High grade glioma, NOS grade 4

Case contributed by Dalia Ibrahim


Headache and recent seizures.

Patient Data

Age: 30 years
Gender: Female

Right temporal, insular, and frontoparietal deep periventricular/basal ganglia areas of abnormal signal eliciting high signal on T2 & FLAIR WI. The parietotemporal deep periventricular patches show diffusion restriction and areas of mild heterogenous post-contrast enhancement. They exert a positive mass effect in the form of compression of the right lateral ventricle.

MRS showed markedly elevated Choline peak and Cho/Cr ratio, reduced NAA.

Radiological findings are suggestive of high-grade glioma (grade 3 or 4).

Stereotactic biopsy


Stereotactic biopsy of the deep periventricular parietal lesion showed grade 4 diffuse astrocytic tumor.

Case Discussion

The lesion is seen involving the right temporal, insular, deep frontotemporal-parietal, and basal ganglia lesions, however, the posterior parietotemporal lesions show aggressive features such as diffusion restriction and heterogeneous patchy contrast enhancement.

Biopsy was obtained from the posterior deep periventricular and revealed grade 4 astrocytic tumor. 

In this instance, as IDH status has not been established it is not possible to distinguish between glioblastoma or a grade 4 astrocytoma IDH-mutant. However, the age group of the patient and the less aggressive features of the tumor seen involving the frontal and temporal lobes with lack of enhancement would suggest a malignant transformation of a low-grade astrocytoma or IDH mutant-grade IV astrocytoma.


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