Fig. 3. 33-year-old female patient with a left insular glioblastoma (19q deletion, 1p intact, IDH1 mutation, PTEN and EGFR mutation negative) who presented with syncope and seizure. Preoperative MR images include axial T1 post-contrast (A), axial T2 FLAIR (B), axial DWI (C), axial ADC map (D), spectroscopy with choline to NAA ratio overlay on axial T1 post-contrast (E), corresponding spectroscopy and choline to NAA ratios (F), axial DSC perfusion (G), corresponding perfusion curve (H), and DTI tractography of the left corticospinal tract (I) and left arcuate fasciculus (J) superimposed on axial T2. Post-contrast T1 image (A) demonstrate irregular patchy partial enhancement within the tumor. T2 FLAIR (B) shows the extent of non-enhancing T2 FLAIR hyperintense tumor. The lesion demonstrates areas of restricted diffusion with low ADC values (C and D) and increased relative cerebral blood volume compared to the contralateral side (G and H) with return to baseline of the perfusion curve consistent with a primary glial tumor. Spectroscopy (E and F) demonstrates elevated choline relative to NAA, consistent with a glioma. ADC, apparent diffusion coefficient; DSC, dynamic susceptibility contrast-enhanced; DTI, diffusion tensor imaging; DWI, diffusion weighted imaging; EGFR, epidermal growth factor receptor; FLAIR, fluid attenuated inversion recovery; IDH, isocitrate dehydrogenase; MRI, magnetic resonance image; NAA, N-acetylaspartate; PTEN, phosphatase and tensin homolog.