Metabolite findings in tumefactive demyelinating lesions. Use of proton magnetic resonance spectroscopy for monitoring disease progression in multiple. We therefore set out to assess the contribution of repeated conventional magnetic resonance imaging mri, 1 hmr spectroscopy and magnetization transfer imaging in establishing a correct diagnosis of tumefactive demyelinating lesions tdls. Tumefactive demyelinating lesion tdl or monofocal acute inflammatory demyelination is a locally aggressive form of demyelination usually manifesting as a solitary lesion mimicking a neoplasm on imaging. Alternatively, in the proper clinical context, a presumptive diagnosis can be made on clinical grounds. Tdls are defined as demyelinating lesions larger than 2 cm that often have. In this study, we report a case of cervical ms in a 19yearold patient that was diagnosed based on the mri findings and cerebrospinal fluid analysis. Brain imaging with mri and ct presents over 180 disease processes and normal variants, grouping entities by these basic patterns to accentuate differential diagnostic. Most imaging books are ordered according to underlying etiology.
Tumefactive demyelinating tdl lesions are focal zones of demyelination in the central nervous system and they often mimic the neuroimaging features of an intraxial neoplasm. Brain mri tumefactive demyelination brain mri balo concentric sclerosis cervical spine mri of letm. Corticosteroid therapy has been shown to reduce the size of tdl lesions on followup imaging. Tumefactive multiple sclerosis is a demyelinating disease that demonstrates tumorlike features on magnetic resonance imaging.
Magnetic resonance imaging scans showed a large right frontal mass with surrounding edema and a mild midline shift fig. Tms can mimic clinical and radiological features of a neoplasm, infarction, or abscess and therefore can be diagnostically challenging for clinicians. Magnetic resonance spectroscopy can also help identify these. Lowgrade glioma and reactive gliosis were among the likely differential diagnoses. Magnetic resonance imaging characteristics of tumefactive. Red flags for magnetic resonance imaging diagnosis of multiple sclerosis. The patient underwent a diagnostic stereotactic brain biopsy. Whether tumefactive demyelination constitutes a disease variant within the broad spectrum of multiple sclerosis or rather depicts a different entity is still matter of debate. The initial mri showed a large oval subcortical left frontoparietal lesion, hypertintense on t2 and hypointense on t1weighted sequences, exerting mass effect on adjacent sulci figure, a. Positron emission to mography, magnetic resonance imaging and proton nmr spectroscopy of white matter in multiple sclerosis. Paraneoplastic recurrent tumefactive demyelination in a 62. Tumefactive multiple sclerosis is a rare form of multiple sclerosis ms. Clinical mr neuroimaging, second edition, provides radiologists, neuroscientists and researchers with a clear understanding of each physiological mr methodology and their applications to the major neurological diseases.
Differential diagnosis of such space occupying lesions may not be straightforward and sometimes necessitate brain biopsy. Sometimes these lesions may demonstrate a ringenhancing pattern or other patterns. Diagnosis is difficult as tumefactive ms may mimic the clinical and mri. A challenging diagnosis of lateonset tumefactive multiple. Tumefactive demyelinating lesions or tumefactive multiple sclerosis. Spectroscopic magnetic resonance imaging of a tumefactive. On magnetic resonance spectroscopy, decreased nacetylaspartate. Clinical and radiographic spectrum of pathologically confirmed tumefactive multiple sclerosis.
Tumefactive demyelinating lesion radiology reference article. Tumefactive demyelinating lesion tdl, also sometimes referred to as monofocal acute inflammatory demyelination maid, is a locally aggressive form of demyelination, usually manifesting as a solitary lesion or sometimes a couple of lesions greater than 2 cm that may mimic a neoplasm on imaging. Tumefactive multiple sclerosis tms is a rare variant with 1 per cases of ms and 3 per million cases per year. Diagnosis of tumefactive ms is commonly carried out using magnetic resonance imaging mri and proton mr spectroscopy hmrs. Spectrum of disease, diagnosis and treatment article pdf available in current neurobiology 0701 january 2016 with 990 reads how we measure reads. Mri spectroscopy in neurological disorders book chapter.
Magnetic resonance imaging diagnosis of demyelinating diseases. Proton magnetic resonance spectroscopy differentiates tumefactive demyelinating lesions from gliomas ryotaro ikeguchi et al. Magnetic resonance imaging diagnosis of demyelinating. This case report highlights important diagnostic clues in the differential. Section 1 describes the physical principles underlying each technique and their associated artefacts and pitfalls. Proton magnetic resonance spectroscopy and diffusion. The most common pattern is a nodular pattern of enhancement. Conventional and advanced magnetic resonance imaging in tumefactive demyelina tion. Illustrate the role of multimodal mri with a focus on spectroscopy, diffusion and perfusion imaging to increase diagnostic confidence. The tumefactive demyelinating lesions are defined as large 2 cm. Tumefactive demyelinating lesions can present with features similar, clinically and radiologically, to those of brain tumours. Mass effect and contrast enhancement on neuroimaging make it difficult to distinguish this type of lesion from highgrade gliomas. Lumbar puncture displayed positive oligoclonal bands. Other primary demyelinating diseases such as acute disseminated encephalomyelitis adem and acute haemorrhagic leukoencephalitis can also manifest as tdl.
Tumefactive multiple sclerosis is a condition in which the central nervous system of a person. The atypical demyelinating syndromes are a group of conditions, characterised pathologically by demyelination, that form part of the differential diagnosis of multiple sclerosis ms but differ from it due to variations in clinical presentation, mri. Metabolite findings in tumefactive demyelinating lesions utilizing short echo time proton magnetic resonance spectroscopy. We studied two females and one male, who presented with tdls that led to brain biopsy in two cases, for. Proton mr spectroscopy has been increasingly used to characterize intracranial pathology.
Tumefactive acute demyelinating disease versus neoplasia magnetic resonance imaging and spectroscopy may successfully differentiate between tumefactive demyelinating disease from brain tumors, obviating the need to perform biopsy see below. Tumefactive demyelinating lesions tdl are a rare disease of the central nervous system cns. Mr spectroscopy characteristics of tumefactive demyelinating. We report a patient with a spaceoccupying lesion in the parietal lobe, which presented a serious diagnostic dilemma, between a rare tumefactive demyelinating disease, such as balo concentric sclerosis and a glioma. Conventional and advanced magnetic resonance imaging in tumefactive demyelina tion show all authors. Central nervous system cns inflammatory demyelinating diseases idds, such as multiple sclerosis, can be easily diagnosed based on imaging examinations, such as mri, and assessment of the clinical course of disease. Neuroimaging of tumefactive multiple sclerosis with atypical features. Conventional and advanced magnetic resonance imaging in.
Objective to investigate the utility of proton magnetic resonance spectroscopy mrs in differentiating tdls from gliomas. Ms is a disabling and progressive disease that affects the central nervous system. Tumefactive demyelinating lesion radiology reference. Progression of tumefactive demyelinating lesion in a child. Typical demyelinating lesions appear as small, often ovoid. Jitender saini, somenath chatterjee, bejoy thomas, and chandrasekharan kesavadas.
The alternative diagnosis is of a highgrade diffuse glioma although this is thought less likely. There is no consensus however, regarding the definition of tdls, but typically represent lesions larger than 2 cm in. To identify imaging characteristics of tdls for their proper diagnosis, their differences from malignant gliomas, etc. Glioma, demyelinating diseases and magnetic resonance spectroscopy. Tumefactive acute disseminated encephalomyelitis z ghali. Proton mr spectroscopy of tumefactive demyelinating.
Magnetic resonance spectroscopy mrs represents a relatively new. Tumefactive demyelinating lesions tdls are often misdiagnosed as brain tumors. It is often difficult to accurately differentiate tumefactive demyelinating lesions tdls. Features of tumefactive demyelinating lesion tdl on magnetic resonance imaging mri can facilitate the differential diagnosis of tdl and neoplastic lesions, but vary considerably among patients.
One of the rarer variants of demyelinating lesions is the tumefactive demyelinating lesion. Impaired cognition is the second most common clinical manifestation of tumefactive ms. In rare instances, demyelinating disorders manifest as tumefactive lesions that simulate brain tumors. The clinical use of mr spectroscopy in multiple sclerosis, an acquired demyelinating disease, remains limited despite the various insights into. Diagnosis is difficult as tumefactive ms may mimic the clinical and mri characteristics of a glioma or a cerebral abscess. Tumefactive multiple sclerosis tms is a rare variant of multiple sclerosis ms with atypical features that pose a diagnostic challenge. From the medical records, the patients initial symptoms and edss at the time of diagnosis of tumefactive demyelination, magnetic resonance imaging mri results contemporaneous with the above diagnosis and up to two subsequent mris during the period of observation, treatments if any initiated after the diagnosis of tumefactive demyelination and. Tumefactive demyelinating lesions tdls can simulate intracranial neoplasms in clinical presentation and mr imaging appearance, and surgical biopsy is often performed in suspected tumors. We present a clinical scenario of a patient presenting with left homonymous hemianopia with atypical radiological features. The mri appearance of tumefactive demyelinating lesions. Tdls are most commonly observed in the context of multiple sclerosis ms. The patient was treated with highdose steroid and five sessions of plasma exchange with significant.
Tumefactive demyelinating lesions are generally thought of as solitary lesions, greater than 2 cm, with imaging characteristics mimicking neoplasms. Tumefactive multiple sclerosis requiring emergent biopsy. It is often difficult to accurately differentiate tumefactive demyelinating lesions tdls from gliomas using mri. The mri scan of the brain revealed a space occupying lesion within the occipital lobe and mr spectroscopy highlighted this to be inflammatory in nature, most likely a tumefactive demyelinating lesion tdl. Pitfalls in the diagnosis of a tumefactive demyelinating.
Tumefactive demyelinating lesions tdls are atypical presentations of various. Proton magnetic resonance spectroscopy differentiates tumefactive. Demyelination in the central nervous system sometimes presents with large pseudotumoral lesions mimicking brain neoplasm. The findings of glutamate and glutamine elevations on magnetic resonance spectroscopy and apparent tracts within. Background multiple sclerosis ms is a chronic inflammatory disease of the central nervous system in which there is focal demyelination. However, in real life clinical practice, radiologists usually make their differential diagnoses according to the image patterns, as the etiology is often unknown.
Clinical examination was unremarkable except for a rightsided homonymous hemianopia. From the medical records, the patients initial symptoms and edss at the time of diagnosis of tumefactive demyelination, magnetic resonance imaging mri results contemporaneous with the above diagnosis and up to two subsequent mris during the period of observation, treatments if any initiated after the diagnosis of tumefactive demyelination and later. In this report we describe the clinical, neuroimaging and neuropathological features of six cases of tdl. Cureus tumefactive multiple sclerosis of the cervical. Proton mr spectroscopy has been applied in assessing various intracranial diseases and is increasingly used in diagnosis and clinical management. An older age at onset makes distinguishing tumefactive demyelinating lesion tdl from tumors even more challenging. Tumefactive demyelinating lesions are a rare manifestation of multiple sclerosis ms. Proton magnetic resonance spectroscopy, diffusionweighted axonography, and diffusion tensor tractography in a patient with tumefactive demyelination plaque tdp were evaluated for differential diagnosis from glioblastoma. As the underlying pathophysiology of neoplasms is different from that of demyelinating disease, one may expect the metabolic composition of neoplasms to be. Differentiation of tumefactive demyelinating lesions from high.
Although diagnostic challenges without biopsy have been tried by employing radiological studies and cerebrospinal fluid examinations, histological investigation is still necessary for certain diagnosis in some complicated cases. To use mr spectroscopy to aid in the diagnosis of demyelinating disease and to help differentiate tumefactive demyelinating lesions from neoplastic processes. Saindane am, soonmee c, meng l, xiaonan x, knopp ea, zagzag d. Early reports described ms variants with tumourlike presentation as shilders disease or marburgs variants poser et al. Clinical proton mr spectroscopy in central nervous system disorders. Proton mr spectroscopy of tumefactive demyelinating lesions. Brain biopsy of the tumefactive multiple sclerosis lesi. Mr imaging of the brain was obtained in 4 patients who presented clinically with focal neurologic deficits. Glx has been shown to be specific to tumefactive demyelinating lesions11. This lesion, which had a thin rim of peripheral diffusion restriction, and showed only.
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