Presented By Dr. Shamim Rima M.PHIL RADIOLOGY & IMAGING BSMMU.

BRAIN TUMOUR

Primary neoplasms of the central nervous system (CNS) represent nearly 10% of all tumour reported.

Age Incidence
Cerebral tumours are predominantly tumours of adult life With a peak incidence of 13 cases per 100,000 population at age 55-65. They are relatively uncommon in infants and children at 2 cases per 1,00,000.

BRAIN TUMOUR, Contd.

Primary Tumour Primary intracranial tumour can occur at any age, it is helpful in deferential diagnosis to know that certain tumor occur mainly in certain age groups. Secondary Tumour These affect mainly the middle aged and elderly, with the exception of secondary neuroblastoma which occurs mainly in children.

BRAIN TUMOUR, Contd.

Location
In adults supratentorial tumours out number posterior fossa tumour by a ratio of 7 to 3. But in children this ratio is reversed and posterior fossa tumours are the most common.

DIAGNOSTIC IMAGING

The goals of diagnostic imaging in the Pt. with suspected intracranial tumour include: - Detection of the presence of neoplasm - Localization of the extent of the tumour - Characterization of the nature of the process

Contd ..

DIAGNOSTIC IMAGING 

Plain radiography :
Full skull series include the four views
- Lateral projection

- Occipito frontal projection - Half axial antero posterior (Town s) Projection - Sub mento vertical (base) Projection

Contd ..

DIAGNOSTIC IMAGING: 
CT
- Routine CT examination of the brain and specific area. - Computed tomography cisternography. 

MRI
- Magnetic resonance diffusion imaging

- Magnetic resonance perfusion imaging.
- Magnetic resonance spectroscopy.

Contd ..

DIAGNOSTIC IMAGING: 
Functional Imaging techniques
- Single photon emission computed tomography - Positron emission tomography 

Vascular Imaging
- Conventional intra arterial angiography - Computed tomography angiography - MR angiography - Doppler ultrasound

Contd ..

CLASSIFICATION
Brain tumour may be classified in different ways one of them may be: Primary neoplasm that derived from normal cellular constituents Primary neoplasm that arise from embryologically misplaced tissue Secondary neoplasm from extracranial primary sites that metastasize to the CNS. Non neoplastic condition that can mimic tumour.

Contd ..

CLASSIFICATION OF INTRA CRANIAL TUMOURS:
There are several ways of classifying brain tumours: primary versus secondary intraxial (arising from the brain parenchyma) versus extra axial (arising from tissue covering the brain such as dura) and various regional classification > Supratentorial > Infratentorial > Intraventricular > Pineal region > Sellar region tumours. Contd ..

CLASSIFICATION ACCORDING TO HISTOLOGY

Primary brain tumours are subdivided into two basic groups: Tumours of neuroglial origin (Glioma) Non - glial tumours that are specified by a combination of putative cell origin and specific location. Glial tumors (gliomas) - Astrocytomas Fibrillary astrocytomas Benign astrocytoma Contd ..

GLIAL TUMORS (GLIOMAS)
Astrocytomas : Anaplastic astrocytoma Glioblastoma multiforme Pilocytic astrocytoma Pleomorphic xanthoastrocytoma Subependymal giant cell astrocytoma Oligodendroglioma Ependymal tumours Choroid plexus tumours Contd ..

NONGLIAL TUMOURS
Neuronal and mixed neuronal-glial tumours Ganglioglioma Gangliocytoma Meningeal and mesenchymal tumours Meningioma Hemangiopericytoma Hemangioblastoma Fibrous histiocytoma Contd ..

NONGLIAL TUMOURS
Pineal region tumours Pineocytoma Pineoblastoma Pineal cell tumours Choriocarcinoma Teratoma Germinoma Germ cell tumours

Contd ..

Nonglial tumours

Other cell tumours Benign pineal cysts Astrocytoma Embryonal tumours Neuroblastoma Primitive neuroectodermal tumours (PNET) Cranial and spinal nerve tumours Schwannoma Neurofibroma

NONGLIAL TUMOURS

Hemopoetic neoplasm's Lymphoma Leukemia Plasmacytoma
Pituitary tumours

Contd ..

NONGLIAL TUMOURS

Cysts and tumour like lesions Rathke cleft cyst Dermoid cyst Epidermoid cyst Colloid cyst Enterogenous cyst Neuroglial cyst Lipoma Hamartoma Contd ..

NONGLIAL TUMOURS Contd.
Local extensions from regional tumours Craniopharyngioma Paraganglioma Chordoma According to location Intra axial Extra axial

Points

Intra axial
Within brain parenchyma. Usually not Usually not Effaced

Extra axial
Outside brain parenchyma Yes Yes Often widened Yes

Location Contiguity with bone / flax Bony changes CSF space Corticomedullary buckling

No Destruction Internal carotid artery

GM / WM junction Vascular supply

Preservation External carotid artery

INTRA AXIAL
Primary Glioma Atrocytoma Oligodendroglioma Ependymal tumour Lymphoma Hemangioblastoma Dermoid , epidermoid (rarely) Secondary Metastesis

INTRA AXIAL Contd.
Infratentorial Brainstem glioma Cerebellar astrocytoma Medulloblastoma Ependymoma Meningioma Hemangioblastoma Dermoid

INTRA AXIAL Contd.
Supratentorial Meningeoma Dermoid Epidermoid Pitutary adenoma Pineal region tumour Craniopharyngeoma Chordoma

INTRA AXIAL Contd.
Infratentorial Acoustic neuroma Meningioma Dermoid Chordoma Glomus jugular tumour

OTHER CLASSIFICATION
Pediatric brain tumour Brain stem glioma Optic pathway glioma Medulloblastoma Craniopharyngioma Neuroblastoma Cerebellar astrocytoma Ependymoma

OTHER CLASSIFICATION
Intraventricular tumour Ependymoma Choroid pluxus tumor Colloid cysts Meningioma

CLASSIFICATION

ACCORDING AGE GROUP

YEARS 0-5

CLASSIFICATION Brain Stem Glioma, Optic Nerve Glioma Medulloblastoma, Cerebellar Astrocytoma, Craniopharyngma, Choroid Plexus Papiloma , Pinealoma.

5-15

1515-30 3030-60 60+

Ependymoma Glioma, Meningioma, Acoustic neuroma, Pitutary Tumour, Hemangioblastoma Meningeoma, Acoustic Neuroma, Glioblastoma

CLASSIFICATION ACCORDING TO FREQUENCY

FREQUENCY

CLASSIFICATION
Glioma, Metastasis, Meningioma,

Adult

Pitutary Tumour, Hemangeoblastoma, Lymphoma

Child

Astrocytoma, Medulloblastoma, Ependymoma, Craniopharyngioma

FREQUENCY OF CEREBRAL TUMOURS

Tumour Gliomas Metastases Meningiomas Angiomas Pituitary Adenomas Acoustic Tumours Congenital Tumours Miscellanous

Frequency 31.4 20.3 15.4 5.9 4.4 1.5 2.0 12.3

TUMOUR OF NEUROEPITHELIAL TISSUE

Glioma
Tumours arising from neuroglial cells known as gliomas are most common intracranial brain tumour which comprises 45%- 65% in a series 2/3rd of all brain tumours are primary neoplasm Almost ½ of all brain tumours are glioma ¾ th of all gliomas are astrocytic > ¾ th of all astrocytomas are anaplastic and GBM

ASTROCYTIC TUMOUR
Circumscribed Astrocytoma Juvenile pilocytic astrocytoma Pleomorphic xanthoastrocytoma Subependymal giant cell astrocytoma Diffuse Low grade astrocytoma Anaplastic astrocytoma Glioblastoma multiforme Gliomatosis cerebri Gliosarcoma

WHO CLASSIFICATION

GRADE Grade 1 Grade 2 Grade 3 Grade 4

CLASSIFICATION Pilocytic astrocytoma SGCA(subependymal giant cell astrocytoma) Low grade astrocytoma Anaplastic astrocytoma Glioblastoma multiforme

FEATURES OF LOW GRADE GLIOMA

Age Incidence Location

Younger age group 20-40 yrs 10-20% of astrocytoma cerebral hemisphere frontal and parietel lobe temporal lobe

Histology-

low grade malignancy Seizure

Presenting Symptom -

IMAGING STUDY LOW GRADE GLIOMA

CT NECT : Iso/hypo CECT : Little or no enhancement

IMAGING STUDY LOW GRADE GLIOMA

MRI T1 : Iso/Hypointense T2 : Homogenously hyper

IMAGING STUDY LOW GRADE GLIOMA

PET scan
Fluorodeoxyglucose usually shows reduced uptake compared to the rest of the brain, indicative of hypometabolism

IMAGING STUDY LOW GRADE GLIOMA.

Others

Calcification occurs in 15-20 % cases No perilesional oedema No haemorrhage Mild to moderate mass effect Most are eventually under go malignant degeneration

ANAPLASTIC ASTROCYTOMA

It usually occurs in the middle aged patients Incidence- 20-25% Locations: cerebral hemispheres frontal and temporal lobe Histology- malignant

Presenting Symptom- Seizure, focal neurological deficit

IMAGING STUDY ANAPLASTIC ASTROCYTOMA

CT NECT : Iso/hypo In homogenous mixed density CECT : Enhance strongly, inhomogenously

IMAGING STUDY ANAPLASTIC ASTROCYTOMA

MRI T1: Hypo to iso intense T2 : Heterogenously Hyperintense As typically enhance strongly but non uniformly following contrast administration. Irregular rim enhancement is common

IMAGING STUDY ANAPLASTIC ASTROCYTOMA

OTHER FEATURES
Calcification uncommon

Oedema- perilesional oedema common Haemorrhage may occur Cystic area may present Mass effect Common Histologically malignant

GLIOBLASTOMA MULTIFORME

Half of all astrocytoma are GBM. It is most common supratentorial neoplasm in adult. The most common primary brain tumour, it is also the most malignant astrocytoma Incidence AgeLocationsPresenting symptom40-50%. > 50yrs. cerebral hemisphere, Frontal and temporal lobe, White mater Seizure, Focal neurological deficit, stroke like syndroms

GLIOBLASTOMA MULTIFORME,cont
Infratentorial glioblastoma multiforme is rare and often represents subarachnoid dessimination of supra tentorial origin. Natural historyPrognosisspreads rapidly and diffusely worst prognosis

Median survival is 8 months after operation.

IMAGING STUDY
Imaging study shows multiforme appearance CT NECT : In homogenously mixed density lesion CECT : Enhances strongly, inhomogenously. Ring enhancing lesion due to increased cellularity and neovascularity. Area of central necrosis shows hypodensity

T-1

T-1 C

T-1 C

MRI T1: T1 weighted image shows mixed signal mass with necrosis or cyst formation and thick irregular wall. Marked but in homogenous contrast enhancement is present in majority of glioblastoma multiforme. These tumours are hihgly vascular, haemorrhage of different ages are often present.

MRI T2: T2- weighted image shows very heterogenous mass with mixed signal intensity. Central necrosis is the hall mark. Haemorrhage , necrosis, oedema are present in GBM Angiography A large mass with striking tumours blush, Contrast stasis and pooling in Bizarre vascular channel is typical

IMAGING STUDY Contd.

Other features Calcification uncommon Oedema abundant Mass effect more severe Haemorrhage common

IMAGING STUDY Contd.

Spread Through white mater Sub ependymal seedling Through CSF Rarely through haemtogenous route Extra cerebral metastasis- Lung, Liver, Bone

PILOCYTIC ASTROCYTOMA
This tumour is of grade I of WHO grading Age -most commonly affects the patients in the 2nd decadeof life Site - 2/3rd of pilocytic astrocytoma occurs in cerebellum. 25-30% in the region of optic nerve , chisma, hypothalmus. Remainder in the cerebrum. Generally have benign course because of their lack of invasion and lack of malignant degeneration Better prognosis than infiltrating fibrillary and diffuse astrocytoma.

Pathology
Elongated and fibrillated cells often associated with Rosenthal fiber Eosinophilic granular body common Microcystic area alternate with pilocytic area

IMAGING STUDY

CT
Slightly hypodese to isodense Well-definend core in >50% Cystic component Mural nodule with contrast enhancement Calcification seen in 22% cases Very little or no oedema Mass effect present displaces or compresse 4th ventricle

PILOCYTIC ASTROCYTOMA IMAGING STUDY

MRI Sharply defined macrocystic mass Mural nodule easily identifiable Pronounced contrast enhancement

OLIGODENDROGLIOMA

Arise from a specific type of glial cell- Oligodendrocyte. These are typically unencapsulated but well circumscribed focal white matter tumours that may extent into the cortex and leptomeninges. Foci of cystic degeneration common Hge, necrosis uncommon Incidence 5-10% of gliomas 4th to 5th decade 35-45 yrs. 85% supratentorial Cerebral hemisphere- mostly frontal

Age distributionPeak age Location -

IMAGING STUDY

X-RAY Show characteristic serpigineus calcification.

IMAGING STUDY- OLIGODENDROGLIOMA

CT
NECT- Prominent mass of calcification. Partially calcified mixed density hemispheric mass that extends peripherally to the cortex. CECT- Mild to moderate contrast enhancement occurs

IMAGING STUDY- OLIGODENDROGLIOMA

MRI

T-1

T-1 C

T-2

Heterogenous signal intensity due to calcification T1- weighted image shows mixed hypo or iso intensity lesion T2- weighted image shows hyper intense foci Absent to slight enhancement is typical

IMAGING STUDY- OLIGODENDROGLIOMA

Other features Calcification- occurs in 70-90%, peripherally located, clumped nodules Cysts are common Oedema relatively rare Peritumoural oedema and contrast enhancement is more common in anaplastic astrocytoma Histological feature shows fried egg appearance

EPENDYMOMA
Ependymomas are tumours of the young and are third most common intracranial tumour of children Age distribution1-5 yrs. Incidence2-8% of gliomas 15% of pediatric brain tumour 60% infratentorial more common in children. Location40% supratentorial more common in adult. 4th ventricle, C-P angle, in or near 3rd ventricle

IMAGING STUDY- EPENDYMOMA
CT NECT- Mixed density, isodense or slightly hyperdense Fine calcification seen in approximately 50% of the patients. May have cystic areas CECT- More than 80% contrast enhancement occurs

MRI
T1Heterogenous signal intensity markedly hypointense area due to calcification In homogenous enhancement with gadolinium T2Iso to hyper intensity

Histological feature shows uniform ependymal cells in pattern of rosettes, canal or perivascular pseudorosettes

IMAGING STUDY- EPENDYMOMA 

Other features: Hydrocephalus if in posterior fossa. Fine calcification Headache, nausea, vomiting, papilledema are most common presentation

CHOROID PLEXUS PAPILLOMA

Tumours of choroid plexus are rare, accounting for 0.4-0.6% 0.4of all intracranial tumour Age distribution- > 85% occurs in children distributionin case of children majority of the choroid Location plexus tumour occurs in lateral ventricle In adult most of the choroid plexus papilloma occurs in 4th ventricle

IMAGING STUDY CHOROID PLEXUS PAPILLOMA

CT NECT Iso or hyperdense, 3/4th hyperdense CECT heterogenous contrast enhancement

IMAGING STUDY CHOROID PLEXUS PAPILLOMA
MRI T1 weighted image shows- Predominently isointense showsIntensely contrast enhancement occurs T2 weighted image shows- Iso to hyperintense, showsoccasionally signal void from the vascular pedicle

IMAGING STUDY CHOROID PLEXUS PAPILLOMA

Other features Calcification occurs in 25% cases Hydrocephalus severe Drop metastasis common The imaging differential diagnosis of choroid plexus papilloma In a child CPCs papillary ependymoma medulloblastoma astrocytoma meningioma metastasis

In adult patient

PINEAL TUMOUR
The pineal region is defined as the area of the brain bordered dorsally by the splenium of corpus callosum and the tela choroidea

ventrally by the quadrigeminal plate and midbrain tectum rostrally caudally by the posterior part of 3rd ventricle and by the cerebellar vermis

PINEAL TUMOUR , Cont

The pineal region tumours are rare tumour the incidence of which is 1% of all intra cranial tumour. Types of pineal region tumour are as follows Gemcell tumour Germinoma Teratoma Embryonal carcinoma Choriocarcinoma Pinealoblastoma Pinealocytoma

Pineal cell tumour

PINEAL TUMOUR , Cont

Tumour of supporting cells and adjacent structure Astrocytoma Meningioma Benign pineal cyst Haemangioma Craniopharyngioma Metastic tumour in the pineal region

GERMINOMA

This type of germ cell tumour is most common in the pineal region Incidence Age distribution Consistency 65-72% of all intracranial germ cell tumour 10-30yrs is mainly solid, cystic may be present

Radiological study CT:
NECT- slightly hyperdense Engulfment or displacement of pineal gland is found CECT- Enhancement occurs strongly and uniformly

GERMINOMA RADIOLOGICAL STUDY

MRI

Nonspecific or variable homogeneous masses with signal intensity equal to that of gray matter

T1 T2

hyperintense
homogenous post gd enhancement heterogenous slight hyperintensity

Other features Noncapsulated. Tends to grow slowly by invasion. More radiosesitive. Ependymal spread more common.

TERATOMA
Teratomas derives from all germ layer. These tumour occur mostly in children below 9yrs. Usually within 1st two decade. Origin - two or more germ layers. Age Children . Male predominance.

Imaging study : heterogeneous lesion CT scanContrast CT- Little or no contrast enhancement
Irregular margin

MRITeratoma may be

Nonspecific findings

Mature teratoma Immature teratoma Teratoma with malignant transformation.

PINEO BLASTOMA
This tumour ( PNET) is highly malignant Age distribution -1st and 2nd decade Haemorrhage, calcification, necrosis are common in this type of tumour. Pineoblastoma disseminate through CSF Histologically similar to medulloblastoma and retinoblastoma

Imaging study
CT MRI T 1 weighted image shows hypointense T 2 weighted image shows mixed intensity hyper dense lesion contrast enhancement occurs densely

SELLAR/SUPRASELLAR MASSES
The sellar region is an anatomically complex area composed of the bony sellaturcica, pituitary gland, and adjacent structures

Pituitary adenoma
Older classification Chromophobic Acido philic Basophilic Mixed New classification Pituitary microadenoma (size <10mm) Pituitary macroadenoma (size >10mm)

PITUITARY ADENOMA

Pituitary adenoma is benign slow growing neoplasm. It arises from adenohypophysis (anterior pituitary). Age and sex- more in adult ( < 10% in children) Microadenomas are more common than macroadenoma Pituitary adenoma 75% are endocrinologically active 25% are nonfunctioning, formerly called nonfunctioning tumour or chromophobe adenoma, they are now called null cell adenoma or oncocytoma.

FUNCTIONING PITUITARY TUMOUR
Prolactinoma Somatotrophic tumour(GH secreting) Corticotrophic tumour( ACTH secreting) Mixed Others

Radiological features
Area of haemorrhage, necrosis, cyst formation are less common RI is the most sensitive imaging study for pituitary tumour T 1 weighted image (non contrast) shows hypointense to pituitary gland gland becomes asymmetric gland becomes covex superiorly stalk deviation occurs depression of sellar floor

RADIOLOGICAL FEATURES
After contrast (GD- DTPA) dynamic image is required (GDRapid sequence coronal single slice of T 1 weighted image of sella immediately after I.V. bolus administration of contrast with image obtained consecutively of 10 second interval upto 3 minutes. Hypo intense tumour over 1st 1-2 minute after injection 1On delayed film may mask the presence of tumour T2 weighted image shows focal mild hyper intensity

PITUITARY MACROADENOMA
This type of tumour is usually endocrinologically inactive Incidence- 70Incidence- 70-80% ie twice as common as microadenoma Age distribution of pituitary macroadenoma- 4th to 5th decade of life macroadenomaPituitary macroadenoma becomes symtomatic because of their mass effect- hypo pituitarism, visual problems etc effectMacroadenoma secrets hormone sub unit, so clinically inactive

IMAGING STUDY
X-ray
expansion of sellar cavity thining of bony cortex ballooning of sella

CT
Large, homogenously isodense, rounded midline mass

PITUITARY MACROADENOMA, Cont Extension
Into the suprasellar cystern forming the figure of eight(8 ) Elevate and compress the optic chiasma and 3rd ventricle Laterally into the cavernous sinus May encase the ICA or narrow the vessels Area of haemorrhage, necrosis, cyst formation are common which appear as hypodense within the tumour Acute or subacute haemorrhage causes focal intratumoural hyperdense area Hydrocephalus due to obstruction of foramen monro may occur Calcification is rare

MRI
T 1 weighted image shows hypointense T 2 weighted image shows hyperintensity Extension is better visualized after contrast Both CT and MRI show strong contrast enhancement with some what inhomogenously

MENINGEAL AND MESENCHYMAL TUMOUR

Meningiomas Malignant mesenchymal tumour Hemangiopericytoma Hemangioblastoma

Meningiomas
Meningiomas are most common nonglial primary brain tumour Most common extra axial tumour (13-18%) Age adult tumour 40-60yrs Sex- more in female Cytogenetics-chromosome 22 is important for pathogenesis of meningioma

MENINGIOMAS

Neurofibroma type II is the major predisposing factor for meningioma Origin; Meningioma arises from arachnoid cap cells In children - > 10% becomes multiple

WHO classification
Typical 88-95% Atypical 5-7% Anaplastic 1-2%

Types
globular, flat, compact rounded with invagination of brain Meningioma enplaque Multi centric /multifocal

Location
Cerebral convexity Parasagital Sphenoid ridge Juxtra sellar olfactory groove Posterior fossa Tentorium Pineal region Others optic nerve sheath, intravetrricular 32-45 % 26% 20 % 10 %

10 % 10 %

IMAGE STUDY
X-ray
Hyperostosis Erosion Enlarged vascular channels Tumour calcifications Pneumosinus dilatans

IMAGE STUDY

CT 70% to 75% hyperdense 20% to 25% calcified 90% enhance strongly , uniformly 10% to 15% cystic areas 60% peritumoral edema Hemorrhage rare Area of haemorrhage, necrosis, cyst formation are common which appear as hypodense within the tumour

IMAGE STUDY

Angiography Dual vascular supply common Sunburst of enlarged dural feeders in tumour Extension Into the suprasellar cystern forming the figure of eight(8 ) Elevate and compress the optic chiasma and 3rd ventricle Laterally into the cavernous sinus May encase the ICA or narrow the vessels

IMAGE STUDY -MENINGIOMAS
Area of haemorrhage, necrosis, cyst formation are common which appear as hypodense within the tumour Acute or subacute haemorrhage causes focal intratumoural hyperdense area Hydrocephalus due to obstruction of foramen monro may occur. Calcification is rare

MRI
T 1 weighted image shows hypointense T 2 weighted image shows hyperintensity. Extension is better visualized after contrast. Both CT and MRI show strong contrast enhancement with some what in homogenously

IMAGE STUDY

Other features:
Cystic degeneration may present, Calcification, haemorrhage, Rotational deformity of brain stem, Present with features of extra axial mass

Neurofibroma:
Schwann cell and fibroblast origin, Noncapsulated, Infiltrating, fusiform,

Nerve Sheath Tumour
- Schwannoma - Neurofibroma - Malignant nerve sheath tumour

Schwannoma
Benign tumour of schwann cell origin related to cranial nerves. -90% are solitary -Multiple Schwannoma are associated with neurofibromatosis type 2 90% of intracranial schwannomas are located in the cerebello pontine angle originating from VIII cranial nerve- acoustic neuroma. Age- 40-60 yrs. Sex- female preponderance

All the cranial nerves except olfactory and optic nerve, are partially composed of schwann cells so are potentially site for schwannoma Most arises at the site where axonal sheath switches from glial to schwanncell origin Most common schwannoma vestibular schwannoma, Trigeminal nerve

Other intracranial sites- infratemporal, jugular foramen and bulb. Clinical feature depends upon specific nerve involvement and size Vestibulo-cochlear nerve- Tinnitus, sensory neural hearing impairment Trigeminal nerve- Facial sensory impairment, ataxia, exoph thalmos, diplopia, corneal reflex loss

RADIOLOGICAL STUDY
Mass causes >2 mmdifference between right and left I.A.C (Internal acoustic canal) Erosion and flattening of I.A.C. I A C > 8mm

CT
NECT - Is to slight hypodense CECT Small tumour uniformly enhances

MRI
More sesitive than CT T 1 weighted image- 2/3rd slightly hypointense, 1/3rd iso intense

RADIOLOGICAL STUDY

T 2 weighted image mild to markedly increased signal intensity. After contrast- intense enhancement Homogenous- 62% small Heterogenous- 22% large Extension of cerebello pontine angle tumopur into IAC causes cone ice cream appearance

RADIOLOGICAL STUDY

Other Features
Cystic degeneration may present, Calcification, haemorrhage, Rotational deformity of brain stem, Present with features of extra axial mass

Neurofibroma
Schwann cell and fibroblast origin, Noncapsulated, Infiltrating, fusiform

Point
1. Pathology

Schwannoma
Schwann cell origin Encapsulated Focal, Round Cyst, Hge, necrosisnecrosiscommon Malignant degeneration not NF2 Common 40-60 Yrs 40Cranial nerve esp. CN VIII Sharply delineated Heterogenous T1-70% -Hypo 30% -ISO intense T2- Hyper intense EnhancementEnhancement- strong

Neurofibroma
Schwann cell + Fibroblast Uncapsulated Infiltrating, Fusiform Rear Malignant degeneration- 5 degenerationto 10%

2. ssociation 3. Incidence 4. Age 5. Location 6. Imaging

NF1 Uncommon Any age cutaneous and spinal nerve Poorly delineated, infiltrating Homogenous T1- mostly ISO intense T2- Hyper intense EnhancementEnhancement- moderate

CEREBELLOPONTINE ANGLE (CPA) CISTERN MASSES

Normal Anatomy
The cerebellopontine angle (CPA) cistern between the anterolateral surface of the pons and cerebellum and the posterior surface of the petrous temporal bone. Important structures within the CPA cistern include the fifth, seventh, and eighth cranial nerves, the superior and anterior inferior cerebellar arteries, and tributaries of the superior petrosal veins

CEREBELLOPONTINE ANGLE (CPA) CISTERN MASSES

Normal Anatomy

The majority of CPA tumours in adults are extraaxial. Imaging findings that distingush extraaxail from intraaxail masses include the following: 1.Enlarged CPA cistern. 2.A CSF cleft between the mass and adjacent brain . 3. Brainstem rotation. 4. Displaced cerebellar hemisphere cortex.

CEREBELLOPONTINE ANGLE (CPA) CISTERN MASSES

Common CPA masses
- Vestubular schwannoma (acoustic neuroma) - Meningioma - Epidermoid - Other schwannoma

Less common
- Arachnoid cyst - Metastases - Vascular - Lipoma - Dermoid.

CEREBELLOPONTINE ANGLE (CPA) CISTERN MASSES

Intraventricular Tumour

One tenth of all CNS tumour involve the ventricle. Imaging characteristics are usually nonspecific; exact location of the mass and age of the patients are the most helpfull information in the diagnosis of these lesions

INTRAVENTRICULAR MASSES IN ADULT

In Lateral Ventricle
- Astrocytoma(anaplastic, glioblastoma) - Central neurocytoma. - Subepedymoma. - Oligodendroglioma. - Choroid plexus papilloma. - Meningioma. - Metastases

Foramen Of Monro/Third Ventricle
- Colloid cyst - Central neurocytoma - Astrocytoma Extrinsic mass- pituitary adenoma, aneurysm, germinoma

INTRAVENTRICULAR MASSES IN ADULT

Aqueduct/Fourth Ventricle
- Midbrain glioma - Metastases - Subependymoma - Haemangiblastoma

INTRAVENTRICULAR MASSES IN CHILDREN
1. Lateral ventricle Choroid plexus tumour. PNET Astrcytoma Ependymoma 2. Third ventricle. Craniopharyngioma Subependymoma Germinoma 3. Fourth ventricle Pylocytic astrocytoma Medulloblastoma Ependymoma Exophytic tumour

Aqueduct/Fourth Ventricle
- Midbrain glioma - Metastases - Subependymoma - Haemangiblastoma

COLLOID CYST

A cystic tumour arising from an embryological remnant in the anterior roof of 3rd ventricle. It is neuro epithelial cyst comprises 2% of all glioma and 0.5-1% of all intracranial tumour. Site- most commonly found in the 3rd ventricle but may in septum pellucidum. Age- usually 20-50 years. Pathogenesis- comprises of fibrous epithelial lined wall filledwith either mucoid or dense hyaloid substance. Colloid cyst is slow growing, benign tumour. It blocks the foramina of Monro causing obstructive hydrocephalus involving only the lateral ventricle. Although it is a slow growing benign tumour, there is risk of sudden death.

COLLOID CYST

Presentation
Most commonly presents with intermittent acute intracranial hypertension due to episodic obstruction of foramen Monro. Most clinically significant cysts are > 1.5 cm in diameter. Sudden death may occur due to acute blockage of C.S.F flow resulting herniation

Radiological Findings
Lesion is situated in the anterior 3rd ventricle causing obstruction of foramen of Monro and dilatation of lateral ventricle

COLLOID CYST

CT Scan Of Brain
Findings are variable. Most cysts are hyper dense ( 2/3rd ), 1/3rd are isodense. A well delineated round or ovoid non calcified anterior 3rd ventricular mass. Enhancement, following contrast administration is usually absent.

M.R.I.
The most common appearance is a mass that is hyperintense on T1 and hypointense on T2. The signal intensity of colloid cyst vary widely. Rim enhancement on contrast administration is observed in some cases

COLLOID CYST

Rathke Cleft Cyst
Etiology
Primitive stomodial remnant(Rathke pouch). Pathology:Cyst with variable contents. Columnar, cuboidal or squamous epithelium

Age and gender
Any age but mostly adult. Female: Male 2-3: 1.

Location
70% both intra sellar and suprasellar, 20-25% intrasellar and <5% completly suprasellar

MEDULLOBLASTOMA

Most common malignant pediatric brain tumour. Incidence: 15-20% of intracranial tumour in children. Male: Female 2:1. Age: most in 1st decade. 75% in 4-8 years. Site: 75% arises in the cerebellar vermis mostly in midline, in the apex of 4th ventricle. 25% arises in lateral cerebellum. Highly radiosensitive and moderately chemo sensitive. Metastasis occur early in the CSF. Prognosis is very poor

MEDULLOBLASTOMA

Radiological study
CT scan of brain: Rounded or ovoid, mainly homogenous iso to slightly hyper dense mass. Obstructive hydrocephalus is common. calcification occurs in 15% patients Moderately strong, relatively homogenous enhancement is seen following contrast administration. Typical medulloblastoma fills the 4th ventricle and extends through foramen of Magendie in to the cysterna magna. T 1 weighted image shows heterogeneous hypointense, cyst in 7580%. T 2 weighted image shows hypo to hyper intense. Contrast enhancement is variable. Moderately enhancement which is heterogeneous in nature. Many medulloblastoma shows partial enhancement following contrast administration.

CRANIOPHARYNGIOMA
Craniopharyngiomas arise from the squamous epithelial rests along the involuted hypophyseal Rathke s duct. Incidence: 3-5% of primary brain tumour. 50% of pediatric brain tumour. Age: > 50% in children, peak between 8-12 years. Location: 70 % combined suprasellar and intrasellar

Imaging study
CT scan of brain90% partially cystic, 90% calcification present, 90% nodular or rim enhancement occur

MRI of Brain
Variable signal, most common is hypointense in T 1 weighted image and hyperintense in T2 weighted image

INTRACRANIAL METASTASES

Representing 1/4th to 1/3rd of all brain tumour. Common: Skull Leptomeninges Parenchymal (most common). Less common: Dural Pial Sub pial Parenchymal metastases: Location any where but most common in cortico medullary junction ( grey mater- white mater interface).

INTRACRANIAL METASTASES

Pathology
Welldefined circumscribed nodule of variable size May be solid partially cystic, filled with mucinous material, necrotic material, haemorrhagic fluid.

Imaging Study
CT: NECT- mostly isodense lesion / hyperdense lesionExample-Thyroid carcinoma, Lung carcinoma,choriocarcinoma, malignant melanoma, sarcoma

INTRACRANIAL METASTASES

Cystic metastasis
Mucin producing tumour adenocarcinoma arising from stomach, small and large intestine, pancreas, ovary,breast cancer

Cystic and calcified metastasis
Rare- breast carcinoma, lung cancer. CECT:Most enhance strongly, both solid and ring shaped pattern are noted

MRI
T 1 weighted image-shows variable features most non haemorrhagic tumour slightly hyper intense. Some non haemorrhagic tumour hyper intense

INTRACRANIAL METASTASES

MRI

T 2 weighted image - Most are hyper intense with iso intense rim Some are hypointense on T 2 W image mucin secreting tumour from adenocarcinoma of G I T. After contrast, most enhances strongly. Solid, rim, mixed enhancement are seen. High dose contrast (0.2-0.3 mmol/kg) normal 0.1 mmol/kg more sensitive and helpful for identification of early, small, additional foci.

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