Tumefactive demyelinating lesion

Case contributed by Hani Makky Al Salam


Middle age female presented with left sided weakness.

Patient Data

Age: Middle age
Gender: Female

Note: This case has been tagged as "legacy" as it no longer meets image preparation and/or other case publication guidelines.

CT brain


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.

The following day, brain MRI was performed, showing an intra-axial mass in the right temporal lobe with extension into the adjacent parietal and frontal lobes. The lesion is estimated to measure 6 cm 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 a central lactate peak. 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. 


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 preservation of axons (NFP).

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