Tumefactive demyelinating lesion

Case contributed by Dr Hani Salam

Presentation

Middle age female presented with left sided weakness.

Patient Data

Age: Middle age
Gender: Female

CT brain

Modality: CT

Brain CT scan demonstrates hypodense lesion seen over the right fronto-parietal-temporal area surrounded by vasogenic edema and causing midline shift to the left side. This lesion shows peripheral enhancement post IV contrast.

Modality: MRI

The following day, brain MRI was performed, an intra-axial mass in the right temporal lobe with extension into the adjacent parietal and frontal lobes. The lesion is estimated to measure 6cm in size. The brightness on FLAIR extends beyond the borders of the lesion into the adjacent basal ganglia and subinsular white matter and extends posteriorly to the occipital lobe and involves all the white matter structures of the right temporal lobe. This FLAIR signal may represent tumoral edema or true infiltration.

Case Discussion

The large right temporal lesion demonstrates contradictory findings. The lesion exerts significant mass effect and demonstrates enhancement on conventional imaging. The spectroscopy studies demonstrate central lactate. No clear cut elevation in choline was demonstrated. The pattern of enhancement is incomplete. The contradictory findings raise the possibility that this lesion may not be neoplastic in nature. Consider a tumofactive demyelinating lesion as well as neoplasm for this lesion.

The patient went on to have a biopsy. 

Pathology:

Histopathology and special stains are in favor of demyelinating disease process. Section show white matter changes exhibiting gliosis, reactive astrocyte and numerous lipid-laden macrophages.

Special stains (LFB-PAS & MBP) show loss of myelin and relative preserved of axons (NFP).

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Case Information

rID: 7637
Case created: 15th Nov 2009
Last edited: 26th Nov 2015
Inclusion in quiz mode: Included

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