Effaced Sulci, Focal



Effaced Sulci, Focal


Anne G. Osborn, MD, FACR



DIFFERENTIAL DIAGNOSIS


Common



  • Cortical Contusion


  • Cerebral Ischemia-Infarction, Acute


  • Spontaneous Intracranial Hemorrhage


  • Subdural Hematoma


  • Epidural Hematoma


  • Neurocysticercosis


Less Common



  • Primary CNS Neoplasm



    • Meningioma


    • Oligodendroglioma


    • Ganglioglioma


    • Diffuse Astrocytoma, Low Grade


    • DNET


    • Pleomorphic Xanthoastrocytoma


  • Metastases, Parenchymal


  • Metastases, Skull and Meningeal


  • Abscess


  • Meningitis


  • Focal Cortical Dysplasia


  • Tuberous Sclerosis Complex


  • Thrombosed Cortical Vein(s)


Rare but Important



  • Extra-Axial Empyema


  • Meningioangiomatosis


  • Superficial Siderosis


ESSENTIAL INFORMATION


Key Differential Diagnosis Issues



  • Focal = one or several sulci (not hemisphere or whole brain)


  • Key concept: Is sulcal effacement caused by lesion within sulcus itself or underlying gyrus?



    • Intra- vs. extra-axial causes


    • Parenchymal > > sulcal disease


  • Imaging



    • Sulcal, gyral masses can be isodense on NECT, isointense on T1-weighted MR → difficult to detect!!


    • CECT, T2WI, FLAIR, T1 C+ scans most helpful


Helpful Clues for Common Diagnoses



  • Cortical Contusion



    • History of closed head injury


    • Heterogeneous hyper-/hypodense swollen gyri


    • Look for focal traumatic SAH adjacent to contusions


  • Cerebral Ischemia-Infarction, Acute



    • Cortical branch occlusion → gyral swelling


    • Difficult to see on NECT, T1/T2WI


    • DWI helps distinguish ischemia (restricts) from neoplasm (usually doesn’t)


  • Spontaneous Intracranial Hemorrhage



    • Children/young adult



      • Vascular malformation, venous occlusion, drug abuse


    • Middle-aged, older adults



      • Amyloid angiopathy, hypertension


      • Hemorrhagic neoplasm (metastasis, GBM)


  • Subdural Hematoma



    • Usually crescentic, spreads over hemisphere → more generalized sulcal effacement


    • Occasionally focal, mimics EDH


  • Epidural Hematoma



    • Focal, biconvex extra-axial hematoma


    • Severe compression of underlying sulci


    • Mimics: Plasmacytoma, extra-medullary hematopoiesis, etc.


  • Neurocysticercosis



    • NCC cysts typically in subarachnoid spaces, depths of sulci


    • Intense pial inflammatory reaction may efface sulci


Helpful Clues for Less Common Diagnoses



  • Primary CNS Neoplasms



    • Any cortical, subcortical neoplasm causes local mass effect, expanded parenchyma/compressed sulci


    • Age, history helpful



      • Child, young adult with longstanding seizures: Ganglioglioma (cyst, Ca++ common), DNET (“bubbly” appearance), low grade astrocytoma


      • Adult: Meningioma (dural-based, often Ca++), oligodendroglioma (Ca++ common, variable enhancement), PXA (look for “dural tail”)


  • Metastases, Parenchymal



    • May cause focal mass, variable edema


    • Almost always enhances


  • Metastases, Skull and Meningeal



    • Dural-based, usually isodense/isointense with brain


    • Look for skull lesions



  • Abscess



    • Gray-white junction common site


    • Early stage (cerebritis) typically does not enhance


    • Late cerebritis/capsule stages → ring-enhancement


    • Sulci compressed but don’t enhance unless meningitis also present


    • DWI shows restriction early, helps distinguish abscess from neoplasm


  • Meningitis



    • Diffuse > focal, symmetric > asymmetric


    • Rarely affects solitary sulci; multiple adjacent sulci typically involved


    • FLAIR, T1 C+ scans best for detecting subtle disease


  • Focal Cortical Dysplasia

Aug 7, 2016 | Posted by in NEUROLOGY | Comments Off on Effaced Sulci, Focal

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