EURORAD ESR

Case 13166

An interesting case of tumefactive demyelination

Author(s)
Kalia Shekhar, Cecil M Deepti, Chaturvedi Arti, Shekhar Abhishek, Kapoor Dinesh

Department of Radiology,
Fortis Hospital,
B -22, Sector - 62,
Pin- 201301, Noida;
Email:shekhar6903@gmail.com
 
Patient
male, 44 year(s)
 
 
  • Figure 1
    CECT Brain

    CECT showing an ill-defined hypoattenuating lesion in left centrum semiovale.

     
    Area of Interest: Neuroradiology brain; Imaging Technique: PET-CT; Procedure: Image compression; Special Focus: Inflammation;
     
     
  • Figure 2
    MRI Brain T2/T1WI and FLAIR sequences
     

    Axial T2WI image showing an ill-defined hyperintensity in left centrum semiovale. No definite mass effect is noted.

     
    Area of Interest: Neuroradiology brain; Imaging Technique: MR; Procedure: Imaging sequences; Special Focus: Inflammation;

    Axial T1WI image showing an ill-defined hypointensity in left centrum semiovale. No definite mass effect is noted.

     
    Area of Interest: Neuroradiology brain; Imaging Technique: MR; Procedure: Imaging sequences; Special Focus: Inflammation;

    Axial FLAIR image showing an ill-defined hyperintensity in left centrum semiovale.

     
    Area of Interest: Neuroradiology brain; Imaging Technique: MR; Procedure: Imaging sequences; Special Focus: Inflammation;

    Coronal T2WI image showing an ill-defined hyperintensity in left centrum semiovale, periventricular and subcortical white matter. No definite mass effect is noted.

     
    Area of Interest: Neuroradiology brain; Imaging Technique: MR; Procedure: Imaging sequences; Special Focus: Inflammation;
     
     
  • Figure 3
    Axial diffusion-weighted image and ADC map of the brain
     

    Diffusion-weighted image showing altered arc-like hyperintensity at the periphery of the lesion, representing acute aetiology.

     
    Area of Interest: Neuroradiology brain; Imaging Technique: MR-Diffusion/Perfusion; Procedure: Imaging sequences; Special Focus: Inflammation;

    The diffusion hyperintensity shows signal drop on ADC maps suggestive of restricted diffusion at the periphery of the lesion (arrows); The central region of the lesion shows normal diffusion.

     
    Area of Interest: Neuroradiology brain; Imaging Technique: MR-Diffusion/Perfusion; Procedure: Imaging sequences; Special Focus: Inflammation;
     
     
  • Figure 4
    Post gadolinium MRI Brain coronal and axial sequences
     

    Post-contrast coronal MRI image showing a faint rim of discontinuous enhancement at the medial aspect of the lesion with open ring towards cortical grey matter.

     
    Area of Interest: Neuroradiology brain; Imaging Technique: MR; Procedure: Imaging sequences; Special Focus: Inflammation;

    Post-contrast axial MRI image showing a faint rim of discontinuous enhancement at the medial aspect of the lesion with open ring towards cortical grey matter.

     
    Area of Interest: Neuroradiology brain; Imaging Technique: MR; Procedure: Imaging sequences; Special Focus: Inflammation;
     
     
  • Figure 5
    MR spectroscopy brain
     

    MRI spectroscopy indicating the region of interest.

     
    Area of Interest: Neuroradiology brain; Imaging Technique: MR-Functional imaging; Procedure: Imaging sequences; Special Focus: Inflammation;

    MRI spectroscopy graph at 144 TE showing elevated choline and creatine levels with reduction in NAA and inverted lactate peak.

     
    Area of Interest: Neuroradiology brain; Imaging Technique: MR-Spectroscopy; Procedure: Imaging sequences; Special Focus: Inflammation;

    MRI Spectroscopy graph at 35 TE showing elevation of glutamine /glutamate peak.

     
    Area of Interest: Neuroradiology brain; Imaging Technique: MR-Spectroscopy; Procedure: Imaging sequences; Special Focus: Inflammation;
     
     
  • Figure 6
    Arterial spin labelling
     

    T1WI showing hypointense lesion in left centrum semiovale region. (for reference)

     
    Area of Interest: Neuroradiology brain; Imaging Technique: MR; Procedure: Imaging sequences; Special Focus: Inflammation;

    A colored arterial spin labelling map demonstrating rim of hyperperfusion giving a characteristic open ring appearance (yellow; ROI-1) in the active zone of demyelination in left centrum semiovale region.

     
    Area of Interest: Neuroradiology brain; Imaging Technique: MR-Diffusion/Perfusion; Procedure: Imaging sequences; Special Focus: Inflammation;
     
     
  • Figure 7
    FDG - PET CT Brain

    FDG- PET CT image demonstrating photopaenia (reduced uptake of FDG) in the lesion. SUV max 2.5

     
    Area of Interest: Neuroradiology brain; Imaging Technique: PET-CT; Procedure: Imaging sequences; Special Focus: Inflammation;
     
     
  • Figure 8
    Histopathology
     

    Photomicrograph of the biopsied specimen of the lesion showing prominent macrophages and a bizzare gemistocyte (large blue-stained cell) which may lead to incorrect diagnosis of glial neoplasm.

     
    Area of Interest: Neuroradiology brain; Imaging Technique: Experimental; Procedure: Diagnostic procedure; Special Focus: Tissue characterisation;

    Photomicrograph of the biopsied specimen shows prominent perivascular lymphocyte and histiocytic proliferation.

     
    Area of Interest: Neuroradiology brain; Imaging Technique: Experimental; Procedure: Diagnostic procedure; Special Focus: Tissue characterisation;

    Photomicrograph of the biopsied specimen after myelin stain showing normal myelinated brain parenchyma on right side(in blue), compared with area of the demyelination(pink on left side).

     
    Area of Interest: Neuroradiology brain; Imaging Technique: Experimental; Procedure: Diagnostic procedure; Special Focus: Tissue characterisation;
     
     
  • Figure 9
    Follow-up MRI brain after 6 months post treatment
     

    Diffusion-weighted image shows no definite rim of restriction, which was appreciated in the initial scans.

     
    Area of Interest: Neuroradiology brain; Imaging Technique: MR-Diffusion/Perfusion; Procedure: Imaging sequences; Special Focus: Inflammation;

    Contrast-enhanced T1WI axial MRI image showing no enhancement. Surgical changes are also seen in left fronto-parietal calvarium (related to previous biopsy).

     
    Area of Interest: Neuroradiology brain; Imaging Technique: MR; Procedure: Imaging sequences; Special Focus: Inflammation;

    Axial T2/ FLAIR image shows reduction in the size and extent of the white matter signal alteration.

     
    Area of Interest: Neuroradiology brain; Imaging Technique: MR; Procedure: Imaging sequences; Special Focus: Inflammation;
     
     
CECT showing an ill-defined hypoattenuating lesion in left centrum semiovale.
 
Axial T2WI image showing an ill-defined hyperintensity in left centrum semiovale. No definite mass effect is noted.
 
Axial T1WI image showing an ill-defined hypointensity in left centrum semiovale. No definite mass effect is noted.
 
Axial FLAIR image showing an ill-defined hyperintensity in left centrum semiovale.
 
Coronal T2WI image showing an ill-defined hyperintensity in left centrum semiovale, periventricular and subcortical white matter. No definite mass effect is noted.
 
Diffusion-weighted image showing altered arc-like hyperintensity at the periphery of the lesion, representing acute aetiology.
 
The diffusion hyperintensity shows signal drop on ADC maps suggestive of restricted diffusion at the periphery of the lesion (arrows); The central region of the lesion shows normal diffusion.
 
Post-contrast coronal MRI image showing a faint rim of discontinuous enhancement at the medial aspect of the lesion with open ring towards cortical grey matter.
 
Post-contrast axial MRI image showing a faint rim of discontinuous enhancement at the medial aspect of the lesion with open ring towards cortical grey matter.
 
MRI spectroscopy indicating the region of interest.
 
MRI spectroscopy graph at 144 TE showing elevated choline and creatine levels with reduction in NAA and inverted lactate peak.
 
MRI Spectroscopy graph at 35 TE showing elevation of glutamine /glutamate peak.
 
T1WI showing hypointense lesion in left centrum semiovale region. (for reference)
 
A colored arterial spin labelling map demonstrating rim of hyperperfusion giving a characteristic open ring appearance (yellow; ROI-1) in the active zone of demyelination in left centrum semiovale region.
 
FDG- PET CT image demonstrating photopaenia (reduced uptake of FDG) in the lesion. SUV max 2.5
 
Photomicrograph of the biopsied specimen of the lesion showing prominent macrophages and a bizzare gemistocyte (large blue-stained cell) which may lead to incorrect diagnosis of glial neoplasm.
 
Photomicrograph of the biopsied specimen shows prominent perivascular lymphocyte and histiocytic proliferation.
 
Photomicrograph of the biopsied specimen after myelin stain showing normal myelinated brain parenchyma on right side(in blue), compared with area of the demyelination(pink on left side).
 
Diffusion-weighted image shows no definite rim of restriction, which was appreciated in the initial scans.
 
Contrast-enhanced T1WI axial MRI image showing no enhancement. Surgical changes are also seen in left fronto-parietal calvarium (related to previous biopsy).
 
Axial T2/ FLAIR image shows reduction in the size and extent of the white matter signal alteration.
 
 
 
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