← All patterns
Multiple T2 white-matter lesions (MS vs mimics)
NeuroMRI
Multiple T2/FLAIR hyperintensities in cerebral white matter. Distribution and morphology separate demyelination from small-vessel and other mimics.
Differential
Multiple sclerosis
common- •Periventricular ovoid lesions perpendicular to ventricles (Dawson fingers)
- •Involvement of callososeptal interface, juxtacortical and infratentorial regions
- •Enhancing (open-ring) active plaques; central vein sign
Chronic small-vessel ischaemia
common- •Older, hypertensive/diabetic patient
- •Confluent deep and subcortical white matter, spares callosum
- •Basal ganglia lacunes, no enhancement
Migraine / vasculitis
less-common- •Small punctate subcortical foci, no callosal involvement
- •Younger patient with headache history
ADEM
less-common- •Large, poorly-marginated lesions of the SAME age
- •Post-infectious/post-vaccination, monophasic; children
- •Deep grey-matter (thalami) involvement
Neuromyelitis optica spectrum disorder
rare- •Longitudinally extensive cord lesions (≥3 segments)
- •Optic neuritis; area postrema/periependymal lesions
- •AQP4-IgG positive
Progressive multifocal leukoencephalopathy
rare- •Asymmetric subcortical U-fibre involvement
- •No mass effect, minimal/no enhancement
- •Immunosuppression (JC virus)
Key discriminators
- •Lesion orientation (Dawson fingers / perpendicular to ventricles)
- •Callosal / juxtacortical / infratentorial involvement
- •Lesions of differing ages (dissemination in time) vs same age (ADEM)
- •Cord and optic nerve involvement (MS/NMOSD)
- •Age and vascular risk factors
Work-up / next steps
- 1.Dedicated MS protocol including sagittal FLAIR and post-contrast T1
- 2.Whole-spine MRI and orbits if demyelination suspected
- 3.CSF oligoclonal bands; serum AQP4 and MOG antibodies
- 4.Apply McDonald criteria for dissemination in space and time
References
- Thompson AJ et al. McDonald criteria 2017. Lancet Neurol.
- Radiopaedia: Multiple sclerosis.
Educational clinical decision support only. This differential does not make a diagnosis, is not a medical device, and must never substitute for interpretation by a qualified radiologist correlated with the full clinical picture and prior imaging.