Skip to main content
AAN.com
Clinical and Ethical Challenges
February 18, 2013

Restricted diffusion preceding gadolinium enhancement in large or tumefactive demyelinating lesions

February 2013 issue
3 (1) 15-21

Summary

Although restricted diffusion without coincident contrast enhancement is most commonly associated with cerebral ischemia, large or tumefactive multiple sclerosis (MS) lesions may demonstrate this pattern initially, followed by subsequent gadolinium (Gd) enhancement. The clinical and MRI characteristics of 3 patients with MS with this imaging pattern are reviewed. All patients had brain MRI lesions >1 cm in diameter, in locations consistent with new neurologic symptoms, and with prominent restricted diffusion but no Gd enhancement. Demyelinating lesion etiologies were supported by CSF findings, laboratory exclusion of alternative diagnoses, lesion evolution, or additional lesions characteristic of MS on brain MRI. Follow-up imaging within 2–4 weeks showed decreased restricted diffusion with patchy Gd enhancement which resolved on subsequent imaging. This imaging evolution may reflect early demyelination prior to inflammation-associated blood–brain barrier disruption.

Get full access to this article

View all available purchase options and get full access to this article.

REFERENCES

1.
Schaefer PW, Grant PE, Gonzalez RG. Diffusion-weighted MR imaging of the brain. Radiology 2000;217:331–345.
2.
Rovira A, Pericot I, Alonso J, et al. Serial diffusion-weighted MR imaging and Proton MR spectroscopy of acute large demyelinating brain lesions: case report. Am J Neuroradiol 2002;23:989–994.
3.
Gass A, Niendorf T, Hirsch JG. Acute and chronic changes of the apparent diffusion coefficient in neurological disorders: biophysical mechanisms and possible underlying histopathology. J Neurol Sci 2001;186:S15–S23.
4.
Balashov KE, Lindzen E. Acute demyelinating lesions with restricted diffusion in multiple sclerosis. Mult Scler 2012;18:1–9.
5.
Bugnicourt JM, Garcia PY, Monet P, et al. Marked reduced apparent diffusion coefficient in acute multiple sclerosis lesion. Neurology 2010;e87.
6.
Rosso C, Remy P, Creange A, et al. Diffusion-weighted MR imaging characteristics of an acute strokelike form of multiple sclerosis. Am J Neuroradiol 2006;27:1006–1008.
7.
Balashov KE, Aung LL, Dhib-Jalbut S, et al. Acute multiple sclerosis lesion: conversion of restricted diffusion due to vasogenic edema. J Neuroimaging 2011;21:202–204.
8.
Zeid NA, Pirko I, Erickson B, et al. Diffusion-weighted imaging characteristics of biopsy-proven demyelinating brain lesions. Neurology 2012;78:1655–1662.
9.
Werring DJ, Brassat D, Droogan AG, et al. The pathogenesis of lesions and normal-appearing white matter changes in multiple sclerosis: a serial diffusion MRI study. Brain 2000;123:1667–1676.
10.
Rocca MA, Cercignani M, Iannucci G, et al. Weekly diffusion-weighted imaging of normal appearing white matter in MS. Neurology 2000;55:882–884.
11.
Henderson APD, Barnett MH, Parratt JDE, et al. Multiple sclerosis: distribution of inflammatory cells in newly forming lesions. Ann Neurol 2009;66:739–753.
12.
Lassman H. Hypoxia-like tissue injury as a component of multiple sclerosis lesions. J Neurol Sci 2003;206:187–191.
13.
Karonen JO, Kaarina Partanen JL, Vanninen RL, et al. Evolution of MR contrast enhancement patterns during the first week after acute ischemic stroke. Am J Neuroradiol 2001;22:103–111.
14.
Su KG, Banker G, Bourdette D, et al. Axonal degeneration in multiple sclerosis: the mitochondrial hypothesis. Curr Neurol Neurosci Rep 2009;9:411–417.
15.
Yacoub HA, Al-Qudahl ZA, Lee H-J, et al. Tumefactive multiple sclerosis presenting as acute ischemic stroke. J Vasc Interv Neurol 2011;4:21–23.

Information & Authors

Information

Published In

Neurology® Clinical Practice
Volume 3Number 1February 2013
Pages: 15-21

Publication History

Published in print: February 2013
Published online: February 18, 2013

Permissions

Request permissions for this article.

Disclosures

M. Hyland has nothing to disclose. R. Bermel reports having received consulting fees from Biogen Idec, Novartis, Teva, and Astellas, and research funding from Novartis. J. Cohen reports having received consulting fees from Teva. Go to Neurology.org/cp for full disclosures.

Study Funding

No targeted funding reported.

Authors

Affiliations & Disclosures

Megan Hyland, MD
Department of Neurology (MH), University of Rochester Medical Center, Rochester, NY; and Mellen Center for MS Treatment and Research (RAB, JAC), Neurological Institute, Cleveland Clinic, Cleveland, OH.
Disclosure
Scientific Advisory Boards:
1.
None
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
NONE
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
Robert A. Bermel, MD
Department of Neurology (MH), University of Rochester Medical Center, Rochester, NY; and Mellen Center for MS Treatment and Research (RAB, JAC), Neurological Institute, Cleveland Clinic, Cleveland, OH.
Disclosure
Scientific Advisory Boards:
1.
Novartis, Questcor
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
Biogen Idec, Teva Neuroscience, Novartis
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
Biogen Idec, Teva Neuroscience, Astellas
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
Novartis
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
National Multiple Sclerosis Society Research Grant RG4449A1/T
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
Jeffrey A. Cohen, MD
Department of Neurology (MH), University of Rochester Medical Center, Rochester, NY; and Mellen Center for MS Treatment and Research (RAB, JAC), Neurological Institute, Cleveland Clinic, Cleveland, OH.
Disclosure
Scientific Advisory Boards:
1.
Biogen Idec3/11/2011, Consulting meeting, $9100Elan12/10/2010, Consulting meeting, $2250Novartis11/19/2010, Consulting meeting, $6600Teva4/22/2011, Consulting meeting, $36001/23/2012, Consulting meeting, $2500Vaccinex5/15/2011, Consulting meeting, $4000
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
Novartis4/12/2011, Speaker, $2500
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
Cambridge University Press, JA Cohen and RA Rudick, eds, Multiple Sclerosis Therapeutics, 4th edition, 2011
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
Research support paid to my institution from: Biogen Idec, Genzyme, Novartis, Receptos, Synthon, Teva
Research Support, Government Entities:
1.
Department of Defense, PR093324, PI, 2010-14NIH, 1 RO1 NS074787, 2011-4
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
Nancy Davis Center Without Walls, 2007, $25,000Nancy Davis Center Without Walls, 2008, $25,000
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE

Notes

Correspondence to: [email protected]

Metrics & Citations

Metrics

Citations

Download Citations

If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Select your manager software from the list below and click Download.

Cited By
  1. Differential imaging of atypical demyelinating lesions of the central nervous system, La radiologia medica, 126, 6, (827-842), (2021).https://doi.org/10.1007/s11547-021-01334-y
    Crossref
  2. Fulminant inflammatory demyelination presenting as stroke‐in‐evolution in an elderly subject, Brain and Behavior, 11, 8, (2020).https://doi.org/10.1002/brb3.1967
    Crossref
  3. Mitochondrial leukoencephalopathies: A border zone between acquired and inherited white matter disorders in children?, Multiple Sclerosis and Related Disorders, 20, (84-92), (2018).https://doi.org/10.1016/j.msard.2018.01.003
    Crossref
  4. Emergency Department MRI Scanning of Patients with Multiple Sclerosis: Worthwhile or Wasteful?, American Journal of Neuroradiology, 38, 1, (12-17), (2016).https://doi.org/10.3174/ajnr.A4953
    Crossref
  5. Clinicoradiologic features distinguish tumefactive multiple sclerosis from CNS neoplasms, Neurology Clinical Practice, 7, 1, (53-64), (2016)./doi/10.1212/CPJ.0000000000000319
    Abstract
  6. Neuro-oncology dilemma: Tumour or tumefactive demyelinating lesion, Multiple Sclerosis and Related Disorders, 4, 6, (555-566), (2015).https://doi.org/10.1016/j.msard.2015.07.013
    Crossref
  7. Diffusion-Weighted Methods, Brain Tumor Imaging, (99-110), (2015).https://doi.org/10.1007/174_2015_1052
    Crossref
Loading...

View Options

Get Access

Login options

Check if you have access through your login credentials or your institution to get full access on this article.

Personal login Institutional Login
Purchase Options

Purchase this article to get full access to it.

Purchase Access, $39 for 24hr of access

View options

Full Text

View Full Text

Full Text HTML

View Full Text HTML

Media

Figures

Other

Tables

Share

Share

Share article link

Share