title: MR spectroscopy of intracranial tuberculomas: A singlet peak at 3.8 ppm as potential marker to differentiate them from malignant tumors.
abstract: OBJECTIVE
  The diagnosis of intracranial tuberculomas is often challenging. Our purpose is to describe the most common metabolic patterns of tuberculomas by MR spectroscopy (MRS) with emphasis on potential specific markers.
  
  
  METHODS
  Single-voxel MRS short echo time was performed in 13 cases of tuberculomas proven by histology and/or response to anti-mycobacterial therapy. For comparison MRS was also performed in 19 biopsy-proven malignant tumors (13 high-grade gliomas and six metastasis). Presence of metabolic peaks was assessed visually and categorical variables between groups were compared using chi-square. Metabolite ratios were compared using Mann-Whitney test and diagnostic accuracy of the metabolite ratios was compared using receiver-operating characteristic (ROC) curves analysis.
  
  
  RESULTS
  Spectroscopic peaks representing lipids and glutamate/glutamine (Glx) as well as a peak at ∼3.8 ppm were well defined in 77% (10/13), 77% (10/13) and 69% (nine of 13) of tuberculomas, respectively. Lipid and Glx peaks were also present in most of the malignant lesions, 79% (15/19) and 74% (14/19) respectively. However, a peak at ∼3.8 ppm was present in only 10% (two of 19) of the tumor cases (p < 0.001). Higher Cho/Cr and mI/Cr ratios helped discriminate malignant lesions with an area under the ROC curve of 0.86 (SE: 0.078, p < 0.002, CI: 0.7-1) and 0.8 (SE: 0.1, p < 0.009, CI: 0.6-1), respectively. Threshold values between 1.7-1.9 for Cho/Cr and 0.8-0.9 for mI/Cr provided high specificity (91% for both metabolites) and adequate sensitivity (75% and 80%, respectively) for discrimination of malignant lesions.
  
  
  CONCLUSIONS
  A singlet peak at ∼3.8 ppm is present in the majority of tuberculomas and absent in most malignant tumors, potentially a marker to differentiate these lesions. The assignment of the peak is difficult from our analysis; however, guanidinoacetate (Gua) is a possibility. Higher Cho/Cr and mI/Cr ratios should favor malignant lesions over tuberculomas. The presence of lipids and Glx is non-specific.
authors.affiliation: Section of Neuroradiology, Department of Radiology, University of Cincinnati Medical Center, USA moralehc@ucmail.uc.edu.
authors.forename: Humberto
authors.initials: H
authors.lastname: Morales
authors.affiliation: Centro de Resonancia Magnetica (CEREMA), Peru.
authors.forename: David
authors.initials: D
authors.lastname: Alfaro
authors.affiliation: Centro de Resonancia Magnetica (CEREMA), Peru.
authors.forename: Carlos
authors.initials: C
authors.lastname: Martinot
authors.affiliation: Department of Radiology, Hospital Quiron, Spain.
authors.forename: Nicolas
authors.initials: N
authors.lastname: Fayed
authors.affiliation: Section of Neuroradiology, Department of Radiology, University of Cincinnati Medical Center, USA.
authors.forename: Mary
authors.initials: M
authors.lastname: Gaskill-Shipley
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D001932:Brain Neoplasms / Q000175:diagnosis* / Q000556:secondary; D002648:Child; D002675:Child, Preschool; D003937:Diagnosis, Differential; D005260:Female; D005910:Glioma / Q000175:diagnosis*; D006801:Humans; D009682:Magnetic Resonance Spectroscopy; D008297:Male; D008875:Middle Aged; D012372:ROC Curve; D012680:Sensitivity and Specificity; D016862:Tuberculoma, Intracranial / Q000175:diagnosis*; D055815:Young Adult
keywords: MR spectroscopy; high-grade glioma; intracranial tuberculoma; metastasis