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MR spectroscopy evaluation of right-sided frontal lesion

Case Study
Abbas, Yasser, M.D., Ph.D. Cairo, Misr Radiology Center Egypt
Ibrahim, Ahmed, MD Cairo, Misr Radiology Center Egypt

Patient history:

A 30-year-old male presented at Misr Radiology Center with left hemiparesis and history of headache and epileptic seizures.

MR examination:

Conventional MRI was performed at 1.5T using axial T1- and T2-weighted MRI sequences among other pre- and post-contrast sequences. These were followed by two single voxel spectroscopic sequences at TE 31 & 144, respectively, after placing single voxel on tissue portion of the lesion.

MRS images/spectra and interpretation:

Axial T1-weighted Axial T2-weighted
Axial T1-weighted
Axial T2-weighted


The axial T1-weighted image shows a low signal intensity right frontal lesion with consequent positive mass effect on ipsilateral frontal horn of lateral ventricle.


The axial T2-weighted image demonstrates that the lesion is heterogeneously hyperintense.





The SV TE 31 spectrum shows elevation of the lactate peak, and to a lesser extent, the lipid peak.


The SV TE 144 spectrum shows the same findings and confirms the lactate elevation as it is reversed in the opposite side on this particular TE.


The MRS data of this relatively large right frontal lesion show remarkable reductions of NAA - the normal neuronal marker - and creatine, which represents cellular energetics. Conversely, there is remarkable elevation of the lactate peak, and to a lesser extent, the lipid peaks - with lactate having its characteristic doublet at the 1.3 ppm frequency. The lactate peak is shifted to the opposite side on the TE 144 spectrum, denoting anaerobic glycolysis and some necrosis.


The milder elevation of choline at 3.2 ppm represents some astrocytosis and gliosis rather than accentuated cell membrane turnover. There also is mild elevation of myo-inositol due to astrocytosis, which usually occurs with inflammatory processes. NAA is markedly reduced at the 2 ppm position. This spectral pattern is highly suggestive of an active inflammatory process and not of a malignant neoplastic process. Consequently, it is more suggestive of an active inflammatory demyelinating process, most likely of the primary variety, such as tumefactive multiple sclerosis or perhaps a secondary one, such as acute disseminated encephalomyelitis (ADEM).


The pertinent metabolic ratios of the MRS study indicate elevated choline-to-NAA and choline-to-creatine ratios. Furthermore, there is remarkable elevation of the lactate-to-creatine ratio and mild elevation of the lipid-to-creatine and myo-inositol-to-creatine ratios.

Working diagnosis:

Active demyelinating process either primary, such as tumefactive MS versus secondary, such as ADEM. A neoplastic process is excluded.

Impact of MRS:

When conventional MRI scans fail to differentiate a lesion with certainty, MRS can facilitate diagnosis by demonstrating distinct metabolic signatures of disparate pathologies, thereby informing treatment options.


More information in the Clinical View article:

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Mar 27, 2006

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