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Periventricular Enhancing Lesions 0edb9603-ea97-4f3b-be82-21d53c42be32
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1fa14dfd-71ea-4960-908e-e720313bc63a Santhosh Gaddikeri, MD
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30ce27b2-237f-4aff-a88f-65ead356335b Marinos Kontzialis, MD
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Brain d7a3032c-c0c2-4516-837e-59885e1d3d24 54 02/14/23 Periventricular Enhancing Lesions Brain, Differential Diagnosis, Ventricles, Periventricular Regions, Generic Imaging Patterns, Periventricular Enhancing Lesions Periventricular Enhancing Lesions | STATdx Periventricular Enhancing Lesions DDX true
Brain
Differential Diagnosis
Ventricles, Periventricular Regions
Generic Imaging Patterns
Periventricular Enhancing Lesions

title: "Periventricular Enhancing Lesions" docid: "0edb9603-ea97-4f3b-be82-21d53c42be32" authors:

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  • "Brain"
  • "Differential Diagnosis"
  • "Ventricles, Periventricular Regions"
  • "Generic Imaging Patterns"
  • "Periventricular Enhancing Lesions"

ESSENTIAL INFORMATION

  • Key Differential Diagnosis Issues

    • DWI MR may help differentiate various etiologies

  • Helpful Clues for Common Diagnoses

    • Multiple Sclerosis - Most common acquired CNS autoimmune demyelinating disease - Callososeptal interface involvement - Subcallosal striations - Ovoid lesions radiating from ventricular surface of corpus callosum (CC) into pericallosal white matter (WM) corresponding to perivenular inflammation - Juxtacortical lesions - Acute demyelinating lesions = may show restricted diffusion, enhancement (nodular, ring, or incomplete rim) - Tumefactive demyelination - Demyelinating lesions > 2 cm; may be mistaken for tumor when edema & mass effect - May occur in neuroinflammatory conditions, including multiple sclerosis (MS) & ADEM - Most closely linked with MS often at time of 1st presentation - Look for characteristic incomplete ring of enhancement
    • ADEM - Monophasic demyelination triggered by febrile illness or vaccination; impaired consciousness - Multifocal WM + deep gray matter (GM) lesions; periventricular + CC lesions larger than in MS - Complete or partial resolution of lesions without development of new lesions - Enhancement typical
    • Glioblastoma, IDH-Wildtype - Most common primary intracranial neoplasm - Rapid enlargement, thick irregular enhancement, necrotic core - Heterogeneous, hyperintense T2 FLAIR mass + surrounding vasogenic edema/tumor infiltration - Tumor extends beyond visible signal changes
    • Lymphoma, Primary CNS - Immunocompetent: May be T2 hypointense related to high nuclear:cytoplasmic ratio, solid enhancement - Immunocompromised: May be heterogeneous from hemorrhage, necrosis, rim enhancement - Often crosses CC - Mild surrounding edema is typical - Enhancing lesion(s) within basal ganglia (BG) &/or periventricular WM
    • Metastases, Parenchymal - Round enhancing lesion(s) at GM-WM interface - May be punctate to massive with variable surrounding edema, mass effect - 50% solitary - Primary tumor often known

  • Helpful Clues for Less Common Diagnoses

    • Abscess - Central restricted diffusion, enhancing T2-hypointense rim, surrounding vasogenic edema
    • Septic Emboli - Scattered, small juxtacortical hyperintensities - Develop into small, ring-enhancing microabscesses
    • Toxoplasmosis, Acquired - Multiple WM & BG ring-enhancing masses - May show target sign - DWI restriction variable - Typically seen in HIV patients
    • Neurocysticercosis - Vesicular phase: Small 10-mm cysts with central scolex, no edema, follows CSF - Colloidal phase: Cyst may enlarge, may be hyperintense to CSF, surrounding edema, enhancement - Granular nodular & calcified phase: Cyst retracts, wall thickens, edema resolves, calcifies
    • Germinoma - Enhancing midline mass (pineal, suprasellar) typical - Occurs in BG or thalamus 5-10% - Hyperdense on CT - CSF spread common
    • Vasculitis - Irregularities, stenosis, & vascular occlusions - Multifocal cortical/subcortical & BG T2 hyperintensities; DWI restriction if acute - Patchy enhancement typical - High-resolution MR may show vessel wall enhancement
    • Lyme Disease - MS-like WM lesions (may enhance) - ± multiple enhancing cranial nerves - ± cauda equina, meningeal enhancement
    • Ependymoma - Majority (2/3) infratentorial - 4th ventricle in child - ± extension through lateral recesses into cerebellopontine angle cisterns - 1/3 are supratentorial - Most are extraventricular - Typically periventricular WM - Heterogeneous enhancing mass - 50% are calcified - Cysts, hemorrhage common
    • Neurosarcoid - Periventricular T2-hyperintense lesions - Enhancing parenchymal lesions - Leptomeningeal disease - Hypothalamus/pituitary involvement - Cranial nerve involvement - Dural involvement - Vasculitis
    • Neuromyelitis Optica Spectrum Disorders - Recurrent, often bilateral optic neuritis &/or longitudinally extensive cord lesions > 3 vertebral segments - Periventricular/periependymal hyperintensities following distribution of aquaporin-4 - Patchy enhancement with blurred margins (cloud-like enhancement) in cerebral lesions - "Pencil-thin" ependymal enhancement - Rarely, well-marginated nodular enhancement or meningeal enhancement

  • Helpful Clues for Rare Diagnoses

    • Leukemia - Typically involves dura - May see along penetrating vessels or ependyma - Enhancing mass(es) in child
    • Susac Syndrome - Triad of encephalopathy, branch retinal artery occlusions, hearing loss - Endotheliopathy of cerebral precapillary arterioles - Characteristic multifocal lesions involving central fibers of CC = small infarcts
    • Alexander Disease - Diffuse symmetric bifrontal WM signal abnormality & enhancement - Near-total lack of myelin - Infant with macrocephaly, seizures, developmental delay
    • Ependymal/Subependymal Veins (Mimic) - Normal periventricular venous structures may become engorged with various pathologies - Venous thrombosis, vascular malformations (arteriovenous malformation, developmental venous anomaly)
    • CLIPPERS - Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids - Recently described inflammatory CNS disorder - Predominant brainstem & pons involvement - Punctate perivascular enhancement with surrounding T2 FLAIR hyperintensities - Lesions typically clustered in pons, & adjacent rhombencephalic structures may extend into spinal cord & supratentorial GM & WM
    • Immune Reconstitution Inflammatory Syndrome (IRIS) - Atypical/worsening imaging appearance of infection in HIV/AIDS following initiation of HAART - Immune reconstitution leading to inflammatory response to preexisting infection - Pathogens: JC virus (progressive multifocal leukoencephalopathy), TB, CMV, Cryptococcus, others
    • Behçet Disease - Vasculitis with venous predominance - Asymmetric mesodiencephalic junction hyperintense lesion with cranial & caudal extension ± enhancement - Midbrain involvement with sparing of red nucleus suggestive of vasogenic edema - Findings likely secondary to venous thrombosis with reversible edema - Associated enhancement in acute lesions may mimic tumor

References

Selected References

  1. Clarke L et al: Magnetic resonance imaging in neuromyelitis optica spectrum disorder. Clin Exp Immunol. 206(3):251-65, 2021

Images

Selected Images

Axial T1 C+ MR demonstrates multiple lesions with nodular, broken ring, and curvilinear enhancement in juxtacortical , deep and periventricular white matter (WM), consistent with active demyelinating lesions in a patient with multiple sclerosis. Multiple Sclerosis Axial T1 C+ MR demonstrates multiple lesions with nodular, broken ring, and curvilinear enhancement in juxtacortical , deep and periventricular white matter (WM), consistent with active demyelinating lesions in a patient with multiple sclerosis.

Axial T1 C+ 3D SPGR MR demonstrates a large, enhancing lesion involving bifrontal periventricular WM and corpus callosum . Biopsy revealed demyelination. There is encephalomalacia in the bilateral parietal lobes . Tumefactive Demyelination Axial T1 C+ 3D SPGR MR demonstrates a large, enhancing lesion involving bifrontal periventricular WM and corpus callosum . Biopsy revealed demyelination. There is encephalomalacia in the bilateral parietal lobes .

Coronal T1 C+ MR shows multiple patchy/confluent, avidly enhancing lesions involving gray matter , WM , and along periventricular region , findings consistent with ADEM. Patient had upper respiratory tract infection 1 week before neurologic symptom onset. ADEM Coronal T1 C+ MR shows multiple patchy/confluent, avidly enhancing lesions involving gray matter , WM , and along periventricular region , findings consistent with ADEM. Patient had upper respiratory tract infection 1 week before neurologic symptom onset.

Coronal T1 C+ SPGR MR shows a necrotic enhancing mass in the right temporal lobe periventricular region . There is additional nodular foci along the septum and ependyma of of the 3rd ventricle . Biopsy revealed glioblastoma, IDH-wildtype. Glioblastoma, IDH-Wildtype Coronal T1 C+ SPGR MR shows a necrotic enhancing mass in the right temporal lobe periventricular region . There is additional nodular foci along the septum and ependyma of of the 3rd ventricle . Biopsy revealed glioblastoma, IDH-wildtype.

Axial T1 C+ SPGR MR demonstrates a large, avidly enhancing mass in the right cerebellum adjacent to the 4th ventricle. Biopsy revealed lymphoma. Note mild mass effect on the 4th ventricle and surrounding hypointensity due to edema . Lymphoma, Primary CNS Axial T1 C+ SPGR MR demonstrates a large, avidly enhancing mass in the right cerebellum adjacent to the 4th ventricle. Biopsy revealed lymphoma. Note mild mass effect on the 4th ventricle and surrounding hypointensity due to edema .

Axial CECT shows rim-enhancing, periventricular metastatic lesions adjacent to the right ventricular atrium in a patient with lung carcinoma. An additional enhancing metastasis involves the left choroid plexus. Metastases, Parenchymal Axial CECT shows rim-enhancing, periventricular metastatic lesions adjacent to the right ventricular atrium in a patient with lung carcinoma. An additional enhancing metastasis involves the left choroid plexus.

Axial T1 C+ MR demonstrates a rim-enhancing lesion in the left occipital lobe , which showed restricted diffusion and was consistent with an abscess. The abscess shows intraventricular rupture with loculated intraventricular enhancement . Abscess Axial T1 C+ MR demonstrates a rim-enhancing lesion in the left occipital lobe , which showed restricted diffusion and was consistent with an abscess. The abscess shows intraventricular rupture with loculated intraventricular enhancement .

Coronal T1 C+ SPGR MR demonstrates a right ring-enhancing lesion with an eccentric target sign , consistent with toxoplasmosis (acquired) in this patient with HIV/AIDS. Note surrounding edema and mass effect . Toxoplasmosis, Acquired Coronal T1 C+ SPGR MR demonstrates a right ring-enhancing lesion with an eccentric target sign , consistent with toxoplasmosis (acquired) in this patient with HIV/AIDS. Note surrounding edema and mass effect .

Axial T1 C+ MR demonstrates linear periventricular and perivascular enhancement along the medullary veins. Meningeal biopsy revealed primary CNS vasculitis. Vasculitis Axial T1 C+ MR demonstrates linear periventricular and perivascular enhancement along the medullary veins. Meningeal biopsy revealed primary CNS vasculitis.

Axial T1 C+ MR demonstrates periventricular , ependymal , and perivascular enhancement . Biopsy of enlarged lung hilar lymph nodes was consistent with sarcoidosis. Neurosarcoid Axial T1 C+ MR demonstrates periventricular , ependymal , and perivascular enhancement . Biopsy of enlarged lung hilar lymph nodes was consistent with sarcoidosis.

Axial T1 C+ 3D SPGR MR demonstrates periventricular edema and enhancement around the 3rd ventricle. CSF was positive for antiaquaporin-4 IgG. These findings are consistent with neuromyelitis optica. Neuromyelitis Optica Spectrum Disorders Axial T1 C+ 3D SPGR MR demonstrates periventricular edema and enhancement around the 3rd ventricle. CSF was positive for antiaquaporin-4 IgG. These findings are consistent with neuromyelitis optica.

Axial T1 C+ MR in a 9-year-old boy with acute myeloid leukemia demonstrates multiple foci of nodular enhancement in the periventricular and perivascular regions, suggesting leukemic infiltration. Leukemia Axial T1 C+ MR in a 9-year-old boy with acute myeloid leukemia demonstrates multiple foci of nodular enhancement in the periventricular and perivascular regions, suggesting leukemic infiltration.

Axial T1 C+ MR shows multiple foci of perivascular enhancement in the pons and bilateral middle cerebellar peduncles around the 4th ventricle. This completely resolved after steroids (not shown), suggestive of CLIPPERS. CLIPPERS Axial T1 C+ MR shows multiple foci of perivascular enhancement in the pons and bilateral middle cerebellar peduncles around the 4th ventricle. This completely resolved after steroids (not shown), suggestive of CLIPPERS.

Axial T1 C+ MR shows a hypointense lesion in the right temporooccipital region with periventricular extension with marginal enhancement . In this patient with HIV/AIDS and progressive multifocal leucoencephalopathy (PML) (on HAART therapy), this is suggestive of PML-IRIS. Immune Reconstitution Inflammatory Syndrome (IRIS) Axial T1 C+ MR shows a hypointense lesion in the right temporooccipital region with periventricular extension with marginal enhancement . In this patient with HIV/AIDS and progressive multifocal leucoencephalopathy (PML) (on HAART therapy), this is suggestive of PML-IRIS.

Additional Images

Axial T1 C+ MR shows a characteristic tumefactive multiple sclerosis (MS) plaque with irregular, thick partial ring enhancement and mass effect . These lesions may cross the corpus callosum and mimic tumors. Multiple Sclerosis Axial T1 C+ MR shows a characteristic tumefactive multiple sclerosis (MS) plaque with irregular, thick partial ring enhancement and mass effect . These lesions may cross the corpus callosum and mimic tumors.

Axial T1 C+ MR shows numerous enhancing MS plaques in the periventricular and subcortical WM. Note the typical lack of mass effect. ADEM and Lyme disease may be identical. Multiple Sclerosis Axial T1 C+ MR shows numerous enhancing MS plaques in the periventricular and subcortical WM. Note the typical lack of mass effect. ADEM and Lyme disease may be identical.

Coronal T1 C+ MR shows classic incomplete ring-enhancing focus in the right frontal WM with minimal mass effect. No other enhancing foci were seen. Multiple Sclerosis Coronal T1 C+ MR shows classic incomplete ring-enhancing focus in the right frontal WM with minimal mass effect. No other enhancing foci were seen.

Axial T1 C+ MR shows characteristic imaging findings of glioblastoma that include a large, heterogeneous mass with thick, aggressive rim enhancement and central necrosis. There is mass effect and effacement of the anterior lateral ventricles. Glioblastoma, IDH-Wildtype Axial T1 C+ MR shows characteristic imaging findings of glioblastoma that include a large, heterogeneous mass with thick, aggressive rim enhancement and central necrosis. There is mass effect and effacement of the anterior lateral ventricles.

Axial T1 C+ FS MR shows a large, heterogeneously enhancing occipital lobe mass with central necrosis. Note extension across the splenium of the corpus callosum , characteristic of glioblastoma multiforme. Glioblastoma, IDH-Wildtype Axial T1 C+ FS MR shows a large, heterogeneously enhancing occipital lobe mass with central necrosis. Note extension across the splenium of the corpus callosum , characteristic of glioblastoma multiforme.

Axial T1 C+ FS MR shows multifocal enhancement in periventricular WM, fornices , and septum pellucidum . Noncontiguous regional involvement (satellite lesions) is a less common pattern in glioblastoma multiforme. Glioblastoma, IDH-Wildtype Axial T1 C+ FS MR shows multifocal enhancement in periventricular WM, fornices , and septum pellucidum . Noncontiguous regional involvement (satellite lesions) is a less common pattern in glioblastoma multiforme.

Axial T1 C+ MR demonstrates a solidly enhancing mass with mild surrounding vasogenic edema, consistent with primary CNS lymphoma in an immunocompetent patient. In immunocompromised lymphoma, the lesions tend to present with ring enhancement. Lymphoma, Primary CNS Axial T1 C+ MR demonstrates a solidly enhancing mass with mild surrounding vasogenic edema, consistent with primary CNS lymphoma in an immunocompetent patient. In immunocompromised lymphoma, the lesions tend to present with ring enhancement.

Axial T1 C+ MR shows homogeneous enhancement within multiple periventricular WM foci. Lack of significant surrounding T2 abnormality (not shown) and mild mass and corpus callosum involvement is common. Lymphoma, Primary CNS Axial T1 C+ MR shows homogeneous enhancement within multiple periventricular WM foci. Lack of significant surrounding T2 abnormality (not shown) and mild mass and corpus callosum involvement is common.

Axial T1 MR shows the neoplasm is an uncommon cause of vasculitis in this case of intravascular (angiocentric) lymphoma. Note numerous foci of punctate, linear, and confluent enhancement . Lymphoma, Primary CNS Axial T1 MR shows the neoplasm is an uncommon cause of vasculitis in this case of intravascular (angiocentric) lymphoma. Note numerous foci of punctate, linear, and confluent enhancement .

Axial T1 C+ MR shows multiple periventricular and subcortical metastatic enhancing lesions in a patient with lung adenocarcinoma. Metastases, Parenchymal Axial T1 C+ MR shows multiple periventricular and subcortical metastatic enhancing lesions in a patient with lung adenocarcinoma.

Axial T1 C+ MR shows enhancing lesions in the periventricular WM in this patient with a history of breast cancer. Metastases, Parenchymal Axial T1 C+ MR shows enhancing lesions in the periventricular WM in this patient with a history of breast cancer.

Axial T1 C+ MR demonstrates a large, ring-enhancing lesion in the left frontal lobe with mild surrounding vasogenic edema. The lesion was drained surgically, yielding Streptococcus anginosus cerebral abscess. Abscess Axial T1 C+ MR demonstrates a large, ring-enhancing lesion in the left frontal lobe with mild surrounding vasogenic edema. The lesion was drained surgically, yielding Streptococcus anginosus cerebral abscess.

Axial T1 C+ FS MR shows a ring-enhancing mass in the left frontal lobe. Thin-walled enhancement is typical of an abscess. Note the impending intraventricular rupture . Abscess Axial T1 C+ FS MR shows a ring-enhancing mass in the left frontal lobe. Thin-walled enhancement is typical of an abscess. Note the impending intraventricular rupture .

Axial T1 C+ MR shows bilateral rim- enhancing lesions with a targetoid appearance , characteristic of CNS toxoplasmosis. This was the initial presentation of a patient who suffered from undiagnosed HIV/AIDS. Toxoplasmosis, Acquired Axial T1 C+ MR shows bilateral rim- enhancing lesions with a targetoid appearance , characteristic of CNS toxoplasmosis. This was the initial presentation of a patient who suffered from undiagnosed HIV/AIDS.

Coronal T1 C+ MR shows multifocal masses with ring enhancement . Nodular enhancement is also frequently seen. Toxoplasmosis often lacks restricted diffusion on MR, unlike most abscesses. Toxoplasmosis, Acquired Coronal T1 C+ MR shows multifocal masses with ring enhancement . Nodular enhancement is also frequently seen. Toxoplasmosis often lacks restricted diffusion on MR, unlike most abscesses.

Coronal T1 C+ MR shows a large, mixed solid and cystic heterogeneously enhancing mass involving the right basal ganglia . Up to 10% of CNS germinomas arise within the basal ganglia. Germinoma Coronal T1 C+ MR shows a large, mixed solid and cystic heterogeneously enhancing mass involving the right basal ganglia . Up to 10% of CNS germinomas arise within the basal ganglia.

Axial T1 C+ MR shows patchy, multifocal enhancement consistent with subacute infarcts in this patient with lupus vasculitis. Vasculitis is often in the cortical and subcortical WM, although basal ganglia involvement is common. Associated DWI restriction may be seen. Vasculitis Axial T1 C+ MR shows patchy, multifocal enhancement consistent with subacute infarcts in this patient with lupus vasculitis. Vasculitis is often in the cortical and subcortical WM, although basal ganglia involvement is common. Associated DWI restriction may be seen.

Axial T1 C+ MR shows multifocal punctate foci of periventricular enhancement with associated T2 hyperintensity (not shown) without significant mass effect. The pattern of involvement in Lyme disease mimics MS lesions. Lyme Disease Axial T1 C+ MR shows multifocal punctate foci of periventricular enhancement with associated T2 hyperintensity (not shown) without significant mass effect. The pattern of involvement in Lyme disease mimics MS lesions.

Axial NECT shows a left periventricular enhancing mass with small cystic areas that are commonly present. Ependymomas more commonly are in or near the 4th ventricle but may be supratentorial (1/3 of cases). Calcifications are seen in 50%. Ependymoma Axial NECT shows a left periventricular enhancing mass with small cystic areas that are commonly present. Ependymomas more commonly are in or near the 4th ventricle but may be supratentorial (1/3 of cases). Calcifications are seen in 50%.

Axial NECT shows a periventricular, supratentorial ependymoma containing coarse calcifications . There is marked peritumoral edema. Note the subfalcine shift and obstructed ventricles. Ependymoma Axial NECT shows a periventricular, supratentorial ependymoma containing coarse calcifications . There is marked peritumoral edema. Note the subfalcine shift and obstructed ventricles.

Axial T1 C+ MR shows bilateral periventricular linear perivascular enhancement in sarcoidosis. Note additional leptomeningeal enhancement . Neurosarcoid Axial T1 C+ MR shows bilateral periventricular linear perivascular enhancement in sarcoidosis. Note additional leptomeningeal enhancement .

Axial T1 C+ MR shows linear enhancing foci in deep and periventricular WM that parallel the course of the cerebral microvasculature. This form of "carcinomatous encephalitis" is a rare intracranial manifestation of systemic leukemia. Leukemia Axial T1 C+ MR shows linear enhancing foci in deep and periventricular WM that parallel the course of the cerebral microvasculature. This form of "carcinomatous encephalitis" is a rare intracranial manifestation of systemic leukemia.

Sagittal FLAIR MR shows multiple hyperintense lesions in the corpus callosum, typical for Susac syndrome and MS. Enhanced scans typically show leptomeningeal enhancement. Susac Syndrome Sagittal FLAIR MR shows multiple hyperintense lesions in the corpus callosum, typical for Susac syndrome and MS. Enhanced scans typically show leptomeningeal enhancement.

Axial T1 C+ MR shows characteristic near-total lack of WM myelination and striking enhancement of the deep periventricular white matter . These patients usually present with a large head. Alexander Disease Axial T1 C+ MR shows characteristic near-total lack of WM myelination and striking enhancement of the deep periventricular white matter . These patients usually present with a large head.

Axial CECT shows dilated ependymal veins due to venous congestion in an infant with a large vein of Galen malformation. Ependymal/Subependymal Veins (Mimic) Axial CECT shows dilated ependymal veins due to venous congestion in an infant with a large vein of Galen malformation.

Axial T1 C+ MR shows marked enhancement of the deep nuclei in the setting of subacute venous infarction due to deep venous thrombosis. Note subependymal venous congestion . Ependymal/Subependymal Veins (Mimic) Axial T1 C+ MR shows marked enhancement of the deep nuclei in the setting of subacute venous infarction due to deep venous thrombosis. Note subependymal venous congestion .

Axial T1 C+ MR shows punctate and confluent enhancement in bilateral subcortical and periventricular white matter in PML-IRIS in an AIDS patient following initiation of HAART. There was associated hyperintense T2 FLAIR signal and mild mass effect. Immune Reconstitution Inflammatory Syndrome (IRIS) Axial T1 C+ MR shows punctate and confluent enhancement in bilateral subcortical and periventricular white matter in PML-IRIS in an AIDS patient following initiation of HAART. There was associated hyperintense T2 FLAIR signal and mild mass effect.

Axial T1 C+ MR demonstrates hypointense lesions centered in the bilateral thalami around the 3rd ventricle in a patient with neuromyelitis optica. Note faint peripheral enhancement on the right representing active demyelination. Typical neuromyelitis optica lesions are periventricular/periependymal following the distribution of aquaporin-4. Neuromyelitis Optica Spectrum Disorders Axial T1 C+ MR demonstrates hypointense lesions centered in the bilateral thalami around the 3rd ventricle in a patient with neuromyelitis optica. Note faint peripheral enhancement on the right representing active demyelination. Typical neuromyelitis optica lesions are periventricular/periependymal following the distribution of aquaporin-4.

Axial T1 C+ MR demonstrates periventricular enhancement around the 4th ventricle in a patient with neurosarcoid. Neurosarcoid Axial T1 C+ MR demonstrates periventricular enhancement around the 4th ventricle in a patient with neurosarcoid.

Axial T1 C+ MR demonstrates a large periventricular enhancing mass, a glioblastoma, centered in the genu and body of the corpus callosum. The main differential consideration for a mass involving the corpus callosum and crossing the midline is lymphoma. Glioblastoma, IDH-Wildtype Axial T1 C+ MR demonstrates a large periventricular enhancing mass, a glioblastoma, centered in the genu and body of the corpus callosum. The main differential consideration for a mass involving the corpus callosum and crossing the midline is lymphoma.

Axial T1 C+ MR demonstrates periventricular and smaller subcortical enhancing lesions in a patient with primary CNS lymphoma. The larger periventricular lesions show solid enhancement, which is the norm in immunocompetent lymphoma patients. Lymphoma, Primary CNS Axial T1 C+ MR demonstrates periventricular and smaller subcortical enhancing lesions in a patient with primary CNS lymphoma. The larger periventricular lesions show solid enhancement, which is the norm in immunocompetent lymphoma patients.

Axial T1 C+ MR shows bilateral multiple periventricular enhancing demyelinating lesions in a patient with ADEM. ADEM typically follows an infection or vaccination and can involve gray matter. ADEM Axial T1 C+ MR shows bilateral multiple periventricular enhancing demyelinating lesions in a patient with ADEM. ADEM typically follows an infection or vaccination and can involve gray matter.

Axial T1 C+ MR shows extensive bilateral periventricular and subcortical enhancing lesions in a patient with PML-IRIS. Unlike PML, PML-IRIS demonstrates mass effect and enhancement. Immune Reconstitution Inflammatory Syndrome (IRIS) Axial T1 C+ MR shows extensive bilateral periventricular and subcortical enhancing lesions in a patient with PML-IRIS. Unlike PML, PML-IRIS demonstrates mass effect and enhancement.

Axial C+ MR demonstrates a rim-enhancing periventricular lesion , which was consistent with a toxoplasmosis abscess. Note local mass effect and surrounding hypointense vasogenic edema . The main differential consideration in an immunocompromised HIV patient would be lymphoma. Toxoplasmosis, Acquired Axial C+ MR demonstrates a rim-enhancing periventricular lesion , which was consistent with a toxoplasmosis abscess. Note local mass effect and surrounding hypointense vasogenic edema . The main differential consideration in an immunocompromised HIV patient would be lymphoma.

Axial T1 C+ MR demonstrates punctate stippled enhancement in the pons and adjacent middle cerebellar peduncles . This is the typical perivascular enhancement pattern in CLIPPERS, and it can extend to involve the supratentorial brain. CLIPPERS Axial T1 C+ MR demonstrates punctate stippled enhancement in the pons and adjacent middle cerebellar peduncles . This is the typical perivascular enhancement pattern in CLIPPERS, and it can extend to involve the supratentorial brain.

Axial T1 C+ MR demonstrates bilateral periventricular punctate and patchy linear enhancement in a patient with pathologically confirmed primary CNS vasculitis. Vasculitis Axial T1 C+ MR demonstrates bilateral periventricular punctate and patchy linear enhancement in a patient with pathologically confirmed primary CNS vasculitis.

Axial T1 C+ MR demonstrates multiple bilateral enhancing subcortical and periventricular septic emboli of variable size and appearance in a patient with Escherichia coli septicemia. Septic Emboli Axial T1 C+ MR demonstrates multiple bilateral enhancing subcortical and periventricular septic emboli of variable size and appearance in a patient with Escherichia coli septicemia.

Axial T1 C+ MR demonstrates a typical incomplete ring of enhancement in tumefactive demyelination . Such lesions can present with variable degrees of mass effect. The incomplete ring of enhancement allows differentiation from neoplastic causes. Tumefactive Demyelination Axial T1 C+ MR demonstrates a typical incomplete ring of enhancement in tumefactive demyelination . Such lesions can present with variable degrees of mass effect. The incomplete ring of enhancement allows differentiation from neoplastic causes.

Axial T1 C+ MR shows several periventricular and juxtacortical enhancing lesions in a patient with relapsing/remitting multiple sclerosis. Note no associated mass effect. Multiple Sclerosis Axial T1 C+ MR shows several periventricular and juxtacortical enhancing lesions in a patient with relapsing/remitting multiple sclerosis. Note no associated mass effect.

Coronal T1 C+ MR shows numerous foci of enhancement in the subcortical and periventricular WM. Fuzzy enhancing margins are typical for demyelination. ADEM typically follows an infection or vaccination. ADEM Coronal T1 C+ MR shows numerous foci of enhancement in the subcortical and periventricular WM. Fuzzy enhancing margins are typical for demyelination. ADEM typically follows an infection or vaccination.

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