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Saridas F, Mesut G, Ceylan CY, Ozpar R, Ozsen M, Koc ER, Tolunay S, Hakyemez B, Turan OF. Prognostic factors of tumefactive demyelinating lesions and differential features for multiple sclerosis in etiology. Mult Scler Relat Disord 2024; 85:105537. [PMID: 38460252 DOI: 10.1016/j.msard.2024.105537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Revised: 02/09/2024] [Accepted: 03/04/2024] [Indexed: 03/11/2024]
Abstract
BACKGROUND Many different pathologies may underlie tumefactive demyelinating lesions. Identifying clinical and radiologic distinguishing features before pathologic examination is essential for diagnosis and treatment. In this study, we aimed to determine the clinical and radiologic features affecting the etiology and disease course of patients with tumefactive lesions (TDL). MATERIALS AND METHODS We included 35 clinicoradiologically or histologically diagnosed TDL patients in our center over 11 years. Patient records were retrospectively evaluated and recorded. Clinical features, cerebral neuroimaging, and histologic biopsy preparations, if any, were assessed by three independent neurologists, two neuroradiologists, and two pathologists at admission and follow-up, respectively. RESULTS The mean age of patients with TDL was 40.02±14.40 years. Symptom onset was 15 (1-365) days. The most common complaints at initial presentation were hemiparesis or hemiplegia, sensory complaints, and cognitive impairment (aphasia or apraxia). The lesions were most commonly localized in the frontal lobe (42.9 %). Mass effect was 17.1 %, edema 60 %, diffusion restriction 62.1 %, and contrast enhancement 71.9 % (mostly ring-shaped (68.8 %)) on MR images. Acute onset and OCB type-2 positivity were associated with MS diagnosis. On the other hand, CSF protein levels above 45 mg/dL were found to be related to non-MS etiologies. Only the predominance of aphasia or apraxia at onset was a risk factor for early high disability (EDSS>4; 3rd month). Subacute-chronic onset, being older than 40 years, or having brainstem symptoms at onset were independent risk factors for late high disability (2nd year). CONCLUSION Acute onset or OCB type 2 positivity is a clue for early diagnosis of MS, while elevated CSF protein is a clue for demyelinating diseases other than MS. Presentation with cognitive dysfunction at onset is an independent risk factor for early disability, while age above 40 years, subacute-chronic presentation and brainstem findings at presentation are independent risk factors for late disability.
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Affiliation(s)
- Furkan Saridas
- Bursa Uludağ University Medicine Faculty, Department of Neurology, Türkiye.
| | - Gizem Mesut
- Bursa Uludağ University Medicine Faculty, Department of Neurology, Türkiye
| | - Ceren Yayla Ceylan
- Bursa Uludağ University Medicine Faculty, Department of Radiology, Türkiye
| | - Rifat Ozpar
- Bursa Uludağ University Medicine Faculty, Department of Radiology, Türkiye
| | - Mine Ozsen
- Bursa Uludağ University Medicine Faculty, Department of Pathology, Türkiye
| | - Emine Rabia Koc
- Bursa Uludağ University Medicine Faculty, Department of Neurology, Türkiye
| | - Sahsine Tolunay
- Bursa Uludağ University Medicine Faculty, Department of Pathology, Türkiye
| | - Bahattin Hakyemez
- Bursa Uludağ University Medicine Faculty, Department of Radiology, Türkiye
| | - Omer Faruk Turan
- Bursa Uludağ University Medicine Faculty, Department of Neurology, Türkiye
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Le D, Trinh K, Das N, Kuo AH. T2-fluid attenuated inversion recovery mismatch in tumefactive multiple sclerosis. BJR Case Rep 2023; 9:20220138. [PMID: 36873238 PMCID: PMC9976723 DOI: 10.1259/bjrcr.20220138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 11/15/2022] [Accepted: 11/15/2022] [Indexed: 01/13/2023] Open
Abstract
The T2-fluid attenuated inversion recovery (FLAIR) mismatch sign has been suggested as an imaging marker of isocitrate dehydrogenase-mutant 1p/19q non-codeleted gliomas with 100% specificity. Tumefactive demyelination is a common mimic of neoplasm that has led to unnecessary biopsies and even resections. We report a case of tumefactive multiple sclerosis in a 46-year-old male without prior symptomatic demyelinating episodes that demonstrates the T2-FLAIR mismatch sign. Our findings suggest the T2-FLAIR mismatch sign should not be used as a differential feature between glioma and tumefactive demyelination. Because typical isocitrate dehydrogenase-mutant 1p/19q non-codeleted gliomas typically do not demonstrate significant enhancement, such diagnosis should be reserved when post-contrast images are unavailable.
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Affiliation(s)
- Duc Le
- Texas Tech University Health Sciences Center, Lubbock, Texas, United States
| | - Kelly Trinh
- Texas Tech University Health Sciences Center, Lubbock, Texas, United States
| | | | - Anderson H Kuo
- Department of Radiology, Midland Memorial Hospital, Midland, Texas, United States
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Paramaguru R, Ramkumar S. Tumefactive Demyelination: A Common Radiological Masquerader of Malignancy and the Expeditious Diagnostic Applicability of Crush Smear Cytology. Cureus 2022; 14:e29751. [PMID: 36340536 PMCID: PMC9621740 DOI: 10.7759/cureus.29751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2022] [Indexed: 11/08/2022] Open
Abstract
Tumefactive demyelinations (TDs) are demyelinating central nervous system lesions that masquerade as neoplastic lesions on radiological images. Brain biopsy is often required for confirmatory diagnosis. Since crush cytology has become a routine practice, a thorough knowledge of the cytomorphologic features of TD is required to prevent misdiagnosis. In this report, we describe the cytomorphological and histomorphological features of a case of TD.
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Pérez CA, Patnaik A, Oommen S, Redko A, Mathis SB. Tumefactive Demyelinating Lesions in Children: A Rare Case of Conus Medullaris Involvement and Systematic Review of the Literature. J Child Neurol 2020; 35:690-699. [PMID: 32552343 DOI: 10.1177/0883073820924147] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Tumefactive demyelinating lesions are an uncommon manifestation of demyelinating disease that mimic primary central nervous system neoplasms and can pose a diagnostic challenge in patients without a pre-existing diagnosis of multiple sclerosis. Although a biopsy may be required to distinguish TDL from neoplasms or infection, certain ancillary and radiographic findings may preclude the need for invasive diagnostic procedures. We describe the case of a 15-year-old boy with a tumefactive demyelinating lesion involving the conus medullaris. An exhaustive systematic literature search of pediatric cases of TDL yielded an additional 78 cases. This review summarizes the current knowledge and recommendations for the diagnosis and management of this condition, highlighting the clinical, demographic, and radiologic features of 79 reported cases, including our own. Furthermore, it underscores areas of the literature where evidence is still lacking. Further research is needed to optimize clinical detection and medical management of this condition.
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Affiliation(s)
- Carlos A Pérez
- Division of Multiple Sclerosis and Neuroimmunology, Department of Neurology, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Anish Patnaik
- McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Sherwin Oommen
- Division of Child and Adolescent Neurology, Department of Pediatrics, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Alissa Redko
- McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Scott B Mathis
- McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
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Biswas S, Nagaraj C, Mangalore S, Gupta AK. Tumefactive Demyelination versus Primary Central Nervous System Lymphoma on 18F-Fluorodeoxyglucose Positron Emission Tomography Magnetic Resonance Imaging: A Twist in the Tale. Indian J Nucl Med 2019; 34:237-240. [PMID: 31293309 PMCID: PMC6593932 DOI: 10.4103/ijnm.ijnm_31_19] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Demyelinating lesions of the central nervous system (CNS) are classically known to be hypometabolic on 18F-Flurodeoxyglucose Positron Emission Tomography (18F-FDG PET). However, demyelinating lesions may show increased tracer uptake on 18F-FDG PET and can radiologically mimic neoplasm. Delayed tracer uptake on FDG PET is one of the diagnostic hallmarks of primary CNS lymphoma (PCNSL). Here, we present two cases in which the brain lesions showed increased FDG uptake on delayed integrated PET Magnetic Resonance Imaging (MRI), which were pathologically proven as CNS demyelination. Such demyelinating lesions may also act as "sentinel lesions" and potential harbinger of PCNSL on follow-up.
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Affiliation(s)
- Shamick Biswas
- Department of Neuroimaging and Interventional Radiology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Chandana Nagaraj
- Department of Neuroimaging and Interventional Radiology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Sandhya Mangalore
- Department of Neuroimaging and Interventional Radiology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Arun Kumar Gupta
- Department of Neuroimaging and Interventional Radiology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
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Jain RS, Khan I, Kandelwal K, Desai T. Tumefactive demyelinating lesions (TDLs): A case series of clinicoradiological features. Clin Neurol Neurosurg 2017; 162:91-94. [DOI: 10.1016/j.clineuro.2017.09.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 09/03/2017] [Accepted: 09/28/2017] [Indexed: 11/25/2022]
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Chinese Guidelines for the Diagnosis and Management of Tumefactive Demyelinating Lesions of Central Nervous System. Chin Med J (Engl) 2017; 130:1838-1850. [PMID: 28748858 PMCID: PMC5547837 DOI: 10.4103/0366-6999.211547] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Indexed: 01/15/2023] Open
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Hiremath SB, Muraleedharan A, Kumar S, Nagesh C, Kesavadas C, Abraham M, Kapilamoorthy TR, Thomas B. Combining Diffusion Tensor Metrics and DSC Perfusion Imaging: Can It Improve the Diagnostic Accuracy in Differentiating Tumefactive Demyelination from High-Grade Glioma? AJNR Am J Neuroradiol 2017; 38:685-690. [PMID: 28209583 DOI: 10.3174/ajnr.a5089] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Accepted: 12/04/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND PURPOSE Tumefactive demyelinating lesions with atypical features can mimic high-grade gliomas on conventional imaging sequences. The aim of this study was to assess the role of conventional imaging, DTI metrics (p:q tensor decomposition), and DSC perfusion in differentiating tumefactive demyelinating lesions and high-grade gliomas. MATERIALS AND METHODS Fourteen patients with tumefactive demyelinating lesions and 21 patients with high-grade gliomas underwent brain MR imaging with conventional, DTI, and DSC perfusion imaging. Imaging sequences were assessed for differentiation of the lesions. DTI metrics in the enhancing areas and perilesional hyperintensity were obtained by ROI analysis, and the relative CBV values in enhancing areas were calculated on DSC perfusion imaging. RESULTS Conventional imaging sequences had a sensitivity of 80.9% and specificity of 57.1% in differentiating high-grade gliomas (P = .049) from tumefactive demyelinating lesions. DTI metrics (p:q tensor decomposition) and DSC perfusion demonstrated a statistically significant difference in the mean values of ADC, the isotropic component of the diffusion tensor, the anisotropic component of the diffusion tensor, the total magnitude of the diffusion tensor, and rCBV among enhancing portions in tumefactive demyelinating lesions and high-grade gliomas (P ≤ .02), with the highest specificity for ADC, the anisotropic component of the diffusion tensor, and relative CBV (92.9%). Mean fractional anisotropy values showed no significant statistical difference between tumefactive demyelinating lesions and high-grade gliomas. The combination of DTI and DSC parameters improved the diagnostic accuracy (area under the curve = 0.901). Addition of a heterogeneous enhancement pattern to DTI and DSC parameters improved it further (area under the curve = 0.966). The sensitivity increased from 71.4% to 85.7% after the addition of the enhancement pattern. CONCLUSIONS DTI and DSC perfusion add profoundly to conventional imaging in differentiating tumefactive demyelinating lesions and high-grade gliomas. The combination of DTI metrics and DSC perfusion markedly improved diagnostic accuracy.
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Affiliation(s)
- S B Hiremath
- From the Departments of Imaging Sciences and Interventional Radiology (S.B.H., A.M., S.K., C.N., C.K., T.R.K., B.T.)
| | - A Muraleedharan
- From the Departments of Imaging Sciences and Interventional Radiology (S.B.H., A.M., S.K., C.N., C.K., T.R.K., B.T.)
| | - S Kumar
- From the Departments of Imaging Sciences and Interventional Radiology (S.B.H., A.M., S.K., C.N., C.K., T.R.K., B.T.)
| | - C Nagesh
- From the Departments of Imaging Sciences and Interventional Radiology (S.B.H., A.M., S.K., C.N., C.K., T.R.K., B.T.)
| | - C Kesavadas
- From the Departments of Imaging Sciences and Interventional Radiology (S.B.H., A.M., S.K., C.N., C.K., T.R.K., B.T.)
| | - M Abraham
- Neurosurgery (M.A.), Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - T R Kapilamoorthy
- From the Departments of Imaging Sciences and Interventional Radiology (S.B.H., A.M., S.K., C.N., C.K., T.R.K., B.T.)
| | - B Thomas
- From the Departments of Imaging Sciences and Interventional Radiology (S.B.H., A.M., S.K., C.N., C.K., T.R.K., B.T.)
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Open-ring enhancement in pseudotumoral multiple sclerosis: important radiological aspect. Case Rep Neurol Med 2014; 2014:951690. [PMID: 24839572 PMCID: PMC4009287 DOI: 10.1155/2014/951690] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2014] [Accepted: 03/22/2014] [Indexed: 11/17/2022] Open
Abstract
Introduction. Observation of open-ring enhancement in magnetic resonance imaging (MRI) is considered a specificity marker for diagnosing pseudotumoral multiple sclerosis (MS). This finding is of great value in the differential diagnosis of tumefactive lesions. Case Report. We describe a 55-year-old white woman, with previous history of ovarian cancer and recent history of fatigue and bilateral retroorbital pain. Important bilateral visual impairment evolved over one month. Physical examination detected the presence of right homonymous hemianopia. Cranial MRI showed an expanding lesion with open-ring enhancement. Given the range of diagnostic possibilities, a stereotactic biopsy was performed, and histopathological examination was consistent with an active demyelinating disease. The patient was treated with 1 g of methylprednisolone and symptoms improved following a significant reduction in the lesion. Conclusions. We highlight the MRI results suggestive of pseudotumoral MS, especially open-ring enhancement, which is an important radiologic aspect to diagnosis and can assist in avoiding unnecessary biopsies.
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