High-grade gliomas are malignant, rapidly progressive primary brain tumors, with isocitrate dehydrogenase (IDH) wildtype glioblastoma being the most common in adults, as well as the most fatal.^[1-3] Symptomatic presentation of brain tumors is non-specific, depending upon the location and size.^[4] The most common symptoms of temporal-parietal lesions include memory impairment, speech disorders, seizures, visual field defects, and hallucinations.^[5-7]

A 54-year-old male with a history of drug, alcohol and tobacco abuse, and hepatitis C presented to the Emergency Room (ER) after being found unconscious with sphincter dysautonomia, most likely due to a postictal state. His relatives reported inappropriate behavior for the past three months, assumed to be a consequence of drug abuse. At admission he had global aphasia and grade four right hemiparesis. Computed tomography (CT) scan(Fig. 1)and magnetic resonance imaging (MRI)(Fig. 2A, B)showed a large intra-axial left temporal lesion with a central soft tissue component and multiple peripheral cystic areas, with extensive perilesional vasogenic edema and signs of hydrocephalus with a marked deviation of the midline structures, consistent with a high-grade primary brain tumor. The patient was referred to neurosurgery, where a resection of the mass was performed. Postoperative MRI showed complete lesion resection with no complications, maintaining global aphasia and grade four hemiparesis. Pathology revealed wild-type IDH glioblastoma with a C228T mutation of the TERT gene promoter related to some resistance to radiotherapy. He was referred to a neuro-oncologist but missed all follow-up appointments. Six months later the tumor returned to its initial size(Figs 3, 4)and the patient ultimately passed away.

The authors present a case of a 54-year-old male patient who was diagnosed with a large glioblastoma at a late stage and had only six months of life following the diagnosis. This large tumor represents a rare diagnosis in Western countries at present.^[4]

The majority of patients diagnosed with glioblastoma exhibit initial symptoms such as headaches, seizures, and cognitive dysfunction. Over time, these patients may also experience focal neurological signs. Contrarily, atypical presentations, including hallucinations, unconventional seizure patterns, pain syndrome, personality shifts, syncope episodes, vertigo, and distinctive focal neurological indications, such as dermatomal hypoesthesia or psychiatric manifestations, have been sporadically documented in the extant literature.^[4-7] While it is acknowledged that brain tumors may manifest with mild or non-specific symptoms, the size and the affected territory of the tumor in this case suggest an earlier onset and the presence of symptomatic epilepsy, focal neurological signs, and cognitive dysfunction.

The unexpected mild clinical picture and late diagnosis were most likely caused by drug abuse, which masked neurologic signs and symptoms that had been present for several months, depending on the size and territory affected by the tumor.

At the same time, the fact that the patient was not willing to undergo additional treatments and had been lost to follow-up emphasizes the importance of strong social support in allowing for more time with quality of life. Despite recent advances, glioblastoma is still an incurable tumor with an average survival time of six to 20 months, depending on treatment options.^[8,9] In appropriately selected patients, aggressive surgery may relieve symptoms and prolong survival.^[10]

Large tumors of this kind are rare in nations with sophisticated neurology services and access to cutting-edge neuroimaging equipment. In this case report, the diagnosis was likely delayed due to the patient’s history of drug abuse, which made it challenging to distinguish neurological symptoms from behavioral issues. This highlights the importance of effective communication among psychiatrists, neurologists, and neuroradiologists, especially considering the tumor had been growing for several months without being detected.