Open-ring imaging sign - Highly specific for atypical brain demyelination

Objective: To test the specificity for demyelination of a new neuroimaging sign: contrast enhancement shaped as an open ring or a crescent circumscrib ed to the white matter. Background: Brain demyelination can cause ring enha ncement mimicking neoplasm or infection on CT or MRI. Methods: A MEDLINE se arch of pathology-proved demyelination yielded 32 illustrated cases of ring -enhancing lesions published between 1981 and 1995. Controls consisted of t he same number of published images of neoplasms and infections, pathology p roved, and matched by year of publication, and age and gender of the patien t. Two neuroradiologists read the images twice independently 1 year apart. Results: Interrater agreement was good (kappa = 0.64 and 0.66 for either re ading). 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 like lihood ratio of demyelination versus neoplasm averaged 5.2, and versus infe ction, 17.2. That is, if the lesions had the same incidence in the populati on, 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: T he open-ring sign is often present in large, contrast-enhancing demyelinati ng lesions and helps to differentiate them from neoplasms and infections.