Presentation
Right-sided paresthesia.
Patient Data
Large lobar intraparenchymal hematoma centered in the left parietal lobe, with pronounced surrounding edema particularly inferior to the lesion with mass effect.
CTA (not shown): The circle of Willis and intracranial arteries are unremarkable, with no aneurysm, significant stenosis or vascular malformation.
Conclusion: Large intraparenchymal hemorrhage with prominent surrounding vasogenic edema raises the possibility of an underlying intracranial tumor.
The heterogeneous lesion within the left frontoparietal white matter shows susceptibility, consistent with intraparenchymal hemorrhage. On the postcontrast imaging, there is an irregular enhancing rim, which extends toward the ventricle. Significant surrounding T2 hyperintense signal abnormality is noted. There is local mass effect, with sulcal effacement. No subfalcine line or transtentorial herniation. The lesion is solitary, with no further intracranial mass identified. Periventricular white matter T2/FLAIR hyperintensity is consistent with chronic small vessel ischemia. No intracranial aneurysm or other vascular abnormality is demonstrated.
Conclusion: Left frontoparietal tumor, with intratumoral hemorrhage. The location and solitary nature favor high-grade glioma (glioblastoma) over metastasis.
Case Discussion
The patient went on to have a biopsy.
Histology
Sections show multiple fragments of a cellular glial neoplasm. The tumor has significant nuclear pleomorphism with a moderate amount of eosinophilic cytoplasm. Mitotic figures are seen. Endovascular proliferation and necrosis is present.
IMMUNOHISTOCHEMISTRY:
- GFAP - positive
- IDH1 - negative
- ATRX - positive
- p63 - focal staining in 20% of tumor cells
- Ki67 - 20%
FINAL DIAGNOSIS: glioblastoma IDH wild type (WHO grade IV).
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