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Dr. Prashant Pote
Jr.III
Department of Radiology
 Pediatric brain tumors(PBT) are 15-20% of all
brain tumors. Second most common
pediatric tumor next to leukemia.
 Overall, supratentorial and infratentorial
tumors occur in equal frequency.
Supratentorial more common <2yrs;
infratentorial more common 4-10 yrs; equally
common after 10yrs age
 Posterior fossa
 Supratentorial
 Intraparenchymal
 Sellar/Suprasellar
 Extra-axial
 Astrocytoma
 Ependymoma
 Desmoplastic Infantile Ganglioglioma (DIG)
 Dysembryoplastic neuroepithelial tumor (DNET)
 Teratoma
 Ganglioglioma/Gangliocytoma
 Primitive NeuroectodermalTumor (PNET)
 Atypical teratoid/rhabdoid tumors
 Craniopharyngioma
 Astrocytoma
 Rathke cleft cyst
 Germ cell tumors
 Hypothalamic hamartoma
 Langerhans cell histioctyosis
 Pituitary adenoma
 Choroid plexus papilloma /carcinoma
 Langerhans cell histiocytosis
 Epidermoid/Dermoid
 Arachnoid cyst
 Metastasis
Pediatric brain tumors
1. Teratoma.
2. CNS PNET
3. Choroid plexus papilloma
4. Anaplastic astrocytoma
5. DIG
Cortically-based tumors
• DNET
• Ganglioglioma
• Oligodendroglioma
• PXA
Intraventricular tumors
 Ependymoma, subependymoma
 Central neurocytoma
 Choroid plexus papilloma/carcinoma
Pineal region tumors
• Pineal parenchymal tumors
(pineocytoma/blastoma)
• Germ cell tumors (germinoma, teratoma, etc)
Dural-based tumors and mimics
• Meningioma
• Metastasis
• Inflammatory pseudotumor
• Infection (e.g., tuberculosis)
• Extramedullary hematopoiesis
 Local intracranial extension from
extracranial neoplasms
• Chordoma
• Paraganglioma
• Carcinomas (e.g., nasopharyngeal squamous
cell),sarcomas (rhabdomyosarcoma)
 Neoplasms that often have cyst + nodule
• Pilocytic astrocytoma
• Ganglioglioma
• Hemangioblastoma
• Craniopharyngioma
 30% of hemispheric tumors. Most common
cerebral hemispheric tumor
 Peak incidence at 7-8yrs age
 Low grade astrocytomas more common
 Glioblastoma Multiforme (GBM)WHO IV/IV ~
20%
 Typically involve basal ganglia, thalamus
 Can be multi-centric
 Cerebellum is most common site followed by in
and around optic nerve/chiasm,
hypothalamus/third ventricle.
 Cerebral hemisphere –uncommon.
 Cerebellum and cerebralTm: cyst with mural
nodule.
 Optic nerve/chiasm/third ventricle: solid
infiltrating.
 Hemorrhage uncommon; if present its
pilomyxoid astrocytoma
SagittalT2WI shows a
mixed solid and cystic focal lesion in the
right frontoparietal region (arrows).The
solid component of the lesion has
intermediate
signal, and the cystic component has
high signal.
Sagittal postcontrastT1WI
shows prominent Gd-contrast enhancement
at the solid component of the lesion
Post contrast
 Differs from PA in clinical course,
presentation and histological appearance.
 60%- suprasellar, 40%cerebral hemisphere
 Cerebellum and fourth ventricle ;rare
 Age: Suprasellar- infants and children <4 yrs
Atypical location – adolescent and in adults
 Imaging: A large H shaped suprasellar mass,
mixed SI, heterogeneous enhancement with
hemorrhage
Pediatric brain tumors
 First two decades of life, mean age 11 yrs
 An enhancing lesion at foramen of Monro
should be considered SEGA until proven
otherwise.
 Calcification,
 TSC other feature; SEN, cortical tubers, white
matter radial migration lines
 SEGA or SEN; progressive enlargement.
Tuberous Sclerosis- SEGA
T2
Post contrastT1
 Children and young adults, 2/3rd under 18 yr
 Well delineated cortically based mass that
contacts the leptomeninges
 70%; cyst with nodule, 30% solid with
intratumoral cysts
 Calcification 40%, hemorrhage rare
 Moderate enhancement ofTm nodule post
contrast
Pediatric brain tumors
 30% of ependymomas
 Peak incidence between 1-5yrs age
 Histologically similar to infratentorial
ependymomas – fourth ventricle and CPA.
 Differs! typically in periventricular white
matter and cerebral hemisphere
parenchyma.
AxialT2WI
shows a lesion with heterogenous high signal
containing a cystic zone in the inferior
right frontal lobe.
Postcontrast axialT1WI
shows irregular peripheral enhancement at
lesion.
 Arises from subpial astrocytes
 Found between1-months age w/peak at 3-6
months. Occasionally seen up to 5yrs
 Cortically based tumor nodule.
Post contrastT1
Desmoplastic infantile ganglioglioma
T1
 Imaging findings:
 Large cyst w/cortically based enhancing tumor
nodule
 Solid component avidly enhances;
leptomeningeal and dural enhancement,
enhancement
 Occupies majority of cerebral hemisphere
 Looks worse than it is!!
 Greater then 75% survival after 15yrs
w/complete resection
 Cause of 20% cases of medically refractory
epilepsy
 60% in temporal lobe, 30% frontal lobe
 Solid and cystic tumors
 Scalloping of inner table skull
 Associated w/cortical dysplasia
 Slow to No growth!
•Multicystic cortically based
lesion
•25% have calcifications
•20-40% enhancement
•Characteristic “bright
rim”on FLAIR .
•Usually no edema, no
mass effect.
FLAIR
T2
T2
Post contrastT1
DNET
 Found in adolescents
 Associated with mesial temporal sclerosis
Most common in temporal, parietal, frontal
lobes
 Difference betweenGG and GC is histological
 Clinical: Partial complex seizures
Imaging findings:
•Solid or cystic or cyst w/mural
nodule
•Variable enhancement
•35% w/calcifications
•If peripheral location, then
scalloping of adjacent calvarium
•Hemorrhage and necrosis absent
GRE
Post contrastT1
Pediatric brain tumors
Pediatric brain tumors
a AxialT2WI shows a large lesion
with heterogeneous high signal in the right
frontal lobe extending across the corpus
callosum to the left frontal lobe
b Postcontrast
sagittalT1WI shows irregular enhancement
in a portion of the lesion.
 occur in the paediatric population, usually
during the first 10 years of life,
 Circumscribed or invasive lesions. Low to
intermediate signal onT1WI; intermediate to
high signal onT2WI.
 VariableGd-contrast enhancement.
 Frequent dissemination into the
leptomeninges.
 Highly malignant tumors located in the
cerebrum,pineal gland, and cerebellum.
 2-5% of tumors in children less then 15 yrs
 Midline lesion typically in pineal gland, third
ventricle
 Most are benign
 Imaging findings:
 Midline mass with calcifications and fat
 Enhancement of soft tissue components
 Malignant teratomas have more vasogenic
edema, irregular, less well defined.
Pediatric brain tumors
Teratoma
Pediatric brain tumors
 Choroid plexus papilloma /carcinoma
 Langerhans cell histiocytosis
 Epidermoid/Dermoid
 Arachnoid cyst
 Metastasis
 Arise from epithelium of choroid plexus
 5% of supratentorial tumors
 Typically age 1-5yrs
 Male predominance
 Most common in trigone of left lateral
ventricle
 CPC more irregular and invasive then CPP but
diagnosis is histological
 Clinical: Hydrocephalus
 Imaging:
 CPP is lobulated, homogeneous mass with
frond like excrescence.
 Punctate calcifications, hyperdense on CT
 Intense enhancement on CT/MR
 CPC irregular, heterogeneous w/cystic
necrosis, invasive and vasogenic edema
T2 Choroid plexus papilloma Post contratT1
Choroid plexus papilloma
-CT
Choroid plexus papilloma
T2 Post contratT1
Choroid plexus carcinoma
T2
Post contrast
T1
FLAIR
DWI
 Craniopharyngioma
 Astrocytoma
 Rathke cleft cyst
 Germ cell tumors
 Hypothalamic hamartoma
 Langerhans cell histioctyosis
 Pituitary adenoma
 Hypopituitarism– craniopharyngioma
 Diabetes insipidus – LCH,
 Precocious puberty– hamartoma of tuber
cinereum, hypothalamic glioma
 Amenorrhea– pituitary adenoma, Rathke
cleft cyst
 Thought to arise from remnant of
craniopharyngeal duct.
 Adamantinomatous(children) and papillary
(adults) types
 15% supratentorial tumors, 50% suprasellar
tumors
 2 peaks: 10-14 yrs age; 4th to 6th decade of
life
 Rim enhancement of cysts; heterogeneous enhancement solid portions
Pediatric brain tumors
Pediatric brain tumors
 Benign epithelial lined cyst in sella
 Arises from remnants of Rathke pouch in
pituitary gland with frequent suprasellar
extension.
 Rare in children
CT: Cystic
nonenhancing,
noncalcified mass
MRI:T1 orT2
hyperintense
No enhancement
T1
Post contrastT1
 Suprasellar type arises from optic chiasm or
hypothalamus
 M=F 4yrs age
 30-50% have family history of NF1
 Clinical: Hydrocephalus, decreased vision,
pituitary dysfunction (short stature)
 Imaging findings:
 T2, FLAIR hyperintense
 Fusiform or lobulated enlargement optic
nerves with heterogeneous enhancement
 Gliomas in patients without NF1 have cystic
components.
POST ContrastT1
T2
T1
 Imaging findings:
 MR: Infundibular thickening w/uniform
enhancement
 Iso to hypointense onT1,T2 and FLAIR
 When large, can have areas of cystic necrosis
 REMEMBER: HIGH ASSOCIATION
W/DIABETES INSIPIDUS!!.
Pediatric brain tumors
 Heterotopic gray matter generally located in
tuber cinereum
 Can originate from floor third ventricle,
mamillary bodies.
 Can be sessile or pedunculated
 Large lesions cause gelastic seizures; small
lesions have precocious puberty
 Found in 33% of patients w/precocious
puberty
MR: Isointense onT1, slightly hyperintense on
T2, Non enhancing
Post contrastT1
Pediatric brain tumors

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Pediatric brain tumors

  • 2.  Pediatric brain tumors(PBT) are 15-20% of all brain tumors. Second most common pediatric tumor next to leukemia.  Overall, supratentorial and infratentorial tumors occur in equal frequency. Supratentorial more common <2yrs; infratentorial more common 4-10 yrs; equally common after 10yrs age
  • 3.  Posterior fossa  Supratentorial  Intraparenchymal  Sellar/Suprasellar  Extra-axial
  • 4.  Astrocytoma  Ependymoma  Desmoplastic Infantile Ganglioglioma (DIG)  Dysembryoplastic neuroepithelial tumor (DNET)  Teratoma  Ganglioglioma/Gangliocytoma  Primitive NeuroectodermalTumor (PNET)  Atypical teratoid/rhabdoid tumors
  • 5.  Craniopharyngioma  Astrocytoma  Rathke cleft cyst  Germ cell tumors  Hypothalamic hamartoma  Langerhans cell histioctyosis  Pituitary adenoma
  • 6.  Choroid plexus papilloma /carcinoma  Langerhans cell histiocytosis  Epidermoid/Dermoid  Arachnoid cyst  Metastasis
  • 8. 1. Teratoma. 2. CNS PNET 3. Choroid plexus papilloma 4. Anaplastic astrocytoma 5. DIG
  • 9. Cortically-based tumors • DNET • Ganglioglioma • Oligodendroglioma • PXA
  • 10. Intraventricular tumors  Ependymoma, subependymoma  Central neurocytoma  Choroid plexus papilloma/carcinoma Pineal region tumors • Pineal parenchymal tumors (pineocytoma/blastoma) • Germ cell tumors (germinoma, teratoma, etc)
  • 11. Dural-based tumors and mimics • Meningioma • Metastasis • Inflammatory pseudotumor • Infection (e.g., tuberculosis) • Extramedullary hematopoiesis
  • 12.  Local intracranial extension from extracranial neoplasms • Chordoma • Paraganglioma • Carcinomas (e.g., nasopharyngeal squamous cell),sarcomas (rhabdomyosarcoma)
  • 13.  Neoplasms that often have cyst + nodule • Pilocytic astrocytoma • Ganglioglioma • Hemangioblastoma • Craniopharyngioma
  • 14.  30% of hemispheric tumors. Most common cerebral hemispheric tumor  Peak incidence at 7-8yrs age  Low grade astrocytomas more common  Glioblastoma Multiforme (GBM)WHO IV/IV ~ 20%  Typically involve basal ganglia, thalamus  Can be multi-centric
  • 15.  Cerebellum is most common site followed by in and around optic nerve/chiasm, hypothalamus/third ventricle.  Cerebral hemisphere –uncommon.  Cerebellum and cerebralTm: cyst with mural nodule.  Optic nerve/chiasm/third ventricle: solid infiltrating.  Hemorrhage uncommon; if present its pilomyxoid astrocytoma
  • 16. SagittalT2WI shows a mixed solid and cystic focal lesion in the right frontoparietal region (arrows).The solid component of the lesion has intermediate signal, and the cystic component has high signal. Sagittal postcontrastT1WI shows prominent Gd-contrast enhancement at the solid component of the lesion
  • 18.  Differs from PA in clinical course, presentation and histological appearance.  60%- suprasellar, 40%cerebral hemisphere  Cerebellum and fourth ventricle ;rare  Age: Suprasellar- infants and children <4 yrs Atypical location – adolescent and in adults  Imaging: A large H shaped suprasellar mass, mixed SI, heterogeneous enhancement with hemorrhage
  • 20.  First two decades of life, mean age 11 yrs  An enhancing lesion at foramen of Monro should be considered SEGA until proven otherwise.  Calcification,  TSC other feature; SEN, cortical tubers, white matter radial migration lines  SEGA or SEN; progressive enlargement.
  • 22.  Children and young adults, 2/3rd under 18 yr  Well delineated cortically based mass that contacts the leptomeninges  70%; cyst with nodule, 30% solid with intratumoral cysts  Calcification 40%, hemorrhage rare  Moderate enhancement ofTm nodule post contrast
  • 24.  30% of ependymomas  Peak incidence between 1-5yrs age  Histologically similar to infratentorial ependymomas – fourth ventricle and CPA.  Differs! typically in periventricular white matter and cerebral hemisphere parenchyma.
  • 25. AxialT2WI shows a lesion with heterogenous high signal containing a cystic zone in the inferior right frontal lobe. Postcontrast axialT1WI shows irregular peripheral enhancement at lesion.
  • 26.  Arises from subpial astrocytes  Found between1-months age w/peak at 3-6 months. Occasionally seen up to 5yrs  Cortically based tumor nodule.
  • 28.  Imaging findings:  Large cyst w/cortically based enhancing tumor nodule  Solid component avidly enhances; leptomeningeal and dural enhancement, enhancement  Occupies majority of cerebral hemisphere  Looks worse than it is!!  Greater then 75% survival after 15yrs w/complete resection
  • 29.  Cause of 20% cases of medically refractory epilepsy  60% in temporal lobe, 30% frontal lobe  Solid and cystic tumors  Scalloping of inner table skull  Associated w/cortical dysplasia  Slow to No growth!
  • 30. •Multicystic cortically based lesion •25% have calcifications •20-40% enhancement •Characteristic “bright rim”on FLAIR . •Usually no edema, no mass effect.
  • 32. DNET
  • 33.  Found in adolescents  Associated with mesial temporal sclerosis Most common in temporal, parietal, frontal lobes  Difference betweenGG and GC is histological  Clinical: Partial complex seizures
  • 34. Imaging findings: •Solid or cystic or cyst w/mural nodule •Variable enhancement •35% w/calcifications •If peripheral location, then scalloping of adjacent calvarium •Hemorrhage and necrosis absent
  • 38. a AxialT2WI shows a large lesion with heterogeneous high signal in the right frontal lobe extending across the corpus callosum to the left frontal lobe b Postcontrast sagittalT1WI shows irregular enhancement in a portion of the lesion.
  • 39.  occur in the paediatric population, usually during the first 10 years of life,  Circumscribed or invasive lesions. Low to intermediate signal onT1WI; intermediate to high signal onT2WI.  VariableGd-contrast enhancement.  Frequent dissemination into the leptomeninges.  Highly malignant tumors located in the cerebrum,pineal gland, and cerebellum.
  • 40.  2-5% of tumors in children less then 15 yrs  Midline lesion typically in pineal gland, third ventricle  Most are benign
  • 41.  Imaging findings:  Midline mass with calcifications and fat  Enhancement of soft tissue components  Malignant teratomas have more vasogenic edema, irregular, less well defined.
  • 45.  Choroid plexus papilloma /carcinoma  Langerhans cell histiocytosis  Epidermoid/Dermoid  Arachnoid cyst  Metastasis
  • 46.  Arise from epithelium of choroid plexus  5% of supratentorial tumors  Typically age 1-5yrs  Male predominance  Most common in trigone of left lateral ventricle  CPC more irregular and invasive then CPP but diagnosis is histological  Clinical: Hydrocephalus
  • 47.  Imaging:  CPP is lobulated, homogeneous mass with frond like excrescence.  Punctate calcifications, hyperdense on CT  Intense enhancement on CT/MR  CPC irregular, heterogeneous w/cystic necrosis, invasive and vasogenic edema
  • 48. T2 Choroid plexus papilloma Post contratT1
  • 50. Choroid plexus papilloma T2 Post contratT1
  • 53. DWI
  • 54.  Craniopharyngioma  Astrocytoma  Rathke cleft cyst  Germ cell tumors  Hypothalamic hamartoma  Langerhans cell histioctyosis  Pituitary adenoma
  • 55.  Hypopituitarism– craniopharyngioma  Diabetes insipidus – LCH,  Precocious puberty– hamartoma of tuber cinereum, hypothalamic glioma  Amenorrhea– pituitary adenoma, Rathke cleft cyst
  • 56.  Thought to arise from remnant of craniopharyngeal duct.  Adamantinomatous(children) and papillary (adults) types  15% supratentorial tumors, 50% suprasellar tumors  2 peaks: 10-14 yrs age; 4th to 6th decade of life
  • 57.  Rim enhancement of cysts; heterogeneous enhancement solid portions
  • 60.  Benign epithelial lined cyst in sella  Arises from remnants of Rathke pouch in pituitary gland with frequent suprasellar extension.  Rare in children
  • 61. CT: Cystic nonenhancing, noncalcified mass MRI:T1 orT2 hyperintense No enhancement T1 Post contrastT1
  • 62.  Suprasellar type arises from optic chiasm or hypothalamus  M=F 4yrs age  30-50% have family history of NF1  Clinical: Hydrocephalus, decreased vision, pituitary dysfunction (short stature)
  • 63.  Imaging findings:  T2, FLAIR hyperintense  Fusiform or lobulated enlargement optic nerves with heterogeneous enhancement  Gliomas in patients without NF1 have cystic components.
  • 65.  Imaging findings:  MR: Infundibular thickening w/uniform enhancement  Iso to hypointense onT1,T2 and FLAIR  When large, can have areas of cystic necrosis  REMEMBER: HIGH ASSOCIATION W/DIABETES INSIPIDUS!!.
  • 67.  Heterotopic gray matter generally located in tuber cinereum  Can originate from floor third ventricle, mamillary bodies.  Can be sessile or pedunculated  Large lesions cause gelastic seizures; small lesions have precocious puberty  Found in 33% of patients w/precocious puberty
  • 68. MR: Isointense onT1, slightly hyperintense on T2, Non enhancing