What is the role of CT and MRI studies in the workup of CNS lupus?

Updated: May 04, 2021
  • Author: Pradeep C Bollu, MD; Chief Editor: Niranjan N Singh, MBBS, MD, DM, FAHS, FAANEM  more...
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Joseph et al reported that 35% of computed tomography (CT) brain scans were abnormal and 65% of magnetic resonance (MR) scans, but CT scanning remains valuable in identifying hemorrhages and larger infarcts in patients with systemic lupus erythematosus (SLE). [15]

Neuroradiologic evaluation favors magnetic resonance imaging (MRI) over CT scanning, because subtle ischemia or cerebritis may be seen with greater sensitivity. The most common findings with either study are ischemic zones that may correspond to cortical or subcortical infarcts and may be large or small according to the size of vessel involved and the mechanism of stroke. See the image below for an example of ischemia visible on MRI.

This axial, T2-weighted brain magnetic resonance i This axial, T2-weighted brain magnetic resonance image (MRI) demonstrates an area of ischemia in the right periventricular white matter of a 41-year-old woman with longstanding systemic lupus erythematosus (SLE). She presented with headache and subtle cognitive impairments but no motor deficits. Faintly increased signal intensity was also seen on T1-weighted images, with a trace of enhancement following gadolinium that is too subtle to show on reproduced images. The distribution of the abnormality is consistent with occlusion of deep penetrating branches, such as may result from local vasculopathy, with no clinical or laboratory evidence of lupus anticoagulant or anticardiolipin antibody. Cardiac embolus from covert Libman-Sacks endocarditis remains less likely due to the distribution.

Other vague areas of patchy cortical or subcortical abnormality (lucency on CT scan, T2 signal intensity on MRI) may correspond to small vessel vasculitis or cerebritis, but distinction from opportunistic infection (e.g., toxoplasmosis, progressive multifocal leukoencephalopathy) often cannot be made on radiographic grounds, requiring other studies, including cerebral biopsy. With either CT scanning or MRI, contrast enhancement increases the sensitivity for acute and subacute cerebral lesions.

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