The evaluation of contrast-enhancing brain lesions: pitfalls in current practice

The definitive diagnosis of space-occupying brain lesions can be established more readily since the advent of computerized tomographic (CT) scanning. Some brain lesions are more clearly defined when contrast-enhancing agents are utilized; however, so-called ring-enhancing lesions are not pathognomonic for specific neurological entities. Review of the literature suggests that at least four disorders must be considered in the differential diagnosis of contrast-enhancing lesions. These include mature brain abscesses of any etiology, cerebrovascular accidents, and primary or metastatic brain tumors. Since the medical and surgical management of these conditions is quite different, it is critical to establish a diagnosis before therapy is instituted. In many instances the combination of history, physical examination, laboratory, and radiologic examination will enable physicians to correctly diagnose the etiology of such brain lesions. However, we present two cases for which the above clinical and non-invasive parameters led to incorrect working diagnoses. Brain biopsy was required before appropriate management was eventually instituted. Potentially, such delays in diagnosis and institution of therapy can result in unnecessary morbidity and mortality. Each case illustrates the need to substantiate a presumptive diagnosis based on these clinical and radiographic criteria, regardless of how "typical" lesions may appear on CT scans.