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   Table of Contents      
PHOTO ESSAY
Year : 2017  |  Volume : 65  |  Issue : 11  |  Page : 1217-1218

Revisiting the “Tram-Track” sign


1 Department of Ophthlamic Plastic Surgery and Ocular Oncology, Advanced Eye Hospital and Institute, Navi Mumbai, India
2 Department of Radiology, Mayo Clinic, Rochester, MN 55901, USA
3 Clinico Path Labs, Chembur, Mumbai, India

Date of Submission21-Jun-2017
Date of Acceptance28-Aug-2017
Date of Web Publication13-Nov-2017

Correspondence Address:
Akshay Gopinathan Nair
Advanced Eye Hospital and Institute, 30, The Affaires, Palm Beach Road, Sanpada, Sector 17, Navi Mumbai - 400 705, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_510_17

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Keywords: Breast cancer, meningioma, metastasis, neuritis, optic nerve


How to cite this article:
Nair AG, Iyer VR, Gopinathan I. Revisiting the “Tram-Track” sign. Indian J Ophthalmol 2017;65:1217-8

How to cite this URL:
Nair AG, Iyer VR, Gopinathan I. Revisiting the “Tram-Track” sign. Indian J Ophthalmol [serial online] 2017 [cited 2019 Dec 9];65:1217-8. Available from: http://www.ijo.in/text.asp?2017/65/11/1217/218067

A 55-year-old female presented with a 3-week-old history of sudden decrease in vision in the right eye. Visual acuity was 20/1200 (right eye) and 20/20 (left eye). A relative afferent pupillary defect, proptosis of 2 mm, and disc edema were noted in the right eye [Figure 1a].
Figure 1: (a) Disc edema in the right eye. (b) Is a coronal, postcontrast fat-suppressed T1-weighted image showing enhancement and thickening of the right optic nerve sheath with the central nonenhancing nerve

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On magnetic resonance imaging, T1-weighted [Figure 1]b and fat-suppressed T2-weighted images [Figure 2]a and [Figure 2]b demonstrated irregular nodular thickening along the right optic nerve (arrows) with a T2-hypointense nodular deposit on the optic nerve sheath (arrow, 2B). Postcontrast fat-suppressed axial T1-weighted contiguous images [Figure 2]c and [Figure 2]d demonstrate irregular peripheral enhancement of the nodular region (arrow, 2C). In addition, marked enhancement and thickening of the right optic nerve sheath with the central nonenhancing nerve can be seen (arrow, 2D). While an optic nerve sheath meningioma was being considered as a likely diagnosis, a detailed systemic history gave a significant finding: the patient had a history of undergoing lumpectomy, chemotherapy, and radiation to the left breast, six years ago for invasive ductal carcinoma (T2N0M0). On examination, a firm lump was palpable in the left breast. On positron emission tomography imaging, “hot spots” were found in the left breast, liver, right orbit, and multiple bony sites. Percutaneous liver biopsy confirmed the diagnosis of metastatic breast cancer. A cerebrospinal fluid analysis was done subsequently, as requested by the treating oncologist, as a part of her systemic chemotherapy, which was positive for tumor cells. Therefore, this classic “tram-track” appearance [Figure 2]d was due to leptomeningeal carcinomatosis from breast cancer.
Figure 2: (a and b) are axial T1-weighted and fat-suppressed T2-weighted images, respectively, which show irregular nodular thickening along the right optic nerve (arrows) with a T2-hypointense nodular deposit on the optic nerve sheath (arrow, 2b). Postcontrast fat-suppressed axial T1-weighted contiguous images through the orbit (c and d) demonstrate irregular peripheral enhancement of the nodular region (arrow, 2c). The classical tram-track appearance is seen in figure 2D (arrow)

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The optic nerve tram-track sign is most commonly seen in optic nerve sheath meningiomas, which typically cause segmental or circumferential enlargement of the optic nerve sheath. On contrast imaging, the nerve can be seen as an unenhanced central linear structure surrounded by the enhanced meningioma.[1] Other conditions which can present with a tram-track appearance of the optic nerve include inflammatory diseases such as demyelinating optic neuritis, sarcoidosis, idiopathic orbital inflammatory disease, perioptic hemorrhage, leukemic infiltration, Erdheim–Chester disease, and metastases.[2],[3]

Metastases from the breast to the optic nerve can mimic optic nerve sheath meningiomas.[4],[5] Generally speaking, metastases of breast cancer account for the majority of ocular and orbital metastases; however, breast cancer metastasizing specifically to the optic nerve is uncommon, with only a handful of cases being reported.[6] Furthermore, recurrent breast cancer presenting as vision loss is decidedly rare and can exhibit the tram-track sign on imaging.[4],[7]


  Conclusion Top


Tram-track sign may be a radiological feature of optic nerve metastasis from breast cancer

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Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Kanamalla US. The optic nerve tram-track sign. Radiology 2003;227:718-9.  Back to cited text no. 1
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2.
Gala F. Magnetic resonance imaging of optic nerve. Indian J Radiol Imaging 2015;25:421-38.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Johns TT, Citrin CM, Black J, Sherman JL. CT evaluation of perineural orbital lesions: Evaluation of the “tram-track” sign. AJNR Am J Neuroradiol 1984;5:587-90.  Back to cited text no. 3
[PUBMED]    
4.
Fox B, Pacheco P, DeMonte F. Carcinoma of the breast metastatic to the optic nerve mimicking an optic nerve sheath meningioma: Case report and review of the literature. Skull Base 2005;15:281-7.  Back to cited text no. 4
[PUBMED]    
5.
Backhouse O, Simmons I, Frank A, Cassels-Brown A. Optic nerve breast metastasis mimicking meningioma. Aust N Z J Ophthalmol 1998;26:247-9.  Back to cited text no. 5
[PUBMED]    
6.
Font RL, Ferry AP. Carcinoma metastatic to the eye and orbit III. A clinicopathologic study of 28 cases metastatic to the orbit. Cancer 1976;38:1326-35.  Back to cited text no. 6
[PUBMED]    
7.
Cherekaev VA, Lasunin NV, Stepanian MA, Rotin DL, Grigor'eva NN, Vetlova ER, et al. Breast carcinoma metastasis to the optic nerve: Case report and review of literature. Zh Vopr Neirokhir Im N N Burdenko 2013;77:42-8.  Back to cited text no. 7
    


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