From the Guidelines
Non-Ischemic Cerebral Enhancing Lesions (NICELs) should be diagnosed and managed based on a comprehensive approach that includes neuroimaging, laboratory tests, and sometimes brain biopsy, with treatment depending on the underlying cause, as recommended by the most recent guidelines 1.
Diagnosis and Management
NICELs can result from various conditions including tumors (primary brain tumors or metastases), infections (abscesses, encephalitis), inflammatory processes (multiple sclerosis, sarcoidosis), vascular malformations, or post-treatment changes.
- Diagnosis requires comprehensive neuroimaging with MRI using multiple sequences (T1, T2, FLAIR, diffusion-weighted imaging, and contrast enhancement) to characterize the lesion, as suggested by recent studies 1.
- Additional diagnostic workup may include lumbar puncture for CSF analysis, blood tests for inflammatory markers or infectious agents, and sometimes brain biopsy for definitive diagnosis.
- Treatment depends entirely on the underlying cause - antibiotics for infections, steroids for inflammatory conditions, antiepileptic drugs for seizures, surgical resection for tumors, or radiation/chemotherapy for malignancies.
Prognosis and Outcomes
Prognosis varies widely based on the specific etiology, with some conditions being curable and others requiring long-term management.
- Early diagnosis and appropriate treatment are essential for improving outcomes, as some causes of NICELs can progress rapidly if not addressed promptly.
- The use of advanced imaging techniques, such as diffusion-weighted imaging, perfusion MRI, and magnetic resonance spectroscopy, can provide valuable information on tumor cellularity, perfusion, and metabolism, and help guide treatment decisions 1.
Recent Guidelines and Recommendations
Recent guidelines recommend the use of standardized tissue sampling and processing during resection of diffuse intracranial glioma, and emphasize the importance of intraoperative neuronavigation and biological imaging to improve outcomes 1.
- The use of 5-aminolevulinic acid (5-ALA) or fluorescein for intraoperative fluorescent labeling of tumors can also help improve the accuracy of tumor resection 1.
From the Research
Non-Ischemic Cerebral Enhancing Lesion Characteristics
- Non-ischemic cerebral enhancing (NICE) lesions are a rare complication following endovascular therapy (EVT) for intracranial aneurysms, presenting as delayed-onset enhancing lesions on MRI 2.
- NICE lesions can pose diagnostic challenges due to their resemblance to neoplastic or infectious processes 2.
- These lesions are characterized by punctate, nodular, and annular enhancing lesions with peri-lesional edema on MRI 2, 3.
Clinical Presentation and Course
- The clinical spectrum of NICE lesions following aneurysm EVT therapy spans a wide range of neurological symptoms, including headache, focal neurological signs, epileptic seizures, and cognitive deficits 3, 4.
- Symptoms can occur after a mean time of 15 days (±13.42, SD) after EVT 4.
- The clinical course is most commonly benign, although persistent long-term enhancement is frequent 3.
- Patients with NICE lesions may remain asymptomatic or experience mild symptoms, while others may develop mild disability 3.
Treatment and Management
- Treatment with glucocorticosteroids (GCS) has been shown to lead to symptom resolution in some patients 2, 4.
- Other immunotherapies, such as mycophenolate mofetil (MMF), tocilizumab (TCZ), and azathioprine (AZA), have also been used to manage NICE lesions, with varying degrees of success 4.
- The use of rituximab (RTX) and cyclophosphamide (CYC) has not resulted in disease stabilization in some cases 4.