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Radiology Quiz- Winners to be featured here.

Please give your comments on these MRI images. Please submit your answers in the comments section only for consideration, give the findings and possible diagnosis or D/D.  List of people who give correct answers within 3days will be featured in this blog along with the correct answer which will be posted on 17th January.

Answer: Tumefactive demyelination with open rim enhancement.

Explanation: The open-ring or white-matter-crescent sign. This sign may help distinguish ring enhancing lesions caused by demyelination from more frequent causes, like neoplasms or abscesses. Note that the ring enhancement in the demyelinating lesion is open in areas abuting the cortex or other gray matter areas, such as the amigdala. The enhancement corresponds to the areas of most active demyelinating activity, with marked breakdown of the blood brain barrier. Once demyelination is complete, in the center of the lesion, enhancement abates. The cortex does not enhance.
The open ring sign is a relatively specific sign for demyelination, helpful in distinguishing between ring enhancing lesions. The enhancing component is thought to represent advancing front of demyelination and thus favours the white matter side of the lesion. The open part of the ring will therefore usually point towards the grey matter 
Often patients with such lesions undergo biopsy, where the histology can be difficult to interpret. Abundant bizarre astrocytes with frequent mitoses can suggest the diagnosis of GBM. Toxoplasmosis may also be suggested by the presence of giant cells (Creutzfeldt cells). As such, careful assessment of imaging is essential to avoid unnecessary and misleading intervention.

Further reading: Open-ring imaging sign: highly specific for atypical brain demyelination.
Masdeu JC, Quinto C, Olivera C, Tenner M, Leslie D, Visintainer P. Source. Departments of Neurology, New York Medical College (St. Vincent's Hospital and Westchester Medical Center), Valhalla, NY , USA.

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Radiology Quiz- Winners to be featured here. Reviewed by Sumer Sethi on Saturday, January 14, 2012 Rating: 5


joe jose said...

hyperintense areas noted on flair images in left temporal and right occipital regions-- which shows ring enhancement on post contrast images- suggestive of demyelinating changes.

imuwithash said...

Multiple Incompleter ring enhancing lesion noted predominantly in white matter and Periventricluar region ! My first D/D Tumefactive MS, ADEM and other white matter demyelination ! In Balos type MS complete ring is seen !

Pankaj Ahire said...

Tumefactive demyelination with open rim enhancement.

Pankaj Ahire said...

Tumefactive demyelination with open rim enhancement.

Pankaj Ahire said...

Tumefactive demyelination with open rim enhancement.

Pankaj Ahire said...

Tumefactive demyelination with open rim enhancement.

Prashant Gupta said...

tumefactive demyelination

Robert Prejs said...

Tumefactive Multiple Sclerosis
DD: Balo Concentric Sclerosis

Karunakaran M said...

Tumefactive Demyelinating Lesions (TDLs)

Imaging shows multiple lesions in both cerebral hemispheres with OPEN RING pattern of ring enhancement, with the incomplete ring facing the grey matter side.

- Karunakaran M Kalathi

girish said...

tumefactive demeyelination

vaibhav Deshpande said...

Diagnosis : Glioblastoma Multiformis

findings :
plate 1:
1- right occipital & left parieto temporal region showing homogeneous enhancement with with regular margins
2-midline shift is present suggestive of cerebral edema may be secondary due to underlying mass / tumour / glioblastoma

Plate2 :
1:Left frontoparito temporal region showing homogenous opacity along with lucency in parieto temporal region suggestive of glioblastoma along with foci of haemorrhagic cyst in it.

2: midline shift is present which is due to cerebral oedema

1 : Rim Enhancement along with hypoechoic foci seen characteristic f Glioblastoma

plate 4:
1:b/l lateral venticles showing enhancement in posterior limb

2: right occipital & left parieto temporal region showing enhancement.
left parieto temporal lesion

Diagnosis : cystic haemorhhagic tumour suggestive of glioblastoma neuroformae located in right occipital & left parito temporal region with characteristic ring enhancement with cystic lesion in the mass. Tumour infiltrating posterior limb of lateral ventricle it also shows midline shift suggestive of vasogenic oedema..

DDs :
1.pilocytic astrocytoma
2. vascular mass due to VHL (Ventricular involvement presnt in this case)
3.Granulomatous disease
4.mixed glial tumour
5. subarchnoid haaemorrhage

Please co relate it clinically

vikas said...

tumifactive demyelination

mitesh said...

tumefactive demyelination.

shahnawaz bashir said...

d/d: Tumefactive multiple sclerosis

shahnawaz bashir said...

tumefactive MS

SN DESAI said...

tumefactive demyelination with incomplete ring sign....
multiple well defined lesions with lack of mass effect and significant perilesional edema
incomplete ring towards the grey matter side of the lesion...
enhancement suggests advancing edge of the lesion which is towards the white matter
D/D: glioma,cerebritis,lymphoma

Wael Nemattalla said...

Acute tumefactive demyelinating lesions.

FLAIR hyperintensities involving deep and subcortical white matter with involvement of subcortical U fibers. Post-contrast images show typical "incomplete ring sign".

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