Glioblastoma with pseudo-arteriovenous malformation features: Combined arterial spin-labeling assessment and preoperative embolization

Background: Glioblastoma (GBM) may occasionally present with prominent vascular features that mimic an arteriovenous malformation (AVM), leading to diagnostic and therapeutic challenges. Pseudo-AVM GBMs are rare, and their recognition is essential to avoid misdiagnosis and inappropriate management. Case Description: We report a 67-year-old male with a 2-month history of progressive headache, memory impairment, and speech difficulties. Neurological examination demonstrated mild right-sided limb weakness, homonymous hemianopsia, and expressive aphasia. Brain magnetic resonance imaging (MRI), computed tomography angiography, and digital subtraction angiography revealed a left temporal GBM with AVM-like vascular features. Arterial spin labeling (ASL) perfusion MRI revealed marked hyperperfusion and early venous drainage, providing noninvasive confirmation of tumor-related shunting. To reduce intraoperative bleeding risk, partial preoperative embolization of feeding arteries from the middle cerebral artery was performed, followed by gross total microsurgical resection. Histopathological examination demonstrated a hypervascular GBM, isocitrate dehydrogenase (IDH)-wildtype, with microvascular proliferation and necrosis confirmed by immunohistochemistry and polymerase chain reaction. Postoperative recovery was uneventful, and adjuvant chemoradiation according to the Stupp protocol was recommended. Conclusion: This case highlights pseudo-AVM GBM as a diagnostic and therapeutic challenge and demonstrates the value of ASL perfusion MRI and presurgical embolization in selected hypervascular tumors.