Skip to main content

Advertisement

SpringerLink
Log in

Brainstem lesions: MRI review of standard morphological sequences

  • Review article
  • Published:
Acta Neurologica Belgica Aims and scope Submit manuscript

Abstract

MRI signal changes in the brainstem are observed in a multitude of disorders including vascular diseases, neoplastic lesions, degenerative diseases, inflammatory disorders, metabolic diseases, infections, and trauma. In some diseases, brainstem involvement is typical and sometimes isolated, while in other diseases, brainstem lesions are only observed occasionally in the presence of other typical extra-brainstem abnormalities. In this review, we will discuss the MRI characteristics of brainstem lesions observed in different disorders associated with frequent and less frequent brainstem involvement. Identification of the origin of the brainstem lesion depends on the exact localisation of the lesion(s) inside the brainstem, the presence and the characteristics of associated lesions seen outside the brainstem, the signal changes on different MRI sequences, the evolution over time of the radiological abnormalities, the history and clinical state of the patient, and other radiological and non-radiological examinations.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7

Similar content being viewed by others

References

  1. Tatu L, Moulin T, Bogousslavsky J, Duvernoy H (1996) Arterial territories of human brain: Brainstem and cerebellum. Neurology 47(5):1125–1135

    Article  CAS  PubMed  Google Scholar 

  2. Connell L, Koerte IK, Laubender RP, Morhard D, Linn J, Becker HC et al (2012) Hyperdense basilar artery sign—a reliable sign of basilar artery occlusion. Neuroradiology 54(4):321–327

    Article  PubMed  Google Scholar 

  3. Ernst M, Romero JM, Buhk J-H, Cheng B, Herrmann J, Fiehler J, et al. Sensitivity of Hyperdense Basilar Artery Sign on Non-Enhanced Computed Tomography. Hendrikse J, editor. PLoS ONE. 2015 Oct 19;10(10):e0141096.

  4. Sylaja PN, Coutts SB, Krol A, Hill MD, Demchuk AM (2008) When to Expect Negative Diffusion-Weighted Images in Stroke and Transient Ischemic Attack. Stroke 39(6):1898–1900

    Article  CAS  PubMed  Google Scholar 

  5. Chen X, Wang J, Shan Y, Cai W, Liu S, Hu M et al (2019) Cerebral small vessel disease: neuroimaging markers and clinical implication. J Neurol 266(10):2347–2362

    Article  PubMed  Google Scholar 

  6. Hakky MM, Erbay KD, Brewer E, Midle JB, French R, Erbay SH (2013) T2 Hyperintensity of medial lemniscus: higher threshold application to ROI measurements is more accurate in predicting small vessel disease. J Neuroimaging 23(3):345–351

    Article  PubMed  Google Scholar 

  7. Erbay SH, Brewer E, French R, Midle JB, Zou KH, Lee GM et al (2012) T2 Hyperintensity of medial lemniscus is an indicator of small-vessel disease. Am J Roentgenol 199(1):163–168

    Article  Google Scholar 

  8. Fakan B, Reisz Z, Zadori D, Vecsei L, Klivenyi P, Szalardy L (2020) Predictors of localization, outcome, and etiology of spontaneous intracerebral hemorrhages: focus on cerebral amyloid angiopathy. J Neural Transm 127(6):963–972

    Article  PubMed  Google Scholar 

  9. Aguilar MI, Brott TG (2011) Update in Intracerebral Hemorrhage. The Neurohospitalist 1(3):148–159

    Article  PubMed  PubMed Central  Google Scholar 

  10. Flemming KD, Link MJ, Christianson TJH, Brown RD (2012) Prospective hemorrhage risk of intracerebral cavernous malformations. Neurology 78(9):632–636

    Article  CAS  PubMed  Google Scholar 

  11. Kashefiolasl S, Bruder M, Brawanski N, Herrmann E, Seifert V, Tritt S et al (2018) A benchmark approach to hemorrhage risk management of cavernous malformations. Neurology 90(10):e856–e863

    Article  PubMed  Google Scholar 

  12. Salman RA-S, Hall JM, Horne MA, Moultrie F, Josephson CB, Bhattacharya JJ, et al (2012) Untreated clinical course of cerebral cavernous malformations: a prospective, population-based cohort study. Lancet Neurol 11(3):217–24

  13. Hou K, Li G, Qu L, Liu H, Xu K, Yu J (2020) Intracranial dural arteriovenous fistulas with brainstem engorgement: an under-recognized entity in diagnosis and treatment. Front Neurol 11:526550

  14. Grigoryan G, Sitnikov A, Grigoryan Y (2020) Hemifacial spasm caused by the brainstem developmental venous anomaly: a case report and review of the literature. Surg Neurol Int 6(11):141

    Article  Google Scholar 

  15. Rudie JD, Rauschecker AM, Nabavizadeh SA, Mohan S (2018) Neuroimaging of dilated perivascular spaces: from benign and pathologic causes to mimics: perivascular spaces. J Neuroimaging 28(2):139–149

    Article  PubMed  Google Scholar 

  16. Kwee RM, Kwee TC (2007) Virchow-robin spaces at MR imaging. Radiographics 27(4):1071–1086

    Article  PubMed  Google Scholar 

  17. Wardlaw JM, Smith C, Dichgans M (2019) Small vessel disease: mechanisms and clinical implications. Lancet Neurol 18(7):684–696

    Article  PubMed  Google Scholar 

  18. Reyes-Botero G, Mokhtari K, Martin-Duverneuil N, Delattre J, Laigle-Donadey F (2012) Adult brainstem gliomas. Oncologist 17(3):388–397

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  19. Villanueva-Meyer JE, Mabray MC, Cha S (2017) Current clinical brain tumor imaging. Neurosurgery 81(3):397–415

    Article  PubMed  PubMed Central  Google Scholar 

  20. Fink JR, Muzi M, Peck M, Krohn KA (2015) Multimodality brain tumor imaging: MR imaging, PET, and PET/MR imaging. J Nucl Med 56(10):1554–1561

    Article  CAS  PubMed  Google Scholar 

  21. Schob S, Meyer J, Gawlitza M, Frydrychowicz C, Müller W, Preuss M, et al (2016) Diffusion-Weighted MRI reflects proliferative activity in primary CNS lymphoma. Coles JA, editor. PLoS ONE 11(8):e0161386.

  22. Yuh EL, Barkovich AJ, Gupta N (2009) Imaging of ependymomas: MRI and CT. Childs Nerv Syst 25(10):1203

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  23. Luna LP, Drier A, Aygun N, Mokhtari K, Hoang-Xuan K, Galanaud D et al (2021) MRI features of intra-axial histiocytic brain mass lesions. Clin Radiol 76(2):159.e19-159.e28

    Article  CAS  Google Scholar 

  24. Kim H-J, Jeon B, Fung VSC (2017) Role of magnetic resonance imaging in the diagnosis of multiple system atrophy. Mov Disord Clin Pract 4(1):12–20

    Article  PubMed  Google Scholar 

  25. Deguchi K, Ikeda K, Kume K, Takata T, Kokudo Y, Kamada M et al (2015) Significance of the hot-cross bun sign on T2*-weighted MRI for the diagnosis of multiple system atrophy. J Neurol 262(6):1433–1439

    Article  CAS  PubMed  Google Scholar 

  26. Mascalchi M, Vella A (2018) Neuroimaging Applications in Chronic Ataxias. In: International Review of Neurobiology [Internet]. Elsevier [cited 2021 Feb 19]. p. 109–62. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0074774218301119

  27. Whitwell JL, Höglinger GU, Antonini A, Bordelon Y, Boxer AL, Colosimo C et al (2017) Radiological biomarkers for diagnosis in PSP: Where are we and where do we need to be? Neuroimaging Biomarkers for Diagnosis in PSP. Mov Disord 32(7):955–971

    Article  PubMed  PubMed Central  Google Scholar 

  28. Sugiyama A, Sato N, Nakata Y, Kimura Y, Enokizono M, Maekawa T et al (2018) Clinical and magnetic resonance imaging features of elderly onset dentatorubral-pallidoluysian atrophy. J Neurol 265(2):322–329

    Article  PubMed  Google Scholar 

  29. Sugiyama A, Sato N, Kimura Y, Fujii H, Shigemoto Y, Suzuki F, et al (2020) The cerebellar white matter lesions in dentatorubral-pallidoluysian atrophy. J Neurol Sci 416:117040

  30. Fabes J, Matthews L, Filippini N, Talbot K, Jenkinson M, Turner MR (2017) Quantitative FLAIR MRI in Amyotrophic Lateral Sclerosis. Acad Radiol 24(10):1187–1194

    Article  PubMed  PubMed Central  Google Scholar 

  31. Sastre-Garriga J, Tintoré M, Nos C, Tur C, Río J, Téllez N et al (2010) Clinical features of CIS of the brainstem/cerebellum of the kind seen in MS. J Neurol 257(5):742–746

    Article  PubMed  Google Scholar 

  32. Tintore M, Rovira A, Arrambide G, Mitjana R, Rio J, Auger C et al (2010) Brainstem lesions in clinically isolated syndromes. Neurology 75(21):1933–1938

    Article  CAS  PubMed  Google Scholar 

  33. Minneboo A, Barkhof F, Polman CH, Uitdehaag BMJ, Knol DL, Castelijns JA (2004) Infratentorial Lesions Predict Long-term Disability in Patients With Initial Findings Suggestive of Multiple Sclerosis. Arch Neurol 61(2):217

    Article  PubMed  Google Scholar 

  34. Nakashima I, Fujihara K, Okita N, Takase S, Itoyama Y (1999) Clinical and MRI study of brain stem and cerebellar involvement in Japanese patients with multiple sclerosis. J Neurol Neurosurg Psychiatry 67(2):153–157

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  35. Nakashima I, Fujihara K, Kimpara T, Okita N, Takase S, Itoyama Y (2001) Linear pontine trigeminal root lesions in multiple sclerosis: clinical and magnetic resonance imaging studies in 5 cases. Arch Neurol [Internet]. 2001 Jan 1 [cited 2021 Feb 19];58(1). Available from: http://archneur.jamanetwork.com/article.aspx?doi=https://doi.org/10.1001/archneur.58.1.101

  36. Keegan BM, Kaufmann TJ, Weinshenker BG, Kantarci OH, Schmalstieg WF, Paz Soldan MM et al (2016) Progressive solitary sclerosis: Gradual motor impairment from a single CNS demyelinating lesion. Neurology 87(16):1713–1719

    Article  PubMed  PubMed Central  Google Scholar 

  37. Chan KH (2011) Brain involvement in neuromyelitis optica spectrum disorders. Arch Neurol 68(11):1432

    Article  PubMed  Google Scholar 

  38. Kim HJ, Paul F, Lana-Peixoto MA, Tenembaum S, Asgari N, Palace J et al (2015) MRI characteristics of neuromyelitis optica spectrum disorder: an international update. Neurology 84(11):1165–1173

    Article  PubMed  PubMed Central  Google Scholar 

  39. Banks SA, Morris PP, Chen JJ, Pittock SJ, Sechi E, Kunchok A et al (2021) Brainstem and cerebellar involvement in MOG-IgG-associated disorder versus aquaporin-4-IgG and MS. J Neurol Neurosurg Psychiatry 92(4):384–390

    Article  Google Scholar 

  40. Koelman DLH, Mateen FJ (2015) Acute disseminated encephalomyelitis: current controversies in diagnosis and outcome. J Neurol 262(9):2013–2024

    Article  CAS  PubMed  Google Scholar 

  41. Kalra S, Silman A, Akman-Demir G, Bohlega S, Borhani-Haghighi A, Constantinescu CS et al (2014) Diagnosis and management of Neuro-Behçet’s disease: international consensus recommendations. J Neurol 261(9):1662–1676

    Article  PubMed  Google Scholar 

  42. Simon NG, Parratt JD, Barnett MH, Buckland ME, Gupta R, Hayes MW et al (2012) Expanding the clinical, radiological and neuropathological phenotype of chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS). J Neurol Neurosurg Psychiatry 83(1):15–22

    Article  PubMed  Google Scholar 

  43. Taieb G, Duflos C, Renard D, Audoin B, Kaphan E, Pelletier J et al (2012) Long-term Outcomes of CLIPPERS (Chronic Lymphocytic Inflammation With Pontine Perivascular Enhancement Responsive to Steroids) in a Consecutive Series of 12 Patients. Arch Neurol [Internet]. 69(7). Available from: http://archneur.jamanetwork.com/article.aspx?doi=https://doi.org/10.1001/archneurol.2012.122

  44. Martin RJ (2004) Central pontine and extrapontine myelinolysis: the osmotic demyelination syndromes. J Neurol Neurosurg Psychiatry. 2004 75(suppl_3):iii22–8

  45. Kallakatta RN, Radhakrishnan A, Fayaz RK, Unnikrishnan JP, Kesavadas C, Sarma SP (2011) Clinical and functional outcome and factors predicting prognosis in osmotic demyelination syndrome (central pontine and/or extrapontine myelinolysis) in 25 patients. J Neurol Neurosurg Psychiatry 82(3):326–331

    Article  PubMed  Google Scholar 

  46. Ruzek KA, Campeau NG, Miller GM (2004) Early diagnosis of central pontine myelinolysis with diffusion-weighted imaging. AJNR Am J Neuroradiol 25(2):210–213

    PubMed  PubMed Central  Google Scholar 

  47. Manzo G, De Gennaro A, Cozzolino A, Serino A, Fenza G, Manto A (2014) MR imaging findings in alcoholic and nonalcoholic acute Wernicke’s encephalopathy: a review. Biomed Res Int 2014:1–12

    Article  Google Scholar 

  48. Nardone R, Venturi A, Golaszewski S, Caleri F, Tezzon F, Ladurner G (2010) MR atypical wernicke encephalopathy showing extensive brain stem and diencephalic involvement. J Neuroimaging 20(2):204–207

    Article  PubMed  Google Scholar 

  49. Rovira A, Alonso J, Córdoba J (2008) MR imaging findings in hepatic encephalopathy. AJNR Am J Neuroradiol 29(9):1612–1621

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  50. Li K, Yang Y, Guo D, Sun D, Li C (2020) Clinical and MRI features of posterior reversible encephalopathy syndrome with atypical regions: a descriptive study with a large sample size. Front Neurol 24(11):194

    Article  CAS  Google Scholar 

  51. Bonfante E, Koenig MK, Adejumo RB, Perinjelil V, Riascos RF (2016) The neuroimaging of Leigh syndrome: case series and review of the literature. Pediatr Radiol 46(4):443–451

    Article  PubMed  Google Scholar 

  52. Baertling F, Rodenburg RJ, Schaper J, Smeitink JA, Koopman WJH, Mayatepek E et al (2014) A guide to diagnosis and treatment of Leigh syndrome. J Neurol Neurosurg Psychiatry 85(3):257–265

    Article  PubMed  Google Scholar 

  53. Salari M, Fayyazi E, Mirmosayyeb O (2018) Magnetic resonance imaging findings in diagnosis and prognosis of Wilson disease. J Res Med Sci 23(1):23

    Article  PubMed  PubMed Central  Google Scholar 

  54. Dusek P, Litwin T, Członkowska A (2019) Neurologic impairment in Wilson disease. Ann Transl Med 7(S2):S64–S64

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  55. Hitoshi S, Iwata M, Yoshikawa K (1991) Mid-brain pathology of Wilson’s disease: MRI analysis of three cases. J Neurol Neurosurg Psychiatry 54(7):624–626

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  56. Demaerel P, Van Dessel W, Van Paesschen W, Vandenberghe R, Van Laere K, Linn J (2011) Autoimmune-mediated encephalitis. Neuroradiology 53(11):837–851

    Article  PubMed  Google Scholar 

  57. Michev A, Musso P, Foiadelli T, Trabatti C, Lozza A, Franciotta D et al (2019) Bickerstaff Brainstem Encephalitis and overlapping Guillain-Barré syndrome in children: report of two cases and review of the literature. Eur J Paediatr Neurol 23(1):43–52

    Article  CAS  PubMed  Google Scholar 

  58. Köhler W, Curiel J, Vanderver A (2018) Adulthood leukodystrophies. Nat Rev Neurol 14(2):94–105

    Article  CAS  PubMed  Google Scholar 

  59. Ayrignac X, Boutiere C, Carra-dalliere C, Labauge P (2016) Posterior fossa involvement in the diagnosis of adult-onset inherited leukoencephalopathies. J Neurol 263(12):2361–2368

    Article  CAS  PubMed  Google Scholar 

  60. Shen Y, Jian W, Li J, Dai T, Bao B, Nie H (2018) Bilateral wallerian degeneration of the middle cerebellar peduncles secondary to pontine infarction: A case series. J Neurol Sci 388:182–185

    Article  PubMed  Google Scholar 

  61. Konno T, Broderick DF, Tacik P, Caviness JN, Wszolek ZK (2016) Hypertrophic olivary degeneration: a clinico-radiologic study. Parkinsonism Relat Disord 28:36–40

    Article  PubMed  PubMed Central  Google Scholar 

  62. Bertrand A, Leclercq D, Martinez-Almoyna L, Girard N, Stahl J-P, De-Broucker T (2017) MR imaging of adult acute infectious encephalitis. Med Mal Infect 47(3):195–205

    Article  CAS  PubMed  Google Scholar 

  63. Breville G, Koralnik IJ, Lalive PH (2021) Brainstem progressive multifocal leukoencephalopathy. Eur J Neurol 28(3):1016–1021

    Article  PubMed  Google Scholar 

  64. Hodel J, Outteryck O, Dubron C, Dutouquet B, Benadjaoud MA, Duhin E et al (2016) Asymptomatic progressive multifocal leukoencephalopathy associated with natalizumab: diagnostic precision with MR imaging. Radiology 278(3):863–872

    Article  PubMed  Google Scholar 

  65. Wijburg MT, Witte BI, Vennegoor A, Roosendaal SD, Sanchez E, Liu Y et al (2016) MRI criteria differentiating asymptomatic PML from new MS lesions during natalizumab pharmacovigilance. J Neurol Neurosurg Psychiatry 87(10):1138–1145

    Article  PubMed  Google Scholar 

  66. Sandhu S, Soule E, Fiester P, Natter P, Tavanaiepour D, Rahmathulla G et al (2019) Brainstem diffuse axonal injury and consciousness. JCIS 28(9):32

    Article  Google Scholar 

Download references

Acknowledgements

We would like to thank Dr. Sarah Kabani (Service de Biostatistique, Epidémiologie Clinique, Santé Publique et Innovation en Méthodologie (BESPIM), CHU de Nîmes, 4 Rue du Professeur Debré, 30029 Nîmes Cedex 09) for proofreading our manuscript.

Author information

Authors and Affiliations

  1. Department of Neurology, CHU Nîmes, Hôpital Carémeau, University of Montpellier, 4 Rue du Professeur Debré, 30029, Nîmes Cedex 9, France

    Dimitri Renard, Jean-Sebastien Guillamo, Ioana Ion & Eric Thouvenot

  2. Institut de Génomique Fonctionnelle, CNRS UMR5203, INSERM 1191, University of Montpellier, Montpellier, France

    Eric Thouvenot

Authors
  1. Dimitri Renard
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Jean-Sebastien Guillamo
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Ioana Ion
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Eric Thouvenot
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Dimitri Renard.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical statement

The subject has given her informed consent to report data given. The manuscript was approved by the institute’s committee on human research.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Renard, D., Guillamo, JS., Ion, I. et al. Brainstem lesions: MRI review of standard morphological sequences. Acta Neurol Belg 122, 597–613 (2022). https://doi.org/10.1007/s13760-022-01943-y

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s13760-022-01943-y

Keywords

Search

Navigation