66 years, Female, GBM, had SRS to basal ganglia lesion, patient on PD 1 and CTLA4 Abs. Compared to 12/17/2015, there is interval increase in masslike T2/FLAIR hyperintensity involving the left optic tract, hypothalamus, and extending into the optic chiasm highly suspicious for tumor progression. There is also increased associated enhancement.There are postsurgical changes in the left anterior temporal lobe with blood products again seen along the posterior aspect of the resection cavity similar to prior. There is however interval increase in FLAIR hyperintensity in the left anterior temporal lobe posterior to the resection cavity with increased heterogeneous areas of nodular enhancement suspicious for tumor progression. More superiorly, at the level of the left basal ganglia, left periatrial white matter, and the left posterior temporal lobe, there is also increase in masslike FLAIR hyperintensity as well as increased in enhancement with mild restricted diffusion. Perfusion images demonstrate elevated cerebral blood volumes in the above-mentioned areas of increased enhancement and FLAIR hyperintensity.As before there is a left occipital resection cavity which communicates with the atrium of the left lateral ventricle. There is no midline shift or herniation. No hydrocephalus. There is diffuse opacification of the right maxillary sinus as before.
Compared to 12/17/2015, findings are highly concerning for progression of multifocal glioblastoma, particularly in the region of the left optic tract and posterior to the anterior left temporal resection cavity as describe above. Additional areas of increased FLAIR hyperintensity and enhancement described above in the left basal ganglia and the left posterior temporal cortex are also suspicious. These areas demonstrate elevated cerebral blood volumes.