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Differential diagnosis of a vanishing brain space occupying lesion in a child
Sherifa A Hamed1, Mohamad A Mekkawy1, Hosam Abozaid1
1Sherifa A Hamed, Department of Neurology and Psychiatry, Assiut University Hospital, Assiut 71516, Egypt.
Insights
A pediatric vanishing brain lesion initially suspected as a tumor resolved with treatment. Magnetic resonance spectroscopy later confirmed gliosis, not neoplasm, aiding diagnosis.
Area of Science:
- Pediatric Neurology
- Neuroimaging
- Neuro-oncology
Background:
- A 14-year-old presented with symptoms suggestive of a brain mass, including fever, vomiting, and hemiparesis.
- Initial Magnetic Resonance Imaging (MRI) revealed a large intra-axial mass in the left temporal lobe and brainstem, enhancing with gadolinium (Gd).
Observation:
- The patient received intravenous antibiotics, mannitol, dexamethasone, and craniospinal radiotherapy due to suspected neoplastic lesions like lymphoma or glioma.
- Significant clinical improvement was observed within 15 days, with steroids tapered over four months.
- Follow-up MRI showed a reduced, non-enhancing lesion, but the patient later developed recurrent epilepsy.
Findings:
- Electroencephalography identified a left temporal epileptic focus.
- Subsequent single voxel proton (1H) MR spectroscopy (MRS) demonstrated reduced N-acetyl-aspartate (NAA)/creatine (Cr) and choline (Cho)/Cr ratios, indicating gliosis rather than a neoplasm.
- Diffusion-weighted images were normal.
Implications:
- Solitary brain masses in children present diagnostic challenges.
- MRS proved crucial in differentiating between neoplastic and non-neoplastic (pseudotumor) lesions.
- This case highlights the diagnostic utility of MRS in pediatric brain lesions.
Abstract:
We describe clinical, diagnostic features and follow up of a patient with a vanishing brain lesion. A 14-year-old child admitted to the department of Neurology at September 2009 with a history of subacute onset of fever, anorexia, vomiting, blurring of vision and right hemiparesis since one month. Magnetic resonance imaging (MRI) of the brain revealed presence of intra-axial large mass (25 mm × 19 mm) in the left temporal lobe and the brainstem which showed hypointense signal in T1W and hyperintense signals in T2W and fluid attenuated inversion recovery (FLAIR) images and homogenously enhanced with gadolinium (Gd). It was surrounded by vasogenic edema with mass effect. Intravenous antibiotics, mannitol (2 g/12 h per 2 d) and dexamethasone (8 mg/12 h) were given to relief manifestations of increased intracranial pressure. Whole craniospinal radiotherapy (brain = 4000 CGy/20 settings per 4 wk; Spinal = 2600/13 settings per 3 wk) was given based on the high suspicion of neoplastic lesion (lymphoma or glioma). Marked clinical improvement (up to complete recovery) occurred within 15 d. Tapering of the steroid dose was done over the next 4 mo. Follow up with MRI after 3 mo showed small lesion in the left antero-medial temporal region with hypointense signal in T1W and hyperintense signals in T2W and FLAIR images but did not enhance with Gd. At August 2012, the patient developed recurrent generalized epilepsy. His electroencephalography showed the presence of left temporal focus of epileptic activity. MRI showed the same lesion as described in the follow up. The diffusion weighted images were normal. The seizures frequency was decreased with carbamazepine therapy (300 mg/12 h). At October 2014, single voxel proton (1H) MR spectroscopy (MRS) showed reduced N-acetyl-aspartate (NAA)/creatine (Cr), choline (Cho)/Cr, NAA/Cho ratios consistent with absence of a neoplasm and highly suggested presence of gliosis. A solitary brain mass in a child poses a considerable diagnostic difficulty. MRS provided valuable diagnostic differentiation between tumor and pseudotumor lesions.
