Milky Way sign (of PML)

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The milky way sign, also known less memorably merely as punctate pattern, is an MRI feature described in progressive multifocal leukoencephalopathy (PML) and is particularly useful when distinguishing this from new lesions of multiple sclerosis ^1,2.

Terminology

Although the term "milk way appearance" has primarily been reported in the context of progressive multifocal leukoencephalopathy, other pathologies share a similar appearance (see differential diagnosis below).

Additionally, the term has also been used to denote the punctate enhancement pattern often seen in the same patients on post-contrast T1 weighted images ³.

This sign should not be confused with the similarly named starry sky appearance (MRI) seen in multiple biliary hamartomas and the starry sky appearance (ultrasound) seen in a variety of liver pathologies.

Pathology

The sign is believed to be the result of the accumulation of CD8-positive T-cells within the perivascular spaces with ensuing inflammation ².

Radiographic features

MRI

The sign denotes multiple punctate regions of high T2 surrounding the main component of the new lesion, appearing reminiscent of white stars on the dark background of the sky ^1,2.

Differential diagnosis

Although the term milky way sign is mostly used in the context of progressive multifocal leukoencephalopathy a similar pattern has been reported in a number of other conditions including ²:

-<p>The <strong>milky way sign</strong>, also known less memorably merely as <strong>punctate pattern</strong>, is an MRI feature described in <a title="Progressive multifocal leukoencephalopathy" href="/articles/progressive-multifocal-leukoencephalopathy">progressive multifocal leukoencephalopathy (PML) </a>and is particularly useful when distinguishing this from new lesions of <a title="Multiple sclerosis" href="/articles/multiple-sclerosis">multiple sclerosis</a> <sup>1,2</sup>. </p><h4>Terminology</h4><p>Although the term "milk way appearance" has primarily been reported in the context of progressive multifocal leukoencephalopathy, other pathologies share a similar appearance (see differential diagnosis below). </p><p>Additionally, the term has also been used to denote the punctate enhancement pattern often seen in the same patients on post-contrast T1 weighted images <sup>3</sup>. </p><p> </p><h4>Pathology</h4><p>The sign is believed to be the result of the accumulation of CD8-positive T-cells within the perivascular spaces with ensuing inflammation <sup>2</sup>.</p><h4>Radiographic features</h4><h5>MRI</h5><p>The sign denotes multiple punctate regions of high T2 surrounding the main component of the new lesion, appearing reminiscent of white stars on the dark background of the sky <sup>1,2</sup>. </p><h4>Differential diagnosis</h4><p>Although the term milky way sign is mostly used in the context of <a href="/articles/progressive-multifocal-leukoencephalopathy">progressive multifocal leukoencephalopathy </a> a similar pattern has been reported in a number of other conditions including <sup>2</sup>: </p><ul>
-<li><a title="Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS)" href="/articles/chronic-lymphocytic-inflammation-with-pontine-perivascular-enhancement-responsive-to-steroids-clippers">CLIPPERS</a></li>
~~-<li><a title="CNS vasculitis" href="/articles/central-nervous-system-vasculitides">CNS vasculitis</a></li>~~
~~-<li><a title="Neurosarcoidosis" href="/articles/neurosarcoidosis">neurosarcoidosis</a></li>~~
+<p>The <strong>milky way sign</strong>, also known less memorably merely as <strong>punctate pattern</strong>, is an MRI feature described in <a href="/articles/progressive-multifocal-leukoencephalopathy">progressive multifocal leukoencephalopathy (PML) </a>and is particularly useful when distinguishing this from new lesions of <a href="/articles/multiple-sclerosis">multiple sclerosis</a> <sup>1,2</sup>. </p><h4>Terminology</h4><p>Although the term "milk way appearance" has primarily been reported in the context of progressive multifocal leukoencephalopathy, other pathologies share a similar appearance (see differential diagnosis below). </p><p>Additionally, the term has also been used to denote the punctate enhancement pattern often seen in the same patients on post-contrast T1 weighted images <sup>3</sup>. </p><p>This sign should not be confused with the similarly named <a href="/articles/starry-sky-appearance-mri">starry sky appearance (MRI)</a> seen in <a href="/articles/multiple-biliary-hamartomas-1">multiple biliary hamartomas</a> and the <a href="/articles/starry-sky-appearance-ultrasound-1">starry sky appearance (ultrasound)</a> seen in a variety of liver pathologies. </p><h4>Pathology</h4><p>The sign is believed to be the result of the accumulation of CD8-positive T-cells within the perivascular spaces with ensuing inflammation <sup>2</sup>.</p><h4>Radiographic features</h4><h5>MRI</h5><p>The sign denotes multiple punctate regions of high T2 surrounding the main component of the new lesion, appearing reminiscent of white stars on the dark background of the sky <sup>1,2</sup>. </p><h4>Differential diagnosis</h4><p>Although the term milky way sign is mostly used in the context of <a href="/articles/progressive-multifocal-leukoencephalopathy">progressive multifocal leukoencephalopathy </a> a similar pattern has been reported in a number of other conditions including <sup>2</sup>: </p><ul>
+<li><a href="/articles/chronic-lymphocytic-inflammation-with-pontine-perivascular-enhancement-responsive-to-steroids-clippers">CLIPPERS</a></li>
+<li><a href="/articles/central-nervous-system-vasculitides">CNS vasculitis</a></li>
+<li><a href="/articles/neurosarcoidosis">neurosarcoidosis</a></li>

References changed:

1. Wijburg MT, Witte BI, Vennegoor A, Roosendaal SD, Sanchez E, Liu Y, Martins Jarnalo CO, Uitdehaag BM, Barkhof F, Killestein J, Wattjes MP. MRI criteria differentiating asymptomatic PML from new MS lesions during natalizumab pharmacovigilance. (2016) Journal of neurology, neurosurgery, and psychiatry. 87 (10): 1138-45. <a href="https://doi.org/10.1136/jnnp-2016-313772">doi:10.1136/jnnp-2016-313772</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/27530808">Pubmed</a> <span class="ref_v4"></span>
2. Hodel J, Darchis C, Outteryck O, Verclytte S, Deramecourt V, Lacour A, Zins M, Pruvo JP, Vermersch P, Leclerc X. Punctate pattern: A promising imaging marker for the diagnosis of natalizumab-associated PML. (2016) Neurology. 86 (16): 1516-23. <a href="https://doi.org/10.1212/WNL.0000000000002586">doi:10.1212/WNL.0000000000002586</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/27009257">Pubmed</a> <span class="ref_v4"></span>
3. Sinnecker T, Hadisurya J, Schneider-Hohendorf T, Schwab N, Wrede K, Gembruch O, Gold R, Hellwig K, Pilgram-Pastor S, Adams O, Albrecht P, Hartung HP, Aktas O, Kraemer M. Extensive immune reconstitution inflammatory syndrome in Fingolimod-associated PML: a case report with 7 Tesla MRI data. (2019) BMC neurology. 19 (1): 190. <a href="https://doi.org/10.1186/s12883-019-1407-2">doi:10.1186/s12883-019-1407-2</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/31399069">Pubmed</a> <span class="ref_v4"></span>

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