Radiology Commons^™

Bleeding Stomal Varices In Portal Hypertension, Karen Tran-Harding, Michael A. Winkler, Driss Raissi

Radiology Faculty Publications

We report a case of a 50-year-old man with a history of liver cirrhosis and colon cancer post end colostomy presenting to the emergency department with stomal bleeding and passage of clots into the colostomy bag. The patient was treated with transjugular intrahepatic portosystemic shunt (TIPS) and concomitant embolization of the stomal varices via the TIPS shunt using N-butyl cyanoacrylate mixed with ethiodol. Although stomal variceal bleeding is uncommon, this entity can have up to 40% mortality upon initial presentation, given the challenges in diagnosis and management. Currently, there are no established standard treatments for stomal variceal bleeding. In addition, …

Patient And Hospital Characteristics Predictive Of Inferior Vena Cava Filter Usage In Venous Thromboembolism Patients: A Study From The 2013 To 2014 Nationwide Readmissions Database, Amie Goodin, Ming Chen, Driss Raissi, Qiong Han, Hong Xiao, Joshua Brown

Radiology Faculty Publications

To examine the association between patient and hospital characteristics and inferior vena cava filter (IVCF) utilization in patients with venous thromboembolism (VTE).

The 2013 to 2014 Nationwide Readmissions Database was used to define a cohort of patients with VTE aged ≥ 18 after a primary VTE diagnosis. Comorbidities of interest were classified via diagnosis codes and IVCF placement was identified via procedure code. Chi square analysis tested differences between patient and hospital-level characteristics and whether or not IVCFs were placed. A hierarchical logistic regression model estimated the relationship between patient-level factors (demographics, socioeconomic status, comorbidities), hospital-level factors (bed size, teaching …

Mri Of Suspected Appendicitis During Pregnancy: Interradiologist Agreement, Indeterminate Interpretation And The Meaning Of Non-Visualization Of The Appendix, Richard Tsai, Constantine Raptis, Kathryn J. Fowler, Joseph W. Owen, Vincent M. Mellnick

Radiology Faculty Publications

Objective: To determine the degree of interradiologist agreement between the MRI features of appendicitis during pregnancy, the outcomes associated with an indeterminate interpretation and the negative predictive value of non-visualization of the appendix.

Methods: Our study was approved by the institutional review board at the Washington University in St. Louis, Missouri (WUStL) and was HIPAA (Health Insurance Portability and Accountability Act of 1996)-compliant. The informed consent requirement was waived. Cases of suspected appendicitis during pregnancy evaluated using MRI were retrospectively identified using search queries. Scans were re-reviewed by two radiologists (7 and 9 years experience, respectively) to evaluate the interradiologist …

Robust Head Ct Image Registration Pipeline For Craniosynostosis Skull Correction Surgery, Shusil Dangi, Hina Shah, Antonio Porras, Beatriz Paniagua, Cristian Linte, Marius George Linguraru, Andinent Enquobahrie

Radiology Faculty Publications

Craniosynostosis is a congenital malformation of the infant skull typically treated via corrective surgery. To accurately quantify the extent of deformation and identify the optimal correction strategy, the patient-specific skull model extracted from a pre-surgical computed tomography (CT) image needs to be registered to an atlas of head CT images representative of normal subjects. Here, the authors present a robust multi-stage, multi-resolution registration pipeline to map a patient-specific CT image to the atlas space of normal CT images. The proposed registration pipeline first performs an initial optimisation at very low resolution to yield a good initial alignment that is subsequently …

Gastrointestinal Bleeding From Supraduodenal Artery With Aberrant Origin, Qiong Han, Chenghao Qian, Gaby Gabriel, Steven Krohmer, Driss Raissi

Radiology Faculty Publications

Angiography and endovascular embolization play an important role in controlling acute arterial upper gastrointestinal hemorrhage, particularly when endoscopic intervention fails to do so. In our case, the patient presented with recurrent life-threatening bleed in spite of multiple prior endoscopic interventions and gastroduodenal artery embolization. Our teaching points focus on the role of angiography in acute upper gastrointestinal bleed and when to conduct empiric embolization, while reviewing the supraduodenal artery as an atypical but important potential culprit for refractory upper gastrointestinal bleed.

Breast Cancer Screening In Patients With Newly Diagnosed Lung And Colorectal Cancer: A Population-Based Study Of Utilization, Gelareh Sadigh, Ruth C. Carlos, Kevin C. Ward, Jeffrey M. Switchenko, Renjian Jiang, Kimberly E. Applegate, Richard Duszak Jr.

Radiology Faculty Publications

Purpose—To assess breast cancer screening utilization in Medicare beneficiaries with colorectal and lung cancer versus cancer-free controls.

Methods—Female fee-for-service Medicare beneficiaries who were ≥ 67 years old and diagnosed with lung or colorectal cancer between 2000 and 2011 and who reported to a Surveillance, Epidemiology, and End Results (SEER) registry (case group) were followed for 2 years after their diagnoses, unless death, a diagnosis of breast cancer, or the end of 2013 came first. A similar number of cancer-free controls were individually matched to cases by age, race, registry region, and follow-up time. Screening utilization was defined as …

Primary Lung Carcinoid Metastatic To The Breast, Marianna Zagurovskaya, Karen Tran-Harding, Richard Gibbs

Radiology Faculty Publications

Lung carcinoid tumors account for approximately 2% of lung cancers, with 10% of the tumors represented by the atypical type. While atypical carcinoids are metastatic to intrathoracic lymph nodes in approximately half of the cases on the initial presentation, distant metastases are seen in only 20% of the patients and are found most frequently in bones, liver, adrenal glands, and brain. We present a case of an unusual metastatic disease to the breast in 51-year-old female who developed a new breast mass 2 years after left lower lobectomy due to atypical carcinoid tumor. Atypical pulmonary carcinoid metastases to the breast …

The Use Of Intraosseous Needles For Injection Of Contrast Media For Computed Tomographic Angiography Of The Thoracic Aorta, Michael A. Winkler, Cynthia Talley, Connor Woodward, Alexander Kingsbury, Frank Appiah, Hossam Elbelasi, Kevin P. Landwehr, Xingzhe Li, Dominik Fleischmann

Radiology Faculty Publications

Background

The objective of this study is to evaluate the safety and quality of computed tomographic angiography of the thoracic aorta (CTA-TA) exams performed using intraosseous needle intravenous access (ION-IVA) for contrast media injection (CMI).

Methods

All CTA-TA exams at the study institution performed between 1/1/2013 and 8/14/2015 were reviewed retrospectively to identify those exams which had been performed using ION-IVA (ION-exams). ION-exams were then analyzed to determine aortic attenuation and contrast-to-noise ratio (CNR). Linear regression was used to determine how injection rate and other variables affected image quality for ION-exams. Patient electronic medical records were reviewed to identify any …

Altered Cerebellar Biochemical Profiles In Infants Born Prematurely, Marie Brossard-Racine, Jonathan Murnick, Marine Bouyssi-Kobar, Janie Coloumbe, Taeun Chang, Catherine Limperopoulos

Radiology Faculty Publications

This study aims to compare the cerebellar biochemical profiles in preterm (PT) infants evaluated at term equivalent age (TEA) and healthy full-term newborns using proton magnetic resonance spectroscopy (1H-MRS). We explore the associations between altered cerebellar metabolite profiles and brain injury topography, severity of injury, and prematurity-related clinical complications. We prospectively collected high quality 1H-MRS in 59 premature infants born ≤32 weeks and 61 healthy full term controls. 1H-MRS data were processed using LCModel software to calculate absolute metabolite concentration for N-acetyl-aspartate (NAA), choline (Cho) and creatine (Cr). PT infants had significantly lower cerebellar NAA (p < 0.025) and higher Cho (p < 0.001) at TEA when compared to healthy controls. Creatine was not different between the two groups. The presence of cerebellar injury was consistently associated with reduced concentrations for NAA, Cho, and Cr. Postnatal infection was negatively associated with NAA and Cr (p < 005), while cerebral cortical brain injury severity was inversely associated with both Cho and Cr (p < 0.01). We report for the first time that premature birth is associated with altered cerebellar metabolite profiles when compared to term born controls. Infection, cerebellar injury and supratentorial injury are important risk factors for impaired preterm cerebellar biochemistry.

Ureterovaginal Fistula Secondary To Retained Vaginal Foreign Body In A Young Girl, Anjum Bandarkar, Adebunmi O. Adeyiga, Eglal Shalaby-Rana

Radiology Faculty Publications

We present the case of a 13-year-old girl with a recurrent urinary tract infection, malodorous vaginal discharge, and urinary incontinence caused by a retained vaginal foreign body. The foreign body, an aerosol cap retained for over 2 years, resulted in the formation of a ureterovaginal fistula, an extremely rare complication. The critical value of ultrasound and magnetic resonance urography in delineating the foreign body, the fistulous tract, and the intraperitoneal urine leak is described. Through this unique diagnostic dilemma, we wish to highlight that the evaluation of persistent unusual urinary symptoms and vaginal discharge in a young girl must include …

Ct And Pet Findings For Urachal Adenocarcinoma: A Case Report, Merissa Zeman, Ethan Silver, Esma A. Akin

Radiology Faculty Publications

As urachal adenocarcinomas are rare cancers, experience with diagnosing and staging them are limited. To help illustrate CT and PET imaging findings and the role they each play in the workup of urachal adenocarcinomas, we present the case of a 43 y.o. male who was diagnosed at our institution with a T3aN0M0 high grade mucin-producing urachal adenocarcinoma.

Composite Iron Oxide–Prussian Blue Nanoparticles For Magnetically Guided T1-Weighted Magnetic Resonance Imaging And Photothermal Therapy Of Tumors, Shraddha Kale, Rachel Burga, Elizabeth E. Sweeney, Zungho Zun, Raymond Sze, Anthony Tuesca, J Anand Subramony, Rohan Fernandes

Radiology Faculty Publications

Theranostic nanoparticles offer the potential for mixing and matching disparate diagnostic and therapeutic functionalities within a single nanoparticle for the personalized treatment of diseases. In this article, we present composite iron oxide-gadolinium-containing Prussian blue nanoparticles (Fe3O4@GdPB) as a novel theranostic agent for T1-weighted magnetic resonance imaging (MRI) and photothermal therapy (PTT) of tumors. These particles combine the well-described properties and safety profiles of the constituent Fe3O4 nanoparticles and gadolinium-containing Prussian blue nanoparticles. The Fe3O4@GdPB nanoparticles function both as effective MRI contrast agents and PTT agents as determined by characterizing studies performed in vitro and retain their properties in the presence …

Peritoneal Mesothelioma In A Young Woman: Case Report Of Radiopathologic Findings And Review Of The Literature, Amy L Ellenbogen, Stephanie Barak, Esma A. Akin

Radiology Faculty Publications

Peritoneal mesothelioma is a rare diagnosis most often seen in middle-aged men and exceedingly rarely in individuals in their teens and twenties. Diagnosis is often delayed secondary to nonspecific presenting symptoms and a misconception that there must be a history of asbestos exposure to garner such a diagnosis. Here, we present the case of a 21 year-old female with a histologically confirmed diagnosis of peritoneal mesothelioma and review the key radiologic and histologic findings of this rare diagnosis.

New Findings, Classification And Long-Term Follow-Up Study Based On Mri Characterization Of Brainstem Encephalitis Induced By Enterovirus 71, Hongwu Zeng, Feiqiu Wen, Wenxian Huang, Yungen Gan, Weibin Zeng, Ranran Chen, Yanxia He, Yonker Wang, Zaiyi Liu, Changhong Liang, Kelvin K. L. Wong

Radiology Faculty Publications

Background To report the diversity of MRI features of brainstem encephalitis (BE) induced by Enterovirus 71. This is supported by implementation and testing of our new classification scheme in order to improve the diagnostic level on this specific disease.

Methods Neuroimaging of 91 pediatric patients who got EV71 related BE were hospitalized between March, 2010 to October, 2012, were analyzed retrospectively. All patients underwent pre- and post-contrast MRI scan. Thereafter, 31 patients were randomly called back for follow-up MRI study during December 2013 to August 2014. The MRI signal patterns of BE primary lesion were analyzed and classified according to …

Method And Phantom To Study Combined Effects Of In-Plane (X,Y) And Z-Axis Resolution For 3d Ct Imaging., David Goodenough, Josh Levy, Smari Kristinsson, Jesper Fredriksson, Hildur Olafsdottir, Austin Healy

Radiology Faculty Publications

Increasingly, the advent of multislice CT scanners, volume CT scanners, and total body spiral acquisition modes has led to the use of Multi Planar Reconstruction and 3D datasets. In considering 3D resolution properties of a CT system it is important to note that both the in-plane (x,y) and z-axis (slice thickness) influence the visual-ization and detection of objects within the scanned volume. This study investigates ways to consider both the in-plane resolution and the z-axis resolution in a single phantom wherein analytic or visualized analysis can yield information on these combined effects. A new phantom called the "Wave Phantom" is …

Prospective Evaluation Of The Influence Of Iterative Reconstruction On The Reproducibility Of Coronary Calcium Quantification In Reduced Radiation Dose 320 Detector Row Ct., Andrew D Choi, Eric S Leifer, Jeannie Yu, Sujata M Shanbhag, Kathie Bronson, Andrew E Arai, Marcus Y Chen

Radiology Faculty Publications

BACKGROUND: Coronary artery calcium (CAC) predicts coronary heart disease events and is important for individualized cardiac risk assessment. This report assesses the interscan variability of CT for coronary calcium quantification using image acquisition with standard and reduced radiation dose protocols and whether the use of reduced radiation dose acquisition with iterative reconstruction (IR; "reduced-dose/IR ") allows for similar image quality and reproducibility when compared to standard radiation dose acquisition with filtered back projection (FBP; "standard-dose/FBP") on 320-detector row computed tomography (320-CT).

METHODS: 200 consecutive patients (60 ± 9 years, 59% male) prospectively underwent two standard- and two reduced-dose acquisitions (800 …

Prospective Evaluation Of The Influence Of Iterative Reconstruction On The Reproducibility Of Coronary Calcium Quantification In Reduced Radiation Dose 320 Detector Row Ct., Andrew D. Choi, Eric S Leifer, Jeannie Yu, Sujata M Shanbhag, Kathie Bronson, Andrew E Arai, Marcus Y Chen

Radiology Faculty Publications

BACKGROUND: Coronary artery calcium (CAC) predicts coronary heart disease events and is important for individualized cardiac risk assessment. This report assesses the interscan variability of CT for coronary calcium quantification using image acquisition with standard and reduced radiation dose protocols and whether the use of reduced radiation dose acquisition with iterative reconstruction (IR; "reduced-dose/IR ") allows for similar image quality and reproducibility when compared to standard radiation dose acquisition with filtered back projection (FBP; "standard-dose/FBP") on 320-detector row computed tomography (320-CT).

METHODS: 200 consecutive patients (60 ± 9 years, 59% male) prospectively underwent two standard- and two reduced-dose acquisitions (800 …

Mr Imaging Findings In Xp21.2 Duplication Syndrome, Matthew T. Whitehead, Guy Helman, Andrea L. Gropman

Radiology Faculty Publications

Xp21.2 duplication syndrome is a rare genetic disorder of undetermined prevalence and clinical relevance. As the use of chromosomal microarray has become first line for the work-up of childhood developmental delay, more gene deletions and duplications have been recognized. To the best of our knowledge, the imaging findings of Xp21.2 duplication syndrome have not been reported. We report a case of a 33 month-old male referred for developmental delay that was found to have an Xp21.2 duplication containing IL1RAPL1 and multiple midline brain malformations.

Mri Signal Intensity Differentiation Of Brainstem Encephalitis Induced By Enterovirus 71: A Classification Approach For Acute And Convalescence Stages, Hongwu Zeng, Wenxian Huang, Feiqiu Wen, Yonker Wang, Yungen Gan, Weibin Zeng, Ranran Chen, Yanxia He, Zaiyi Liu, Changhong Liang, Kelvin K. L. Wong

Radiology Faculty Publications

Background: The objective of this study is to assess standardized histograms of signal intensities of T1 signal and T2 signal on sagittal view without enhancement during (1) acute stage, and (2) convalescence stage of pediatric patients with Enterovirus 71 related brainstem encephalitis (BE), and with respect to (3) healthy normal.

Methods: Our subjects were hospitalized between March 2010 and October 2012, and underwent pre- and post-contrast MRI studies. The research question to be answered is whether the comparison of the MRI image intensity histograms and relevant statistical quantification can add new knowledge to the diagnosis of BE patients. So, both …

Comparison Of Drug Delivery With Autoinjector Versus Manual Prefilled Syringe And Between Three Different Autoinjector Devices Administered In Pig Thigh, Robert Hill, John Wilmot, Beth Belluscio, Kevin Cleary, David Lindisch, Robin Tucker, Emmanuel Wilson, Rajesh Shukla

Radiology Faculty Publications

Parenteral routes of drug administration are often selected to optimize actual dose of drug delivered, assure high bioavailability, bypass first-pass metabolism or harsh gastrointestinal environments, as well as maximize the speed of onset. Intramuscular (IM) delivery can be preferred to intravenous delivery when initiating intravenous access is difficult or impossible. Drugs can be injected intramuscularly using a syringe or an automated delivery device (autoinjector). Investigation into the IM delivery dynamics of these methods may guide further improvements in the performance of injection technologies. Two porcine model studies were conducted to compare differences in dispersion of injectate volume for different methods …

A Single Baseline Ultrasound Assessment Of Fibroid Presence And Size Is Strongly Predictive Of Future Uterine Procedure: 8-Year Follow-Up Of Randomly Sampled Premenopausal Women Aged 35-49 Years., Donna D. Baird, T M Saldana, D L Shore, Michael C. Hill, J M Schectman

Radiology Faculty Publications

STUDY QUESTION: How well can a single baseline ultrasound assessment of fibroid burden (presence or absence of fibroids and size of largest, if present) predict future probability of having a major uterine procedure?

SUMMARY ANSWER: During an 8-year follow-up period, the risk of having a major uterine procedure was 2% for those without fibroids and increased with fibroid size for those with fibroids, reaching 47% for those with fibroids ≥4 cm in diameter at baseline.

WHAT IS KNOWN ALREADY: Uterine fibroids are a leading indication for hysterectomy. However, when fibroids are found, there are few available data to help clinicians …

Functional Properties Of Resting State Networks In Healthy Full-Term Newborns., Josepheen De Asis-Cruz, Marine Bouyssi-Kobar, Iordanis Evangelou, Gilbert Vezina, Catherine Limperopoulos

Radiology Faculty Publications

Objective, early, and non-invasive assessment of brain function in high-risk newborns is critical to initiate timely interventions and to minimize long-term neurodevelopmental disabilities. A prerequisite to identifying deviations from normal, however, is the availability of baseline measures of brain function derived from healthy, full-term newborns. Recent advances in functional MRI combined with graph theoretic techniques may provide important, currently unavailable, quantitative markers of normal neurodevelopment. In the current study, we describe important properties of resting state networks in 60 healthy, full-term, unsedated newborns. The neonate brain exhibited an efficient and economical small world topology: densely connected nearby regions, sparse, but …

Case 213: Primary Spenic Angiosarcoma, John J. Krol, Vera V. Krol, Adrian Dawkins, Halemane S. Ganesh

Radiology Faculty Publications

A 75-year-old woman with a medical history of gastroesophageal reflux disease and type II diabetes presented to the hospital with a 3-month history of gradually worsening headaches, vague upper abdominal pain, and lower back pain. The patient denied fevers, night sweats, contact with sick individuals, occupational exposure to infection, bleeding, immunodeficiency, intravenous drug use, alcohol or tobacco abuse, history of malignancy, family history of genetic disorders, and international travel. Physical examination revealed a skin-colored mass protruding from the right side of her forehead, but there were no other notable abnormalities. Her diabetes was managed with diet, and the only prescription …

Case 213, John J. Krol, Vera V. Krol, Adrian Dawkins, Halemane S. Ganesh

Radiology Faculty Publications

No abstract provided.

Variability In Eit Images Of Lung Ventilation As A Function Of Electrode Planes And Body Positions, Jie Zhang, Robert Patterson

Radiology Faculty Publications

This study is aimed at investigating the variability in resistivity changes in the lung region as a function of air volume, electrode plane and body position. Six normal subjects (33.8 ± 4.7 years, range from 26 to 37 years) were studied using the Sheffield Electrical Impedance Tomography (EIT) portable system. Three transverse planes at the level of second intercostal space, the level of the xiphisternal joint, and midway between upper and lower locations were chosen for measurements. For each plane, sixteen electrodes were uniformly positioned around the thorax. Data were collected with the breath held at end expiration and after …

Manganese-Containing Prussian Blue Nanoparticles For Imaging Of Pediatric Brain Tumors, Matthieu F. Dumont, Sridevi Yadavilli, Raymond Sze, Javad Nazarian, Rohan Fernandes

Radiology Faculty Publications

Pediatric brain tumors (PBTs) are a leading cause of death in children. For an improved prognosis in patients with PBTs, there is a critical need to develop molecularly-specific imaging agents to monitor disease progression and response to treatment. In this paper, we describe manganese-containing Prussian blue nanoparticles as agents for molecular magnetic resonance imaging (MRI) and fluorescence-based imaging of PBTs. Our core-shell nanoparticles consist of a core lattice structure that incorporates and retains paramagnetic Mn²⁺ ions, and generates MRI contrast (both negative and positive). The biofunctionalized shell is comprised of fluorescent avidin, which serves the dual purpose of enabling …

Neuroimaging Of A Pilocytic Astrocytoma With Anaplastic Features And Diffusion Tensor Imaging Characteristics, Lara Walkoff, Andrew J. Degnan, Mark Ghassibi, Robert V. Jones, Jonathan H. Sherman, Lucien M. Levy

Radiology Faculty Publications

We report the magnetic resonance imaging findings of an adult patient with a biopsy-proven pilocytic astrocytoma with anaplastic features. Pilocytic astrocytomas rarely occur in adults, and presentation with anaplastic features such as rapid mitotic activity, hypercellularity, and atypia is particularly uncommon. Accurate neuroimaging diagnosis is essential, but differentiation from more malignant neoplastic lesions may be challenging. Diffusion tensor imaging may potentially provide information on cell proliferation, vascularity, and fiber destruction, which can have implications for treatment and prognosis. In this case, tractography and fractional anisotropy maps demonstrated displacement of adjacent parenchyma and relatively intact fractional anisotropy, which is more suggestive …

Dysembryoplastic Neuroepithelial Tumor With Atypical Presentation: Mri And Diffusion Tensorcharacteristics, Kalyan Paudel, Samuel Borofsky, Robert V. Jones, Lucien M. Levy

Radiology Faculty Publications

We report the neuroimaging findings of a 26-year-old female patient with a biopsy-proven dysembryoplastic neuroepithelial tumor (DNET). DNETs are an uncommon, usually benign, glial-neural cortical neoplasm of children and young adults who typically present with intractable seizures. DNETs may occur in any region of the supratentorial cortex, but have a predilection for the temporal lobes. Accurate neuroimaging diagnosis is essential since patients with DNET benefit from complete resection. However, accurate differentiation from other cortical lesions may be challenging. Typical conventional Magnetic Resonance Imaging (MRI) features can help in the differentiation from other similar cortical tumors. Diffusion tensor imaging can also …

Towards Omni-Tomography -- Grand Fusion Of Multiple Modalities For Simultaneous Interior Tomography, Ge Wang, Jie Zhang, Hao Gao, Victor Weir, Hengyong Yu, Wenxiang Cong, Xiaochen Xu, Haiou Shen, James Bennett, Mark Furth, Yue Wang, Michael Vannier

Radiology Faculty Publications

We recently elevated interior tomography from its origin in computed tomography (CT) to a general tomographic principle, and proved its validity for other tomographic modalities including SPECT, MRI, and others. Here we propose "omni-tomography", a novel concept for the grand fusion of multiple tomographic modalities for simultaneous data acquisition in a region of interest (ROI). Omni-tomography can be instrumental when physiological processes under investigation are multi-dimensional, multi-scale, multi-temporal and multi-parametric. Both preclinical and clinical studies now depend on in vivo tomography, often requiring separate evaluations by different imaging modalities. Over the past decade, two approaches have been used for multimodality …

Neuroimaging Of Tumefactive Multiple Sclerosis With Atypical Features, Rohit Koppula, Andrew J. Degnan, Mark Ghassibi, Peter Duggan, Robert Jones, Lucien M. Levy

Radiology Faculty Publications

Tumefactive demyelinating lesions or tumefactive multiple sclerosis constitute a unique presentation of demyelinating disease which frequently mimics intracranial neoplasm, infection or other, non-demyelinating intracranial pathology. Consequently, these lesions, which are larger than typical multiple sclerosis plaques and generally characterized by certain magnetic resonance imaging features including edema and incomplete ring enhancement, pose a serious diagnostic challenge that frequently prompts biopsy in initial evaluation. Biopsy can be averted when imaging features for tumefactive multiple sclerosis are seen on MRI. Herein, we present a biopsy-proven case of tumefactive multiple sclerosis with atypical imaging features, evaluated using magnetic resonance and diffusion tensor imaging.