Cognition on the Clock: The Neuropsychologist’s Role in Time-Sensitive Brain Tumor Care and Treatment Planning

Case Study

A 67-year-old, right-handed woman presented with expressive language difficulties within the context of two previous resections (September 2023; February 2024) of a recurrent left temporal glioblastoma. Medical history is significant for hypothyroidism and osteoarthritis. Her psychiatric history is notable for increasingly prevalent symptoms of depression, with onset beginning after the first glioblastoma resection. She began experiencing recurrent thoughts about her future and potential preparations for death, given her health status. Minimal changes were reported in her cognitive or adaptive functioning after the first resection; following the second resection (i.e., five months later), significant changes were observed in her daily life from both a cognitive and adaptive perspective. Specifically, the patient and her partner noticed changes in her language functioning, including difficulties processing verbal information (e.g., understanding what others say, following instructions provided to her), word-finding difficulties, and fluency problems (e.g., sound or word substitutions). Changes in her ability to retain information were noted (e.g., appointment times, names of grandchildren). Her partner noted increased frustration in response to minor stressors. Changes in peripheral vision were reported; she refrained from driving due to this change. Variability in her adaptive functioning was also noted; she required assistance with many of the instrumental tasks that she had previously managed independently (e.g., managing household finances, keeping track of medications). No changes were noted in her ability to complete self-care tasks (e.g., dressing, grooming, bathing, toileting).

 Neurology and Neuroimaging Findings

In August 2023, an initial brain CT scan revealed a left temporal lobe mass with extensive vasogenic edema and a significant midline shift of 4.5mm. In September 2023, a brain MRI confirmed a 3cm rim-enhancing mass in the left temporal lobe with surrounding edema, extending to the left basal ganglia and hemithalamus. The first resection was conducted at that time. A CT scan conducted two days post-surgery revealed residual tumor, surgical hemorrhage, continued midline shift, pneumocephalus, and a small volume of subarachnoid hemorrhage.

MRI spectroscopy from January 2024, compared to the brain MRI from the same month  revealed FLAIR hyperintense signal in the left temporoparietal white matter adjacent to the surgical resection. A head CT/CTA and MRI studies from February 2024 revealed edema in the left temporoparietal lesion with a mass lesion measuring 2.8cm x 2.8cm.

Neuropsychological Findings

The patient was oriented to person, place, and time. She exhibited intact insight. Her premorbid intellectual functioning was presumed to be average, based on her educational and vocational history. On neuropsychological testing, she exhibited average visual-spatial construction, visual-motor integration, and visual perception. She exhibited appropriate spontaneous speech (e.g., singing) and preserved grammar and syntax. The most notable dysfunction was in expressive and receptive language domains. On formal measures of expressive language functioning, she demonstrated significant weaknesses in areas of fluency, repetition of speech, and confrontation naming. She was observed to have significant difficulty following complex, multi-step instructions, and conversational speech that was offered quickly. Although measures of learning, memory, attention, and executive functioning were selected carefully, taking her language deficits into consideration, it is likely that her language weaknesses impacted her performance across these other cognitive domains, as her performance fell substantially below age-expectations across these skills as well. Executive dysfunction in tasks with low language demands (e.g., visual scanning, sequencing, set-shifting) was present.

Treatment Recommendations

The alignment between her language impairments evident on cognitive testing, in conjunction with the imaging findings of a left temporal lesion, provided concrete data to guide subsequent interventions, including speech-language therapy and cognitive rehabilitation programs. Our patient exhibited preserved singing abilities, despite significant deficits in spoken language. While singing may not be an ideal long-term strategy for rehabilitation, it was recommended as an avenue to consider for preserving her expressive communication abilities.

Discussion

This case illustrates clear connections between tumor size, tumor location, and method of treatment with the cognitive outcomes identified through neuropsychological testing. However, this case also underscores the importance of baseline testing within the field of neuro-oncology. Unfortunately, this case is without baseline data (i.e., testing prior to the first resection); baseline evaluations not only assist in determining a patient’s functioning prior to the identification of the tumor, but establishes an understanding of functioning prior to treatment for later comparison in the face of waxing and waning and/or deterioration. Although we may rely on tumor and treatment characteristics and typical neuropsychological outcomes to predict areas of deficit, each patient presents with a unique premorbid cognitive profile, thus increasing the importance of baseline data.