Presentation
Chronic headache. Behavioral changes.
Patient Data
There is a hypodense cystic mass in the left basal ganglia region with a hyperdense rim showing suspicious nodular thickening and surrounding perifocal edema causing mild midline shift to the right and partial left ventricular compression. There is a hyperdense region in the left temporal lobe.
An MRI was performed for better evaluation.
There is a space-occupying intra-axial mass in the left internal capsule. It has a central T1 hypointense, and T2 hyperintense core. According to the ADC map, it has elevated diffusion levels compared to normal brain tissue except for a thin peripheral rim, which shows diffusion restriction. The latter is the solid component around the cystic part of the tumor. On SWI images, there are small blooming artefacts.
In the contrast-enhanced images, we can see a clear, hyperintense ring around the mass. There is a minor stand-alone ring enhancement in the para-olfactory area, but it is the same in all other respects as the previous one.
Around the mass, there is an irregular perifocal elevation of diffusion on the ADC map, representing vasogenic edema. The left ventricle is partially compressed.
Case Discussion
This intra-axial tumor is a ring-enhancing lesion, which has a fairly broad differential.
It has a nodular wall which is more common in a neoplasm. The ring is complete, making demyelination less likely. There is a diffusion restriction in the wall which favors a highly cellular tumor like glioblastoma. The fluid content doesn't show diffusion restriction making an abscess unlikely and instead, a tumor with a central necrosis a more likely diagnosis. The smaller lesion adjacent to the bigger, primary lesion favors multifocal glioblastoma.
Biopsy confirmed the diagnosis of glioblastoma multiforme, IDH wildtype.
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