T2-fluid attenuated inversion recovery mismatch in tumefactive multiple sclerosis

Abstract

The T2-fluid attenuated inversion recovery (FLAIR) mismatch sign has been suggested as an imaging marker of isocitrate dehydrogenase-mutant 1p/19q non-codeleted gliomas with 100% specificity. Tumefactive demyelination is a common mimic of neoplasm that has led to unnecessary biopsies and even resections. We report a case of tumefactive multiple sclerosis in a 46-year-old male without prior symptomatic demyelinating episodes that demonstrates the T2-FLAIR mismatch sign. Our findings suggest the T2-FLAIR mismatch sign should not be used as a differential feature between glioma and tumefactive demyelination. Because typical isocitrate dehydrogenase-mutant 1p/19q non-codeleted gliomas typically do not demonstrate significant enhancement, such diagnosis should be reserved when post-contrast images are unavailable.

Brain Tumor Imaging: Review of Conventional and Advanced Techniques

“…34 35 36 Despite the reportedly high specificity of the T2-FLAIR mismatch sign, it has also been seen in non-glial neoplasms and even in demyelinating lesions, thus necessitating caution when reporting this sign without consideration of additional imaging features to suggest a glioma. 37 38…”

“…[34][35][36] Despite the reportedly high specificity of the T2-FLAIR mismatch sign, it has also been seen in non-glial neoplasms and even in demyelinating lesions, thus necessitating caution when reporting this sign without consideration of additional imaging features to suggest a glioma. 37,38 Oligodendrogliomas are typically slow growing but locally aggressive tumors. They have both IDH-mutant and 1p/ 19q codeletion status, making the histologic features previously needed for diagnosis helpful but not necessarily ancillary features.…”