PMC7332710_01
(a) FLAIR magnetic resonance imaging showing right temporal and insular lesion with right to left mass effect and surrounding edema. (b and c) CT with contrast demonstrating irregular enhancement of a large right temporal and insular lesion. (d) A coronal view of the preoperative CT with contrast, with an emphasis on the Sylvian fissure and middle cerebral artery (MCA) being pushed upward (asterisk).
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F1
Contrasted computed tomography (CT) with contrast revealed a large mass with irregular enhancement and MRI revealed moderate perilesional edema with mass effect [Figure 1]. Two wafers were placed along the cephalad resection cavity in direct contact with the exposed portion of the Sylvian fissure and the remainder along the posterior resection wall [Figure 1].
(a) Postoperative CT with minimal hemorrhage in the posterior aspect of the resection cavity. (b) The T1 magnetic resonance imaging (MRI) with contrast respectively, with small amount of residual tumor anterosuperiorly and medially, with small amount of hemorrhage within the resection cavity and no evidence of hemorrhage within the basal cisterns. (c) Diffusion-weighted imaging without any evidence of infarct. (d) A T2 MRI with hypointensities along exposed middle cerebral artery (asterisks), representing Gliadel wafer lining the vessel and cavity.
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F2
Immediate postoperative CT revealed small volume hemorrhage within the posteromedial aspects of the resection cavity, measured to be about 1.7 cm3 per volumetric analysis through OsiriX software (Apple, California) [Figure 2]. MRI on postoperative day 1 revealed subtotal resection with improved mass effect but persistent edema [Figure 2].
(a) FLAIR magnetic resonance imaging revealing stable perilesional edema on postoperative day 8. (b) Diffusion-weighted imaging showcasing a right posterior limb of the internal capsule acute infarct. (c-f) Cerebral angiographic images of the anterior circulation displaying moderate vasospasm in the right supraclinoid internal carotid artery (ICA), the carotid terminus, A1 of the anterior cerebral artery, and M1 of the middle cerebral artery (MCA). (e and f) Improvement in caliber and diameter of supraclinoid ICA and MCA after angioplasty and intra-arterial injection of nicardipine.
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F3
MRI revealed stable edema and an acute ischemic stroke in the right posterior limb of the internal capsule [Figure 3]. A1 of the anterior cerebral artery, and M1 of the MCA [Figure 3]. After intra-arterial injection of 20 mg of nicardipine and angioplasty of the right MCA and supraclinoid ICA, there was some improvement in vessel diameter and caliber [Figure 3].