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f184750a-90b4-47a7-907b-23b05d70357a Chang Yueh Ho, MD
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Differential Diagnosis
Brain Parenchyma, General
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ESSENTIAL INFORMATION

  • Key Differential Diagnosis Issues

    • Adult-onset seizures are more likely acquired - Acute symptomatic seizure ≤ 1 week of brain injury - Remote symptomatic seizure: Beyond 1 week - Encephalomalacia and gliosis can also cause seizures - Epilepsy: When 2 or more seizures occur 24 hours apart

  • Helpful Clues for Common Diagnoses

    • Trauma - Diffuse axonal injury and contusions - Intracranial hemorrhage (subdural hemorrhage and subarachnoid hemorrhage) can also present with seizures without parenchymal findings
    • Stroke - Most common cause in older adults
    • Infection - All cerebral and meningeal infection can cause seizure - Meningitis, encephalitis, and abscess - Look for herpes encephalitis - CNS tuberculosis and neurocysticercosis are common causes outside of USA
    • Drug Use and Withdrawal - Withdrawal from alcohol, benzodiazepines, barbiturates - Illicit drug use and drugs, which lower seizure threshold
    • Metabolic - Hyper- or hypoglycemia - Hyponatremia, hypocalcinemia, hypomagnesemia, hypothyroidism - Hyperammonemia from hepatic encephalopathy - Uremic encephalopathy
    • Neoplasms - Glioblastoma most common in older adults - Cortically based tumors primarily in older children to young adults
    • Neurodegenerative Disease - Dementia: Alzheimer - Demyelinating disease: Multiple sclerosis

  • Helpful Clues for Less Common Diagnoses

    • Oligodendroglioma, IDH-Mutant and 1p/19q-Co-Deleted - 70-90% present with seizures - Cortically based T2-hyperintense mass, rare enhancement
    • Mesial Temporal Sclerosis - Most common cause of intractable temporal lobe seizures - Hippocampal atrophy and sclerosis - May see ipsilateral mammillary body and forniceal atrophy
    • Paraneoplastic and Autoimmune Encephalitis - Both paraneoplastic and nonparaneoplastic - 80% have bilateral/unilateral edema of temporal lobes - Limbic system most common, also brainstem, cerebellum, and spinal cord
    • Posterior Reversible Encephalopathy Syndrome - 60-75% present with seizure - Patchy parietooccipital cortical/subcortical T2/FLAIR hyperintense edema - Associated with hypertension, chemotherapy, high-dose steroids, immunomodulation, sepsis, kidney failure, preeclampsia/eclampsia, autoimmune disease

  • Helpful Clues for Rare Diagnoses

    • Pleomorphic Xanthoastrocytoma - 75% of patients present with seizures - Cortical cyst + enhancing nodule is classic - Reactive involvement of adjacent meninges typical: Dural tail

References

Selected References

  1. Akrami H et al: Neuroanatomic markers of posttraumatic epilepsy based on MR imaging and machine learning. AJNR Am J Neuroradiol. 43(3):347-53, 2022
  2. Tierney TS et al: Initial experience with magnetic resonance-guided focused ultrasound stereotactic surgery for central brain lesions in young adults. J Neurosurg. ePub, 2022
  3. DeSalvo MN et al: Contralateral preoperative resting-state functional MRI network integration is associated with surgical outcome in temporal lobe epilepsy. Radiology. 294(3):622-7, 2020
  4. Kaur S et al: Adult onset seizures: clinical, etiological, and radiological profile. J Family Med Prim Care. 7(1):191-7, 2018
  5. Berg AT et al: Revised terminology and concepts for organization of seizures and epilepsies: report of the ILAE Commission on Classification and Terminology, 2005-2009. Epilepsia. 51(4):676-85, 2010

Images

Selected Images

Coronal NECT shows hyperdense acute hemorrhage in the inferior frontal lobes in a patient with a history of motor vehicle collision. The inferior frontal and anterior temporal lobes are the most common locations for traumatic contusions. Trauma Coronal NECT shows hyperdense acute hemorrhage in the inferior frontal lobes in a patient with a history of motor vehicle collision. The inferior frontal and anterior temporal lobes are the most common locations for traumatic contusions.

Coronal NECT shows hyperdense acute hemorrhage in the inferior frontal lobes in a patient with a history of motor vehicle collision. The inferior frontal and anterior temporal lobes are the most common locations for traumatic contusions. Trauma Coronal NECT shows hyperdense acute hemorrhage in the inferior frontal lobes in a patient with a history of motor vehicle collision. The inferior frontal and anterior temporal lobes are the most common locations for traumatic contusions.

Axial NECT shows loss of gray-white differentiation of the frontal and temporal operculum as well as the insular cortex consistent with infarct . Note the hyperdensity in the sylvian fissure from thrombosed middle cerebral artery (MCA) branches . Stroke Axial NECT shows loss of gray-white differentiation of the frontal and temporal operculum as well as the insular cortex consistent with infarct . Note the hyperdensity in the sylvian fissure from thrombosed middle cerebral artery (MCA) branches .

Sagittal T1 C+ MR shows abnormal enhancement in the suprasellar and prepontine cistern , inferior frontal lobe , and quadrigeminal plate cistern , consistent with tuberculomas. CNS tuberculosis is the most common cause of seizures from infection worldwide. Infection Sagittal T1 C+ MR shows abnormal enhancement in the suprasellar and prepontine cistern , inferior frontal lobe , and quadrigeminal plate cistern , consistent with tuberculomas. CNS tuberculosis is the most common cause of seizures from infection worldwide.

Axial b=1000 DWI MR shows increased signal in the tail of the hippocampi , medial thalami , insular cortex , and cingulate cortex in a patient with hyperammonemia from hepatic encephalopathy. Metabolic Axial b=1000 DWI MR shows increased signal in the tail of the hippocampi , medial thalami , insular cortex , and cingulate cortex in a patient with hyperammonemia from hepatic encephalopathy.

Axial T1 C+ MR shows an irregular ring-enhancing mass in the left medial temporal lobe and occipital lobe. This was a glioblastoma, IDH-wildtype at biopsy. Neoplasms Axial T1 C+ MR shows an irregular ring-enhancing mass in the left medial temporal lobe and occipital lobe. This was a glioblastoma, IDH-wildtype at biopsy.

Axial FLAIR MR shows a large, T2-hyperintense mass in the left frontal lobe extending across the corpus callosum to the right frontal lobe and centrally to involve the basal ganglia. This was a 1p/19q co-deleted oligodendroglioma at biopsy. These tumors are often calcified and located in the frontal lobe. Neoplasms Axial FLAIR MR shows a large, T2-hyperintense mass in the left frontal lobe extending across the corpus callosum to the right frontal lobe and centrally to involve the basal ganglia. This was a 1p/19q co-deleted oligodendroglioma at biopsy. These tumors are often calcified and located in the frontal lobe.

Coronal FLAIR MR shows increased T2 signal and relative volume loss of the right hippocampal formation , consistent with mesial temporal sclerosis in this patient with temporal lobe seizures. Mesial Temporal Sclerosis Coronal FLAIR MR shows increased T2 signal and relative volume loss of the right hippocampal formation , consistent with mesial temporal sclerosis in this patient with temporal lobe seizures.

Axial FLAIR MR shows bilateral T2 hyperintensity in the occipital lobe cortex and subcortical white matter. In this patient with hypertension and renal failure, PRES was diagnosed. The DWI images were negative. Imaging of PRES often completely resolves when hypertension is controlled. Posterior Reversible Encephalopathy Syndrome Axial FLAIR MR shows bilateral T2 hyperintensity in the occipital lobe cortex and subcortical white matter. In this patient with hypertension and renal failure, PRES was diagnosed. The DWI images were negative. Imaging of PRES often completely resolves when hypertension is controlled.

Additional Images

Coronal T1 C+ MR shows central heterogeneous enhancement of a low- intensity tumor involving the cortex of the posterior frontal lobe, consistent with oligodendroglioma. Oligodendroglioma, IDH-Mutant and 1p/19q-Co-Deleted Coronal T1 C+ MR shows central heterogeneous enhancement of a low- intensity tumor involving the cortex of the posterior frontal lobe, consistent with oligodendroglioma.

Axial FLAIR MR shows bilateral hyperintensity of the hippocampi and medial temporal lobes . In this patient with a history of lung cancer, this is consistent with autoimmune encephalitis. Paraneoplastic and Autoimmune Encephalitis Axial FLAIR MR shows bilateral hyperintensity of the hippocampi and medial temporal lobes . In this patient with a history of lung cancer, this is consistent with autoimmune encephalitis.

Axial FLAIR MR shows bilateral hyperintensity of the insular cortex in this patient with ovarian cancer, consistent with autoimmune paraneoplastic encephalitis. Paraneoplastic and Autoimmune Encephalitis Axial FLAIR MR shows bilateral hyperintensity of the insular cortex in this patient with ovarian cancer, consistent with autoimmune paraneoplastic encephalitis.

Coronal FLAIR MR shows a cortical hyperintense mass in the posterior frontal lobe with a focal cyst . This was a pleomorphic xanthoastrocytoma at surgery. Pleomorphic Xanthoastrocytoma Coronal FLAIR MR shows a cortical hyperintense mass in the posterior frontal lobe with a focal cyst . This was a pleomorphic xanthoastrocytoma at surgery.

Sagittal T2 MR shows a well-circumscribed T2-hyperintense mass involving the posterior frontal cortex . This is a typical location and appearance for oligodendroglioma. 70-90% of patients with this tumor present with seizures due to its cortical nature. Oligodendroglioma, IDH-Mutant and 1p/19q-Co-Deleted Sagittal T2 MR shows a well-circumscribed T2-hyperintense mass involving the posterior frontal cortex . This is a typical location and appearance for oligodendroglioma. 70-90% of patients with this tumor present with seizures due to its cortical nature.

Coronal FLAIR MR shows atrophy and hyperintensity of the left hippocampus , consistent with left mesial temporal sclerosis. There is also loss of the normal internal architecture of the left hippocampus and ex vacuo dilatation of the left temporal horn . Mesial Temporal Sclerosis Coronal FLAIR MR shows atrophy and hyperintensity of the left hippocampus , consistent with left mesial temporal sclerosis. There is also loss of the normal internal architecture of the left hippocampus and ex vacuo dilatation of the left temporal horn .

Axial CBF map from arterial spin labeling shows relative hypoperfusion of the left temporal lobe compared to the right in this patient with left mesial temporal sclerosis. This is consistent with interictal seizure focus. Mesial Temporal Sclerosis Axial CBF map from arterial spin labeling shows relative hypoperfusion of the left temporal lobe compared to the right in this patient with left mesial temporal sclerosis. This is consistent with interictal seizure focus.

Axial T1 C+ MR shows a cyst and heterogeneously enhancing nodule involving the cortex. There is an incidental developmental venous anomaly . Pleomorphic Xanthoastrocytoma Axial T1 C+ MR shows a cyst and heterogeneously enhancing nodule involving the cortex. There is an incidental developmental venous anomaly .

Coronal FLAIR MR shows hyperintensity and swelling of the right hippocampus and bilateral parahippocampal gyri . In a patient with acute encephalopathy, seizures, and fever, herpes encephalitis must be excluded. Infection Coronal FLAIR MR shows hyperintensity and swelling of the right hippocampus and bilateral parahippocampal gyri . In a patient with acute encephalopathy, seizures, and fever, herpes encephalitis must be excluded.

Axial T2 FS MR shows bilateral hippocampal hyperintensity and edema . Herpes encephalitis typically involves the medial temporal lobes asymmetrically and the insular cortex. The basal ganglia is usually spared, and there is deceased diffusion of the cortex early in the disease. Infection Axial T2 FS MR shows bilateral hippocampal hyperintensity and edema . Herpes encephalitis typically involves the medial temporal lobes asymmetrically and the insular cortex. The basal ganglia is usually spared, and there is deceased diffusion of the cortex early in the disease.

Axial NECT shows a heterogeneous mass causing a seizure in the right frontal lobe extending to the basal ganglia with midline shift. There are areas of hyperdensity suggesting a high-grade neoplasm. This was a glioblastoma at biopsy. Neoplasms Axial NECT shows a heterogeneous mass causing a seizure in the right frontal lobe extending to the basal ganglia with midline shift. There are areas of hyperdensity suggesting a high-grade neoplasm. This was a glioblastoma at biopsy.

Axial FLAIR MR in this patient with ovarian cancer shows T2 hyperintensity of the temporal lobes , consistent with autoimmune, paraneoplastic, limbic encephalitis. Compared to herpes encephalitis, autoimmune encephalitis is more likely to be bilateral, symmetric without decreased diffusion. The basal ganglia are more commonly involved. Paraneoplastic and Autoimmune Encephalitis Axial FLAIR MR in this patient with ovarian cancer shows T2 hyperintensity of the temporal lobes , consistent with autoimmune, paraneoplastic, limbic encephalitis. Compared to herpes encephalitis, autoimmune encephalitis is more likely to be bilateral, symmetric without decreased diffusion. The basal ganglia are more commonly involved.

Axial FLAIR MR shows bilateral T2 hyperintensity in the parietal lobe cortex and subcortical white matter. In this patient with malignant hypertension, PRES was suspected. Posterior Reversible Encephalopathy Syndrome Axial FLAIR MR shows bilateral T2 hyperintensity in the parietal lobe cortex and subcortical white matter. In this patient with malignant hypertension, PRES was suspected.

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