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Last updated: 26 May 2024

Systematic approach to MR imaging of brain lesions

In general, there are 4 MR sequences that will tell you 99% of what you need to know:
  • T2 FLAIR
  • T1 post-contrast
  • DWI
  • GRE/SWI/SWAN/T2*

T2 FLAIR
“What is grossly abnormal?” anything abnormal = bright on T2 FLAIR

T1+gadolinium
“Where is the BBB disrupted?” Also:“What is the vascular composition?” Always compare T1+gad sequences to pure T1 without contrast (if also bright on pure T1, then BBB not necessarily disrupted)

DWI
Bright = abnormal = “diffusion-restricting” = could be hypercellularity, ischemia, demyelination, abscess. The above applies only if the corresponding area is dark on ADC sequence (if also bright on ADC, then just T2 shine-through)

GRE/SWI/SWAN/T2
This helps to distinguish nuances among entities on your differential. In general, abnormal = dark (blood, vascularity; abscesses tend to have dark rims on SWI)

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