T2-Fluid-Attenuated Inversion Recovery (FLAIR) Mismatch as a Novel Specific MRI Marker for Adult Low-Grade Glioma (LGG): A Case Report

Astrocytic tumors are primary central nervous system tumors. They are the most common tumors arising from glial cells. In the new WHO classification 2021, adult-type diffuse astrocytic gliomas subdivide into isocitrate dehydrogenase (IDH)-mutant astrocytoma, IDH-mutant and 1p/19q-codeleted oligodendroglioma, and IDH-wildtype glioblastoma. The T2-fluid-attenuated inversion recovery (FLAIR) mismatch sign describes the MRI appearance of IDH-mutant astrocytoma, it is considered a highly specific radiogenomic signature for diffuse astrocytoma, as opposed to other lower-grade. MRI is the first and most accurate diagnostic tool for low-grade gliomas (LGGs). It is particularly helpful in distinguishing a diffuse astrocytoma from an oligodendroglioma that will not demonstrate T2-FLAIR mismatch. The tumor displays a hyperintense signal on T2-weighted images and a hypointense signal on T2-weighted FLAIR images, which distinguishes it from other types of diffuse gliomas. We report a case of a 29-year-old female patient who was diagnosed with IDH-mutant 1p/19q-non-codeleted diffuse astrocytoma based on MRI T-2 FLAIR mismatch sign, which is confirmed by the molecular analysis in the pathology lab. Our aim of this report is to confirm the power of the MRI findings in the diagnosis of glioma genotypes and to assess neurosurgeons in the preoperative surgical planning.