PMC8479237_01
A: Axial MRI brain T2 FLAIR image demonstrating left parietal convexity hyperintensity with associated vasogenic edema. B: Axial MRI brain T2 FLAIR image demonstrating additional areas of tumor involvement. C: Axial fused FDG:PET CT image demonstrating hypermetabolic region of tumor in setting of increased seizure activity prior to patient's initial surgery. D: Axial fused FDG:PET CT image obtained with 6-hour delay demonstrating persistent hypermetabolic activity prior to initial surgery. E: Post-operative axial MRI brain T2 FLAIR image demonstrating subtotal resection from first part of two-step resection. F: Post-operative axial MRI brain T2 FLAIR image demonstrating additional area of resection from second part of the procedure. G: Axial MRI brain T2 FLAIR image after completion of chemoradiation demonstrating increased hyperintensity in the treatment area. H: Axial MRI brain T2 FLAIR image demonstrating stable hyperintensity despite increased seizure frequency. I: Axial fused FDG:PET CT image demonstrating hypermetabolic region of tumor in setting of increased seizure activity after surgery and completion of chemoradiation. J: Axial fused FDG:PET CT image obtained with 6-hour delay demonstrating persistent hypermetabolic activity in setting of increased seizure activity after surgery and completion of chemoradiation. K: Axial MRI brain T2 FLAIR image demonstrating additional resection for seizure focus.
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Upon evaluation, an MRI brain identified a non-enhancing left parietal convexity hyperintensity with associated vasogenic edema, consistent with a glioma (Fig. 1A, 1B). FDG-PET identified cortical hypermetabolism at the confluence of the posterior portion of the long gyrus of the insula, postcentral gyrus, and frontal operculum (Fig. 1C) with persistent FDG uptake at 6-hour delay (Fig. 1D). She underwent craniotomy for a two-part subtotal resection of the tumor with post-operative MRI demonstrating residual non-enhancing left frontoparietal tumor (Fig. 1E, F). Post-radiation therapy MRI brain demonstrated increased FLAIR signal change with no new areas or enhancement or hyperperfusion, consistent with treatment-related changes (Fig. 1G). An MRI brain demonstrated post-operative and post-radiation therapy changes with stable residual tumor volume and no clear evidence of tumor recurrence or progression (Fig. 1H). FDG-PET identified a margin along the posterior medial aspect of the tumor bed with increased FDG perfusion (Fig. 1I) maintained on repeat imaging with six-hour delay (Fig. 1J). FDG uptake at 1 hour was 8.2 SUV max and at 6 hours was 14.0 SUV max. Based on this localization, decision was made to resect the hypermetabolic region in an attempt to resolve the drug-resistant focal motor status epilepticus (Fig. 1K).
A. Left fronto-central (F3,C3) onset ictal discharge; rhythmic low voltage beta activity (arrow); Bipolar montage (Sen. 10 muv/mm, LFF 1.6 Hz, HFF 70 Hz) B. Brief focal aware seizures without scalp EEG changes except rhythmic myogenic artifact in the right temporal derivations (arrow) Bipolar montage (Sen. 10 muv/mm, LFF 1.6 Hz, HFF 70 Hz) C. Composite of rhythmicity spectrogram, FFT spectrogram, amplitude averaged EEG over eight hours when patient was in focal motor status (epilpesia partialis continua).
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While surgical planning was in progress, the patient developed recurrent fronto-central onset seizures characterized by paraesthesias in the right arm, right side of her face and word finding difficulty (Fig. 2 A). Video-EEG recorded brief, stereotyped events characterized by rhythmic movements of the right cheek and forehead with preserved awareness occurring 12-15 times per hour consistent with focal motor status epilepticus (epilpesia partialis continua) (Fig. 2C). There were no associated scalp EEG changes with these brief seizures except rhythmic myogenic artifact over the right hemisphere derivations (Fig. 2B).
A. H&E 10x image demonstrating hypercellular tumor with microvascular proliferation; B. H&E 20x image demonstrating area of necrosis; C. H&E 20x image with evidence of subpial tumor infiltration. Findings are consistent with a diagnosis of glioblastoma.
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Pathology was consistent with glioblastoma, isocitrate dehydrogenase (IDH) wildtype by genetic sequencing, O6-methylguanine-DNA methyl-transferase (MGMT) methylation status indeterminate due to discordant result from two laboratories (Fig. 3).