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Review ArticleSYSTEMATIC REVIEW/META-ANALYSIS

Posterior fossa ring-enhancing lesions in the adult immunocompetent host: illustrative cases, systematic review, and proposed diagnostic algorithm

Elisabeth Van Boxstael, Alexia de Hennin, Eric Vigneul, Pasquale Scoppettuolo, Souraya El Sankari, Anna Paola Bocchio, Serena Borrelli, Valentina Lolli, Vincent van Pesch, Sofia Maldonado Slootjes, Patrice Finet, Àlex Rovira, Daniel S Reich and Pietro Maggi
American Journal of Neuroradiology January 2025, ajnr.A8677; DOI: https://doi.org/10.3174/ajnr.A8677
Elisabeth Van Boxstael
1Department of Neurology, Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
MD
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Alexia de Hennin
1Department of Neurology, Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
MD
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Eric Vigneul
2Department of Neurosurgery, Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
3Laboratory of Neural Differentiation (NEDI), Animal Molecular and Cellular Biology Group, Louvain Institute of Biomolecular Science and Technology, Université catholique de Louvain, Louvain-La-Neuve, Belgium
MD
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Pasquale Scoppettuolo
1Department of Neurology, Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
MD
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Souraya El Sankari
1Department of Neurology, Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
MD, PhD
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Anna Paola Bocchio
4Department of Radiology, Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
MD
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Serena Borrelli
5Department of Neurology, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
6Neuroinflammation Imaging Lab (NIL), Institute of NeuroScience, Université catholique de Louvain, Brussels, Belgium
MD
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Valentina Lolli
7Department of Radiology, Hôpital Erasme, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
MD
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Vincent van Pesch
1Department of Neurology, Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
MD, PhD
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Sofia Maldonado Slootjes
8Department of Neurology, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium
9NEUR Research Group, Vrije Universiteit Brussel, Brussels, Belgium
MD
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Patrice Finet
2Department of Neurosurgery, Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
MD
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Àlex Rovira
10Section of Neuroradiology, University Hospital Vall d’Hebron, Barcelona, Spain
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Daniel S Reich
11Translational Neuroradiology Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA.
MD, PhD
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Pietro Maggi
1Department of Neurology, Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
6Neuroinflammation Imaging Lab (NIL), Institute of NeuroScience, Université catholique de Louvain, Brussels, Belgium
MD, PhD
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ABSTRACT

PURPOSE: Posterior fossa ring-enhancing lesions (PFREL) in the adult immunocompetent hosts pose a diagnostic challenge. We aimed to evaluate the spectrum of PFREL etiologies and propose a diagnostic algorithm.

METHODS: This study involved a retrospective analysis of PFREL cases from our institution (January 2023 to April 2024) and a systematic literature review conducted using Embase and PubMed databases following the PRISMA 2020 guidelines. Clinical and radiological features from these cases formed the basis of a diagnostic algorithm, which was further refined via an additional comprehensive literature review, and finally validated on an independent set of PFREL cases.

RESULTS: The systematic review (467 studies, 56 selected after inclusion/exclusion criteria) revealed that PFREL etiology was infectious in 52%, tumoral in 38% and inflammatory in 2% of cases. At initial presentation, mean age was 48 years and 36% of patients had multiple PFREL. Headache was the most common symptom (46%). Among those with reported outcomes, 36% showed complete resolution of symptoms, 29% showed improvement with residual symptoms, and 16% died. The diagnostic algorithm was created from a total of 116 PFREL cases (10 from our institutional series, 56 from the systematic literature review and 50 supplementary cases found in the literature) and included 29 possible PFREL etiologies. In the validation set (16 patients), the algorithm provided the correct diagnosis in each case.

CONCLUSION: PFREL in immunocompetent adults encompass a broad differential diagnosis. Our algorithm integrates clinical and radiologic data to assist in identifying the underlying cause of PFREL, potentially reducing the need for neurosurgical biopsy. This approach aims to enhance diagnostic accuracy, leading to better treatment decisions and improved patient outcomes.

ABBREVIATIONS: ADEM = acute disseminated encephalomyelitis; CLL = chronic lymphocytic leukemia; CSF = cerebrospinal fluid; DLBCL: diffuse large B cell lymphoma; FLAIR = fluid attenuated inversion recovery; MeSH = medical subject headings; MRI = magnetic resonance imaging; NIHSS = National Institutes of Health Stroke Scale; NMOSD = neuromyelitis optic spectrum disorder; PFREL = posterior fossa ring enhancing lesion; PRISMA = Preferred Reporting Items for Systematic reviews and Meta-Analyses; SUV max = maximum standardized uptake value.

Footnotes

  • On behalf of all authors, the corresponding author states that there is no conflict of interest.

  • ↵* These authors contributed equally

  • © 2025 by American Journal of Neuroradiology

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Accepted Manuscript
Elisabeth Van Boxstael, Alexia de Hennin, Eric Vigneul, Pasquale Scoppettuolo, Souraya El Sankari, Anna Paola Bocchio, Serena Borrelli, Valentina Lolli, Vincent van Pesch, Sofia Maldonado Slootjes, Patrice Finet, Àlex Rovira, Daniel S Reich, Pietro Maggi
Posterior fossa ring-enhancing lesions in the adult immunocompetent host: illustrative cases, systematic review, and proposed diagnostic algorithm
American Journal of Neuroradiology Jan 2025, ajnr.A8677; DOI: 10.3174/ajnr.A8677

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Accepted Manuscript
Posterior fossa ring-enhancing lesions in the adult immunocompetent host: illustrative cases, systematic review, and proposed diagnostic algorithm
Elisabeth Van Boxstael, Alexia de Hennin, Eric Vigneul, Pasquale Scoppettuolo, Souraya El Sankari, Anna Paola Bocchio, Serena Borrelli, Valentina Lolli, Vincent van Pesch, Sofia Maldonado Slootjes, Patrice Finet, Àlex Rovira, Daniel S Reich, Pietro Maggi
American Journal of Neuroradiology Jan 2025, ajnr.A8677; DOI: 10.3174/ajnr.A8677
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