Mr spectroscopy free download as powerpoint presentation. Tuberculomas involving the cns are not uncommon in developing countries. Shah1 and rona woldenberg1,2 1department of radiology, north shore university hospital, 300 community drive, manhasset, ny 11030, usa 2department of radiology, new york university school of medicine, new york, ny, usa received 18 august. Spinal cord hemangioblastoma with subarachnoid hemorrhage. Tuberculomas are conglomerate caseous foci within the substance of the brain that develop from deepseated tubercles acquired during a recent or remote period of bacillemia. T2weighted magnetic resonance image of a patient with a tuberculoma in the right parietal lobe. Advances in technology to localize epileptogenic focus, especially with high resolution magnetic resonance imaging mri, have substantially improved the success of surgical treatment. Our purpose is to describe the most common metabolic patterns of tuberculomas by mr spectroscopy mrs with emphasis on potential specific markers. Full text of brain imaging with mri and ct pdf united vrg see other formats. The main challenge in the management of brain tuberculoma is its diagnosis. It is an unusual presentation of tuberculoma, as only few similar cases have been reported previously. This is perhaps a little harsh, however, it is fair to say that mrs.
We present a case of an unusual masslike giant extraaxial tuberculoma during pregnancy. On the basis of the hypothesis that the biochemical environment depends on the infecting organism and might be different in tuberculous compared with pyogenic brain abscesses, this study attempted to determine whether pyogenic brain abscesses can be. Ct scan and mri in diagnosis of tuberculosis of brain and spine international archives of integrated medicine, vol. Magnetic resonance spectroscopy a new ray of hope article pdf available january 2015 with 97 reads how we measure reads. Differentiation of tubercular infection and metastasis. Axial enhanced ct scan of brain, showing three enhancing lesions in pons.
A noncaseating granuloma is hyperintense on t2 and hypointense on t1 and. Centrally located, active lesions may reach considerable size without producing signs of. Magnetic resonance spectroscopy mrs provides additional biochemical information that can be useful. This imagefocused book emphasises the most pertinent clinical information relevant to the diagnostic process. Sir, a 24yearold man presented with repeated episodes of giddiness of four days duration.
Advanced magnetic resonance imaging mri techniques such as diffusion, perfusion and mr spectroscopy mrs may be used for this. The epidemiology of patients with tuberculomas is the same as that of other cns. We describe three cases of cerebral tuberculoma in aids patients and discuss diagnostic, therapeutic and prognostic issues, with emphasis in the distinction from cerebral tuberculous abscesses. Sellar tuberculoma with hemorrhage is even more rare. Two cases case 3 and case 10 required mild sedation for mri study. Multiple brain tuberculomas and role of open brain biopsy. Metabolic mapping includes use of mri and mr spectroscopy in differentiating various ring enhancing lesions like abscess, tumour like glioblastoma multiformae, tuberculoma, radiation necrosis and metastasis. Spinal cord compression can be due to various causes but spinal intramedullary tuberculoma is a rare cause.
Grossman and yousem said if you need this to help you, go back to page 1. In addition, the magnetic resonance imaging mri features of tb abscesses are nonspecific and may mimic abscesses of other infectious etiology. Angiography revealed the mass to be relatively avascular, but also showed marked narrowing of the posterior circulation vessels, suggesting arteritis. Pdf magnetic resonance spectroscopy in differentiation of. Brain imaging with ct and mri presents over 180 disease processes and normal variants, grouping entities by these basic patterns to accentuate differential diagnostic features. A 40yearold female patient presented with a 1month history of persistent headache and blurred vision on the left side. Similarly, in atypical imaging presentation advance mr imaging such as diffusion imaging, and proton magnetic resonance spectroscopy techniques are important for better tissue characterization as described above. In mr spectroscopy mrs, neuro metabolite naa is considered as a.
We report a case that had an intramedullary spinal cord tuberculomas in which the diagnosis was made histologically, without evidence of symptoms of systemic tuberculosis. Purposethe diagnosis of intracranial tuberculomas is often challenging. Role of advanced diagnostic imaging in intracranial tuberculoma. Though these lesions are seen at any level of cord, the thoracic cord is the most commonly involved segment. Mr imaging features are nonspecific with respect to the causative organism for patients with brain abscesses. Mr spectroscopy in tuberculoma of brain bmj case reports. It commonly causes meningitis and parenchymal tuberculomas. Mri was done with t1w, t2w, t2w flairand t1w contrast studies mr spectroscopy was. Spectrum of mr imaging findings in spinal tuberculosis. Computerized tomographic ct scanning was introduced in 1971, and magnetic resonance imaging mri a decade or so later, and both these technologies had an immediate and far. Journal of pediatric neurology volume 5, issue 3 journals.
The puzzle of choline and lipid peak on spectroscopy sciencedirect. Oct, 2014 1h mr spectroscopy of tuberculoma on mri, a tuberculomas appearance varies depending upon its stage of maturation, i. Magnetic resonance spectroscopy mrs identified a lipid peak in all the lesions fig 1 and a diagnosis of tuberculoma was considered. Magnetic resonance spectroscopy, neurocysticercosis, ringenhancing lesion, tuberculoma. Arora introduction mr spectroscopy provides a measure of brain chemistry. The alternative to a tuberculoma is a tuberculous abscess. We present magnetic resonance mr findings in case of sellar and suprasellar tuberculoma with hemorrhage. Difference between ncc and tuberculoma in ct brain visualization of scolex by mri or as eccentric dot on ct is characteristic of ncc. Mr spectroscopy mrs helps to differentiate tuberculoma from other infective granulomas. Gadoliniumdtpaenhanced mri and positron emission tomography of stereotactic laserinduced interstitial thermal therapy in cerebral gliomas pages 3739 bettag, dr. The most common nuclei that are used are 1h proton, 23na sodium, 31p phosphorus. The patient often presents with seizures of recent onset. Mri study has been used in the diagnosis of tuberculoma in the brain, brainstem2 and spinal cord, but mri features of tuberculosis tb abscesses are nonspecific and may mimic abscesses of other infectious aetiology.
Magnetic resonance imaging mri of the liver has evolved into a powerful imaging modality for the detection and characterization of focal liver pathology. Mr spectroscopy medical specialties clinical medicine. Diffusion weighted imaging radiology reference article. Hematological and biochemical examination results were. Cerebral tuberculoma is a disease of young adults below 30 yearsold and sex distribution is equal 2. Intracranial tuberculous granuloma radiology reference. The appearances of intracranial tuberculoma on ct and mri are described. Multivoxel mr spectroscopic imagingdistinguishing intracranial tumors from nonneoplastic. There are several different metabolites, or products of metabolism, that can be measured to differentiate between tumor types.
There is no specific ct finding for tuberculomas 9 whereas mri may give more specific information 3. High quality ct and mri scans show multiple typical and distinguishing images for each entity. Role of mri in evaluation of ring enhancing lesions in brain in correlation with mr spectroscopy. In tbendemic regions, primary pulmonary tb often begins early in childhood with the inhalation of the tubercle bacillus raviglione and obrien 2005. Etiological confirmation is frequently made either by demonstration of acidfast bacilli in a pathology specimen or histological evidence of epithelioidgiant cell granulomas with caseous necrotic material. Cns tuberculosis various common forms include tuberculous meningitis, tuberculoma, calcified tubercular granuloma, abscesses, and in spine osseous involvement is more common than non osseous spinal cord and spinal meningeal involvement. Magnetic resonance imaging in stroke radiology imaging. Shah1 and rona woldenberg1,2 1department of radiology, north shore university hospital, 300 community drive, manhasset, ny 11030, usa. Mri spectroscopy for md radiodiagnosis and imaging for academic purposes only. A tuberculoma is a clinical manifestation of tuberculosis which conglomerates tubercles into a firm lump, and so can mimic cancer tumors of many types in medical imaging studies. Feb 07, 2015 mr spectroscopy is conducted on the same machine as conventional mri.
Mri not only identifies specific epileptogenic substrates, but also determines the specific treatment and predicts prognosis and should be the imaging modality of choice in the evaluation of cps. Three children with late infantile ncl and six age. Full text of brain imaging with mri and ct pdf united vrg. Mr spectroscopy is conducted on the same machine as conventional mri. Intramedullary tuberculoma imt is a rare form of spinal tuberculosis. Part 1, techniques and normal agerelated appearances lubdha m. Mri of the brain revealed ring enhancing sellar lesions with other enhancing lesions and leptomeningeal enhancement. Mri spectroscopy and diffusionweighted imaging may be helpful in making the diagnosis. In an endemic area, cerebral tuberculomas have to be considered as. Magnetic resonance spectroscopy mrs of the brain can. Humera ahsan department of radiology aga khan university hospital.
Mri study has been used in the diagnosis of tuberculoma in the brain, brainstem 2 and spinal cord, but mri features of tuberculosis tb abscesses are. Google scholar 63 cerejo a, vaz r, feyo pb, cruz c. The mri signal characteristics of intracranial tuberculoma are extremely diverse. Mri and proton spectroscopy in children with late infantile neuronal ceroid. Magnetic resonance spectroscopy linkedin slideshare. Clinical presentation and magnetic resonance findings in. In patients in whom neuroimaging is not characteristic it may be difficult to differentiate between the two. Case report clinical presentation and magnetic resonance.
Difference between ncc and tuberculoma in ct brain. Clinical application of mr spectroscopy in identifying biochemical. If mri is also inconclusive, a stereotaxic or excision biopsy is mandatory. The diagnosis is confirmed by testing hormone levels, and by radiographic imaging of the pituitary for example, by ct scan or mri. The main aim was to avoid radiation exposure wherever it was possible especially in female children. Initial in vivo brain spectroscopy studies were done in the. On the basis of the hypothesis that the biochemical environment depends on the infecting organism and might be different in tuberculous compared with pyogenic brain abscesses, this study attempted to determine. Mri has inherent sensitivity and capability to detect ring enhancing lesions. Identification of diffuse and focal brain lesions by clinical magnetic. Spinal cord compression due to primary intramedullary. This type of lesion is rare 2 cm in size, has a lowdensity centre with ring enhancement and on mri is of low signal on t1 and high signal on t2. Magnetic resonance spectroscopy in pituitary tuberculoma saini k s, patel a l, shaikh w a, magar l n, pungaonkar s a abstract magnetic resonance spectroscopy mrs is a new, noninvasive method of diagnosing a lesion in cases where magnetic resonance mr imaging cannot reliably differentiate between two or more possible aetiologies. Magnetic resonance spectroscopy has been suggested as a method to distinguish tuberculomas from cysticercosis.
We report two cases of ringenhanced intracranial tuberculoma in which magnetic resonance mr proton spectroscopy and diffusionweighted dw imaging were useful in the differential diagnosis. The differential diagnosis includes pituitary tuberculoma, especially in developing countries and in immumocompromised patients. Etiology of complex partial seizures, hippocampal sclerosis, magnetic resonance imaging brain, neurocysticercosis, neuroinfections, tuberculoma. Paraffin section with hematoxylin and eosin stain showing marked nuclear pleomorphism and mitotic figures. Eight patients 6 males and 2 females with intracranial tuberculomas studied over the past 4 years are presented. The tuberculous infection of the pituitary gland and sellar region is characterized by the presence of an acute or chronic inflammatory reaction and may occur in the absence of systemic tuberculosis. Sellar tuberculomas are extremely rare lesions with nonspecific clinical manifestations. The imaging appearance of tuberculoma on mri depends on the stage of the tuberculoma. Sagittal t1weithed mri scans with gadolinium showing multiple ring enhancing lesions. Diffusionweighted magnetic resonance imaging of acute focal cerebral ischemia. Cerebral tuberculoma mimics brain tumor, both clinically and radiographically. Four patients had aids and among the four nonaids patients 1 had undergone hepatic transplantation.
The socalled target sign with a central nidus of calcification surrounded by a ring of enhancement was once thought to be diagnostic of a tuberculoma, but is now known to be quite non specific. Mri techniques continued to evolve during the 1990s and profoundly influenced many aspects of epilepsy clinical practice. Magnetic resonance imaging mri can be helpful for diagnosing imt at an early stage and it is also very useful in followup. While the mri uses signals from hydrogen protons to form anatomic images, the proton mrs uses this information to determine the concentration of brain metabolites such as nacetyl aspartate naa, choline cho, creatine cr, and lactate in the tissue. Proton magnetic resonance spectroscopy linkedin slideshare. A clinical study to identify the possible etiology of complex. Magnetic resonance spectroscopy in differentiation of. Intracranial tuberculous granulomas, also known as cns tuberculomas, are common in endemic areas and may occur either in isolation or along with tuberculous meningitis. Biopsy of the lesion was reported as consistent with tuberculoma. Proton spectroscopy is easier to perform and provides much higher signaltonoise than either sodium or phosphorus. Mri study has been used in the diagnosis of tuberculoma in the brain, brainstem 2 and spinal cord, but mri features of tuberculosis tb abscesses are nonspecifi c and may mimic abscesses of.
However, as in our case, a glioma masquerades as a tuberculoma, valuable time would have been lost with anti tubercular drugs. All the cases were studied with ct and 6 underwent mri. Raman spectroscopy provides a powerful, rapid diagnostic. The authors feel, it is prudent to get a mrimri spectroscopy done in a mass lesion. In vivo magnetic resonance spectroscopy mrs is a specialized technique associated with magnetic resonance imaging mri magnetic resonance spectroscopy mrs, also known as nuclear magnetic resonance nmr spectroscopy, is a noninvasive, ionizingradiationfree analytical technique that has been used to study metabolic changes in brain tumors, strokes, seizure disorders, alzheimers. Primary tb is due to firsttime exposure to mycobacterium bacilli. Role of mri and mr spectroscopy in the evaluation of ring. Magnetic resonance perfusion and spectroscopy in a giant. Imt has an incidence of 2 cases per 2000 cases of central nervous system tuberculosis. In vivo magnetic resonance spectroscopy mrs is a specialized technique associated with magnetic resonance imaging mri magnetic resonance spectroscopy mrs, also known as nuclear magnetic resonance nmr spectroscopy, is a noninvasive, ionizingradiationfree analytical technique that has been used to study metabolic changes in brain tumors, strokes. Trainee and practising radiologists will find brain imaging with ct and mri an invaluable and clinically relevant tool for learning and teaching. Diffusionweighted imaging dwi is a form of mr imaging based upon measuring the random brownian motion of water molecules within a voxel of tissue. Leonard, in aminoffs neurology and general medicine fifth edition, 2014. The focal forms of cns tuberculosis are infrequently described and they are divided into tuberculoma and abscess 4.
However, as lipid peaks are described in both these lesions, mrs may not be helpful 2 nagar v. It will appeal to a broad readership including stroke physicians, neurologists, neurosurgeons, rehabilitation specialists, and others with a clinical or research interest in cerebrovascular disease. Magnetic resonance findings in sellar and suprasellar. Proton mrs can be performed within 1015 minutes and. Ependymoma misdiagnosed as tuberculoma, misguided by. Tuberculosis is common in the developing world and in developed nations secondary to increasing immunocompromise in the population. The activity of a tuberculoma may be judged by the degree of contrast enhancement on followup ct or mri studies. Aim of the study was to characterize findings on magnetic resonance imaging mri and proton magnetic resonance spectroscopy 1 hmrs in children with late infantile neuronal ceroid lipofuscinosis ncl and the relationship between these results and duration of the disorder. In general simplified terms, highly cellular tissues or those with cellular swelling exhibit low. We present a patient with a giant cerebellar tuberculoma which mri led us to believe was a vascular, malignant tumour. The lesion may be actually a glioma mimicking a tuberculoma.
Tuberculoma definition of tuberculoma by medical dictionary. Estimation of role of ct scan and mri in diagnosis of. Mr spectroscopy in tuberculoma of brain request pdf. An isointense or hypointense core with a hyperintense rim on t2weighted and flair images is the most common.
Mri study has been used in the diagnosis of tuberculoma in the brain, brainstem 2 and spinal cord, but mri features of tuberculosis tb abscesses are nonspecific and may mimic abscesses of other infectious aetiology. In addition to the three books and the paper mentioned above, it is worth. Neurocysticercosis ncc vs central nervous system cns. Pdf download for mr spectroscopy of intracranial tuberculomas.
Proceedings of the xiv symposium neuroradiologicum london. Magnetic resonance spectroscopy in pituitary tuberculoma. Magnetic resonance imaging mri findings are usually nonspecific and differentiation from malignant lesions is very difficult, particularly in the absence of tb in other parts of the body such as the lungs or lymph nodes. Extraaxial tuberculoma mimicking meningioma although both ct and mri can demonstrate these findings but mri detects it much earlier. The technique of magnetic resonance spectroscopy usually shortened to mr spectroscopy or mrs allows tissue to be interrogated for the presence and concentration of various metabolites. Mrs may increase specificity of diagnosis by identifying lipids within the lesions that are considered characteristic for tb. Mri contrast enhanced t1w images showing enhancing basal exudates with hydrocephalus. A history of neuroimaging in epilepsy 19092009 shorvon. Role of mri in evaluation of ring enhancing lesions in brain. Plain as well as contrast ct studies were carried out.
Magnetic resonance imaging mri of the brain revealed a lobulated t2weighted hypointense mass lesion in the right cerebellar hemisphere with adjacent vasogenic edema causing mass effect on the fourth ventricle with resultant supratentorial hydrocephalus and periventricular. Differentiation of tuberculous from pyogenic brain. Spectroscopy is a series of tests that are added to the mri scan of brain or spine to measure the chemical metabolism of a suspected lesion. Mri signal intensity correlation with histopathology and localized proton spectroscopy. Neuroimaging is even more important for those patients who have medically intractable seizures. Diffusionweighted mr imaging of the brain radiology. Jan 09, 2004 we present a patient with a giant cerebellar tuberculoma which mri led us to believe was a vascular, malignant tumour. Magnetic resonance spectroscopy mrs is a means of noninvasive physiologic imaging of the brain that measures relative levels of various tissue metabolites purcell and bloch 1952 first detected nmr signals from magnetic dipoles of nuclei when placed in an external magnetic field.
We highlight the need to integrate different imaging. Most of these lesions are intracranial, with the ratio of cranial and spinal lesions averaging 30. Brain tuberculomas, tubercular meningitis, and post. A 17yearold girl presented with headache, vomiting, altered sensorium and vision loss. Giant cerebellar tuberculoma mimicking a malignant tumour. Radiology, university hospital antwerp uza, antwerp, belgium.
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