To describe a cerebral venous infarct (CVI) in a liver transplant recipient presenting with ring-enhancing lesion resembling glioma on MRI with negative MR venography (MRV), highlighting the importance of differential consideration of CVI for ring-enhancing lesions on MRI.

CVI is most often due to cerebral venous thrombosis (CVT) with incidence of 3-5 per million annually. CVI occurs from impaired drainage due to venous outflow obstruction, producing blood-brain-barrier disruption with edema, mass effect, and hemorrhagic transformation. CVI is not a well-described thrombotic complication of post-transplant patients and can mimic infection or neoplasm on MRI.

A 50-year-old woman with alcohol-associated cirrhosis and liver transplant one year prior on tacrolimus presented for acute behavioral changes, word-finding difficulty, and predominantly right-sided temporal headache. Neurologic exam revealed subtle loss of speech fluency and right-hand incoordination. Broad metabolic, infectious, and autoimmune testing of serum and CSF and EEG were unremarkable. CSF was notable for 8 nucleated cells and elevated protein to 59 mg/dL.

Initial CT 5 days after symptom onset showed 2-centimeter area of hypoattenuation in left thalamus with mass effect on the third ventricle.  MRI showed restricted diffusion in left thalamus, thin rim of peripheral enhancement, and larger surrounding area of T2/FLAIR hyperintensity. MRV and CTA brain were normal. Patient improved rapidly without steroids. Surveillance with serial MRI was pursued instead of biopsy for possible ischemic/congestive lesion and to avoid biopsy-associated risks. Serial studies revealed decreasing edema, lesion size, and increasing rim enhancement. PET-CT brain showed hypometabolism of left thalamus. MRI 3 months later showed resolution of enhancement, confirming likely thalamic small vessel CVI.

CVI should be on the differential for ring-enhancing lesions on MRI, even with negative MR venography. This will prompt consideration, where appropriate, to avoid unnecessary interventions like steroids or biopsy in immunosuppressed patients with CVI.