{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,12,12]],"date-time":"2025-12-12T11:26:34Z","timestamp":1765538794444,"version":"3.48.0"},"reference-count":27,"publisher":"MDPI AG","issue":"24","license":[{"start":{"date-parts":[[2025,12,12]],"date-time":"2025-12-12T00:00:00Z","timestamp":1765497600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Diagnostics"],"abstract":"<jats:p>Background and Clinical Significance: Tumefactive demyelinating lesions (TDLs) are large demyelinating lesions that mimic intracranial tumors, posing a diagnostic challenge in both clinical presentation and conventional imaging. Distinguishing TDLs from central nervous system tumors can be challenging due to their similar imaging appearances. Specific magnetic resonance imaging (MRI) features such as open-ring contrast enhancement, mild mass effect, lack of cortical involvement, and rapid responsiveness to corticosteroids favor a demyelinating etiology of the lesion. This report presents a case of a tumefactive demyelination lesion showing a T2\/fluid-attenuated inversion recovery (FLAIR) mismatch sign suggestive of a low-grade astrocytoma, focusing on imaging findings, therapeutic response, and diagnostic considerations. Case Description: A 63-year-old woman presented with headache, progressive speech impairment, and difficulty swallowing. MRI revealed a large lesion in the left frontal lobe with a T2\/FLAIR mismatch sign, which initially suggested a low-grade astrocytoma. Additionally, the lesion was hypodense on noncontrast computed tomography (CT), did not show open-ring enhancement, and only had mild mass effect with perifocal edema. Given these conflicting imaging findings, a biopsy was considered; however, the patient declined the procedure and agreed to a follow-up. Corticosteroid therapy was initiated to reduce swelling, resulting in a significant reduction in the lesion within two weeks. A follow-up MRI confirmed near-complete regression of the lesion after two months. Conclusions: While a T2\/FLAIR mismatch sign correlates with isocitrate dehydrogenase (IDH)-mutant 1p\/19q non-codeleted astrocytoma, the dynamic radiological and clinical response to corticosteroids was more indicative of demyelination. This case highlights the importance of considering TDLs in the differential diagnosis of tumor-like brain lesions to avoid unnecessary invasive interventions like biopsy or surgical removal.<\/jats:p>","DOI":"10.3390\/diagnostics15243174","type":"journal-article","created":{"date-parts":[[2025,12,12]],"date-time":"2025-12-12T11:13:33Z","timestamp":1765538013000},"page":"3174","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Tumefactive Demyelinating Lesion Mimicking Low-Grade Astrocytoma with a T2\/FLAIR Mismatch Sign: A Case Report and Review of the Literature"],"prefix":"10.3390","volume":"15","author":[{"given":"Maria","family":"Karhu","sequence":"first","affiliation":[{"name":"Faculty of Medicine, Riga Stradins University, 16 Dzirciema Street, LV-1007 Riga, Latvia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Roberts","family":"Tume\u013ck\u0101ns","sequence":"additional","affiliation":[{"name":"Faculty of Medicine, Riga Stradins University, 16 Dzirciema Street, LV-1007 Riga, Latvia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Dace","family":"Dzirkale","sequence":"additional","affiliation":[{"name":"Clinic of Neurology, Riga East University Hospital, LV-1079 Riga, Latvia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5722-2435","authenticated-orcid":false,"given":"Kaspars","family":"Auslands","sequence":"additional","affiliation":[{"name":"Clinic of Neurosurgery, Riga East University Hospital, LV-1079 Riga, Latvia"},{"name":"Department of Neurology and Neurosurgery, Riga Stradins University, LV-1007 Riga, Latvia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4893-9725","authenticated-orcid":false,"given":"Can","family":"\u00d6z\u00fctemiz","sequence":"additional","affiliation":[{"name":"Department of Radiology, University of Minnesota, Minneapolis, MN 55455, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Al\u012bna","family":"Flintere Flinte","sequence":"additional","affiliation":[{"name":"Department of Neurology, Pauls Stradins Clinical University Hospital, LV-1002 Riga, Latvia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7457-1901","authenticated-orcid":false,"given":"Arturs","family":"Balodis","sequence":"additional","affiliation":[{"name":"Institute of Diagnostic Radiology, Pauls Stradins Clinical University Hospital, LV-1002 Riga, Latvia"},{"name":"Department of Radiology, Riga Stradins University, LV-1007 Riga, Latvia"},{"name":"Faculty of Medicine and Life Sciences, University of Latvia, LV-1004 Riga, Latvia"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2025,12,12]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"1759","DOI":"10.1093\/brain\/awn098","article-title":"Clinical and radiographic spectrum of pathologically confirmed tumefactive multiple sclerosis","volume":"131","author":"Lucchinetti","year":"2008","journal-title":"Brain"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"1426","DOI":"10.1038\/s41598-024-52048-w","article-title":"Tumefactive demyelinating lesions: A retrospective cohort study in Thailand","volume":"14","author":"Ongphichetmetha","year":"2024","journal-title":"Sci. Rep."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"104992","DOI":"10.1016\/j.msard.2023.104992","article-title":"Tumefactive Demyelinating Lesions versus CNS Neoplasms, a Comparative Study","volume":"79","author":"Chew","year":"2023","journal-title":"Mult. Scler. Relat. Disord."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"4570","DOI":"10.1016\/j.radcr.2022.09.008","article-title":"Recurrent tumefactive demyelinating lesions in an elderly woman","volume":"17","author":"Weil","year":"2022","journal-title":"Radiol. Case Rep."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"53","DOI":"10.1212\/CPJ.0000000000000319","article-title":"Clinicoradiologic features distinguish tumefactive multiple sclerosis from CNS neoplasms","volume":"7","author":"Lin","year":"2017","journal-title":"Neurol. Clin. Pract."},{"key":"ref_6","doi-asserted-by":"crossref","unstructured":"Vakrakou, A.G., Brinia, M.-E., Svolaki, I., Argyrakos, T., Stefanis, L., and Kilidireas, C. (2022). Immunopathology of Tumefactive Demyelinating Lesions-From Idiopathic to Drug-Related Cases. Front. Neurol., 13.","DOI":"10.3389\/fneur.2022.868525"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"72","DOI":"10.1016\/j.msard.2017.04.003","article-title":"Tumefactive demyelinating lesions: A comprehensive review","volume":"14","author":"Algahtani","year":"2017","journal-title":"Mult. Scler. Relat. Disord."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"186","DOI":"10.2214\/AJR.20.23226","article-title":"A Review of Clinical and Imaging Findings in Tumefactive Demyelination","volume":"217","author":"Nakayama","year":"2021","journal-title":"Am. J. Roentgenol."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"1427","DOI":"10.1212\/WNL.54.7.1427","article-title":"Open-ring imaging sign: Highly specific for atypical brain demyelination","volume":"54","author":"Masdeu","year":"2000","journal-title":"Neurology"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"1643","DOI":"10.3174\/ajnr.A5775","article-title":"MRI Findings in Tumefactive Demyelinating Lesions: A Systematic Review and Meta-Analysis","volume":"39","author":"Suh","year":"2018","journal-title":"Am. J. Neuroradiol."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"32","DOI":"10.1016\/j.jns.2017.08.005","article-title":"Tumefactive demyelinating lesions of 15 patients: Clinico-radiological features, management and review of the literature","volume":"381","author":"Barbosa","year":"2017","journal-title":"J. Neurol. Sci."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"10113","DOI":"10.1038\/s41598-020-67244-7","article-title":"Clinicopathological analysis of T2-FLAIR mismatch sign in lower-grade gliomas","volume":"10","author":"Deguchi","year":"2020","journal-title":"Sci. Rep."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"20210825","DOI":"10.1259\/bjr.20210825","article-title":"T2-FLAIR mismatch sign: A roadmap of pearls and pitfalls","volume":"95","author":"Pinto","year":"2021","journal-title":"Br. J. Radiol."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"225","DOI":"10.1007\/s00234-018-2148-4","article-title":"There is an exception to every rule\u2014T2-flair mismatch sign in gliomas","volume":"61","author":"Johnson","year":"2018","journal-title":"Neuroradiology"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"vdad149","DOI":"10.1093\/noajnl\/vdad149","article-title":"Longitudinal characteristics of T2-FLAIR mismatch in IDH-mutant astrocytomas: Relation to grade, histopathology, and overall survival in the GLASS-NL cohort","volume":"5","author":"Vallentgoed","year":"2023","journal-title":"Neuro-Oncol. Adv."},{"key":"ref_16","first-page":"20220138","article-title":"T2-fluid attenuated inversion recovery mismatch in tumefactive multiple sclerosis","volume":"9","author":"Le","year":"2023","journal-title":"BJR Case Rep."},{"key":"ref_17","doi-asserted-by":"crossref","unstructured":"Petr\u00e1\u0161ov\u00e1, M., \u0160rotov\u00e1, I., Kol\u010dava, J., \u0160toura\u010d, P., Hynkov\u00e1, L., Ke\u0159kovsk\u00fd, M., Pikulov\u00e1, H., Neuman, E., Kren, L., and Vl\u010dkov\u00e1, E. (2024). Case report: Diagnostic challenge: A new multiple sclerosis \u201crelapse\u201d leading to the diagnosis of anaplastic astrocytoma. Front. Neurol., 14.","DOI":"10.3389\/fneur.2023.1324269"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"7180","DOI":"10.19082\/7180","article-title":"Tumefactive multiple sclerosis masquerade as a central nervous system tumor: A case report","volume":"10","author":"Turkistani","year":"2018","journal-title":"Electron. Physician"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"931","DOI":"10.3329\/bjms.v21i4.60259","article-title":"Tumefactive demyelination-A Rare Presentation of Multiple Sclerosis","volume":"21","author":"Zafar","year":"2022","journal-title":"Bangladesh J. Med. Sci."},{"key":"ref_20","first-page":"e29457","article-title":"T2-Fluid-Attenuated Inversion Recovery (FLAIR) Mismatch as a Novel Specific MRI Marker for Adult Low-Grade Glioma (LGG): A Case Report","volume":"14","author":"Slaghour","year":"2022","journal-title":"Cureus"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"776","DOI":"10.3174\/ajnr.A6045","article-title":"The Central Vein Sign in Radiologically Isolated Syndrome","volume":"40","author":"Suthiphosuwan","year":"2019","journal-title":"AJNR Am. J. Neuroradiol."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"146","DOI":"10.25259\/SNI_239_2022","article-title":"Tumefactive multiple sclerosis versus high grade glioma: A diagnostic dilemma","volume":"13","author":"French","year":"2022","journal-title":"Surg. Neurol. Int."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"e1418","DOI":"10.1212\/WNL.0000000000206820","article-title":"Tumefactive Demyelination in MOG Ab-Associated Disease, Multiple Sclerosis, and AQP-4-IgG-Positive Neuromyelitis Optica Spectrum Disorder","volume":"100","author":"Cacciaguerra","year":"2023","journal-title":"Neurology"},{"key":"ref_24","first-page":"254","article-title":"Progression of tumefactive demyelinating lesion in a child demonstrated with MRI","volume":"13","author":"Brogna","year":"2017","journal-title":"Radiol. Case Rep."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"41","DOI":"10.21141\/PJP.2021.14","article-title":"Corticosteroid-associated Changes Resembling a Demyelinating Brain Lesion in Diffuse Large B-cell Lymphoma (DLBCL): A Case Report","volume":"6","author":"Uy","year":"2021","journal-title":"Philipp. J. Pathol."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"225","DOI":"10.1111\/bpa.12496","article-title":"Diagnostic red flags: Steroid-treated malignant CNS lymphoma mimicking autoimmune inflammatory demyelination","volume":"28","author":"Engel","year":"2018","journal-title":"Brain Pathol."},{"key":"ref_27","doi-asserted-by":"crossref","unstructured":"Boyle, T., Fernando, S.L., Drummond, J., Fontes, A., and Parratt, J. (2023). Phenotyping variants of tumefactive demyelinating lesions according to clinical and radiological features\u2014A case series. Front. 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