Radiology Terminology: What Are Punctate And Confluent Lesions?

Sometimes radiologists use terms that you don’t fully understand. Yet, you need to understand these terms to know how to find the lesions in the brain images.

Without assessing the lesions carefully, you won’t be able to extract the information that will help you improve your assessments and treatments.

In this video, I talk about the terms punctate and confluent lesions. I explain exactly what they mean, and the information they give you.

I also use three clinical examples to show you exactly how I use this information to modify my assessments and treatments.

Both punctate and confluent, are words used in the English language in general, rather than being specific to radiology. Punctate means dot like, whilst confluent refers to an area that appears like a stain or a puddle.

When you come across the terms punctate or confluent lesions in the radiology reports, you’ll need to go through an analysis process that has three steps:

1. Find – After reading the radiology report, you’ll need to identify the lesions on the brain images.
2. Evaluate – Clarify how many lesions there are.
3. Locate – Identifying exactly the location of the lesions. You’ll have to identify the specific anatomical structures affected by the lesions.

Once you have all this information, you’ll be able to use it to improve your assessments and treatments, as you’ll see in the examples below.

Let me share with you three examples of how I analyse punctate and confluent lesions.

This is a case of someone I treated who suffered a stroke. The radiology report mentioned a confluent lesion related to the infarct and confluent lesions that were present pre morbidly.

When I looked at the brain images, I could see that the confluent lesion that was related to the infarct affected both the white matter and the grey matter but wasn’t that extensive. In fact, the confluent lesions that were there pre morbidly, were even more extensive, and they were indicative of underlying pathological processes. As a result, this person did not recover as fast as he wanted to, neither did he reach his pre morbid capacity.

This is a case I was asked to consult on, regarding a lady who had MS and just had COVID. She lost her ability to walk and the clinician was struggling to determine the cause. Was the immobility because of an exacerbation of MS or was it the result of two weeks in bed due to COVID?

When I looked at the brain images, I could see multiple punctate lesions, but they weren’t many, they were small, and they couldn’t explain the extent of deterioration the clinician was describing.

This meant that this lady was probably losing function because of deconditioning rather than exacerbation of the MS. The implications were that:

• In the assessment I’d expect to see some muscle weakness but no other neurological symptoms.
• The assessment would need to focus on strength assessment.
• Treatment could be intensive, and the clinician could push her hard in rehab.

The third example is of a person that was diagnosed with Functional Neurological Disorder. The main complaint of this lady was foot dystonia.

When I looked at the brain images, I could see that she had punctate lesions that were not typical of her presentation nor of her age. It prompted me to ask questions around drug use. Was she using drugs? Perhaps recreational drugs? What medications was she taking?

After further investigations with the GP, it became apparent that one of the medications she was taking was causing the dystonia. So in fact, she did not have FND, she had dystonia secondary to one of her medications.

This of course changes the treatment completely. The client was not treated for FND anymore, she needed a medical review for changing the medications causing the foot dystonia.

This article and the three case studies demonstrate the important of understanding the terminology radiologists use. 

Understanding the terms punctate and confluent lesions, will enable you to you know what to look for in the brain images. Once you see the extent and location of the lesion/s you’ll be able to understand your client’s presentation better, assess them more carefully, and be more focused with your treatment.