the Same? Seminars in Pediatric Neurology. 2009 March; 16(1):23-26
- McCrory P., Meeuwisse W., Johnston K., Dvorak J., Aubry M., Molloy M., Cantu R. Consensus statement on concussion in sport – The 3rd International Conference on concussion in sport, held in Zurich, November 2008. Journal of Clinical Neuroscience. 16(2009)755-763.
- Norden AD., Chheda MG., Wen PY. Uncommon brain tumors. www.uptodate.com. 2011.
- Pandita A, Balasubramaniam A., Perrin R., Shannon P., Guha A. Malignant and benign ganglioglioma: a pathological and molecular study. Neuro-oncol. 2007 April; 9(2): 124-134.
- Varlet P., Peyre M., Boddaert N., Miguel C., Sainte-Rose C., Puget S. Childhood gangliogliomas with ependymal differentiation. Neuropathology and Applied Neurology (2009). 35, 437-441.

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