A 31-year-old male patient presented with a 3-month history of gradually worsening headache and progressive left-sided weakness. He denied any history of seizures or any other significant medical or surgical history. On examination, the patient had papilledema, left-sided upper motor neuron type facial weakness, and left hemiparesis (MRC Grade 4) with pronator drift. Plantars were upgoing on the left side, suggesting complete lateralization. Rest of the examination was unremarkable.
Magnetic resonance imaging (MRI) revealed diffuse signal abnormality, multifocal lesions in the right frontal, temporal lobes with an involvement of the right thalamus, and extension into the right half of the brainstem up to the pons. Some of the lesions were cortical and subcortical in location and cystic changes were also seen in the tumor on T2-weighted imaging [Figure 1]. There was infiltration of the corpus callosum and extension to the contralateral left side and patchy lace-like enhancement on postcontrast T1-weighted images [Figure 2]. No diffusion restriction or susceptibility was noted. Along with MR spectroscopy (MRS) findings [Figure 3], a radiological diagnosis of low-grade multifocal glioma was made.
Biopsy was done and microscopy of the lesion revealed a tumor invading glial tissue composed of sheets of round cells with moderate, pale eosinophilic to clear cytoplasm, round to slightly oval vesicular nuclei, and predominantly inconspicuous nucleoli. Characteristic chicken-wire vasculature was present. Occasional scattered mitoses were seen without any endothelial vascular proliferation or necrosis. Tumor cells showed positivity for immunostain glial fibrillary acidic protein, occasional weak positivity for p53, and low Mib-1 (Ki-67) index (1-2%). Immunostain alpha-thalassemia/mental retardation syndrome, X-linked was intact. Based on these combined features, diagnosis of oligodendroglioma, not otherwise specified, WHO Grade II was favored [Figure 4].
No further surgical treatment was offered due to extensive involvement with a grave patient prognosis. A postbiopsy computed tomography (CT) scan was carried out because the patient had a sudden drop in his Glasgow Coma Scale. The CT scan showed diffuse brain edema and confirmed coarse calcifications within parts of the lesion [Figure 5]. Efforts were made to reduce the intracranial pressure with osmotic therapy, but the patient remained in a vegetative state.