Magnetic resonance spectroscopy mrs is a promising technique for the. When the myelin sheath is damaged, nerve impulses slow or even stop, causing neurological problems. Multiple large tumefactive ms plaques in a young man. Tumefactive demyelinating lesion tdl is a rare variation of multiple sclerosis ms, 1 which presents as a profound brain edema or mass due to an acute demyelination in the central nervous system. Metabolite findings in tumefactive demyelinating lesions utilizing short echo time proton magnetic resonance spectroscopy. As with tumefactive demyelination, balos sclerosis lesions are often mistaken for primary brain. Mr imaging and multiple sclerosis differential diagnosis book. Request pdf characterization of tumefactive demyelinating lesions using mr imaging and invivo proton mr spectroscopy diagnosis of tumefactive. Approximately half of tumefactive demyelinating lesions have pathologic contrast enhancement, usually in the form of ring enhancement 2, 4 figs. In turn, the reduction in conduction ability causes deficiency in sensation, movement, cognition, or other functions depending on which nerves are involved. Magnetic resonance imaging mri is a medical imaging technique used in radiology to visualize internal structures of the body in detail. Jan 10, 2016 whether tumefactive demyelination is another manifestation of ms or represents a distinct entity is apparently a matter of contention. In rare instances, demyelinating disorders manifest as tumefactive lesions that simulate brain tumors. Tumefactive demyelinating lesions tdls can simulate intracranial neoplasms in clinical presentation and mr imaging appearance, and surgical biopsy is often performed in suspected tumors.
Seeing demyelination on mri dr garys multiple sclerosis. Metabolite findings in tumefactive demyelinating lesions utilizing. Metabolite findings in tumefactive demyelinating lesions. It plays a part in several chronic conditions, including multiple sclerosis. As the underlying pathophysiology of neoplasms is different from that of demyelinating disease, one may expect the metabolic composition of neoplasms to be significantly different. In particular, differential diagnosis between tumefactive demyelinating lesions tdls and brain tumours is often challenging lucchinetti et al. Certain features on standard as well as advanced mri can potentially promote the diagnosis of tumefactive demyelination and obviate the need for biopsy. It is often difficult to accurately differentiate tumefactive demyelinating lesions tdls. 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. Axial mri and mr spectroscopy data acquired at 3 tesla in a 30 year old woman with tumefactive ms. Lumbar puncture displayed positive oligoclonal bands.
A demyelinating disease is any condition that results in damage to the protective covering myelin sheath that surrounds nerve fibers in your brain, optic nerves and spinal cord. Other questions include how best to treat an acute attack as well as the optimal timing of therapy to prevent relapse. Tumefactive multiple sclerosis is a demyelinating disease that demonstrates tumorlike features on magnetic resonance imaging. Demyelination is something that occurs in several different diseases. A large body of published work shows that proton hydrogen 1 1 h magnetic resonance mr spectroscopy has evolved from a research tool into a clinical neuroimaging modality. Progression of tumefactive demyelinating lesion in a child. 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. This is the best way to tell what the severity of the demyelination is, what the demyelination could be caused by, and what disease the demyelination could. Proton magnetic resonance spectroscopy differentiates. This is a good example of tumefactive demyelination with the typical advancing edge of enhancement.
The mri appearance of tumefactive demyelinating lesions. A tumefactive demyelinating lesion tdl is defined as a solitary demyelinating lesion greater than 2 cm. As the underlying pathophysiology of neoplasms is different from that of demyelinating disease, one may expect the metabolic composition of neoplasms to be. Pdf 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. Oct 01, 2019 demyelination is damage to the myelin sheath around nerves. Even the advanced mri techniques, such as mr spectroscopy, led to equivocal results because both normalized choline increase and nacetyl. The mri appearance of these lesions can aid in preoperative diagnosis and assist with the final pathologic interpretation, potentially sparing the patient unnecessary and possibly debilitating procedures and therapies. Frontal tumefactive demyelinating lesion mimicking. Glioblastoma multiforme presenting with an open ring.
Tumefactive demyelination mri a 75 y o male with left side weakness since 3 months. A demyelinating disease is any disease of the nervous system in which the myelin sheath of neurons is damaged. On imaging, they usually present with relatively little mass effect or surrounding edema. Myelin and white matter the gray and white matter of the central nervous system cns differ not only in gross morphology but also in water content and macromolecular components, notably membrane lipids. Additional white matter lesions are present in 85% of patients with td and these may be reassuring if their distribution is typical for ms and if the tumefactive lesions have radiological characteristics in. Distinguishing tumefactive lesions from other etiologies of intracranial space occupying lesions is essential to avoid inadvertent surgical or toxic chemotherapeutic.
Mri makes use of the property of nuclear magnetic resonance nmr to image nuclei of atoms inside the body. Tumefactive demyelinating lesion radiology reference. Tumefactive demyelinating lesions tdls are atypical presentations of various. Proton mr spectroscopy of tumefactive demyelinating lesions article pdf available in american journal of neuroradiology 238. Proton mr spectroscopy and 201 tl spect showed findings supportive of the diagnosis of malignant glioma in all cases. Clinical and radiographic spectrum of pathologically confirmed tumefactive multiple sclerosis. 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. Saindane am, soonmee c, meng l, xiaonan x, knopp ea, zagzag d. While perfusion can be mildly increased along the periphery of the lesion, it is often much less than would be expected with a high grade glioma. Characterization of tumefactive demyelinating lesions. Positron emission to mography, magnetic resonance imaging and proton nmr spectroscopy of white matter in multiple sclerosis. Herein, the authors present a summary of brain disorders in which mr spectroscopy has an impact on patient. Differentiation of tumefactive demyelinating lesions from high.
Commonly the enhancement patterns will be in the form of an open ring, with the incomplete portion of the ring on the gray matter side of the lesion. A previous mri and ct report mentions a recent ischemic lesion in right parietal white matter with restricted diffusion and was on anti coagulant therapy. Tumefactive demyelination tumefactive demyelinating tdm lesions present a considerable diagnostic challenge. Primary central nervous system lymphoma pcnsl may rarely be preceded by sentinel demyelination, a pathologic entity characterized by histologically confirmed demyelinating inflammatory brain lesions that mimic multiple sclerosis ms or acute disseminated encephalomyelitis adem. This is the best way to tell what the severity of the demyelination is, what the. Section 1 describes the physical principles underlying each technique and their associated artefacts and pitfalls. Proton magnetic resonance spectroscopy differentiates tumefactive demyelinating lesions from gliomas. Tumefactive demyelinating lesions tdls are often misdiagnosed as brain tumors. This method is reliable because mris assess changes in proton density. This damage impairs the conduction of signals in the affected nerves.
Pitfalls in the diagnosis of a tumefactive demyelinating. Mr imaging initially revealed parenchymal mass lesions. Recently, without biopsy, some tms cases were diagnosed by magnetic resonance spectroscopy mrs, positron emission tomography pet, cerebrospinal fluid. Whether tumefactive demyelination is another manifestation of ms or represents a distinct entity is apparently a matter of contention. Magnetic resonance imaging characteristics of tumefactive. Tumefactive demyelinating lesions prove to be a diagnostic dilemma to neurosurgeons, radiologists, and pathologists. May 21, 2016 the patient was diagnosed with acute multifocal demyelination, presumed to be acute disseminated encephalomyelitis or tumefactive multiple sclerosis, and treated with intravenous corticosteroids. Tumefactive lesions are an uncommon manifestation of demyelinating disease and can pose a diagnostic challenge in patients without a preexisting diagnosis of multiple sclerosis. 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.
Characterization of tumefactive demyelinating lesions using mr. This case report highlights important diagnostic clues in the differential. Tumefactive multiple sclerosis requiring emergent biopsy and. Tumefactive multiple sclerosis is a condition in which the central nervous system of a person has multiple demyelinating lesions with atypical characteristics for those of standard multiple sclerosis ms. Multiple sclerosis ms is the most common demyelinating disease. Tumefactive multiple sclerosis requiring emergent biopsy.
Proton mr spectroscopy has been increasingly used to characterize intracranial pathology. Inflammatory demyelination occasionally forms a solitary mass lesion clinically and radiographically indistinguishable from glioma, replete with enhancement and mass effect. Ms is a disabling and progressive disease that affects the central nervous system. She improved rapidly but shortly after discharge developed worsening rightsided weakness and dysarthria and returned several weeks later. Mri is often sufficient to make a diagnosis of tumefactive demyelination and the results of biopsy can be inconclusive or misleading. Tumefactive demyelination does not usually originate as apostinfectious or postvaccination response. Background multiple sclerosis ms is a chronic inflammatory disease of the central nervous system in which there is focal demyelination. Given the age of the patient, the diagnosis was confirmed with a biopsy. Imaging of demyelinating diseases final linkedin slideshare. Proton mr spectroscopy has been applied in assessing various intracranial diseases and is increasingly used in diagnosis and clinical management. Spectroscopic magnetic resonance imaging of a tumefactive demyelinating lesion article in neuroradiology 4412. Clinical and magnetic resonance imaging mri distinctions between tumefactive demyelination and brain tumors in children.
Neurological disorders and imaging physics, volume 1 book home. In this report we describe the clinical, neuroimaging and neuropathological features of six cases of tdl. To use mr spectroscopy to aid in the diagnosis of demyelinating disease and to help differentiate tumefactive demyelinating lesions from neoplastic processes. Clinical examination was unremarkable except for a rightsided homonymous hemianopia. T1 hypointense top row left oval, subcortical lesion with corresponding flair hyperintense signal top row right and faint rim of incomplete horseshoe enhancement bottom row left. Tdls are defined as demyelinating lesions larger than 2 cm that often have.
This is the best way to tell what the severity of the demyelination is, what the demyelination could be caused by, and what disease the. Hmrs and conventional magnetic resonance imaging mri. The clinical use of mr spectroscopy in multiple sclerosis, an acquired demyelinating disease, remains limited despite the various insights into. Clinical, imaging, and followup observations in thirtynine patients. Oct 09, 2011 tumefactive demyelination mri a 75 y o male with left side weakness since 3 months. Metabolic assessment of monofocal acute inflammatory demyelination using mr spectroscopy and 11 cmethionine, 11 c. The incomplete rim of enhancement and low t1 signal is fairly classic for a tumefactive, demyelinating lesion. Inflammatory demyelinating disease mimicking malignant glioma. Proton magnetic resonance spectroscopy differentiates tumefactive. It is very important to differentiate tdl from glioma, because steroid use is a poor prognostic factor in glioblastoma steroids are often used in tdl shields et al. Oct 01, 2018 tumefactive demyelination last updated. Large, atypical demyelinating lesions on mri can be difficult to distinguish between primary central nervous system tumors and are referred to as tumefactive demyelinating lesions. Illustrate the role of multimodal mri with a focus on spectroscopy, diffusion and perfusion imaging to increase diagnostic confidence.
Part 2, t1weighted imagingbased differential diagnosis christopher j. Tumefactive demyelinating lesions can present with features similar, clinically and radiologically, to those of brain tumours. R neelima 1, k krishnakumar 2, md nair 3, c kesavadas 4, divyata rajendra hingwala 4, vv radhakrishnan 1, sruthi s nair 3 1 department of pathology, sree chitra tirunal institute of medical sciences and technology, trivandrum, kerala, india 2 department of. Interpreting the overlapping radiologic and clinical characteristics associated with each of these. Proton mr spectroscopy of tumefactive demyelinating. Tumefactive multiple sclerosis is a rare form of multiple sclerosis ms. Saini j, chatterjee s, thomas b, kesavadas c 2011 conventional and advanced magnetic resonance imaging in tumefactive demyelination. To identify imaging characteristics of tdls for their proper diagnosis, their differences from malignant gliomas, etc. Tumefactive demyelinating lesion is defined as large solitary demyelinating lesion with imaging characteristics mimicking neoplasm. We report a case of tumefactive demyelinating lesion tdl diagnosed using 1hmagnetic resonance spectroscopy. Characterization of tumefactive demyelinating lesions using mr imaging and invivo proton mr spectroscopy article in multiple sclerosis 152. However, demyelinating lesions seen in multiple sclerosis or tumefactive demyelination during the active phase of inflammation can also enhance, though the enhancement pattern of these lesions can be faint, with minimal perilesional vasogenic edema, and the enhancing rim may be incomplete. These atypical features include size more than 2 cm, mass effect, edema, andor ring enhancement. Tumefactive multiple sclerosis or tumefactive demyelinating lesion tdl is one of the rare variants of multiple sclerosis ms posing a diagnostic challenge and a therapeutic enigma since it is difficult to distinguish from a true central nervous system cns neoplasm or other cns lesions on magnetic resonance imaging mri.
Spectroscopic magnetic resonance imaging of a tumefactive. Demyelination is damage to the myelin sheath around nerves. Demyelination in the central nervous system sometimes presents with large pseudotumoral lesions mimicking brain neoplasm. Because of its tumorlike features on magnetic resonance imaging mri 1, 2, histological investigation had played an important role for definite diagnosis of tms 3, 4. Proton mr spectroscopy of tumefactive demyelinating lesions. Clinical proton mr spectroscopy in central nervous system disorders. 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. 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.
Tumefactive multiple sclerosis tms is a demyelinating disease. It is called tumefactive as the lesions are tumorlike and they mimic tumors clinically, radiologically and sometimes pathologically. Chinese guidelines for the diagnosis and management of. Nov, 20 saini j, chatterjee s, thomas b, kesavadas c 2011 conventional and advanced magnetic resonance imaging in tumefactive demyelination. Tumefactive demyelinating lesion tdl is defined as a solitary demyelinating lesion greater than 2 cm. Glioblastoma multiforme presenting with an open ring pattern. It is important to be aware of the differential diagnosis of tumefactive demyelination, in order to direct appropriate investigation. Most patients with lowgrade gliomas had an absence of contrast enhancement on mri and lower uptake of. Mri showed a mass lesion with prolonged t1 and t2 values and gadolinium enhancement in all cases. Choosing when to biopsy a tumefactive lesion to exclude alternative pathology can be difficult. Mass effect and contrast enhancement on neuroimaging make it difficult to distinguish this type of lesion from highgrade gliomas. 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. When a single large or multiple small tumefactive demyelinating lesions are present, the correct presurgical diagnosis is often difficult, as the mri appearance, comprising enhanced t1weighted images, t2weighted images, and even proton mr spectroscopy, is not specific for these lesions. It is important for medical professionals and patients to know that seeing demyelination on mri scans is the only way to properly identify it and see what parts of the body it is affecting.
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