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Neurology India, Vol. 58, No. 6, November-December, 2010, pp. 978-979 Letter to Editor Mirror-image insular glioma Sachin A Borkar, Vivek Tandon, SS Kale, AK Mahapatra Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi - 110 029, India Date of Acceptance: 17-Sep-2010 Code Number: ni10283 PMID: 21150085 Sir, A 35-year-old man presented to our outpatient services with 2-year history of complex partial seizures, mild holocranial headache and cognitive impairment. Neurological examination did not reveal any focal neurological deficit. His mini-mental examination score (MMSE) was 28/30. Non-contrast cranial computerized tomography (CT) revealed hypodense space occupying lesion in bilateral insular region in a mirror-image fashion [Figure - 1]a. Magnetic resonance imaging (MRI) brain confirmed the CT findings. The lesion was hypointense on T1-weighted image, hyperintense on T2-weighted image and fluid attenuated inversion recovery [FLAIR] images with minimal inhomogeneous post-contrast enhancement [[Figure - 1]b-d]. MR spectroscopy showed choline peak and elevated choline/N-acetylaspartate ratio [Figure - 1]e. A preoperative diagnosis of glial tumor was considered. Right fronto-temporal craniotomy with subtotal excision of right insular glioma was carried out via trans-sylvian approach. The insular and opercular branches of middle cerebral artery were preserved. The patient had an uneventful postoperative course and was discharged on 7 th postoperative day. Histopathological examination revealed a moderately cellular tumor with microcystic change, moderate pleomorphism and occasional mitosis. No endothelial cell proliferation or necrosis was seen. MIB-1 labeling index was 8%. The tumor was p53 negative. Overall features were suggestive of anaplastic astrocytoma (WHO grade III). The patient was referred for radiotherapy and chemotherapy and was doing well at the last follow-up. Multicentric gliomas are well-separated lesions, localized in different lobes or hemispheres, which cannot be ascribed to dissemination through commissural pathways; cerebrospinal fluid (CSF), blood or local extension. [1] Multicentric glioma is a rare entity, and very few cases have been reported in the literature till date [2],[3],[4],[5],[6] and the incidence ranges from 2.3% to 9.1%. [1] Pathak et al[2] quoted the incidence of multicentric gliomas as low as 0.4% amongst 500 glial tumors over a period of 8 years. These tumors may be synchronous or metachronous in clinical presentation. In some studies, metachronous lesions have been reported to be associated with better prognosis. [6] These tumors are usually high-grade lesions (WHO grade III, IV). [2],[3],[4],[5],[6] To the best of the authors' knowledge, multicentric anaplastic astrocytoma presenting as bilateral mirror-image insular masses has not been reported previously. Lack of direct continuity or subarachnoid enhancement on CT scan and MRI brain suggests its primary multicentric origin. Despite advances in neuroradiological techniques, in case of multicentric cerebral lesions, differential diagnosis may require biopsy or surgical excision. [1] The diagnosis is best made by biopsy or surgery. [5] References
Copyright 2010 - Neurology India The following images related to this document are available:Photo images[ni10283f1.jpg] |
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