Unusual presentation of a large epidermoid tumor in a chronic migraine patient: Case report

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ackground: Epidermoid tumors comprise 0.5%-1.5% of brain tumors with predilection for the cerebellopontine angle, fourth ventricle, suprasellar region and spinal cord. Rarely do these slow growing tumors become symptomatic. We report an unusual presentation of a patient with chronic migraine leading to the diagnosis of a large epidermoid tumor. Methods: We report the case of a 21 year-old female with a history of migraine headaches since age 11. She presented to the outpatient neurology clinic for management of her frequent headaches, which occurred 4-5 times per week and were associated with photophono-phobia and osmophobia. She had not been previously imaged. She also had a history of anxiety and depression, and for two years, was seeing a psychotherapist for worsening anxiety and overwhelming sensations of fear. Episodes were triggered by extreme emotional stress, and were accompanied by staring spells, abnormal facial movements, and an "out of body" sensation. Neurological examination was unremarkable, and an electroen-cephalogram revealed frequent spikes, sharps, and slow wave discharges arising from the right temporal region. This prompted investigation with an MRI, which demonstrated a large cystic extra-axial mass centered near the right cerebellopontine angle, measuring up to 4.5 3 3.4 3 4.9 cm, resulting in displacement of the adjacent brainstem and encasement of the basilar artery. Superiorly there was extension of the mass into the medial right middle fossa measuring 6.2 3 4.4 3 4.3 cm causing mass effect on the right mesial temporal lobe and abutting the right internal carotid and middle cerebral arteries with an associated 5 mm midline shift. The lesion demonstrated T2 hyperin-tensity with mild diffusion restriction. Findings were suggestive of a large epidermoid tumor. Results: Patient was referred for neurosurgical evaluation and successfully underwent two-stage resection of the mass. Conclusion: Challenges exist in diagnosing headache patients who present with atypical psychiatric symptoms that precede neurological symptomatology. This often leads to a missed or delayed diagnosis. Slow-growing intracranial masses should be considered in the evalua-tion of such patients.




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