Glioblastoma

Case contributed by Dr Edward Ganly

Presentation

Collapse, prolonged seizure. History of alcohol abuse. Gram negative bacteremia.

Patient Data

Age: 70 years
Gender: Male

initial presentation

CT
  • 35 x 21 x 23 mm well circumscribed focal area of hypodensity within the right frontal lobe. This shows rim enhancement with a small amount of neighboring vasogenic edema.
  • Mild effacement of neighboring sulci and lateral ventricle temporal horn.
  • No associated hemorrhage.
  • Other patchy areas of subcortical white matter hypodensity that do not enhance, consistent with small vessel ischemic change.
  • Grey-white differentiation is otherwise normal.
  • There is opacification in the left frontal, anterior ethmoidal and the visualized aspect of superior left maxillary sinuses.

1 month later, post-craniotomy

CT
  • The rim enhancing lesion has increased in size to 48mm x 42mm x 38mm
  • Increasing vasogenic edema and mass effect on the right lateral ventricle
  • 2mm midline shift

Case Discussion

  • The lesion was initially presumed to be a cerebral abscess after discussion with the neurosurgery on-call team and he was commenced on ceftriaxone and metronidazole (allergy to penicillin).
  • He was given comprehensive treatment for his alcoholism and malnutrition with a significant improvement over the treatment phase.
  • His level of consciousness returned to normal but he had a persistent left homonymous hemianopia and resting upper motor neuron right facial weakness.
  • After the follow up CT showed increasing size of the lesion, urgent aspiration was recommended.
  • Needle aspiration of the lesion produced xanthochromic clear fluid which clotted
    on reduction of temperature to ambient room temperature, consistent with fluid from a high grade glioma.

Histology:
Sections show brain tissue involved by a cellular and infiltrative tumor. The tumor cells have enlarged, angulated and hyperchromatic nuclei and abundant fibrillary cytoplasm. Mitotic figures are numerous and there are foci of glomeruloid microvascular proliferation and necrosis. Acute inflammation is not prominent. Appearances are of glioblastoma, WHO grade 4.
This is a historical case, and IDH mutation status was not routinely assessed at the time.

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