Differential Diagnosis of

White Matter Lesions

Multifocal Disease
Multiple sclerosis
White matter ischemia
Virchow-Robin Spaces
Migraine
Progressive Multifocal Leukoencephalopathy (PML)
Acute disseminated encephalomyelitis (ADEM)
Cerebral arteritis/vasculitis
Periventricular leukomalacia
Diffuse axonal injury
Central pontine myelinolysis
Diffuse Disease
White matter ischemia
HIV encephalitis
Radiation injury
Chemotherapy: methotrexate, cisplatin, cytosine arabinoside, carmustine, and thiotepa
Hereditary metabolic disorders
Contiguous Periventricular Pattern
White matter ischemia
Cytomegalovirus ventriculitis

Multiple Sclerosis

Oval or ovoid
Periventrical
Corpus callosum frequently involved
Perpendicular to the ventricular surface (Dawsons fingers)
Subcoritcal U-fibers, temporal lobes, brainstem, cerebellum
and spinal cord
Optic nerve involvement
Hypointense on T1
Focally enhanced on Godolinium

Axial T1

Axial T2

Sagittal
T2

Virchow-Robin Spaces
CSF spaces surrounding penetrating leptomeningeal
vessels
Round, usual less than 1-2mm
Extremely large VR spaces (>1 cm) seen in basal
ganglia region
Around atria, near the anterior commissure and in the
brainstem
Hypointense on FLAIR

Axial T2

Axial
FLAIR

White Matter Ischemia

Most common cause of WML on MRI
Periventricular caps, subcortical white matter, optic
radiations, basal ganglia and brain stem
Spares the corpus callosum
MRI spinal cord usually normal
Mildly hypointense on T1

Axial
FLAIR

Coronal T1

Migraine
Multiple, small, punctate lesions
Commonly involves anterior temporal lobe, basal
ganglia, pons
Resemble deep white matter ischemia, also mildly
hypointense on T1

Axial T1

Axial T2

Axial
FLAIR

Progressive Multifocal
Leukoencephalopathy (PML)

Patchy, asymmetrical distribution

Round or oval, homogenous with well defined margins
Classically involves frontal and parieto-occipital lobes
Less commonly affects corpus callosum
Not enhanced by Gadolinium

Axial T2

Axial
FLAIR

Axial
Gadolinium T1

Acute Disseminated
Encephalomyelitis (ADEM)
Patchy, asymmetrical distribution
Commonly involves brainstem, cerebrum,
cerebellum, and spinal cord
Incomplete, spotty enhancement on Gadolinium

Axial
FLAIR

Axial
FLAIR

Axial
Gadolinium T1

Back to Mr. G

Lumbar puncture preformed on 20/10/15

Gram stain: negative
FEME: clear, RBC 1 WBC 2 protein 0.42
Oligoclonal band: pending

MacDonalds Criteria (2010)

CLINICAL
(ATTACK
S)

OBJECTIVE
CLINICAL
EVIDENCE OF
LESION

ADDITIONAL CRITERIA TO MAKE DX

2 or more
attacks

2 or more lesions
OR 1 lesion with
reasonable
historical evidence
of a prior attack

None. Clinical evidence alone will suffice; additional evidence desirable but
must be consistent with MS

2 or more
attacks

1 lesion

Dissemination in space OR
Await further clinical attack implicating a different CNS site

2 or more lesions

Dissemination in time OR
A new T2 and/or contrast-enhancing lesions(s) on follow-up MRI, irrespective
of its timing OR
Await a second clinical attack

1 lesion

Dissemination in space OR
Await further clinical attack implicating a different CNS site AND
Dissemination in time OR
A new T2 and/or contrast-enhancing lesions(s) on follow-up MIR, irrespective
of its timing OR
Await a second clinical attack

1 attack

1 attack

0
(progressi
on from
onset)

One year of disease progression (retrospective or prospective) AND at least

2 out of 3 criteria:
1. Dissemination in space in the brain based on 1 T2 lesion in
periventricular, juxtacortical or infratentorial regions
2. Dissemination in space in the spinal cord based on 2 T2 lesions
3. Positive CSF

References
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Polman CH, Reingold SC, Banwell B, et al. Diagnostic criteria for multiple
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Cajade-Law AG, Cohen JA, Heier LA. Vascular causes of white matter
disease. Neuroimaging Clinics of North America 1993;3(2):361-375.
Caldemeyer KS, Edwards MK, Smith RR, Moran CC. Viral and postviral
demyelination central nervous system infection. Neuroimaging Clinics of
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Johnson BA. A practical approach to white matter disease. Advanced
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Gladstone JP, Dodick DW. Migraine and cerebral white matter lesions:
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