Cerebral ring enhancing lesions

Last revised by Assoc Prof Frank Gaillard on 27 May 2022

The differential for peripheral or ring enhancing cerebral lesions includes:

A helpful mnemonic is MAGIC DR

Radiographic features

No single feature is pathognomonic, although a cystic lesion that markedly restricts centrally (the fluid component) on DWI should be considered an abscess until proven otherwise.

Many features of the lesion, as well as clinical presentation and patient demographics, need to be taken together to help narrow the differential. Helpful rules of thumb include:

  • enhancing wall characteristics
    • thick and nodular favors neoplasm
    • thin and regular favors abscess
    • incomplete ring often opened toward the cortex favors demyelination
    • intermediate to low T2 signal capsule favors abscess
    • restricted diffusion of enhancing wall favors GBM or demyelination
  • surrounding edema
    • extensive edema relative to lesion size favors abscess
    • increased perfusion favors neoplasm (metastases or primary cerebral malignancy)
  • central fluid content
    • restricted diffusion favors abscess
    • an absence of diffusion restriction favor a tumor with a central necrotic component (classically metastases)
  • number of lesions
    • similar sized rounded lesions at grey-white matter junction favors metastases or abscesses
    • irregular mass with adjacent secondary lesions embedded in the same region of 'edema' favors GBM
    • small (<1-2 cm) lesions with thin walls, especially if other calcific foci are present, suggest neurocysticercosis.
See also
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Cases and figures

  • Case 1: abscess
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  • Case 2: metastasis
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  • Case 3: demyelination (ADEM)
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  • Case 4: glioblastoma
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  • Case 5: stroke
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  • Case 6: radionecrosis
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