Presentation
Code stroke. Presents with slurred speech, headache, right hand altered sensation.
Patient Data
Left frontoparietal mass with positive mass effect. Grey white differentiation is preserved with no evidence of stroke.
The mass is ill-defined and heterogeneously, and is intra-axial involving grey and white matter with ill-defined surrounding hypodensity. Only localized 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 tumor. Tumor 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 tumor necrosis. Immunohistochemistry results show tumor 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 labeling index: Approximately 40%.
DIAGNOSIS: High grade glioma, IDH1 wild type, favoring glioblastoma (WHO Grade IV).
Case Discussion
Quite often code stroke symptoms are not from acute stroke (both ischemic and hemorrhagic). 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).