Cortical Hyperintensity T2/FLAIR

Karen L. Salzman, MD

DIFFERENTIAL DIAGNOSIS

Common

Cerebral Ischemia-Infarction, Acute
Cerebral Contusion
Hypotensive Cerebral Infarction
Status Epilepticus
Herpes Encephalitis

Less Common

Diffuse Astrocytoma, Low Grade
Acute Hypertensive Encephalopathy, PRES
Vasculitis
Oligodendroglioma
Anaplastic Oligodendroglioma
Hypoxic-Ischemic Encephalopathy, NOS
DNET
Pleomorphic Xanthoastrocytoma
Tuberous Sclerosis Complex
Cerebritis
Hypoglycemia

Rare but Important

MELAS (Acute Presentation)
Creutzfeldt-Jakob Disease (CJD)
Dysplastic Cerebellar Gangliocytoma

ESSENTIAL INFORMATION

Key Differential Diagnosis Issues

Vast majority of cortical lesions are related to ischemia & trauma
Remainder of lesions much less common and include primarily tumors & infections
DWI may help differentiate lesions

Helpful Clues for Common Diagnoses

Cerebral Ischemia-Infarction, Acute
- T2 hyperintensity in a typical vascular distribution (ACA, MCA, PCA)
- Wedge-shaped, involves gray matter (GM) & white matter (WM)
- DWI restriction
Cerebral Contusion
- T2 hyperintensity in inferior frontal & temporal lobe GM & subcortical WM
- Blood products nearly always present
- CT: Patchy superficial hemorrhages with surrounding edema
- History of trauma
Hypotensive Cerebral Infarction
- “Border zone” or watershed infarct related to insufficient cerebral blood flow
- T2 hyperintense cortically based, wedge-shaped lesions at border zone between vascular territories
- Edematous gyri with local mass effect
- May involve basal ganglia (BG) & thalamus
- DWI positive acutely
Status Epilepticus
- T2 hyperintensity in GM &/or subcortical WM with mild mass effect
- May focally involve hippocampus or corpus callosum
- DWI positive acutely; variable enhancement
Herpes Encephalitis
- T2 hyperintensity in the limbic system & temporal lobes; DWI positive
- Subtle blood products, patchy enhancement common
- Typically bilateral, but asymmetric
- Acute onset, often with fever; may present with seizures

Helpful Clues for Less Common Diagnoses

Diffuse Astrocytoma, Low Grade
- Infiltrating T2 hyperintense WM mass
- May extend to involve cortex
- No enhancement typical
Acute Hypertensive Encephalopathy, PRES
- Patchy cortical/subcortical PCA territory lesions in a patient with severe acute/subacute hypertension (HTN)
- Parietooccipital T2 hyperintense cortical lesions in 95%
- DWI: Usually normal
- Variable patchy enhancement
- Diverse causes, clinical entities with HTN
Vasculitis
- Multiple small areas of T2 hyperintensity in deep & subcortical WM, often bilateral
- GM involvement common
- DWI positive in acute setting
- Variable enhancement
Oligodendroglioma
- Calcified T2 hyperintense frontal mass
- Slowly growing but diffusely infiltrating cortical/subcortical mass
- Variable enhancement
Anaplastic Oligodendroglioma
- Calcified frontal lobe mass involving cortex/subcortical WM, ± enhancement
- May appear discrete, but always infiltrative
- Difficult to differentiate from oligodendroglioma
Hypoxic-Ischemic Encephalopathy, NOS
- Bilateral cortical involvement common
- Deep gray nuclei often involved
- DWI positive in acute setting
DNET
- Well-demarcated, wedge-shaped “bubbly” cortical mass
- Temporal & parietal lobes most common
- May remodel overlying bone
- Typically a young patient with longstanding seizures
Pleomorphic Xanthoastrocytoma
- Supratentorial T2 hyperintense cortical mass with adjacent enhancing dural “tail”
  
  Only gold members can continue reading. Log In or Register to continue
  Share this:
  Click to share on Twitter (Opens in new window)
  Click to share on Facebook (Opens in new window)
  Related
  
  Related posts:
  
  Falx Lesions Multiple Hypointense Foci on T2 Solitary Parenchymal Calcification Bithalamic Lesions Fusiform Arterial Enlargement Enlarged Neural Foramen
  
  Stay updated, free articles. Join our Telegram channel