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0928 Bt

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  • 1. Brain Tumors
  • 2. PATTERN ANALYSIS <ul><li>Basic Approach </li></ul><ul><li>◎ Where is the lesion? </li></ul><ul><li>. Intraaxial </li></ul><ul><li>. Extraaxial </li></ul><ul><li>◎ How old is the patient ? </li></ul><ul><li>. Child </li></ul><ul><li>. Adult </li></ul><ul><li>◎ INTRAAXIAL </li></ul><ul><li>. internal to PIA </li></ul><ul><li>. (brain parenchyma) </li></ul><ul><li>◎ EXTRAAXIAL </li></ul><ul><li>. external to PIA </li></ul><ul><li>. (meninges, nerve sheath) </li></ul><ul><li>◎ INTRAVENTRICULAR </li></ul><ul><li>. Lateral </li></ul><ul><li>. Third </li></ul><ul><li>. Fourth </li></ul>
  • 3. INTRAAXIAL: <ul><li>◎ Differential: </li></ul><ul><li>. CORTEX </li></ul><ul><li>. GRAY/WHITE JUNCTION </li></ul><ul><li>. DEEP WHITE MATTER </li></ul><ul><li>. DEEP GRAY MATTER </li></ul><ul><li>◎ Differential: </li></ul><ul><li>. Glioma </li></ul><ul><li>. Medulloblastoma </li></ul><ul><li>. Hemangioblastoma </li></ul><ul><li>. Metastases </li></ul><ul><li>. Infarct/hematoma </li></ul><ul><li>. AVM/congenital </li></ul><ul><li>. Abscess/inflammation </li></ul>
  • 4.  
  • 5. EXTRAAXIAL LESIONS <ul><li>(Location) </li></ul><ul><li>Subarachnoid </li></ul><ul><li>Subdural </li></ul><ul><li>Epidural </li></ul><ul><li>Calvarium (skull base) </li></ul><ul><li>Scalp (soft tissues) </li></ul><ul><li>◎ Differential : </li></ul><ul><li>. Meningioma </li></ul><ul><li>. Pituitary adenoma </li></ul><ul><li>. Craniopharyngioma </li></ul><ul><li>. Schwannoma </li></ul><ul><li>. Chordoma </li></ul><ul><li>. Dermoid/epidermoid, cyst, lipoma </li></ul><ul><li>. Hematoma, metastasis, infection </li></ul>
  • 6. Determining Tumor Location <ul><li>◎ Intraaxial Tumors </li></ul><ul><li>Usually not contiguous with bone or falx </li></ul><ul><li>Usually no bony changes </li></ul><ul><li>Effaced CSF spaces, cisterns </li></ul><ul><li>Destruction GM/WM jcn </li></ul><ul><li>Internal vasc.supply </li></ul><ul><li>◎ Extraaxial Tumors </li></ul><ul><li>Contiguity with bone or falx </li></ul><ul><li>Usually bony changes </li></ul><ul><li>Widened CSF spaces, cisterns </li></ul><ul><li>Preservation GM/WM junction </li></ul><ul><li>External vascular suppy by dural branches </li></ul>
  • 7.  
  • 8. Case 1. <ul><li>68-year-old female with seizures. </li></ul>
  • 9.  
  • 10. Meningioma <ul><li>Originates from arachnoid cap cells </li></ul><ul><li>40-60 years old </li></ul><ul><li>F>M </li></ul><ul><li>20% of all brain tumors </li></ul><ul><li>Uncommon in children and if present, think of NF2 </li></ul><ul><li>90% are supratentorial </li></ul>
  • 11. Meningioma <ul><li>◎ Location </li></ul><ul><li>45%: cerebral convexity along falx and lateral to it </li></ul><ul><li>20%: sphenoid ridge </li></ul><ul><li>10%: juxtasellar </li></ul><ul><li>10%: olfactory groove </li></ul><ul><li>10%: posterior fossa clivus </li></ul><ul><li>tentorium </li></ul>
  • 12.  
  • 13. Morphology <ul><li>Round, unilobulated, sharp margin is most common </li></ul><ul><li>Dural tail : extension of tumor or dural reaction along dural surface </li></ul><ul><li>Edema is absent in 40% because of slow growth </li></ul>
  • 14.  
  • 15. Bony abnormalities <ul><li>No changes (common) </li></ul><ul><li>Hyperostosis (common) </li></ul><ul><li>Bone erosion (rare) </li></ul>
  • 16. CT Findings <ul><li>Hyperdense (75%) or isodense (25%) on noncontrast CT </li></ul><ul><li>Strong homogeneous enhancement, 90% </li></ul><ul><li>Similar density as falx on enhanced and unenhanced CT </li></ul><ul><li>Calcifications, 25% </li></ul><ul><li>Cystic areas, 15% </li></ul>
  • 17.  
  • 18. MRI Findings <ul><li>Isodense with gray matter typically </li></ul><ul><li>Strong gad enhancement </li></ul><ul><li>Best technique for seeing dural tail </li></ul><ul><li>Dural tail is suggestive but not specific for meningioma </li></ul><ul><li>Increased vascular flow voids </li></ul>
  • 19.  
  • 20.  
  • 21. Case 2. <ul><li>32-year-old male with several week's history of headaches with increasing severity. </li></ul>
  • 22.  
  • 23.  
  • 24. Differential Diagnosis <ul><li>Epidermoid tumor </li></ul><ul><li>Arachnoid cyst </li></ul><ul><li>Teratoma </li></ul>
  • 25. Epidermoid Tumor (Inclusion Cyst) <ul><li>Benign masses that arise in a variety of locations within the CNS </li></ul><ul><li>The most common locations are in the posterior fossa and CP angle,in the quadrigeminal plate cistern, and under the temporal lobe </li></ul><ul><li>These tumors are extra -axial masses but can extend into the ventricles </li></ul>
  • 26. Epidermoid Tumor (Inclusion Cyst) <ul><li>Not truly neoplastic and merely reflect an entity of ectodermal origin, one with desquamated skin </li></ul><ul><li>Similarly dermoid is of ectodermal origin, one with skin appendages like hair and sebaceous cysts </li></ul><ul><li>These are lumped together, as well as teratomas which are true neoplasms of multipotential germ cells </li></ul>
  • 27.  
  • 28. Another Analogy <ul><li>Think of types of salad dressings: </li></ul><ul><ul><li>You can have vinegar (epidermoids which are of singular density) </li></ul></ul><ul><ul><li>You can have oil and vinegar (dermoids have fat and fluid </li></ul></ul><ul><ul><li>You can have oil and vinegar and croutons (teratomas have fat, fluid, and solid components) </li></ul></ul>
  • 29. Epidermoid Tumor (Inclusion Cyst) <ul><li>M=F </li></ul><ul><li>Peak incidence in the 20-40 range </li></ul><ul><li>Extradural epidermoids are 9x less common than intradural ones and arise within the diploic space, petrous bone, and temporal bone with sclerotic borders </li></ul>
  • 30. CT Findings <ul><li>Low density </li></ul><ul><li>Expand to fill the interstices of the CSF space </li></ul><ul><li>Aggressive at insinuating itself around normal brain structures and often has scalloped edges </li></ul><ul><li>Nonenhancing lobulated lesion </li></ul>
  • 31.  
  • 32. Distinguishing Epidermoid from Arachnoid Cyst <ul><li>MR is most useful </li></ul><ul><li>These lesions are hypointense on T1 and hyperintense on T2, similar to CSF </li></ul><ul><li>Intensity on proton density-weighted imaging is usually inhomogeneous and often hyperintense to CSF </li></ul><ul><li>KEY: flair imaging tells them apart </li></ul><ul><ul><li>Epidermoids are bright and cysts are black </li></ul></ul>
  • 33.  
  • 34. Case 3. <ul><li>38-year-old male with constant left facial pain. </li></ul>
  • 35. Findings
  • 36. Findings <ul><li>The mass is lobular, expansile, and heterogeneously enhancing, with extension anteriorly to the orbital apex and posteriorly to the cerebellopontine angle. The internal auditory canal is normal and is seen below the lesion. </li></ul>
  • 37. Cerebellopontine Angle Masses <ul><li>S chwannoma (8th >> > 5th) </li></ul><ul><li>A neurysm, arachnoid cyst </li></ul><ul><li>M eningioma, mets </li></ul><ul><li>E pidermoid, ependymoma </li></ul>
  • 38. Trigeminal Schwannoma <ul><li>Benign tumors of Schwann cell origin, which are much less common than acoustic neuroma. </li></ul><ul><li>They may arise from any portion of the fifth cranial nerve, but most often arise from the semilunar ganglion portion of the nerve, within Meckel's cave. </li></ul><ul><li>Presenting complaints include trigeminal neuralgia or paresthesias within the trigeminal nerve distribution . </li></ul>
  • 39. Demographics of CPA Masses <ul><li>7/9 S chwannoma, 8th > > 5th </li></ul><ul><li>1/9 M eningioma (tentorial/petrous) </li></ul><ul><li>1/9 &quot;Other&quot;: </li></ul><ul><ul><li>E pidermoid (1/18) </li></ul></ul><ul><ul><li>Mets, aneurysm, etc. </li></ul></ul><ul><ul><li>Glioma (ependymoma) </li></ul></ul><ul><ul><li>A rachnoid cyst, Cystadenoma </li></ul></ul>
  • 40. Differentiating Schwannoma from Meningioma <ul><li>Meningioma </li></ul><ul><ul><li>Dural tail </li></ul></ul><ul><ul><li>Makes obtuse angle with petrous bone </li></ul></ul><ul><ul><li>No relationship to IAC </li></ul></ul><ul><ul><li>Homogeneous </li></ul></ul><ul><li>Schwannoma </li></ul><ul><ul><li>No dural tail </li></ul></ul><ul><ul><li>Makes acute angle with petrous bone </li></ul></ul><ul><ul><li>Enlarges IAC </li></ul></ul><ul><ul><li>Heterogeneous if large </li></ul></ul>
  • 41.  
  • 42.  
  • 43. <ul><li>46-year old female with worsening headache. </li></ul>
  • 44.  
  • 45. Differential Diagnosis <ul><li>Glioblastoma multiforme </li></ul><ul><li>Brain abscess </li></ul><ul><li>Metastases </li></ul>
  • 46. Gliomas
  • 47.  
  • 48. Glioblastoma Multiforme <ul><li>Forty to fifty percent of primary central nervous system tumors are gliomas . </li></ul><ul><li>Approximately 50% of these are glioblastoma multiforme . </li></ul><ul><li>Glioblastoma multiforme refers to a malignant neoplasm with abundant glial pleomorphism, numerous mitotic figures and giant cells, vascular hyperplasia, and focal areas of necrosis. </li></ul>
  • 49. Glioblastoma Multiforme <ul><li>5 th_ 7th decades </li></ul><ul><li>Usually develops in the cerebral hemispheres (more often in the frontal lobes than the temporal lobes or basal ganglia) but almost never in the cerebellum. </li></ul><ul><li>It grows as an irregular mass in the white matter and infiltrates the surrounding parenchyma by coursing along white matter tracts, frequently involving the corpus callosum and crossing the midline to produce the characteristic &quot; butterfly &quot; appearance. </li></ul>
  • 50. Radiology <ul><li>Usually heterogeneous low density mass on CT </li></ul><ul><li>Strong contrast enhancement </li></ul><ul><li>Hemorrhage, necrosis common </li></ul><ul><li>Calcification uncommon </li></ul><ul><li>Extensive vasogenic edema and mass effect </li></ul><ul><li>Bihemispheric spread via c.c (butterfly lesion) </li></ul><ul><li>CSF seeding: drop metastases </li></ul>
  • 51.  
  • 52.  
  • 53. <ul><li>A 8-year-old man presented with hemisensory deficit </li></ul>
  • 54.  
  • 55. Astrocytomas <ul><li>Represent 80% of gliomas </li></ul><ul><li>Most occur in cerebral hemispheres in adults </li></ul><ul><li>The differentiation of the types is made histologically, not by imaging </li></ul>
  • 56.  
  • 57.  
  • 58. FIBRILLARY ASTROCYTOMA (GRADE II) <ul><li>4-year old male with complex partial seizures and developmental delay </li></ul>
  • 59. ANAPLASTIC ASTROCYTOMA (GRADE III)
  • 60. PILOCYTIC ASTROCYTOMA (GRADE I) <ul><li>11-year-old male presented with headaches, morning nausea, and blurred vision Cerebellar astrocytoma </li></ul>
  • 61. PATTERNS OF ENHANCEMENT and WHO GRADING (based on histologic criteria)
  • 62.  
  • 63. <ul><li>37-year-old with headaches, nausea, and vomiting. </li></ul>
  • 64.  
  • 65. Lateral Ventricle Masses: Ddx <ul><li>>30 y.o </li></ul><ul><ul><li>Subependymoma </li></ul></ul><ul><ul><li>Astrocytoma </li></ul></ul><ul><ul><li>Mets </li></ul></ul><ul><ul><li>Oligodendroglioma </li></ul></ul><ul><ul><li>Meningioma </li></ul></ul><ul><ul><li>Central neurocytoma </li></ul></ul>
  • 66. Oligodendroglioma
  • 67. Oligodendroglioma <ul><li>Uncommon, slow growing glioma that presents as a large mass </li></ul><ul><li>5-10% of primary brain tumors </li></ul><ul><li>Peak age: 30-50 y.o </li></ul><ul><li>Usually tumors are mixed (astrocytoma/oligo) and rarely are “pure” </li></ul><ul><li>Located in cerebral hemispheres, most common in frontal lobe </li></ul>
  • 68. Oligodendroglioma <ul><li>Typified by high rate of calcification (40-80%) </li></ul><ul><li>Peak age is 5 th -6 th decade </li></ul><ul><li>M>F </li></ul><ul><li>There are no known established risk factors </li></ul><ul><li>Recent epidemiological work has suggested that gliomas may be associated with repeated exposure to high-voltage electrical lines </li></ul>
  • 69. Oligodendroglioma <ul><li>Because these tumors arise from oligodendrocytes, they usually occur in the cerebral white matter, and because there are relatively more oligodendrocytes in the frontotemporal area, oligodendrogliomas have a predilection for these areas. </li></ul><ul><li>As a result, the tumor may cause personality changes, or cause seizures, because of their infiltrative nature. </li></ul>
  • 70. Oligodendroglioma <ul><li>The tumor, when pure, has a benign, course. </li></ul><ul><li>However, oligodendrogliomas are often histologically mixed (>50%) with astrocytic forms. </li></ul><ul><ul><li>When present, it acts as a medium grade neoplasm with a high rate of recurrence. </li></ul></ul>
  • 71. 32-year-old male presented with headaches and ataxia.
  • 72. Hemangioblastoma <ul><li>Benign neoplasms of vascular origin . </li></ul><ul><li>They are not malformations. </li></ul><ul><li>They account for less than 3% of all intracranial neoplasms. </li></ul><ul><li>These tumors are most common in young and middle-aged adults, where the incidence in males exceeds that of females. </li></ul>
  • 73. Hemangioblastoma <ul><li>The cerebellar hemisphere is the most common location, although they may be located in the spinal cord , brain stem, or cerebral hemispheres. </li></ul><ul><li>10-20 percent of hemangioblastomas occur as part of the von Hippel-Lindau disease </li></ul>
  • 74. Hemangioblastoma:CT Findings <ul><li>60% of these tumors are cystic. </li></ul><ul><li>The enhancing mural nodule is a common finding in hemangioblastoma. </li></ul><ul><li>At CT, the cystic portion of the tumor appears low density and does not enhance, while the mural nodule enhances homogeneously and intensely. </li></ul>
  • 75. MR Findings <ul><li>Cystic tumor with intense enhancement of the peripheral nodule following gadolinium administration. </li></ul><ul><li>If the vascular nodule has bled or is proteinaceous, it may be hyperintense on short TR precontrast sequences. </li></ul><ul><li>More than one enhancing tumor nodule may be seen. </li></ul><ul><li>40% of hemangioblastomas are solid and display variable degrees of contrast enhancement. </li></ul>
  • 76. 10-year-old presented with 10 days of vomiting, unsteady gait, slurred speech, headache, and diplopia.
  • 77. Medulloblastoma (PNET)
  • 78. 18-month-old child was evaluated for irritability, nausea, and vomiting
  • 79.  
  • 80. Ependymoma of the fourth ventricle
  • 81. Metastases <ul><li>30-50% of intracerebral tumors </li></ul><ul><li>Location in order of frequency: </li></ul><ul><ul><li>Jcn GM/WM </li></ul></ul><ul><ul><li>Deep parenchymal structures </li></ul></ul><ul><ul><li>Brainstem </li></ul></ul><ul><li>Most common primaries </li></ul><ul><ul><li>Lung cancer, 50% </li></ul></ul><ul><ul><li>Breast, 20% </li></ul></ul><ul><ul><li>Colon, rectum 15% </li></ul></ul><ul><ul><li>Kidney 10% </li></ul></ul><ul><ul><li>Melanoma 10% </li></ul></ul>
  • 82. Metastases
  • 83.  
  • 84. Differential Diagnosis: Ring Enhancement <ul><li>Tumor (primary, mets, lymphoma) </li></ul><ul><li>Infection, inflammation (abscess, granuloma, MS, toxo, cysticercosis </li></ul><ul><li>Vascular (resolving hematoma, infarct, thrombosed vascular malformation, thrombosed aneurysm) </li></ul>
  • 85. Resolving hematoma Brain abscess Necrotic tumor (lymphoma) Case 1 Case 2 Case 3 T1WI T1C+ T2WI FLAIR DWI ADC
  • 86. Thanks for Your Attention !

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