Punctate and curvilinear gadolinium enhancing lesions in the brain: a practical approach
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Cerebral punctate and curvilinear gadolinium enhancements (PCGE) correspond to opacification of small vessel lumen or its perivascular areas in case of blood-brain barrier (BBB) disruption. We will discuss the possible causes of intra-parenchymal central nervous system PCGE.
Our review is based on French database including patients presenting with central nervous system PCGE and literature search using PubMed database with the following keywords: punctate enhancement, linear enhancement, and curvilinear enhancement. Disorders which displayed linear leptomeningeal or periventricular enhancements without intra-parenchymal PCGE are excluded of this review.
Among our 39 patients with PCGE, 16 different diagnoses were established. After combining our PCGE causes with those described in the literature, we propose a practical approach. Besides physiologic post-contrast enhancement of small vessels, three pathologic conditions may exhibit PCGE: (1) small collateral artery network seen in Moyamoya syndrome, (2) small veins congestions related to developmental or acquired venous outflow disturbance, and (3) disorders causing small vessels BBB disruption indicated by T2 and FLAIR hyperintensities in the corresponding areas of PCGE. Disruption of the BBB could be caused by a direct injury of the endothelial cell, as in posterior reversible encephalopathy syndrome, Susac syndrome, and radiochemotherapy-induced injuries, or by an angiocentric cellular infiltrate, as in inflammatory disorders, demyelinating diseases, host immune responses fighting against infections, prelymphoma states, lymphoma, and in CLIPPERS.
PCGE may conceal several causes, including physiological and pathological conditions. Nevertheless, a practical approach could improve its management and limit the indications of brain biopsy to very specific situations.
KeywordsPunctate enhancement Curvilinear enhancement Linear enhancement Blood-brain barrier CLIPPERS
Diffusion-weighted images with increased
Apparent diffusion coefficient
Magnetic resonance imaging
Punctate and curvilinear gadolinium enhancements
Posterior reversible encephalopathy syndrome
Systemic lupus erythematosus
Langerhans cell histiocytosis
Non-Langerhans cell histiocytosis
Primary arteritis of the CNS
Acute demyelinating encephalomyelitis\
Neuromyelitis optica spectrum disorders
Immune reconstitution inflammatory syndrome
Progressive multifocal leukoencephalopathy
Primary CNS lymphoma
Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids
We want to especially thank Mr Benjamin Taieb for his help in figure design.
Compliance with ethical standards
We declare that this manuscript does not contain clinical studies. Anonymized data with a number were used to develop a practical approach.
Conflict of interest
We declare that we have no conflict of interest.
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