Salt and pepper sign

The salt and pepper sign is used to refer to a speckled appearance of tissue. It is used in many instances, but most commonly on MRI. Please note that pathologists also use the term.

Differential diagnosis

Vascular tumors

Used to describe some highly vascular tumors which contain foci of hemorrhage, typically a paraganglioma. The appearance is on T1 weighted sequences, and is made up of:

  • punctate regions of hyperintensity = salt
  • small flow voids = pepper

Typical tumors with this appearance include:

Similar appearance may be seen on T2 sequences or post contrast T1 sequences in patients with juvenile nasopharyngeal angiofibromas 6.

This appearance can also be seen in other hypervascular tumors such as metastatic hypernephroma or metastatic thyroid carcinoma 7.

Sjögren syndrome

The parotid gland in Sjögren syndrome has also been described as having a salt and pepper appearance, due to a combination of punctate regions of calcification (pepper) and fatty replacement (salt)

Vertebral hemangioma

A less common usage for the term is for vertebral hemangiomas which have a coarser black and white dotted appearance especially on axial T2 and T1 images (salt = fat, pepper = coarsened trabeculae).

MRI noise artefact

A related use of the term is to describe the noise sometimes seen in MRI images. 

When you think about it, you can probably find folk who have used the term for all sorts of lesions; any lesion that has a fine granular imaging texture will do the trick.

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Article information

rID: 4630
Section: Signs
Synonyms or Alternate Spellings:
  • Pepper and salt sign

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Cases and figures

  • Case 1: vertebral hemangioma
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  • Case 3: glomus T1 C+
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  • Case 3: glomus T2
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