Multiple Large Tumefactive MS Plaques in a Young Man: A Diagnostic Enigma and Therapeutic Challenge

Tumefactive Demyelinating Lesions in Children: A Rare Case of Conus Medullaris Involvement and Systematic Review of the Literature

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.

Synchronous Presentation of a Cervical Spinal Schwannoma and Primary Progressive Multiple Sclerosis in a 65-year-old Man

Schwannomas are common benign neoplasms of the myelinating cells surrounding peripheral nerve axons. Though uncommon, lesions arising in the cervical spine may produce radicular pain and myelopathic weakness. Multiple sclerosis (MS) is a common autoimmune disorder with the capacity to mimic nearly any neurologic disease, including spinal cord neoplasms. We report the third case of synchronously presenting primary progressive MS and spinal schwannoma.

A 65-year-old man presented with six months of progressive weakness and pain of the right shoulder, forearm, and hand. MRI demonstrated a contrast-enhancing transforaminal lesion at C7, most consistent with a benign nerve sheath tumor. Additional history disclosed several years of worsening fatigue, accompanied by bilateral weakness and lancinating leg pain. MRI of the neuraxis demonstrated abnormalities consistent with chronic demyelinating disease intracranially and within the spinal cord; cerebrospinal fluid (CSF) analysis revealed nine oligoclonal bands and an elevated IgG index, resulting in the diagnosis of MS. Given the symptomatic C7 lesion, the patient subsequently underwent right C6-C7 facetectomy, gross total resection of the tumor, and C6-T1 posterior instrumented fusion. Postoperatively, the patient rapidly recovered normal right upper extremity function, and pathology confirmed benign schwannoma.

Synchronously presenting co-morbid neurologic diagnoses are exceedingly rare. Nonetheless, the high incidence and protean nature of MS make it particularly susceptible to such confounding clinical cases. Correspondingly, MS should be considered when neurologic abnormalities are not compatible with a focal radiographic lesion, and the present report emphasizes the value of a good history and exam in unraveling similarly challenging cases.

Tumefactive Multiple Sclerosis, A Rare Variant Presenting as Multiple Ring-enhancing Lesions in an Immunocompetent Patient: A Case Report

Tumefactive multiple sclerosis (TMS) is a rare entity which can be difficult to diagnose unless definitive diagnostic measures are taken. TMS is characterized by solitary or multiple lesions that are sized > 2 cm, with/without mass effect, edema, and ring enhancement on magnetic resonance imaging (MRI). The demyelinating lesion can mimic infections, vascular lesions, and inflammatory lesions. The clinical presentation is highly dependent on the area of the brain which is affected, and this can lead to a variety of signs and symptoms. Herein, we present the case of a 40-year-old immunocompetent female with a history of right-sided numbness of her face, arm, and leg associated with muscle weakness for about a week. Workup included an MRI showing ring-enhancing lesions in the white matter of the brain, zero oligoclonal bands in the CSF, a normal immunoglobulin G (IgG) index, and an elevated myelin basic protein (MBP) in the CSF. A biopsy was obtained that showed predominant macrophage infiltrate with loss of myelin but the preservation of axons. Suspecting a demyelinating pathology, the patient was informed that she would be started on intravenous dexamethasone for an eight-day course. With subsequent completion of this course in the hospital, the patient was discharged on oral prednisone daily for a month and a referral leading to a definitive diagnosis of TMS. The patient was started on interferon beta-1a and subsequently relapsed due to noncompliance. However, further workup showed a reduction in the mass-like lesions and a response to therapy. If suspicion for TMS is high despite workup, steroids can be used with immunomodulators in the interim to combat symptoms and potentially reduce lesions and potentially subvert the need for biopsy.

Coexistence of Multiple Sclerosis and Brain Tumor: An Uncommon Diagnostic Challenge

Nonneoplastic demyelinating processes of the brain with mass effect on magnetic resonance imaging can cause diagnostic difficulties. It requires differential diagnosis between the tumefactive demyelinating lesion and the coexistence of neoplasm. We document the case of 41-year-old woman with clinical and radiological findings suggestive of multiple sclerosis. Additional investigations confirmed the coexistence of astrocytoma. This report emphasizes the importance of considering brain tumors in the differential diagnosis of primary demyelinating disease presenting with a cerebral mass lesion.

Is size an essential criterion to define tumefactive plaque? MR features and clinical correlation in multiple sclerosis

Tumefactive multiple sclerosis is an inflammatory demyelinating disease of the central nervous system. It has recently been described as a rare subtype of multiple sclerosis (MS) characterised by the appearance of solitary or multiple space-occupying lesions associated with imaging characteristics mimicking neoplasm. Atypical features include plaque size >2 cm with mass effect, oedema, and/or ring enhancement on magnetic resonance (MR) images.This study is a retrospective review designed to evaluate the prevalence of tumefactive plaques in a selected population of 440 MS patients referred to our MS centre in Southern Italy between 2005 and 2014. We analysed the radiographic features of lesions ranging in size from 0.5 to 2 cm to establish whether smaller plaques with MR characteristics similar to tumefactive plaques present different symptoms, disease evolution and prognosis. We also aimed to ascertain if MR features suggestive of biological aggressiveness could be useful prognostic criteria for a correct diagnosis of the disease and subsequent treatment. Our data suggest that lesions 0.5-2 cm and >2 cm have similar MR features and clinical evolution.

Recurrent tumefactive demyelination: An unusual presentation

Tumefactive multiple sclerosis (MS) is a rare variant of MS characterized by the presence of large demyelinating plaques of more than 2 cm, identified with magnetic resonance imaging (MRI). Distinguishing tumefactive lesions from other etiologies of intracranial space occupying lesions is necessary to avoid the inadvertent intervention. We had a 14-year-old girl who presented to us with two episodes of subacute hemiparesis over a span of 6 months. Her MRI brain showed large lesions, which were hyperintense on T2-weighted/flair images with incomplete ring enhancement open towards the gray matter in postgadolinium images with minimal surrounding edema and mass effect. We treated her as a case of tumefactive demyelination (TD) with steroids after which patient recovered with minimal deficits. TD occurs more commonly in women and young adults and is reported rarely. TD in a young girl with recurrence in such short span causing bilateral hemiparesis has never been reported.

A rare presentation of atypical demyelination: tumefactive multiple sclerosis causing Gerstmann's syndrome

Background

Tumefactive demyelinating lesions are a rare manifestation of multiple sclerosis (MS). Differential diagnosis of such space occupying lesions may not be straightforward and sometimes necessitate brain biopsy. Impaired cognition is the second most common clinical manifestation of tumefactive MS; however complex cognitive syndromes are unusual.

Case presentation

We report the case of a 30 year old woman who presented with Gerstmann’s syndrome. MRI revealed a large heterogeneous contrast enhancing lesion in the left cerebral hemisphere. Intravenous corticosteroids did not stop disease progression. A tumour or cerebral lymphoma was suspected, however brain biopsy confirmed inflammatory demyelination. Following diagnosis of tumefactive MS treatment with natalizumab effectively suppressed disease activity.

Conclusions

The case highlights the need for clinicians, radiologists and surgeons to appreciate the heterogeneous presentation of tumefactive MS. Early brain biopsy facilitates rapid diagnosis and management. Treatment with natalizumab may be useful in cases of tumefactive demyelination where additional evidence supports a diagnosis of relapsing MS.

Tumefactive demyelination: an unusual cause of a spontaneously resolving homonymous hemianopia

A 21-year-old man presented to eye casualty complaining of altered vision associated with headache and vomiting upon waking. Clinical examination was unremarkable except for a right-sided homonymous hemianopia. The MRI scan of the brain revealed a space occupying lesion within the occipital lobe and MR spectroscopy highlighted this to be inflammatory in nature, most likely a tumefactive demyelinating lesion (TDL). Lumbar puncture displayed positive oligoclonal bands. The patient was managed conservatively and made a full recovery, with normal visual fields recorded after a 3 month follow-up. This is a case of a TDL manifesting itself as an unusual cause of homonymous hemianopia; misdiagnosis of TDL is common and potentially damaging to the patient.

Neuroimaging of tumefactive multiple sclerosis with atypical features

Tumefactive demyelinating lesions or tumefactive multiple sclerosis (TMS) constitute a unique presentation of demyelinating disease that frequently mimics intracranial neoplasm, infection or other, nondemyelinating intracranial pathology. Consequently, these lesions, which are larger than typical multiple sclerosis plaques and are generally characterized by certain MRI features including edema and incomplete ring enhancement, pose a serious diagnostic challenge that frequently prompts biopsy in initial evaluation. Biopsy can be averted when imaging features for TMS are seen on MRI. We present a biopsy-proven case of TMS with atypical imaging features, evaluated using MRI and diffusion-tensor imaging.