Gliosarcoma mimicking post-traumatic hemorrhage

Focal hyperattenuating areas with intervening mixed densities are noted in the right temporal parenchyma along the right Sylvian fissure showing perilesional edema.

Thin SDH is noted along the right frontotemporal parietal convexity.

Early mass effect is noted in the form of effacement of sulci, fissures and right lateral ventricle causing midline shift of 4 mm to the left is noted.

Differentials: Ruptured MCA branch aneurysm/hemorrhagic space-occupying lesion.

Suggested CT cerebral angiogram for further evaluation.

CT angiography reveals displacement of the adjacent MCA vessels with no abnormal bulbosity or saccular outpouching. No abnormal vascular nidus was seen. Thus there was no imaging evidence of vascular abnormalities such as an aneurysm or AVM. It was decided to proceed with MRI to exclude non vascular causes.

There is a focal intraparenchymal hemorrhage which is isointense on T1 and heterointense on T2 in the right temporo-polar parenchyma. 

There is early mass effect with effacement of the right lateral ventricle and midline shift of 2 mm to the left side.

It shows few cystic areas and eccentric patchy enhancement most prominently seen on subtracted images along the anteroinferior aspect with gyriform pattern and adjacent dural involvement. Few other punctate areas of enhancement are also noted.

There is a thin SDH measuring 3 mm along the right cerebral convexity.

In view of delayed post-traumatic presentation, unusual imaging pattern with enhancement on subtracted images, and no obvious vascular abnormalities, we suggested histopathological correlation to exclude underlying neoplastic etiology / less likely other atypical infective etiologies. 

HPE confirmed the presence of an underlying high-grade spindle cell neoplasm along with the blood clot. IHC findings were in favor of gliosarcoma.