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
-
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”
Stay updated, free articles. Join our Telegram channel
-

Full access? Get Clinical Tree

