Multiple Sclerosis Like Lesions

Multiple sclerosis (MS) is a clinical diagnosis that should never be made using neuroimaging alone. In 78-95% of clinically diagnosed MS patients, gadolinium-enhanced magnetic resonance imaging (MRI) features include ovoid periventricular, infratentorial, temporal lobe, and corpus callosum white matter lesions that are isointense to hypointense on Tl-weighted images, and show high intensity on proton density and T2-weighted images. Many conditions have to be taken into account in the differential diagnosis of multiple white matter high-signal abnormalities on proton density and T2-weighted images. Other conditions may produce lesions with or without enhancement, and can occur in a patient population similar to that with MS. The list of diseases with clinical and neuroimaging features similar to those of multiple sclerosis includes the following.

Subcortical arteriosclerotic encephalopathy

Methamphetamine, cocaine, heroin Hexachlorophene, lead, isoniazid, chemotherapeutic agents, eclampsia

The most common type, resulting from a deficiency of the enzyme arylsulfatase A

E.g., associated with adrenal cortical insufficiency and the accumulation of very long chain fatty acids in the white matter, adrenal cortex, and plasma due to impairment in peroxisomes of p-oxidation

Deficiency of the enzyme aspartoacyclase Deficiency of p-galactosidase

Neurosarcoidosis The granulomatous process invades and thromboses affected blood vessels, and produces a granulomatous angiitis similar to primary angiitis of the CNS. High-intensity white matter in sarcoid may be indistinguishable from MS

Lyme disease Neuroborreliosis. Approximately 10-15% of patients with Lyme disease have CNS involvement. High-signal contrast-enhancing subcortical abnormalities on proton density and T2-weighted images on MRI in the frontal and parietal lobes, the basal ganglia and pons, cranial nerves (facial nerve)

Vasculitides Multisystem immune-related vasculitis, with CNS in volvement in 10-49% of cases, e.g. systemic lupus erythematosus, Behcet's disease. May resemble MS clinically and due to a white matter lesion pattern in the brain and spinal cord

Neurosyphilis Contrast-enhanced MRI shows patchy enhancement involving the basal ganglia or the middle cerebral artery territories

Tuberculosis Single or multiple lesions located in the cerebral hemi sphere and basal ganglia in adults, and in the cerebellum in children. On MRI with gadolinium injection, a hypodense rim may separate the hyperintense center from the peripheral hyperintense edema on T2-weighted images, and Tl-weighted images often show nodular enhancement

Viral infection

Devic's disease, or neuro-

myelitis optica

Diffuse sclerosis

(Schilder's disease)

Myelopathy

Acute disseminated encephalomyelitis

An acute, rapidly progressing form of MS with bilateral, relatively symmetric and large areas of demy-elination, often involving the centrum semiovale and the occipital lobes; seen usually in childhood, and rarely in those over 40

Acute monophasic inflammatory demyelination, distinguished from MS by its clinical courseā€”a single acute episode including fever and headache. The locations and characteristics of the lesions on the MRI may be indistinguishable from MS

Balo's disease (concentric sclerosis)

Hypertension and ischemic white matter lesions

Virchow-Robin spaces

Lesions associated with migraine

Multi-infarct dementia, leukoareosis, and Binswanger's disease

Normal aging

Metastases and brain abscesses

Motor neuron disease Intracranial tumor Vitamin B12 deficiency

Represents a histological MS lesion with alternating concentric regions of demyelination and normal brain

In elderly patients with malignant hypertension, highsignal patchy or diffuse bilateral periventricular white matter abnormalities, most likely representing small-vessel disease manifesting as lacunar, deep white matter infarctions

Dilated perivascular spaces enlarge with age and hypertension and occur in characteristic locations, typically in the basal ganglia, around the ventricular atria, centrum semiovale, brain stem. The perivascular spaces remain isodense to CSF, whereas lesions are hypodense on the proton density-weighted MRI sequence

High-intensity abnormalities in the centrum semiovale and frontal white matter in young patients under 40.The lesions appear to be a diffuse process, possibly resulting from platelet microemboli or primary neuronal damage related to the pathophysiology of migraine

Affects the elderly population, and the predominant clinical manifestations are cognitive and behavioral disorders. The MRI shows periventricular white matter and centrum ovale watershed infarcts, similar in appearance to the demyelinating lesions of MS; however, in contrast to the MS lesions, there are no associated lesions in the basal ganglia, brain stem, or occipital horns, and there is sparing of the subcortical U fibers

In healthy individuals of 52 - 72 years of age, atrophic periventricular demyelination has been found in 53.4% and white matter infarcts are seen in 13.4%. Incidental white matter T2 hyperintensities occur frequently in elderly people

Rarely produce lesional patterns quite similar to MS. The presence of a mass effect and a clinical history suggesting a remote source for the lesions is important

Especially brain stem, cerebellum

Gastrectomy, gastric carcinoma, malabsorption syndromes

CSF: cerebrospinal fluid; CNS: central nervous system; MRI: magnetic resonance imaging; MS: multiple sclerosis.

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