Wk 4, Case 5 - Review

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

Findings
Heterogeneously enhancing mass within the right frontal operculum (inferior frontal gyrus pars opercularis), 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 mucous retention cyst within the left maxillary sinus. Orbits normal. Scalp and calvarium unremarkable aside from frontotemporal scalp fiducial markers.

Impression
Right frontal opercular mass, likely a high-grade glioma

Findings
Postsurgical changes of right frontoparietal craniotomy for right frontal opercular mass resection. There is a thin peripheral rim of enhancement at the resection cavity, without residual nodularity. Scattered susceptibility artifact at the cavity margins, compatible with hemosiderin deposition, and small fluid-fluid level with T2 signal hypointensity and susceptibility artifact within the cavity, also compatible with blood products. Similar surrounding expansile T2/FLAIR signal hyperintensity with mild mass effect. There is effacement of sulci at the right frontoparietal convexity, partial effacement of the right lateral ventricle and third ventricle, and leftward midline shift measuring approximately 2 mm.

Smooth right cerebral convexity pachymeningeal enhancement is likely reactive. Probable small capillary telangiectasia involving the aspect of the right pons. No other sites of abnormal parenchymal enhancement or additional areas of expansile T2/FLAIR signal hyperintensity.

There is minimal resection diffusion limited to the margins of the cavity, without restricted diffusion to indicate an acute territorial infarct.

Small extra-axial fluid collection associated with the craniotomy flap, measuring 5-6 mm in thickness. The ventricular system is otherwise normal in size and configuration for age, unchanged. Basal cisterns are patent. Partially empty sella. Flow voids at the skull base are maintained.

The orbits are within normal limits. Unchanged large mucous retention cyst in the left maxillary sinus with otherwise minimal paranasal sinus mucosal thickening. There are small bilateral mastoid effusions, nonspecific. Postsurgical changes in the scalp, with right scalp edema.

Impression
Postsurgical changes of right frontoparietal craniotomy with right frontal opercular mass resection. There is a thin rim of peripheral enhancement at the resection site, without residual nodularity, consistent with gross total resection of enhancing tumor. Unchanged expansile FLAIR hyperintensity in the right frontoparietal region contributing to minimal leftward midline shift.

Patient History
Glioblastoma, IDH-wild type, MGMT negative. Follow up 5 months postop, 3 months following completion of concurrent chemoradiotherapy.

Report
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.

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. No hemorrhage, acute cortical infarction, or midline shift.

Ventricles: Normal for age.
Extra-Axial Spaces: Small extra-axial collection is again noted at the site of surgery mildly decreased in size from 0.6 cm to 0.4 cm.
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.

Impression
Interval appearance of nodular enhancement in the periphery of the right frontal resection cavity with associated mild hyperperfusion that is indeterminate for tumor progression. Consider short term followup with repeat DSC perfusion for better assessment.

Patient History
Glioblastoma, IDH-wild type, MGMT negative. Follow up 7 months postop, 5 months following completion of concurrent chemoradiotherapy.

Report
Findings
Brain:
Continued enlargement of thick nodular enhancement that marginates the right frontal resection cavity, with nodular components along the anterior, posterior medial, and superior aspects extending to the centrum semiovale. Restricted diffusion is demonstrated in the solid enhancing components especially along the posteromedial and superomedial aspects along with markedly increased perfusion on leakage-corrected CBV map.

Marked increase in 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.

There is mild mass effect with diffuse sulcal effacement over the right cerebral convexity, and 4 mm leftward midline shift measuring at the level of septum pellucidum, increased from prior.

No new hemorrhage or acute cortical infarction.

Ventricles: No hydrocephalus.
Extra-axial Spaces: Trace amount of extra axial fluid subjacent to the craniotomy site, similar compared to the prior exam.
Intracranial Flow-Voids: Preserved.
Cranium/scalp: Stable postsurgical changes related to right craniotomy.

Impression
Continued enlargement of thick nodular enhancement marginating the right frontal resection cavity with restricted diffusion and increased perfusion, consistent with tumor progression.