brain tumor amogh
TRANSCRIPT
-
8/3/2019 Brain Tumor Amogh
1/119
APPROACH TO BRAIN
TUMORS
DR AMOGH R
FINAL YR DMRD
-
8/3/2019 Brain Tumor Amogh
2/119
-
8/3/2019 Brain Tumor Amogh
3/119
RADIOLOGICAL
INVESTIGATIONS IN
INTRACRANIAL TUMOURS
-
8/3/2019 Brain Tumor Amogh
4/119
PLAIN RADIOGRAPHY
Plain radiographic findings in brain tumours are
of historical interest, but radiologists should still
be familiar with signs of raised intracranial
pressure (ICP) such as erosion of the laminadura of the dorsum sellae, or a J-shaped sella.
Skull radiography may also demonstrate tumour
calcification and enlargement of middle
meningeal artery grooves in meningiomas.
-
8/3/2019 Brain Tumor Amogh
5/119
-
8/3/2019 Brain Tumor Amogh
6/119
Diagnostic catheter angiography
The use of diagnostic catheter angiography forbrain tumours has dramatically decreased withthe advances in cross-sectional imaging.
It is occasionally performed to assess thevascular supply of meningiomas pre-operatively.
Otherwise it is now mostly performed inconjunction with pre-operative or palliative
tumour embolizations or intra-arterialchemotherapy for treatment of high-gradegliomas
-
8/3/2019 Brain Tumor Amogh
7/119
-
8/3/2019 Brain Tumor Amogh
8/119
Magnetic resonance imaging
MRI is the preferred investigation of patients with
suspected intracranial tumours.
It provides a better soft-tissue differentiation and
tumour delineation than CT and advanced MRimaging techniques, such as diffusion-weighted
(DWI) and perfusion-weighted (PWI) imaging
and MR spectroscopy (MRS), allow the
assessment of physiological and metabolicprocesses
-
8/3/2019 Brain Tumor Amogh
9/119
SPECTROSCOPY
-
8/3/2019 Brain Tumor Amogh
10/119
DWI
-
8/3/2019 Brain Tumor Amogh
11/119
FMRI
-
8/3/2019 Brain Tumor Amogh
12/119
COMPUTED TOMOGRAPHY
Most clinically symptomatic brain tumours
are detectable on CT, by virtue of mass
effect and/or altered attenuation.
Intra-axial tumours are usually of low
attenuation on non-enhanced CT images.
High attenuation areas within a tumour
indicate tumour calcification or recent
intratumoural haemorrhage.
ABBREVIATED WHO
-
8/3/2019 Brain Tumor Amogh
13/119
ABBREVIATED WHO
CLASSIFICATION OF BRAIN
TUMOURS
-
8/3/2019 Brain Tumor Amogh
14/119
-
8/3/2019 Brain Tumor Amogh
15/119
-
8/3/2019 Brain Tumor Amogh
16/119
-
8/3/2019 Brain Tumor Amogh
17/119
Approach
Age of the patient. Intra- or extra-axial and in what anatomical compartment does it lie? Is it a solitary mass or is there multi-focal disease? On CT and MR we look for tissue characteristics like calcifications,
fat, cystic components, contrast enhancement and signal intensity
on T1WI, T2WI and DWI. Most brain tumors are of low signal intensity on T1WI and high onT2WI.
Therefore high signal intensity on T1WI or low signal on T2WI canbe an important clue to the diagnosis.
Lesion that simulates a tumor - like an abscess, MS-plaque,
vascular malformation, aneurysm or an infarct with luxury perfusion.
-
8/3/2019 Brain Tumor Amogh
18/119
-
8/3/2019 Brain Tumor Amogh
19/119
Incidence of CNS tumors
-
8/3/2019 Brain Tumor Amogh
20/119
Age distribution
Specific tumors occur under the ageof 2, like choroid plexus papillomas,anaplastic astrocytomas andteratomas.
In the first decademedulloblastomas, astrocytomas,ependymomas,
craniopharyngeomas and gliomasare most common, whilemetastases are very rare.When they do occur at this age,metastases of a neuroblastoma arethe most frequent.
In adults about 50% of all CNSlesions are metastases. Other
common tumors in adults areastrocytomas, glioblastomamultiforme, meningiomas,oligodendrogliomas, pituitaryadenomas and schwannomas.
Astrocytomas occur at any age, butglioblastoma multiforme is mostlyseen in older people.
-
8/3/2019 Brain Tumor Amogh
21/119
Although cancer is rare in
children, brain tumors are
the most common type of
childhood cancer after
leukemia and lymphoma.Most of the tumors in
children are located
infratentorially.
The most common supra-and infratentorial tumors
are listed in the table on
the left.
-
8/3/2019 Brain Tumor Amogh
22/119
The most common tumors in adults
Note that metastases are byfar the most common.It is important to realise that50% of metastases aresolitary.
Particularly in the posteriorfossa, metastases should be inthe top 3 of the differentialdiagnostic list.Hemangioblastoma is anuncommon tumor, but it is the
most common primary intra-axial tumor in the adult.Supratentorially, metastasesare also the most commontumors, followed by gliomas.
-
8/3/2019 Brain Tumor Amogh
23/119
TUMOR SPREAD
-
8/3/2019 Brain Tumor Amogh
24/119
Intra- versus Extraaxial
When we study an intracranialmass, the first thing we want toknow is whether the mass liesin- or outside of the brain.If it is outside the brain orextra-axial, then the lesion is
not actually a brain tumor, butderived from the lining of thebrain or surroundingstructures.Eighty percent of these extra-axial lesions will be either ameningioma or aschwannoma.On the other hand, in an adultan intra-axial tumor will be ametastasis or astrocytoma in75% of cases.
-
8/3/2019 Brain Tumor Amogh
25/119
Schwannoma in CPA-region with
typical features of an extraaxial
tumor (T2WI)
-
8/3/2019 Brain Tumor Amogh
26/119
There is a CSF cleft (yellow arrow). The subarachnoid vessels that run on the surface of the brain are displaced by the
lesion (blue arrow).
There is gray matter between the lesion and the white matter (curved red arrow). The subarachnoid space is widened because growth of an extra-axial lesion tends topush away the brain.
All these signs indicate that this is a typical extra-axial tumor.In the region of the CPA 90% of the extra-axial tumors are schwannomas.
-
8/3/2019 Brain Tumor Amogh
27/119
Coronal enhanced T1WI. Meningioma with dural tail, hyperostosis of
adjacent bone and homogeneous enhancement
Another sign of an extra-axialorigin is a broad dural base ora dural tail of enhancement asis typically seen inmeningiomas.
This may also occur in other
extra-axial tumors, but it is lesscommon.
Another sign of an extra-axialorigin are bony changes. Bonychanges are seen in bonetumors like chordomas,
chondrosarcomas andmetastases.They can also be secondary,as is seen in meningiomas andother tumors
-
8/3/2019 Brain Tumor Amogh
28/119
Melanoma metastasis
This lesion surely has the appearance of a meningioma: these tumors canbe hypointense on T2 due to a fibrocollageneous matrix or calcificationsand frequently produce reactive edema in the adjacent white matter of thebrain.
However, there is gray matter on the anteromedial and posteromedial sideof the lesion (red arrow).
This indicates that the lesion is intra-axial.
-
8/3/2019 Brain Tumor Amogh
29/119
Local tumor spread
Astrocytomas spread along the white matter tracts and do not respect the bounderiesof the lobes.
Because of this infiltrative growth, in many cases the tumor is actually larger than canbe depicted with MR.
Ependymomas of the fourth ventricle in children tend to extend through the foramenof Magendie to the cisterna magna and through the lateral foramina of Luschka to thecerebellopontine angle
Oligodendrogliomas typically show extension to the cortex.
-
8/3/2019 Brain Tumor Amogh
30/119
Subarachnoid seeding
Some tumors show subarachnoid seeding andform tumoral nodules along the brain and spinalcord.
This is seen in PNET, ependymomas, GBMs,lymphomas, oligodendrogliomas and choroidplexus papillomas.
Primitive neuroectodermal tumours (PNET) form
a rare group of tumors, which develop fromprimitive or undifferentiated nerve cells.These include medulloblastomas andpineoblastomas
-
8/3/2019 Brain Tumor Amogh
31/119
One of the most important roles of imaging is to assess the extent ofa tumor.
This is shown in the case on the left in a patient who presented withmultiple cranial nerve abnormalities.On the images we see an extra-axial tumor in the region of the leftcavernous sinus. There is homogeneous enhancement with a broaddural tail.This is typical for a meningioma.
-
8/3/2019 Brain Tumor Amogh
32/119
MASS EFFECT
Another important consideration is the effect on
the surrounding structures.
Primary brain tumors are derived from brain cells
and often have less mass effect for their sizethan you would expect, due to their infiltrative
growth.
This is not the case with metastases and extra-
axial tumors like meningiomas or schwannomas,which have more mass effect due to their
expansive growth.
-
8/3/2019 Brain Tumor Amogh
33/119
Diffusely infiltrating intra-axial tumor occupying most ofthe right hemisphere with only a minimal mass effect.
This is typical for the infiltrative growth seen in primarybrain tumors. There is no enhancement so this would probably be a
low-grade astrocytoma.
-
8/3/2019 Brain Tumor Amogh
34/119
MIDLINECROSSING
-
8/3/2019 Brain Tumor Amogh
35/119
Multifocal disease
Multiple tumors in the brain usually indicatemetastatic disease
Primary brain tumors are typically seen in asingle region, but some brain tumors like
lymphomas, multicentric glioblastomas andgliomatosis cerebri can be multifocal.
Some tumors can be multifocal as a result ofseeding metastases: this can occur in
medulloblastomas (PNET-MB), ependymomas,GBMs and oligodendrogliomas. Meningiomas and schwannomas can be
multiple, especially in neurofibromatosis type II.
-
8/3/2019 Brain Tumor Amogh
36/119
Multiple brain tumors can be seen
in phacomatoses:
1. Neurofibromatosis II: meningiomas,
ependymomas, optic nerve gliomas,
choroid plexus papillomas
2. Tuberous Sclerosis: subependymal
tubers, intraventricular giant cell
astrocytomas, ependymomas
3. von Hippel Lindau: hemangioblastomas
-
8/3/2019 Brain Tumor Amogh
37/119
Many non-tumorous diseases like small
vessel disease, infections (septic emboli,
abscesses) or demyelinating diseases like
MS can also present as multifocal disease.
-
8/3/2019 Brain Tumor Amogh
38/119
LEFT: Metastases.
RIGHT: Multiple meningiomas and a schwannoma
in a patient with Neurofibromatosis II
-
8/3/2019 Brain Tumor Amogh
39/119
Cortical based tumors
Most intra-axial tumors are located in thewhite matter.Some tumors, however,spread to or are located in the gray matter.
The differential diagnosis for these corticalbased tumors includes oligodendroglioma,ganglioglioma and DysembryoplasticNeuroepithial Tumor (DNET).
Patients with a cortically based tumorusually present with complex seizures.
A DNET is a rare benign neoplasm, usually in a cortical and temporal location.
-
8/3/2019 Brain Tumor Amogh
40/119
45-year-old female with a stable seizure disorder(complex-partial) for 15 years.
There is a non-enhancing, cortically based tumor. This is a ganglioglioma. The differential diagnosis includes DNET and pilocytic
astrocytoma.
-
8/3/2019 Brain Tumor Amogh
41/119
These cortically based tumors have to be
differentiated from non-tumorous lesions
like cerebritis, herpes simplex
encephalitis, infarction and post-ictalchanges.
-
8/3/2019 Brain Tumor Amogh
42/119
Oligodendroglioma
52-year-old female who, overthe period of one year,complained of headache andneck pain. There is a recentonset of tonic-clonic seizures.The CT shows a mass with
calcifications, which extendsall the way to the cortex.Although this is a large tumorthere is only limited masseffect on surroundingstructures, which indicates thatthis is an infiltrating tumor.
The most likely diagnosis is.The differential diagnosisincludes a malignantastrocytoma or a glioblastoma.
-
8/3/2019 Brain Tumor Amogh
43/119
CT and MR Characteristics
-
8/3/2019 Brain Tumor Amogh
44/119
Fat - Calcification - Cyst
Fat has a low density on CT (- 100HU).On MR, fat has a high signal intensity on both T1- andT2WI.
On sequences with fat suppression fat can be
differentiated from high signal caused by subacutehematoma, melanin, slow flow etc.
When you see high signal on T1WI always look forchemical shift artefact, as this indicates the presence offat.The chemical shift artefact occurs as alternating bands
of high and low signal on the boundaries of a lesion and isseen only in the frequency encoding direction.
-
8/3/2019 Brain Tumor Amogh
45/119
Ruptured dermoid cyst.
Fat within a tumor is seen in lipomas, dermoidcysts and teratomas.
Some tumors can have a high density on CT.This is typically seen in lymphoma, colloid cyst
and PNET-MB (medulloblastoma
-
8/3/2019 Brain Tumor Amogh
46/119
Calcification
-
8/3/2019 Brain Tumor Amogh
47/119
Calcified mass in the
suprasellar region,
causing obstructive
hydrocephalus. This location in the
suprasellar region and
the calcification are
typical for acraniopharyngioma.
-
8/3/2019 Brain Tumor Amogh
48/119
Craniopharyngiomas are slow growing,
extra-axial, squamous epithelial, calcified,
cystic tumors arising from remnants of
Rathke's cleft.
They are located the (supra)sellar region
and primarily seen in children with a small
second peak incidence in older adults.
-
8/3/2019 Brain Tumor Amogh
49/119
The calcification is not appreciated on the MR images, but
is easily seen on CT.
The calcification and the extension of the tumor to the
cortex are very typical for an oligodendroglioma.
An astrocytoma should be in the differential.
-
8/3/2019 Brain Tumor Amogh
50/119
Calcified meningioma
A patient with progressive visual loss.On the coronal and sagittal TW1I there is a large mass centeredaround the sella with a broad dural base.
There is extension into the sella.This patient was booked for decompression.
Only after the CT was performed, was it appreciated how denselycalcified this tumor is.
-
8/3/2019 Brain Tumor Amogh
51/119
Cystic versus Solid
There are many cystic lesions that can
simulate a CNS tumor.
These include epidermoid, dermoid,
arachnoid, neuroenteric and neuroglial
cysts.
Even enlarged perivascular spaces of
Virchow Robin can simulate a tumor.
-
8/3/2019 Brain Tumor Amogh
52/119
In order to determine whether a lesion
is a cyst or cystic mass look for the
following characteristics:
Morphology
Fluid/fluid level
Content usually isointense to CSF on T1,
T2 and FLAIR
DWI: restricted diffusion
-
8/3/2019 Brain Tumor Amogh
53/119
An arachnoid cyst is isointense to CSF on
all sequences.
Tumor necrosis may sometimes look like a
cyst, but it is never completely isointense
to CSF.
-
8/3/2019 Brain Tumor Amogh
54/119
Craniopharyngioma with an enhancing rim surrounding the cysticcomponent.
Neuroenteric cyst with the contents of which have the same signalintensity as CSF.
Glioblastoma multiforme (GBM) with a central cystic component.The enhancement in GBM is usually more irregular.
-
8/3/2019 Brain Tumor Amogh
55/119
MOST LESIONS ARE LOW ON
T1 AND HIGH ON T2
BUT.......
-
8/3/2019 Brain Tumor Amogh
56/119
-
8/3/2019 Brain Tumor Amogh
57/119
A patient who presented with apoplexy. The high signal is due tohemorrhage in a pituitary macroadenoma.
The patient in the middle has a glioblastoma multiforme, whichcaused a hemorrhage in the splenium of the corpus callosum.
On the right is a patient with a metastasis of a melanoma.The high signal intensity is due to the melanin content.
-
8/3/2019 Brain Tumor Amogh
58/119
-
8/3/2019 Brain Tumor Amogh
59/119
Low on T2
Most tumors will be bright on T2WI due toa high water content.
When tumors have a low water content
they are very dense and hypercellular andthe cells have a high nuclear-cytoplasmasmic ratio.
These tumors will be dark on T2WI.The classic examples are CNS lymphomaand PNET (also hyperdense on CT).
-
8/3/2019 Brain Tumor Amogh
60/119
Calcifications are mostly dark on T2WI. Paramagnetic effects cause a signal drop and
are seen in tumors that contain hemosiderin. Proteinaceous material can be dark on T2
depending on the content of the protein itself.A classic example of this is the colloid cyst.
Flow voids are also dark on T2 and indicate thepresence of vessels or flow within a lesion.
This is seen in tumors that contain a lot ofvessels like hemangioblastomas, but also innon-tumorous lesions like vascularmalformations
-
8/3/2019 Brain Tumor Amogh
61/119
Melanoma metastases have a low SI on T2WI as a result of themelanin.
GBM can have a low SI on T2WI because sometimes they have a
high nuclear-cytoplasmic ratio. Most GBM's, however, arehyperintense on T2WI. PNET typically has a high nuclear-cytoplasmic ratio. PNET is
mostly located in the region of the 4th ventricle, but another, lesscommon, location is in the region of the pineal gland.
-
8/3/2019 Brain Tumor Amogh
62/119
Mucinous metastases can have a low SI on T2WI because theyoften contain calcifications..
Meningiomas are mostly of intermediate signal.
They can have a high SI on T2WI if they contain a lot of water.They can have a low SI on T2WI if they are very dense andhypercellular or when they contain calcifications.
-
8/3/2019 Brain Tumor Amogh
63/119
-
8/3/2019 Brain Tumor Amogh
64/119
Diffusion weighted imaging
Normally water protons have the ability to diffuseextracellularly and loose signal.High intensity on DWI indicates restriction of the ability ofwater protons to diffuse extracellularly.Restricted diffusion is seen in abscesses, epidermoidcysts and acute infarction (due to cytotoxic edema).
In cerebral abscesses the diffusion is probably restricteddue to the viscosity of pus, resulting in a high signal onDWI.
In most tumors there is no restricted diffusion - even innecrotic or cystic components.This results in a normal, low signal on DWI.
-
8/3/2019 Brain Tumor Amogh
65/119
-
8/3/2019 Brain Tumor Amogh
66/119
Perfusion Imaging
Perfusion imaging can play an important role in
determining the malignancy grade of a CNS
tumor.
Perfusion depends on the vascularity of a tumorand is not dependent on the breakdown of the
blood-brain barrier.
The amount of perfusion shows a better
correlation with the grade of malignancy of atumor than the amount of contrast enhancement.
-
8/3/2019 Brain Tumor Amogh
67/119
-
8/3/2019 Brain Tumor Amogh
68/119
-
8/3/2019 Brain Tumor Amogh
69/119
Blood brain barrier
The brain has a unique triple layered
blood-brain barrier (BBB) with tight
endothelial junctions in order to maintain a
consistent internal milieu. Contrast will not leak into the brain unless
this barrier is damaged.
Enhancement is seen when a CNS tumordestroys the BBB.
-
8/3/2019 Brain Tumor Amogh
70/119
Extra-axial tumors such as meningiomas
and schwannomas are not derived from
brain cells and do not have a blood-brain
barrier. Therefore they will enhance. There is also no blood-brain barrier in the
pituitary, pineal and choroid plexus
regions.
-
8/3/2019 Brain Tumor Amogh
71/119
Some non-tumoral lesions enhance
because they can also break down the
BBB and may simulate a brain tumor.
These lesions include like infections,demyelinating diseases (MS) and
infarctions.
-
8/3/2019 Brain Tumor Amogh
72/119
Contrast enhancement cannot visualize the full
extent of a tumor in cases of infiltrating tumors,
like gliomas.
The reason for this is that tumor cells blend withthe normal brain parenchyma where the blood
brain barrier is still intact.
Tumor cells can be found beyond the enhancing
margins of the tumor and beyond any MR signalalteration - even beyond the area of edema.
-
8/3/2019 Brain Tumor Amogh
73/119
42 y/o male with mild head trauma. On the T2WI there is a lesion in the left temporal lobe, found
incidentally.
There was no enhancement and the DWI was normal. During follow-up there was a slight increase in size.
This was diagnosed as a low-grade astrocytoma.
-
8/3/2019 Brain Tumor Amogh
74/119
In gliomas - like astrocytomas,
oligodendrogliomas and glioblastoma
multiforme - enhancement usually
indicates a higher degree of malignancy. Therefore when during the follow up of a
low-grade glioma the tumor starts to
enhance, it is a sign of malignanttransformation..
-
8/3/2019 Brain Tumor Amogh
75/119
Gangliogliomas and pilocytic astrocytomas are
the exceptions to this rule: they are low-grade
tumors, but they enhance vividly.
-
8/3/2019 Brain Tumor Amogh
76/119
The amount of enhancement depends onthe amount of contrast that is delivered tothe interstitium.
In general, the longer we wait, the betterthe interstitial enhancement will be.The optimal timing is about 30 minutesand it is better to give contrast at the start
of the examination and to do theenhanced T1WI at the end.
-
8/3/2019 Brain Tumor Amogh
77/119
LEFT: Schwannoma extending into the middle
cranial fossa with homogeneous enhancement
RIGHT: Primary Lymphoma known for its vividenhancement
-
8/3/2019 Brain Tumor Amogh
78/119
No enhancement is seen in
Low grade astrocytomas
Cystic non-tumoral lesions:
Dermoid cyst
Epidermoid cyst
Arachnoid cyst
-
8/3/2019 Brain Tumor Amogh
79/119
An intra-axial tumor in an adult. It is centered in the temporal lobe and involves the cortex.Although there is massive infiltrative growth involving a large part ofthe right cerebral hemisphere, there is only minimal mass effect.
There is no enhancement.
These features are typical for a low-grade astrocytoma.
H h
-
8/3/2019 Brain Tumor Amogh
80/119
Homogeneous enhancement
Metastases
Lymphoma
Germinoma and other pineal gland tumors Pituitary macroadenoma
Pilocytic astrocytoma and hemangioblastoma(only the solid component)
Ganglioglioma Meningioma and Schwannoma
-
8/3/2019 Brain Tumor Amogh
81/119
P t h h t
-
8/3/2019 Brain Tumor Amogh
82/119
Patchy enhancement
Metastases
Oligodendroglioma
Glioblastoma multiforme
Radiation necrosis
-
8/3/2019 Brain Tumor Amogh
83/119
Gioblastoma multiforme (GBM). The enhancement indicates that this is a high-grade tumor, but only
parts of it enhance. There is also a cystic component with ringenhancement.
The tumor cells probably extend beyond the area of edema as seenon the FLAIR image.This is because gliomas grow infiltratively into normal brain - initiallywithout any MR changes.
-
8/3/2019 Brain Tumor Amogh
84/119
Although is a large tumor, the mass-effect is limited.This indicates that there is marked infiltrative growth, acharacteristic typical for gliomas.
Notice the heterogeneity on both T2WI and FLAIR.
There is patchy enhancement.All these findings are typical for a GBM.Virtually no other tumor behaves in this way.
-
8/3/2019 Brain Tumor Amogh
85/119
Ri h t
-
8/3/2019 Brain Tumor Amogh
86/119
Ring enhancement
Ring enhancement is seen in metastasesand high-grade gliomas.
It is also seen in non-tumorous lesions like
abscesses, some MS-plaques andsometimes in an old hematomas.
-
8/3/2019 Brain Tumor Amogh
87/119
-
8/3/2019 Brain Tumor Amogh
88/119
Conspicuity of tumors with contrast
This is a patient with Neurofibromatosis II.
After the administration of contrast the twomeningiomas and the schwannoma are easilyseen.
-
8/3/2019 Brain Tumor Amogh
89/119
Leptomeningeal metastases are usually not seen without theadministration of intravenous contrast.
The case on the left demonstrates the abnormal enhancement
along the brainstem, along the folia of the cerebellum (yellow arrow)and along the fifth intracranial nerve (blue arrow) in a patient withleptomeningeal metastases.
-
8/3/2019 Brain Tumor Amogh
90/119
Differential diagnosis
for specific anatomic area
-
8/3/2019 Brain Tumor Amogh
91/119
Sk ll base
-
8/3/2019 Brain Tumor Amogh
92/119
Skull base
These tumors either arise fromextracranial structures like the sinuses
(sinonasal carcinoma), or from the skull
base itself (chordoma, chondrosarcoma,fibrous dysplasia).
Chordoma is usually located in the
midline, while chondrasarcoma usuallyarises off the midline.
-
8/3/2019 Brain Tumor Amogh
93/119
Midline tumorarising from theclivus.
This is the typical
presentation of achordoma.The differentialdiagnosis would
include ametastasis and achondrosarcoma.
-
8/3/2019 Brain Tumor Amogh
94/119
Skull base tumor locatedoff midline.
This is a typicalpresentation for achondrosarcoma.
The differential diagnosiswould include ametastasis and aparaganglioma.Chondrosarcomas canbe located in the midline
and chordomas aresometimes located offmidline but those casesare exceptional.
Skull Base Paraganglioma
-
8/3/2019 Brain Tumor Amogh
95/119
Skull Base Paraganglioma.
-
8/3/2019 Brain Tumor Amogh
96/119
58-year-old male with a gradual onset of right facial pain andnumbness and a recent onset of double vision.
There is an enhancing mass anterior to the skull base and also inthe region of the right cavernous sinus.In the bone window setting there is sclerosis of the skull base,particularly in the region of the clivus.
PTO
CONTD
-
8/3/2019 Brain Tumor Amogh
97/119
A normal clivus is bright on T1WI as a result of the fatty bonemarrow.
There is an enhancing mass anterior to the clivus.
On the coronal images we see the enhancement extending throughthe foramen ovale to the right of the cavernous sinus.
-
8/3/2019 Brain Tumor Amogh
98/119
The diagnosis is a nasopharyngealsquamous cell carcinoma with intracranial
extension.
The differential diagnosis would include:skull base metastasis, lymphoma, chronic
infection and even a meningioma -
although this would be an unusual way fora meningioma to spread.
-
8/3/2019 Brain Tumor Amogh
99/119
-
8/3/2019 Brain Tumor Amogh
100/119
Mass in the suprasellar cistern. On the NECT we can see that it contains calcium. On the T1WI there is a hyperintense area that shows no
enhancement (i.e. cystic). There are other components that show enhancement. The tumor is complicated by a hydrocephalus.
These findings are very specific for a craniopharyngeoma.
-
8/3/2019 Brain Tumor Amogh
101/119
PTO
-
8/3/2019 Brain Tumor Amogh
102/119
-
8/3/2019 Brain Tumor Amogh
103/119
Notice the normal inferiorly displacedpituitary gland.
This means it is not a macroadenoma.
The diagnosis is a craniopharyngioma. The differential diagnosis would include an
astrocytoma and a meningioma.
-
8/3/2019 Brain Tumor Amogh
104/119
-
8/3/2019 Brain Tumor Amogh
105/119
52-year-old male with hearing loss on the right.The images show an unusual cystic mass with enhancingseptations.
There is also some enhancement within the internal acoustic canal.Based on the images the most likely diagnosis would be a cysticschwannoma, but this happened to be an uncommon, cysticpresentation of a meningioma.
-
8/3/2019 Brain Tumor Amogh
106/119
-
8/3/2019 Brain Tumor Amogh
107/119
-
8/3/2019 Brain Tumor Amogh
108/119
Based on these images the differentialdiagnosis would include:
Meningioma
Pineocytoma
Germ Cell Tumor
This happened to be a meningioma.
Ruptured pineal region dermoid
-
8/3/2019 Brain Tumor Amogh
109/119
Ruptured pineal region dermoid.
-
8/3/2019 Brain Tumor Amogh
110/119
12 y/o male with upward gaze paralysis.
There is a tumor located in the pineal region. The tumor contains calcifications. There is homogeneous enhancement, which is common for a tumor
in the pineal regionBased on the age of the patient, the location and the tumorcharacteristics, this is most likely a germinoma.
-
8/3/2019 Brain Tumor Amogh
111/119
Giant cell astrocytoma
-
8/3/2019 Brain Tumor Amogh
112/119
Giant cell astrocytoma.
4th ventricle
-
8/3/2019 Brain Tumor Amogh
113/119
4th ventricle
-
8/3/2019 Brain Tumor Amogh
114/119
In children tumors in the 4th ventricle are verycommon.
Astrocytomas are the most common followed bymedulloblastomas (or PNET-MB),
ependymomas and brainstem gliomas with adorsal exophytic component.
In adults tumors in the 4th ventricle areuncommon.
Metastases are most frequently seen, followedby hemangioblastomas, choroid plexuspapillomas and dermoid and epidermoid cysts.
Tumor Mimics
-
8/3/2019 Brain Tumor Amogh
115/119
Many non-tumorous lesions can mimic abrain tumor.
Abscesses can mimic metastases.
Multiple sclerosis can present with amass-like lesion with enhancement, also
known as tumefactive multiple sclerosis..
In the parasellar region one should alwaysconsider the possibility of a aneurysm
-
8/3/2019 Brain Tumor Amogh
116/119
-
8/3/2019 Brain Tumor Amogh
117/119
References
http://www.elsevier.com/wps/product/authors/712552http://www.elsevier.com/wps/product/authors/712552 -
8/3/2019 Brain Tumor Amogh
118/119
References
Brain Lesion Locator: Differential Diagnosis by Locat
by James Smirniotopoulos
Diagnostic Neuroradiology by Anne G. Osborn
Textbook ofRadiology and Imaging David
Sutton 7ed
Grainger & Allison's Diagnostic Radiology
www.radiologyassistant.nl
http://www.elsevier.com/wps/product/authors/712552http://www.elsevier.com/wps/product/authors/712552http://www.elsevier.com/wps/product/authors/712552http://rad.usuhs.mil/rad/location/location_frame.htmlhttp://www.elsevier.com/wps/product/authors/712552http://www.elsevier.com/wps/product/authors/712552http://www.elsevier.com/wps/product/authors/712552http://www.elsevier.com/wps/product/authors/712552http://www.elsevier.com/wps/product/authors/712552http://www.elsevier.com/wps/product/authors/712552http://www.elsevier.com/wps/product/authors/712552http://www.elsevier.com/wps/product/authors/712552http://www.elsevier.com/wps/product/authors/712552http://www.elsevier.com/wps/product/authors/712552http://www.elsevier.com/wps/product/authors/712552http://www.elsevier.com/wps/product/authors/712552http://www.elsevier.com/wps/product/authors/712552http://thepiratebay.org/torrent/4265111/Textbook_of_Radiology_and_Imaging_David_Sutton_7edhttp://thepiratebay.org/torrent/4265111/Textbook_of_Radiology_and_Imaging_David_Sutton_7edhttp://thepiratebay.org/torrent/4265111/Textbook_of_Radiology_and_Imaging_David_Sutton_7edhttp://thepiratebay.org/torrent/4265111/Textbook_of_Radiology_and_Imaging_David_Sutton_7edhttp://thepiratebay.org/torrent/4265111/Textbook_of_Radiology_and_Imaging_David_Sutton_7edhttp://rad.usuhs.mil/rad/location/location_frame.html -
8/3/2019 Brain Tumor Amogh
119/119