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Cerebellar cyst a case on mri

It is simple analysis for a case with signs of cerebellar dysfunction

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Cerebellar cyst a case on mri

  1. 1. Cerebellar cyst: A case on MRI Dr Rekha khare MD. Radiology
  2. 2. Case presentation • A young asian man about 22year came for MRI • Clinical presentation was in favor of Cerebellar dysfunction : Ataxia/ incordination/ gait disturbance Headache
  3. 3. Investigations • His routine lab investigations Blood & Urine were with in normal limit • MRI findings in different sequences: A large left cerebellar cystic mass with non enhanced wall. Cyst is with a small mural nodule vividly enhanced and with flow voids. Cyst is crossing midline and compressing IV ventricle so causing dilatation of 3rd and lateral ventricle Impression: left cerebellar cyst crossing midline and causing hydrocephalus
  4. 4. T2 sequence axial
  5. 5. T2 axial contd.
  6. 6. T2 axial contd.
  7. 7. T1 sequence axial
  8. 8. T1 axial contd.
  9. 9. T1 axial contd.
  10. 10. Flair sequence
  11. 11. Flair contd.
  12. 12. Flair contd.
  13. 13. GRE sequence
  14. 14. GRE contd…
  15. 15. GRE contd.
  16. 16. T2 sequence sagittal
  17. 17. T2 sagittal contd.
  18. 18. T2 sagittal contd.
  19. 19. T2 sagittal contd.
  20. 20. T1 sequence with contrast
  21. 21. T1 with contrast contd.
  22. 22. T1 with contrast contd.
  23. 23. D/D Cerebellar cyst • Haemangioblastoma • Astrocytoma • Sub acute infarction • Vascular lesion • Adult Meduloblastoma – rare much more solid • Metastasis –usually old with primary
  24. 24. Haemangioblastoma Cushing and Bailey introduced the term Haemangioblastoma in 1928 Clinical symptoms: Headache-70% Hydrocephalus /ICH- 50% Cerebellar dysfunction- 50-60% altered mental state-10% Polycythemia due to erythropoietin production occurs in 5-40% SYMPTOMS DEPENDS ON ANATOMIC LOCALIZATION
  25. 25. Haemangioblastoma • It accounts for 1% of all intracranial tumor, in isolation in 80% but is linked with Von Hippel Lindau syndrome • Most common in cerebellum • In adult between 30-65% earlier withVHL • Male : Female :: 1.3- 2.6
  26. 26. Site Haemangioblastoma • Intracranial – 87-97% 95%------ posterior fossa 85% ----- cerebellar hemisphere 10% -----cerebellar vermis 5% -------medulla 5% -------supratentorial Rarely up to CP angle • Spinal – 3-13%
  27. 27. Histo-pathology Haemangioblastoma • Mural nodule with cyst wall not demonstrating tumor involvement in most cases • Fluid of cyst often xanthochromatic • Micro-vascular tumor composed of thin walled vessels with surrounding stroma of connective tissue
  28. 28. Haemangioblastoma on CT • Cyst with nonenhancing wall • Vividly enhanced mural nodule often has prominent serpentine flow voids • Calcification is not a feature • Relatively mild edema and mass effect ** Mistaken for a low density glioma or gliomatous cyst unless the mural nodule is identified in post enhanced scan
  29. 29. Haemangioblastoma on MRI • T1- Fluid filled cyst Hypo intense to isointense mural nodule vividly enhancing • T2- Fluid filled cyst like CSF Hyper intense mural nodule , flow voids due to enlarged vessels at the periphery to cyst
  30. 30. Haemangioblastoma on angiography • Enlarged feeding arteries often dilated draining veins are demonstrated with dense tumor blush centrally
  31. 31. Von-Hippel Lindau disease • It is autosomal dominant hereditary syndrome first described in 1926 by Arvid Vilhelm Lindau • Patient may present with-- 1. cerebellar dysfunction- ataxia and in coordination with or without hydrocephalus 2. Long H/O minor neurological problem or sudden exacerbation
  32. 32. VHL contd….. • VHL includes retinal angiomatosis, CNS haemangioblastoma and various visceral tumors most commonly involving the kidneys and adrenal gland • This syndrome is classified as PHAKOMATOSIS although it does not include any cutaneous manifestation. • It’s dominating mode of transmission compels performing alerts screening of family members of patient diagnosed with VHL
  33. 33. Diagnostic work up VHL • Family history • Detailed funduscopy • Haematocrit & RBC count • MRI with contrast • Arteriography with DSA • Spinal Angiography if spinal lesion on MRI • Urine for Metanephrine- if +ve then 24 hrs VMA • Abdominal CT scan esp. for pancreas, renal and suprarenal
  34. 34. Vascular lesion • Arterio -venous malformation • Cavernoma Both with or without bleed, confirmed on Angiography
  35. 35. Astrocytoma • Pilocytic astrocytoma- in children • GBM - in adults • Ependymoma
  36. 36. Pilocytic astrocytoma on MRI Iso-Hypointense solid component compared to adjacent brain on T1 and significantly Hyper intense solid component on T2
  37. 37. Ependymoma on MRI • Typically heterogenous mass in all modalities Area of necrosis, calcification, cystic changes and hemorrhage frequently seen
  38. 38. Diagnosis of our case • On the basis of MRI imaging and clinical picture most suggestive diagnosis of our case is Haemangioblastoma • Patient has been referred to specialist
  39. 39. Brain Tumor: Systemic approach For analysis of potential brain tumor Questions that need to be answered 1. Age of the patient 2. Localization- intra versus extra axial Which anatomical compartment Mid line crossing 3. CT or MRI- calcification, fat, cystic 4. Contrast enhancement 5. Effect on surrounding structure- mass effect, edema 6. Solitary or multiple 7. Pseudotumour
  40. 40. References • Haemangioblastoma-Central nervous system Dr Bruno Di Muzio and Dr Frank Gaillard et al radiopaedia.org/article/ • Haemangioblastoma: Medscape Reference emedicine.medscape.com/article • Haemangioblastoma: wikipedia.org/wiki/haemangioblastoma • Brain tumor: systemic approach Robin Smithnis and Walter Montanera Radiology Assistant
  41. 41. References contd….. • Haemangioblastoma: Neuroradiology neuroradiology.ws/haemangioblastoma.htm • Cerebellar haemangioblastoma: An unusual cause of syncope eradiology.bidmc.harvard.edu/learning lab/mohamed.pdf • Tumors of uncertain histogenesis- haemangioblastoma Text book of Radiology and Imaging vol 2 David Sutton
  42. 42. Have a good time

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