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MR spectroscopy evaluation of space-occupying lesion

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

MRS of left-sided posterior parietal space-occupying lesion

Patient history:

A 53-year-old male presented at Misr Radiology Center with known space-occupying lesion, with history of repeated epileptic seizures and headaches. Lesion was suspicious of malignant neoplasm.

MR spectroscopy examination:

Conventional MRI at 1.5 T was performed using several pre- and post-contrast sequences, including coronal T2 and axial FLAIR MRI sequences, followed by two single-voxel MRS sequences at TE 31 and 144, respectively, after specifically placing a single voxel on the tissue portion of the lesion.

 

MR images and interpretation:

Axial FLAIR Coronal T2-weighted
Axial FLAIR
Coronal T2-weighted

 

The axial FLAIR image shows a left posterior parietal  space-occupying lesion with intermediate signal surrounded by remarkable vasogenic white matter edema with consequent positive mass effect.

 

The coronal T2-weighted image displays the same lesion of relatively low signal denoting its high cellularity.

 

MRS single voxel TE 31 MRS single voxel TE 144
MRS single voxel TE 31
MRS single voxel TE 144

 

The MRS data show marked elevation of the lipids in two positions, particularly at the 1.3 ppm position, which shows a very pronounced peak, and also at the 0.9 ppm position to a lesser extent.

 

The very high elevation of lipids is highly suggestive of a metastatic deposit rather than a glioma, as metastases are known to metabolize lipids and therefore are associated with these high lipid peaks.

 

In addition to lipid elevation, choline also is elevated, due to accentuated cell membrane turnover, and NAA is markedly reduced. Choline elevation is not well appreciated due to the very high lipid peak, yet relative to the other metabolites, it is clearly elevated, which represents the accentuated cell membrane turnover.

 

The marked reduction of NAA is explained by contamination from the surrounding tissue; the metastasis does not originate from the brain itself, so we don't expect NAA.

 

Accordingly, there is marked elevation of the lipid-to-creatine ratio and the choline-to-creatine and choline-to-NAA ratios also are moderately elevated.

 

Diagnosis:

The high relative lipid peaks are highly suggestive of a metastatic deposit rather than a glioma, indicating that the space-occupying lesion is a metastasis.

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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Case Study
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