Turkisi, Neiirosiirgery 6: 75 - 78, 1996

CASE REPORTS

Kuzey/i: G/iob/asloma Multiforme aiid Periliimom/ Oedema

Childhood Glio blastomaPeritumoral

MultiformeEdema

Without

Çocukluk Çaginda Peritümöral Ödemi BulunmayanGlioblastoma Multiforrne

KA YHAN KUZEYLI, SONER DURU, ERTUGRUL ÇAKIR, SÜLEYMAN BAYKAL,

ABDÜLKADIR REIs, FiRUZAN ESEN, SA VAS CEYLAN, FADiL AKTÜRK

K.T.Ü. Medical Faculty, Departments of Neurosurgery (KK,SD,EÇ,SB,SC,FA),Pathology (AR), and Radiology (FE), Trabzon, Turkey

Abstract: Glioblastoma multiforme comprises 15-20 % ofall intracranial tumours. it makes a peak between the fifthand seventh decades of life but it is rare in childhood. Oneof the radiological and clinical properties of glioblastomamultiforme is perifocal vasogenic oedema associated withthe tumour. In the radiological evaIuation of an 8 -year­old boy with glioblastoma multiforme, perifocal oedemadid not accompany the lesion. The case is discussed withthe cases in the literature.

Key Words: Computed tomography, glioblastomamultiforme, magnetic resonance imaging, peritumoraloedema.

INTRODUCTION

Glioblastoma multiforme (GM) is the mostcommon tumour of the central nervous system(CNS). Itcharacteristically invades the white matterand is rare in childhood (8).

GM is generally surrounded with a peritumoralvasogenic oedema (8), caused by an abnormalincrease in the vascular permeability of the tumourby neovascularisation (9).

An important portion of GMs have perifocalvasogenic oedema in computerized tomography (CT)and generaiiy magnetic resonance imaging (MRI)shows perifocal oedema in T2 weighted images (9).

Özet: Glioblastoma multiforme tüm kafa içi tümörlerin% lS-20'sini olusturur, besinci ve yedinci onyilllar arasindasik rastlanir, çocuklukta nadirdir. Glioblastomamultiforme'nin radyolojik ve klinik özelliklerinden biride tümöre eslik eden degisik derecelerdeki perifokalvazojenik ödemdir. Glioblastoma multiforme'si olan 8yasindaki bir erkek çocugun radyolojikdegerlendirilmesinde perifokal ödemin bulunmamasidikkati çekmis ve olgu literatürdeki benzer olgularlabirlikte tartisilmistir.Anahtar sözcükler: Bilgisayarli tomografi, glioblastomamultiforme, manyetik rezonans görüntülerne,peritümöral ödem

CASE REPORT

An 8-year- old boy was admitted with a 3months history of headache and vomiting.

Neurological examination revealed rightpapilloedema, slight left hemiparesis and extensorplantar response on the left side. There was nopathological changes in the skull x-rays. CT revealeda heterogeneous right temporal mass with ahyperdense lesion in the center consistent withintratumoral haemorrhage (Figure 1). After intra­venous contrast injection a 74x62.5 mm mass, contrastenhancing especially at the periphery was observed(Figure 2). An MRI was performed. Tl- weightedimages revealed a right temporal mass with a large

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Turkis/i Neurosurgery 6: 75 - 78, 1996

hyperintense haemorrhagic center and hypointenseperipheric solid compartments (Figure 3). Protondensity- weighted axial images revealed a righttemporal solid mass with heterogeneous center andhomogeneous hyperintense periphery. The centralhyperintense lesi on in Tl- weighted and proton-

Figure 1: Non-contrast CT showing a right temporal masswith an haemorrhagic hyperdense center. Themass is heterogeneous in density and causingmidline shift.

Figure 3: Tl-weighted coronal MR! image showing a righttemporal mass with an haemorrhagichyperintense center and causing a midline shift.

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Kuzey/i: G/iob/astoma Multiforme aiid Peritiwioral Oedeiiia

density weighted images was concluded to beintratumoral haemorrhage and the homogeneoushyperintense periphery was the solid portion of thetumour (Figure 4).

Figure 2: Contrast enhanced CT showing prominentcontrast enhancement at the tumour periphery.The tumour shows heterogeneous contrastenhancement and there are some non-enhancedparts at the center.

Figure 4: Proton density weighted axial MR image showing aright temporal mass with heterogeneous hyperintensehaemorrhagic center. The peripheral zone of thetumour surrounding the haemorrhagic and necroticcenter is homogeneously hyperintense.

Turkis/i Neurosurgery 6: 75 - 78, 1996

With CT and MRI findings and considering thepatient's age, an initial diagnosis was astrocytomaor ganglioglioma. The tumour was excised subtotally.Giant cells, vascular proliferation and necrosis wereobserved in the turnoral tissue and histopathologicaldiagnosis was GM (Figure 5a). In the transition zonebetween the tumour and brain parenchyma noprominent oedema was observed microscopically(Figure 5b).

The patient was discharged at the tenth post­operative day in good condition and trans ferre d toan oncology department for post-operativeradiotherapy.

Figure Sb: Microphotograph showing the transition zonebetween the tumour and brain parenchyma. Noprominent oedema was observedmicroscopically. (H&E,X 400)

Kuzey/i: G/iob/asloma Multiforme and Perilwnoral Oedema

DISCUSSION

GM is the most common primary CNStumour (5). it peaks between the fifth and seventhdecades of life and is more ra re in childhood (6,8).

GMs are surrounded with a heterogeneous rimin CT. Necrotic fields are common in the center. Cystsand haemorrhagic fields are more rare. The tumourenhances except the necrotic fields. In mare vasculartumours peripheral enhancement can be observed.

. This is usually heterogeneous and more than 5 mm.This feature can be helpful in radiological differentialdiagnosis of GMs with cerebral abscess (9). In 5% ofcystic tumours a thin rim enhancement can beobserved but contrast enhancement is ra rely seen inthe center of the cysts (8).

GMs have big, thin-walled, thrombotic andi orhaemorrhagic vessels. SmaIl vessels, especiaIlycapillaries show characteristic hyperplastic changesespecially prominent in the tumour periphery andin parallel with the contrast enhancement at thetumour's periphery at CT (3).

Vasogenic ederna accompanying mass lesionsof the brain is a known condition. The responsiblephysiopathological mechanisms are; a) permeabilityof the new turnoral microvessels occurring withturnoral angiogenesis, b) changes in themicrovascular permeability, by the excreted turnoralsubstances, c)immunological changes, d) increase ofthe microvascular permeability by the inflammation(2).

By the mechanisms explained above vasogenicoedema widens the subcortical white matter and

causes "digital pseudopod or garland edema". Thismild or prominent peritumoral ederna ischaracteristic for GM (1,8-11), but was not observedin our case (Figures I, 5b).

In CT, there is perifocal vasogenic oedema in88% of GMs and it is usual in T2- weighted images(9). In glioma cases peritumoral ederna may show acorrelation with the turnoral malignancy (4,11).

Our case can be concluded to be a rare case of

GM because of the age of the patient, absence ofprominent periturnoral ederna on CT and MRI, andalso histopathological examination revealed noprominent ederna microscopically. The absence ofperiturnoral ederna can be attributed to changes inthe vasogenic ederna mechanisms.

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Turkis/i Neurosiirgery 6: 75 - 78, 1996

In a review of the literature we could not find a

case of childhood GM without peritumoral oedema(1,6,7,10,12,13).

Correspondence: DLKayhan KuzeyliKTU Tip FakültesiNörosirurji ABD61187, Trabzon, Turkey

REFERENCES

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2. Del Maestro RF, Magyesi JF, Farrell CL: Mechanismsof tumor associated edema: A review. Can J NeurolSci 17:177-183, 1991

3. Esiri MM, Oppenheimer DR: DiagnosticNeuropathology. A Practical Manual, Oxford:Blackwell Scientific Publications, 1989,197 pp.

4. Go GK, Wilmink JT, Molenaar WM: Peritumoral brainedema associated with meningiomas. Neurasurgery 23:175-179, 1988

5. Haaga JR, Alfidi RJ: Computed Tomography of TheBrain, Head and Neck, St Louis: The CV MosbyCompany, 1985, 83 pp.

Kiizeyli: Glioblastoma Miiltiforme a/ld Peritiiinoral Oedema

6. Hall AJ, Wagie VG, Voytek T: High grade astrocytomasin children. Hartford Hospital experience. Conn Med55:135-138,1991

7. Iwama T, Yamada H, Sakai N, Andoh T, Nakashima T,Hirata T, Fumakoshi T: Correlation between magneticresonance imaging and histopathology of intracranialglioma. Neurol Res 13:48-54, 1991

8. Lange S, Grumme T, Kluge W, Ringel K, Meese W:Cerebral and spinal computerized tomography.Kouger. BaseL.1989: 132-135

9. Lee HS, Rao K, Zimmerman RA: Cranial MR! andCT, third edition, New York: Mc Graw-Hill Inc, 1992,323 p.

10. Maravilla KR: Supratentorial gliomas: Radiology inNeurosurgery, in Wilkins RH, Rengachary SS (eds),vol. 1, NewYork, Mc Graw Hill Book Co., 1985:569-573

11. Pedersen H, Gjerris F, Klinken L: Malignancy criteriain computed tomography of primary supratentorialtumors in infancy and childhood. Neuroradiology,31:24-28,1989

12. Wilking M, Wildforster U: Computed tomographicassesment of perifocal edema surraunding tumors ofthe cerebral cortex. Neurosurg Rev 12:55-58,1989

13. Wu RH, Lang Z]' Du CC: Pathological studies of CTfindings in supratentorial astroeytoma: Correlationbetween low density lesions and changes in finestructure.Chin Med J (Eng) 104:685-692,1991

11th Scientific Conventian

Turkish Neurosurgical Society

May 16-20, 1997

Dedeman Hotel, Antalya, Turkey

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