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Updated: May 11, 2026
Magnetic Resonance Imaging of Multiple Sclerosis at 7.0 Tesla
Published on: February 19, 2021
Restricted diffusion preceding gadolinium enhancement in large or tumefactive demyelinating lesions
Megan Hyland1, Robert A Bermel, Jeffrey A Cohen
1Department of Neurology (MH), University of Rochester Medical Center, Rochester, NY; and Mellen Center for MS Treatment and Research (RAB, JAC), Neurological Institute, Cleveland Clinic, Cleveland, OH.
Abstract:
Although restricted diffusion without coincident contrast enhancement is most commonly associated with cerebral ischemia, large or tumefactive multiple sclerosis (MS) lesions may demonstrate this pattern initially, followed by subsequent gadolinium (Gd) enhancement. The clinical and MRI characteristics of 3 patients with MS with this imaging pattern are reviewed. All patients had brain MRI lesions >1 cm in diameter, in locations consistent with new neurologic symptoms, and with prominent restricted diffusion but no Gd enhancement. Demyelinating lesion etiologies were supported by CSF findings, laboratory exclusion of alternative diagnoses, lesion evolution, or additional lesions characteristic of MS on brain MRI. Follow-up imaging within 2-4 weeks showed decreased restricted diffusion with patchy Gd enhancement which resolved on subsequent imaging. This imaging evolution may reflect early demyelination prior to inflammation-associated blood-brain barrier disruption.
Insights
Large tumefactive multiple sclerosis (MS) lesions can mimic cerebral ischemia on MRI with restricted diffusion. However, these MS lesions may show delayed gadolinium enhancement, indicating early demyelination.
Area of Science:
- Neurology
- Radiology
- Neuroimaging
Background:
- Restricted diffusion without contrast enhancement typically suggests cerebral ischemia.
- Large or tumefactive multiple sclerosis (MS) lesions can present with this imaging pattern initially.
- Understanding this presentation is crucial for accurate diagnosis and management.
Purpose of the Study:
- To review the clinical and MRI characteristics of patients with MS exhibiting restricted diffusion without initial contrast enhancement.
- To differentiate MS lesions from ischemic events based on imaging patterns and evolution.
- To elucidate the early imaging findings of demyelination in MS.
Main Methods:
- Case review of 3 patients with MS presenting with specific MRI findings.
- Analysis of lesion size, location, diffusion characteristics, and contrast enhancement patterns.
- Correlation of MRI findings with clinical symptoms, CSF analysis, and follow-up imaging.
Main Results:
- All patients had large ( >1 cm) brain MRI lesions associated with new neurologic symptoms.
- Lesions demonstrated prominent restricted diffusion but no initial gadolinium enhancement.
- Follow-up MRI (2-4 weeks) revealed decreased restricted diffusion and patchy gadolinium enhancement, which later resolved.
Conclusions:
- The initial MRI pattern of restricted diffusion without enhancement in large tumefactive MS lesions can mimic cerebral ischemia.
- This imaging evolution suggests early demyelination preceding blood-brain barrier disruption.
- Distinguishing these MS lesions from ischemia is possible through serial imaging and clinical correlation.
