Presentation
The patient presented with a recently developed, headache after a symptom-free, post-op period.
Patient Data
There is an ill-defined, intra-axial, mass-like hyperintense signal that incompletely suppresses on FLAIR (T2/FLAIR mismatch sign) with near CSF intensity component of about 3.8 x 7.5 cm, which is centered on left temporoparietal region with mass effects as compression of the adjacent brain parenchyma, left lateral ventricle, left basal ganglia, thalamus, mid-brain and mid-line shift (up to 10.0 mm) towards the right.
No post-contrast enhancement is seen.
The calvarial defect is noted in the left front-parietal region.
After follow up of about 6 months the mass lesion is enlarged in size with avid enhancing solid component.
Case Discussion
This case was first interpreted as an extra-axial lesion, thought to be an arachnoid cyst secondary to surgery for a previously resected brain tumor. After reviewing and guidance from senior members it was correctly interpreted as an intra-axial recurrent/residual tumor with a positive T2-FLAIR mismatch sign which is quite specific for astrocytoma, IDH mutant.
Familiarity with this sign is important to avoid important interpretation errors.
After follow up for about 6 month disease process showed interval progression and confirmed WHO II diffuse glioma.
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