Three years ago, Emily Gillespie, then 16, was a healthy and active teen at the height of her ballet career.

In June 2016, she began to have minor headaches. She also heard a faint noise in her ears — she described it as a “whooshing” — and experienced changes in vision when she would stand up. Over the next month, she continued having episodes when she would see black for a few seconds, but it would always resolve itself.

Emily visited her pediatrician, who thought it may be orthostatic hypotension, a form of low blood pressure that occurs when you stand up from sitting or lying down. The condition is a common occurrence in healthy adolescent girls. Emily was advised to drink more water, as dehydration is a known cause of orthostatic hypotension.

During this time, Emily continued to do well in school with no other concerning symptoms. She danced in ballet class without missing a step. She was determined not to let her symptoms interfere with her daily life. But then her symptoms worsened.

Emily Gillespie, center, dancing in a 2018 performance.
Family photo
Emily Gillespie, center, dancing in a 2018 performance.

Within a few weeks, she started to hear the “whooshing” sound more frequently in her right ear when lying down. Doctors diagnosed her with pulsatile tinnitus, a perception of noise that comes from inside the patient’s body. She had no neurological deficits and no symptoms to accompany the headaches that might suggest increased pressure in the brain, such as vomiting.

Emily’s mother decided to take her to an eye doctor for evaluation. This proved to be critical in finding out the cause of these mysterious symptoms.

Solution

The eye specialist immediately noted that Emily had papilledema, swollen optic nerves, and recommended an MRI.

The MRI showed a two-inch tumor inside her brain. Doctors were amazed that Emily was able to continue to perform solos in ballet up to the day before admission with this large of a tumor growing inside her brain.

An MRI shows Emily Gillespie's brain tumor.
CHOP
An MRI shows Emily Gillespie's brain tumor.

Emily was referred to me and we scheduled her for surgery to remove the tumor a couple of days after diagnosis.

Before surgery, Emily was upbeat. Her only concern was how much of her hair I would have to shave, which is the most common question I get asked before brain surgery.

After 14 hours of operating, I removed the entire tumor. The tumor was calcified, meaning it was hard like a rock and very difficult to remove all of it. Normally we use an ultrasonic aspirator, a surgical tool that uses low-frequency vibrations to fragment tissue, at a power of 30-40. For Emily’s tumor, I had to increase the power to 90-100 in order to remove certain areas of the tumor.

We sent the tumor to pathology for a diagnosis.

After surgery, Emily woke up immediately and was eating popsicles that night. She was out of the hospital in a few days and back to dancing just one month later.

Emily Gillespie, right, pictured with her aunt a few days after surgery to remove her tumor.
Family photo
Emily Gillespie, right, pictured with her aunt a few days after surgery to remove her tumor.

Pathology showed she had a meningioma, which is typically a benign tumor that forms in the dura (outer covering of the brain) or spinal cord. But Emily’s tumor had no connection with the dura and was, in fact, in the deepest portions of her brain. This occurs in less than 1 percent of all meningiomas.

This type of tumor is also very unusual at Emily’s age. They are more commonly seen in patients over age 50.

Today, Emily has completely resumed her normal life. She continues to dance and is currently in college. Follow-up MRIs have shown no recurrence of the tumor.

This case illustrates how critical it is for physicians (as well as patients and their families) to continue searching for possible causes that are “outside of the box.” Most patients will have a very common diagnosis, but there are always the “zebras” that should be on the differential.

Shih-Shan Lang Chen, MD, is an attending neurosurgeon in the division of neurosurgery at Children’s Hospital of Philadelphia.