Butterfly glioma

Discussion:

Further history revealed that she had this speech problem for a couple of years which started worsening in the last 3-4 weeks, leading to complete aphasia at the time of presentation. There was also a history of hypothyroidism due to Hashimoto's (Lymphocytic) thyroiditis.

A stereotactic brain biopsy was done and a diagnosis of glioblastoma, IDH wild-type (negative IDH-1 and IDH-2 mutations) was made. MGMT promoter methylation was present.

Due to the highly malignant nature and location of the tumor, no surgery was offered.  The patient was managed conservatively with steroids, tracheostomy, and mechanical ventilation to support fetal maturation; however, her general condition further deteriorated and an emergency C-section was done (around 25 weeks of gestation) due to fetal distress & severe oligohydramnios. 3 weeks later (within two months of the initial presentation), the patient died due to cardiopulmonary arrest.

Glioblastoma, a high-grade astrocytoma (WHO grade IV), is an aggressive primary tumor of the central nervous system. In approximately 3% cases of GBM, the tumor extends inter-hemispherically across the midline through the corpus callosum, simulating the wings of a butterfly. Frontal butterfly gliomas are more common than posterior butterfly gliomas (like this case). Butterfly GBM is a fatal diagnosis with a reported survival rate of a few weeks to months. Complete excision is usually not possible due to the infiltrative nature and bilateral extension of the tumor. Differential diagnosis includes primary CNS lymphoma, tumefactive demyelination, cerebral toxoplasmosis & rarely cerebral metastases.

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