Presentation
headache of long standing duration
Patient Data
MRI showed a rim enhancing necrotic mass in left parieto-occipital region with significant surrounding edema.
Note that the edema crosses the splenium of corpus callosum.
Spectroscopy was done at the rim of the leison and showed elevated cho/cr ratio, however the ratio was not grossly elevated, further prominent lipid/lactate peaks were found and the Cho/NAA ratio was reduced and not increased as one would expect.
This feature confounded the diagnosis of a glioma, tuberculoma can show mildly elevated cho/Cr and shows prominent lipid/lactate peaks. Tumefactive demyelination can have a similar picture as well.
Perfusion imaging was done to further characterize the lesion. It showed a raised rCBV value of 3.35 compared to contralateral normal brain.
Case Discussion
The operative findings, in this case, revealed a necrotic whitish mass. Histopathology revealed a glioblastoma.
Perfusion can be used as a problem-solving technique in equivocal cases as well as to confirm radiological suspicion
It can be integrated into an algorithm as given in the excellent article quoted below.
Note: IDH mutation status is not provided in this case and according to the current (2016) WHO classification of CNS tumors, this tumor would, therefore, be designated as a glioblastoma NOS.