45-year-old man with history of recurrent glioblastoma on Avastin therapy. There are multiple areas of abnormal signal and enhancement, overall increased in extent from the prior examination. There is a large area of heterogeneous, increased T2 signal involving the right thalamus, cerebral peduncle, posterior limb of the internal capsule, putamen, insular cortex, and temporal and parietal white matter with a surrounding, faint T1 hyperintense rim suggestive of blood products or hemorrhage. This area also contains small areas of T2 hyperintense cystic degeneration. This area measures 50 x 49 mm (10/24), previously 40 x 46 mm. Within this area, there is restricted diffusion and decreased cerebral blood volume (image 2).The area of signal abnormality in the right precuneus, post central gyrus, and splenium of the corpus callosum (12/28) appears larger than the prior examination, measuring 39 x 20 mm, previously 35 x 18 mm. This area has changed in enhancement characteristics, now enhancing only peripherally, previously more homogenously. Additionally, there are spiculated areas of internal susceptibility suggestive of vascularization (8/118) and increased cerebral blood volume (image1).An area of signal abnormality in the left periatrial white matter (12/18) has increased in size measuring approximately 13 x 10 mm, previously 10 x 8 mm. This area also has change in enhancement characteristics, now enhancing peripherally, whereas it previously was more homogenous enhancement. Spiculated areas of internal susceptibility are also noted in this region (8/92) and there is increased cerebral blood volume (image 3).There is overall increase in the extent of FLAIR hyperintensity which, in addition to the right frontal, parietal, temporal lobes, and basal ganglia, now includes the left periatrial white matter (3/22). Additionally, there is new T2 and FLAIR hyperintensity in the subcortical white matter of the left parietal lobe (3/20). There is subtle enhancement of the lateral ependymal lining of the right temporal horn (12/14) which extends along the lateral wall of the ventricle. Although there is associated mass effect with compression of the trigone of the right lateral ventricle, the lateral ventricles are mildly enlarged. There is no frank midline shift, or herniation. There is a right transtemporal catheter with surrounding susceptibility artifact indicating chronic blood products. There is no restricted diffusion to suggest acute ischemia. There is no large intracranial hemorrhage. The major flow voids are preserved. The orbits, paranasal sinuses, and calvarium are grossly unremarkable.
1.Extensive tumor centered in the right cerebral hemisphere, overall increased in extent. Tumor involving the right thalamus, cerebral peduncle, internal capsule, putamen, insular cortex, and parietal white matter appears similar to the prior examination with decreased blood volume and diffusion restrictions suggestive of treated tumor.2.Increase in size but change in enhancement pattern of adjacent right precuneus, post central gyrus, and corpus callosum tumor. Increased cerebral blood volume in this region suggests viable tumor.3.Increase in size of satellite left periatrial white matter tumor with change in enhancement pattern. Again, increased cerebral blood volume suggests viable tumor in this location.4.Enhancement along the temporal horn of the right lateral ventricle along with ventriculomegaly is suggestive of ependymal spread.  