Female, 14 years old, with history of high-grade glioma status post craniotomy, chemotherapy and radiotherapy, with prior bevacizumab treatment. Findings are again seen compatible with prior left parietal craniotomy and tumor resection. The resection bed remains mildly hemosiderin stained with gyriform intrinsic T1 hyperintensity similar to prior. T2 hyperintensity around the cavity likely representing gliosis and encephalomalacia is unchanged. No definite enhancement is seen within the operative region.Ill-defined T2 hyperintensity has progressed within the left frontal lobe, also tracking inferiorly into the insula and posteriorly along the roof of the lateral ventricle and involving the corpus callosum. Numerous punctate foci of susceptibility are seen within this region which are increased in number from the prior examination. On postcontrast imaging there is progressive punctate and lacelike enhancement corresponding to this abnormal tissue as well. Subtle progressive pinching of the left frontal horn is seen indicating a slight increase in mass effect.Ill-defined T2 hyperintensity has also progressed in the right cerebral hemisphere, again involving predominantly the frontal lobe but with involvement extending posteriorly and inferiorly along the basal ganglia and insula, into the operculum and along the body of the lateral ventricle. The frontal lobe signal abnormality is associated with nonterritorial ill-defined restricted diffusion which is new from prior. On postcontrast imaging, new smudgy enhancement is seen along the right cingulate gyrus.Punctate foci of susceptibility have become more numerous in the right cerebral hemisphere. In addition, a 4 mm focus of intrinsic T1 hyperintensity in the right posterior cingulate gyrus, and a punctate focus along the right superior frontal sulcus, both associated with susceptibility, could represent relatively more recent blood product. The ventricles are not dilated and are otherwise similar in size and morphology to the prior exam. No midline shift or brain herniation is suspected. A mucous retention cyst is noted in the right maxillary sinus.
Progressive signal abnormality and enhancement is seen in both cerebral hemispheres with new ill-defined nonterritorial restricted diffusion in the right frontal lobe. Significant progression of microhemorrhage is also seen in both hemispheres.It is possible that some degree of treatment effect may underlie the changes described above. However, the morphology and the distribution of the abnormality, including involvement of the peripheral right cerebral hemisphere which likely received relatively low radiation exposure, are more concerning for progressive tumor. The findings are suggestive of a gliomatosis-type pattern of spread.