History: A 66-year-old male patient was admitted to the hospital on June 12, 2017 due to sudden strabismus and convulsions for 2 days. The symptoms gradually aggravated to twitching three times in 24 hours, and he was confused.In the past 11 years, diabetes mellitus had been well-controlled by drugs. Physical examination: blurred consciousness, a poor mental state, and unclear speech. His left upper limb muscle strength was grade 4, left lower limb muscle strength was grade 4, right upper limb muscle strength was grade 5, right lower limb muscle strength was grade 5, and muscle tension was high. Pathological reflex: Babinski sign: left (+), right (+), Chaddock sign: left (+), right (+).
Imaging examination: A head MRI (Fig. 1–4) showed swelling of the right parietal temporal gyrus, thickening of the cerebral cortex, low signal intensity on T1WI, high signal intensity on T2WI, iso-signal on a FLAIR sequence, high signal intensity on a DWI sequence, and a ribbon-shaped lesion with a clear boundary. There was no obvious involvement of the subcortical white matter, and the adjacent sulcus had become shallow. He was diagnosed with viral encephalitis.
Laboratory examination: cerebrospinal fluid glucose was normal; protein levels had increased to 1083.00 mg/L; cerebrospinal fluid immunoglobulin levels were high: albumin was 598.00 mg/L, IgA was 15.80 mg/L, IgG was 72.20 mg/L, and IgM was normal; no malignant tumor cells were found in cerebrospinal fluid smears; and cerebrospinal fluid bacterial smears showed no obvious abnormalities.
Treatment process:according to the patient's symptoms, signs and auxiliary examination,viral encephalitis with epilepsy was considered. After the treatment of antiepileptic, antiviral and relieving brain edema, the patient was discharged on June 20, 2017 after improvement. At the time of discharge, the patient did not complain of obvious discomfort. Physical examination: clear mind, fluent speech, both eyes can move in each direction, bilateral pupil and other large equal circle, bilateral nasolabial sulcus symmetrical, tongue extension in the middle; his left upper limb muscle strength was grade 4, left lower limb muscle strength was grade 4, right upper limb muscle strength was grade 5, right lower limb muscle strength was grade 5 left ༛Babinski sign (-), right Babinski sign (-), Kernig sign (-) .
On January 24, 2018, the patient was readmitted because of "memory loss with slow responses for 20 days". He showed lethargy, decreased calculating ability, and unstable walking. Physical examination: conscious state, good mental state, aphasia, short-term memory loss, normal long-term memory, normal instantaneous memory, decreased calculation ability. His character orientation was normal, his place orientation was decreased, his time orientation was decreased, and his judgment was normal.
Imaging examination: a head MRI scan (Fig. 5–8) showed abnormal signals caused by irregular masses in the right parietal occipital and temporal lobe, T1WI showed low signal intensity, T2WI showed isointense signals, and FLAIR and DWI sequences showed high and low mixed signals. The boundary was unclear, and a large area of necrosis could be seen in the center of the lesion. Edema signal could be seen around it. The trigone, inferior horn and posterior horn of the right ventricle were involved and deformed. MR Enhancement (Fig. 9): The lesion showed inhomogeneous circular enhancement and a central necrotic area without enhancement and was considered a malignant tumor, with GB likely. Magnetic resonance spectroscopy analysis (Fig. 10) showed that NAA was significantly lower in the lesion area than in the contralateral white matter, while Cho was significantly higher and Lac-Lip was significantly higher in the former than in the latter, suggesting that it was a malignant tumor with necrosis. ASL (Fig. 11) showed that the cerebral blood flow (CBF) of the solid components of the lesions had significantly increased, suggesting that the lesion was a malignant tumor.
Laboratory examination: cerebrospinal fluid glucose was high, at 6.40 mmol/L, and protein had significantly increased to more than 3000.00 mg/L. Immunoglobulin in the cerebrospinal fluid had increased: albumin > 1630.00 mg, IgA > 43.10 mg/L, IgG > 109.00 mg/L, and IgM > 4.95 mg/L. No malignant tumor cells were found in cerebrospinal fluid smears. There was no obvious abnormality in the cerebrospinal fluid bacterial smear.
Treatment process:the patient was diagnosed as intracranial malignant tumor. Craniotomy was performed under general anesthesia on February 3, 2018 after admission.The tumor was located in the right temporal and occipital lobes, and part of the tumor was protruding to the surface of the brain. The tumor was gray-red, soft, and rich in blood supply and had no capsule. The boundary between the tumor and the brain tissue was not clear. Under a microscope, the adhesion between the tumor and the brain tissue was separated along the edge of the tumor and reached the midline, down to the tentorium of the cerebellum and deep to the occipital horn of the lateral ventricle.The patient was discharged on February 11, 2018 with stable vital signs and clear mind. There was no obvious abnormality in cardiopulmonary and abdominal examination. The incision healed well and the stitches were removed.Both eyes can move in each direction, bilateral pupil and other large equal circle, bilateral nasolabial sulcus symmetrical.His left upper limb muscle strength was grade 5, left lower limb muscle strength was grade 5, right upper limb muscle strength was grade 5, right lower limb muscle strength was grade 5 left ;Babinski sign (-), right Babinski sign (-), Kernig sign (-). Eventually, he died in August 2018.
Pathological diagnosis: the part of the lesion in the brain tissue was 8 × 4.5 × 3 cm, the section was grayish white, its texture was soft, some areas were grayish brown, and the range was 6 × 5 × 5 cm (Fig. 12–13). Consideration was given to (right temporal occipital) glioblastoma (WHO grade IV, size 6 × 5 × 5 cm). Immunohistochemistry showed: GFAP (+), IDH1 (-), Vimentin (+), Olig-2 (+), S100 (+), NeuN (-), Syn (-), p53 (+), ATRX (-), CD34 (-), BRAFV600E (-), and a Ki-67 positive rate of approximately 60%.