Presentation
Headache, dizziness, and vertigo associated with nausea, vomiting, and decreased level of consciousness for three weeks. No seizures, neurological deficit, or sphincter disturbances.
Patient Data
A heterogeneous focal space-occupying lesion with surrounding vasogenic edema is seen in the right occipital lobe. Mild mass effect is seen over the underlying right lateral ventricle.
Findings: A confluent space-occupying lesion involving the right occipital lobe, white matter along the temporal horn of the right lateral ventricle, splenium of the corpus callosum, and the adjacent dentate gyrus, as well as para-hippocampal gyrus, is noted. A smaller focal lesion is seen in the left occipital lobe. The larger right cerebral lesion is isointense on T1 and mildly hyperintense on T2 weighted images. This lesion has central necrosis, minimal internal bleed, mild diffusion restriction, surrounding vasogenic edema, and shows moderate heterogeneous enhancement. Mild mass effect is seen over the occipital horn and atrium of the right lateral ventricle; minimal contralateral midline shift is also seen.
Impression: Enhancing supratentorial brain lesions; possible differential diagnosis includes lymphoma and multicentric glioblastoma.
Status post right occipital craniotomy for brain tumor biopsy. Postsurgical changes (small amount of air & intraparenchymal hemorrhage) are noted in the right occipital lobe.
Case Discussion
Procedure: Right occipital craniotomy and excisional biopsy.
Diagnosis: Glioblastoma, IDH wild-type, WHO grade IV.
Tumor cells immunoreact positively for GFAP (polyclonal), S100 (polyclonal), and negatively for IDH1 (H09) and P53 (D0-7). The proliferation index is high at about 40-50% using Ki-67 (MIB-1).
Tumor tissue is positive for MGMT promoter methylation.
In this case, the right cerebral lesion has connecting T2/FLAIR signal abnormality, and appears to be multifocal glioblastomas; however, the presence of an enhancing discrete lesion in the left occipital lobe with intervening normal brain parenchyma between the two lesions, is suggestive of multicentric glioblastomas.