Glioblastoma NOS (subtle abnormality on CT)

Case contributed by Dr Bruno Di Muzio

Presentation

Acute onset dysphasia. ?acute stroke

Patient Data

Age: 72-year-old
Gender: Male
CT

CT Brain - Stroke code

Pre and post contrast.

There is subtle abnormality in the left posteromedial temporal lobe, lateral to the trigone of the left lateral ventricle. The hyperdensity becomes more conspicuous on post contrast imaging. There is suggestion of mild mass effect on the trigone of left lateral ventricle. No midline shift. Elsewhere there is no mass or collection.

CONCLUSION: Given the inherent hyperdensity within the left posterior temporal lesion abnormality findings are suspicious for tumour. Dedicated MRI (glioma protocol) is recommended.​

MRI

MRI Brain (glioma protocol)

 

Technique: Multiplanar, multisequence imaging has been obtained through the brain including pre and post contrast sequences, MR perfusion and MR spectroscopy. Comparison made with the previous CT and MRI studies from the previous weeks.

Findings: Within the left posteromedial temporal lobe a lesion with dimensions of 16 mm x 15 mm x 14 mm ( CC x trans x AP ) demonstrates irregular nodular enhancement. The lesion has intrinsic low T1/high T2 signal. There is minimal surrounding FLAIR abnormal signal. This is probably contiguous with an abnormality within the posterior aspect of the left middle temporal gyrus that has cortical FLAIR hyperintense signal and gyral expansion, associated sulcal effacement and local nodular sulcal enhancement.

No susceptibility artefact to suggest recent or previous haemorrhage or calcification. DWI signal within the white matter lesion is hyperintense without low ADC value.

Perfusion studies demonstrate elevated cerebral blood volume. Spectroscopy (not shown) reveals reversal of choline: creatine ratio with a slight decrease in NAA. Elevated choline extends beyond the FLAIR/enhancing abnormality. No elevated myoinositol. No definite bony remodelling.

Conclusion: Overall the findings within the left temporal lobe are most in keeping with tumour. Although slightly unusual, a glial series tumour, particularly a higher grade astrocytoma or oligodendroglioma with the elevated CBV, with local leptomeningeal involvement, is thought most likely.

 

Case Discussion

Patient presenting to the emergency department with acute symptoms that lead the treating team to consider stroke. CT non-contrast revealed a subtle left temporal lobe hyperdensity that could be easily missed and was spotted with the help of sagittal and coronal reformattings.  

The patient went on to have surgery. 

Histology

MICROSCOPIC DESCRIPTION: The sections show fragments of a moderately hypercellular glial tumour mixed with fragments of a blood clot. Tumour cells have fibrillary astrocytic morphology and show moderate nuclear and cellular pleomorphism. Scattered mitotic figures are identified. There is microvascular proliferation with multi-layering of atypical cells around vessel lumena. A small focus of necrosis is present at the edge of one fragment. The features are of glioblastoma (WHO grade IV).

DIAGNOSIS: Glioblastoma (WHO Grade IV).

 

Glioblastomas are the most common primary brain tumour at this age group and usually present as an irregular enhancing masses with central necrotic components. 

Note: IDH mutation status is not provided in this case and according to the current (2016) WHO classification of CNS tumours, this tumour would, therefore, be designated as a glioblastoma NOS

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Case information

rID: 42266
Case created: 13th Jan 2016
Last edited: 29th Jun 2017
Tag: rmh
Inclusion in quiz mode: Included

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