High grade glioma

Case contributed by Dr Henry Knipe

Presentation

Code stroke. Presents with slurred speech, headache, right hand altered sensation.

Patient Data

Age: 70 years
Gender: Male
Modality: CT

Left frontoparietal mass with positive mass effect. Grey white differentiation is preserved with no evidence of stroke. 

Modality: CT

The mass is ill-defined and heterogeneously, and is intra-axial involving grey and white matter with ill-defined surrounding hypodensity. Only localised mass-effect with no midline shift. 

On perfusion imaging, there is increased CBV in the region of the mass.

Extra-axial homogeneously enhancing 7 mm mass lesion adjacent to the right superior frontal gyrus most likely an incidental meningioma. 

Histopathology:

MICROSCOPIC DESCRIPTION: Sections show fragments of a hypercellular glial tumour. Tumour cells show moderate nuclear and cellular pleomorphism with round to oval nuclei and prominent nucleoli. Frequent mitotic figures are identified. There is microvascular proliferation and areas of pallisaded tumour necrosis. Immunohistochemistry results show tumour cells stain:

  • GFAP Positive (focal)
  • Nestin Positive (high)
  • NogoA Positive
  • IDH-1 R132H Negative (not mutated)
  • ATRX Positive (not mutated)
  • MGMT Negative (likely methylated)
  • p53 Positive
  • p16 CDKN2A Negative

Topoisomerase labelling index: Approximately 40%.

DIAGNOSIS: High grade glioma, IDH1 wild type, favouring glioblastoma (WHO Grade IV).

Case Discussion

Quite often code stroke symptoms are not from acute stroke (both ischaemic and haemorrhagic). Masses can certainly have an acute presentation but other causes include Todd paresis post seizure, migraine and Bell palsy. This patient came through as a "code stroke" and hence CT perfusion images were obtained where they would not be part of the routine space occupying lesion CT work-up (but are often done on MRI work-up). 

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Case Information

rID: 46246
Case created: 28th Jun 2016
Last edited: 11th Jul 2016
Inclusion in quiz mode: Included

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