Presentation
Generalized tonic-clonic seizure.
Patient Data
Multiple areas of increased T2 signal involving the cortex are seen on the right with a number of much smaller areas of contrast enhancement, the largest of which is superficial and associated with probable leptomeningeal enhancement.
Presence of non-enhancing cortical tumor is consistent with a diffuse glioma.
MRI a few months later
Repeat MRI a few months later demonstrates a large area of FLAIR hyperintensity involving the cortex and extending to the peritrigonal white matter. Several areas of mass like enhancement within the FLAIR hyperintensity are present. Prominently elevated CBV with prominent elevated choline and lactate with reduced NAA. Local mass effect, with distortion of the trigone
Conclusion: Findings are most in keeping with a multifocal glioblastoma.
Case Discussion
The patient went on to have surgery.
Histology
MICROSCOPIC DESCRIPTION: The sections show features of a densely cellular astrocytic tumor. The tumor cells have elongated, angulated and hyperchromatic nuclei. Scattered mitotic figures are identified. There are foci of microvascular proliferation. Areas of palisaded necrosis are present.
The tumor cells are:
- p53: positive
- IDH1-R132H: negative
- MGMT: negative (likely methylated).
- ATRX: non-mutated
FINAL DIAGNOSIS: glioblastoma (WHO Grade IV), IDH-wildtype.