Progression of tumefactive demyelinating lesion in a child. However, in real life clinical practice, radiologists usually make their differential diagnoses according to the image patterns, as the etiology is often unknown. Sometimes these lesions may demonstrate a ringenhancing pattern or other patterns. A 62yearold man presented with subacutely progressive headache, rightsided weakness, and subtle receptive aphasia. Tumefactive demyelinating lesions are generally thought of as solitary lesions, greater than 2 cm, with imaging characteristics mimicking neoplasms. The patient underwent a diagnostic stereotactic brain biopsy.
Glioma, demyelinating diseases and magnetic resonance spectroscopy. It is often difficult to accurately differentiate tumefactive demyelinating lesions tdls. Tms can mimic clinical and radiological features of a neoplasm, infarction, or abscess and therefore can be diagnostically challenging for clinicians. Tumefactive demyelinating lesion radiology reference. Magnetic resonance spectroscopy mrs represents a relatively new. Tumefactive demyelinating lesions tdls are atypical presentations of various.
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. Tumefactive demyelinating lesions can present with features similar, clinically and radiologically, to those of brain tumours. Proton magnetic resonance spectroscopy differentiates tumefactive demyelinating lesions from gliomas ryotaro ikeguchi et al. To identify imaging characteristics of tdls for their proper diagnosis, their differences from malignant gliomas, etc. The alternative diagnosis is of a highgrade diffuse glioma although this is thought less likely. 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. Neuroimaging of tumefactive multiple sclerosis with atypical features.
The findings of glutamate and glutamine elevations on magnetic resonance spectroscopy and apparent tracts within. Positron emission to mography, magnetic resonance imaging and proton nmr spectroscopy of white matter in multiple sclerosis. Tumefactive acute disseminated encephalomyelitis z ghali. The tumefactive demyelinating lesions are defined as large 2 cm. One of the rarer variants of demyelinating lesions is the tumefactive demyelinating lesion. Clinical examination was unremarkable except for a rightsided homonymous hemianopia. Ms is a disabling and progressive disease that affects the central nervous system. Lowgrade glioma and reactive gliosis were among the likely differential diagnoses.
Cureus tumefactive multiple sclerosis of the cervical. Paraneoplastic recurrent tumefactive demyelination in a 62. Use of proton magnetic resonance spectroscopy for monitoring disease progression in multiple. Tumefactive multiple sclerosis is a condition in which the central nervous system of a person. The most common pattern is a nodular pattern of enhancement.
Introduction the advent of mri has revolutionised the diagnosis and management of multiple sclerosis ms. Differential diagnosis of such space occupying lesions may not be straightforward and sometimes necessitate brain biopsy. Conventional and advanced magnetic resonance imaging in tumefactive demyelina tion show all authors. Magnetic resonance imaging diagnosis of demyelinating diseases. Objective to investigate the utility of proton magnetic resonance spectroscopy mrs in differentiating tdls from gliomas. This case report highlights important diagnostic clues in the differential. Tumefactive demyelinating lesions tdl are a rare disease of the central nervous system cns. 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. Mr imaging of the brain was obtained in 4 patients who presented clinically with focal neurologic deficits. Magnetic resonance imaging scans showed a large right frontal mass with surrounding edema and a mild midline shift fig. An older age at onset makes distinguishing tumefactive demyelinating lesion tdl from tumors even more challenging. Clinical proton mr spectroscopy in central nervous system disorders. Proton magnetic resonance spectroscopy differentiates. On magnetic resonance spectroscopy, decreased nacetylaspartate.
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. Metabolite findings in tumefactive demyelinating lesions. Typical demyelinating lesions appear as small, often ovoid. Tumefactive demyelinating lesion radiology reference article. 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. Brain biopsy of the tumefactive multiple sclerosis lesi. There is no consensus however, regarding the definition of tdls, but typically represent lesions larger than 2 cm in. 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.
Proton mr spectroscopy has been increasingly used to characterize intracranial pathology. It is often difficult to accurately differentiate tumefactive demyelinating lesions tdls from gliomas using mri. Brain mri tumefactive demyelination brain mri balo concentric sclerosis cervical spine mri of letm. 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. We present a clinical scenario of a patient presenting with left homonymous hemianopia with atypical radiological features. A challenging diagnosis of lateonset tumefactive multiple. Brain imaging with mri and ct presents over 180 disease processes and normal variants, grouping entities by these basic patterns to accentuate differential diagnostic. Mri spectroscopy in neurological disorders book chapter. 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. Proton mr spectroscopy of tumefactive demyelinating lesions.
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. Background multiple sclerosis ms is a chronic inflammatory disease of the central nervous system in which there is focal demyelination. Atypical inflammatory demyelinating syndromes of the. Alternatively, in the proper clinical context, a presumptive diagnosis can be made on clinical grounds. To use mr spectroscopy to aid in the diagnosis of demyelinating disease and to help differentiate tumefactive demyelinating lesions from neoplastic processes.
Magnetic resonance imaging diagnosis of demyelinating. Pitfalls in the diagnosis of a tumefactive demyelinating. The mri appearance of tumefactive demyelinating lesions. 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. Tumefactive multiple sclerosis requiring emergent biopsy.
Lumbar puncture displayed positive oligoclonal bands. 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. The imaging features are nonspecific but favor tumefactive demyelination. Tumefactive demyelinating lesions tdls are often misdiagnosed as brain tumors. Magnetic resonance imaging characteristics of tumefactive. Tumefactive multiple sclerosis is a demyelinating disease that demonstrates tumorlike features on magnetic resonance imaging. Tumefactive demyelinating lesions tdls can simulate intracranial neoplasms in clinical presentation and mr imaging appearance, and surgical biopsy is often performed in suspected tumors. Spectroscopic magnetic resonance imaging of a tumefactive.
Diagnosis is difficult as tumefactive ms may mimic the clinical and mri. 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. Differentiation of tumefactive demyelinating lesions from high. Illustrate the role of multimodal mri with a focus on spectroscopy, diffusion and perfusion imaging to increase diagnostic confidence. Clinical and radiographic spectrum of pathologically confirmed tumefactive multiple sclerosis.
Metabolite findings in tumefactive demyelinating lesions utilizing short echo time proton magnetic resonance spectroscopy. 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 with 1 per cases of ms and 3 per million cases per year. 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. Conventional and advanced magnetic resonance imaging in tumefactive demyelina tion. Tdls are defined as demyelinating lesions larger than 2 cm that often have. Section 1 describes the physical principles underlying each technique and their associated artefacts and pitfalls. Red flags for magnetic resonance imaging diagnosis of multiple sclerosis. Spectrum of disease, diagnosis and treatment article pdf available in current neurobiology 0701 january 2016 with 990 reads how we measure reads. 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. We report a case of brain tdl as the initial manifestation of lateonset ms associated with cervico. As the underlying pathophysiology of neoplasms is different from that of demyelinating disease, one may expect the metabolic composition of neoplasms to be.
Saindane am, soonmee c, meng l, xiaonan x, knopp ea, zagzag d. Proton mr spectroscopy has been applied in assessing various intracranial diseases and is increasingly used in diagnosis and clinical management. This lesion, which had a thin rim of peripheral diffusion restriction, and showed only. 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. Impaired cognition is the second most common clinical manifestation of tumefactive ms. Proton magnetic resonance spectroscopy and diffusion. Conventional and advanced magnetic resonance imaging in. 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. Tumefactive demyelinating lesions or tumefactive multiple sclerosis.
In this report we describe the clinical, neuroimaging and neuropathological features of six cases of tdl. Metabolite findings in tumefactive demyelinating lesions utilizing. Mass effect and contrast enhancement on neuroimaging make it difficult to distinguish this type of lesion from highgrade gliomas. Proton magnetic resonance spectroscopy differentiates tumefactive. Most imaging books are ordered according to underlying etiology. Proton mr spectroscopy of tumefactive demyelinating. The clinical use of mr spectroscopy in multiple sclerosis, an acquired demyelinating disease, remains limited despite the various insights into. Glx has been shown to be specific to tumefactive demyelinating lesions11. 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. Corticosteroid therapy has been shown to reduce the size of tdl lesions on followup imaging. Tdls are most commonly observed in the context of multiple sclerosis ms.
Demyelination in the central nervous system sometimes presents with large pseudotumoral lesions mimicking brain neoplasm. Early reports described ms variants with tumourlike presentation as shilders disease or marburgs variants poser et al. Magnetic resonance spectroscopy can also help identify these. The patient was treated with highdose steroid and five sessions of plasma exchange with significant. Tumefactive demyelinating lesions are a rare manifestation of multiple sclerosis ms. Jitender saini, somenath chatterjee, bejoy thomas, and chandrasekharan kesavadas. Other primary demyelinating diseases such as acute disseminated encephalomyelitis adem and acute haemorrhagic leukoencephalitis can also manifest as tdl.
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