A 45-year-old white male presents with a 4-month history of headaches. The headache is generalized, dull, constant, and worsened by bending, coughing and sneezing. It is unresponsive to simple analgesics, and associated with nausea and vomiting. His wife says he has been acting strangely for the last few months, and she has noted a personality change. The neurological examination is non-focal. Fundoscopy reveals papilledema. His CT scan is shown below. Which of the following is the most likely diagnosis?

Question

A 45-year-old white male presents with a 4-month history of headaches.  The headache is generalized, dull, constant, and worsened by bending, coughing and sneezing.  It is unresponsive to simple analgesics, and associated with nausea and vomiting.  His wife says he has been acting strangely for the last few months, and she has noted a personality change.  The neurological examination is non-focal.  Fundoscopy reveals papilledema.  His CT scan is shown below.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

This patient most likely has glioblastoma (grade IV astrocytoma, formerly glioblastoma multiforme), the most common primary brain malignancy. His symptoms (eg, nausea, vomiting, headaches that worsen with changes in position, coughing and sneezing) and physical findings (eg, papilledema) are indicative of increased intracranial pressure, which is most likely due to a space-occupying lesion. Furthermore, the presence of personality changes and strange behavior suggest the lesion is localized to the frontal lobe. The CT/MRI findings of a butterfly appearance with central necrosis is classic for glioblastoma, and the heterogenous, serpiginous contrast enhancement is typical of a high-grade (eg, grade IV) astrocytoma such as a glioblastoma. (Choice A) Patients with brain abscess usually have fever, acute onset of symptoms, and evidence of a systemic infectious process. On neuroimaging, there is often thick and diffuse contrast enhancement resulting in a ring (an inflammatory capsule due to blood-brain barrier breakdown). (Choice B) Patients with brain metastases usually have a duration of symptoms of less than 2 months. The site of metastasis is the gray-white junction or watershed zones. Brain metastases are usually multifocal and spherical in shape. (Choice D) Patients with low-grade (rather than high-grade) astrocytoma usually present with seizures, and have a longer duration of symptoms. Furthermore, contrast enhancement is less likely. (Choice E) Patients with infarction present acutely and usually have risk factors such as diabetes, hypertension, history of smoking, and so on. Contrast enhancement develops over days. Contrast enhancement is heterogenous as in glioblastoma multiforme; however, unlike glioblastoma, it is not progressive and resolves within six to eight weeks. Educational objective: The typical CT/MRI findings in high-grade (eg, grade IV) astrocytoma are heterogenous and serpiginous contrast enhancement. Glioblastoma (grade IV astrocytoma) has a classic butterfly appearance with central necrosis on neuroimaging.

A 45-Year-Old White Male Presents with a 4-Month History of Headaches