PMC5482157_01
Axial cut MR showing right, posterior temporal cystic lesion measuring 1.5 x 1.5 cm with incomplete peripheral enhancement on T1 contrast-enhanced image (a) with mild surrounding vasogenic edema on T2 FLAIR (b)
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F1
Neurologic exam was still normal, however, repeat MRI revealed a right posterior temporal cystic lesion measuring 1.5 x 1.5 cm with incomplete peripheral enhancement characteristic of an open ring sign [Figure 1a], with mild surrounding vasogenic edema [Figure 1b], minimal mass effect, no midline shift, and no restriction on diffusion.
Axial cut MR showing increased size of lesion, measuring 5.3 x 4.2 cm with significant mass effect and surrounding vasogenic edema on T2 FLAIR (a) and a now closed ring pattern of peripheral enhancement on T1 contrast-enchanced image (b). Central cystic component now well-defined and satellite lesions are visible along posterior aspect
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F2
Repeat MRI showed a 5.3 x 4.2 cm lesion with significant mass effect and surrounding vasogenic edema [Figure 2a]. The mass had a more defined central cystic component, did not show restriction on diffusion and a closed ring pattern of peripheral enhancement, as well as satellite lesions along its posterior aspect [Figure 2b].
Sagittal, coronal and axial cuts of lesion on T2-weighted MRI above, below MR spectroscopy shows an increased choline to creatine ratio with a decreased NAA signature
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F3
MR spectroscopy was performed and showed an increased choline-to-creatine ratio with a decreased NAA signature suggestive of a neoplasm [Figure 3].
Axial cut MR perfusion scan shows increased relative blood volume compared to contralateral tissue
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F4
MR perfusion showed increased relative blood volume compared to contralateral tissue, strongly suggesting neoplasia [Figure 4].
H and E sections from the neoplasm show pleomorphic process-forming astrocytic cells around an area of necrosis (pseudopalisading necrosis) (a). Higher power (b) shows the atypical, pleomorphic astrocytic cells characteristic of high-grade astrocytic tumors
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F5
Tumor cells had elongated, pleomorphic, vesicular nuclei with scant cytoplasm [Figure 5a and b].