Comparative evaluation of magnetization transfer MR imaging and in-vivo proton MR spectroscopy in brain tuberculomas
Introduction
Central nervous system (CNS) tuberculosis is a major cause of mortality and morbidity in the developing countries; these still constitutes a large proportion of cases, presenting with space occupying intracranial lesions [1], [2]. However, in the developed world, tuberculomas have become relatively uncommon but nonetheless persistent entity accounting for less than 0.2% of all biopsied brain tumors seen at Neurologic Institute in New York City between 1955 and 1980 [3]. Prompt diagnosis may result in earlier treatment and better outcome; hence, its recognition on imaging is critical for its management. Computed tomography (CT) and MR imaging are the main imaging techniques used in localization and characterization of these lesions [4], [5], [6]. Although MR imaging is superior to CT in characterizing tuberculomas, imaging features are known to overlap with other intracranial focal lesions, such as cysticercus, fungal granulomas and primary and metastatic neoplasm [5].
In-vivo PMRS has been extensively used to observe metabolite changes in different intracranial lesions like tuberculoma, multiple sclerosis, neoplasm and metabolic brain diseases [7], [8], [9]. On in vivo PMRS, lipids at 0.9 ppm, 1.3 ppm, 2.0 ppm and 2.8 ppm have been shown in tuberculomas that appear hypointense on T2 weighted images [8]. Recently, choline (3.22 ppm) has been observed along with lipids at 1.3 ppm and 0.9 ppm in a histologically cellular tuberculomas that showed mixed intensity on T2 weighted image. This resulted in its spectroscopic similarities with a neoplastic lesion [10].
The MT MR technique has recently received attention as an additional sequence to improve image contrast and tissue specificity in various brain diseases [11], [12], [13]. Abnormal MT properties of white matter have been described in patients with CNS disease that appeared normal on conventional spin echo MR images [14], [15], [16]. A number of studies have demonstrated that the MT technique may be useful in characterization of different intracranial lesions and quantitation of true disease load in various intracranial pathologies [11], [12], [13], [17], [18], [19], [20], [21], [22]. T1 weighted MT MR imaging has been found to be useful in differentiation of tuberculomas from cysticercus granuloma [23].
The purpose of the present study was to analyze and compare the results of in vivo PMRS and T1 weighted MT MR imaging in brain tuberculomas and to look for the technique better suited for its tissue characterization.
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Materials and methods
Thirty three patients, who presented from December 1995 to January 2002 with intracranial tuberculomas, were included in this study. There were 18 males and 15 females with age ranged from 7 to 54 years. Informed consent was obtained from all the subjects/guardians before the study. In vivo PMRS and T1 weighted MT MR Imaging were performed in all the 33 cases. In uncooperative patients, sedation was given in appropriate doses. The biopsy of the lesion was performed either under ultrasound
Results
The results of PMRS and T1 weighted MT MR imaging are summarized in Table 1. Tuberculomas were hypointense on T2 weighted images and isointense to hypointense on T1 weighted images with variable perifocal edema in 26 patients. Out of these 26 patients, 21 patients were without meningitis and 5 patients with meningitis. In vivo PMRS in these lesions with voxel placed within the T2 hypointense region showed presence of broad resonances at 0.9 ppm, 1.3 ppm, 2.0 ppm and 2.8 ppm on STEAM sequence
Discussion
The lesions appearing hypointense on T2 weighted images and iso to hypointense on T1 weighted images with variable perifocal edema are considered characteristic of intracranial tuberculomas [4]. The hypointensity on T2 weighted images on histopathology is known to correspond to solid caseation necrosis [1], [28]. Post contrast study in these lesions typically show rim enhancement. Other imaging patterns are predominantly hyperintense lesion with areas of hypointensity on T2 weighted images, and
Acknowledgements
Davender K Vatsal and Sanjeev Chawla acknowledge the financial assistance from Council of Scientific and Industrial Research, New Delhi, India.
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2012, European Journal of RadiologyCitation Excerpt :These lesions are high cellularity with small areas of solid caseation on histopathology [4,5,7]. In the present study, all the intracranial tuberculomas lesions showed small areas of solid caseation on conventional MR imaging and variable Cho, Cr along with Lip on 1H MRS. The enhancing rim of intracranial tuberculomas showed typically a normal-to-mild elevation of the Cho peak, a reduction of the peaks of Cr and NAA, a mild increase of the Cho/Cr, Cho/NAA and Cho/Cho-n ratios, and an elevation of the Lip peak in general agreement with a few published reports [4,5,7]. On the contrary, the contrast-enhancing rim of HGGS showed a higher average Cho levels with no differences of NAA and Cr, which resulted in higher Cho/Cr, Cho/NAA and Cho/Cho-n ratios than tuberculomas.
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