Description of a hemispheric atrophy due to a high-grade astrocytoma. For years it mimicked a primary movement disorder before evolving into a rapidly progressive dementia. This case highlights the diagnostic challenges of atypical glioma presentations.

A 42-year-old woman presented with a four-year history of daily, stereotyped, large-amplitude craniofacial movements initially diagnosed as motor tics. Over time, she developed left hemiparesis, profound anosognosia, spatial disorientation, apraxias, hemispatial neglect, and marked behavioral changes consistent with frontal lobe dysfunction. The insidious, multifocal progression posed a significant diagnostic challenge, with early considerations including autoimmune, infectious, and psychiatric etiologies.

This report describes the patient's evolution through serial neurological and neuropsychological evaluations. Workup included multimodal neuroimaging (MRI, FDG-PET), continuous video-EEG, and serial CSF analyses. Definitive diagnosis was established by right insular brain biopsy with histopathological and immunohistochemical analysis.