PMC9800865_01
(A-D) Angiography imaging showing artero-venous blush lasting till late venous phase. The blush is fed by collaterals originating from P2 segment of the posterior cerebral artery (PCA), and left superior cerebellar artery (SCA). Preoperative post-contrast T1-weighted images in sagittal (E), axial (F), and coronal (G) views, showing the involvement of the tentorium hiatus and the extension to the left thalamo-mesencephalic region; Preoperative T2-weighted images in sagittal (H), axial (I), and coronal (J) views, showing the hypointensity of the tumor and the presence of perilesional edema. Post-operative post-contrast T1-weighted imaging showing residual tumor in sagittal (K), axial (L), and coronal views (M); (N-P) 5-month follow-up post-contrast T1-weighted imaging showing disease recurrence.
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The patient underwent a preoperative brain MRI ( Figures 1E-J ) which disclosed a mass contiguous to the left tentorial free edge and extending into the ipsilateral thalamic and mesencephalic regions. The tumor was hypointense on T1-weighted images (WI) and on T2-WI ( Figures 1H-J ), and hyper/isointense on Fluid Attenuated Inversion Recovery (FLAIR) sequences. Postcontrast T1-WI showed heterogeneous enhancement of the lesion ( Figures 1E-G ), which was 31 millimeters in maximum diameter, and associated with moderate edema in the surrounding brain parenchyma. Postoperatively a brain Digital Subtraction Angiography (DSA) was performed ( Figures 1A-D ) and the presence of a thrombosed giant aneurysm was excluded. Postoperatively, the patient displayed mild expressive dysphasia and moderate right hemiparesis. ( Figures 1K-M ). When MRI was performed, a significant disease recurrence was disclosed ( Figures 1N-P ).
(A) Intraoperative visualization of the tumor, presenting as a hypervascularized mass in the tentorium hiatus; (B) Intraoperative use of in vivo confocal microscopy.
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The lesion was encountered in the left tentorial hiatus and appeared as an extraparenchymal, red and capsular mass with an arterialized surface ( Figure 2A ). On the contrary, In vivo intraoperative confocal microscopy was useful in confirming the presence of the pathologic tissue, showing the presence of high cellularity and vascularized lesion ( Figure 2B ).
(A) H&H showing the presence of blood vessels, smooth muscle cells, and collagen tissue; (B) Confocal microscopy image showing neoplastic tissue characterized by significant neovascularization.
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The tumor specimen underwent histological examination, which reported the presence of blood vessels, smooth muscle cells, and collagen tissue ( Figure 3A ).