Brain tumor

CLINICAL IMAGING CENTER, 1ST AFFILIATED HOSPITAL OF JINAN

UNIVERSITY.
LIU XIAODAN
Brain tumor
Analysis of a potential brain tumor
Age of the patient
Localization: intra- vs extra-axial? What compartment? Midline crossing?
CT and MRI characteristics

Calcification, Fat, Cystic

T1WI, T2WI, DWI
Contrast enhancement
Effect on surrounding structures: Mass effect, edema
Solitary- Multiple
Pseudotumor
 Brain tumor
 Roughly one-third of CNS tumors are metastatic
lesions, one-third are gliomas and one-third is of non-
glial origin.
 Glioma is a non-specific term indicating that the tumor
originates from glial cells like astrocytes,
oligodendrocytes, ependymal and choroid plexus cells.
 Astrocytoma is the most common glioma and can be
subdivided into the low-grade pilocytic type, the
intermediate anaplastic type and the high grade
malignant glioblastoma multiforme(GBM)
 The non-glial cell tumors are a large heterogeneous
group of tumors of which meningioma is the most
common
 Brain tumor
 Age distribution
Brain tumor
Intra- vs extra-axial tumor
When we study the intracranial mass, the first thing we want to know
is whether the mass lies in- or outside of the brain.
If it is outside the brain or extra-axial, then the lesion is not actually a
brain tumor, but derived from the lining of the brain or surrounding
structures.
8% of extra-axial lesions will be either a meningioma or a
schwannoma, on the other hand, in an adult an intra-axial tumor will be
a metastasis or astrocytoma in 75% of cases.
Brain tumor
Signs of extra-axial location
CSF cleft
Displaced subarachnoid vessels 。
Cortical gray between mass and white matter
Displace and expand subarachnoid space
Broad dural base
Bony reaction
• CSF cleft (yellow arrow).

• The subarachnoid vessels

that run on the surface of
the brain are displaced by
the lesion (blue arrow). 

• There is gray matter

between the lesion and
the white matter (curved
red arrow). 

• The subarachnoid space is Schwannoma located in the cerebellopontine angle

widened because growth of an (CPA).
extra-axial lesion tends to push
away the brain
• Broad dural base or a dural
tail of enhancement
(red arrow)

• Bony changes: there is hyperostosis in

the adjacent bone(blue arrow)

meningioma
Glioma
Glioma is a non-specific term used to describe a group of tumors that
arise from glial cells, such as astrocytes (astrocytoma is the commonest
tumor type)
Astrocytoma
Locations: All the brain tissue

Brian stem
Spinal cord
Age: from infant to the elderly
 M ， 30y ， seizure
Astrocytoma

Low grade glioma

CT: iso-dense to the brain parenchyma or
hypodensity
MRI: T1WI: hypointensiy, T1WI T2WI

T2WI: hyperintensity, similar to

brain edma
No enhancement by contrast medium

T1+C T2WI
 Oligodendroglioma
 CT: like low grade astrocytoma,
but always contains calcification CT
 MRI ：

T1WI: mild hyperintensity,

no/mild enhancement by Gd-
DTPA
T2WI: hyperintensity
The calcifications are showed
hypointensity on T1WI and
T2WI

T2WI T1+C
Glioblastoma multiforme(GBM)

 CT and MRI ：
Always very big size
midline crossing
Ill-defined outer margin
Strong enhanced with irregular
central necrosis(cauliflower
pattern)
Peripheral white matter edema
Meningioma
 Meningiomas are the commonest non-glial extracranial tumor and arise
from the meninges of the vault, falx or tentorium
 The commonest sites are the parasagittal region, over the cerebral
convexities and the sphenoid ridges.
 The World Health Organization (WHO) classifies meningiomas into 15
subtypes under 3 major categories:
Grade 1 (typical or benign), representing 88-94% of cases
Grade II (atypical), representing 5-7% of cases
Grade III (anaplastic or malignant), representing 1-2% of cases
 Meningioma
 CT: often denser than the brain parenchyma.
Calcification is common finding
Occasionally, the edema is extensive.
 MRI:
T1WI and T2WI ： Equal to cortical gray matter(most)
Variable, it depends on the component, such as
necrosis, hemorrhagic products, cyst.
 Contrast CT/MRI
Intense homogeneous enhancement(90%), inhomogeneous enhancement due to the
necrosis or rare hemorrhage; dural tail sign
 Bony changes: underlying bone hyperostosis in 15-20% patients.
 Meningioma
Plain CT(bone setting) Contrast CT

dural tail sign

Contrast CT shows homogenous enhancement mass

Plain CT shows a cribriform plate meningioma with circle located in the parietal lobe with dural tail sign.
calcification. Underlying bone hyperostosis on a coronal CT scan with
bone window settings.
Nonenhanced CT shows a malignant CT
meningioma in the frontal convexity that
appears as a spontaneously
hyperattenuating mass with necrosis,
hemorrhage, cystic degeneration. Edema
and midline shift to the left anterior aspect
are also present.

Contrast CT shows inhomogeneous

Contrast CT
enhancing mass with ring-shaped
enhancement.
Nonenhanced axial MRI demonstrates a typical
parasagittal meningioma.
T1-weighted image shows a homogeneous, long-T1,
round mass with thin capsule. The tumor is attached to the
left side of the falx.
Coronal T2-weighted image demonstrates isointense and
inhomogeneous tumor without peripheral edema indicates
a more fibrous and harder character (ie, a fibroblastic
meningioma).

Contrast-enhanced T1-weighted axial magnetic resonance

image demonstrates a typical parasagittal meningioma. A
homogeneous, enhancing, globose mass with dural tail
sign is depicted.
Acoustic neuroma

 The term “acoustic neuroma” is a misnomer as they are

schwannomas that arise from the vestibular branch of the
vestibulocochlear nerve

 Vestibular schwannomas typically arise on the nerve within

the internal auditory canal and may extend out medially into
the cerebellopontine angle.
Classic vestibular schwannoma

 Ice cream and cone

 Larger, homogeneous enhancing CPA
mass
 Smaller funneled IAC component
 Widening of porus acousticus
Vestibular schwannoma
 Large CPA component
(1)may impinge on facial or trigeminal nerves
(2) compress pons or produce 4th ventricular
obstruction

 Bilateral
vestibular schwanomas can be
diagnosed of II type neurofibroma
 Vestibular schwannoma
 LargeCPA-IAC vestibular schwannomas may have cystic CPA
component. Differentiate cystic degeneration from extrinsic arachnoid
cyst

Vestibular schwannoma with Vestibular schwannoma with

intramural cyst arachnoid cyst
 Pituitary tumors

 Pituitary
tumors are divided into
macroadenomas (>1cm) and
microadenomas(<1cm).

 Pituitarymacroadenomas usually extending

superiorly, indentation at the diaphragm sella
can give a snowman appearance
 Pituitary macroadenoma
 CT: typically have attenuation similar
to brain. Sometimes attenuation can
vary depending on haemorrhage, cytic
and necrotic component
 MRI

T1WI and T2WI ： typically

isointense to gray matter
 Contrast:
Solid component
demonstrates moderate to bright
enhancement
Pituitary macroadenoma
 They may compress the optic chiasm and also laterally into the
cavernous sinuses.

Contrast CT shows pituitary macroadenoma with Coronal T1WI shows pituitary macroadenoma
cavenous sinus invasion compress the optic chiasm
 Pituitary microadenoma
 Small, round tumors embedded in the parenchyma of the
pituitary gland.
 Typically isoattenuating or hypoattenuating relative to the
adjacent normal pituitary gland.
 They may not be visible on nonenhanced scans.
Enhancement after the administration of contrast material
occurs but is delayed compared with the immediate,
intense enhancement of the normal pituitary gland. This
effect is due to the absence of a blood-brain barrier while
the adenoma remains hypoattenuating.
 Therefore, about two thirds of microadenomas typically
appear hypoattenuating on dynamic contrast-enhanced
CT/MRI scans.
 Patients usually presents hyperprolactinemia
Pituitary microadenoma

• Dynamic contrast-enhanced MRI

scans ：
After inject contrast medium 30-60min
is the best time to observe the
microadenoma. The contrast
enhanced intensity is lower than the
normal pituitary
Brain metastasis
 Brain metastases are account for approximately 25-30%of intracranial tumors in
hospital patients.
 80% of brain metastases can be accounted for by five primary tumors

1.lung cancer; 2.renal cell carcinoma; 3. breast cancer;

4.melanoma;
5.gastrointestinal tract adenocarcinomas(the majority colorectal
carcinoma)
 80% of metastases localize to the cerebral hemispheres, 15% localize to the
cerebellum and 3% localize to the basal ganglia. Often these tumors can be
found at the gray/white matter junction.
 Brain metastasis
 Brainmetastasis are typically multiple.
 CT ： low density, often surrounded by substantial oedema. If with
haemorrhage shows hyper intensity.
 Contrast: ring-like enhancement
Brain metastasis
 Brain metastasis
 Solitary brain metastasis are hard to differentiate from other intracerebral primary lesion,
such as GBM, lymphoma, abscess.

• Metastasis located in the gray-white matter junction less involve

the deep brain, GBM located in the subcortical white matter,
Extends to ependymal surface
• Metastasis is typically sphere and well circumscribed. GBM have
more complex shape(less spherical) Abscess shows central restricted diffusion
Take home message

 Master the manifestation of common tumors (glioma,

meningioma, pituitary tumor, acoustic neuroma, brain
metastasis) on CT and MRI scan.