case_images: PMC11799682_01
case_images: (a) Multiple foci of GRE blooming seen in left cerebellum, bilateral temporal, bilateral basal ganglia, frontoparietal and occipital region. (b) Lesions are iso to hypointense on T1W/T2W/Flair-attenuated inversion recovery (FLAIR) images. (c and d) Perifocal edema seen around some of these, largest in right frontoparietal parasagittal region measuring 7 mm in axial plane. (e) Small meningioma was found on left posterior frontal region.
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case_images: F1
case_images: On his regular follow-up imaging the previous year, a new small hyperintense lesion on T2 was observed, suggestive of meningioma (1.5 cm x 2 cm) [Figure 1].
case_images: (a) T2 hyperintense lesion (4.2 x 3.5 cm) in the left frontal region with extensive edema with heterogeneous contrast enhancement suggestive of Glioma .(b-e) Another extra-axial T2 hyperintense lesion is in the left posterior frontal region measuring (2.0 x 2.4 cm) with contrast enhancement suggestive of meningioma.
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case_images: F2
case_images: Magnetic resonance spectroscopy shows reduced N-Acetylaspartate (NAA) with raised choline in the left frontal lesion. Choline/NAA ratio is 5-9 times. Findings are suggestive of glioma.
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case_images: F3
case_images: T1 fat-saturated sequences. The complementary magnetic resonance spectroscopy [Figure 3] showed reduced N-Acetylaspartate (NAA) with raised choline (choline/NAA ratio was 5-9 times). The latter findings suggested the presence of new high-grade glioma.
case_images: Postoperative MRI revealing (a) adequate excision of left frontal glioma and (b) partial excision of left posterior frontal meningioma.
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case_images: F4
case_images: The postoperative period was uneventful [Figure 4], discharged 5 days postoperatively.
case_images: High-grade diffuse glioma with astrocytic morphology and immunoprofile suggestive of IDH wild-type glioblastoma (central nervous system WHO Grade 4) (a) Sections show a diffuse high-grade glioma with astrocytic morphology. There is microvascular proliferation and increased mitosis. However, necrosis is not identified. (b) GFAP: Diffuse and strongly positive. (c) p53: Patchy (wild type). (d) IDH: Negative. (e) Ki67: 20%. GFAP: Glial fibrillary acidic protein, IDH: Isocitrate dehydrogenase (10x magnification).
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case_images: F5
case_images: The subsequent histopathological examination of sample A [Figure 5] revealed atypical neuroglial cells with high nuclear-cytoplasmic ratio on a fibrillary background.
case_images: Psammomatous meningioma (central nervous system WHO grade 1) (a) Sections show whorls of meningothelial cells with bland nuclei with nuclear pseudoinclusions in few. Numerous psammoma bodies were noted. Negative for increased mitosis, necrosis, direct brain invasion, and features of atypical or anaplastic meningioma. (b) EMA: Diffuse positive. (c) PR: Weak positive. EMA: Epithethelial membrane antigen, PR: Progesterone receptor.
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case_images: F6
case_images: Histopathological examination of Sample B [Figure 6] showed oval cells in small clusters with psammoma bodies and no mitosis or necrosis.
case_images: MRI Brain revealing (a) partially excised left posterior frontal meningioma and (b,c) right frontal glioma.
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case_images: F7
case_images: On the MRI brain [Figure 7], a T2 hyperintense lesion (3 x 2 cm) in the right frontal region was identified, suspected to be a new focus of high-grade glioma.
case_images: Postoperative noncontrast computed tomography head suggestive of adequate excision of right frontal glioma.
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case_images: F8
case_images: As a result, a right frontal craniotomy was done; an ill-defined, mildly vascular, gray-colored, aspiratable tumor was excised; the postoperative recovery was uneventful [Figure 8].
case_images: (a) Multiple lobulated heterogeneously enhancing lesions in bilateral cerebral hemispheres, bilateral occipitoparietal region, left high frontal subcortical region, right cerebellar hemisphereprotruding into 4th ventricle. (b and c) Largest lesion is noted in 4th ventricle measuring 4.7x3.9x3.1 cm. (d) Irregular gyral enhancement with associated gyral thickening noted in bilateral occipitoparietal regions, possibility of Cerebrospinal fluid (CSF) spread.
case_images: SNI-16-8-g009.jpg
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case_images: F9
case_images: The ensuing contrast MRI [Figure 9] brain revealed multiple lobulated heterogeneous enhancing lesions in both cerebral hemispheres and the region of the right cerebellum, not seen on previous imaging.