Brain tumor like vascular anomaly: Pragmatic management

Symptoms, imaging features, and potential biopsy of intra-axial brain lesions are typically used to guide management and potentially render it more effective. Yet some cases exhibit atypical features that elude classification even in the light of histopathology. We present a case of a middle-aged man with a subcortical left frontal lesion with associated new seizures and lesional progression. The patient underwent biopsy demonstrating hyalinized vessels, chronic hemorrhage, and gliosis without significant proliferative activity. Molecular profiling was negative for BRAF and other gene variants associated with pilocytic astrocytoma, and PIK3CA variants described in cerebral cavernous malformations. Findings were not typical for any known vascular or neoplastic lesion. Lesion was treated with image guided thermal ablation appropriate for vascular or neoplastic etiology, with regression on imaging and no symptomatic recurrence. This illustrates a pragmatic approach to tumor like vascular anomalies, even in the absence of specific diagnostic classification.