Patterns Contrast Enhancement - Smirniotopoulos

Ring Enhancing Lesions

James G. Smirniotopoulos, M.D. Professor of Radiology and Neurology Chairman, Department of Radiology and Nuclear Medicine Uniformed Services University of the Health Sciences 4301 Jones Bridge Road Bethesda, MD 20814 Voice: 301-295-3145 FAX: 301-295-3893 Email: jsmirnio@usuhs.mil Visit us on the WEB at: http://rad.usuhs.edu

Contrast enhancement occurs primarily because of a relative increase in blood volume or blood flow and/or from an abnormal increase in permeability due to an absence of the blood-brain-barrier (BBB). Ring enhancing lesions represent a special subset of contrast enhancing abnormalities. CONTRAST ENHANCEMENT Vascularity Permeability

The popular mnemonic for ring-enhancing lesions is: M - Metastasis, MS A - Abscess (also cerebritis) G - Glioblastoma, Granuloma I -Infarct (esp. Basal ganglia) C - Contusion (rare) A - AIDS (Toxo, etc.) L - Lymphoma (in aids) D - Demyelination (active) R - Resolving hematoma, Radiation change (necrosis) The primary characteristic of ring-enhancing lesions is that the center is composed of avascular tissue (dead or dying neoplastic tissue), old blood, infected and necrotic brain (abscess and cerebritis), tumor secreted fluid, or normal tissue adjacent to bands or rings of abnormal tissue. Therefore one or more of the following is usually present: Necrotic (dead) tissue (neoplasm, radiation necrosis, old infarction) Hemorrhage (blood old or new) Cyst fluid (craniopharyngioma, pilocytic astrocytoma, hemangioblastoma, etc.) Pus (abscess) Normal tissue (reparative phase of demyelination)

Demyelinating Disease
One of the more complex causes of a ring-enhancing lesion is demyelinating disease. The most common and therefore classic example is multiple sclerosis (MS). The underlying lesion in MS is a perivascular inflammatory process associated with destruction and removal of pre-existing normal myelin. During the active phase of inflammation, there is a transient disruption of the blood-brain-barrier. However, since this occurs in the white matter, which is relatively sparsely vascularized (compared to gray matter) the extravasation of contrast is relatively limited and usually not accompanied by perilesional edema. Usually, for a self-limited period of 4-8 weeks, there is limited contrast enhancement in a ring pattern. The ring enhancing area is the advancing zone of inflammation; the center is a region of demyelination with reinstatement of the integrity of the BBB; and on the outside, normal brain not yet affected the process. Because the process is perivascular, one of the characteristic lesions of MS (that usually doesn't enhance) is the perivenular inflammation around the small veins that run perpendicular to the lateral margin of the lateral ventricles - these are the "Dawson fingers" of demyelination.

Abscess and Cerebritis

Acute pyogenic infections of the CNS first cause cerebritis (the brain's version of cellulitis) that then proceeds to an organized abscess. First the infection goes unchecked. Then, the blood-brain-barrier is disrupted, allowing inflammatory cells (polymorphonuclear leukocytes) and proteins (antibiodies) to leave the bloodstream and cross into the brain. As the infection and the immune reaction lead to necrosis, there is a proliferation of capillaries and fibroblasts that will begin to form a wall to separate the infection and dead brain from the normal tissue. The reactive process usually creates, both pathologically and radiologically, a uniform rim of hypervascular connective tissue (granulation tissue) that has a relative uniform and smooth inner and outer margin. The abscess wall is usually of almost uniform thickness, although the white matter side of the abscess is usually thinner than the gray matter side. An abscess wall is invariably less than 10 mm in maximal thickness. CONTRAST ENHANCEMENT Ring Lesion Features For Infection ORGANIZED ABSCESS thin and uniform wall (3-7 mm.) smooth inner margin does not "fill in" on CT, MR? CEREBRITIS (infection w/o organization): variable wall (may be smooth) smooth/variable inner margin has "fill-in" on DDD (w/o fluid level)

CONTRAST ENHANCEMENT Abscess 2 - 4 wks. for ORGANIZED WALL 2 LAYERS MESENCHYMAL (capillaries, fibroblasts, collagen) ASTROGLIAL (reactive astrocytes) WALL facing GM is well formed 3-7 mm WALL FACING WM IS THINNER/WEAKER Daughter Abscess Ventricular Spill ("pyocephalus")

Neoplastic Ring Enhancing Lesions

Neoplastic ring lesions can occur with both benign 'cystic' tumors as well as with aggressive malignant masses. Highly aggressive malignant tumors are often complicated by necrosis - usually central necrosis. Necrosis is usually a progressive irregular haphazard and heterogeneous process. Malignant rings are usually unilocular or multilocular heterogeneous enhancing masses with rims that vary considerable from thin to thick and typically have a very shaggy inner margin. Usually, these features allow necrotic malignant tumors (e.g. glioblastoma multiforme) to be distinguished from more benign inflammatory lesions like an abscess. Unfortunately, benign fluid producing tumors can also become ring-enhancing masses. It may be difficult to distinguish these benign tumors from malignant ones by imaging alone. However, adding in location and patient age can be very helpful. Pilocytic astrocytoma, pleomorphic xanthoastrocytoma, and ganglioglioma usually present in childhood. Pilocytic astrocytoma usually presents in the cerebellum. Pleomorphic xanthoastrocytoma usually occurs in very young children and is usually very superficial. Ganglioglioma also present in young patients (children and adult) in the temporal lobe. Hemangioblastoma usually presents in the cerebellum.

CONTRAST ENHANCEMENT Ring Lesion Features For Neoplasm NECROTIC NEOPLASM: thick and irregular wall shaggy inner margin (usually) may "fill in" heterogeneously on delayed images these are usually aggressive and malignant tumors CYSTIC NEOPLASM: thin wall +/- MURAL NODULE PART OF WALL MAY NOT ENHANCE smooth inner margin uniform fluid enhancement or FLUID LEVEL these are often benign and/or low-grade tumors

Ring enhancing infarct

Ring enhancement in an infarct is very rare. However, when an infarct involves the deep gray matter - like the basal ganglia the shape of the enhancing gray matter will create a ring lesion. CONTRAST ENHANCEMENT Hematoma EARLY: Hyperdense, round/oval Homogeneous mass of RBC's Proportional mass effect for volume Edema "Halo", not spreading LATER: Iso-/Hypodense, smaller Reactive capillaries form outside Uniform rim of enhancement May see "vasogenic" edema

Post Operative Ring Enhancement

CONTRAST ENHANCEMENT Post-Operative RESIDUAL TUMOR (left behind) RECURRENT TUMOR (grew back) INFECTION NORMAL POSTOPERATIVE CHANGE (surgical trauma, healing) RADIATION Tx.?

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