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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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2
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Nafari A, Ghaffary EM, Shaygannejad V, Mirmosayyeb O. Concurrent glioma and multiple sclerosis: A systematic review of case reports. Mult Scler Relat Disord 2024; 84:105455. [PMID: 38330723 DOI: 10.1016/j.msard.2024.105455] [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: 10/20/2023] [Revised: 12/14/2023] [Accepted: 01/18/2024] [Indexed: 02/10/2024]
Abstract
BACKGROUND It is uncommon for individuals with demyelinating disease, notably multiple sclerosis (MS), to be diagnosed with intracranial gliomas. It has been debated whether or not the concurrence of these two disorders is accidental. Clinically, it may be challenging to diagnose someone who has MS and an intracranial tumor simultaneously. We conducted this systematic review to evaluate the glioma patients following MS. METHODS We collected 63 studies from 1672 databases from January 1990 to February 2023, and our inclusion criteria involved peer-reviewed case reports/series studies reporting concurrent MS and glioma in patients, considering various types of gliomas. RESULTS We included 145 cases, 51% were women and 49 % were men, with an average age of 47.4 years. Common symptoms of glioma at admission included seizures (31.2 %), hemiparesis (15.6 %), and headache (14.3 %). 75 % of patients had primarily with relapsing-remitting MS (RRMS). MS treatments included interferon(IFN)-ß (44.6 %), glatiramer acetate (GA) (21.4 %), fingolimod (19.6 %), and natalizumab (19.6 %). The average time between MS and glioma diagnosis was 12.1 years, with various timeframes. Among the 59 reported cases, 45.8 % led to patient fatalities, while the remaining 54.2 % managed to survive. CONCLUSION This co-occurrence, though rare, suggests potential underlying shared mechanisms or vulnerabilities, possibly at a genetic or environmental level. An interdisciplinary approach, combining the expertise of neurologists, oncologists, radiologists, and pathologists, is vital to ensure accurate diagnosis and optimal management of affected individuals. Nonetheless, there is still a significant lack of information regarding this phenomenon, necessitating large-scale population-based studies and experimental research.
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Affiliation(s)
- Amirhossein Nafari
- Isfahan Neurosciences Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Elham Moases Ghaffary
- Isfahan Neurosciences Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Vahid Shaygannejad
- Isfahan Neurosciences Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Omid Mirmosayyeb
- Isfahan Neurosciences Research Center, Isfahan University of Medical Sciences, Isfahan, Iran.
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3
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Boyle T, Fernando SL, Drummond J, Fontes A, Parratt J. Phenotyping variants of tumefactive demyelinating lesions according to clinical and radiological features-A case series. Front Neurol 2023; 14:1092373. [PMID: 36816572 PMCID: PMC9935935 DOI: 10.3389/fneur.2023.1092373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 01/18/2023] [Indexed: 02/05/2023] Open
Abstract
Background Tumefactive demyelinating lesions (TDLs) are defined as lesions >2 cm on MRI of the brain. They are identified in a range of demyelinating diseases including massive demyelination due to Marburg's acute MS, Schilder's Disease, Balo's concentric sclerosis, and Tumefactive MS. Apart from the rare demyelinating variants which are often diagnosed histologically, there are no detailed data to phenotype TDLs. Methods We describe the clinical and radiological features of four similar patients with very large TDLs (>4 cm), that are not consistent with the rare demyelinating variants and may represent a distinct phenotype. Results All patients presented with hemiplegia and apraxia. The mean age at onset was 37 years with an equal sex distribution. All patients were diagnosed with Tumefactive demyelination based on MRI and CSF analysis, precluding the need for brain biopsy. All responded to potent immunotherapy (including high dose corticosteroids, plasma exchange, rituximab, and/or cyclophosphamide). The mean lag from diagnosis to treatment was 1 day. The median EDSS at presentation was six and recovery to a median EDSS of two occurred over 6 months. Conclusion We propose that Tumefactive lesions larger than 4 cm are termed "Giant demyelinating lesions" (GDLs) not only on the basis of size, but a rapid and fulminant demyelinating presentation leading to acute, severe neurological disability that is, nonetheless, responsive to immunotherapy. Further clinical studies are required to ratify this proposed phenotype, establish the immunological profile and best treatment for such patients.
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Affiliation(s)
- Thérèse Boyle
- Clinical Immunology and Allergy, Royal North Shore Hospital, St Leonards, NSW, Australia,Immunology Laboratory, Royal North Shore Hospital, St Leonards, NSW, Australia,Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia,*Correspondence: Thérèse Boyle ✉
| | - Suran L. Fernando
- Clinical Immunology and Allergy, Royal North Shore Hospital, St Leonards, NSW, Australia,Immunology Laboratory, Royal North Shore Hospital, St Leonards, NSW, Australia,Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia
| | - James Drummond
- Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia,Department of Neuroradiology, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Ariadna Fontes
- Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia,Department of Neurology, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - John Parratt
- Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia,Department of Neurology, Royal North Shore Hospital, St Leonards, NSW, Australia
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4
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Chen XY, Chen Y, Fang WH, Wu ZY, Wang DL, Xu YW, Yu LH, Lin YX, Kang DZ, Ding CY. Integrative and comparative single-cell analysis reveals transcriptomic difference between human tumefactive demyelinating lesion and glioma. Commun Biol 2022; 5:941. [PMID: 36085357 PMCID: PMC9463163 DOI: 10.1038/s42003-022-03900-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 08/25/2022] [Indexed: 11/09/2022] Open
Abstract
Tumefactive demyelinating lesion (TDL) is an immune-mediated disease which can be misdiagnosed as glioma. At present, there is no study comparing difference between the two disorders at the cellular level. Here, we perform integrative and comparative single-cell RNA sequencing (ScRNA-seq) transcriptomic analysis on TDL and glioma lesions. At single-cell resolution, TDL is comprised primarily of immune cells, which is completely different from glioma. The integrated analysis reveals a TDL-specific microglial subset involving in B cell activation and proliferation. Comparative analysis highlights remyelination function of glial cells and demyelination function of T cells in TDL. Subclustering and pseudotime trajectory analysis of T cells in TDL reveal their heterogeneity and diverse functions involving in TDL pathogenesis and recovery process. Our study identifies substantial differences between TDL and glioma at single-cell resolution. The observed heterogeneity and potentially diverse functions of cells in TDL may be critical in disease progression. Integrative and comparative single-cell analysis reveals transcriptomic difference between human tumefactive demyelinating lesion and glioma.
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5
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Tomura N, Saginoya T, Kaneko C. 18F-Fluorodeoxy Glucose and 11C-Methionine Accumulation in Demyelinating Lesions. World J Nucl Med 2022; 21:261-266. [DOI: 10.1055/s-0042-1750012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Abstract
Background Few studies have evaluated the accumulation of 18F-fluorodeoxyglucose (FDG), 11C-methionine (MET), and other positron emission tomography (PET) tracers in patients with demyelinating disease.
Purpose This study aimed to investigate the accumulation of FDG-PET/computed tomography (CT) and MET-PET/CT in demyelinating lesions.
Material and Methods A retrospective search of the patient database in our hospital identified five patients with demyelinating disease in whom PET studies performed in the past 10 years revealed accumulation of FDG or MET. The clinical diagnoses were multiple sclerosis (n=1), myelitis (n=1), limbic encephalitis (n=1), chronic inflammatory demyelinating polyneuropathy (CIDP; n=1), and acute demyelinating encephalomyelitis (ADEM; n=1). Two patients received FDG-PET/CT alone and three patients received both FDG-PET/CT and MET-PET/CT on the same day. Images were visually and conjointly reviewed by two radiologists. In semiquantitative evaluation, the maximum standardized uptake value (SUVmax) of the lesion was measured. The lesion-to-normal brain uptake ratio (L/N ratio) was calculated.
Results FDG and/or MET accumulated to a part of the lesions seen on MRI. SUVmax on FDG-PET/CT ranged from 3.8 to 10.3, and L/N ratio on MET-PET/CT ranged from 16.6 to 2.4.
Conclusion It has been established that neoplastic and demyelinating lesions can be differentiated on the basis of FDG or MET uptake. However, as accumulation of FDG and MET can also occur in demyelinating lesions; knowledge of this possibility is of clinical importance.
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Affiliation(s)
- Noriaki Tomura
- Department of Neuroradiology, Radiology, and Neurology, Southern Tohoku Research Institute for Neuroscience, Southern Tohoku General Hospital, Koriyama City, Fukushima, Japan
| | - Toshiyuki Saginoya
- Department of Neuroradiology, Radiology, and Neurology, Southern Tohoku Research Institute for Neuroscience, Southern Tohoku General Hospital, Koriyama City, Fukushima, Japan
| | - Chikako Kaneko
- Department of Neuroradiology, Radiology, and Neurology, Southern Tohoku Research Institute for Neuroscience, Southern Tohoku General Hospital, Koriyama City, Fukushima, Japan
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6
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Yogendran LV, Kalelioglu T, Donahue JH, Ahmad H, Phillips KA, Calautti NM, Lopes MB, Asthagiri AR, Purow B, Schiff D, Patel SH, Fadul CE. The landscape of brain tumor mimics in neuro-oncology practice. J Neurooncol 2022; 159:499-508. [PMID: 35857249 DOI: 10.1007/s11060-022-04087-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Accepted: 07/02/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND OBJECTIVE Differentiating neoplastic and non-neoplastic brain lesions is essential to make management recommendations and convey prognosis, but the distinction between brain tumors and their mimics in practice may prove challenging. The aim of this study is to provide the incidence of brain tumor mimics in the neuro-oncology setting and describe this patient subset. METHODS Retrospective study of adult patients referred to the Division of Neuro-oncology for a presumed diagnosis of brain tumor from January 1, 2005 through December 31, 2017, who later satisfied the diagnosis of a non-neoplastic entity based on neuroimaging, clinical course, and/or histopathology evaluation. We classified tumor mimic entities according to clinical, radiologic, and laboratory characteristics that correlated with the diagnosis. RESULTS The incidence of brain tumor mimics was 3.4% (132/3897). The etiologies of the non-neoplastic entities were vascular (35%), inflammatory non-demyelinating (26%), demyelinating (15%), cysts (10%), infectious (9%), and miscellaneous (5%). In our study, 38% of patients underwent biopsy to determine diagnosis, but in 26%, the biopsy was inconclusive. DISCUSSION Brain tumor mimics represent a small but important subset of the neuro-oncology referrals. Vascular, inflammatory, and demyelinating etiologies represent two-thirds of cases. Recognizing the clinical, radiologic and laboratory characteristics of such entities may improve resource utilization and prevent unnecessary as well as potentially harmful diagnostic and therapeutic interventions.
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Affiliation(s)
- Lalanthica V Yogendran
- Division of Neuro-Oncology, Department of Neurology, University of Virginia, P.O. Box 800394, Charlottesville, VA, 22908, USA
| | - Tuba Kalelioglu
- Department of Radiology & Medical Imaging, University of Virginia, Charlottesville, VA, USA
| | - Joseph H Donahue
- Department of Radiology & Medical Imaging, University of Virginia, Charlottesville, VA, USA
| | - Haroon Ahmad
- Department of Neurology, University of Maryland, Baltimore, MD, USA
| | - Kester A Phillips
- Department of Neurology, The Ben and Catherine Ivy Center for Advanced Brain Tumor Treatment at Swedish Neuroscience Institute, Seattle, WA, USA
| | - Nicole M Calautti
- Division of Neuro-Oncology, Department of Neurology, University of Virginia, P.O. Box 800394, Charlottesville, VA, 22908, USA
| | - Maria-Beatriz Lopes
- Department of Pathology, Divisions of Neuropathology and Molecular Diagnostics, University of Virginia, Charlottesville, VA, USA
| | - Ashok R Asthagiri
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Benjamin Purow
- Division of Neuro-Oncology, Department of Neurology, University of Virginia, P.O. Box 800394, Charlottesville, VA, 22908, USA
| | - David Schiff
- Division of Neuro-Oncology, Department of Neurology, University of Virginia, P.O. Box 800394, Charlottesville, VA, 22908, USA
| | - Sohil H Patel
- Department of Radiology & Medical Imaging, University of Virginia, Charlottesville, VA, USA
| | - Camilo E Fadul
- Division of Neuro-Oncology, Department of Neurology, University of Virginia, P.O. Box 800394, Charlottesville, VA, 22908, USA.
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7
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French H, Fontes-Villalba A, Maharaj M, Naidoo CSY, Bhatia K, Paterson A, Cook R, Parratt J. Tumefactive multiple sclerosis versus high grade glioma: A diagnostic dilemma. Surg Neurol Int 2022; 13:146. [PMID: 35509579 PMCID: PMC9062904 DOI: 10.25259/sni_239_2022] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 03/23/2022] [Indexed: 11/04/2022] Open
Abstract
Background:
Tumefactive demyelinating lesions (TDL) share similar clinical features and magnetic resonance imaging (MRI) characteristics with high grade glioma (HGG). This study develops an approach to navigating this diagnostic dilemma, with significant treatment implications as the management of both entities is drastically different.
Methods:
A retrospective analysis of 41 TDLs and 91 HGG with respect to demographics, presentation and classical MRI characteristics was performed. A diagnostic pathway was then developed to help diagnose TDLs based on whole neuraxis MRI and cerebrospinal fluid (CSF) examination.
Results:
The diagnosis of TDL is more likely than HGG in younger females who present with subacute or chronic symptoms. MRI characteristics favoring TDL over HGG include smaller size, open rim enhancement, little or no associated edema or mass effect and the presence of a T2 hypointense rim. MRI of the whole neuraxis for detection of other lesions typical of multiple sclerosis (MS), in combination with a lumbar puncture (LP) showing positive CSF-specific oligoclonal bands (OCB), was positive in 90% of the TDL cohort.
Conclusion:
The diagnostic pathway, proposed on the basis of specific clinicoradiological features, should be followed in patients with suspected TDL. If MRI demonstrates other lesions typical of MS and LP demonstrates positive CSF-specific OCBs, then patients should undergo a short course of IV steroids to look for clinical improvement. Patients, who continue to deteriorate, do not demonstrate other lesions on MRI or where the LP is negative for CSF-specific OCB, should be considered for biopsy if safe to do so. This pathway will give the patients the best chance at neurological preservation.
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Affiliation(s)
- Heath French
- Departments of Neurosurgery, Royal North Shore Hospital, St. Leonards, New South Wales, Australia,
| | | | - Monish Maharaj
- Department of Neurosurgery, Waikato Hospital, Hamilton, New Zealand,
| | | | - Kartik Bhatia
- Department of Radiology, Children’s Hospital, Westmead,
| | - Amanda Paterson
- Department of Neurosurgery, John Hunter Hospital, New Lambton Heights, New South Wales, Australia
| | - Raymond Cook
- Departments of Neurosurgery, Royal North Shore Hospital, St. Leonards, New South Wales, Australia,
| | - John Parratt
- Neurology, Royal North Shore Hospital, St. Leonards, New South Wales, Australia,
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8
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Vakrakou AG, Brinia ME, Svolaki I, Argyrakos T, Stefanis L, Kilidireas C. Immunopathology of Tumefactive Demyelinating Lesions-From Idiopathic to Drug-Related Cases. Front Neurol 2022; 13:868525. [PMID: 35418930 PMCID: PMC8997292 DOI: 10.3389/fneur.2022.868525] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 02/18/2022] [Indexed: 11/13/2022] Open
Abstract
Tumefactive demyelinating lesions (TDL) represent a diagnostic dilemma for clinicians, and in rare atypical cases a collaboration of a neuroradiologist, a neurologist, and a neuropathologist is warranted for accurate diagnosis. Recent advances in neuropathology have shown that TDL represent an umbrella under which many different diagnostic entities can be responsible. TDL can emerge not only as part of the spectrum of classic multiple sclerosis (MS) but also can represent an idiopathic monophasic disease, a relapsing disease with recurrent TDL, or could be part of the myelin oligodendrocyte glycoprotein (MOG)- and aquaporin-4 (AQP4)-associated disease. TDL can appear during the MS disease course, and increasingly cases arise showing an association with specific drug interventions. Although TDL share common features with classic MS lesions, they display some unique features, such as extensive and widespread demyelination, massive and intense parenchymal infiltration by macrophages along with lymphocytes (mainly T but also B cells), dystrophic changes in astrocytes, and the presence of Creutzfeldt cells. This article reviews the existent literature regarding the neuropathological findings of tumefactive demyelination in various disease processes to better facilitate the identification of disease signatures. Recent developments in immunopathology of central nervous system disease suggest that specific pathological immune features (type of demyelination, infiltrating cell type distribution, specific astrocyte pathology and complement deposition) can differentiate tumefactive lesions arising as part of MS, MOG-associated disease, and AQP4 antibody-positive neuromyelitis optica spectrum disorder. Lessons from immunopathology will help us not only stratify these lesions in disease entities but also to better organize treatment strategies. Improved advances in tissue biomarkers should pave the way for prompt and accurate diagnosis of TDL leading to better outcomes for patients.
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Affiliation(s)
- Aigli G. Vakrakou
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aeginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria-Evgenia Brinia
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aeginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Ioanna Svolaki
- Department of Pathophysiology, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Leonidas Stefanis
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aeginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Constantinos Kilidireas
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aeginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
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9
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Kahovec C, Saini A, Levin MC. Diagnostic Dilemma: An Atypical Case of Astrocytoma in a Patient with Relapsing-Remitting Multiple Sclerosis. Neurol Int 2021; 13:240-251. [PMID: 34204935 PMCID: PMC8293366 DOI: 10.3390/neurolint13020025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 05/18/2021] [Accepted: 05/20/2021] [Indexed: 11/16/2022] Open
Abstract
Distinguishing between tumefactive demyelinating lesions (TDLs) and brain tumors in multiple sclerosis (MS) can be challenging. A progressive course is highly common with brain tumors in MS and no single neuroimaging technique is foolproof when distinguishing between the two. We report a case of a 41-year-old female with relapsing–remitting multiple sclerosis, who had a suspicious lesion within the left frontal hemisphere, without a progressive course. The patient experienced paresthesias primarily to her right hand but remained stable without any functional decline and new neurological symptoms over the four years she was followed. The lesion was followed with brain magnetic resonance imaging (MRI) scans, positron emission tomography–computed tomography scans, and magnetic resonance spectroscopy. Together, these scans favored the diagnosis of a TDL, but a low-grade tumor was difficult to rule out. Examination of serial brain MRI scans showed an enlarging lesion in the left middle frontal gyrus involving the deep white matter. Neurosurgery was consulted and an elective left frontal awake craniotomy was performed. Histopathology revealed a grade II astrocytoma. This case emphasizes the importance of thorough and continuous evaluation of atypical MRI lesions in MS and contributes important features to the literature for timely diagnosis and treatment of similar cases.
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Affiliation(s)
- Chantal Kahovec
- Saskatoon Multiple Sclerosis Clinic, Saskatchewan Health Authority, Saskatoon, SK S7K 0M7, Canada;
| | - Aman Saini
- Office of the Saskatchewan Multiple Sclerosis Clinical Research Chair, College of Medicine, University of Saskatchewan, Saskatoon, SK S7K 0M7, Canada;
| | - Michael C. Levin
- Saskatoon Multiple Sclerosis Clinic, Saskatchewan Health Authority, Saskatoon, SK S7K 0M7, Canada;
- Office of the Saskatchewan Multiple Sclerosis Clinical Research Chair, College of Medicine, University of Saskatchewan, Saskatoon, SK S7K 0M7, Canada;
- Department of Medicine, Neurology Division, College of Medicine, University of Saskatchewan, Saskatoon, SK S7N 0X8, Canada
- Department of Anatomy, Physiology and Pharmacology, College of Medicine, University of Saskatchewan, Saskatoon, SK S7N 5E5, Canada
- Correspondence: ; Tel.: +1-(306)-655-8350
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10
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French HD. Tumefactive multiple sclerosis versus high-grade glioma: A diagnostic dilemma. Surg Neurol Int 2021; 12:199. [PMID: 34084626 PMCID: PMC8168700 DOI: 10.25259/sni_901_2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Accepted: 03/24/2021] [Indexed: 12/28/2022] Open
Abstract
Background: Tumefactive demyelinating lesions (TDLs) share similar clinical features and MRI characteristics with high-grade glioma (HGG). This study develops an approach to navigating this diagnostic dilemma, with significant treatment implications as the management of both entities is drastically different. Methods: A retrospective analysis of 41 TDLs and 91 HGG with respect to demographics, presentation, and classical MRI characteristics was performed. A diagnostic pathway was then developed to help diagnose TDLs based on whole neuraxis MRI and cerebrospinal fluid (CSF) examination. Results: The diagnosis of TDL is more likely than HGG in younger females who present with subacute or chronic symptoms. MRI characteristics favoring TDL over HGG include smaller size, open rim enhancement, little or no associated edema or mass effect, and the presence of a T2 hypointense rim. MRI of the whole neuraxis for detection of other lesions typical of multiple sclerosis (MS), in combination with a lumbar puncture (LP) showing positive CSF-specific oligoclonal bands (OCB), was positive in 90% of the TDL cohort. Conclusion: The diagnostic pathway, proposed on the basis of specific clinicoradiological features, should be followed in patients with suspected TDL. If MRI demonstrates other lesions typical of MS and LP demonstrates positive CSF-specific OCBs, then patients should undergo a short course of IV steroids to look for clinical improvement. Patients who continue to deteriorate, do not demonstrate other lesions on MRI or where the LP is negative for CSF-specific OCB, should be considered for biopsy if safe to do so. This pathway will give the patients the best chance at neurological preservation.
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Affiliation(s)
- Heath David French
- Department of Neurosurgery, Westmead Hospital, Westmead, New South Wales, Australia
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11
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Erbay MF, Kamisli O. A case of high grade glioma following treatment of relapsing-remitting multiple sclerosis with fingolimod. Neurol India 2021; 68:478-480. [PMID: 32415029 DOI: 10.4103/0028-3886.284361] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Multiple sclerosis is a major cause of neurological disability, especially in young adults. There have been several case reports of an increased risk of cancer after long-term treatment for multiple sclerosis. Fingolimod is an immunomodulating agent used in the treatment of relapsing-remitting multiple sclerosis. The side effects commonly associated with fingolimod are cardiac side effects, macular edema, and elevated liver enzyme levels. Increased risks of infection and cancer have also been reported. High grade glioma is an aggressive primary brain tumor. There has been one case report of high grade glioma during fingolimod treatment. Here, we report the case of a 58-year-old woman diagnosed with glioblastoma multiforme after one year of fingolimod treatment for multiple sclerosis.
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Affiliation(s)
| | - Ozden Kamisli
- Department of Neurology, School of Medicine, Inonu University, Malatya, Turkey
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12
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Boziki M, Sintila SA, Ioannidis P, Grigoriadis N. Biomarkers in Rare Demyelinating Disease of the Central Nervous System. Int J Mol Sci 2020; 21:ijms21218409. [PMID: 33182495 PMCID: PMC7665127 DOI: 10.3390/ijms21218409] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 11/06/2020] [Accepted: 11/07/2020] [Indexed: 12/29/2022] Open
Abstract
Rare neurological diseases are a heterogeneous group corresponding approximately to 50% of all rare diseases. Neurologists are among the main specialists involved in their diagnostic investigation. At the moment, a consensus guideline on which neurologists may base clinical suspicion is not available. Moreover, neurologists need guidance with respect to screening investigations that may be performed. In this respect, biomarker research has emerged as a particularly active field due to its potential applications in clinical practice. With respect to autoimmune demyelinating diseases of the Central Nervous System (CNS), although these diseases occur in the frame of organ-specific autoimmunity, pathology of the disease itself is orchestrated among several anatomical and functional compartments. The differential diagnosis is broad and includes, but is not limited to, rare neurological diseases. Multiple Sclerosis (MS) needs to be differentially diagnosed from rare MS variants, Acute Disseminated Encephalomyelitis (ADEM), the range of Neuromyelitis Optica Spectrum Disorders (NMOSDs), Myelin Oligodendrocyte Glycoprotein (MOG) antibody disease and other systemic inflammatory diseases. Diagnostic biomarkers may facilitate timely diagnosis and proper disease management, preventing disease exacerbation due to misdiagnosis and false treatment. In this review, we will describe advances in biomarker research with respect to rare neuroinflammatory disease of the CNS.
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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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Vakrakou AG, Tzanetakos D, Argyrakos T, Koutsis G, Evangelopoulos ME, Andreadou E, Anagnostouli M, Breza M, Tzartos JS, Gialafos E, Dimitrakopoulos AN, Velonakis G, Toulas P, Stefanis L, Kilidireas C. Recurrent Fulminant Tumefactive Demyelination With Marburg-Like Features and Atypical Presentation: Therapeutic Dilemmas and Review of Literature. Front Neurol 2020; 11:536. [PMID: 32714265 PMCID: PMC7344179 DOI: 10.3389/fneur.2020.00536] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 05/14/2020] [Indexed: 12/31/2022] Open
Abstract
Atypical forms of demyelinating diseases with tumor-like lesions and aggressive course represent a diagnostic and therapeutic challenge for neurologists. Herein, we describe a 50-year-old woman presenting with subacute onset of left hemiparesis, memory difficulties and headache. Brain MRI revealed a tumefactive right frontal-parietal lesion with perilesional edema, mass effect and homogenous post-contrast enhancement, along with other small atypical lesions in the white-matter. Brain biopsy of cerebral lesion ruled out lymphoma or any other neoplastic process and patient placed on corticosteroids with complete clinical/radiological remission. Two years after disease initiation, there was disease exacerbation with reappearance of the tumor-like mass. The patient initially responded to high doses of corticosteroids but soon became resistant. Plasma-exchange sessions were not able to limit disease burden. Resistance to therapeutic efforts led to a second biopsy that showed perivascular demyelination, predominantly consisting of macrophages, with a small number of T and B lymphocytes, and the presence of reactive astrocytes, typical of Creutzfeldt-Peters cells. The patient received high doses of cyclophosphamide with substantial clinical/radiological response but relapsed after 7-intensive cycles. She received 4-weekly doses of rituximab with disease exacerbation and brainstem involvement. She eventually died with complicated pneumonia. We present a very rare case of recurrent tumefactive demyelinating lesions, with atypical tumor-like characteristics, with initial response to corticosteroids and cyclophosphamide, but subsequent development of drug-resistance and unexpected exacerbation upon rituximab administration. Our clinical case raises therapeutic dilemmas and points to the need for immediate and appropriate immunosuppression in difficult to treat tumefactive CNS lesions with Marburg-like features.
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Affiliation(s)
- Aigli G Vakrakou
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aeginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Tzanetakos
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aeginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Georgios Koutsis
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aeginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria-Eleptheria Evangelopoulos
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aeginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Elisabeth Andreadou
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aeginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria Anagnostouli
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aeginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Marianthi Breza
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aeginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - John S Tzartos
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aeginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Elias Gialafos
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aeginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Antonios N Dimitrakopoulos
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aeginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Georgios Velonakis
- Research Unit of Radiology, 2nd Department of Radiology, National and Kapodistrian University of Athens, Athens, Greece
| | - Panagiotis Toulas
- Research Unit of Radiology, 2nd Department of Radiology, National and Kapodistrian University of Athens, Athens, Greece
| | - Leonidas Stefanis
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aeginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Constantinos Kilidireas
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aeginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
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Plantone D, Piantadosi C, Ruggieri S, Anelli V, Koudriavtseva T. Tumefactive Demyelinating Lesions and Pregnancy. Neurol India 2020; 67:1519-1521. [PMID: 31857550 DOI: 10.4103/0028-3886.273654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Until now, only one gestational tumefactive demyelinating lesion (TDL) has been described. Here we report two TDL cases occurring during and after the pregnancy. A 26-year-old 6-week pregnant woman developed a 3-cm left frontotemporoparietal subcortical TDL with inhomogeneous partial enhancement. Brain biopsy revealed a subacute demyelinating lesion with abundant macrophages and mild chronic perivascular inflammatory infiltrates. She also had femoralpopliteal deep vein thrombosis. During the 4-year follow-up, magnetic resonance imaging showed only residual biopsied TDL. The second case was a 41-year-woman affected by both multiple sclerosis (MS) and rheumatoid arthritis who developed a 2-cm right anterior corona radiata TDL with sporadic gadolinium-enhancing "annular spots" eight months after delivery. After steroid therapy at the 6-month radiological follow-up, this TDL was half-reduced. Five years earlier, at the beginning of her MS, she already had a 2-cm TDL with incomplete ring enhancement. These two described TDLs formed in prothrombotic conditions and were likely representative of thromboinflammation around and inside the small-medium veins.
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Affiliation(s)
- Domenico Plantone
- S.O.C. Neurologia, Ospedale San Biagio, Piazza Vittime dei Lager Nazifascisti 1, 28845, Domodossola (VB), Italy
| | - Carlo Piantadosi
- UOC Neurology, San Giovanni-Addolorata Hospital, Via dell'Amba Aradam 9, 00184, Rome, Italy
| | - Serena Ruggieri
- Department of Neurology and Psychiatry, Sapienza University, Viale dell'Università 30, 00185, Rome, Italy
| | - Vincenzo Anelli
- Department of Research, Advanced Diagnostics and Technological Innovation, IRCCS Regina Elena National Cancer Institute, IFO, Via Elio Chianesi 53, 00144, Rome, Italy
| | - Tatiana Koudriavtseva
- Department of Clinical Experimental Oncology, IRCCS Regina Elena National Cancer Institute, IFO, Via Elio Chianesi 53, 00144, Rome, Italy
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16
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Don’t Judge a Book by Its Cover: A Clinical Neuropathological Conference Case. Can J Neurol Sci 2020. [DOI: 10.1017/cjn.2020.21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Abstract
We aim to review the imaging appearance of fulminant demyelinating disorders of central nervous system that have different pathological features, clinical course, clinical features, and imaging findings different from classic multiple sclerosis. Routine magnetic resonance imaging (MRI) can help in accurate localization of the lesions, detection of associated lesions, and monitoring of these patients. Advanced MRI combined with routine MRI can aid in differentiation fulminant demyelinating lesions from simulating malignancy. Tumefactive demyelination lesions are located in supratentorial white matter mainly frontal and parietal regions with incomplete rim enhancement. Baló concentric sclerosis shows characteristic concentric onion skin appearance. Schilder disease is subacute or acute demyelinating disorders with one or more lesions commonly involving the centrum semiovale. Marburg disease is the most severe demyelinating disorder with diffuse infiltrative lesions and massive edema involving both the cerebral hemisphere and brain stem.
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Eckel-Passow JE, Decker PA, Kosel ML, Kollmeyer TM, Molinaro AM, Rice T, Caron AA, Drucker KL, Praska CE, Pekmezci M, Hansen HM, McCoy LS, Bracci PM, Erickson BJ, Lucchinetti CF, Wiemels JL, Wiencke JK, Bondy ML, Melin B, Burns TC, Giannini C, Lachance DH, Wrensch MR, Jenkins RB. Using germline variants to estimate glioma and subtype risks. Neuro Oncol 2019; 21:451-461. [PMID: 30624711 PMCID: PMC6422428 DOI: 10.1093/neuonc/noz009] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Twenty-five single nucleotide polymorphisms (SNPs) are associated with adult diffuse glioma risk. We hypothesized that the inclusion of these 25 SNPs with age at diagnosis and sex could estimate risk of glioma as well as identify glioma subtypes. METHODS Case-control design and multinomial logistic regression were used to develop models to estimate the risk of glioma development while accounting for histologic and molecular subtypes. Case-case design and logistic regression were used to develop models to predict isocitrate dehydrogenase (IDH) mutation status. A total of 1273 glioma cases and 443 controls from Mayo Clinic were used in the discovery set, and 852 glioma cases and 231 controls from UCSF were used in the validation set. All samples were genotyped using a custom Illumina OncoArray. RESULTS Patients in the highest 5% of the risk score had more than a 14-fold increase in relative risk of developing an IDH mutant glioma. Large differences in lifetime absolute risk were observed at the extremes of the risk score percentile. For both IDH mutant 1p/19q non-codeleted glioma and IDH mutant 1p/19q codeleted glioma, the lifetime risk increased from almost null to 2.3% and almost null to 1.7%, respectively. The SNP-based model that predicted IDH mutation status had a validation concordance index of 0.85. CONCLUSIONS These results suggest that germline genotyping can provide new tools for the initial management of newly discovered brain lesions. Given the low lifetime risk of glioma, risk scores will not be useful for population screening; however, they may be useful in certain clinically defined high-risk groups.
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Affiliation(s)
| | - Paul A Decker
- Division of Biomedical Statistics & Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - Matt L Kosel
- Division of Biomedical Statistics & Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - Thomas M Kollmeyer
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Annette M Molinaro
- Department of Neurological Surgery, University of California San Francisco (UCSF), San Francisco, California, USA
- Department of Epidemiology and Biostatistics, UCSF, San Francisco, California, USA
| | - Terri Rice
- Department of Neurological Surgery, University of California San Francisco (UCSF), San Francisco, California, USA
| | - Alissa A Caron
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kristen L Drucker
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Corinne E Praska
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Melike Pekmezci
- Department of Pathology, UCSF, San Francisco, California, USA
| | - Helen M Hansen
- Department of Neurological Surgery, University of California San Francisco (UCSF), San Francisco, California, USA
| | - Lucie S McCoy
- Department of Neurological Surgery, University of California San Francisco (UCSF), San Francisco, California, USA
| | - Paige M Bracci
- Department of Epidemiology and Biostatistics, UCSF, San Francisco, California, USA
| | | | | | - Joseph L Wiemels
- Center for Genetic Epidemiology, University of Southern California, Los Angeles, California, USA
| | - John K Wiencke
- Department of Neurological Surgery, University of California San Francisco (UCSF), San Francisco, California, USA
- Department of Epidemiology and Biostatistics, UCSF, San Francisco, California, USA
- Institute of Human Genetics, UCSF, San Francisco, California, USA
| | - Melissa L Bondy
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Beatrice Melin
- Department of Radiation Sciences, Faculty of Medicine, Umeå University, Umeå, Sweden
| | - Terry C Burns
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Caterina Giannini
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Daniel H Lachance
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Margaret R Wrensch
- Department of Neurological Surgery, University of California San Francisco (UCSF), San Francisco, California, USA
- Department of Epidemiology and Biostatistics, UCSF, San Francisco, California, USA
- Institute of Human Genetics, UCSF, San Francisco, California, USA
| | - Robert B Jenkins
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
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Silent Tumefactive Demyelinating Lesions and Radiologically Isolated Syndrome. Case Rep Neurol Med 2019; 2018:8409247. [PMID: 30622825 PMCID: PMC6304209 DOI: 10.1155/2018/8409247] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Accepted: 11/15/2018] [Indexed: 11/24/2022] Open
Abstract
Demyelinating lesions larger than 2 cm in diameter, with or without edema, are known as tumefactive demyelinating lesions (TDLs). They constitute a rare inflammatory demyelinating disorder of the central nervous system. TDLs are typically characterized by headaches, cortical symptoms such as aphasia, hemiparesis, hemisensory deficits, seizures, and changes in consciousness. TDLs may occur in patients with or without an established diagnosis of MS or may occur as the initial demyelinating event. They may also be observed during follow-up in patients with MS, neuromyelitis optica, acute disseminated encephalomyelitis, or other autoimmune diseases. Differential diagnosis includes brain tumors, abscess, granulomatous diseases, and vasculitis. In some cases, it may be very difficult to distinguish TDLs from a tumor, such that biopsy might be needed. However, no cases of asymptomatic TDLs have yet been reported in the literature. Hence, in this report, we present a case involving an asymptomatic TDL detected incidentally during magnetic resonance imaging in an 18-year-old man. The patient did not develop any symptoms during the 1-year follow-up period. During follow-up, the patient was diagnosed with a radiologically isolated syndrome. TDLs have not previously been identified as radiologically isolated syndrome. Thus, reporting similar cases in the future will help in further understanding this phenomenon.
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20
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Yoon RG, Kim HS, Hong GS, Park JE, Jung SC, Kim SJ, Kim JH. Joint approach of diffusion- and perfusion-weighted MRI in intra-axial mass like lesions in clinical practice simulation. PLoS One 2018; 13:e0202891. [PMID: 30192785 PMCID: PMC6128539 DOI: 10.1371/journal.pone.0202891] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Accepted: 08/10/2018] [Indexed: 11/18/2022] Open
Abstract
Although advanced magnetic resonance imaging (MRI) techniques provide useful information for the differential diagnosis of intra-axial mass-like lesions, the specific diagnostic role of multimodal MRI over conventional magnetic resonance imaging (CMRI) alone in the differential diagnosis of mass-like lesions from a large heterogeneous cohort has not been studied. In this study, we aimed to determine the added value of a joint approach of diffusion-weighted imaging (DWI) and dynamic-susceptibility-contrast perfusion imaging (DSC-PWI) for diagnosis of intra-axial mass-like lesions, comparing them with CMRI alone. Furthermore, we performed these evaluations in a manner simulating clinical practice. Our institutional review board approved this retrospective study and waived the requirement for informed consent. A total of 1038 patients with intra-axial mass-like lesions were retrospectively recruited according to their histological and clinico-radiological diagnoses made between January 2005 and December 2014. All patients underwent CMRI, DWI and DSC-PWI. The diagnostic accuracy and confidence in diagnosing each type of intra-axial mass-like lesions, and for differentiating the intra-axial brain tumors from non-neoplastic lesions, were compared according to the MRI protocols. The disease-specific sensitivity of joint approach differed according to specific disease entities in diagnosing each disease category. Joint approach provided the best diagnostic accuracy for discriminating intra-axial brain tumors from non-neoplastic lesions, with high diagnostic accuracy (95.3–96.7%), specificity (82–84.0%), positive-predictive-value (97.0–97.3%), and negative-predictive-value (84.8–92.7%), with the reader’s confidence values being significantly improved over those on CMRI alone (all p-values < 0.001). In conclusion, joint approach of DWI, DSC-PWI to CMRI helps to differentiate non-neoplastic lesions from intra-axial brain tumors, and improves diagnostic confidence compared with CMRI alone. The benefit from the combined imaging differs for each disease category; thus joint approach needs to be customized according to clinical suspicion.
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Affiliation(s)
- Ra Gyoung Yoon
- Department of Radiology, Eulji Medical Center, Eulji University College of Medicine, Seoul, Korea
| | - Ho Sung Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
- * E-mail:
| | - Gil Sun Hong
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Ji Eun Park
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Seung Chai Jung
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Sang Joon Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Jeong Hoon Kim
- Department of Neurosurgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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21
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Shirani A, Wu GF, Giannini C, Cross AH. A case of oligodendroglioma and multiple sclerosis: Occam's razor or Hickam's dictum? BMJ Case Rep 2018; 2018:bcr-2018-225318. [PMID: 29954769 DOI: 10.1136/bcr-2018-225318] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Tumefactive appearing lesions on brain imaging can cause a diagnostic dilemma. We report a middle-aged man who presented with right-sided optic neuritis. A brain MRI showed enhancement of the right optic nerve, and non-enhancing white matter lesions including a 3 cm right frontal lesion with adjacent gyral expansion. Cerebrospinal fluid analysis showed five oligoclonal bands not present in serum. Glatiramer acetate was started for suspected tumefactive multiple sclerosis (MS). A follow-up brain MRI 6 months later showed persistence of the frontal gyral expansion. A brain biopsy led to the diagnosis of an oligodendroglioma, isocitrate dehydrogenase-mutant and 1 p/19q co-deleted (WHO grade II), managed with surgical resection and radiotherapy. Postoperative brain MRI showed a new enhancing periventricular lesion, making the choice of optimal disease-modifying therapy for MS challenging. This case highlights the possibility of coexistence of MS and oligodendroglioma, and emphasises the importance of a tissue diagnosis when atypical MS imaging features are present.
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Affiliation(s)
- Afsaneh Shirani
- Department of Neurology, Washington University in Saint Louis School of Medicine, St Louis, Missouri, USA
| | - Gregory F Wu
- Department of Neurology, Washington University in Saint Louis School of Medicine, St Louis, Missouri, USA
| | - Caterina Giannini
- Department of Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, USA
| | - Anne H Cross
- Department of Neurology, Washington University in Saint Louis School of Medicine, St Louis, Missouri, USA
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23
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A possible role of impaired cell-mediated immunity in the pathogenesis of tumefactive demyelinating lesions. Mult Scler Relat Disord 2017; 18:184-185. [DOI: 10.1016/j.msard.2017.10.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 10/06/2017] [Accepted: 10/08/2017] [Indexed: 12/20/2022]
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Toth GB, Varallyay CG, Horvath A, Bashir MR, Choyke PL, Daldrup-Link HE, Dosa E, Finn JP, Gahramanov S, Harisinghani M, Macdougall I, Neuwelt A, Vasanawala SS, Ambady P, Barajas R, Cetas JS, Ciporen J, DeLoughery TJ, Doolittle ND, Fu R, Grinstead J, Guimaraes AR, Hamilton BE, Li X, McConnell HL, Muldoon LL, Nesbit G, Netto JP, Petterson D, Rooney WD, Schwartz D, Szidonya L, Neuwelt EA. Current and potential imaging applications of ferumoxytol for magnetic resonance imaging. Kidney Int 2017; 92:47-66. [PMID: 28434822 PMCID: PMC5505659 DOI: 10.1016/j.kint.2016.12.037] [Citation(s) in RCA: 212] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Revised: 11/17/2016] [Accepted: 12/06/2016] [Indexed: 01/18/2023]
Abstract
Contrast-enhanced magnetic resonance imaging is a commonly used diagnostic tool. Compared with standard gadolinium-based contrast agents, ferumoxytol (Feraheme, AMAG Pharmaceuticals, Waltham, MA), used as an alternative contrast medium, is feasible in patients with impaired renal function. Other attractive imaging features of i.v. ferumoxytol include a prolonged blood pool phase and delayed intracellular uptake. With its unique pharmacologic, metabolic, and imaging properties, ferumoxytol may play a crucial role in future magnetic resonance imaging of the central nervous system, various organs outside the central nervous system, and the cardiovascular system. Preclinical and clinical studies have demonstrated the overall safety and effectiveness of this novel contrast agent, with rarely occurring anaphylactoid reactions. The purpose of this review is to describe the general and organ-specific properties of ferumoxytol, as well as the advantages and potential pitfalls associated with its use in magnetic resonance imaging. To more fully demonstrate the applications of ferumoxytol throughout the body, an imaging atlas was created and is available online as supplementary material.
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Affiliation(s)
- Gerda B Toth
- Department of Neurology, Oregon Health & Science University, Portland, Oregon, USA
| | - Csanad G Varallyay
- Department of Radiology, Oregon Health & Science University, Portland, Oregon, USA
| | - Andrea Horvath
- Department of Neurology, Oregon Health & Science University, Portland, Oregon, USA
| | - Mustafa R Bashir
- Department of Radiology, Duke University Medical Center, 3808, Durham, North Carolina, USA; Center for Advanced Magnetic Resonance Development, Duke University Medical Center, Durham, North Carolina, USA
| | - Peter L Choyke
- Molecular Imaging Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Heike E Daldrup-Link
- Department of Radiology, Section of Pediatric Radiology, Lucile Packard Children's Hospital, Stanford University, 725 Welch Rd, Stanford, California, USA
| | - Edit Dosa
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - John Paul Finn
- Department of Radiological Sciences, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Seymur Gahramanov
- Department of Neurosurgery, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
| | - Mukesh Harisinghani
- Department of Radiology, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Iain Macdougall
- Department of Renal Medicine, King's College Hospital, London, UK
| | - Alexander Neuwelt
- Division of Medical Oncology, University of Colorado Denver, Aurora, Colorado, USA
| | | | - Prakash Ambady
- Department of Neurology, Oregon Health & Science University, Portland, Oregon, USA
| | - Ramon Barajas
- Department of Radiology, Oregon Health & Science University, Portland, Oregon, USA
| | - Justin S Cetas
- Department of Neurosurgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Jeremy Ciporen
- Department of Neurosurgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Thomas J DeLoughery
- Department of Hematology and Medical Oncology, Oregon Health & Science University, Portland, Oregon, USA
| | - Nancy D Doolittle
- Department of Neurology, Oregon Health & Science University, Portland, Oregon, USA
| | - Rongwei Fu
- School of Public Health, Oregon Health & Science University, Portland, Oregon, USA; Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon, USA
| | | | | | - Bronwyn E Hamilton
- Department of Radiology, Oregon Health & Science University, Portland, Oregon, USA
| | - Xin Li
- Advanced Imaging Research Center, Oregon Health & Science University, Portland, Oregon, USA
| | - Heather L McConnell
- Department of Neurology, Oregon Health & Science University, Portland, Oregon, USA
| | - Leslie L Muldoon
- Department of Neurology, Oregon Health & Science University, Portland, Oregon, USA
| | - Gary Nesbit
- Department of Radiology, Oregon Health & Science University, Portland, Oregon, USA
| | - Joao P Netto
- Department of Neurology, Oregon Health & Science University, Portland, Oregon, USA; Department of Radiology, Oregon Health & Science University, Portland, Oregon, USA
| | - David Petterson
- Department of Radiology, Oregon Health & Science University, Portland, Oregon, USA
| | - William D Rooney
- Advanced Imaging Research Center, Oregon Health & Science University, Portland, Oregon, USA
| | - Daniel Schwartz
- Department of Neurology, Oregon Health & Science University, Portland, Oregon, USA; Advanced Imaging Research Center, Oregon Health & Science University, Portland, Oregon, USA
| | - Laszlo Szidonya
- Department of Neurology, Oregon Health & Science University, Portland, Oregon, USA
| | - Edward A Neuwelt
- Department of Neurology, Oregon Health & Science University, Portland, Oregon, USA; Department of Neurosurgery, Oregon Health & Science University, Portland, Oregon, USA; Portland Veterans Affairs Medical Center, Portland, Oregon, USA.
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25
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Algahtani H, Shirah B, Alassiri A. Tumefactive demyelinating lesions: A comprehensive review. Mult Scler Relat Disord 2017; 14:72-79. [DOI: 10.1016/j.msard.2017.04.003] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2017] [Revised: 03/17/2017] [Accepted: 04/07/2017] [Indexed: 12/29/2022]
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Tarkkonen A, Rissanen E, Tuokkola T, Airas L. Utilization of PET imaging in differential diagnostics between a tumefactive multiple sclerosis lesion and low-grade glioma. Mult Scler Relat Disord 2016; 9:147-9. [PMID: 27645363 DOI: 10.1016/j.msard.2016.07.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Revised: 07/25/2016] [Accepted: 07/25/2016] [Indexed: 10/21/2022]
Abstract
We present a case where a 30-year-old man with a history of combined MS and Charcot-Marie-Tooth (CMT I) disease was additionally diagnosed and treated for grade II glioma (astrocytoma). Tumefactive MS and gliomas are sometimes difficult to distinguish from one another based on conventional magnetic resonance imaging (MRI). In our case, positron emission tomography (PET) scans with(11)C-methionine ((11)C-MET) and (11)C-PK11195 radioligands were performed to aid in differential diagnostics. The diagnosis was confirmed finally by brain biopsy. The usefulness of PET imaging in differential diagnostics between tumefactive MS and glioma is discussed.
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Affiliation(s)
- Aleksi Tarkkonen
- Division of Clinical Neurosciences, Turku University Hospital and University of Turku, Turku, Finland.
| | - Eero Rissanen
- Division of Clinical Neurosciences, Turku University Hospital and University of Turku, Turku, Finland; Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland
| | - Terhi Tuokkola
- Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland
| | - Laura Airas
- Division of Clinical Neurosciences, Turku University Hospital and University of Turku, Turku, Finland; Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland
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27
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Chiavazza C, Cistaro A, Fania P, Bertolotto A, Cavalla P, Rudà R, Pinessi L, Soffietti R. Reversible disconnection syndrome in a case of acute tumefactive demyelinating lesion: a PET study. Neurol Sci 2016; 37:2019-2023. [PMID: 27457655 DOI: 10.1007/s10072-016-2675-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Accepted: 07/18/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Carlotta Chiavazza
- Department of Neurosciences, Multiple Sclerosis Center, University and A.O.U. City of Health and Science, Via Cherasco 15, 10126, Turin, Italy.
| | - Angelina Cistaro
- Positron Emission Tomography Center IRMET S.p.A., Euromedic Inc., Turin, Italy
- Institute of Cognitive Sciences and Technologies, National Research Council, Rome, Italy
| | - Piercarlo Fania
- Positron Emission Tomography Center IRMET S.p.A., Euromedic Inc., Turin, Italy
| | - Antonio Bertolotto
- Regional Multiple Sclerosis Center, San Luigi Gonzaga Hospital, Orbassano, Italy
| | - Paola Cavalla
- Department of Neurosciences, Multiple Sclerosis Center, University and A.O.U. City of Health and Science, Via Cherasco 15, 10126, Turin, Italy
| | - Roberta Rudà
- Department of Neuro-Oncology, University and A.O.U. City of Health and Science, Turin, Italy
| | - Lorenzo Pinessi
- Department of Neurosciences, Multiple Sclerosis Center, University and A.O.U. City of Health and Science, Via Cherasco 15, 10126, Turin, Italy
| | - Riccardo Soffietti
- Department of Neuro-Oncology, University and A.O.U. City of Health and Science, Turin, Italy
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