Seminars in Ultrasound, CT and MRI
Volume 31, Issue 3 , Pages 260-274 , June 2010

Differential Diagnosis of T2 Hyperintense Brainstem Lesions: Part 2. Diffuse Lesions

  • Juan A. Guzmán-De-Villoria, MD

      Affiliations

    • Department of Radiology/Neuroradiology, Hospital General Universitario “Gregorio Marañón,” Madrid, Spain
    • Corresponding Author InformationAddress reprint requests to: Juan A. Guzmán-De-Villoria, Department of Radiology/Neuroradiology, Hospital General Universitario “Gregorio Marañón,” Madrid, Spain, C/ Dr. Esquedo 46, 28007 Madrid, Spain
    • ,
  • Concepción Ferreiro-Argüelles, MD

      Affiliations

    • Department of Radiology, Hospital “Severo Ochoa,” Leganés, Madrid, Spain
    • ,
  • Pilar Fernández-García, MD

      Affiliations

    • Department of Radiology/Neuroradiology, Hospital General Universitario “Gregorio Marañón,” Madrid, Spain

References 

  1. Barkovich AJ, Krischer J, Kun LE, et al. Brain stem gliomas: A classification system based on magnetic resonance imaging. Pediatr Neurosurg. 1990;16:73–83
  2. Recinos PF, Sciubba DM, Jallo GI. Brainstem tumors: Where are we today?. Pediatr Neurosurg. 2007;43:192–201
  3. Ueoka DI, Nogueira J, Campos JC, et al. Brainstem gliomas-retrospective analysis of 86 patients. J Neurol Sci. 2009;281:20–23
  4. Guillamo JS, Doz F, Delattre JY. Brain stem gliomas. Curr Opin Neurol. 2001;14:711–715
  5. Kwon JW, Kim IO, Cheon JE, et al. Paediatric brain-stem gliomas: MRI, FDG-PET and histological grading correlation. Pediatr Radiol. 2006;36:959–964
  6. Molloy PT, Bilaniuk LT, Vaughan SN, et al. Brainstem tumors in patients with neurofibromatosis type 1: A distinct clinical entity. Neurology. 1995;45:1897–1902
  7. Bilaniuk LT, Molloy PT, Zimmerman RA, et al. Neurofibromatosis type 1: Brain stem tumours. Neuroradiology. 1997;39:642–653
  8. Ullrich NJ, Raja AI, Irons MB, et al. Brainstem lesions in neurofibromatosis type 1. Neurosurgery. 2007;61:762–766discussion:766-767
  9. Guillamo JS, Monjour A, Taillandier L, et al. Brainstem gliomas in adults: Prognostic factors and classification. Brain. 2001;124:2528–2539
  10. Shams PN, Waldman A, Plant GT. B cell lymphoma of the brain stem masquerading as myasthenia. J Neurol Neurosurg Psychiatry. 2002;72:271–273
  11. Carlson BA. Rapidly progressive dementia caused by nonenhancing primary lymphoma of the central nervous system. AJNR Am J Neuroradiol. 1996;17:1695–1697
  12. Larner AJ, D’Arrigo C, Scaravilli F, et al. Bilateral symmetrical enhancing brainstem lesions: An unusual presentation of primary CNS lymphoma. Eur J Neurol. 1999;6:721–723
  13. Sanchez-Guerra M, Cerezal L, Leno C, et al. Primary brain lymphoma presenting as Parkinson's disease. Neuroradiology. 2001;43:36–40
  14. Campbell PG, Jawahar A, Fowler MR, et al. Primary central nervous system lymphoma of the brain stem responding favorably to radiosurgery: A case report and literature review. Surg Neurol 64:400-405; discussion. 2005;405
  15. Ducreux D, Wu RH, Mikulis DJ, et al. Diffusion-weighted imaging and single-voxel MR spectroscopy in a case of malignant cerebral lymphoma. Neuroradiology. 2003;45:865–868
  16. Gentry LR, Godersky JC, Thompson BH. Traumatic brain stem injury: MR imaging. Radiology. 1989;171:177–187
  17. Firsching R, Woischneck D, Diedrich M, et al. Early magnetic resonance imaging of brainstem lesions after severe head injury. J Neurosurg. 1998;89:707–712
  18. Bhatoe HS. Primary brainstem injury: Benign course and improved survival. Acta Neurochir (Wien). 1999;141:515–519
  19. Gentry LR, Godersky JC, Thompson B. MR imaging of head trauma: Review of the distribution and radiopathologic features of traumatic lesions. AJR Am J Roentgenol. 1988;150:663–672
  20. Adams H, Mitchell DE, Graham DI, et al. Diffuse brain damage of immediate impact type (Its relationship to “primary brain-stem damage” in head injury). Brain. 1977;100:489–502
  21. Parizel PM, Makkat S, Jorens PG, et al. Brainstem hemorrhage in descending transtentorial herniation (Duret hemorrhage). Intensive Care Med. 2002;28:85–88
  22. Kocer N, Islak C, Siva A, et al. CNS involvement in neuro-Behcet syndrome: An MR study. AJNR Am J Neuroradiol. 1999;20:1015–1024
  23. Akman-Demir G, Bahar S, Coban O, et al. Cranial MRI in Behcet's disease: 134 Examinations of 98 patients. Neuroradiology. 2003;45:851–859
  24. Baysal T, Ozisik HI, Karlidag R, et al. Proton MRS in Behcet's disease with and without neurological findings. Neuroradiology. 2003;45:860–864
  25. Heo JH, Lee ST, Chu K, et al. Neuro-Behcet's disease mimicking multiple brain tumors: Diffusion-weighted MR study and literature review. J Neurol Sci. 2008;264:177–181
  26. Cruz-Flores S, de Assis A, Gondim F, et al. Brainstem involvement in hypertensive encephalopathy: Clinical and radiological findings. Neurology. 2004;62:1417–1419
  27. Bartynski WS, Boardman JF. Distinct imaging patterns and lesion distribution in posterior reversible encephalopathy syndrome. AJNR Am J Neuroradiol. 2007;28:1320–1327
  28. de Seze J, Mastain B, Stojkovic T, et al. Unusual MR findings of the brain stem in arterial hypertension. AJNR Am J Neuroradiol. 2000;21:391–394
  29. Watanabe Y, Mitomo M, Tokuda Y, et al. Eclamptic encephalopathy: MRI, including diffusion-weighted images. Neuroradiology. 2002;44:981–985
  30. Shimono T, Miki Y, Toyoda H, et al. MR imaging with quantitative diffusion mapping of tacrolimus-induced neurotoxicity in organ transplant patients. Eur Radiol. 2003;13:986–993
  31. Nagata M, Maeda M, Tsukahara H, et al. Brain stem hypertensive encephalopathy evaluated by line scan diffusion-weighted imaging. AJNR Am J Neuroradiol. 2004;25:803–806
  32. Chu K, Kang DW, Lee SH, et al. Diffusion-weighted MR findings in brain stem hypertensive encephalopathy: A possibility of cytotoxic edema?. Eur Neurol. 2001;46:220–222
  33. Miller GM, Baker HL, Okazaki H, et al. Central pontine myelinolysis and its imitators: MR findings. Radiology. 1988;168:795–802
  34. Brown WD. Osmotic demyelination disorders: Central pontine and extrapontine myelinolysis. Curr Opin Neurol. 2000;13:691–697
  35. Ruzek KA, Campeau NG, Miller GM. Early diagnosis of central pontine myelinolysis with diffusion-weighted imaging. AJNR Am J Neuroradiol. 2004;25:210–213
  36. Huq S, Wong M, Chan H, et al. Osmotic demyelination syndromes: Central and extrapontine myelinolysis. J Clin Neurosci. 2007;14:684–688
  37. Kiley MA, King M, Burns RJ. Central pontine myelinolysis. J Clin Neurosci. 1999;6:155–157
  38. Menakaya JO, Wassmer E, Bradshaw K, et al. Idiopathic central pontine myelinolysis in childhood. Dev Med Child Neurol. 2001;43:697–700
  39. Bourgouin PM, Chalk C, Richardson J, et al. Subcortical white matter lesions in osmotic demyelination syndrome. AJNR Am J Neuroradiol. 1995;16:1495–1497
  40. Gerard E, Healy ME, Hesselink JR. MR demonstration of mesencephalic lesions in osmotic demyelination syndrome (central pontine myelinolysis). Neuroradiology. 1987;29:582–584
  41. Cramer SC, Stegbauer KC, Schneider A, et al. Decreased diffusion in central pontine myelinolysis. AJNR Am J Neuroradiol. 2001;22:1476–1479
  42. Karaarslan E, Arslan A. Diffusion weighted MR imaging in non-infarct lesions of the brain. Eur J Radiol. 2008;65:402–416
  43. Mazumdar A, Mukherjee P, Miller JH, et al. Diffusion-weighted imaging of acute corticospinal tract injury preceding Wallerian degeneration in the maturing human brain. AJNR Am J Neuroradiol. 2003;24:1057–1066
  44. Uchino A, Sawada A, Takase Y, et al. Transient detection of early Wallerian degeneration on diffusion-weighted MRI after an acute cerebrovascular accident. Neuroradiology. 2004;46:183–188
  45. Kuhn MJ, Mikulis DJ, Ayoub DM, et al. Wallerian degeneration after cerebral infarction: Evaluation with sequential MR imaging. Radiology. 1989;172:179–182
  46. Castillo M, Mukherji SK. Early abnormalities related to postinfarction Wallerian degeneration: Evaluation with MR diffusion-weighted imaging. J Comput Assist Tomogr. 1999;23:1004–1007
  47. Domi T, deVeber G, Shroff M, et al. Corticospinal tract pre-wallerian degeneration: A novel outcome predictor for pediatric stroke on acute MRI. Stroke. 2009;40:780–787
  48. Bouchareb M, Moulin T, Cattin F, et al. Wallerian degeneration of the descending tracts (CT and MRI features of the brain stem). J Neuroradiol. 1988;15:238–252
  49. Uchino A, Imada H, Ohno M. MR imaging of Wallerian degeneration in the human brain stem after ictus. Neuroradiology. 1990;32:191–195
  50. Mark VW, Taub E, Perkins C, et al. Poststroke cerebral peduncular atrophy correlates with a measure of corticospinal tract injury in the cerebral hemisphere. AJNR Am J Neuroradiol. 2008;29:354–358
  51. Pringle CE, Hudson AJ, Munoz DG, et al. Primary lateral sclerosis (Clinical features, neuropathology and diagnostic criteria). Brain. 1992;115:495–520
  52. Brooks BR, Miller RG, Swash M, et al. El Escorial revisited: Revised criteria for the diagnosis of amyotrophic lateral sclerosis. Amyotroph Lateral Scler Other Mot Neuron Disord. 2000;1:293–299
  53. Singer MA, Statland JM, Wolfe GI, et al. Primary lateral sclerosis. Muscle Nerve. 2007;35:291–302
  54. da Rocha AJ, Oliveira AS, Fonseca RB, et al. Detection of corticospinal tract compromise in amyotrophic lateral sclerosis with brain MR imaging: Relevance of the T1-weighted spin-echo magnetization transfer contrast sequence. AJNR Am J Neuroradiol. 2004;25:1509–1515
  55. Swash M, Desai J, Misra VP. What is primary lateral sclerosis?. J Neurol Sci. 1999;170:5–10
  56. Kuipers-Upmeijer J, de Jager AE, Hew JM, et al. Primary lateral sclerosis: Clinical, neurophysiological, and magnetic resonance findings. J Neurol Neurosurg Psychiatry. 2001;71:615–620
  57. Peretti-Viton P, Azulay JP, Trefouret S, et al. MRI of the intracranial corticospinal tracts in amyotrophic and primary lateral sclerosis. Neuroradiology. 1999;41:744–749
  58. Butman JA, Floeter MK. Decreased thickness of primary motor cortex in primary lateral sclerosis. AJNR Am J Neuroradiol. 2007;28:87–91
  59. Hecht MJ, Fellner F, Fellner C, et al. Hyperintense and hypointense MRI signals of the precentral gyrus and corticospinal tract in ALS: A follow-up examination including FLAIR images. J Neurol Sci. 2002;199:59–65
  60. Rovira A, Alonso J, Cordoba J. MR imaging findings in hepatic encephalopathy. AJNR Am J Neuroradiol. 2008;29:1612–1621
  61. Ferenci P, Lockwood A, Mullen K, et al. Hepatic encephalopathy—Definition, nomenclature, diagnosis, and quantification: Final report of the working party at the 11th world congresses of gastroenterology, Vienna, 1998. J Hepatol. 2002;35:716–721
  62. Kiroglu Y, Calli C, Yunten N, et al. Diffusion-weighted MR imaging of viral encephalitis. Neuroradiology. 2006;48:875–880
  63. Nath K, Saraswat VA, Krishna YR, et al. Quantification of cerebral edema on diffusion tensor imaging in acute-on-chronic liver failure. NMR Biomed. 2008;21:713–722
  64. Rovira A, Minguez B, Aymerich FX, et al. Decreased white matter lesion volume and improved cognitive function after liver transplantation. J Hepatol. 2007;46:1485–1490
  65. Kim HK, Lee HJ, Lee W, et al. Pattern approach to MR imaging in patients with end-stage hepatic failure: A proposal for a new disease entity “hepatic encephalopathy continuum. ” Neuroradiology. 2008;50:683–691
  66. Ngai S, Tang YM, Du L, et al. Hyperintensity of the middle cerebellar peduncles on fluid-attenuated inversion recovery imaging: Variation with age and implications for the diagnosis of multiple system atrophy. AJNR Am J Neuroradiol. 2006;27:2146–2148
  67. Gulati A, Virmani V, Singh P, et al. The hot cross bun sign. Neurol India. 2009;57:104–105
  68. Takao M, Kadowaki T, Tomita Y, et al. Hot-cross bun sign' of multiple system atrophy. Intern Med. 2007;46:1883
  69. Srivastava T, Singh S, Goyal V, et al. “Hot cross bun” sign in 2 patients with multiple system atrophy-cerebellar. Neurology. 2005;64:128
  70. Shrivastava A. The hot cross bun sign. Radiology. 2007;245:606–607
  71. Burk K, Skalej M, Dichgans J. Pontine MRI hyperintensities (“the cross sign”) are not pathognomonic for multiple system atrophy (MSA). Mov Disord. 2001;16:535
  72. Soares-Fernandes JP, Ribeiro M, Machado A. “Hot cross bun” sign in variant Creutzfeldt–Jakob disease. AJNR Am J Neuroradiol. 2009;30:E37
  73. Muqit MM, Mort D, Miskiel KA, et al. “Hot cross bun” sign in a patient with Parkinsonism secondary to presumed vasculitis. J Neurol Neurosurg Psychiatry. 2001;71:565–566
  74. Bhattacharya K, Saadia D, Eisenkraft B, et al. Brain magnetic resonance imaging in multiple-system atrophy and Parkinson disease: A diagnostic algorithm. Arch Neurol. 2002;59:835–842
  75. Pullicino P, Ostrow P, Miller L, et al. Pontine ischemic rarefaction. Ann Neurol. 1995;37:460–466
  76. Mantyla R, Pohjasvaara T, Vataja R, et al. MRI pontine hyperintensity after supratentorial ischemic stroke relates to poor clinical outcome. Stroke. 2000;31:695–700
  77. Kwa VI, Stam J, Blok LM, et al. T2-weighted hyperintense MRI lesions in the pons in patients with atherosclerosis (Amsterdam Vascular Medicine Group). Stroke. 1997;28:1357–1360
  78. Zagardo MT, Shanholtz CB, Zoarski GH, et al. Rhombencephalitis caused by adenovirus: MR imaging appearance. AJNR Am J Neuroradiol. 1998;19:1901–1903
  79. Pelligra G, Lynch N, Miller SP, et al. Brainstem involvement in neonatal herpes simplex virus type 2 encephalitis. Pediatrics. 2007;120:e442–e446
  80. Miura S, Kurita T, Noda K, et al. Symmetrical brainstem encephalitis caused by herpes simplex virus. J Clin Neurosci. 2009;16:589–590
  81. Angelini L, Bugiani M, Zibordi F, et al. Brainstem encephalitis resulting from Epstein–Barr virus mimicking an infiltrating tumor in a child. Pediatr Neurol. 2000;22:130–132
  82. Phowthongkum P, Phantumchinda K, Jutivorakool K, et al. Basal ganglia and brainstem encephalitis, optic neuritis, and radiculomyelitis in Epstein–Barr virus infection. J Infect. 2007;54:e141–e144
  83. Petropoulou KA, Gordon SM, Prayson RA, et al. West Nile virus meningoencephalitis: MR imaging findings. AJNR Am J Neuroradiol. 2005;26:1986–1995
  84. Lim CC, Sitoh YY, Hui F, et al. Nipah viral encephalitis or Japanese encephalitis? (MR findings in a new zoonotic disease). AJNR Am J Neuroradiol. 2000;21:455–461
  85. Goh KJ, Tan CT, Chew NK, et al. Clinical features of Nipah virus encephalitis among pig farmers in Malaysia. N Engl J Med. 2000;342:1229–1235
  86. Wasay M, Diaz-Arrastia R, Suss RA, et al. St. Louis encephalitis: A review of 11 cases in a 1995 Dallas, Tex, Epidemic. Arch Neurol. 2000;57:114–118
  87. Shen WC, Chiu HH, Chow KC, et al. MR imaging findings of enteroviral encephaloymelitis: An outbreak in Taiwan. AJNR Am J Neuroradiol. 1999;20:1889–1895
  88. Chu K, Kang DW, Lee JJ, et al. Atypical brainstem encephalitis caused by herpes simplex virus 2. Arch Neurol. 2002;59:460–463
  89. Mihara M, Utsugisawa K, Konno S, et al. Isolated lesions limited to the bilateral substantia nigra on MRI associated with influenza A infection. Eur Neurol. 2001;45:290–291
  90. Hu S, Walker M, Czartoski T, et al. Acyclovir responsive brain stem disease after the Ramsay Hunt syndrome. J Neurol Sci. 2004;217:111–113
  91. Reynaud L, Graf M, Gentile I, et al. A rare case of brainstem encephalitis by Listeria monocytogenes with isolated mesencephalic localization (Case report and review). Diagn Microbiol Infect Dis. 2007;58:121–123
  92. Panegyres PK, Edis R, Beaman M, et al. Primary Whipple's disease of the brain: Characterization of the clinical syndrome and molecular diagnosis. QJM. 2006;99:609–623
  93. Alper G, Knepper L, Kanal E. MR findings in listerial rhombencephalitis. AJNR Am J Neuroradiol. 1996;17:593–596
  94. Kalita J, Misra UK. The substantia nigra is also involved in Japanese encephalitis. AJNR Am J Neuroradiol. 2000;21:1978–1980
  95. Handique SK, Das RR, Barman K, et al. Temporal lobe involvement in Japanese encephalitis: Problems in differential diagnosis. AJNR Am J Neuroradiol. 2006;27:1027–1031
  96. Tien RD, Felsberg GJ, Osumi AK. Herpesvirus infections of the CNS: MR findings. AJR Am J Roentgenol. 1993;161:167–176
  97. Koralnik IJ, Schellingerhout D, Frosch MP. Case records of the Massachusetts General Hospital (Weekly clinicopathological exercises. Case :14, 2004. A 66-year-old man with progressive neurologic deficits). N Engl J Med. 2004;350:1882–1893
  98. Carson KR, Focosi D, Major EO, et al. Monoclonal antibody-associated progressive multifocal leukoencephalopathy in patients treated with rituximab, natalizumab, and efalizumab: A review from the research on adverse drug events and reports (RADAR) project. Lancet Oncol. 2009;10:816–824
  99. Sweeney BJ, Miller RF, Harrison MJ. Progressive multifocal leukoencephalopathy. Br J Hosp Med. 1993;50:187–192
  100. Koralnik IJ. Progressive multifocal leukoencephalopathy revisited: Has the disease outgrown its name?. Ann Neurol. 2006;60:162–173
  101. Kastrup O, Maschke M, Diener HC, et al. Progressive multifocal leukoencephalopathy limited to the brain stem. Neuroradiology. 2002;44:227–229
  102. Whiteman ML, Post MJ, Berger JR, et al. Progressive multifocal leukoencephalopathy in 47 HIV-seropositive patients: Neuroimaging with clinical and pathologic correlation. Radiology. 1993;187:233–240
  103. Post MJ, Yiannoutsos C, Simpson D, et al. Progressive Multifocal Leukoencephalopathy in AIDS: Are There Any MR Findings Useful to Patient Management and Predictive of Patient Survival? AIDS Clinical Trials Group Team. AJNR Am J Neuroradiol. 1999;20:1896–1906
  104. Mark AS, Atlas SW. Progressive multifocal leukoencephalopathy in patients with AIDS: Appearance on MR images. Radiology. 1989;173:517–520
  105. Thurnher MM, Post MJ, Rieger A, et al. Initial and follow-up MR imaging findings in AIDS-related progressive multifocal leukoencephalopathy treated with highly active antiretroviral therapy. AJNR Am J Neuroradiol. 2001;22:977–984
  106. Kuker W, Mader I, Nagele T, et al. Progressive multifocal leukoencephalopathy: Value of diffusion-weighted and contrast-enhanced magnetic resonance imaging for diagnosis and treatment control. Eur J Neurol. 2006;13:819–826
  107. Cosottini M, Tavarelli C, Del Bono L, et al. Diffusion-weighted imaging in patients with progressive multifocal leukoencephalopathy. Eur Radiol. 2008;18:1024–1030

PII: S0887-2171(10)00021-1

doi: 10.1053/j.sult.2010.03.002

Seminars in Ultrasound, CT and MRI
Volume 31, Issue 3 , Pages 260-274 , June 2010

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