Member Comments are provided by individuals and reflect their personal opinions only. Under NO circumstances should you act on any advice or opinion posted in this forum. ALWAYS check with your personal physician before taking any action regarding your health! MedHelp International and our partners, sponsors and affiliates have no obligation to monitor any comments posted on this site, or the content and/or accuracy of such exchanges. MedHelp International does not endorse the views of any user.
Neurology (Expert Forum)
Re: "Disappearing" brain lesions
This forum is for questions and support regarding neurology issues such as: Alzheimer's Disease, ALS, Autism, Brain Cancer, Cerebral Palsy, Chronic Pain, Epilepsy, Fibromyalgia, Headaches, MS, Neuralgia, Neuropathy, Parkinson's Disease, RSD, Sleep Disorders, Stroke, Traumatic Brain Injury.
Re: "Disappearing" brain lesions
by CCF Neurology MD:NT, Jan 01, 1995 12:00AM
Posted By CCF Neurology MD:NT on October 12, 1998 at 21:29:45:
In Reply to: "Disappearing" brain lesions posted by Jeanette on October 12, 1998 at 05:05:56:
Age 41, female, excellent health until I was recently admitted thru ER with a right visual field problem (about 40% of the right side is a blind spot), confusion, mild headache behind left eye, some memory problems, walking problems due to balance, slow heart rate,thowing PVC's, and very low blood pressure. Vision blurred totally and the right foot went numb the next day. Initial diagnosis was a stroke, but MRI showed 4 brain lesions and significant brain swelling. Decadron and anti-coagulants started immediately after admission. The anti-coagulants were discontinued within 3 days, decadron continued for about 6 weeks.
One large lesion on top of head, not encapsulated. Three other lesions deeper, not accessable, small, all encapsulated. Contrast was used. Physicians assumed cancer (some thought two different types of cancer), and we spent 1 1/2 weeks looking for source with no results. Finally did needle biopsy of large lesion with inconclusive results except for gliosis (sp). At this point, two neurosurgeons recommended craniotomy for another biopsy and to get out as much as possible of the large lesion. Third opinion recommended steriotactic biopsy of one of the smaller lesions. Nearly 2 1/2 weeks after admission. I'm glad to report that I went for this approach. The procedure was stopped before the biopsy as the sterotactic MRI showed no brain lesions anymore. There was still significant swelling, but far less than on the original MRI. Reduced swelling clearly coincided with reduction in symptoms.
Other information:
History of many collagen vascular/auto-immune problems 15-20 years ago. Never diagnosed.
History of pneumonia one month prior to onset of brain swelling.
Family history of auto-immune disorders including MS, endocarditis, chron's disease.
No abnormalities in ANY testing except MRI and brain biopsy (as noted above). Extensive infectious disease and rhumatology work-ups have not shown anything, and even the sed rate is normal. Evidence of very old toxoplasmosis infection (probably 20 years ago). Spinal tap did show increased WBC, but I understand this is non-specific.
Current status (six weeks after episode): Follow-up MRI shows marked decrease in swelling. Still some in the visual field area, which is the only symptom that has not gotten better. Most other problems are resolved, except for mild confusion, minimal memory lapses, some vision blurring and left leg is still somewhat numb. Right visual field still shot to hell and I still feel like I'm not "thinking" the same way I used to. Nonetheless, under the circumstances, I'm not complaining!
Physicians are mystified. Diagnosis being considered include CNS vaculitis, lymphoma, some other auto-immune problem, infection or absess (abscess) (related to pneumonia?). Have seen or will be seeing neurosurgeon, neurologist, rheumatologist, infectious disease specialist, internist, cardiologist and possibly oncologist. Most are affiliated with a teaching hospital (though not a major facility as we do not have one here).
My questions:
1. I am given to understand that these "disappearing" brain lesions are VERY unusual. The neurosurgeon was quite shocked when he saw the MRI taken during the stereotactic procedure. The other physician's seem equally shocked. Can anyone give me an idea of how commonly this happens?
2. Other tests you might recommend?
3. Other possible diagnosis you might consider?
4. Thoughts on if this visual field problem and other problems will just clear itself up? The neurosurgeon best guess is that it will resolve itself and an absolute diagnosis will never be finalized. The neurologist does not agree. He feels that a diagnosis is still possible, and some the problems may be permanent. (I know this will be difficult to answer with out examination and MRI's, but your experience counts. I promise to take it with a grain of salt.)
thank you all for your help and suggestions.
Dear Jeanette:
The actual appearance of the serial MRI's is critically important. Any description of the lesion, however good, cannot substitute for the pictures.
Disappearing enhancing lesions (either spontaneous, or on treatment with corticosteroids, as in your case) are not common. They include primary CNS lymphoma, neurosarcoidosis, acute multiple sclerosis plaques, leuckoencephalopathy of hypertensive encephalopathy, lesions of cerebral venous thrombosis, lesions associated with seizures, occasionally some forms of infection (encephalitis, abscesses, cysticercosis), primary CNS vasculitis, and various other obscure transient encephalopathies. This is an incomplete list.
The lesions I have most commonly seen biopsied (with non-specific result), that subsequently became smaller (or disappeared) are primary CNS lymphoma, multiple sclerosis plaque, and lesions of venous thrombosis.
Cases like yours can be incredibly difficult to diagnose. Additional tests that are helpful in appropriate cases include angiograms, repeated high-volume spinal taps for cytology or flow-cytometry, and repeat biopsies. Some of these tests are invasive and are undertaken in a situation like yours only if there is evidence of disease progression/relapse.
I hope this is helpful. Good luck!
In Reply to: "Disappearing" brain lesions posted by Jeanette on October 12, 1998 at 05:05:56:
Age 41, female, excellent health until I was recently admitted thru ER with a right visual field problem (about 40% of the right side is a blind spot), confusion, mild headache behind left eye, some memory problems, walking problems due to balance, slow heart rate,thowing PVC's, and very low blood pressure. Vision blurred totally and the right foot went numb the next day. Initial diagnosis was a stroke, but MRI showed 4 brain lesions and significant brain swelling. Decadron and anti-coagulants started immediately after admission. The anti-coagulants were discontinued within 3 days, decadron continued for about 6 weeks.
One large lesion on top of head, not encapsulated. Three other lesions deeper, not accessable, small, all encapsulated. Contrast was used. Physicians assumed cancer (some thought two different types of cancer), and we spent 1 1/2 weeks looking for source with no results. Finally did needle biopsy of large lesion with inconclusive results except for gliosis (sp). At this point, two neurosurgeons recommended craniotomy for another biopsy and to get out as much as possible of the large lesion. Third opinion recommended steriotactic biopsy of one of the smaller lesions. Nearly 2 1/2 weeks after admission. I'm glad to report that I went for this approach. The procedure was stopped before the biopsy as the sterotactic MRI showed no brain lesions anymore. There was still significant swelling, but far less than on the original MRI. Reduced swelling clearly coincided with reduction in symptoms.
Other information:
History of many collagen vascular/auto-immune problems 15-20 years ago. Never diagnosed.
History of pneumonia one month prior to onset of brain swelling.
Family history of auto-immune disorders including MS, endocarditis, chron's disease.
No abnormalities in ANY testing except MRI and brain biopsy (as noted above). Extensive infectious disease and rhumatology work-ups have not shown anything, and even the sed rate is normal. Evidence of very old toxoplasmosis infection (probably 20 years ago). Spinal tap did show increased WBC, but I understand this is non-specific.
Current status (six weeks after episode): Follow-up MRI shows marked decrease in swelling. Still some in the visual field area, which is the only symptom that has not gotten better. Most other problems are resolved, except for mild confusion, minimal memory lapses, some vision blurring and left leg is still somewhat numb. Right visual field still shot to hell and I still feel like I'm not "thinking" the same way I used to. Nonetheless, under the circumstances, I'm not complaining!
Physicians are mystified. Diagnosis being considered include CNS vaculitis, lymphoma, some other auto-immune problem, infection or absess (abscess) (related to pneumonia?). Have seen or will be seeing neurosurgeon, neurologist, rheumatologist, infectious disease specialist, internist, cardiologist and possibly oncologist. Most are affiliated with a teaching hospital (though not a major facility as we do not have one here).
My questions:
1. I am given to understand that these "disappearing" brain lesions are VERY unusual. The neurosurgeon was quite shocked when he saw the MRI taken during the stereotactic procedure. The other physician's seem equally shocked. Can anyone give me an idea of how commonly this happens?
2. Other tests you might recommend?
3. Other possible diagnosis you might consider?
4. Thoughts on if this visual field problem and other problems will just clear itself up? The neurosurgeon best guess is that it will resolve itself and an absolute diagnosis will never be finalized. The neurologist does not agree. He feels that a diagnosis is still possible, and some the problems may be permanent. (I know this will be difficult to answer with out examination and MRI's, but your experience counts. I promise to take it with a grain of salt.)
thank you all for your help and suggestions.
Dear Jeanette:
The actual appearance of the serial MRI's is critically important. Any description of the lesion, however good, cannot substitute for the pictures.
Disappearing enhancing lesions (either spontaneous, or on treatment with corticosteroids, as in your case) are not common. They include primary CNS lymphoma, neurosarcoidosis, acute multiple sclerosis plaques, leuckoencephalopathy of hypertensive encephalopathy, lesions of cerebral venous thrombosis, lesions associated with seizures, occasionally some forms of infection (encephalitis, abscesses, cysticercosis), primary CNS vasculitis, and various other obscure transient encephalopathies. This is an incomplete list.
The lesions I have most commonly seen biopsied (with non-specific result), that subsequently became smaller (or disappeared) are primary CNS lymphoma, multiple sclerosis plaque, and lesions of venous thrombosis.
Cases like yours can be incredibly difficult to diagnose. Additional tests that are helpful in appropriate cases include angiograms, repeated high-volume spinal taps for cytology or flow-cytometry, and repeat biopsies. Some of these tests are invasive and are undertaken in a situation like yours only if there is evidence of disease progression/relapse.
I hope this is helpful. Good luck!
