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Case 375

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A 59-year-old man presented with a one-month history of headache, reduced visual acuity, difficulty with balance and walking and intermittent episodes of memory loss. On examination, patient was alert, oriented, with right homonymous hemianopsia at confrontation testing of the visual field, lowering of the right lower limb during the Mingazzini manoeuver and right hemiparetic gait. Magnetic resonance image (MRI) of the brain is shown (Images 1-4).

Considering the clinical and radiological findings, what is the most likely diagnosis?

a) Glioblastoma

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b) Primary central nervous system lymphoma

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c) Brain abscess

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d) Brain metastases

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Image Analysis

 

Image 1: T1-weighted non-contrast-enhanced magnetic resonance image (MRI) of the brain, sagittal view showing an expansive and heterogeneous mass, mostly hypointense, in the left temporo-parieto-occipital area, with necrosis (green arrow) and perilesional vasogenic edema (in red).

Image 2: T2-weighted MRI of the brain, axial view showing a left temporo-parieto-occipital expansive and heterogeneous mass, affecting the splenium of the corpus callosum, with necrosis (green arrow) and perilesional vasogenic edema (in red), which cause contralateral midline shift.

Image 3: FLAIR MRI of the brain, axial view showing a left temporo-parieto-occipital expansive and heterogeneous mass, affecting the splenium of the corpus callosum, with necrosis (green arrow) and perilesional vasogenic edema (in red), which cause contralateral midline shift.

Image 4: T1-weighted contrast-enhanced MRI of the brain, axial view showing a left temporo-parieto-occipital expansive mass with mostly peripheral heterogeneous enhancement, affecting the splenium of the corpus callosum, with necrosis (green arrow) and contralateral extension.

Highlights

           - Glioblastoma (GBM) is one of the most common and lethal malignant tumor of the central nervous system, with astrocytic origin (grade IV);

           - There is a slight male preponderance, with a peak incidence between 45 and 70 years of age and the only risk factor identified until now is prior radiation exposure;

           - Patients typically present with progressive symptoms and evolve over the course of 3 months; main symptoms are: headache, focal neurologic symptoms, intracranial hypertension and seizures;

           - Patients with a suspected GBM should undergo MRI of the brain and confirmation of the diagnosis is given by histopathological analysis;

           - Initial treatment is surgical resection with adjuvant radiation therapy and chemotherapy; prognosis is poor.

References

           - Rocha AJ, Vedolin L, Mendonça RA. Encéfalo. Colégio Brasileiro de Radiologia. Rio de Janeiro: Elsevier, 2012;

           - Heemann GC, Heemann ACC. Glioblastoma multiforme recém-diagnosticado: diagnóstico e tratamento cirúrgico inicial. Acta Médica, vol. 39, nº 2, 2018;

           - Osborn, Salzman, Barkovich, Katzman, Provenzale, Harnsberger, Blaser, Ho, Hamilton, Jhaveri, Illner, Moore, Thurnher, Harder, Jones, Loevner, Lesbit, Vézina, Hedlund, Raybaud, Grant, Ng, Anzai, Rees, Quigley, Anderson, Shah, Rassner. Diagnóstico por imagem: cérebro. 2nd edition. Ed. Guanabara Koogan, 2011;

           - Cunha MLV, Júnior FAA, Veríssimo DCA, Rehder R, Maingue JA, Silva PEC, Bark SA, Borba LAB. Gliomas múltiplos: relato de caso e revisão de literatura. J Bras Neurocirurg 21(2): 107-110, 2010;

           - Cunha MLV, Esmeraldo ACS, Henriques LAW, Júnior MAMS, Medeiros RTR, Botelho RV. Elderly patients with glioblastoma: the impact of surgical ressection extent on survival. Rev Assoc Med Bras 2019, 65(6): 745-754.

Author

Felipe Eduardo Fagundes Lopes, 5th year medical student at Universidade Federal de Minas Gerais (UFMG).

E-mail: felipelopes.med[at]outlook.com

Supervisor

Alexandre Varella Giannetti, neurosurgeon at Hospital das Clínicas da UFMG and associated professor of the Department of Surgery at UFMG.

 

Paola Isabel Silva Barros, radiologist at Hospital das Clínicas da UFMG and professor of the Department of Anatomy and Image at UFMG.

Reviewers

Gustavo Vargas Borgongino Monteiro, André Marzano, Jhonatas Pereira Santos, Letícia de Melo Elias and Professor Júlio Guerra Domingues.

Translated by

Gabriella Yuka Shiomatsu, 5th year medical student at UFMG

E-mail: gabriellashiomatsu[at]gmail.com

Test question

(CESPE-UnB – Medical Residency Examination, 2009).

Nowadays, computed tomography (CT) and/or magnetic resonance image (MRI) are essential for diagnosis and monitoring of brain tumors. These imaging exams allow the description of some typical characteristics that influence even in the choice of the best area for biopsy. Regarding this subject, choose the right answer.

a) Glial tumors behave similarly to normal parenchyma, that is, with focal tissue expansion and necrosis; however, without hemorrhage or enhancement; they are usually low grade lesions;

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b) Areas of necrosis should be chosen for biopsy in tumors;

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c) CT is superior to MRI for assessment of tumors in the posterior fossa;

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d) MRI is the exam of choice for patients with cardiac pacemakers;

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e) Enhanced tumors, hemorrhage and/or necrosis, in general, are those with the highest degree of malignancy and present infiltration of adjacent tissues, as classically occurs in glioblastoma.

25%
   

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