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MR Spectroscopy Case Study
Glioblastoma Multiforme Grade 3
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Prepared by Greg Brown    Royal Adelaide Hospital North Terrace Adelaide South Australia 5000
February 28th 2001		 Back to MRS Page
Images and Spectra obtained on a Siemens VISION 1.5T using Numairs VB33E software and sequences.  Images and Spectra converted to jpeg by eFilm.
Presentation Imaging MRS Technique MRS Results Histopathology Discussion

Presentation
3/5/00 27 year old female transferred from country hospital. Unwell for several weeks with tiredness, intermittent headaches and neurologic disturbances. One seizure 1/5/00. CT shows ? diffuse oedema ? encephalopathy ? VST 
Working diagnosis after:  Herpes Simplex encephalitis. Treated with acyclovir and steroids
N.B. MRS was not installed until June 2000
6/10/00 Assumed HSE Increased headaches, diplopia, déjà vu
Imaging
MRI 3/5/00 Oedema of the grey matter within the right temporal lobe medially. Cortical swelling and effacement of the temporal horn of eh lateral ventricle. Appearances "virtually diagnostic of Herpes Simplex Encepahlitis.
MRI 9/5/00 Patient is clinically surprisingly well.  No change the the dgree or extent of predominantly right sided oedema.
MRI 6/10/00 Previous MRI unavailable. 3 cm irregular enhancing lesion within the right temporal lobe surrounded by oedema causing mid line shift. "The elevated Choline on the spectroscopy would indicate that the lesion is likely to be neoplastic rather than infective."

MRS Technique
SVS SE 135 of the right temporal lobe within the centre of the high signal lesion on T2 images.

MRS Results
Location of the voxel made for a poor shim (10Hz) shown as increased line width and poor spectral resolution of the Choline and Creatine peaks.
Choline (3.2 ppm) is obviously increased and NAA (2 ppm) is markedly decreased.  An inverted doublet at 1.3 ppm was difficult to phase relative to NAA but is inverted at Te 135, and represents Lactate.
The appearances are characteristic of a tumour with necrosis
 
Cho Cr NAA Lactate Lipid Cho/Cr  NAA/Cr NAA/Cho Cr/Cho
14.16 16.3 12.23 37.05 no  0.87 0.75 0.86 1.15

 
Histopathology
Brain biopsy after MRI in October.  Fragments of glioblastoma multiforme showing a spectrum of histopathological changes.  Extensive tumour necrosis. A cyst was resected containing eosinophilic fibrillar coagulum and surrounded by necrotic tumour cells.
Discussion
A useful spectra, obtained in the face of a restless patient and sub optimal shim made the correct diagnosis unequivocally. MRI appearances of the October scan strongly suggested tumour, however the cyst was not well appreciated.   Had MRS been available at the initial presentation 5 months earlier it would be expected to show the same characteristics of tumour and a correct diagnosis would have been established despite the MRI appearances being consistent with HSV encephalitis.