Diffuse brainstem glioma

Case contributed by Dr Mostafa El-Feky

Presentation

Seizures, confusion and fainting attacks.

Patient Data

Age: 45 years
Gender: Male
MRI

Diffuse pontine expansion extending to the cerebral peduncles, notably the left one. The expansion is measuring 3 x 3.5 x 3.2 cm. It is expressing T1 isointense, T2 and FLAIR slightly hyperintense signals. Faint enhancement is noted at the posterior aspect of the pons on postcontrast T1. 

The expansion exerts effacement of the basal cisterns and reduction of the mamillopontine distance up to 5 mm. No edema is noted along the brainstem.

There is near-normal/no diffusion restriction, the mean ADC value of the lesion = 0.933 x 10-3 mm2/sec as compared to the brain 0.924 x 10-3 mm2/sec.

Spectroscopy (TE 135 msec) shows: Cho/Cr ratio =1.03, Cho/NAA ratio=1.76, NAA/Cho ratio = 0.56, NAA/Cr ratio = 0.64 and a small lactate peak.

Case Discussion

Features are suggestive of diffuse brainstem gliomaCholine peak and elevation of Cho/NAA ratio are noted on MR spectroscopy which favor glioma. The pons is the most common location for brainstem glioma with poor prognosis. 

DSC Perfusion-weighted imaging (not uploaded) showed iso-perfused pontine expansion in relation to the brain parenchyma and hypoperfused compared to the cerebellar parenchyma.

In many centers when features are typical, no biopsy is carried out, as biopsies of the brainstem have high morbidity, and histological confirmation often has little impact on treatment. 

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