title: Open-ring imaging sign: highly specific for atypical brain demyelination.
abstract: OBJECTIVE
  To test the specificity for demyelination of a new neuroimaging sign: contrast enhancement shaped as an open ring or a crescent circumscribed to the white matter.
  
  
  BACKGROUND
  Brain demyelination can cause ring enhancement mimicking neoplasm or infection on CT or MRI.
  
  
  METHODS
  A MEDLINE search of pathology-proved demyelination yielded 32 illustrated cases of ring-enhancing lesions published between 1981 and 1995. Controls consisted of the same number of published images of neoplasms and infections, pathology proved, and matched by year of publication, and age and gender of the patient. Two neuroradiologists read the images twice independently 1 year apart.
  
  
  RESULTS
  Interrater agreement was good (kappa = 0.64 and 0.66 for either reading). Test-retest reliability was high (kappa = 0.75 and 0.74 for either rater). The open-ring sign clearly distinguished demyelinating lesions from neoplasms and infections. For demyelination versus neoplasm or infection, the specificity of the reading by the first neuroradiologist was 93.8 (95% CI, 86 to 98), and that of the second was 84.4 (95% CI, 74 to 92). The likelihood ratio of demyelination versus neoplasm averaged 5.2, and versus infection, 17.2. That is, if the lesions had the same incidence in the population, in the presence of an open-ring sign demyelination would be five times more likely than neoplasm and 17 times more likely than infection. However, given the much higher incidence of neoplasms and infections, these lesions are still frequently responsible for open-ring enhancement.
  
  
  CONCLUSIONS
  The open-ring sign is often present in large, contrast-enhancing demyelinating lesions and helps to differentiate them from neoplasms and infections.
authors.affiliation: Departments of Neurology, New York Medical College (St. Vincent's Hospital and Westchester Medical Center), Valhalla, NY , USA. masdeu@nymc.edu
authors.forename: J C
authors.initials: JC
authors.lastname: Masdeu
authors.forename: C
authors.initials: C
authors.lastname: Quinto
authors.forename: C
authors.initials: C
authors.lastname: Olivera
authors.forename: M
authors.initials: M
authors.lastname: Tenner
authors.forename: D
authors.initials: D
authors.lastname: Leslie
authors.forename: P
authors.initials: P
authors.lastname: Visintainer
mesh_terms: D000328:Adult; D001706:Biopsy; D001932:Brain Neoplasms / Q000175:diagnosis* / Q000000981:diagnostic imaging; D002494:Central Nervous System Infections / Q000175:diagnosis* / Q000000981:diagnostic imaging; D003711:Demyelinating Diseases / Q000175:diagnosis* / Q000000981:diagnostic imaging; D003937:Diagnosis, Differential; D005260:Female; D005909:Glioblastoma / Q000175:diagnosis* / Q000000981:diagnostic imaging; D006801:Humans; D007089:Image Enhancement / Q000379:methods*; D008279:Magnetic Resonance Imaging; D008297:Male; D015588:Observer Variation; D011237:Predictive Value of Tests; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity; D014057:Tomography, X-Ray Computed