AM Saindane

B Schrader

Costantinos Sfagos

Costas Potagas

Dimitrios Stergios Evangelopoulos

EM Frohman

G Stranjalis

H Murai

H Tsuda

IS Haldorsen

JO Tavee

Maria Eleptheria Evangelopoulos

MPA Omuro

N De Stefano

TM Schofield

V Vuorinen

VM Sattelmeyer

X Zhang

Y Mao-Draayer

English

PubMed

Maria Evangelopoulos

Dimitrios Evangelopoulos

Springer - Publisher Connector

BioMed CentralCases Journal
ssOpen AcceCase Report
Homonymous hemianopsia as the leading symptom of a tumor like 
demyelinating lesion: a case report
Maria Eleptheria Evangelopoulos1, Dimitrios Stergios Evangelopoulos*2, 
Costas Potagas1 and Costantinos Sfagos1
Address: 1Department of Neurology, University of Athens, Aiginitio University Hospital, Athens, Greece and 2Department of Orthopaedic, 
University of Athens, KAT Accidents' Hospital, Athens, Greece
Email: Maria Eleptheria Evangelopoulos - evangelopoulos@yahoo.gr; Dimitrios Stergios Evangelopoulos* - ds.evangelopoulos@gmail.com; 
Costas Potagas - potagas@med.uoa.gr; Costantinos Sfagos - sfagos@med.uoa.gr
* Corresponding author    
Abstract
Introduction: Differential diagnosis of a cerebral lesion can prove to be a very challenging task for
the treating physician. Many non-neoplastic neurological diseases can mimic brain neoplasms on
neuroimaging.
Case presentation: A previously healthy 23-year-old male, presented with blurred vision to the
Emergency Department of our Hospital. After initial clinical and serological examination, he was
admitted to our clinic for further investigation. Neurological examination showed left
homonymous hemianopsia. Brain MRI revealed edema of the right parietal lobe, compressing the
posterior region of the right ventricle. Serum viral, immunological and paraneoplasmatic testing
were negative. Spectroscopic MRI described the lesions as tumefactive demyelinated plaques. After
treating the patient with intravenous corticosteroids, his symptoms rapidly improved and the
extensive lesion of the parietal lobe decreased.
Conclusion: In case of young patients with tumor-like lesions, demyelination should always be
considered in the differential diagnosis.
Introduction
Differential diagnosis of a cerebral lesion can prove to be
a very challenging task for the treating physician. Many
non-neoplastic neurological diseases including multiple
sclerosis, stroke, pyogenic abscess, progressive multifocal
leukoencephalopathy, acute disseminated encephalomy-
elitis, toxoplasmosis, tuberculosis, cysticercosis, fungal
infections, syphilis, sarcoidosis, Behçet disease, radiation
necrosis, venous thrombosis can mimic brain neoplasms
on neuroimaging [1,2]. Some of these diseases have a
benign character and can be managed without exposing
patients to the unnecessary risks of a surgical procedure
[3,4]. On the other hand, certain brain tumors can appear
de novo, in the absence of prior existing lesions, mimick-
ing other diseases [5,6]. Therefore, an accurate and timely
diagnosis is essential in such cases and special techniques
are required for proper differential diagnosis.
We present the case of a patient, without a previous his-
tory of multiple sclerosis, presenting with a large brain
Published: 21 December 2009
Cases Journal 2009, 2:9366 doi:10.1186/1757-1626-2-9366
Received: 30 November 2009
Accepted: 21 December 2009
This article is available from: http://www.casesjournal.com/content/2/1/9366
© 2009 Evangelopoulos et al; licensee BioMed Central Ltd. 
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), 
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 5
(page number not for citation purposes)
Cases Journal 2009, 2:9366 http://www.casesjournal.com/content/2/1/9366lesion mimicking a brain tumor. We discuss the diagnos-
tic process and techniques in the management of tumefac-
tive Multiple Sclerosis.
Case presentation
A previously healthy 23-year-old Caucasian male was
referred to our Emergency Department. Upon admission,
he reported a 3-weeks old history of blurred vision and
instability, lasting for 5 days.
On physical examination, patient's vital signs, ECG and
general medical condition were normal. He was fully alert
and oriented. Neurological examination revealed a left
homonymous hemianopsia. Tendon reflexes were equally
elicited on both sides for upper and lower limbs and a
Babinski sign was detected on the left side. There was not
any bowel or bladder dysfunction. No other motor or sen-
sory deficit was found in the Neurological examination.
Brain MRI presented a large lesion at the right parietal
lobe extending till the temporal lobe with consequent
edema, compressing the posterior aspect of the right ven-
tricle. Few small periventricalar lesions were found in
both cerebral hemispheres as well as in the cerebellum.
No lesion showed gadolinium enhancement (Figure 1).
Staging with thoracic and abdominal CT scans had not
revealed any other lesions. Cervical MRI did not detect
any spinal cord lesions.
Therefore, intracranial lesions such as tumors (CNS Lym-
phoma), abscess, sarcoidosis and demyelinating disease
should lead the differential diagnosis.
Patient's routine blood tests were within normal range.
Mantoux was negative. Serum Sace was normal. Electro-
phoresis and immunoelectrophoresis were mot indicative
of any pathology. CSF examination showed pleiocytosis
(92 cells), mostly lymphocytes and few mononuclear cells
while IgG Index was increased and oligoclonal bands were
positive. Serum viral examination for HIV, HBV, HCV,
HSV1, HSV2 and CMV was negative, while VZV IgG were
detected at remarkably high titers (VZV IgG: 784.84 (pos-
itive: normal values < 60)
Visual and auditory evoqued potentials did not show any
delayed responses. Visual fields examination showed left
homonymous hemianopsia (Figure 2).
After thorough examination of all clinical radiological
and laboratory findings, (negative staging, increased sig-
nal intensity in T2W and Flair sequences, CSF examina-
tion), our differential diagnosis was mainly limited to a
primary brain tumor, or to tumefactive Multiple Sclerosis.
Accordingly, we proceeded to a Spectroscopic MRI [7].
The extensive lesion of the right hemisphere showed a
decrease in the concentration of N-acetylaspartate and cre-
atine, while a 50% increase in the concentration of
choline was detected. No differences were found in the
concentration of myoinositol between the two hemi-
spheres. Several small lesions were found in the white
matter of both cerebral hemispheres and the cerebellum,
indicative of a demyelinating disease (Figure 3, Figure 4,
Figure 5).
The patient received cortisol i.v., 1 gr Solumedrole i.v. for
5 days, substituted by per os administered cortisol. His
neurological status gradually improved. During a five year
follow up, he had no relapses and brain MRI showed a
considerable decrease of the size of the tumor like demy-
elinating lesion.
Discussion
Homonymous hemianopsia (HH) is the commonest
form of acquired homonymous visual field defect. The
most common causes of HH are stroke, head injury and
intracranial tumors [8]. HH has been related to neurosar-
coidosis [9]. Symptomatic homonymous visual field
defects are relatively rare in MS, encountered in 1% of
patients. On the other hand, single, rare, tumor-like MS
lesions may present with uncommon symptoms, includ-
ing HH [10-14].
In our case, the patient presented with left homonymous
hemianopsia due to a demyelinating lesion of the right
MRI upon admission: T2W & Flair sequences revealed a lesion extending from the right parietal to the t mporal lobe, compr ssing the p sterior aspect of th  right ventricleFigur  1
MRI upon admission: T2W & Flair sequences 
revealed a lesion extending from the right parietal to 
the temporal lobe, compressing the posterior aspect 
of the right ventricle. No lesion showed gadolinium 
enhancement.Page 2 of 5
(page number not for citation purposes)
Cases Journal 2009, 2:9366 http://www.casesjournal.com/content/2/1/9366hemisphere mimicking brain tumour. Although he had
no history of multiple sclerosis and hemianopsia is a rel-
atively unusual first manifestation of this disease, oligocli-
nal bands were positive and IgG index was increased.
Visual fields were normal four months after the episode.
During a five year follow up after the episode, the patient
remained free of any neurological symptoms (Figure 6).
Diagnostically, MRI imaging of tumor like demyelinating
lesions (TLDL) resemble brain tumors, and diagnosis is
quite difficult [1]. The use of additional techniques may
assist to distinguish the nature of these lesions. Perfusion-
Weighted MRI (PWI), proton Magnetic Resonance Spec-
troscopy (MRS) as well as Thallium-201 Single-Photon
Emission Computed Tomography (SPECT) and 18-FDG
Positron Emission Tomography (PET), may be applied for
an accurate differential diagnosis of a brain tumor [7]. In
our case, MRS gave a detailed description of the lesion and
assisted the final diagnosis. A common finding of the
acute MS lesion is the reduced NAA levels due to axonal
damage and neuronal mitochondrial dysfunction which
is proposed to be reversible over time. Furthermore, eleva-
tion of choline is consistently found in acute MS lesions
probably due to reactive astrogliosis and demyelination
[15].
Conclusion
Treating physicians should always bear in mind of tume-
factive MS when encountering a cerebral lesion, since
Visual fields revealing left homonymous hemianopsiaF gure 2
Visual fields revealing left homonymous hemianopsia.
MRI spectroscopyFigure 3
MRI spectroscopy.Page 3 of 5
(page number not for citation purposes)
Cases Journal 2009, 2:9366 http://www.casesjournal.com/content/2/1/9366despite the demanding differential diagnosis by means of
special techniques, this disease has a benign character and
can be managed without exposing patients to the unnec-
essary risks of a surgical procedure.
Abbreviations
CMV: cytomegalovirus; CSF: cerebrospinal fluid; CT: com-
puter tomography; ECG: electrocardiogram; FDG: 18-
fluorodeoxyglucose; HBV: hepatitis B virus; HCV: hepati-
tis C virus; HH: homonymous hemianopsia; HIV: human
immunodeficiency virus; HSV1: herpes virus 1; HSV2:
herpes virus 2; IV: intravenous; MRI: magnetic resonance
imaging; MRS: proton magnetic resonance spectroscopy;
PWI: perfusion-weighted MRI; SPECT: single-photon
emission computed tomography; PET: positron emission
tomography; VZV: varicella zoster virus.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
MEE, CP and CS were the treating physicians. MEE and
DSE involved in acquisition of data. MEE, DSE, and CS
involved in drafting of the manuscript. All authors read
and approved the final manuscript.
Consent
Written informed consent was obtained from the patient
for publication of this case report and any accompanying
MRI spectroscopyFigure 4
MRI spectroscopy.
MRI spectroscopyFigure 5
MRI spectroscopy.
MRI at 5 year follow-upFigure 6
MRI at 5 year follow-up.Page 4 of 5
(page number not for citation purposes)
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Homonymous hemianopsia as the leading symptom of a tumor like demyelinating lesion: a case report

Crossref

Akashi T: A case of multiple sclerosis with homonymous hemianopia examined by positron emission tomography.

Alexia without agraphia in multiple sclerosis: case report with magnetic resonance imaging localization. Mult Scler

Biousse V: Homonymous hemianopia in stroke.

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Debulking or biopsy of malignant glioma in elderly people: a randomised study. Acta Neurochir (Wien)

Delattre JY: Pitfalls in the diagnosis of brain tumours. Lancet Neurol

DL: In vivo differentiation of astrocytic brain tumors and isolated demyelinating lesions of the type seen in multiple sclerosis using 1H magnetic resonance spectroscopic imaging. Ann Neurol

Leff AP: Rehabilitation of hemianopia.

Mehdorn HM: Spontaneous intracranial haematomas caused by neoplasms. Acta Neurochir (Wien)

O: Diagnostic delay in primary central nervous system lymphoma. Acta Oncol

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S: The neuro-ophthalmology of multiple sclerosis. Lancet Neurology

Stereotactic biopsy in the era of advanced neuroimaging. Does the minimal therapeutic gain justify its current wide use? Minim Invasive Neurosurg

T: A case of multiple sclerosis with incongruous homonymous hemianopia due to lateral geniculate body lesion. Rinsho Shinkeigaku

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Homonymous hemianopsia as the leading symptom of a tumor like demyelinating lesion: a case report

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