RARE-27. EXTRACRANIAL METASTATIC GLIOBLASTOMA PRESENTING WITH LHERMITTE’S PHENOMENON, TORTICOLLIS AND QUADRIPARESIS

Abstract

Objective: Illustrate a case of extracranial glioblastoma metastasis presenting with a cervical myelopathy, torticollis and Lhermitte's phenomenon. Background(s): Extracranial glioblastoma metastases are exceedingly rare, though described in the literature. Epidural glioblastoma metastasis presenting as a cervical myelopathy with torticollis and Lhermitte's phenomenon has not previously been described in the English literature. Case: A 20-year-old male status post subtotal bifrontal "butterfly" glioblastoma resection complicated by perioperative left ACA infarction developed unsteadiness, progressive quadriparesis, urinary retention, and lethargy over 48 hours. He was six months postoperative status post radiotherapy with concomitant and adjuvant temozolomide. Physical exam was notable for flattened affect, environmental dependence, and neck stiffness with rightward torticollis. Motor examination revealed prominent gegenhalten, and moderate weakness of the deltoid, triceps, biceps, wrist extensors and finger extensors with lateralization of weakness to the left. There was an upper motor neuron pattern of weakness present in the bilateral lower extremities, this again lateralized to the left. Rectal tone was preserved. Reflexes were pathologically brisk in the bilateral upper extremities with extensor response to plantar stimulation on the right, and equivocal response on the left. The patient was able to sit upright with assistance; he was unable to stand unassisted. There was decreased pinprick sensation in the lower extremities and chest relative to the upper extremities. Inflammatory markers were markedly elevated. CT head did not show a significant change from prior imaging. Broad spectrum antibiotics were started at meningeal doses. LP was not performed. Emergent cervical MRI was obtained which revealed a mass lesion compressing the cervical spine at C2- C5 (In retrospect the lesion could be seen months prior on surveillance imaging). The patient underwent urgent posterior decompression with debulking of the mass. Due to a strong initial suspicion for abscess, no intra-operative pictures were taken, however final pathology was consistent with metastatic glioblastoma. The patient made minimal recovery post-operatively and unfortunately continued to have progression of both intracranial and extracranial disease. Palliative spinal radiation was pursued. The patient was discharged to hospice and passed within six weeks of presentation. Conclusion(s): Extracranial glioblastoma metastases are exceedingly rare, though described in the literature. Subacute onset of neck pain and torticollis with Lhermitte's phenomenon in a patient with Glioblastoma may represent epidural cervical spine metastases. As treatments and patient survival improve glioblastoma metastasis may become more common.