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Case report
peer-reviewed

Spontaneous Resolution of a Confounding Insular Lesion



Abstract

Insular gliomas were previously considered inoperable lesions and were typically treated via biopsy, chemotherapy and/or radiation, if not observation alone. Stereotactic biopsies of low grade insular gliomas can underestimate tumor grade or fail to establish malignancy. Moreover, the survival advantages of maximal safe resection for insular lesions are increasingly being recognized. As such, early surgical resection is increasingly being performed. As with most lesions, a differential diagnosis exists for apparent insular gliomas, with definitive diagnosis generally obtained upon resection. We report an illuminating case that presented similarly to an insular glioma undergoing malignant transformation, but resolved spontaneously following a nondiagnostic biopsy. A 53-year-old female patient presented with aphasia and dizziness, followed by syncope and a 30-minute loss-of-consciousness. Imaging findings included a 12 mm region of contrast enhancement and central necrosis within a larger 3.5 cm expansile, T2-hyperintense lesion involving most of the left insula and extending into the anterior left temporal lobe. Imaging was felt most consistent with high-grade glioma. Stereotactic biopsy demonstrated nonspecific gliosis without definitive neoplastic tissue. A systemic workup was unrevealing, and thus an open procedure was subsequently planned in the intraoperative magnetic resonance imaging (MRI) suite. Preoperative MRI demonstrated interval resolution of the original lesion, despite profound T2 hyperintensity along the needle tract; thus, the planned resection was aborted. Subsequent imaging and systemic studies failed to establish a definitive infectious, neoplastic, autoimmune, or other diagnosis. However, poor dentition, history of a recent dental procedure, and the tiny central focus of diffusion restriction on the index MRI rendered abscess the most parsimonious explanation. On follow-up imaging, the lesion was noted to have further resolved without intervention. Our case illustrates the complexity of managing insular lesions and highlights the potential for alternate pathologies that can mimic insular glioma. Additionally, it provides a humbling reminder that, even in the presence of seemingly pathognomonic imaging findings, a differential diagnosis of insular lesions must be thoughtfully considered in patient counseling and presurgical planning.



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Case report
peer-reviewed

Spontaneous Resolution of a Confounding Insular Lesion


Author Information

Ali S. Haider Corresponding Author

Texas A&M College of Medicine

Health Science Center, Scott & White Clinic

Christopher S. Graffeo

Neurologic Surgery, Mayo Clinic

Neurologic Surgery, Mayo Clinic

Avital Perry

Neurologic Surgery, Mayo Clinic

Lucas P. Carlstrom

Neurologic Surgery, Mayo Clinic

Terry C. Burns

Neurologic Surgery, Mayo Clinic

Department of Neurological Surgery, Mayo Clinic


Ethics Statement and Conflict of Interest Disclosures

Human subjects: Consent was obtained by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.


Case report
peer-reviewed

Spontaneous Resolution of a Confounding Insular Lesion


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Case report
peer-reviewed

Spontaneous Resolution of a Confounding Insular Lesion

  • Author Information
    Ali S. Haider Corresponding Author

    Texas A&M College of Medicine

    Health Science Center, Scott & White Clinic

    Christopher S. Graffeo

    Neurologic Surgery, Mayo Clinic

    Neurologic Surgery, Mayo Clinic

    Avital Perry

    Neurologic Surgery, Mayo Clinic

    Lucas P. Carlstrom

    Neurologic Surgery, Mayo Clinic

    Terry C. Burns

    Neurologic Surgery, Mayo Clinic

    Department of Neurological Surgery, Mayo Clinic


    Ethics Statement and Conflict of Interest Disclosures

    Human subjects: Consent was obtained by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

    Acknowledgements


    Article Information

    Published: January 11, 2018

    DOI

    10.7759/cureus.2053

    Cite this article as:

    Haider A S, Graffeo C S, Perry A, et al. (January 11, 2018) Spontaneous Resolution of a Confounding Insular Lesion. Cureus 10(1): e2053. doi:10.7759/cureus.2053

    Publication history

    Received by Cureus: January 02, 2018
    Peer review began: January 03, 2018
    Peer review concluded: January 07, 2018
    Published: January 11, 2018

    Copyright

    © Copyright 2018
    Haider et al. This is an open access article distributed under the terms of the Creative Commons Attribution License CC-BY 3.0., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

    License

    This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Abstract

Insular gliomas were previously considered inoperable lesions and were typically treated via biopsy, chemotherapy and/or radiation, if not observation alone. Stereotactic biopsies of low grade insular gliomas can underestimate tumor grade or fail to establish malignancy. Moreover, the survival advantages of maximal safe resection for insular lesions are increasingly being recognized. As such, early surgical resection is increasingly being performed. As with most lesions, a differential diagnosis exists for apparent insular gliomas, with definitive diagnosis generally obtained upon resection. We report an illuminating case that presented similarly to an insular glioma undergoing malignant transformation, but resolved spontaneously following a nondiagnostic biopsy. A 53-year-old female patient presented with aphasia and dizziness, followed by syncope and a 30-minute loss-of-consciousness. Imaging findings included a 12 mm region of contrast enhancement and central necrosis within a larger 3.5 cm expansile, T2-hyperintense lesion involving most of the left insula and extending into the anterior left temporal lobe. Imaging was felt most consistent with high-grade glioma. Stereotactic biopsy demonstrated nonspecific gliosis without definitive neoplastic tissue. A systemic workup was unrevealing, and thus an open procedure was subsequently planned in the intraoperative magnetic resonance imaging (MRI) suite. Preoperative MRI demonstrated interval resolution of the original lesion, despite profound T2 hyperintensity along the needle tract; thus, the planned resection was aborted. Subsequent imaging and systemic studies failed to establish a definitive infectious, neoplastic, autoimmune, or other diagnosis. However, poor dentition, history of a recent dental procedure, and the tiny central focus of diffusion restriction on the index MRI rendered abscess the most parsimonious explanation. On follow-up imaging, the lesion was noted to have further resolved without intervention. Our case illustrates the complexity of managing insular lesions and highlights the potential for alternate pathologies that can mimic insular glioma. Additionally, it provides a humbling reminder that, even in the presence of seemingly pathognomonic imaging findings, a differential diagnosis of insular lesions must be thoughtfully considered in patient counseling and presurgical planning.



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Ali S. Haider

Texas A&M College of Medicine

For correspondence:
aralam09@gmail.com

Christopher S. Graffeo

Neurologic Surgery, Mayo Clinic

Avital Perry

Neurologic Surgery, Mayo Clinic

Lucas P. Carlstrom

Neurologic Surgery, Mayo Clinic

Terry C. Burns

Neurologic Surgery, Mayo Clinic

Ali S. Haider

Texas A&M College of Medicine

For correspondence:
aralam09@gmail.com

Christopher S. Graffeo

Neurologic Surgery, Mayo Clinic

Avital Perry

Neurologic Surgery, Mayo Clinic

Lucas P. Carlstrom

Neurologic Surgery, Mayo Clinic

Terry C. Burns

Neurologic Surgery, Mayo Clinic