Weekly Image Challenge – April 9, 2023

Select the most likely diagnosis on the MRI of a 21 years old gentleman who had presented with progressively worsening left-hand weakness.

  1. Ependymoma
  2. Astrocytoma
  3. AVM
  4. Hemangioblastoma
  5. Metastasis


The diagnosis is hemangioblastoma. It’s a predominantly cystic lesion with enhancing nodules, but there can be a large enhancing solid component as well. It is iso- to hypo-intense on T1. The flow voids and multiple cysts on T2 are typical for this diagnosis. Cyst walls seldom enhance.

Ependymoma is a close differential but it is usually a solid-enhancing lesion and there may be associated syringomyelia. There is often an associated hemosiderin ring (Cap sign) on T2.

Astrocytoma shows heterogenous contrast enhancement and is also predominantly a solid lesion.

Metastasis is usually dural-based, and there is a history of the primary tumor. It is uncommon in young adults.

An AVM usually has flow voids, but it does not show contrast enhancement apart from the nidus. It is not associated with cysts.