3D FLAIR and post-contrast T1-weighted reformats (axial and sagittal) depict an intraaxial mass with a contrast-enhanced component and a non-enhancing, high T2 signal intensity infiltrative component. pCASL perfusion, overlaid on the post-contrast T1W images, displays a highly perfused zone (star) outside the enhanced lesion.
Susceptibility weighted imaging demonstrates abnormal vessels (arrow) and small foci of intratumoral susceptibility signal intensities (arrowheads) inside the contrast-enhancing and necrotic component.
The contrast-enhancing component is in high DWI signal intensity with heterogeneous apparent diffusion coefficient (ADC), and low fractional anisotropy (FA). Left arcuate fasciculus tracking demonstrates displaced fibers within the non-enhancing component of the lesion.
Multi-voxel MR spectroscopy (MRS) is performed with TE 135 ms. High choline (membrane proliferation) and low N-acetyl-aspartate (neuronal loss) are seen in both contrast-enhancing and non-enhancing parts of the lesion. Elevated lipids and lactate in areas are seen close to the contrast-enhancing lesion (necrosis).
The diagnosis is left frontal glioblastoma multiforme (WHO grade 4)
Impact of using advanced MR imaging techniques:
Ring contrast-enhancing lesion has a wide range of etiology, including, various tumors, infections and even some pseudotumoral inflammatory diseases. FLAIR high-signal intensity around an intraaxial enhancing lesion is also nonspecific on morphological imaging alone (edema or infiltrative tumor). Further characterization of both components with MR spectroscopy, susceptibility weighted imaging, diffusion and perfusion imaging helps clinicians to rule out pseudotumoral lesions, approach tumor classification and full extent, in order to optimize therapeutic management. In this patient, the high choline and high CBF on perfusion outside the enhancing lesion are very suggestive of high grade glioma.
Using Ingenia 3.0T with the 32-channel dS Head coil allows both high SNR and high acceleration factors to keep duration of each sequence short and thus allows to perform a comprehensive examination in an acceptable time.