PMC9282822_01
Diagnostic imaging gallery. (a and b) Emergent brain CT. (a) This baseline study shows cortical thickening with sulcus collapse in the right frontotemporal region (black arrows), and an area of low density involving the adjacent frontal white matter (white arrows). (b) Focal gyriform enhancement can be observed (white arrows) after the administration of intravenous contrast. (c-e) Coronal (c and d) and 3D (e) reconstructions of a cerebral CTA study obtained immediately (c and e) and 4 min after contrast administration (d). The former reveals a striking multisegmental luminal stenosis, with narrowing of the right middle cerebral arterial tree (white arrows in c and black arrows in e) and distal vascular occlusion (black arrows in c); the late-phase study (d) shows prominent contrast deposits (black arrows) in said arterial structures. (f-n) Preoperative brain MRI study.(f) Coronal slices corresponding to the FLAIR sequence that demonstrates an abnormally increased signal coating the opercular brain surface (black arrows) and the arterial vessels running through an unoccupied Sylvian cistern (transparent arrow); also notice the signal alteration involving the right insular, frontal, and temporal parenchyma (white arrows); (g) Coronal slice corresponfing to FLAIR sequence obtained after administration of paramagnetic contrast. It demonstrates abnormally increased sign at the opercular brain surface (black arrows), and the arterial vessels through the Sylvian cistern (transparent arrow). (h-k) Diffusion-weighted MRI slices (h and j) displaying increased signal in the frontal lobe (black arrow in j), temporal, periventricular area (black arrow in h), and corpus callosum (white arrow in j); the two latters show signal restriction in the corresponding ADC maps (i and k), restriction periventricular area (black arrow in i) k) note the corresponding alterations in the frontal lobe (black arrow) and periventricular area (white arrow). (l-n) T1 sequence after the administration of gadolinium coronal sections is shown in a sequential, anteroposterior order - reveals irregular opercular and insular gyral enhancement (white arrows in l), diffuse and irregular thickening of the walls of the right middle cerebral artery from its origin (double-headed white arrow in m), a homogeneous uptake of both optic nerves (black arrows in l), and irregular enhancement in the corpus callosum (black arrow in n). (o-p) Control MRI study obtained after oncologic treatment; these coronal slices from the T1W sequence after administration of paramagnetic contrast, demonstrate no enhancement of previously affected structures with faint, apparently residual, and right frontal leptomeningeal uptake (white arrows in o).
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F1
Imaging studies revealed signs of ischemia in different stages affecting the right insula together with the frontal and temporal opercula, frontal lobe white matter edema, and LMC with an invasion of the right middle cerebral arterial wall and its branches [Figures 1a-l]. Signs of pial neoplastic deposits were also observed surrounding the corpus callosum, associated with focal ischemia, and the anterior optic pathways [Figures 1l-n]. Postsurgical imaging studies are shown in Figures 1o-p. The initial response was favorable, manifesting neuroradiological improvement in the MRI control study obtained 4 months after the surgical procedure [Figures 1o-p].
Macro- and microscopic pathological findings. (a) Surgical photograph obtained after performing a right frontal craniotomy, with partial exposure of the second (F2) and third (F3) convolutions. The opercular area presents an apparently normal superficial vascular pattern (transparent arrow), while the dorsal area of the exposed surgical field presents a hypovascular appearance (solid arrow); note the opacity of the Sylvian cistern and some neighboring sulci that display a grayish-yellowish coloration (small arrows in the lower right margin). (b) Low magnification view of the biopsy specimen showing epithelial cell proliferation with glandular differentiation, together with diffuse leptomeningeal infiltration and multiple cortical neoplastic foci (HE, x4). (c) At higher magnification, it is observed that the latters (arrows) are arranged inside spaces delimited by endothelium (HE, x20). (d) Intense staining for cytokeratin 7, denoting the epithelial nature of the tumor cells (CK7, x20).
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F2
Finally, an open brain biopsy was performed [Figure 2a] that included a leptomeningeal-cortical-subcortical block of tissue from the frontal lobe. Microscopic findings were consistent with a definite diagnosis of LMC with multifocal cortical lymphovascular invasion [Figures 2b-d].