Glioblastom ve yüksek dereceli gliom

Özet

Glioblastom çoğunlukla erişkinlerde gelişen, hızla ilerleyebilen infiltratif bir intraaksiyel tümördür. Acilde BT, tümörün kendisini kesin sınıflandırmaktan çok kanamayı, ödemi ve yaşamı tehdit eden kitle etkisini hızla gösterir. Kontrastlı MRG tümörün yayılımını ve nekrotik kontrastlanan bileşenini daha iyi karakterize eder; BT bulguları histolojik ya da moleküler tanı yerine geçmez. Orta hat basısı, hidrosefali veya herniasyonun gözden kaçması acil değerlendirmeyi geciktirip nörolojik kötüleşmeye yol açabilir.

Faz ve pencere

Kontrastsız tanısal

Kontrastsız BT’de kitle genellikle hiperdens veya heterojen görünebilir; çevresinde vazojenik ödem kaynaklı hipodensite, ventrikül basısı ve intralezyonel kanama aranır. Kontrastsız BT nekrotik kontrastlanan halkayı göstermez.

Kontrastlı tanısal

Düzensiz, kalın ya da nodüler periferik/solid kontrastlanma ile çevrelenen santral kontrastlanmayan nekroz görülebilir; çevresel ödem eşlik edebilir. Bu örüntü yüksek dereceli nekrotik gliomu destekler ancak özgül değildir; metastaz ve apse gibi ayırıcı tanılar sürer. BT yumuşak doku yayılımını sınırlı gösterir; MRG daha ayrıntılıdır.

Önerilen pencereler: Beyin (G 80 / M 40), Kemik (G 1800 / M 400).

BT bulguları

• Yüksek dereceli astrositomlar tipik olarak intraaksiyel, diffüz infiltratif beyin tümörleridir.
• Santral kontrastlanmayan hipodens nekroz — kontrastlı incelemede düzensiz periferik/solid canlı tümör dokusuyla çevrelenebilir.
• Peritümöral hipodensite — glioblastomda çevresel vazojenik ödem görülebilir.
• Korpus kallozum boyunca uzanım — karşı hemisfere geçen infiltratif tümör kelebek biçimli kitle oluşturabilir.
• İntralezyonel hiperdens odak — akut kanama olabilir; kalsifikasyon daha seyrektir.
• Kitle etkisi — lateral ventrikül kompresyonu, orta hat kayması ve sisternlerde silinme şeklinde görülebilir.

Ölçütler ve sınıflamalar

WHO CNS5 ve güncel terminoloji

WHO CNS5 (2021) kapsamında glioblastom, IDH-yabanıl tip, CNS WHO derece 4 olarak adlandırılır. IDH-mutant derece-4 diffüz gliom “Astrositom, IDH-mutant, CNS WHO derece 4” olarak sınıflanır. Bu histomoleküler tanı yalnız görüntüleme ile kurulamaz. cIMPACT-NOW Update 11 (2025) tanı ölçütleri için öneriler sunar; WHO CNS5’i resmen değiştirmez.

Normalde

Aynı aksiyel düzeyde normal frontal ve parietal korteks simetrik gri cevher yoğunluğunda, aradaki beyaz cevher ise homojen ve daha düşük atenüasyondadır. Kontrastsız BT’de orta hat kayması, ventrikül basısı ve sisternlerde silinme gibi kitle etkisi bulguları dikkatlice değerlendirilir.

Ayırıcı tanı

Beyin metastazlarında çevresel vazojenik ödem eşlik edebilir.

Primer santral sinir sistemi lenfoması

derin/periventriküler yerleşim ve kontrastlı incelemede daha homojen solid kontrastlanma düşündürür.

Beyin apsesi

halka biçimli lezyon yapabilir; merkezî difüzyon kısıtlanması MRG’de ayırıcıdır.

Subakut enfarkt

vasküler alana uyan kortikomedüller hipodensite ve zamanla gelişen kitle etkisi görülebilir.

Tuzaklar

• Ödem sınırını tümör sınırı sayma: infiltratif gliom kontrastlanmayan ödemli görünen beyaz cevherin içine uzanabilir; BT bu ayrımı kuramaz.
• Tek, halka biçimli lezyonu glioblastom kabul etme: soliter metastaz ve apse de benzer görünebilir; kontrastlı MRG ve klinik bağlam gerekir.
• Kontrastsız BT’de belirgin halka görmeyi bekleme: nekrozun kontrastlanan kenarı ancak kontrast sonrası incelemede değerlendirilir.

Kendini dene

1. Erişkinde korpus kallozum tutulumu, santral nekroz ve periferik kontrastlanma yüksek dereceli gliomla uyumlu olabilir. En olası görüntüleme tanısı nedir?

   • Glioblastom fenotipinde yüksek dereceli gliom
   • Menenjiyom
   • Nörotoksoplazmoz
   • Kavernom
   Cevabı göster

   Glioblastom fenotipinde yüksek dereceli gliom. Kallozumu aşan infiltratif kitle, düzensiz kontrastlanan canlı periferik bölüm ve santral nekroz yüksek dereceli gliom, özellikle glioblastom fenotipiyle uyumludur. Halka kontrastlanan gliom benzeri lezyonlarda metastaz ve apse ayırıcı tanıda kalabilir; görüntüleme tek başına moleküler tümör sınıfını belirlemez.

2. Korpus kallozumu geçen frontal kitle ve orta hat basısı saptanıyor. Hangi bulgu acil kitle etkisini gösterir?

   • Bazal sistern silinmesi
   • Dural kuyruk
   • Kortikal kalsifikasyon
   • Sulkus genişlemesi
   Cevabı göster

   Bazal sistern silinmesi. Bazal sisternlerin silinmesi artmış basınç ve olası transtentoryal herniasyon açısından kritik kitle etkisidir. Dural kuyruk ekstraaksiyel menenjiyomu düşündürür; kalsifikasyon tek başına acil bası bulgusu değildir; sulkus genişlemesi bası değil hacim kaybını destekler.

İlgili konular

• Beyin metastazı
• Primer santral sinir sistemi lenfoması
• Beyin apsesi

Kaynaklar

Bu sayfadaki 41 cümle ve 2 quiz sorusu aşağıdaki kaynaklardan alıntılarla tek tek karşılaştırıldı; 10 cümle bu karşılaştırmada düzeltildi (2026-10-09).

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