Identifying Tumefactive Demyelination on Synthetic MRI Myelin Maps

Tumefactive demyelinating lesions and brain neoplasms often present as a diagnostic challenge due to overlapping radiographic features among conventional imaging modalities ultimately resulting in uncertainty if a biopsy is warranted to establish a definitive diagnosis. Synthetic MRI (SyMRI) is a novel imaging technique providing myelin maps to aid with diagnosis, yet its use in pediatric patients remains largely unexplored. Therein, we report a pediatric case utilizing SyMRI to assist in differentiating tumefactive demyelination from a recurrent glioma. This 16-year-old female with a history of ganglioglioma, presented with sudden left-sided weakness. The initial MRI suggested either a glial neoplasm or a demyelinating lesion, prompting consideration of a biopsy. SyMRI revealed a unique "rim of decreased myelination," challenging the initial diagnosis. Within 1 week from admission, the patient's symptoms resolved without recurrence. Immunotherapy resolved the demyelinating lesion, supporting the initial SyMRI finding. The case demonstrates the potential of SyMRI in pediatric neuroradiology, highlighting a distinct "rim of demyelination" and its comparison to gliomas aiding in the diagnostic process.