Figure 2 Series of brain images obtained during the patient’s course of treatment. (A) Brain MRI at time of diagnosis of grade 4 astrocytoma. T1 post-contrast coronal plane (left), T1 post-contrast axial plane (middle), and T2 coronal plane (right) showing a right frontal lobe cystic and solid mass with significant cerebral edema. Mass effect throughout the right cerebral hemisphere is apparent, with frontal and parietal cortical effacement and a 6 mm right-to-left midline shift. (B) Brain MRI following completion of chemoradiotherapy. T1 post-contrast axial plane (left), T1 post-contrast coronal plane (middle), and T2 coronal plane (right), show post-surgical changes following right frontoparietal astrocytoma resection. The increased thick nodular enhancement and diffusion restriction of the wall of the resection cavity are related to post-radiation changes. Stable extensive T2/FLAIR hyperintense signal is visible in the right cerebral hemisphere and along the corticospinal tracts, representing a non-enhancing tumor. (C) Brain MRI on admission to the PICU. T1 post-contrast axial plane (left), T2 coronal plane (middle), and T1 post-contrast coronal plane (right) show interval hemorrhage within the surgical cavity bed and operative changes from astrocytoma resection, with stable peripheral nodular enhancement likely representing post-radiation changes. No new focal nodular contrast enhancement to suggest tumor recurrence was seen. (D) Brain MRI at onset of new seizures and central apnea. T2 coronal plane (left), T1 post-contrast axial plane (middle), and T1 post-contrast coronal plane (right) showed new feathery enhancement adjacent to the resection cavity and strong enhancement along the right corticospinal tracts at the cerebral peduncle. The findings were of greater concern for tumor growth than for radiation necrosis. (E) Brain MRI following loss of gag and cough reflexes and decreased responsiveness. FLAIR axial plane (left), T1 pre-contrast sagittal plane (middle), and T1 post-contrast coronal plane (right) showing interval disease progression with increased size and mass effect of a multifocal right hemispheric mass, now with increased extension into the right thalamus and cerebral peduncles, and new involvement of the pons. Increased mass effect at the foramen of Monro with increased obstructive hydrocephalus and early right uncal herniation was visible.