J Korean Soc Radiol.  2013 Nov;69(5):337-341. 10.3348/jksr.2013.69.5.337.

A Tumefactive Multiple Sclerosis Lesion in the Brain: An Uncommon Site with Atypical Magnetic Resonance Image Findings

• Jeong MS
• Kim HS
• Kim JH
• Kim EK
• Choi YS

• KMID: 2002849
• DOI: http://doi.org/10.3348/jksr.2013.69.5.337

Abstract

Tumefactive multiple sclerosis (MS) is a rare type of demyelinating disease. Typical magnetic resonance (MR) image findings show incomplete ring enhancement with a mild mass effect. This lesion is otherwise indistinguishable from other mass-like lesions in the brain. Knowledge of the MR imaging findings for tumefactive MS is thus helpful for correct diagnosis and appropriate therapy. In this report we describe the MR image findings for pathology-confirmed tumefactive MS in an uncommon location, alongside a discussion of its aggressive features.

MeSH Terms

Brain*
Demyelinating Diseases
Magnetics*
Magnets*
Multiple Sclerosis*

Figure

• 

  Fig. 1 A 43-year-old female with tumefactive multiple sclerosis. A. An irregularly shaped mass-like lesion approximately 5 cm in size involves the white matter of the left temporal lobe. The lesion shows high signal intensity on axial T2-weighted image and extends to the left posterior thalamus, posterior limb of the internal capsule, and the external capsule. Also this hyperintensity extends to the periventricular white matter near the left lateral ventricular atrium. B, C. After gadolinium enhancement, the lesion demonstrates thick and irregular rim-like enhancement with extension along the course of the left internal capsule on coronal image (B) and the left midbrain crus, with incomplete rim enhancement on axial image (C). D. Magnetic resonance spectroscopy of the mass in left temporal lobe demonstrates elevated choline and lactate, and decreased N-acetylaspartate.

• 

  Fig. 2 Photomicrography of the center of the mass. Section shows proliferation of reactive astrocyte and perivascular infiltration of lymphocytes and histiocytes (H&E, ×200).

• 

  Fig. 3 After two months of steroid therapy, the irregular hyperintense lesion markedly decreases in size; the lesion have been located in the left temporal lobe, midbrain, internal capsule, external capsule, and posterior thalamus on the axial T2-weighted image.

Reference

1. Rusin JA, Vezina LG, Chadduck WM, Chandra RS. Tumoral multiple sclerosis of the cerebellum in a child. AJNR Am J Neuroradiol. 1995; 16:1164–1166.

2. Comi G. Multiple sclerosis: pseudotumoral forms. Neurol Sci. 2004; 25:Suppl 4. S374–S379.

3. Kim DS, Na DG, Kim KH, Kim JH, Kim E, Yun BL, et al. Distinguishing tumefactive demyelinating lesions from glioma or central nervous system lymphoma: added value of unenhanced CT compared with conventional contrast-enhanced MR imaging. Radiology. 2009; 251:467–475.

4. Elsone L, Platkajis A, Karelis G, Dzelzite S, Murzina M. Tumefactive multiple sclerosis mimicking neoplasm. Acta Chirurgica Latviensis. 2010; 10:91–97.

5. Lucchinetti CF, Gavrilova RH, Metz I, Parisi JE, Scheithauer BW, Weigand S, et al. Clinical and radiographic spectrum of pathologically confirmed tumefactive multiple sclerosis. Brain. 2008; 131(Pt 7):1759–1775.

6. Mandrioli J, Ficarra G, Callari G, Sola P, Merelli E. Monofocal acute large demyelinating lesion mimicking brain glioma. Neurol Sci. 2004; 25:Suppl 4. S386–S388.

7. Annesley-Williams D, Farrell MA, Staunton H, Brett FM. Acute demyelination, neuropathological diagnosis, and clinical evolution. J Neuropathol Exp Neurol. 2000; 59:477–489.

8. Law M, Yang S, Wang H, Babb JS, Johnson G, Cha S, et al. Glioma grading: sensitivity, specificity, and predictive values of perfusion MR imaging and proton MR spectroscopic imaging compared with conventional MR imaging. AJNR Am J Neuroradiol. 2003; 24:1989–1998.

9. Given CA 2nd, Stevens BS, Lee C. The MRI appearance of tumefactive demyelinating lesions. AJR Am J Roentgenol. 2004; 182:195–199.

10. Schwartz KM, Erickson BJ, Lucchinetti C. Pattern of T2 hypointensity associated with ring-enhancing brain lesions can help to differentiate pathology. Neuroradiology. 2006; 48:143–149.

11. Kantarci OH, Weinshenker BG. Natural history of multiple sclerosis. Neurol Clin. 2005; 23:17–38. v