Presentation
Seizure.
Patient Data
A left temporal lobe poorly marginated, hypodense lesion is seen and demonstrates a contrast enhancing rim.
The periphery of the lesion appears to extend into the left frontal lobe superiorly. A further 5mm rim contrast enhancing focus is shown in the left frontal lobe further superiorly.
Extensive surrounding vasogenic edema results in sulci effacement, effacement of the left Sylvan fissure and of the ventricular system. Associated 8 mm right sided midline shift.
In the posterior fossa, there is a retrocerebellar hypodensity shown most consistent with an arachnoid cyst.
No other intra or extra-axial mass, collection or acute focal abnormality is identified.
No suspicious bony lesion.
Conclusion:
Left temporal poorly marginated, hypodense and rim contrast enhancing lesion is thought most in keeping with a high-grade astrocytoma. Extensive surrounding vasogenic edema.
Retrocerebellar arachnoid cyst.
Within the left temporal lobe anteriorly there is a mass which is predominantly isointense on T1/T2 weighted sequences and demonstrates irregular enhancement on post-contrast imaging.
On these susceptibility weighted images, there are foci of low signal demonstrated inferiorly within the lesion. Foci of high signal intensity on the diffusion weighted imaging consistent with high cellularity.
The mass demonstrates vasogenic/tumoral edema extending to the temporal lobe including the posterior limb of the internal capsule. There is approximately 9 mm of midline shift towards the right.
No hydrocephalus. Right cerebral hemispheric sulcal effacement.
MRS within the central aspect of the mass demonstrates the presence of lactate and the absence of other metabolites.
CBV at the margin of the lesion demonstrates increased vascularity.
Also seen within the posterior fossa is an extra-axial mass which demonstrates T2 hyperintensity and FLAIR suppression measuring 3.8 cm overlying the superior aspect of the left cerebellum consistent an arachnoid cyst
The patient underwent tumor resection (confirming the diagnosis of glioblastoma) and Stupp protocol. For a year after the diagnosis, he was followed up with MRI studies that have shown stable FLAIR signal abnormalities on the left temporal lobe.
New enhancing mass lesions are seen, within the left temporal lobe posterior to the temporal horn of the left lateral ventricle, as well as in the left posterior thalamic region, posterior to the left cerebral peduncle. This areas have reduced ADC and equivocal elevated cerebral blood volume (CBV). MR spectroscopy is non-contributory. Mildly increased FLAIR signal.
Conclusion: Disease progression with 2 new areas of contrast enhancement.
Case Discussion
First CT and MRI showing typical features that lead to a GBM diagnosis on imaging. This tumor is extremely aggressive and average survival is around 12 months after the diagnosis. Even with the standard treatment, which consists of surgical resection followed by radiotherapy and temozolomide, the tumor usually recurs after some months (disease progression).
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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