E-ISSN 1858-8360 | ISSN 0256-4408
 

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SUDANESE JOURNAL OF PAEDIATRICS

2021; Vol 21, Issue No. 1

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Imaging features of brainstem glioma in a 6-year-old child

Ravikant Kaushik (1), Mukta Mital (1), Kastubh Gupta (1)

(1) Department of Radiodiagnosis, Subharti Medical College, Meerut, Uttar Pradesh, India

Correspondence to:

Mukta Mital

Department of Radiodiagnosis, Subharti Medical College, Meerut, Uttar Pradesh, India.

Email: muktamital [at] yahoo.com

Received: 18 April 2020 | Accepted: 25 July 2020

How to cite this article:

Kaushik R, Mital M, Gupta K. Imaging features of brainstem glioma in a 6-year-old child. Sudan J Paediatr. 2021;21(1):98–101.

https://doi.org//10.24911/SJP.106-1587039828


A 6-year-old male child presented to the paediatric outpatient department with a history of diplopia, palatal palsy, torticollis, facial weakness, facial numbness, gait ataxia, incoordination, focal weakness, headaches and vomiting. It was difficult to establish an exact time for the onset of symptoms. The patient was referred to the Department of Radiology for contrast-enhanced computed tomography (CT) of head. Findings showed an expanded brain stem with ill-defined non-enhancing hypodense lesion in the right side of midbrain and pons involving cerebellar peduncle displacing the fourth ventricle towards the left side (Figure 1). Magnetic resonance image (MRI) of the brain revealed significant expansion of the brainstem by large expansile space-occupying lesion (SOL) measuring 38 mm × 28 mm × 35 mm in the pons (Figure 2A and B). The mass lesions showed hyperintensity on the T2W images, and FLAIR showed the hyperintensity too (Figure 2C). On postcontrast images (Figure 2D), the lesion showed no contrast enhancement. Magnetic resonance spectroscopy (MRS) of the lesion (Figure 3) revealed high choline (Ch) and low N-acetyl-aspartate (NAA) (Figure 4). According to age, sex and imaging features of the mass lesion, the diagnosis of brainstem glioma was given.

Diffuse brainstem gliomas are infiltrating astrocytomas and most frequently arise in the pons. These tumours present in childhood (3-10 years of age) [1]. Symptoms are cranial nerve palsies and the signs of raised intracranial pressure. In the sporadic form, the prognosis is poor with 2-year survival being only 20% (median survival less than 1 year) [2]. Typical findings are hypodense lesions on CT and decreased intensity in brain magnetic resonance imaging T1, heterogeneously increased in T2, and usually minimal enhancement in T1 contrast image MRI. CT scan is less accurate than MRI but appropriate when MRI is not available. Cerebrospinal fluid examination is often important for differential diagnosis [3]. Brain MRI, with and without gadolinium contrast, is considered to be the ‘gold standard’ for the diagnosis of brain stem gliomas. Unless the diagnosis of the tumour is in doubt, biopsy is seldom performed outside specialised biomedical research protocols for diffuse intrinsic pontine glioma [2]. Biopsy may be indicated for brain stem tumours that are focal or atypical, especially when the tumour is progressive or when surgical excision may be possible.

Figure 1. CT head axial image showing an expanded brain stem with ill-defined non-enhancing hypodense lesion in the right side of midbrain and pons, involving cerebellar peduncle and displacing the fourth ventricle towards the left side (arrow).

Figure 2. Brain MRI (A) T2 axial and (B) sagittal image showing significant expansion of the brainstem by large expansile SOL measuring 38 mm × 28 mm × 35 mm in the pons, involving the brachium pontis on the the right side with significant expansion of the brainstem and mild mass effect and deformity of the fourth ventricle (arrows). (C) The SOL displayed heterogeneity bright signals on T2 FLAIR (arrow). (D) The mass lesion showed no enhancement on postcontrast study (arrow).

Differential diagnosis includes medulloblastoma and ependymoma. Ependymoma usually arises from the floor of the fourth ventricle, typically squeezes out the foramen of Luschka, shows calcification too and does not usually cause as much diffusion restriction [4]. Medulloblastoma has similar demographic, especially if around the fourth ventricle, and does not tend to extend through foramina, enhancement is more homogenous, and calcification is less common [5].

Figure 3. MRS of the lesion.

Figure 4. High Ch and low NAA peaks revealed by MRS of the lesion (arrows).


Conflicts of interest

The authors declare that there is no conflict of interest regarding the publication of this article.


Funding

None.


Consent for publication

Written informed consent was obtained from all the participants.


Ethical approval

Ethics clearance and approval of the study were granted by the ethics committee of the institute. Signed informed consent for participation and publication of medical details was also obtained from the parents of the patient. Confidentiality was ensured at all stages.


REFERENCES

  1. Rajeswarie RT, Rao S, Nandeesh BN, Yasha TC, Santosh V. A simple algorithmic approach using histology and immunohistochemistry for the current classification of adult diffuse glioma in a resource-limited set-up. J Clin Pathol. 2018;71:323–9. https://doi.org/10.1136/jclinpath-2017-204638
  2. Freeman CR, Farmer JP. Pediatric brain stem gliomas: a review. Int J Radiat Oncol Biol Phys. 1998;40:265–71. https://doi.org/10.1016/S0360-3016(97)00572-5
  3. Ostrom QT, de Blank PM, Kruchko C, Petersen CM, Liao P, Finlay JL, et al. Alex’s Lemonade Stand Foundation infant and childhood primary brain and central nervous system tumors diagnosed in the United States in 2007-2011. Neuro Oncol. 2015;16 Suppl 10(Suppl 10):x1–36. https://doi.org/10.1093/neuonc/nou327
  4. Basati SS, Harris TJ, Linninger AA. Dynamic brain phantom for intracranial volume measurements. IEEE T Biomed Eng. 2011;58:1450–5. https://doi.org/10.1109/TBME.2010.2050065
  5. Celma MS, Busquets FB, Genestar JV, Suárez JA, Flaqué MV, Escoda AC, et al. 6ER-011 drug utilisation study of bevacizumab in a teaching referral paediatric hospital. Eur J Hosp Pharm. 2018;25:A234. https://doi.org/10.1136/ejhpharm-2018-eahpconf.504


How to Cite this Article
Pubmed Style

Kaushik R, Mital M, Gupta K. Imaging features of brainstem glioma in a 6-year-old child. Sudan J Paed. 2021; 21(1): 98-101. doi:10.24911/SJP.106-1587039828


Web Style

Kaushik R, Mital M, Gupta K. Imaging features of brainstem glioma in a 6-year-old child. http://www.sudanjp.com/?mno=99793 [Access: October 16, 2021]. doi:10.24911/SJP.106-1587039828


AMA (American Medical Association) Style

Kaushik R, Mital M, Gupta K. Imaging features of brainstem glioma in a 6-year-old child. Sudan J Paed. 2021; 21(1): 98-101. doi:10.24911/SJP.106-1587039828



Vancouver/ICMJE Style

Kaushik R, Mital M, Gupta K. Imaging features of brainstem glioma in a 6-year-old child. Sudan J Paed. (2021), [cited October 16, 2021]; 21(1): 98-101. doi:10.24911/SJP.106-1587039828



Harvard Style

Kaushik, R., Mital, . M. & Gupta, . K. (2021) Imaging features of brainstem glioma in a 6-year-old child. Sudan J Paed, 21 (1), 98-101. doi:10.24911/SJP.106-1587039828



Turabian Style

Kaushik, Ravikant, Mukta Mital, and Kastubh Gupta. 2021. Imaging features of brainstem glioma in a 6-year-old child. Sudanese Journal of Paediatrics, 21 (1), 98-101. doi:10.24911/SJP.106-1587039828



Chicago Style

Kaushik, Ravikant, Mukta Mital, and Kastubh Gupta. "Imaging features of brainstem glioma in a 6-year-old child." Sudanese Journal of Paediatrics 21 (2021), 98-101. doi:10.24911/SJP.106-1587039828



MLA (The Modern Language Association) Style

Kaushik, Ravikant, Mukta Mital, and Kastubh Gupta. "Imaging features of brainstem glioma in a 6-year-old child." Sudanese Journal of Paediatrics 21.1 (2021), 98-101. Print. doi:10.24911/SJP.106-1587039828



APA (American Psychological Association) Style

Kaushik, R., Mital, . M. & Gupta, . K. (2021) Imaging features of brainstem glioma in a 6-year-old child. Sudanese Journal of Paediatrics, 21 (1), 98-101. doi:10.24911/SJP.106-1587039828





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