Post on 29-Dec-2015
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 Nguyen
The Ottawa Hospital
EE-07
Disclosure
Dr Thanh Binh Nguyen has received an investigator-initiated research grant from Bayer Pharmaceutical
Purpose
Peri-ictal pseudoprogression “PIPG”
= Transient MR abnormalities in patients with brain tumor–related seizures that can incorrectly suggest tumor progression.
Purpose
To present the MR findings of PIPG including diffusion and perfusion imaging.
To differentiate PIPG from true tumor progression and avoid unnecessary interventions.
Case Report
Presentation: August 2013
36 year-old man
Several simple and complex partial seizures with and without generalization.
Case Report
History: 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
Case Report
Management: August 2013
Admission MRI Treatment: phenytoin and levetiracetam No recurrence of seizures
Imaging findings
Baseline post-operative MR (Sept. 2012) before presentation:
Left frontal craniotomyPostoperative changesNo diffusion restriction
FLAIR DWI
Imaging findings
T1 post-contrast CBV
Postoperative changesNo concerning enhancementNo increased CBV
Baseline post-operative MR (Sept. 2012) before presentation:
Imaging findings
FLAIR
Left frontal cortical swelling and hyperintensity
MRI Aug. 2013 at presentation:
Imaging findings
Left frontal cortical diffusion restriction
DWI & ADC
MRI Aug. 2013 at presentation:
Imaging findings
T1 post-contrast
T1 pre-contrast
Enhancement
Left frontal cortical/leptomeningeal enhancement
MRI Aug. 2013 at presentation:
Imaging findings
Dynamic Susceptibility Contrast Perfusion
Cortical increased CBV in the left frontal region
MRI Aug. 2013 at presentation:
Imaging findings
FLAIR
Resolution of swelling and signal abnormality
MRI follow up Oct. 2013:
Imaging findings
DWI and ADC
MRI follow up Oct. 2013:
Resolution of diffusion restriction
Imaging findings
Enhancement
MRI follow up Oct. 2013:
T1 pre-contrast
T1 post-contrast
Resolution of leptomeningeal/cortical enhancement
Imaging findings
Dynamic Susceptibility Contrast Perfusion
Resolution of increased CBV in the left frontal region
MRI follow up Oct. 2013:
Summary
Peri-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 treatment
Summary
Previously described seizure-associated MRI abnormalities: 2-4
Cortical swellingCortical T2/FLAIR hyperintensityCortical diffusion restriction Cortical and/or leptomeningeal enhancement Increased cerebral blood volume (rCBV)
Summary
Mechanism 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 enhancement
Summary
PIPG TUMOR RECURRENCE
Distribution Predominantly cortical Predominantly subcortical
Reversibility Transient & reversible Progressive
Diffusion restriction
Cortical Not limited to the cortexNot a constant feature
Contrast enhancement
Cortical &/or focal leptomeningeal
Predominantly subcorticalLeptomeningeal enhancement
more common diffuse
Perfusion Increased Increased
References1. Rheims S, Ricard D, van den Bent M et al. Peri-ictal
pseudoprogression in patients with brain tumor. Neuro Oncol. Jul 2011; 13(7): 775–782
2. Rath JJG, Smits M, Ducray F, van den Bent M. J. Increased rCBV in status epilepticus. J Neurol 2012;259:1746–1748
3. Kim 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.
4. 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.
5. 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—252
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