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docs_md/articles/adem-brain_ed94b660-cf20-4ebb-8d6f-2b93505f2928.md
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@@ -452,8 +452,8 @@ breadcrumbs:
![Axial T1 C+ MR in the same patient shows marked, irregular enhancement of nearly all lesions. As ADEM is a monophasic illness, enhancement of most lesions is typical; all lesions have a similar time course. Enhancement of multiple sclerosis lesions is more variable.](images/app.statdx.com_image_thumbnail_64ffcf26-7ca7-4104-bfa4-b6548f582028_annotated_true_size_900_quality_90_04a7a3f4_20251018T152315Z.jpg)
*Axial T1 C+ MR in the same patient shows marked, irregular enhancement of nearly all lesions. As ADEM is a monophasic illness, enhancement of most lesions is typical; all lesions have a similar time course. Enhancement of multiple sclerosis lesions is more variable.*
![Axial FLAIR MR in a 5-year-old with ADEM following an EBV infection demonstrates more subtle findings with abnormal hyperintensity in the left basal ganglia <img src='/img/arrows/WS.png'/> and right parietal cortex/subcortical white matter <img src='/img/arrows/WO.png'/>.](images/app.statdx.com_image_thumbnail_903a6a28-4877-4eb7-801d-dee46bf162bd_annotated_true_size_900_quality_90_85ce8fb7_20251018T152316Z.jpg)
*Axial FLAIR MR in a 5-year-old with ADEM following an EBV infection demonstrates more subtle findings with abnormal hyperintensity in the left basal ganglia <img src='/img/arrows/WS.png'/> and right parietal cortex/subcortical white matter <img src='/img/arrows/WO.png'/>.*
![Axial FLAIR MR in a 5-year-old with ADEM following an EBV infection demonstrates more subtle findings with abnormal hyperintensity in the left basal ganglia <img src='img/arrows/WS.png'/> and right parietal cortex/subcortical white matter <img src='img/arrows/WO.png'/>.](images/app.statdx.com_image_thumbnail_903a6a28-4877-4eb7-801d-dee46bf162bd_annotated_true_size_900_quality_90_85ce8fb7_20251018T152316Z.jpg)
*Axial FLAIR MR in a 5-year-old with ADEM following an EBV infection demonstrates more subtle findings with abnormal hyperintensity in the left basal ganglia <img src='img/arrows/WS.png'/> and right parietal cortex/subcortical white matter <img src='img/arrows/WO.png'/>.*
![Axial T1 C+ MR in the same patient reveals no abnormal lesional contrast enhancement.](images/app.statdx.com_image_thumbnail_6ec7cb98-de90-4247-963e-31be1fa7ee52_annotated_true_size_900_quality_90_7360436d_20251018T152315Z.jpg)
*Axial T1 C+ MR in the same patient reveals no abnormal lesional contrast enhancement.*
@@ -464,17 +464,17 @@ breadcrumbs:
![Coronal FLAIR MR in the same patient confirms characteristic lesion distribution. Contrast-enhanced imaging (not shown) demonstrated no lesional enhancement.](images/app.statdx.com_image_thumbnail_1e485e05-a9d9-4ec8-9ff1-359d53745e1c_annotated_true_size_900_quality_90_18d4794b_20251018T152315Z.jpg)
*Coronal FLAIR MR in the same patient confirms characteristic lesion distribution. Contrast-enhanced imaging (not shown) demonstrated no lesional enhancement.*
![Axial T2WI MR shows hyperintense lesions in the brachium pontis bilaterally, typical for demyelination. The right-sided lesion shows a targetoid <img src='/img/arrows/WS.png'/> appearance. Enhancement of several lesions was present on postcontrast T1 images (not shown).](images/app.statdx.com_image_thumbnail_18b81bfe-32d0-46ae-9261-89c5ac6de92e_annotated_true_size_900_quality_90_67a641ed_20251018T152316Z.jpg)
*Axial T2WI MR shows hyperintense lesions in the brachium pontis bilaterally, typical for demyelination. The right-sided lesion shows a targetoid <img src='/img/arrows/WS.png'/> appearance. Enhancement of several lesions was present on postcontrast T1 images (not shown).*
![Axial T2WI MR shows hyperintense lesions in the brachium pontis bilaterally, typical for demyelination. The right-sided lesion shows a targetoid <img src='img/arrows/WS.png'/> appearance. Enhancement of several lesions was present on postcontrast T1 images (not shown).](images/app.statdx.com_image_thumbnail_18b81bfe-32d0-46ae-9261-89c5ac6de92e_annotated_true_size_900_quality_90_67a641ed_20251018T152316Z.jpg)
*Axial T2WI MR shows hyperintense lesions in the brachium pontis bilaterally, typical for demyelination. The right-sided lesion shows a targetoid <img src='img/arrows/WS.png'/> appearance. Enhancement of several lesions was present on postcontrast T1 images (not shown).*
![Axial FLAIR MR shows large, confluent regions of hyperintense signal <img src='/img/arrows/CC.png'/> in the periventricular and subcortical white matter in a 14-year-old who presented with neck stiffness, fatigue, and seizures.](images/app.statdx.com_image_thumbnail_9d547a6a-7b9d-43b8-b2bf-3cb459f98fe8_annotated_true_size_900_quality_90_04b3f6ff_20251018T152315Z.jpg)
*Axial FLAIR MR shows large, confluent regions of hyperintense signal <img src='/img/arrows/CC.png'/> in the periventricular and subcortical white matter in a 14-year-old who presented with neck stiffness, fatigue, and seizures.*
![Axial FLAIR MR shows large, confluent regions of hyperintense signal <img src='img/arrows/CC.png'/> in the periventricular and subcortical white matter in a 14-year-old who presented with neck stiffness, fatigue, and seizures.](images/app.statdx.com_image_thumbnail_9d547a6a-7b9d-43b8-b2bf-3cb459f98fe8_annotated_true_size_900_quality_90_04b3f6ff_20251018T152315Z.jpg)
*Axial FLAIR MR shows large, confluent regions of hyperintense signal <img src='img/arrows/CC.png'/> in the periventricular and subcortical white matter in a 14-year-old who presented with neck stiffness, fatigue, and seizures.*
![Axial SWI MR in the same patient shows petechial hemorrhages <img src='/img/arrows/CS.png'/> in regions of FLAIR signal abnormality.](images/app.statdx.com_image_thumbnail_c88bfbb2-5923-4952-8c80-65ac436e467b_annotated_true_size_900_quality_90_68ef6089_20251018T152316Z.jpg)
*Axial SWI MR in the same patient shows petechial hemorrhages <img src='/img/arrows/CS.png'/> in regions of FLAIR signal abnormality.*
![Axial SWI MR in the same patient shows petechial hemorrhages <img src='img/arrows/CS.png'/> in regions of FLAIR signal abnormality.](images/app.statdx.com_image_thumbnail_c88bfbb2-5923-4952-8c80-65ac436e467b_annotated_true_size_900_quality_90_68ef6089_20251018T152316Z.jpg)
*Axial SWI MR in the same patient shows petechial hemorrhages <img src='img/arrows/CS.png'/> in regions of FLAIR signal abnormality.*
![Sagittal T1 C+ MR in same patient shows extensive irregular ring enhancement <img src='/img/arrows/CC.png'/> involving multiple subcortical white matter lesions. Acute hemorrhagic leukoencephalopathy (AHL) is a rare manifestation of ADEM, occurring in 2% of cases. AHL is associated with a very poor prognosis. Aggressive therapeutic management is a prerequisite to avoid usual disease course with fatal outcome.](images/app.statdx.com_image_thumbnail_64cb6152-89e6-4027-b778-5d559cb3efeb_annotated_true_size_900_quality_90_a908aeb7_20251018T152321Z.jpg)
*Sagittal T1 C+ MR in same patient shows extensive irregular ring enhancement <img src='/img/arrows/CC.png'/> involving multiple subcortical white matter lesions. Acute hemorrhagic leukoencephalopathy (AHL) is a rare manifestation of ADEM, occurring in 2% of cases. AHL is associated with a very poor prognosis. Aggressive therapeutic management is a prerequisite to avoid usual disease course with fatal outcome.*
![Sagittal T1 C+ MR in same patient shows extensive irregular ring enhancement <img src='img/arrows/CC.png'/> involving multiple subcortical white matter lesions. Acute hemorrhagic leukoencephalopathy (AHL) is a rare manifestation of ADEM, occurring in 2% of cases. AHL is associated with a very poor prognosis. Aggressive therapeutic management is a prerequisite to avoid usual disease course with fatal outcome.](images/app.statdx.com_image_thumbnail_64cb6152-89e6-4027-b778-5d559cb3efeb_annotated_true_size_900_quality_90_a908aeb7_20251018T152321Z.jpg)
*Sagittal T1 C+ MR in same patient shows extensive irregular ring enhancement <img src='img/arrows/CC.png'/> involving multiple subcortical white matter lesions. Acute hemorrhagic leukoencephalopathy (AHL) is a rare manifestation of ADEM, occurring in 2% of cases. AHL is associated with a very poor prognosis. Aggressive therapeutic management is a prerequisite to avoid usual disease course with fatal outcome.*
### Additional Images
@@ -485,11 +485,11 @@ breadcrumbs:
![Axial DWI MR shows increased signal in areas of FLAIR hyperintensity (not shown). The foci were hypointense on ADC images, indicating diffusion restriction. Both white matter and gray matter involvement is present. Diffusion restriction is an uncommon imaging finding and is associated with a worse prognosis.](images/app.statdx.com_image_thumbnail_68ac872b-ffc7-45df-944b-c92acff8b7cb_annotated_true_size_900_quality_90_bb79bfc6_20251018T152321Z.jpg)
*Axial DWI MR shows increased signal in areas of FLAIR hyperintensity (not shown). The foci were hypointense on ADC images, indicating diffusion restriction. Both white matter and gray matter involvement is present. Diffusion restriction is an uncommon imaging finding and is associated with a worse prognosis.*
![Coronal T2WI MR shows large, confluent regions of hyperintense signal in the white matter <img src='/img/arrows/WO.png'/> and deep gray nuclei <img src='/img/arrows/WS.png'/> of a child with ADEM. Although ADEM predominantly involves white matter, gray matter is often affected.](images/app.statdx.com_image_thumbnail_4c698420-da7a-4ef8-a9a5-486dae2fb2ad_annotated_true_size_900_quality_90_b8fc7613_20251018T152322Z.jpg)
*Coronal T2WI MR shows large, confluent regions of hyperintense signal in the white matter <img src='/img/arrows/WO.png'/> and deep gray nuclei <img src='/img/arrows/WS.png'/> of a child with ADEM. Although ADEM predominantly involves white matter, gray matter is often affected.*
![Coronal T2WI MR shows large, confluent regions of hyperintense signal in the white matter <img src='img/arrows/WO.png'/> and deep gray nuclei <img src='img/arrows/WS.png'/> of a child with ADEM. Although ADEM predominantly involves white matter, gray matter is often affected.](images/app.statdx.com_image_thumbnail_4c698420-da7a-4ef8-a9a5-486dae2fb2ad_annotated_true_size_900_quality_90_b8fc7613_20251018T152322Z.jpg)
*Coronal T2WI MR shows large, confluent regions of hyperintense signal in the white matter <img src='img/arrows/WO.png'/> and deep gray nuclei <img src='img/arrows/WS.png'/> of a child with ADEM. Although ADEM predominantly involves white matter, gray matter is often affected.*
![MRS at long echo time (TE) in a patient with acute lesions in ADEM demonstrates an ↑ choline <img src='/img/arrows/CC.png'/>, ↓ NAA <img src='/img/arrows/CS.png'/>, and the presence of a lactate doublet <img src='/img/arrows/WS.png'/>. Increase in choline with corresponding reductions in NAA normalize as the clinical and conventional neuroimaging abnormalities resolve.](images/app.statdx.com_image_thumbnail_d84ff7a6-ae85-4c5d-b939-1711e1a097ef_annotated_true_size_900_quality_90_fdcfb7a4_20251018T152322Z.jpg)
*MRS at long echo time (TE) in a patient with acute lesions in ADEM demonstrates an ↑ choline <img src='/img/arrows/CC.png'/>, ↓ NAA <img src='/img/arrows/CS.png'/>, and the presence of a lactate doublet <img src='/img/arrows/WS.png'/>. Increase in choline with corresponding reductions in NAA normalize as the clinical and conventional neuroimaging abnormalities resolve.*
![MRS at long echo time (TE) in a patient with acute lesions in ADEM demonstrates an ↑ choline <img src='img/arrows/CC.png'/>, ↓ NAA <img src='img/arrows/CS.png'/>, and the presence of a lactate doublet <img src='img/arrows/WS.png'/>. Increase in choline with corresponding reductions in NAA normalize as the clinical and conventional neuroimaging abnormalities resolve.](images/app.statdx.com_image_thumbnail_d84ff7a6-ae85-4c5d-b939-1711e1a097ef_annotated_true_size_900_quality_90_fdcfb7a4_20251018T152322Z.jpg)
*MRS at long echo time (TE) in a patient with acute lesions in ADEM demonstrates an ↑ choline <img src='img/arrows/CC.png'/>, ↓ NAA <img src='img/arrows/CS.png'/>, and the presence of a lactate doublet <img src='img/arrows/WS.png'/>. Increase in choline with corresponding reductions in NAA normalize as the clinical and conventional neuroimaging abnormalities resolve.*
![Axial FLAIR MR shows bilateral, multiple asymmetric, flocculent, hyperintense lesions of ADEM.](images/app.statdx.com_image_thumbnail_ec8663a5-52f2-4149-8d68-5f8c603f1b79_annotated_true_size_900_quality_90_4d798e7a_20251018T152322Z.jpg)
*Axial FLAIR MR shows bilateral, multiple asymmetric, flocculent, hyperintense lesions of ADEM.*
@@ -515,15 +515,15 @@ breadcrumbs:
![Axial DWI MR confirms the rare manifestation of ADEM, displaying bilateral striatal necrosis, as evidenced by asymmetric confluent restricted diffusion involving gray matter and white matter of bilateral corpus striatum.](f0e2bac7-bbc9-45da-8e3f-ddd9151ed43a)
*Axial DWI MR confirms the rare manifestation of ADEM, displaying bilateral striatal necrosis, as evidenced by asymmetric confluent restricted diffusion involving gray matter and white matter of bilateral corpus striatum.*
![Axial T2WI MR shows multiple bilateral but asymmetric, T2-hyperintense foci <img src='/img/arrows/WS.png'/>. None of the lesions demonstrates significant mass effect in this adult patient with ADEM. Imaging mimics multiple sclerosis, vasculitis, and microvascular ischemia.](36c82d94-ffcc-4bee-8ea6-91d4e8368bb8)
*Axial T2WI MR shows multiple bilateral but asymmetric, T2-hyperintense foci <img src='/img/arrows/WS.png'/>. None of the lesions demonstrates significant mass effect in this adult patient with ADEM. Imaging mimics multiple sclerosis, vasculitis, and microvascular ischemia.*
![Axial T2WI MR shows multiple bilateral but asymmetric, T2-hyperintense foci <img src='img/arrows/WS.png'/>. None of the lesions demonstrates significant mass effect in this adult patient with ADEM. Imaging mimics multiple sclerosis, vasculitis, and microvascular ischemia.](36c82d94-ffcc-4bee-8ea6-91d4e8368bb8)
*Axial T2WI MR shows multiple bilateral but asymmetric, T2-hyperintense foci <img src='img/arrows/WS.png'/>. None of the lesions demonstrates significant mass effect in this adult patient with ADEM. Imaging mimics multiple sclerosis, vasculitis, and microvascular ischemia.*
![Axial FLAIR MR shows a large, tumefactive, hyperintense ADEM lesion <img src='/img/arrows/WS.png'/> with mass effect less than expected for the size of the lesion. Another clue to its nonneoplastic nature is the right-sided lesion <img src='/img/arrows/WC.png'/>.](84bb9f5f-d05b-4391-bd16-8beea63e1fbb)
*Axial FLAIR MR shows a large, tumefactive, hyperintense ADEM lesion <img src='/img/arrows/WS.png'/> with mass effect less than expected for the size of the lesion. Another clue to its nonneoplastic nature is the right-sided lesion <img src='/img/arrows/WC.png'/>.*
![Axial FLAIR MR shows a large, tumefactive, hyperintense ADEM lesion <img src='img/arrows/WS.png'/> with mass effect less than expected for the size of the lesion. Another clue to its nonneoplastic nature is the right-sided lesion <img src='img/arrows/WC.png'/>.](84bb9f5f-d05b-4391-bd16-8beea63e1fbb)
*Axial FLAIR MR shows a large, tumefactive, hyperintense ADEM lesion <img src='img/arrows/WS.png'/> with mass effect less than expected for the size of the lesion. Another clue to its nonneoplastic nature is the right-sided lesion <img src='img/arrows/WC.png'/>.*
![MRS at a long TE in the same patient shows the tumefactive lesion has a depressed choline <img src='/img/arrows/WC.png'/> and NAA <img src='/img/arrows/WO.png'/> metabolites in the presence of a large lactate doublet <img src='/img/arrows/WS.png'/>. This MRS helps distinguish this lesion from a neoplasm. MRS of ADEM may show elevated choline acutely.](8d4a240b-4ac5-4002-86f6-76f8dd742664)
*MRS at a long TE in the same patient shows the tumefactive lesion has a depressed choline <img src='/img/arrows/WC.png'/> and NAA <img src='/img/arrows/WO.png'/> metabolites in the presence of a large lactate doublet <img src='/img/arrows/WS.png'/>. This MRS helps distinguish this lesion from a neoplasm. MRS of ADEM may show elevated choline acutely.*
![MRS at a long TE in the same patient shows the tumefactive lesion has a depressed choline <img src='img/arrows/WC.png'/> and NAA <img src='img/arrows/WO.png'/> metabolites in the presence of a large lactate doublet <img src='img/arrows/WS.png'/>. This MRS helps distinguish this lesion from a neoplasm. MRS of ADEM may show elevated choline acutely.](8d4a240b-4ac5-4002-86f6-76f8dd742664)
*MRS at a long TE in the same patient shows the tumefactive lesion has a depressed choline <img src='img/arrows/WC.png'/> and NAA <img src='img/arrows/WO.png'/> metabolites in the presence of a large lactate doublet <img src='img/arrows/WS.png'/>. This MRS helps distinguish this lesion from a neoplasm. MRS of ADEM may show elevated choline acutely.*
![Axial FLAIR MR shows typical findings of ADEM with peripheral, subcortical hyperintense foci <img src='/img/arrows/WC.png'/>. Bilateral insular involvement is seen <img src='/img/arrows/WS.png'/>. Periventricular and callososeptal lesions, which are typical of multiple sclerosis, are not commonly seen in ADEM.](261b8d47-c109-457f-b28e-2151acebd773)
*Axial FLAIR MR shows typical findings of ADEM with peripheral, subcortical hyperintense foci <img src='/img/arrows/WC.png'/>. Bilateral insular involvement is seen <img src='/img/arrows/WS.png'/>. Periventricular and callososeptal lesions, which are typical of multiple sclerosis, are not commonly seen in ADEM.*
![Axial FLAIR MR shows typical findings of ADEM with peripheral, subcortical hyperintense foci <img src='img/arrows/WC.png'/>. Bilateral insular involvement is seen <img src='img/arrows/WS.png'/>. Periventricular and callososeptal lesions, which are typical of multiple sclerosis, are not commonly seen in ADEM.](261b8d47-c109-457f-b28e-2151acebd773)
*Axial FLAIR MR shows typical findings of ADEM with peripheral, subcortical hyperintense foci <img src='img/arrows/WC.png'/>. Bilateral insular involvement is seen <img src='img/arrows/WS.png'/>. Periventricular and callososeptal lesions, which are typical of multiple sclerosis, are not commonly seen in ADEM.*