60894493

1/ Anamnesis:

- Motor tasks for hands (bilateral finger-tapping) and feet (bilateral toe moving), lip pouting and language
task (noun-to-verb generation) were explained, well understood and practiced prior to the scan.

- The patient is right-handed and left leg dominant. He reports language difficulties, troubles
concentrating while in a conversation and headaches.

2/ Structural, DWI and PWI data:

1- The known right frontal lobe intra-axial corticosubcortical lesion is noted measuring about RL 44mm x
AP 62mm x CC 44mm, extending through the body of the corpus callosum contralaterally to the centrum
semiovale at a maximum RL distance of 75mm. The lesion implicates the superior and middle frontal and
cingulate gyrus, the centrum semiovale, as well as the body of the corpus callosum, extending to the
contralateral centrum semiovale.

2- The lesion is exerting mild mass effect on adjacent structures, effacing the cortical sulci and
compressing the adjacent gyri. There is no compression of the ventricular system and no midline shift.
There is more perilesional edema compared to images of the prior scan (28th April 2023) and the lesion
involves the cortex in the superior frontal gyrus with signs of thickening.

3- The lesion has predominantly homogenous signal intensity on T2 and T1 weighted images (WIs),
showing low signal on T1WI and high signal on T2WI, which does not suppresses on FLAIR images.

4- Postcontrast images show a focal area of enhancement, measuring about 19 x 9mm in the cortex of
the right superior frontal gyrus, adjacent to a cortical vein that drains into the superior sagittal sinus (SE
1703, IM 196,197/220). There are some (about 20) visible hypointense punctate foci on susceptibility WIs
widely distributed within the lesion that primarily correspond to microbleeds.

5- DWI/ADC maps show that the lesion has primarily elevated ADC values > 1.1x10^-3 mm^2/s,
compared to normal white matter (NWM) ADC = 0.7x10^-3 mm^2/s, with the exception of the noted
focal enhancing cortical area, that shows diffusion restriction with ADC values around 6.4x10^-3 mm^2/s.

6- Perfusion WIs show a generally hypoperfused lesion with low rCBV ratio (< 1 to NWM) and the focal
cortical enhancing area with high rCBV ratio (>5.3 to NWM), which correlates to a progression of a low
grade to a high grade lesion.

3/ BOLD fMRI:

The patient is right handed. The following tasks were used (and exercised outside the scanner):
a) For the sensory-motor system we employed a bilateral finger-tapping (FT), lip pouting task, and a toe
movement task versus rest task.

- There is bilateral activation of the somatotopically organized sensory-motor network, including bilateral
primary sensory-motor cortex (SM1, corresponding to activity in the pre and postcentral gyri), the
supplementary motor area (SMA, corresponding to the medial surface of the superior frontal gyrus), the
premotor cortex (PMC), the secondary sensory cortex (S2), the parietal proprioceptive cortex (PPC -
corresponding to the superior parietal lobule - SPL), and bilateral cerebellum.

- The lesion's local mass effect causes a moderate deformation of the right SMA compared to the left.

- The closest sensory-motor functional zones to the lesion are:

1. The representation of the left hand, foot and lips in SMA is posteromedially adjacent to the lesion, with
no measurable separation.

2. The representation of the left hand and the left side of the lips in PMC is about 1 cm posterolateral to
the lesion.

3- The representation of the left hand and lip in M1 is about 0.5 - 1 cm posterolateral to the lesion,
representation of the left foot about 1.5 - 2 cm posteromedial to the lesion.

b) For the language function, a noun-to-verb generation task versus rest (with matched visual input) was
used. This resulted in significant activation of:

- Left fusiform and bilateral calcarine gyri (corresponding functionally to "reading"-areas).

- Bilateral middle and superior temporal gyrus (corresponding to Wernicke's area), L>>R.

- Bilateral supramarginal and angular gyri (Geschwind's area), L>>>R.

- Bilateral inferior frontal gyrus (corresponding functionally to Broca's area on the left and it’s right side
homologue), L>>R.

- Bilateral middle frontal gyrus (corresponding functionally to area 55b), L>R.

- Bilateral middle frontal gyrus (Premotor cortex), L>R.

- Bilateral DLPFC (Dorsolateral prefrontal cortex).

- Bilateral superior frontal gyrus (SMA).

- Bilateral superior parietal lobule (attention and working memory), L>R.

- Bilateral cerebellar, slightly more activity in the right hemisphere.

* Thus, the language function in this right handed patient appears to have a bilateral activation with left
sided cerebral representation.

- The closest language functional zones to the lesion are:

1- Right SMA is mostly medially deformed by the mass effect of the lesion, with no measurable
separation.

2- Right PMC is posterolaterally adjacent to the lesion, with no measurable separation.

3. Right DLPFC is about 1.5 - 2 cm inferior and anterolateral to the lesion.

4- Right-side homologue of Broca's area is about 2 - 2.5 cm inferolateral to the lesion.

5. Left PMC is about 1-1.5 cm lateral to the extending signal abnormality of the lesion in the left centrum
semiovale.

6. Broca’s area is about 3 – 3.5 cm anterolateral and inferior to the extending signal abnormality of the
lesion in the left centrum semiovale.

4/ dMRI-FT:

Fiber tractography was performed using the CSD algorithm, which is capable of resolving complex
intravoxel fiber orientations.

The fiber bundles traced are the bilateral Corticospinal tracts (CST) (conducting motor and sensory
impulses), the medial lemniscus (ML) (conducting sensory impulses), the Arcuate fasciculi (AF), frontal
aslant tract (FAT), and the Uncinate fasciculi (UF) (conducting language, fluency, and attentional
functions), the Inferior Fronto-Occipital fasciculi (IFOF), the Inferior longitudinal fasciculi (ILF), middle
longitudinal fasciculi (MdLF), and the Cingulum bundles (Cingulate and Parahippocampal bundles), as
well as the Optic Tracts and Radiations on both sides.

- dMRI-FT shows slight deformation and displacement in the right sided perilesional fiber bundles
compared to the left side.

- Bilaterally well-developed AFs are noted with a slightly greater complexion on the left side.

- The fiber bundles most closely related to the lesion are:

1- The right FAT is included in the lesion in its upward trajectory, partially reconstructed, deformed and
displaced.

2- The right AF is slightly displaced laterally, adjacent to the lesion with no measurable separation.

3- The right CC is included in the lesion, only slightly deformed compared to the contralateral.

4- The right CST is displaced slightly posterior to the lesion, with no measurable separation.

5- The right IFOF is about 1.5 cm inferior to the lesion in the anterior part.

Conclusion:

- Imaging features of a diffuse right superior frontal lesion, with interval progression in size,
characteristics and contralateral extension, likely progression from a low grade into a high grade glioma
(glioblastoma).
- Task-based BOLD fMRI shows the lesion's proximity to the representation of the hands and lips in M1,
PMC, as well as to the representation of the language area as detailed above.

- dMRI-FT shows bilaterally well-developed AFs, and demonstrates the lesion's proximity and consequent
partial reconstruction the right FAT, with slight deformation of the right CC and slight displacement of the
right AF and CST.

Dr. Filip Samardzic

Dr. Ahmed Radwan

Prof. Dr. Stefan Sunaert