Imagistic aspects in craniocerebral pathologies

Imagistic aspects in cerebral neoplasms

The intracranial tumors represents a heterogenic group, being localised especially at the supra- or
infranevraxial level of the brain. The age of occuring is a very important factor especially in the
course of a differential diagnosis. Some brain tumors occur at the age below 2 years, such as
teratomas, choroid plexus papillomas; other brain tumors occur at the age below 10 years, such
as ependimomas, astrocytomas, medulloblastomas or craniopharyngiomas. In the adulthood the
most frequent types of brain tumors ar the metastases, the gliomas, the meningiomas and the
schwanomas. The multiform glioblastoma is characteristic to the elderly people.
The purpose of imaging in cerebral tumors:
- Intracranial pathology confirmation
- Lesion characterization
- Biopsy guiding and determining the therapeutic conduct
- Follow-up.

The MRI is the gold standard tool for diagnosing a brain tumor.

Clasification according to the tumor location:

- intranevraxial tumors in pediatric population: - infratentorial : pilocytic
astrocytoma, ependimoma, brainstem glioma, medulloblastoma
- supratentorial: astrocitoma,
primitive neuroectodermal tumor, dysembryoplasticneuroepithelial tumor
- intranevraxial tumors in adulthood: - infratentorial: - metastases and
hemangioblastoma
- supratentorial: metastases, gliomas
- extranevraxial tumors– derived from adiacent structures of the brain (in the most
frequent cases- schwanomas and meningiomas).

Primary brain tumors:

 3rd GRADE ANAPLASTIC ASTROCYTOMA
 50 year old pacient with headache, dysarthria and confusion
 Left temporal brain tumor with a well-circumscribed shape with a heterogeneous
signal in T2, T1 and Flair, especially when there are necrosis areas and hematic
residues in interior with brain edema and mass effect on the parenchymal tissue
 After contrast enhancement it presents periferic and central heterogeneous
gadolinophilia

AXIAL T2 AXIAL T2
 CORONAL T1 +Contrast AXIAL T1 +Contrast

 74 year patient
with headaches and left hemiplegia
 Heterogeneous tisular mass with central necrotic areas, fluid signal, heamtic
residues, localised in the left frontal lobe with heterogeneous gadolinophilia at the
tisular level, with marked perilesional vasogenic edema with compresive effect on
the lateral ventricle and median shift of the brain parenchyma.

AXIAL T2
 AXIAL T1+Contrast AXIAL T1+Contrast

 4th GRADE GLIOBLASTOMA

 59 year patient with headaches and pronounced fatigability

 Deep tisular mass localised in the right temporo-parietal aspect of the brain at the
level of lentiform nucleus, right posterior arm of the internal capsule, the thalamic
nuclei, the splenium, with an irregular shape, polilobular shape with
gadolinophilia enhancement and hematic residues with vasogenic edema and
median line shift on the parenchymal tissue.

AXIAL T2
 AXIAL T1 +Contrast

 FIBRILLARY ASTROCYTOMA

 40 year patient with headache and a loss of consciousness episode

 On a CT scan performedthereishypodense area in the left frontal cortico-
subcorticalregionwithout mass effect on the parenchymal tissue
withheterogeneous aspect thatincludepartially the leftsuperior frontal gyrus
.It’sshapeisiregullar, heterogeneouswith multiple bloodpetechiae.
 CEREBELLAR MEDULOBLASTOMA
 42 year patient with headaches and vertigo

 On the MRI and CT-scan images the left cerebellar hemisphere presents an
anarchic tissular organization with heterogenous hypersignal in T2, hyposignal in
T1, intensively restricted in DWI/ADC sequences, with nodular gadolinophilia,
mostly emphasized in the perifery in the contact with the cerebellar parenchyma.
The lesion described doesn’t produce cerebellar edema, but has a compressive
effect on the brainstem and the 4th ventricle, with inferior displacement of the
cerebellar amygdala and moderate supratentorial hydrocephalus with
periventricular hypersignalin T2/FLAIR (transependimar edema).
 AXIAL T2
AXIAL T2+Contrast

 CEREBRAL METASTASES
 73 year old patient known with malign melanoma

 On the right periventricular , right frontal, posterior temporal and right temporal
aspect of the brain are highlighted some nodular formations: the frontal one is
heterogenous with hyper-hypo signal in T2, T1, FLAIR with a small restrictive
peripheric bud, with peripheric gadolinophilia, parenchymal edema and compresive
effect on the frontal portion of the right lateral ventricle. The temporal lesions
present hyposignal in all sequences with focal edema and ring-like gadolinophilia.
 AXIAL T2 FLAIR
AXIAL T2

AXIAL T1+Contrast AXIAL T1+Contrast

 43 year old patient known with mammary cancer

 At the level of the left frontal lobe is highlighted o gigantic nodular mass, with
heterosignal in T2, FLAIR and T1, with cetral necrotic areas and hematic residues; the
mass described presents intense gadolinophilia, inhomogeneous especially in the
periphery, on the internal shape of the mass described is highlighted a tissular bud, and in
the proximity of the posteromedial shape there is another nodular mass similar to the
lesion anteriorly described, having an important mass effect on the left lateral ventricle
which appears with a compressed frontal horn and a subfalciform herniation of the
median line structures shifting to the right with a left transtentorial herniation in contact
with the left antero-lateral face of the pons
 AXIAL T2

AXIAL T1+Contrast
 42 year old
patient with malign melanoma, adresses to the emergency room with dyzartria
 On the radiologicfindingsthere are multiple lesions with dense structures and
parenchymal edema, some of them inhomogeneous, localized supra- and
infratentorial.
 68 year old patient known with laryngian cancer adresses the emergency room
for left hemiparesis
 On the radiologic findings there are multiple spontaneous hyperdense nodular
formations, with massive finger-like edema in the right cerebral hemisphere with
an important compression on the right lateral ventricle and a minimum shift of the
cerebral structures to the left and diffuse edema in the right cerebral hemisphere.
 PSEUDOTUMOR LESIONS – CEREBRAL HYDATID CYST
 23 year old patient known with hepatic hydatidosis adresses the emergency room for
headaches, vomiting and blindness.

 On the imagistic findings at the high left frontal aspect there is gigantic mass with fluid
signal, nonrestrictive, with an interior septum; on the postcontrast aspect the lesion
appears with a very fine peripheral load at the lesion wall, without parietal iodophilic
buds or intralesional, with the shift of the adjacent vascular structures.

AXIAL T1+Contrast AXIAL T2

 CT

 MENINGIOMAS
 Non-glima extrenevraxial tumors
 Classified in: - primary intradural

- primary epidural

 Many of them are benign, but a small percentage of them can be malign
 Simptomatology: - asimptomatic
- headaches
- paresthesia

 76 year old patient adresses the emergency room for right inferior limb paresthesias
with a suddenly onset
 On the radiologic findings there is a left high parietal mass very dense on FLAIR,
lightweighted signal on T1 and T2, with a regular shape.
AXIAL T1+Contrast AXIAL T2

 61 year old adresses the emergency room for tonico-clonico ictus, loss of
consciousness followed by temporo-spatial dezorientation and confusion.
 On the radiologic findings there is a multi lobular mass with parenchyma-like
signal in T2/FLAIR, hyposignal in T1, restrictive in DWI and ADC, with heamtic
residues, intense gadolinophilic and at the high frontal level exceedind the median
line.
 AXIAL T2

SAGITAL T1+Contrast AXIAL T1+Contrast

 SCHWANNOMAS

 Benign tumors with axonal sheath origin

 Well circumscribed mass with mass effect on the adjacent structures, without
infiltration or invasion of the parechyma

 64 year old patient adresses the emergency room for a postictal condition
 AXIAL – SCHWANOM VESTIBULO-COHLEAR STANG

 62 year old patient adresses the emergency room for headaches

 On the imagistic findings there is a right ponto-cerebellar angle

extranevraxial tissular mass, light inhomogeneous, spontaneous
hyperdense, with T2 and FLAIR hypersignal, T1 hyposignal as against the
cerebellar parenchyma, with hematic residues localised intralesional .
 AXIAL T1+Contrast
AXIAL T2

IMAGISTIC ASPECTS IN TRAUMATIC

BRAIN INJURIES

The cerebral hemorrhages are classified in traumatic (with or without fractures discernable on
CT-scan or radiography) and non - traumatic (hemorrhagic stroke and the subarachoid
hemorrhage caused by the rupture of a microaneurysm).

 Cranian fractures  
  Caused by a high energy force applied on the bone, that will deform it beyond its
elastic limit.

    Cranian fractures classification:

 According to how the bone is interested (totally or partially): ca be full or partial

(fissures);
 According to the topography: fractures of neurocranium or viscerocranium;
 According to how they communicate with the exterior: can be opened or closed;
 According to the shape: liniar, cominutive, diastatic, depressed in the subjacentstructures;
 According to the disposition of the bone fragments in the fracture locus: can be intrusive
and extrusive (projectile outlet).

 The posttraumatic brain hemorrhagesare:

Extranevraxial:
 Subdural hematoma (SDH)
 Epidural hematoma (EDH)
 Subarachnoid hemorrhage (SAH)

Intranevraxial:

 Hemorrhagic contusions from coup or ”contrecoup’’

 Diffuse axonal injury (DAI)

 50 year old patient addresses the emergency room for headaches and vomiting
started following a traumatic brain injury occurred as a result of a car accident
 On the radiologicfindingsthereis a right mastoid fracture with multiple left
temporal fractures and a left large sphenoid wing fracture.
 33 year old patient addresses the emergency room for an ictal status that produced a
traumatic brain injury
 On the imagistic findings there is a fracture with a ramified right temporal-parietal
trajectory; left frontal-parietal subdural hematoma, hematic contusions and a left frontal-
parietal subarachnoid hemorrhage with diffuse edema in the left cerebral hemisphere.
 HEMATOMAS:

 The epidural hematoma is a hemorrhagic collection formed in the virtual space between
dura mater and the internal plate of the cranium being associated often with cranial
fractures. The hemorrhagic source in most cases is arterial, from a rupture of the middle
meningeal artery.
 The shape is biconvex or lentiform and the CT-scan shows a hyperdense heterogeneous
fluid structure that can or cannot have mass effect.
 31 year old patient addresses the emergency room for a traumatic brain injury
with loss of consciousness followed after a forehead blow
 The CT-scan shows a left frontal epiduralhematoma
 The subdural hematomais a hemorrhagic collection formed in the space between the
dura mater and arachnoid layer often produced after a traumatic brain injury. The CT-
scan shows a crescent-like hemorrhage with hyper intensity.
 68 year oldpatient addresses the emergency room for headache and
confusion.
 The CT-scan shows an acute subdural hematoma in the left T-O aspect.
 The subarachnoid hemorrhage is an acute, sudden bleeding, in subarachnoid space,
most frequently observed after a traumatic brain injury or a ruptured aneurysm. The CT-
scan sensitivity is highly influenced by both the quantity of the blood and of the time
elapsed since the onset of the hemorrhage. The CT-scan shows a hyper intense image that
fills the subarachnoid space.

 77 year old patient addresses the emergency room for a traumatic brain injury
 The CT-scan shows a left high parietal epidural hematoma, with serpiginous
hyper intense spots in the left high frontal, right temporal and left temporal
aspects of the brain, where it associates small hematic petechiae.
 The parenchymatous hematoma is formed in the cerebral hemispheres parenchyma as a
result of a traumatic brain injury. Is characterized by a well circumscribed hemorrhage,
localized in the white matter of the cerebral hemispheres.
 61 year old patient known with hypertension addresses the emergency room for
headache and vertigo
 On the right superficial parieto-occipital aspect is evidentiated an intrecerebral
lesion with T2 and T1 heterosignal, with peripheric edema.
 76 yearoldpatient that presents a right hemiparesis
 The CT-scan showsa left thalamo-capsulo-lenticular intraparenchymatous
hematoma with edema and contact with the 3rd ventricle and minimum
hemorrhage in the posterior horns of the lateral ventricle.
 HEMORRHAGIC CONTUSIONS – are small cortical bleedings produced by coup or
countercoup, most frequently localized in the fronto-basal and temporal anterior aspect of
the brain.
 80 year old patient presents confusion after a traumatic brain injury
 The CT-scan shows hemorrhagic contusions bilaterally fronto-temporal, with
peripheral edema, bilateral fronto-temporal subarachnoid hemorrhage, subdural
hematoma bilaterally in the fronto-temporo-parietal aspect.
 THE CEREBRAL HERNIATIONis reffering to the displacement of the cerebral tissue
from its normal location, in an adjacent space, as a result of a mass effect. Is a life
threatening affliction and requires a prompt diagnostic.
 The cerebral herniation is clasiffied as intracranial or extracranial. An intracranial
herniation can be subfalciform (the most frequent type), transtentorial (ascended or
descended), transsphenoidal or amygdalian. The brain herniation can have
compressive effects on the nerves and arteries of the brain (causing hemorrhage or
ischaemia) or circulatory obstruction of CSF resulting in a hydrocephaly.

Tumoral mass that causes falx herniation with

contralateral displacement of the median line.

Selective bibliography:

 Osborn AG, Heaston DK, Wing SD.

Diagnosis of ascending transtentorial
herniation by cranial computed
tomography. AJR Am J Roentgenol.
Intraparenchymatous hematoma that causes
descending transtentorial herniation (uncal).

1978;130 (4): 755-60.

  W Dahnert. Radiology Review Manual. Lippincott Williams & Wilkins. (2011)
  Provenzale JM. Imaging of traumatic brain injury: a review of the recent medical
literature. AJR Am J Roentgenol. 2010;194 (1): 16-9.
  Davis PC. Head trauma. AJNR Am J Neuroradiol. 2007;28 (8): 1619-21. 
 Lee B, Newberg A. Neuroimaging in traumatic brain imaging. NeuroRx. 2005;2 (2): 372-
83.
 Maas A, Stocchetti N, Bullock R. The Lancet Neurology. 2008;7 (8)
 Diagnostic Imaging. Brain. Anne G. Osborn [et al.], First Edition
 CT and MRI of the whole body. John R. Haaga/ Daniel T . Boll [et al.], Sixth Edition
 https://radiopaedia.org/
 https://radiologyassistant.nl/

 The images are from the personal collection of the Radiology department from SCJU
Sibiu.