44-year-old man presented in 2008 with acute onset of confusion and dizziness. Brain MRI scan showed a lesion in the left temporal lobe. A biopsy of the lesion was performed in 2009. He presented almost exactly three years later, in 2011, for his regular follow-up Brain MRI scan. The clinical profile of the patient now includes progressive cognitive decline, severe motor dysfunction, muscle weakness and difficulty in speech.
Neurological examination (March 2011) reveals signs of spasticity (muscle weakness, clonus, exaggerated deep tendon reflexes).
His drug screen was negative for meth and heroin. He did have evidence of rhabdomyolysis.
The first Brain MRI scan (March 2008) demonstrates the presence of an ill-defined , T2 hyperintense, T1 hypointense lesion in the medial part of the left temporal lobe, with no associated edema or mass effect. Post contrast images reveal no enhancement of the lesion. Interestingly, there is enlargement of the areas affected by the lesion.
Brain MRI scan (March 2011) shows an obvious increase in the size of the lesion which extends in the right cerebral hemisphere through the anterior commissure and the corpus callosum. The lesion demonstrates mass effect and is characterized by perilesional angiogenic edema and ring pattern of enhancement. The lesion contains areas of hemorrhage and necrosis.
All the aforementioned features are compatible with the malignant degeneration of a low grade astrocytoma to a high grade brain glioma (Multiforme Glioblastoma).
Differential diagnostic list of a low -grade astrocytoma comprises of infarction , lymphoma and encephalitis.
The main differential diagnosis of a butterfly-type lesion includes GBM, lymphoma, oligodendroglioma and demyelinating disease.
Dx: Secondary Glioblastoma, 3 yrs from primary astrocytoma
Dx Confirmed by: Ιmaging findings and biopsy
He has been receiving chemotherapy schemes and undergoing radiotherapy. Currently, he is in bad clinical condition. He suffers from severe muscle weakness, cognitive decline and visual impairment.
The patient underwent a course of radiation treatment on June 2010. Also, he has been receiving chemotherapy on a regular basis . So, we have to note that part of the tumor necrosis and enhancement as well as some of the white matter T2 hyperintesity changes are due to radiation effects .
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