The British Journal of Radiology, 82 (2009), e204–e207

CASE REPORT

Glioblastoma multiforme presenting as a haemorrhagic minimally enhancing mass of the trigone
1

N M HAMBLY, MBBChBAO, MRCPI, FFRRCSI, 2M A FARRELL, MBBChBAO, MRCPath, 1T G SCANLON, MBBChBAO,
3
1
MRCPI, FFRRCSI, A MCERLEAN, MBBChBAO, MRCPI, FFRRCSI and E C KAVANAGH, MBBChBAO, MRCPI, FFRRCSI
1

Department of Radiology, Mater Misericordiae University Hospital and Departments of 2Neuropathology and
Radiology, Beaumont Hospital, Dublin, Ireland

3

ABSTRACT. Tumours of the trigone are rare, representing less than 2.5% of all
intracranial tumours. The most common cause in adults is a meningioma. Glioblastoma
multiforme of the trigone is extremely rare, with only six cases reported in the
literature. We present a case of a gliobastoma multiforme of the trigone presenting in
a 57-year-old man with temporal lobe seizures. Imaging revealed a haemorrhagic
minimally enhancing mass of the trigone. Histology showed a high-grade malignant
glial-derived neoplasm of World Health Organization Grade IV.

Received 7 July 2008
Revised 28 September
2008
Accepted 3 November
2008
DOI: 10.1259/bjr/41022799
’ 2009 The British Institute of
Radiology

Tumours of the trigone are rare, representing less than
2.5% of intracranial tumours [1–4]. There is a broad range of
differential diagnoses, with the most common causes in
adults being meningioma and metastases [1, 2, 5, 6].
Intraventricular meningiomas constitute less than 2% of
all intracranial meningiomas but they represent the vast
majority of trigonal tumours in adults [1, 3–5]. Glioblastoma
multiforme (GBM) of the trigone is extremely rare, with
only six cases having been reported in the literature [3, 4, 7,
8]. We present a rare case of a GBM of the trigone of the
lateral ventricle presenting as a haemorrhagic minimally
enhancing mass.

Case report
A 57-year-old man with no previous medical history
presented to accident and emergency following an
episode of collapse with associated urinary incontinence
preceded by a gustatory hallucination. No definite tonic
clonic seizure activity was noted. The patient reported a
2-year history of intermittent episodes of ‘‘a strange taste
followed by loss of concentration’’.
Neurological examination was normal on presentation. A non-contrast CT brain scan performed 3 h after
presentation revealed a normal brain parenchyma and
ventricular system, with no intraventricular masses
identified (Figure 1).
Electroencephalography (EEG) at presentation showed
intermittent disturbances of predominantly left temporal
lobe function. The patient was commenced on oral

anticonvulsant medication and discharged for MRI brain
and neurology review as an outpatient.
He underwent an outpatient MRI brain 2 months after
initial presentation (Figure 2a–d). This showed a 3 cm
well-circumscribed mass in the left lateral ventricle
centred on the trigone. The mass demonstrated mild
peripheral enhancement and marked susceptibility artefact on gradient echo sequences. Owing to the marked
interval change since the earlier normal CT brain scan,
this was felt to represent haemorrhage rather than
calcification. A pre- and post-contrast CT brain scan
was performed, which showed a 3 cm hyperdense mass
in the trigone of the left lateral ventricle with minimal
enhancement and no associated hydrocephalus
(Figure 3).
The patient reported no new symptoms, and neurological examination remained unremarkable. He was
referred for urgent neurosurgical evaluation and transferred to the National Neurosurgical Unit where he
underwent a left temporal burrhole biopsy with stealth
navigation.
Histology showed appearances consistent with a highgrade malignant glial-derived neoplasm of World Health
Organization (WHO) Grade IV with rare oligodendroglial areas. Histology also confirmed the presence of
haemorrhage but no calcification (Figure 4).
The patient was reviewed by clinical oncology and
radiation oncology, and was discharged on oral steroids
and anticonvulsant medication for palliative radiotherapy as an outpatient.

Discussion
Address correspondence to: Niamh Hambly, Knockrickard,
Claremorris, Co Mayo, Ireland. E-mail: niamhhambly@yahoo.co.uk

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Intraventricular tumours are rare, accounting for up to
10% of all cerebral neoplasms. 50% of intraventricular
The British Journal of Radiology, October 2009

Case report: Glioblastoma multiforme of the ventricular trigone

Figure 1. A 57-year-old man presenting with an episode of
collapse. Non-contrast CT shows normal ventricles.

tumours in adults occur in the lateral ventricle and, of
these, less than 50% are located in the trigone [1–5].
Intraventricular tumours may arise from the lining of
the ventricle (the ependymal cells and supependymal
plate of glial cells), the choroid plexus or the adjacent
brain parenchyma. Metastases may also present in the
venticles. Masses are considered intraventriclular on
radiological studies if they are centred completely or
predominantly in the ventricle (with little extraventricular extent) and if they expand or conform to the shape
of the ventricle. MRI is superior to CT in defining the
exact tumour location, margins and extent [1].
There is a broad differential for mass lesions arising
within the lateral ventricle, including meningioma,
choroid plexus papilloma, choroid plexus carcinoma,
subependymoma, subependymal giant cell astrocytoma,
metastases, lymphoma, ependymoma, dermoid cyst,
astrocytoma, central neurocytoma, oligodendroglioma,
primitive neuroectodermal tumour, teratoma, vascular
malformations, cysticercosis, ependymal and arachnoidal cysts, sarcoma, xanthogranulomatous degeneration
of the choroid and GBM [1–9].
The imaging features of most intraventricular tumours
are non-specific, and the differential can be guided by
demographic features such as patient age and sex.
Intraventricular tumours may be subdivided into those
arising in the atrium or trigone, the body and the frontal
horn. The frequency of tumours varies with location and
is a useful diagnostic indicator.
Trigonal tumours tend to be relatively asymptomatic
and can reach a large size before diagnosis. Most
tumours present with headache; other symptoms include
nausea and vomiting, episodes of collapse, memory loss,
seizures, mental status changes, ataxia and focal motor
deficits [7, 8].
The British Journal of Radiology, October 2009

In adults over 40 years of age, the most common
trigonal tumour is a meningioma, representing up to
100% of trigonal tumours in one series [1].
Intraventricular meningiomas constitute less than 2% of
all intracranial meningiomas, with the most common
location being the trigone [1, 3–5]. In adults, the other
main differential is metastases. Intraventricular metastases are rare, accounting for 0.9–4.6% of all cerebral
metastases, and most commonly arise from renal or lung
cancer. The most common site is the lateral ventricle [1–
5]. Intraventricular GBMs of the lateral ventricle are rare
and, when they occur, the most common site is the body
of the lateral ventricle [1, 2]. They are thought to arise
from glial cells adjacent to the ventricle. GBMs of the
trigone are extremely rare, with only six previous cases
reported in the literature [3, 4, 7, 8].
In patients aged 10–40 years, the most common
trigonal lesions are astrocytomas, ependymomas and
vascular malformations. The most common trigonal
lesion in the first decade is the choroid plexus papilloma
or choroid plexus carcinoma [1, 2, 5, 6].
Intraventricular meningiomas usually present as wellcircumscribed hyperattenuating masses, which demonstrate intense enhancement and are calcifed in approximately 50% of cases [1, 5]. Intraventricular metastases
also usually demonstrate intense contrast enhancement.
In our case, the mass demonstrated only mild peripheral
contrast enhancement. The imaging features of intraventricular GBM should be the same as those elsewhere in
the central nervous system, i.e. inhomogeneity, contrast
enhancement and an infiltritive appearance. However,
three of the previous case reports describing the imaging
features of trigonal GBMs also described only minimal
enhancement [4, 7, 8]. In the other three cases, the
imaging features were not described [3]. The mass in our
case was relatively well circumscribed, a feature also
described by Park et al [8]. The other two cases that
described imaging features demonstrated lobulated
irregular margins [4, 7].
Another differential for a minimally enhancing wellcircumscribed mass of the choroid plexus in adults is
xanthogranulomatous degeneration of the choroid. This
is a rare benign lesion occurring almost exclusively in
adults, and it is frequently an incidental finding. CT
usually demonstrates symmetrical tumefactions of the
choroid plexus with peripheral calcifications and central
low density, and the masses usually demonstrate T2
weighted hyperintensity on MRI. Most do not enhance
but marginal enhancement has sometimes been reported
[10].
None of the other trigonal GBMs described in the
literature demonstrated intratumoural haemorrhage. The
overall incidence of haemorrhage in brain tumours is
5.1%, with the highest incidence being in pituitary
adenomas (15.8%). Of those lesions occurring in the
choroid plexus, choroid plexus papillomas are the most
likely to demonstrate haemorrhage, with an incidence of
16.7%. Although the incidence of haemorrhage in GBMs
is relatively high at 7.8%, it has never been described in a
trigonal lesion. Haemorrhage from a meningioma is rare,
with an incidence of 1.3%. Other rare causes of
haemorrhage in the choroid plexus include vascular
malformations and vasculitidies [10, 11].
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N M Hambly, M A Farrell, T G Scanlon et al

(a)

(b)

(c)

(d)

Figure 2. A 57-year-old man 2 months after an episode of collapse and left temporal lobe seizure. (a) Coronal T2 weighted, (b)
axial gradient echo and axial T1 weighted (c) pre- and (d) post-contrast sequences show a haemorrhagic minimally enhancing
mass in the trigone of the left lateral ventricle.

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The British Journal of Radiology, October 2009

Case report: Glioblastoma multiforme of the ventricular trigone

Figure 4. Representative image of a partly necrotic, densely
cellular, glial-derived malignant brain tumour — glioblastoma multiforme (haematoxylin and eosin stain, 640).

Figure 3. A 57-year-old man presenting with temporal lobe
seizure. A pre-contrast CT brain scan shows a well-circumscribed haemorrhagic mass in the trigone of the left lateral
ventricle.

Conclusions
GBM is a rare cause of a trigonal mass lesion in an
adult patient, with meningioma and metastases being the
most common tumours in this age group. However, all
intraventricular mass lesions require neurosurgical
referral and biopsy, as the imaging features are relatively
non-specific.

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