Clinical Study
Normal or non-diagnostic neuroimaging studies prior to the detection of malignant primary brain tumors

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Abstract

We aimed to describe a single institution experience of neuroimaging failure to demonstrate malignant primary brain tumors. We retrospectively reviewed case histories for all newly diagnosed adult patients with malignant primary brain tumors treated at a single institution between 1 July 2006 and 30 June 2008. We specifically looked at patients in whom neuroimaging was normal or non-diagnostic at initial presentation. Among 193 patients with malignant primary brain tumors, there were 102 with World Health Organization (WHO) grade IV gliomas (glioblastoma multiforme, GBM), 54 with anaplastic gliomas, 18 with low grade gliomas, and 19 with primary central nervous system lymphomas (PCNSL). Initial imaging was normal in nine patients and abnormal but non-diagnostic in an additional eight patients with primary brain cancer. Normal or non-diagnostic neuroimaging was not uncommon among patients with GBM. Dramatic, rapid tumor growth is possible. Close interval clinical and radiographic follow-up can be important especially in the management of elderly patients presenting with seizures and non-diagnostic neuroimaging studies.

Introduction

With increasing access to advanced neuroimaging techniques in Emergency Departments (ED), contrast-enhanced CT scans and MRI are often performed to investigate new neurologic complaints within days or even hours of onset. Confusion arises when such studies are normal or reveal non-specific abnormalities despite overt symptoms or signs. Patients are often perplexed when later studies reveal abnormalities typical for aggressive, malignant neoplasms.

Section snippets

Materials and methods

As part of a specialty neuro-oncology service, the neurosurgeon (M.S.) and the neuro-oncologist (A.D.) retrospectively identified 17 patients with a malignant primary brain tumor with non-diagnostic neuroimaging (CT scan or MRI) from a total cohort of consecutive, newly diagnosed patients with a malignant brain tumor treated between 1 July 2006 and 30 June 2008. Data on clinical characteristics were gathered by a retrospective review of patients’ charts. A neuroradiologist (K.B.) re-reviewed

Results

Of the 193 newly diagnosed, consecutive patients with brain tumors diagnosed between 1 July 2006 and 30 June 2008, 102 patients had World Health Organization (WHO) grade IV gliomas (glioblastoma multiforme, GBM), 18 had low grade gliomas (LGG), 54 had anaplastic gliomas (AG), and 19 had primary central nervous system lymphomas (PCNSL). No patients with LGG or AG had a history of normal neuroimaging. Normal neuroimaging was found in eight of 102 patients with GBM (8%) and one of 19 patients with

Discussion

This retrospective study carries significant risk for recollection bias. To minimize such risks, we included all consecutive malignant primary brain tumor patients diagnosed by us at a single institution within a specified two year period. In addition, patients who reported normal neuroimaging studies that could not be verified were included in the total patient number, but excluded as neuroimaging failures. However, a much larger study than our 193 patients is needed to accurately predict

Conclusions

Patients who have normal brain CT scans or MRI after an accident, or because of new neurological symptoms, may prove to have high grade gliomas upon repeat imaging done months or years after the initial studies. If non-specific abnormalities are seen on T2-weighted MRI alone, follow-up imaging should be done within, at most, three months.

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