case_images: PMC5820902_01
case_images: Preoperative scan prior to first surgery. Axial T2: Increased T2 signal involving grey and white matter in right temporal lobe anteriorly, extending into the right ganglionic region infralaterally within which a reasonably well defined "mass" containing several small "encystic" foci infralaterally is apparent. (Top Row). Axial and coronal T1 (+-gadolinium): Enhancement of the central component in the temporal lobe extending into the ganglionic region infralaterally; apart from the foci of cystic change (middle and bottom row)
case_images: AJNS-13-78-g001.jpg
case_images: PMC5820902_01_AJNS-13-78-g001.jpg
case_images: F1
case_images: Magnetic resonance imaging (MRI) brain [Figure 1] revealed a right temporal lobe enhancing lesion extending into the frontal lobe with extensive surrounding edema causing significant mass effect with a likely radiological diagnosis of glioblastoma.
case_images: Postoperative scan within 48 h of surgery. Axial FLAIR (fluid attenuated inversion recovery): Postoperative cavity from right temporal lobectomy. Residual deep tumor extending into ganglionic region
case_images: AJNS-13-78-g002.jpg
case_images: PMC5820902_01_AJNS-13-78-g002.jpg
case_images: F2
case_images: After discussion at the multi-disciplinary meeting, he underwent craniotomy and right temporal lobectomy for debulking of the lesion with a satisfactory 48-h postoperative MRI [Figure 2] and an uneventful postoperative recovery.
case_images: Histology of tissue from the first operation revealed widespread necrosis (a, low power) with hypercellularity (b) on high power. The Ki67 proliferation index was brisk (c). The necrosis showed a laminar pattern with perivascular lymphocytic cuffs (d, high power and e, low power). In a few small foci, astrocytes showed quite marked nuclear atypia (d and f)
case_images: AJNS-13-78-g003.jpg
case_images: PMC5820902_01_AJNS-13-78-g003.jpg
case_images: F3
case_images: Histology [Figure 3] revealed widespread infarction, with some sparing of cortical layer I.
case_images: Preoperative scan prior to second surgery. Axial FLAIR (fluid-attenuated inversion recovery)- post operative cavity effaced by enlargement of the mass. More extensive increased T2 signal anterosuperiorly (Top row). Coronal T1 with gadolinium - enhancing mass now fills the previous postoperative cavity and is more extensive in the right ganglionic region (bottom row)
case_images: AJNS-13-78-g004.jpg
case_images: PMC5820902_01_AJNS-13-78-g004.jpg
case_images: F4
case_images: A repeat MRI [Figure 4] revealed recurrence of his temporal lesion and in view of his equivocal diagnosis, diffusion and perfusion-weighted MRI and MR spectroscopy was performed which revealed features suggesting a highly aggressive tumor.
case_images: Histology of tissue from the second operation showed much more marked hypercellularity with glial fibrillary acidic protein expression in immunohistochemistry (a and b). The Ki67 proliferation index was much higher (c). The cell density and atypia was more marked than in the first specimen (d) and there was vascular proliferation (e) and necrosis (f)
case_images: AJNS-13-78-g005.jpg
case_images: PMC5820902_01_AJNS-13-78-g005.jpg
case_images: F5
case_images: Histology [Figure 5] from the second operation differed from the first specimen by having much more extensive regions of glial hypercellularity with nuclear atypia, an elevated Ki67 proliferation index, mitotic figures and dense glial fibrillary acidic protein immunoreactivity.