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Axial FLAIR (Fig 1) and coronal T2 (Fig 2) images of the brain demonstrate an infiltrative hyperintense mass diffusely involving the entire brainstem, left thalamus/basal ganglia and the white matter of the entire left cerebral hemisphere. The involved structures are enlarged causing mass effect with rightward midline shift and partial effacement of the left lateral ventricle. The right internal capsule and midbrain also demonstrate subtle FLAIR and T2 hyperintensity suspicious for neoplastic infiltration as well. No enhancement is seen on the coronal post contrast T1 image (Fig 3).
Gliomatosis cerebri is an infiltrative glial tumour growth pattern with involvement of at least three lobes of the brain and frequently bilateral. Interhemispheric spread of disease is achieved via the commissural fibres and interthalamic adhesion. The involved structures are diffusely enlarged causing regional mass effect with midline shift, herniation or sulcal effacement. Gliomatosis cerebri typically do not demonstrate enhancement unless complicated by foci of higher grade malignant progression.
Importantly, whereas gliomatosis was previously considered a distinct entity, since the 2016 update to the WHO classification of CNS tumours it is now merely thought of as a growth pattern.