CASE 12844 Published on 23.07.2015

Glioblastoma multiforme with leptomeningeal dissemination



Case Type

Clinical Cases


Guilherme Silva, MD; Duarte Vieira, MD; Dias Costa, MD

Department of Neuroradiology,
São João Hospital Center,
Porto, Portugal

48 years, female

Area of Interest Neuroradiology brain ; Imaging Technique MR
Clinical History
Inaugural generalized seizure in a patient with previous contact (months) with a tuberculosis-infected person. At the time, blood work analyses revealed a Mantoux’s test turning positive and positive interferon-gamma release assay, but no clinical evidence of active tuberculosis was found and no medical treatment was initiated.
Imaging Findings
Fig. 1. Cerebral MRI axial T1WI, shows round lesion on right temporo-insular region with margins isointense to grey matter (curve arrow).

Fig. 2. Cerebral MRI axial T2WI (a) and FLAIR (b), shows lesion's margins with isointense signal to grey matter (arrowhead), necrotic/cystic core and perilesional oedema extending into white matter of frontal, temporal, insular lobes and around basal ganglia (asterisks).

Fig. 3. Lesion has no restriction on DWI (asterisk). (a) b-1000, (b) ADC map.

Fig. 4. On T1 post-gadolinium lesion shows ring-enhancing pattern (arrowheads): (a) axial, (b) coronal, (c) sagittal and (d) magnified T1 MPRAGE on axial plane. Adjacent leptomeningeal enhancement is present (arrows in a, c and d).
Glioblastoma multiforme (GBM) is the most common primary intracerebral tumour in adults, representing 12-15% of intracranial tumours and 60-75% of astrocytic subtype. [1]

GBM is more common between 45 and 75 years of age and in men (ratio M/F 1.26). [2] GBM is a WHO grade IV neoplasm and could develop as a primary tumour or secondary to degeneration from lower grade CNS neoplasm. More commonly, it is a solitary lesion but it could present as multi-centric synchronous tumours. Typical GBM occurs in cerebral hemispheres’ subcortical white matter and has a rapid infiltrative dissemination along white matter tracts such as corpus callosum, internal capsule or fornix. In this case we could see enhancement of the pia mater adjacent to the lesion - leptomeningeal dissemination -, a feature rarely associated with this neoplasm that occurs in around 4% of cases. [3]

Clinical features are dependent of the tumour’s location and size. In the primary type, the tumour is generally bigger and patients could experience symptoms of raised intracranial pressure like nausea or vomiting. Focal neurologic deficits or epilepsy are also common.

Besides biopsy, MRI is the best method of diagnosis. [4] On conventional sequences, the lesion has hyperintense signal on T2 and iso/hypointense signal on T1, relatively to white matter. Typically, this neoplasm has irregular ring-like enhancement after gadolinium; when no necrotic core is present (generally in smaller lesions), homogeneous enhancement could be observed. [1] In spite of high cellular margins, restriction on DWI is not very common. Perfusion MRI could be helpful to differentiate GBM from metastasis, due to recovery curves analysis (GBM has higher recovery). [5] Also, it can be useful in planning stereotactic biopsy, especially in the tumours with nodular enhancement (biopsy should include the areas with higher blood perfusion). Unfortunately, we did not perform perfusion MRI in this case because of technical issues.

The present treatment is tumour debulking (when feasible), followed by chemotherapy (temozolomide) and radiotherapy. [6] The aggressive nature of this neoplasm makes life expectancy short and death generally occurs in 9-12 months after the diagnosis. [2] MRI has a major role in evaluating disease progression after surgical and/or medical treatment, especially to differentiate radionecrosis from tumour progression with perfusion MRI.

Teaching points:
- GBM is the most common primary intracerebral tumour in adults
- GBM shows rapid growth and disseminates along white matter tracts
- Leptomeningeal dissemination can occur in a small percentage of cases
- MRI is the best method for diagnosis and follow-up
- Perfusion MRI is helpful for diagnosis, surgical planning and treatment evaluation
Differential Diagnosis List
Glioblastoma multiforme
CNS tuberculosis
Final Diagnosis
Glioblastoma multiforme
Case information
DOI: 10.1594/EURORAD/CASE.12844
ISSN: 1563-4086