Presentation
New development of speech disturbance, dysphasia. Clinical team wanted to exclude any contraindications to thrombolysis for ischaemic stroke.
Patient Data
No haemorrhage, recent infarct or hyperdense vessel.
Small cystic structure in left temporal lobe.
Solitary left temporal cystic lesion, centred on grey/white matter junction.
Faint peripheral enhancement. No nodule.
Surrounding cortical thickening, hyperintense on T2w. High local FLAIR signal.
No infarct or DWI abnormality.
Increase in size of left temporal lesion, including the internal cystic component, surrounding enhancement with a posterior nodule, and white matter FLAIR abnormality. Some SWI abnormality compatible with blood products.
Some imaging features shared with ganglioglioma or DNET, but the rapid increase, enhancement pattern and blood products are more concerning for a more aggressive process such as metastasis or glioblastoma.
Case Discussion
Histology findings:
Microscopy: pleomorphic astrocytic tumour which diffusely infiltrates surrounding brain tissue. Predominantly composed of gemistocytic cells although some regions or more cohesive small cell apearance. Microvascular proliferation and intrinsic tumour necrosis identified.
Immunohistochemistry:
GFAP positive
MIB1 high index proliferation
ATRX positive (not mutated)
IDH1 negative (not mutated)
H3K27M negative
P53 focal upregulation
NeuN and synapthophysin in surrounding cortical tissue but negative within the tumour
MGMT 1.1% (unmethylated)
Comment: left temporal glioblastoma, WHO grade 4, IDH1 wild-type, unmethylated
Discussion:
New onset seizures in adults >40 years old merit neuroimaging with trauma, vascular disease and tumours common causative conditions.
Although there are a variety of smaller low grade tumours typically considered epileptogenic, high grade tumours such as glioblastoma should be in consideration. Small cortical lesions can initially present with seizures rather than the headaches or focal neurological deficits larger lesions elicit.
Unable to process the form. Check for errors and try again.