Posttraumatic Glioma: Report of a Case
A 37-year-old man was admitted in October 2002 with a several months history of medically refractory seizures and a more recent onset of headache and confusion. His past clinical history was relevant for a major brain trauma with left temporal hemorrhage, which occurred in 1977 and which was demonstrated by CT scanning as indicated by the clinical charts of another hospital. At admission, he showed mild confusion, short-term memory deficit but no speech impairment. MRI demonstrated a T1 hypointense and T2 hyperintense lesion in the left insular region, which did not enhance with gadolinum (fig. ). The lesion was exposed via a pterional approach and wide splitting of the Sylvian fissure and generously removed; however, it was intentionally not radically removed. No clear limit with the surrounding normal parenchyma could be seen at surgery. Histological examination revealed a moderately increased cellularity (fig. ) compatible with diffuse astrocytoma (grade II according to the WHO classification). In addition, pseudo-cystic areas containing hemosiderin pigment and CD68-positive macrophages, interstitial hemosiderin-loaded macrophages and inflammatory cells were also detected (fig. ). These findings would indicate the presence of a pre-existing hemorrhage. After surgery, the patient's confusion definitely improved, as did the focal epilepsy. This latter was well controlled with a low medication dosage until 2004, when, due to recrudescence of the seizures, he underwent a MRI that again documented an abnormal area in the deep left temporal region (fig. ). The lesion was removed via a transulcal left temporal approach and again removal was not radical. Histological examination in this occasion gave evidence of only local degenerative posttraumatic changes. Again, focal epilepsy improved. He was readmitted in December 2006 because an MRI follow-up study (fig. ), performed again because of worsening of the seizures, had demonstrated an area of contrast enhancement in the context of the previously abnormal area. The patient was submitted for surgery via the same previous temporal craniotomy, and the lesion was apparently totally removed. Histological examination now revealed (fig. ) an anaplastic astrocytoma (grade III according to the WHO classification). The postoperative course was uncomplicated. The patient underwent postoperative radiation treatment and chemotherapy. At the last follow-up, 5 years after surgery, the patient was well and had no signs of recurrence.