PMC5364932_01
CT and MRI findings pre-operatively (A-C), at day 1 after the operation (D-F), and at day 12 (G-I). A: CT with contrast medium showing a ring-enhanced mass with irregular margins (diameter, 40 mm) in the temporal lobe and insula. B: T2-weighted image showing a hyperintense lesion. C, F: Diffusion-weighted MRI (DWI) showing no hyperintense lesions. D: CT showing entrapped air in the resected cavity (arrows). E: T2-weighted image showing mild perifocal edema and subdural air. G: CT showing enlargement of entrapped air in the resected cavity (arrows) with perifocal edema (arrowheads). H: T2-weighted images showing severe edema. I: DWI showing a hyperintense lesion in the left corona radiata, suggesting acute cerebral infarction. CECT: contrast-enhanced computed tomography, CT: computed tomography, MRI: magnetic resonance imaging.
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F1
Computed tomography (CT) revealed a mass located in the left temporal lobe and insula, which showed apparent ring enhancement (diameter, 40 mm) with irregular margins under a contrast medium (Fig. 1A). Magnetic resonance imaging (MRI) showed that the hyperintense lesion was accompanied with mild perifocal edema on T2-weighted imaging (Fig. 1B). Postoperative CT at day 1 revealed the subtotal removal of the tumor and the presence of entrapped air near the Gliadel wafers in the tumor resection cavity (Fig. 1D). There was no indication of acute infarction events on diffusion-weighted imaging before and after surgery (Fig. 1C, F). Emergent CT showed edema in the frontal lobe and the augmentation of air in the tumor resection cavity, although the subdural postoperative air had disappeared (Fig. 1G). MRI revealed severe edema at the basal ganglia on a T2-weighted image (Fig. 1H) and acute ischemic stroke in the left corona radiata (Fig. 1I).
Intraoperative pictures (A-C) and postoperative MRI at day 1 (D, E). A: Tumor resected cavity before implantation of Gliadel. B: The location of Gliadel in high magnification (C) and low magnification. Axial (D) and coronal (E) image on T1-weighted image showing the location of Gliadel (arrows). MRI: magnetic resonance imaging.
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F2
Although the left lenticulostriate artery (LSA) was invisible during the operation (Fig. 2A), the tumor was close to it. The tumor was resected subtotally, and two Gliadel wafers were placed and secured with fibrin glue at the deep portion of the temporal lobe (Fig. 2B-E) and the posterior portion close to the posterior limb of the internal capsule. Angiography performed at day 13 revealed stenosis of the left LSA, which was just below the entrapped air close to the Gliadel (Figs. 2B, 3A). The stenosis of the left LSA had improved and perforators from middle cerebral artery were conspicuous at day 39 compared to the finding at day 13, suggesting this was a vasospasm (Figs. 2D, 3C).
Angiographic findings at day 13 (A, B) and day 39 (C, D). A: Digital subtraction angiography (DSA): left internal carotid artery injection (AP view) showing stenosis of a major branch of lenticulostriate arteries (LSAs, arrow). B: Reformatted coronal image of three-dimensional rotational angiography (3DRA) showing stenosis of the left LSA (arrow) below the air related to Gliadel (arrowhead). C: DSA showing recovery of LSA stenosis. D: Reformatted coronal image of 3DRA showing no stenosis and disappearance of air.
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F3
Angiography performed at day 13 revealed stenosis of the left LSA, which was just below the entrapped air close to the Gliadel (Figs. 2B, 3A). The stenosis of the left LSA had improved and perforators from middle cerebral artery were conspicuous at day 39 compared to the finding at day 13, suggesting this was a vasospasm (Figs. 2D, 3C). The air in the cavity had disappeared (Fig. 3D).