A 56-year-old woman was admitted to the hospital with new onset of tonic-clonic seizures. She had no significant medical or drug history. Results of the physical examination were normal, with no neurocognitive impairment. Her white blood cell count was 12 200/μL (to convert to × 109/L, multiply by 0.001), and her neutrophil count was 10 200/μL (to convert to × 109/L, multiply by 0.001). Magnetic resonance (MR) imaging demonstrated homogeneous asymmetrical swelling and enlargement of both thalami with distortion of both lateral ventricles. The thalamic lesions were isointense on T1-weighted images (Figure 1A) and hyperintense on T2-weighted images (Figure 1B) and fluid attenuation inversion recovery images (Figure 1C), with no enhancement after contrast administration. Magnetic resonance spectroscopy of the tumor revealed increased myo-inositol levels, diminished N-acetyl aspartate levels, and an increased creatine peak with an elevated creatine to choline ratio (Figure 2). A radiological diagnosis of bithalamic glioma was made. A stereotactic biopsy confirmed bilateral grade II astrocytomas. The patient was treated with dexamethasone, valproate sodium, and radiotherapy. She remained seizure free at the last follow-up visit.
Imaging of the thalami. A, Axial T1-weighted image shows diffuse isointense swelling of both thalami (arrows) with distortion of both lateral ventricles. B, Axial T2-weighted image shows homogeneous hyperintense swelling of both thalami (arrows). C, Fluid-attenuated inversion recovery sequence shows bilateral thalamic hyperintensities (arrows).
Magnetic resonance spectroscopy shows a high creatine (Cr) to choline (Cho) ratio with reduced N-acetyl aspartate (NAA) and raised myo-inositol (Ins dd1) levels. Cr2 indicates creatine2; I, integral; Lac, lactate.
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