Figure 2.

Radiological characteristics of two patients presented with tumefactive lesions with recurrent disease course with TDL (recurrent TDL). (a)–(g): Patient 1 presented with two simultaneous TDLs at initial TDL attack; in the right parietal lobe [(a)] and in the splenium of the corpus callosum [(b)]. On the second attack, a new TDL was observed in the pons [(c)] with Gd+ [(d)], another brain area distinct from the initial attack. Two years after rituximab and cyclophosphamide treatment all TDLs were significantly reduced in size [(e)–(g)]. A brain biopsy was performed in the persistent lesion in the splenium of the corpus callosum, which was indicative of demyelination. (h)–(n): Patient 2 presented with two TDLs at the initial tumefactive attack in the right corona radiata [(h)] with subtle Gd+ [(i)] and in the left parietal-temporal region [(j) and (k)] with no Gd+ [(l)]. Two years after, a second clinical attack occurred due to an increase in size of the initial TDL at the right centrum semiovale [(m)] without Gd+ [(n)]. The patient initially received intravenous cyclophosphamide cycles that were discontinued due to treatment failure and switched to rituximab after the second clinical attack resulting in disease remission.

T2-weighted image: (a). FLAIR images: (b), (c), (e) to (h), (j), (k), (m). T1-weighted contrast-enhanced images: (d), (i), (l), (n).

FLAIR, fluid-attenuated inversion recovery; Gd+, gadolinium enhancement; TDL, tumefactive demyelinating lesion.