Differential diagnosis of a vanishing brain space occupying lesion in a child

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.

Keywords: Vanishing brain mass, Gliosis, Unconfirmed diagnosis, Lymphoma, Granuloma

Core tip: A vanishing brain space occupying lesion is defined as reduction or disappearance of a brain lesion spontaneously or after steroid treatment to ≤ 70% of its size before establishing its definitive diagnosis. A vanishing solitary neoplastic/non-neoplastic (pseudotumor) (e.g., infection/abscess, granuloma, radiation necrosis, multiple sclerosis) brain mass in a child poses a considerable diagnostic difficulty particularly deeply seated lesions in which tissue diagnosis is difficult to be done. In clinical practice, neuroimaging has to be done every 6-12 mo for at least 3-5 years to follow up after complete remission of the patient. Magnetic resonance spectroscopy (MRS) has been proved to be valuable for diagnostic differentiation between tumor and pseudotumor lesions. MRS provides information related to the metabolic activity in the culprit lesion (e.g., neoplastic processes, demyelination, cell necrosis or gliotic changes).