Journal of Postgraduate Medicine Medknow Publications and Staff Society of Seth GS Medical College and KEM Hospital, Mumbai, India ISSN: 0022-3859 EISSN: 0972-2823 Vol. 56, Num. 2, 2010, pp. 152-153

Journal of Postgraduate Medicine, Vol. 56, No. 2, April-June, 2010, pp. 152-153

Case Snippet

Cerebellar glioblastoma presenting with clinical and imaging features of posterior circulation stroke

Vermani N, Mann HS¹, Brar RS, Bagai M²

Departments of Radiology, ¹ Neurology and ² Pathology, Fortis Hospital, Mohali, India

Correspondence Address: Dr. Nittin Vermani, Department of Radiology, Fortis Hospital, Mohali, India

drnv23@gmail.com

Code Number: jp10041

PMID: 20622398

DOI: 10.4103/0022-3859.65287

A 65-year-old male patient presented to us with headache, vomiting, gait disturbance and vertigo. All these features were of rapid onset and had developed over a period of two to three days. Suspecting an acute ischemic event, the patient was admitted to the hospital. Detailed neurological examination done after initial symptomatic improvement showed features of right cerebellar involvement. Magnetic Resonance Imaging (MRI) was also done on Day 3 of hospital admission. A 1.5 T MRI scanner was used to perform a pre-contrast study followed by post-gadolinium spin echo T1W cranial MR imaging examination in various planes. There was a well-defined area of altered signal intensity in a portion of right cerebellar hemisphere and vermis, corresponding to territory of right posterior inferior cerebellar artery and showing a sharp demarcation with adjacent uninvolved portions [Figure - 1]. No apparent restriction of diffusion was, however, present. After injection of gadolinium, a folial enhancement pattern was observed [Figure - 2]. Rapid onset of symptoms, confinement of signal changes to a vascular territory and folial pattern of contrast enhancement led us to consider subacute infarction as the presumptive diagnosis. Following symptomatic improvement, the patient was discharged from the hospital and advised a follow-up examination.

The patient presented again three weeks later with worsening of symptoms. A repeat MRI showed an increase in the size of involved portion of cerebellum as well as the severity of obstructive hydrocephalus due to compression of the fourth ventricle [Figure - 3]. These unexpected findings argued against infarction; a revised diagnosis of a neoplastic lesion was considered. Surgical biopsy of the lesion was performed. The impression of the frozen section and the intraoperative consultation, as well as the final histological diagnosis, was glioblastoma multiforme (GBM). A gross total resection was, therefore, done. Following surgery, temozolomide (dose - 135 mg/ day orally, calculated at 75 mg/ square meter of body surface area) was administered to the patient concomitant with focal radiotherapy and maintenance therapy with temozolomide is being continued. The patient was clinically stable on a follow-up visit six months after surgery. Headache, vomiting and other features of raised intracranial pressure had improved whereas gait ataxia and clinical signs of cerebellar dysfunction persisted. A follow-up MR examination of the brain showed no obvious recurrent mass and the patient did not have any features of radiculopathy or myelopathy. Although spinal MR imaging for the early detection/exclusion of asymptomatic spinal leptomeningeal seeding in cases of high-grade brain gliomas is advocated as a baseline investigation as per neurooncological principles, it had to be avoided in our patient due to financial constraints.

Glioblastoma multiforme (GBM) usually arises in supratentorial location. Occurrence of GBM in the cerebellum is extremely rare, with a frequency of 0 to 3.4% reported in literature. ^[1],[2] We have found only a single case report published from India that describes cerebellar GBM in adults. ^[3] Symptoms caused by cerebellar GBM are diverse and non-specific. ^[4] Presentation of cerebellar glioblastoma with stroke-like features is exceedingly uncommon and a search of Medline database shows a single case report, wherein a cerebellar GBM with the clinical picture of Wallenberg′s syndrome has been described. ^[5] Folial pattern of parenchymal contrast enhancement on MRI, as observed in our case, may add to the difficulty in distinguishing a subacute cerebellar infarct from glioblastoma. Follow-up imaging for temporal evolution of lesion is often helpful in such cases.

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