Case Reportan 87-year-old female patient presented with progressive and severe vertigo, headache and disorientation. The symptoms had developed within 3 weeks and at the time of admission she was unable to walk due to vertigo. On magnetic resonance imaging (MRi) three intracranial lesions were detected. a stereotactic biopsy of the right temporal lesion was performed with the patient under local anesthesia after obtaining informed consent. after making a right temporal burr hole a biopsy cannula was inserted and a stereotactic serial biopsy was performed. The cannula was inserted further into the cyst and 23 ml of a xanthochromic fluid was aspirated. The patients' neurological status improved quickly and on the day after the operation she was able to walk again without headache and vertigo and orientation also improved significantly. However, the cyst refilled within 1 week and the clinical situation deteriorated again. in a second stereotactic operation a Rickham reservoir was implanted, another 20 ml of cyst fluid was aspirated and a second biopsy was taken. The patients condition did not improve after the second cyst aspiration as on the first time and remained disorientated. no further therapy was initiated on patients and relatives request.
ImagingT2 images (Fig. 1a, b) showed two hyperintense mass lesions located in the right temporal and occipital lobes. a third lesion (Fig. 1c) could be detected at the level of the interthalamic adhesion affecting both thalami. The two lobar lesions had large cystic compartments with isointense nodular areas which exhibited homogeneous contrast enhancement on T1-weighted images after administration of gadolinium (Fig. 2a, b). The thalamic lesions did not show any signs of a disrupted blood-brain barrier (Fig. 2c). The lobar lesions presented with a mass effect resulting in compression and dislocation of the right lateral ventricle. Both lobar lesions were surrounded by what seemed to be perifocal edema. Diffusion-weighted images showed some restricted diffusion within the nodular portions of the lobar lesions (Fig. 3)
Differential Diagnosis
Glioblastoma MultiformeGlioblastomas are the most frequent primary brain tumor, showing a peak age from 45-75 years. Glioblastomas usually occur as a single entity but radiologically defined multifocal lesions are not unusual and histological examination can usually demonstrate a connection between the different lesions in many cases. Histologically true multifocal glioblastomas represent about 2.5% of cases. Typically glioblastomas present radiologically with a thick, irregularly enhancing margin of neoplastic tissue surrounding a
