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Supratentorial Brain Neoplasm

Valerie L Ward, MD
Amir A Zamani, MD

October 23, 1996

Presentation

A 54-year-old man with a history of depression presented with worsening confusion.

Imaging Findings

Sagittal T1-weighted MR image
Axial T2-weighted MR images
Contrast-enhanced T1-weighted MR images

A sagittal T1-weighted magnetic resonance (MR) image shows a large area of low signal abnormality in the left frontal lobe (arrow). This abnormality is fairly well-defined and exerts mass effect on the frontal horn and body of the left lateral ventricle.

Axial T2-weighted MR images demonstrate extensive high signal abnormality in the left frontal lobe. This high signal abnormality is actually composed of an oval-shaped 4.5 x 3 cm mass (black arrow) and a large amount of surrounding white matter abnormality (white arrows). The internal signal of the mass is heterogeneous and consistent with cystic degeneration and necrosis. Punctate black foci in the mass represent signal voids from vessels within the mass. Mass effect on the left lateral ventricle (arrow) is again demonstrated. The mass blurs the gray matter-white matter interface and expands the white matter. Therefore, this is an intra-axial mass. There is no significant midline shift.

Contrast-enhanced axial and coronal T1-weighted MR images show that the mass has irregular ring-enhancement (black arrows). There is some heterogeneous enhancement within the mass. The surrounding white matter abnormality has a low signal intensity (white arrows).

Differential Diagnosis

The MR imaging characteristics of this mass suggest that the most likely diagnosis is glial cell tumor, specifically glioblastoma multiforme. Another possible diagnosis is metastasis, the most common supratentorial mass in an adult. In addition, a metastasis can have marked edema and intense ring enhancement. However, metastatic disease may present as multiple brain lesions, and this patient has no known history of an underlying malignancy. Other gliomas such as an anaplastic astrocytoma or oligodendroglioma are less likely diagnoses.

Diagnosis

Glioblastoma multiforme (pathology proven)

Discussion

A glial cell tumor (or glioma) is a tumor comprising astrocytes, oligodendrocytes or ependymal cells. Gliomas account for 50% of all primary central nervous system tumors, and astrocytomas constitute 70% of all gliomas. Astrocytomas are graded by their degree of histologic malignancy. Fibrillary astrocytomas include low grade, well-differentiated astrocytomas, intermediate grade anaplastic astrocytomas, and high grade glioblastoma multiforme (GBM). GBM is the most common and most malignant glioma and carries a 10%-15% two-year survival rate.

GBM occurs most commonly in men aged 45 to 55. (There is a 3:2 male predominance.) The tumor arises most frequently in the deep white matter of the frontal lobe. Other locations include the temporal lobe and basal ganglia. Its imaging appearance is that of an expansive mass with central necrosis, intense ring enhancement, and a large amount of surrounding white matter (vasogenic) edema. Hemorrhage is commonly present within the mass as are multiple blood vessels (ie, neovascularity). Most of these imaging characteristics are demonstrated in this patient. GBM may spread along white matter tracts including the corona radiata, corticospinal tracts, commissars, and corpus callosum. Butterfly glioma refers to a GBM with bihemispheric spread across the corpus callosum. Other modes of spread of this tumor include seeding via the subarachnoid, subpial, and subependymal routes.

References

1. Brandt WE, Helms CA. Fundamentals of diagnostic radiology. Baltimore: Williams & Wilkins, 1994.

2. Edelman RR, Hesselink JR, Newhouse J, Sartoris DJ. Clinical magnetic resonance imaging. Philadelphia:Saunders, 1990.

3. Grossman RI, Yousem DM. Neuroradiology: the requisites. St Louis: Mosby, 1994.

4. Stark DD, Bradley WG. Magnetic resonance imaging. 2nd ed. St Louis: Mosby, 1992.

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