Periventricular Enhancing Lesions



Periventricular Enhancing Lesions


Bronwyn E. Hamilton, MD



DIFFERENTIAL DIAGNOSIS


Common



  • Multiple Sclerosis


  • ADEM


  • Lymphoma, Primary CNS


Less Common



  • Glioblastoma Multiforme


  • Abscess


  • Toxoplasmosis, Acquired


  • Germinoma


  • Metastases, Parenchymal


  • Vasculitis


  • Lyme Disease


  • Ependymoma


Rare but Important



  • Leukemia


  • Susac Syndrome


  • Alexander Disease


  • Ependymal/Subependymal Veins (Mimic)


ESSENTIAL INFORMATION


Key Differential Diagnosis Issues



  • Multiple sclerosis (MS) is most common cause of a periventricular enhancing lesion in a young adult


  • Main differential diagnosis: ADEM, Lyme disease, Susac syndrome, & lymphoma


  • DWI MR may help differentiate various etiologies



    • DWI “bright” lesions: Abscess, vasculitis, MS (variable), toxo (variable)


Helpful Clues for Common Diagnoses



  • Multiple Sclerosis



    • Multiple periventricular/perivenous T2 hyperintensities


    • Callososeptal interface characteristic


    • May cross corpus callosum


    • May be tumefactive (single mass lesion)


    • Enhancement during active demyelination, may be nodular, ring, or incomplete rim (horseshoe)


  • ADEM



    • Multifocal white matter (WM) & basal ganglia (BG) hyperintensities, 10-14 days post infection/vaccination


    • Enhancement typical


    • Callososeptal interface often spared


    • May be tumefactive


    • May be identical to MS


  • Lymphoma, Primary CNS



    • Enhancing periventricular WM or BG mass


    • Often extend along ependymal surfaces


    • Often crosses corpus callosum


    • Solid appearing mass with low T2 signal, mild DWI restriction


    • Hyperdense on CT


Helpful Clues for Less Common Diagnoses



  • Glioblastoma Multiforme



    • Peripherally enhancing WM mass with central necrosis


    • Surrounding T2 hyperintensity & significant mass effect common


    • Often crosses corpus callosum


  • Abscess



    • Ring enhancing mass in periventricular WM


    • Smooth, thin, linear enhancement


    • DWI restriction characteristic


  • Toxoplasmosis, Acquired



    • Multiple WM & BG ring enhancing masses


    • May show “target” sign


    • DWI restriction variable


    • Typically seen in HIV patients


  • Germinoma



    • Enhancing midline mass (pineal, suprasellar) typical


    • Occurs in BG or thalamus 5-10%


    • Hyperdense on CT


    • CSF spread common


  • Metastases, Parenchymal



    • Gray-white junctions & multiple enhancing lesions typical


    • May occur in periventricular WM


    • Primary tumor often known


  • Vasculitis



    • Irregularities, stenosis & vascular occlusions


    • Multifocal cortical/subcortical & BG T2 hyperintensities; DWI restriction if acute


    • Patchy enhancement typical


    • Angiography remains gold standard for diagnosis


  • Lyme Disease



    • Periventricular T2 hyperintensities + enhancement in patient with skin rash & flu-like illness


    • Cranial nerve enhancement may occur



      • CN7 often involved


    • May be identical to MS



  • Ependymoma



    • Majority (2/3) infratentorial



      • 4th ventricle in a child


      • ± Extension through lateral recesses into CPA cisterns


    • 1/3 are supratentorial



      • Most are extraventricular


      • Typically periventricular WM


    • Heterogeneous enhancing mass


    • 50% are calcified


    • Cysts, hemorrhage common


Helpful Clues for Rare Diagnoses

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Aug 7, 2016 | Posted by in NEUROLOGY | Comments Off on Periventricular Enhancing Lesions

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