Wk 4, Case 5 - Review

Patient History
57-year-old male who initially presented to outside hospital with facial droop and was found to have right frontal lobe mass, now presenting for preoperative imaging.

Findings
Heterogeneously enhancing mass within the right frontal operculum, measuring 2.8 x 2.9 x 2.9 cm (anteroposterior by transverse by craniocaudal).

Surrounding T2 FLAIR hyperintense signal likely reflecting a combination of nonenhancing infiltrative tumor and vasogenic edema, with minimal leftward subfalcine herniation and right uncal herniation, though without cerebellar tonsillar herniation.

DSC perfusion leakage corrected relative cerebral blood volume map demonstrates markedly increased blood volume to the mass relative to the normal brain parenchyma.

No areas of restricted diffusion (remote from the mass) to suggest acute infarct. No acute intracranial hemorrhage or extra-axial collection.

Gray-white matter differentiation is otherwise preserved. Ventricular size within normal limits for patient age. Major intracranial flow voids intact. Partially empty sella turcica.

Paranasal sinuses and mastoid air cells clear aside from mucosal polyp or retention cyst within the left maxillary sinus. Orbits normal. Scalp and calvarium unremarkable aside from frontotemporal scalp fiducial markers.

Partially visualized cervical spine appears unremarkable aside from likely an ossiculum terminale.

Impressions
Stable size and appearance of right frontal opercular mass, likely a high-grade glioma

Patient History
HIGH GRADE GLIOMA: follow up

Findings
Brain Parenchyma: Right frontotemporal craniotomy with underlying resection cavity in the right frontotemporal lobe. Surrounding T2/FLAIR signal is mildly increased compared to prior study. More prominent nodular enhancement is noted in the lateral and also anterior aspect of the resection cavity with no increased perfusion on leakage-corrected rCBV maps. New enhancing lesion is noted superior and medial to the resection cavity measuring 1.2 cm with mildly increased perfusion. Small extra-axial collection is again noted at the site of surgery mildly decreased in size from 0.6 cm to 0.4 cm. Faint area of enhancement in pons with no corresponding signal change in T1 or FLAIR is likely a small capillary telangiectasias. No other mass or abnormal enhancement in the brain parenchyma or leptomeninges.

No hemorrhage, acute cortical infarction, or midline shift.

Ventricles and Sulci: Normal for age.
Extra-Axial Spaces: No extra-axial fluid collection.
Intracranial Flow-Voids: Arterial and venous sinus flow voids appear normal.

Orbits: Normal
Paranasal Sinuses: Retention cyst is noted in the left maxillary sinus.
Minimal mucosal thickening is noted within bilateral ethmoid air cells.
Mastoid Air Cells: Clear
Cranium: Other than post craniotomy changes, decreasing in this region
normal limits.
Extracranial Soft Tissues: None

Impressions
Postoperative changes in the right frontotemporal region with interval appearance of nodular enhancement in the periphery of the resection cavity and in the adjacent brain parenchyma with associated mild hyperperfusion that is indeterminate for tumor progression. Consider short term followup with repeat DSC perfusion for better assessment.

Patient History
HIGH GRADE GLIOMA: follow up

Findings:
BRAIN FINDINGS:

Status post right pterional craniotomy and resection of high-grade glioma of the right frontal lobe. There is peripheral contrast enhancement along the resection cavity with mild nodularity along the anterior aspect, which is unchanged compared to the prior exam. Overall size of the enhancing area is unchanged. Surrounding FLAIR hyperintensity suggestive of vasogenic edema is roughly similar.

On the other hand, there is nodularity along the superior and posterior aspect of the resection cavity and appears to be slightly larger, although less solid. It corresponds with a nodular focus of restricted diffusion, without elevated perfusion although on Olea post processed images there is very modest elevation of CBV above the white matter background. Surrounding FLAIR hyperintensity slightly decreased.

Very minimal interval increase in ventricular size although overall within normal limits. The configuration of the ventricles is unchanged from the prior exam. There is no extra-axial fluid collections. No evidence of acute infarct or intraparenchymal hemorrhage. The bilateral orbits are normal. Moderate sized mucous retention cyst is seen within the left maxillary sinus. No effusion seen in the mastoid air cells. Aside from the prior craniotomy, the calvarium is intact.

Impressions
Status post resection of right frontal atypical infiltrating glioma with overall unchanged peripheral enhancement in the anterior aspect of the resection cavity but somewhat altered appearance in the enhancing nodule along the superior and posterior aspect of the resection cavity that demonstrates restricted diffusion and modestly elevated blood volume. Surrounding FLAIR hyperintensity associated with this nodule is decreased in interval. These findings may still represent posttreatment change and continued follow-up is recommended.

Patient History
GBM. History of glioblastoma (IDH-wild type, MGMT negative, newly diagnosed R frontal glioblastoma WHO grade IV s/p) and ER+/PR+/HER2- IDC of the right breast.

Findings
Brain Parenchyma:
Postsurgical changes related to right pterional craniotomy for resection of right frontal glioblastoma.
The resection cavity measures 1.5 x 1.2 cm, decreased in size compared to the prior exam.
Trace amount of extra axial fluid subjacent to the craniotomy site, similar compared to the prior exam.

Thick nodular enhancement marginating the resection cavity, with nodular components along the anterior and posterior medial aspect at the level of the surgical cavity and with more pronounced abnormal soft tissue enhancement along the superior aspect extending to the centrum semiovale. This demonstrates restricted diffusion corresponding to the solid enhancing components especially along the
posteromedial and superomedial aspects along with increased perfusion on corrected CBV map, similar compared to the prior exam.

Redemonstration of extensive T2/FLAIR signal hyperintensity surrounding the resection cavity and enhancing abnormality, extending to the right centrum semiovale and inferiorly into the subinsular white matter and posterior limb of the right internal capsule, similar compared to the prior exam.

There is mild mass effect with diffuse sulcal effacement over the convexity, and 4 mm leftward midline shift measuring at the level of septum pellucidum, similar compared to the prior exam.

No new hemorrhage or acute cortical infarction.

No enhancing lesions in the rest of the brain. No diffusion restriction elsewhere in the intracranial compartment.

Ventricles and Sulci: Unchanged
Intracranial Flow-Voids: Preserved.
Paranasal Sinuses: Large mucous retention cyst in the left maxillary sinus.
Mastoid Sinuses: Clear.
Orbits: Normal.
Cranium: No acute abnormality.

Impressions
Postsurgical changes related to resection of right frontal glioblastoma with interval slight decrease in size of the resection cavity. Thick nodular enhancement marginating the resection cavity with restricted diffusion and increased perfusion, consistent with tumor progression, minimally changed compared to the prior exam.