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. 2014:2014:951690.
doi: 10.1155/2014/951690. Epub 2014 Apr 15.

Open-ring enhancement in pseudotumoral multiple sclerosis: important radiological aspect

Frederico Carvalho de Medeiros  1 , Lucas Alverne Freitas de Albuquerque  2 , Jose Eymard Homem Pittella  3 , Renata Brant de Souza  1 , Antonio Pereira Gomes Neto  1 , Paulo Pereira Christo  1
Affiliations

Open-ring enhancement in pseudotumoral multiple sclerosis: important radiological aspect

Frederico Carvalho de Medeiros et al. Case Rep Neurol Med. 2014.

Abstract

Introduction. Observation of open-ring enhancement in magnetic resonance imaging (MRI) is considered a specificity marker for diagnosing pseudotumoral multiple sclerosis (MS). This finding is of great value in the differential diagnosis of tumefactive lesions. Case Report. We describe a 55-year-old white woman, with previous history of ovarian cancer and recent history of fatigue and bilateral retroorbital pain. Important bilateral visual impairment evolved over one month. Physical examination detected the presence of right homonymous hemianopia. Cranial MRI showed an expanding lesion with open-ring enhancement. Given the range of diagnostic possibilities, a stereotactic biopsy was performed, and histopathological examination was consistent with an active demyelinating disease. The patient was treated with 1 g of methylprednisolone and symptoms improved following a significant reduction in the lesion. Conclusions. We highlight the MRI results suggestive of pseudotumoral MS, especially open-ring enhancement, which is an important radiologic aspect to diagnosis and can assist in avoiding unnecessary biopsies.

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Figures

Figure 1
Figure 1
Cranial MRI showing (a) axial, (b) sagittal, and (c) coronal T1-weighted contrast enhanced views with open-ring enhancement of a hypointense lesion in the parietooccipital region with splenium corpus callosum involvement. (d) Axial FLAIR-weighted image showing hyperintense lesion in the parietooccipital region with extensive splenium corpus callosum involvement. (e) Rim lesions: coronal T2-weighted images showing a hypointensity margin relative to the hyperintensity of the lesion center and periphery.
Figure 2
Figure 2
Histological sections of cerebral white matter of pseudotumoral multiple sclerosis. (a) Increased cellularity of the white matter due to infiltration by macrophages. Hematoxylin-eosin. (b) Junction of the normal (left) and demyelinated white matter (right), showing the well-defined limits of the demyelinated area. Luxol fast blue. (c) Relative axonal preservation in the demyelinated area. Immunohistochemistry for neurofilament. (d) Diffuse and perivascular infiltration (arrow) by macrophages. Immunohistochemistry for CD68.
Figure 3
Figure 3
FLAIR-weighted cranial MRI demonstrating important reduction in the lesion following treatment.
Figure 4
Figure 4
(a) Sagittal and (b) axial T1-weighted cervical/thoracic MRI showing contrast enhanced lesion at the T2-T3 level.
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