0:01

All right, let's, uh, you know,

0:02

it's funny about the IDH type.

0:04

Uh, this is one example where you want to be a mutant.

0:08

You don't wanna be a wild type, you wanna be a mutant.

0:11

So for all those, um, X-Men fans out there,

0:16

be a mutant because you have a better prognosis.

0:18

Unfortunately, this case I'm about to show you

0:21

is an IDH wild type.

0:24

So by definition, along with that, TERT and EGFR

0:29

and the Trisomy seven, monosomy 10 molecular

0:33

genetic findings of glioblastoma.

0:36

This was an IDH wild type.

0:38

So in this example, we have a case where the lesion is

0:44

actually not bad as far as the definition on the flare scan.

0:48

You see that as we go inferiorly.

0:50

There is a component which extends to the penal surface

0:53

of the occipital horn

0:55

of the left lateral ventricle here on the flare imaging.

0:59

So it doesn't have perfectly well-defined mark margins.

1:03

It actually has a little bit of ill-defined,

1:05

and I'm not sure whether some

1:07

of the medial temporal lobe also is involved over here.

1:11

When we look at the post gadolinium enhanced imaging

1:15

in the bottom left image,

1:19

what we see is a tumor that has necrosis.

1:24

It is a tumor that has a border with the dura.

1:28

Again, something that may be a imaging feature

1:33

that puts you at risk

1:35

for subarachnoid seating if it gets out to the door

1:38

or if it gets to the append surface of the ventricle.

1:41

As I said previously, with regard to that issue,

1:45

although the flare signal went all the way out

1:47

to the ventricular surface, this lesion has a little bit

1:50

of a knuckle that approaches the eima of the

1:55

left lateral ventricle,

1:56

but we don't see enhancement of the append.

2:00

It does have sort of a multi lobulated appearance here,

2:03

which is typical of an infiltrative tumor.

2:08

On our T two wade scan,

2:10

we see again a lesion which is hypervascular.

2:14

Note that from a hypervascular standpoint,

2:17

I'm talking about the number

2:18

of blood vessels within this lesion.

2:20

This is another imaging feature that should be reported on

2:23

that there are numerous vessels coursing

2:25

through this lesion, and therefore the potential

2:28

for either these being arteries

2:30

and distal occlusion infarcts,

2:33

or these being veins with the potential

2:36

for a cortical venous infarction is going to be problematic

2:40

as well as the risk of increased blood loss

2:43

during the resection of this tumor.

2:46

It may be that upon looking at this

2:48

and you know, potentially taking a biopsy

2:51

and finding that it's a wild type, that they may not be

2:53

so aggressive about trying

2:55

to remove the majority of the lesion.

2:57

Notice that on our

2:58

Perfusion map that the necrotic portion

3:02

of the tumor obviously is going to have hypoperfusion.

3:06

Uh, let's look at our gray scale again.

3:08

So, once again, the gray matter here is blue.

3:12

The white matter is greenish,

3:16

and you can see the lateral ventricle frontal horns here,

3:19

and this is the lateral ventricles are green.

3:22

So green is hypoperfusion since the CSF does not get a

3:26

perfusion, whereas the blue, which is the gray matter here,

3:31

is the hyper perfused area.

3:34

So it has a hyper perfused periphery.

3:39

As well as that, that little knuckle that we talked about

3:41

that showed contrast enhancement

3:43

and that was approaching the left lateral ventricle,

3:46

that little knuckle of tissue is hyper perfused, presumably

3:49

to be higher grade.

3:51

Um, let's see whether I can pull up the a DC

3:56

map on this case.

3:58

And not exactly dark,

4:02

but not bright on the a DC map.

4:05

There are darker areas here,

4:07

and again, you can put markers on here

4:12

and do region of interest analysis.

4:14

Let's, let's see what turns out when we do that,

4:17

because in general, we say if something is, you know,

4:20

less than 800, so this is 8 46.

4:24

It's kind of borderline values,

4:27

but less than 800, definitely higher grade tumor

4:29

and more worrisome for a glioblastoma or grade four tumor.

4:34

In this case, 847 seems to be where we have

4:38

the lowest A DC values.

4:42

So whether it's imaging features are present

4:46

or not of necrosis of low A, D, c,

4:48

hyperperfusion, et cetera.

4:50

This is IDH wild type by definition,

4:53

a molecular glioblastoma with the turt

4:56

and the eeg, FR, et cetera.

4:57

It does have some of the imaging features

4:59

that we would naturally suggest were a higher grade tumor,

5:03

be it an IDH mutant grade four,

5:05

or the IDH wild type glioblastoma.

5:08

By virtue of the necrosis, the hyperperfusion,

5:11

the lower A DC, not dramatically lower, but low A DC.

5:15

So this is our example of IDH wild type glioblastoma.