Multiple cerebral gliomas mimicking central nervous system inflammatory demyelinating diseases: A rare case with review of literature

Abstract

Rationale: Multiple cerebral gliomas (MCGs), usually classified into multifocal and multicentric subtypes, represent major diagnostic challenges as their clinical, radiologic, and pathohistological features are not uniform, often mimicking brain metastatic tumors or central nervous system inflammatory demyelinating diseases (IDD).

Patient concerns: Here, we report a rare case of MCGs with isolated seizures and 4 lesions in the brain, that was initially misdiagnosed as IDD during treatment.

Diagnosis: The pathological diagnosis was astrocytoma, which was classified as a World Health Organization grade II glioma.

Interventions: The patient was treated with dexamethasone and sodium valproate when he was misdiagnosed as having IDD. After the pathological diagnosis was obtained, he was treated with temozolomide and radiotherapy.

Outcomes: Three months after the above treatment, the health of the patient had improved; he was asymptomatic, and presented with better radiological manifestations.

Lessons: Diagnostic imaging is valuable in differential diagnosis. Magnetic resonance spectroscopy is a promising technique for the assessment and characterization of lesions, though its role in definitive diagnosis is not yet defined. Brain tissue biopsy remains the golden standard for definitive diagnosis. In China, for various reasons, craniotomy biopsy is not performed routinely in patients with multiple intracranial lesions, and stereotactic cranial biopsy may be a more viable option because of its safety and cost-effectiveness. In summary, this case demonstrates that MCGs need to be included in the differential diagnosis of unknown intracranial multiple lesions.

Figure 1

Head MRI and enhancing scanning demonstrated 4 lesions, 1 each in the left temporal (1), frontal (3), and temporal-parietal (2) lobes, and in the right paramedian frontal lobe beneath the cortex (4). These lesions had low signals in T1WIs and high signals in T2WIs and DWI without obvious edema and mass effect. Three lesions were partially enhanced with gadolinium dimeglumine, whereas the lesion in the right paramedian frontal lobe beneath the cortex did not show such an enhancement. An elevated Cho/NAA ratio was examined using MRS in regions with lesions. Cho = choline; DWI = diffusion weighted imaging; MRI = magnetic resonance imaging; MRS = magnetic resonance spectroscopy; NAA = N-acetyl-aspartate; T1WI = T1-weighted image; T2WI = T2-weighted image.

Figure 2

Head MRI and enhancing scanning showed that all the 4 lesions were larger in size compared with those in Figure 3. The lesions showed more obvious enhancement, and the lesion in the right paramedian frontal lobe beneath the cortex, which was not enhanced in Figure 3, showed significant enhancement. Cho = choline; DWI = diffusion weighted imaging; MRI = magnetic resonance imaging; MRS = magnetic resonance spectroscopy; NAA = N-acetyl-aspartate; T1WI = T1-weighted image.

Figure 3

Immunohistochemical examination images. GFAP and Ki67 were positive. GFAP = glial fibrillary acidic protein; HE = hematoxylin-eosin.

Figure 4

Head MRI and enhancing scanning images obtained 3 months after treatment with temozolomide. The lesions were much smaller compared with those in Figure 4, with little enhancement. The lesion in the left temporal had disappeared. MRI = magnetic resonance imaging.

Figure 5

Classification of MCGs. MCGs = multiple cerebral gliomas.

Figure 6

The possible pathogenesis of MCGs. MCGs = multiple cerebral gliomas.