Peri Ictal Pseudoprogression from Tumor Recurrence in a Patient with Treated Glioma Value of Diffusion Weighted and Perfusion Imaging Dr Nader Zakhari and Dr Thanh Nguyen The Ottawa Hospital ID: 514091
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Differentiation of Peri-Ictal Pseudoprogression from Tumor Recurrence in a Patient with Treated Glioma: Value of Diffusion Weighted and Perfusion Imaging
Dr Nader Zakhari and Dr Thanh NguyenThe Ottawa Hospital
EE-07 Slide2
DisclosureDr Thanh Binh Nguyen has received an investigator-initiated research grant from Bayer PharmaceuticalSlide3
PurposePeri-ictal pseudoprogression
“PIPG”= Transient MR abnormalities in patients with brain tumor–related seizures
that can incorrectly suggest tumor progression. Slide4
Purpose To present the MR findings of PIPG including diffusion and perfusion imaging.
To differentiate PIPG from true tumor progression and avoid unnecessary interventions.Slide5
Case ReportPresentation: August 2013 36 year-old man
Several simple and complex partial seizures with and without generalization. Slide6
Case ReportHistory: February 2010 3 years earlier was diagnosed with left frontal anaplastic astrocytoma (III/IV)
Treatment (completed in 2010): Surgery Adjuvant radiation (60 Gy in 6 weeks) Concomitant and adjuvant Temozolomide Slide7
Case ReportManagement: August 2013 Admission MRI
Treatment: phenytoin and levetiracetam No recurrence of seizuresSlide8
Imaging findings
Baseline post-operative
MR
(Sept. 2012) before presentation:
Left frontal craniotomy
Postoperative changes
No diffusion restriction
FLAIR
DWISlide9
Imaging findings
T1 post-contrast
CBV
Postoperative changes
No concerning enhancement
No increased
CBV
Baseline post-operative
MR
(Sept. 2012) before presentation:Slide10
Imaging findings
FLAIR
Left frontal cortical swelling and hyperintensity
MRI Aug. 2013 at presentation:Slide11
Imaging findings
Left frontal cortical diffusion restriction
DWI & ADC
MRI Aug. 2013 at presentation:Slide12
Imaging findings
T1 post-
contrast
T1 pre-
contrast
E
nhancement
Left frontal cortical/leptomeningeal enhancement
MRI Aug. 2013 at presentation:Slide13
Imaging findings
Dynamic Susceptibility Contrast Perfusion
Cortical increased
CBV
in the left frontal region
MRI Aug. 2013 at presentation:Slide14
Imaging findings FLAIR
Resolution of swelling and signal abnormalityMRI follow up Oct. 2013:Slide15
Imaging findings DWI and ADC
MRI follow up Oct. 2013:
Resolution of diffusion restrictionSlide16
Imaging findings Enhancement
MRI follow up Oct. 2013:
T1 pre-contrast
T1 post-contrast
Resolution of leptomeningeal/cortical enhancementSlide17
Imaging findings Dynamic Susceptibility Contrast Perfusion
Resolution of increased CBV in the left frontal regionMRI follow up Oct. 2013:Slide18
SummaryPeri-ictal pseudoprogression “PIPG”1
Seizure-associated MR abnormalities in the surgical bed mimicking tumor progression Rare entity ( <1%) Survivors of glioma who have undergone radiotherapy Average 10 years after treatmentSlide19
SummaryPreviously described seizure-associated MRI abnormalities: 2-4
Cortical swellingCortical T2/FLAIR hyperintensityCortical diffusion restriction Cortical and/or leptomeningeal enhancement Increased cerebral blood volume (
rCBV)
Slide20
SummaryMechanism of seizure-associated MRI abnormalities: 2-5 metabolism of seizing neurons
Compensatory blood flow: perfusion metabolism > blood flow:Local tissue hypoxia diffusion restrictionAnaerobic metabolism: lactate & Pco2: vascular dilatation & leakiness disruption of blood brain barrier and
enhancementSlide21
Summary
PIPGTUMOR RECURRENCE
Distribution
Predominantly cortical
Predominantly subcortical
Reversibility
Transient & reversible
Progressive
Diffusion restriction
Cortical
Not limited to the cortex
Not a constant feature
Contrast enhancement
Cortical &/or
focal leptomeningeal
Predominantly subcortical
Leptomeningeal enhancement more common diffuse
Perfusion
Increased
Increased Slide22
ReferencesRheims S, Ricard D, van den Bent M et al. Peri-ictal pseudoprogression in patients with brain tumor. Neuro Oncol. Jul 2011; 13(7): 775–782Rath
JJG, Smits M, Ducray F, van den Bent M. J. Increased rCBV in status epilepticus. J Neurol 2012;259:1746–1748Kim JA, Chung
JI, Yoon PH et al. Transient MR Signal Changes in Patients with Generalized Tonicoclonic Seizure or Status Epilepticus: Periictal
Diffusion-weighted Imaging. AJNR Am J Neuroradiol 2001; 22:1149–1160.
Szabo
K,
Poepel
A,
Pohlmann
-Eden B et al. Diffusion-weighted and perfusion MRI demonstrates parenchymal changes in complex partial status epilepticus. Brain (2005), 128, 1369–1376
.
Canasa
N,
Breiac
P,
Soares
P et al. The
electroclinical-imagiological
spectrum and long-term outcome of transient
periictal
MRI abnormalities. Epilepsy Research 2010;91:240—252Slide23
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