title: Punctate and curvilinear gadolinium enhancing lesions in the brain: a practical approach.
abstract: BACKGROUND
  Cerebral punctate and curvilinear gadolinium enhancements (PCGE) correspond to opacification of small vessel lumen or its perivascular areas in case of blood-brain barrier (BBB) disruption. We will discuss the possible causes of intra-parenchymal central nervous system PCGE.
  
  
  METHODS
  Our review is based on French database including patients presenting with central nervous system PCGE and literature search using PubMed database with the following keywords: punctate enhancement, linear enhancement, and curvilinear enhancement. Disorders which displayed linear leptomeningeal or periventricular enhancements without intra-parenchymal PCGE are excluded of this review.
  
  
  RESULTS
  Among our 39 patients with PCGE, 16 different diagnoses were established. After combining our PCGE causes with those described in the literature, we propose a practical approach. Besides physiologic post-contrast enhancement of small vessels, three pathologic conditions may exhibit PCGE: (1) small collateral artery network seen in Moyamoya syndrome, (2) small veins congestions related to developmental or acquired venous outflow disturbance, and (3) disorders causing small vessels BBB disruption indicated by T2 and FLAIR hyperintensities in the corresponding areas of PCGE. Disruption of the BBB could be caused by a direct injury of the endothelial cell, as in posterior reversible encephalopathy syndrome, Susac syndrome, and radiochemotherapy-induced injuries, or by an angiocentric cellular infiltrate, as in inflammatory disorders, demyelinating diseases, host immune responses fighting against infections, prelymphoma states, lymphoma, and in CLIPPERS.
  
  
  CONCLUSIONS
  PCGE may conceal several causes, including physiological and pathological conditions. Nevertheless, a practical approach could improve its management and limit the indications of brain biopsy to very specific situations.
authors.affiliation: Department of Neurology, CHU Montpellier, Hopital Guy de Chauliac, 80 avenue Augustin Fliche, 34295, Montpellier Cedex 5, France. taiebguillaume@gmail.com.
authors.forename: Guillaume
authors.initials: G
authors.lastname: Taieb
authors.affiliation: Department of Neurology, Mazarin, Goupe Hospitalier Pitié Salpêtrière, Paris, France.
authors.forename: Alberto
authors.initials: A
authors.lastname: Duran-Peña
authors.affiliation: Department of Neuroradiology, CHU Montpellier, Hopital Guy de Chauliac, Montpellier, France.
authors.forename: Nicolas Menjot
authors.initials: NM
authors.lastname: de Chamfleur
authors.affiliation: Department of Neurology, Fondation Rothschild, Paris, France.
authors.forename: Antoine
authors.initials: A
authors.lastname: Moulignier
authors.affiliation: Department of Neurology, CHU Nîmes, Hôpital Caremeau, Nîmes, France.
authors.forename: Eric
authors.initials: E
authors.lastname: Thouvenot
authors.affiliation: Department of Neurology, CHU Montpellier, Hopital Guy de Chauliac, 80 avenue Augustin Fliche, 34295, Montpellier Cedex 5, France.
authors.forename: Thibaut
authors.initials: T
authors.lastname: Allou
authors.affiliation: Department of Neurology, CHU De Lille, Lille, France.
authors.forename: Arnaud
authors.initials: A
authors.lastname: Lacour
authors.affiliation: Department of Neurology, Mazarin, Goupe Hospitalier Pitié Salpêtrière, Paris, France.
authors.forename: Khe
authors.initials: K
authors.lastname: Hoang-Xuan
authors.affiliation: APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie, Marseille, France.
authors.forename: Jean
authors.initials: J
authors.lastname: Pelletier
authors.affiliation: Department of Neurology, CHU Montpellier, Hopital Guy de Chauliac, 80 avenue Augustin Fliche, 34295, Montpellier Cedex 5, France.
authors.forename: Pierre
authors.initials: P
authors.lastname: Labauge
mesh_terms: D000328:Adult; D000368:Aged; D001921:Brain / Q000098:blood supply / Q000000981:diagnostic imaging* / Q000473:pathology*; D002561:Cerebrovascular Disorders / Q000000981:diagnostic imaging* / Q000473:pathology*; D003287:Contrast Media; D003937:Diagnosis, Differential; D005260:Female; D006801:Humans; D007089:Image Enhancement / Q000379:methods; D018810:Magnetic Resonance Angiography / Q000379:methods*; D008297:Male; D008875:Middle Aged
chemical_list: D003287:Contrast Media
keywords: Blood-brain barrier; CLIPPERS; Curvilinear enhancement; Linear enhancement; Punctate enhancement