Differential Diagnosis for Multiple Periventricular and Juxtacortical Lesions

Given the scenario where there are multiple periventricular and juxtacortical lesions without signs of dissemination in time, no contrast agent enhancement of the lesions, and no infratentorial lesions, the differential diagnosis can be categorized as follows:

• Single Most Likely Diagnosis

  • Migraine: Although migraine is often associated with white matter lesions, the presence of multiple periventricular and juxtacortical lesions without other typical migraine features (like dissemination in time or enhancement with contrast) makes it less likely but still possible due to the variability in presentation. However, given the lack of more specific indicators for other conditions, it remains a consideration.

• Other Likely Diagnoses

  • Small Vessel Disease: This condition is a common cause of white matter lesions, especially in older adults, and can present with periventricular and juxtacortical lesions without enhancement or dissemination in time.
  • Multiple Sclerosis (MS) - Relapsing-Remitting Type without clear dissemination in time: Although MS typically shows dissemination in time and space, early or mild cases might not fulfill these criteria, making it a consideration, albeit less likely given the specifics.
  • Chronic Small Vessel Occlusive Disease: Similar to small vessel disease, this can cause white matter lesions but might be more associated with vascular risk factors.

• Do Not Miss Diagnoses

  • Vasculitis (e.g., Primary Central Nervous System Vasculitis): Although less common, vasculitis can present with variable neurological symptoms and imaging findings, including white matter lesions. Missing this diagnosis could lead to severe consequences due to the need for immunosuppressive treatment.
  • Infectious Diseases (e.g., Neurosyphilis, Lyme Disease): Certain infections can cause white matter lesions and have serious consequences if not treated promptly.
  • Leukodystrophies: A group of rare, inherited disorders characterized by progressive damage to the white matter of the brain, which could present with similar imaging findings.

• Rare Diagnoses

  • Mitochondrial Encephalomyopathy, Lactic Acidosis, and Stroke-like episodes (MELAS): A rare mitochondrial disorder that can cause stroke-like episodes and white matter lesions.
  • Susac Syndrome: A rare condition characterized by small vessel occlusion leading to white matter lesions and often associated with hearing loss and visual disturbances.
  • CADASIL (Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy): An inherited condition leading to stroke and dementia, characterized by white matter lesions, typically without enhancement or significant mass effect.