Presentation
Acute onset dysphasia. ?acute stroke
Patient Data
Pre and post contrast.
There is subtle abnormality in the left posteromedial temporal lobe, lateral to the trigone of the left lateral ventricle. The hyperdensity becomes more conspicuous on post contrast imaging. There is suggestion of mild mass effect on the trigone of left lateral ventricle. No midline shift. Elsewhere there is no mass or collection.
CONCLUSION: Given the inherent hyperdensity within the left posterior temporal lesion abnormality findings are suspicious for tumor. Dedicated MRI (glioma protocol) is recommended.
Technique: Multiplanar, multisequence imaging has been obtained through the brain including pre and post contrast sequences, MR perfusion and MR spectroscopy. Comparison made with the previous CT and MRI studies from the previous weeks.
Findings: Within the left posteromedial temporal lobe a lesion with dimensions of 16 mm x 15 mm x 14 mm ( CC x trans x AP ) demonstrates irregular nodular enhancement. The lesion has intrinsic low T1/high T2 signal. There is minimal surrounding FLAIR abnormal signal. This is probably contiguous with an abnormality within the posterior aspect of the left middle temporal gyrus that has cortical FLAIR hyperintense signal and gyral expansion, associated sulcal effacement and local nodular sulcal enhancement.
No susceptibility artefact to suggest recent or previous hemorrhage or calcification. DWI signal within the white matter lesion is hyperintense without low ADC value.
Perfusion studies demonstrate elevated cerebral blood volume. Spectroscopy (not shown) reveals reversal of choline: creatine ratio with a slight decrease in NAA. Elevated choline extends beyond the FLAIR/enhancing abnormality. No elevated myoinositol. No definite bony remodeling.
Conclusion: Overall the findings within the left temporal lobe are most in keeping with tumor. Although slightly unusual, a glial series tumor, particularly a higher grade astrocytoma or oligodendroglioma with the elevated CBV, with local leptomeningeal involvement, is thought most likely.
Case Discussion
Patient presenting to the emergency department with acute symptoms that lead the treating team to consider stroke. CT non-contrast revealed a subtle left temporal lobe hyperdensity that could be easily missed and was spotted with the help of sagittal and coronal reformattings.
The patient went on to have surgery.
Histology
MICROSCOPIC DESCRIPTION: The sections show fragments of a moderately hypercellular glial tumor mixed with fragments of a blood clot. Tumor cells have fibrillary astrocytic morphology and show moderate nuclear and cellular pleomorphism. Scattered mitotic figures are identified. There is microvascular proliferation with multi-layering of atypical cells around vessel lumena. A small focus of necrosis is present at the edge of one fragment. The features are of glioblastoma (WHO grade IV).
DIAGNOSIS: Glioblastoma (WHO Grade IV).
Glioblastomas are the most common primary brain tumor at this age group and usually present as an irregular enhancing masses with central necrotic components.
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.
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