APPROACH TO

CEREBELLOPONTINE
ANGLE LESIONS
CPA
• A wedge shaped extra-axial CSF -filled subarachnoid
cistern that lies between cerebellum and pons.
Contents
• CN VI, VII, VIII
• flocculus of the cerebellum
• foramen Luschka/ choroid plexus
• anterior inferior cerebellar artery (AICA), superior cerebellar artery
(SCA)
• CN V lies superior to/at the superior aspect of the space
• CN IX, X, XI lie inferior to/at the inferior aspect of the space
• middle cerebellar peduncle
CP ANGLE LESIONS
• Vestibular schwannoma
• Meningoma
• Epidermoid and dermoid cyst
• Arachnoid cyst
• Metastasis
• Vascular lesions
• CP angle lipoma
• Other nerve schwannoma
• Endolymphatic sac tumor
• Lesions of the cerebellopontine angle (CPA) are frequent and
represent 6–10% of all intracranial tumors.
• Vestibular schwannomas and meningiomas are the two most
frequent lesions and account for approximately 85–90% of all CPA
tumors
Vestibular schwannomas
• nearly 8% of intracranial tumors in adults
• The patients usually are in their 40s–60s
• 80 to 90% of tumors of CP angle.
• Typically they present with adult-onset
unilateral sensorineural hearing loss or tinnitus.
• Bilateral vestibular schwannomas are pathognomonic for
neurofibromatosis type 2 (NF2)
• These are generally benign and slow growing tumors with
rare malignant degeneration when associated with NF-1
Pathology
• Vestibular schwannomas arise
from perineural elements of the
Schwann cell and are similar in
pathology to other peripheral
schwannomas.
• Histologic examination of
schwannomas reveal compact
Antoni Type A tissue and loose
textured, often cystic, Antoni
Type B tissue.
• Antoni A tissue consists of densely packed palisades of fibrous and
neural tissue -darker signal on T2WI.
• Antoni B tissue is a loose myxomatous tissue -brighter on T2WI.
• Depending on amount of Antoni A and B tissue within schwannomas-
variable SI may be brighter than /or simulate meningioma.
• Malignant schwannomas may be seen in patients with NFI
• Degree of IAC widening and the tumor extent ventral and caudal to
the IAC on NCCT can predict postoperative hearing loss.
 CT
• On noncontrast CT, these lesions usually are isodense or
hypodense to adjacent brain.
• They are seen at the porus acusticus, which may be
widened.
• CT detection of a small intracanalicular lesion without
associated bony changes may be difficult
• Large lesions extend to and fill the CP angle cistern and
may displace and distort the brain stem.
• Enhancement of these lesions is fairly intense and usually
homogeneous, although large lesions may show
inhomogeneous enhancement.
• Calcification is extremely rare and a hemorrhagic lesion is
rarely seen
MRI
• On T1-weighted images these lesions are isointense to hypointense to brain.
• On T2-weighted images they are hyperintense and may be inhomogeneous.
• The inhomogeneity may reflect cystic degeneration, hemorrhage, or vascularity of the
lesion.
• Often these lesions are rather round or oval in their cisternal portion, and they taper
as they extend into the internal auditory canal (IAC).
• The relations of the lesion to the brain stem, fifth cranial nerve, and lower cranial
(ninth, tenth, and eleventh) nerves may be seen best on good-quality coronal and
axial thin sections.
• Rarely there is sufficient deformity of the fourth ventricle to produce hydrocephalus
• At times part of the tumor may be cystic, or there may be an associated arachnoid cyst
adjacent to tum
(a)Axial T1-weighted MR image shows
low to intermediate signal intensity
of the mass (arrows).

(b) Axial contrast-enhanced fat-

suppressed T1-weighted MR image
shows avid enhancement of the mass
(arrows), which has an internal
nonenhancing cystic focus.
Imaging
• On imaging, vestibular schwannomas are seen
as enhancing CPA mass lesions with variable
extension into the internal auditory canal in
most cases, resulting in the description of an
‘‘ice-cream cone’’ tumor.
• The intracanalicular component often causes
widening of the porus acusticus resulting in the
trumpeted IAM sign in up to 90% of cases.

• Generally, a small “CSF cap” is present between

the intracanalicular component and the cochlea.
• c) Axial T2-weighted MR image shows
heterogeneous high signal intensity of
the schwannoma (straight arrows). The
mass enlarges the porus acusticus
internus (arrowheads) and exerts a mass
effect on the brainstem (*) and middle
cerebellar peduncle (curved arrows),
with a disproportionately small amount
of edema, given the size of the mass.

• (d) Axial gradient-recalled-echo MR

image shows the schwannoma (straight
arrows) with foci of susceptibility
artifact (curved arrows), which indicate
intratumoral microhemorrhage.
Schwannomas: A patient of
neurofibromatosis 2 with bilateral
acoustic schwannomas and right
facial nerve schwannoma in region of
geniculate ganglion.

These lesions are isointense on T2WI

(A) and shows
homogenous enhancement on contrast
administration (B).
• The low T2 acoustic schwannomas have a predominance of the
Antoni Type A tissue.
• Large tumors have predominant Antoni Type B tissue and appear
heterogeneous secondary to presence of regions of internal
necrosis/cyst formation
Acoustic Schwannomas: Axial T2
(A) image shows an iso-
hyperintense CPA mass with
extension into IAC,
areas on susceptibility on SWI
(B) and heterogeneous
enhancement (C). Cystic acoustic
schwannomas
with multiple septations and
fluid-fluid levels on T2WI (D),
extension into IAC and
heterogeneous enhancement (E
and F).
FIGS.
• Peritumoral cysts are also associated (7 to 10%) with large lesions-
believed to be secondary to elevation and deformation of the
leptomeninges.
• Some patients who have vestibular schwannomas larger than 2 cm in
diameter demonstrate a tiny area of hyperintensity in the dorsal brain
stem on T2WIs at the lateral angle of the fourth ventricular floor.
• This may represent degeneration of the vestibular nucleus and should
not be confused with infarction
• Contrast-enhanced T1-
weighted axial magnetic
resonance image through the
internal auditory canal shows
a heterogeneously enhancing
intracanalicular-cisternal
vestibular schwannoma
(white arrow). Anterior to the
schwannoma, a tumor-related
cyst is depicted (black
arrow).
Contrast-enhanced T1-weighted
magnetic resonance image at the
level of the internal auditory canal
shows a strongly enhancing cisternal
vestibular schwannoma (arrow) that
compresses the adjacent pons and
cerebellum and distorts the fourth
ventricle.
Vestibular schwannoma. Axial
contrast-enhanced T1-
weighted magnetic resonance
image shows an
intracanalicular mass (arrow).
• Small tumors typically show homogeneous enhancement, whereas
larger lesions more often have heterogeneous enhancement due to
presence of hemorrhage and cystic areas.
• Occasionally, vestibular schwannomas show extension into the
cochlea and “dural tails” of enhancement.
• The major treatment options for patients with a vestibular
schwannoma are surgery, radiation therapy, and observation.
CONCLUSION
• On CT: Round CPA cistern/ tapers in IAC
• isodense / hypodense to adjacent brain.
• +/- Porus-IAC Widening.
• Large-central areas of cystic Degeneration +/- adjacent extramural
meningeal/arachnoid cyst.
• On MRI: iso/hypo on T1W, Hyper on T2WI
• inhomog-cystic degeneration
Meningiomas
• Meningiomas are extra-axial neoplastic lesions arising from
arachnoidal cap cells.
• 40-60 yrs, more in females
• Approximately, 10% of all intracranial meningiomas arise in the
infratentorial compartment.
• They are the second most common CPA tumor and account for 10% of
CPA masses.
• They usually arise from the posterior petrous surface or the underside
of the tentorium.
CT
• On noncontrast CT, meningiomas are well-
demarcated lesions related to the petrous bone,
usually with a broad base against the bone.
• They are isodense to hyperdense compared to the
adjacent brain.
• Calcification may be seen.
• Enhancement usually is strong and homogeneous
• Cystic lesions are uncommon.
• Brain edema may be present to varying degrees.
MRI
• On MR, these lesions may be isointense to
brain on T1-weighted images.
• On T2-weighted images they can be isointense,
hypointense, or hyperintense.
• Cystic components are present and may be
located in the center or periphery of the tumor.
• A cerebrospinal fluid (CSF) cleft may separate
the lesion from adjacent brain.
• Contrast enhancement in meningiomas usually
is strong and homogenous
T2
• A dural tail of enhancement may extend for a variable distance from
the lesion.
• This feature is typical for meningiomas, although it can be seen in
other lesions to include schwannomas and metastases.
Cerebellopontine angle
meningioma. Axial contrast-
enhanced T1-weighted MRI
through the cerebellopontine angle
shows a large cisternal mass.

The intracanalicular component

(white arrow) can mimic a
vestibular schwannoma, although
the broad-based dural attachment
(red arrows) is more consistent with
a meningioma.
Imaging
• On NCCT, meningiomas are frequently hyperdense. Focal areas of
calcification are present in up to 25% of cases.
• A dural tail, the presence of bony reaction, and an obtuse angle with
the dura, as well as the centre of the lesion being located away from
the IAC, suggest meningioma.
• Relatively T2 hypointense signal is characteristic of most
meningiomas, especially the transitional and fibroblastic varieties.
• Necrosis and cystic degeneration are uncommon with meningiomas
and help to differentiate them from schwannomas
• Differentiation of a meningioma from a schwannoma based on their radiological
appearances is not difficult:
• meningiomas rarely expand the IAC, usually have a broad base against petrous
bone, and usually have strong homogeneous enhancement.
• They are usually hyperdense on noncontrast CT.
• Schwannomas are hypodense on noncontrast CT, enhance less homogeneously,
and often cause widening of IACs. (Only 1–2% of schwannomas do not cause
widening of the IAC.)
• Calcification is rare in schwannomas and relatively common with meningiomas.
• Penetration of posterior fossa foramina other than IAC is more common with
meningiomas than schwannomas.
• On SWI, presence of susceptibility foci secondary to hemorrhage
suggest schwannoma rather than meningioma.
• Rarely, meningiomas may originate within the internal auditory canal,
or even within the labyrinth.
• CPA meningioma may extend into the IAC, however canal is often not
widened.
• The presence of a dural tail is suggestive but not pathognomonic of
meningioma.
Meningioma: Extra-
axial CPA mass with
broad dural base,
isointense T2 signal
(A) and avid
contrast enhancement
(B).
Angiography
• Spoke wheel appearance
• Dense venous filling
• Persistant tumor blush comes
early and stays late –mother in law sign
• Well demarcated margins
• Dural vascular supply
Epidermoid and Dermoid
• Epidermoid and dermoid are generally believed to be
congenital/developmental masses rather than neoplastic, arising from
ectodermal heterotopia.
• Both cysts have stratified squamous epithelium inner lining, with dermoids
having additional mesodermal elements such as hair, sebaceous and sweat
glands.
• Epidermoids are slightly more common than dermoids and account for 3–7%
of CPA masses.
• They grow very slowly via desquamation and therefore present late in adults
despite their congenital etiology.
• They may become quite large before becoming symptomatic.
• The CPA is the most common location, followed by the parasellar region
EPIDERMOID
• Epidermoids present with progressive hearing loss, tinnitus, and aseptic
meningitis.
• Hemifacial spasm, trigeminal symptoms, and hydrocephalus (presenting
with headache) may be seen.
• These lesions usually are found in patients between the ages of 20 and 60
years.
• They are slow-growing lesions that burrow into crevices of the brain and
surround and infiltrate cranial nerves and vital posterior fossa vasculature.
• This feature accounts for their irregular margins on the one hand and the
difficulty of complete resection on the other.
• The radiological appearance of an epidermoid reflects the
composition of the lesion
• More common black lesions -hypodense on noncontrast CT,
hypointense on T1-weighted images, hyperintense on T2-weighted
images, and slightly brighter than CSF on intermediate images
• This represents keratomatous debris and cholesterol in solid state.
• The less common “white” lesions are hyperintense on T1-weighted
images and usually hypointense on T2-weighted images.
• This appearance reflects high lipid content.
• .The more common tumor appearance (the “black” tumor) may be
difficult to differentiate from an arachnoid cyst, although arachnoid
cysts tend to have sharper margins and displace rather than infiltrate
vascular structures and cranial nerves.
• diffusion-weighted images may be helpful for this differentiation.
Epidermoids are bright on these images
Epidermoid: MR scans show an extra-axial
right CPA mass which is hypointense on T1WI
(A) and hyperintense on T2WI (B).

• The mass has little internal heterogeneity

on FLAIR images (C); bright on DWI (D)
and
dark on ADC images (E).

No enhancement is seen following gad

administration (F).
• Malignant transformation of an epidermoid (squamous cell
carcinoma) is rare and shows a significant enhancement.
• When epidermoids are hyperintense on T1WI, then they need to be
differentiated from dermoids and lipomas.
• Chemical shift artefact is absent in epidermoids and also a fat
saturation pulse sequence will suppress the high signal of dermoids
and lipomas, but not of epidermoids
• Like epidermoid cysts, dermoid cysts are congenital ectodermal
inclusions but are extremely rare, far less common than epidermoid
cysts
• Dermoids are midline lesions, occurring in the parasellar, frontobasal
region or infratentorial compartment (vermis or fourth ventricle).
• Dermoids on CT are essentially fat density, extra-axial midline masses
that do not enhance on contrast administration.
• They may be associated with bone defect in nasofrontal or occipital
region that indicates the presence of a dermal sinus tract.
• CT is essential for detection of the calvarial defect, while MR
delineates the tumor better.
• Unruptured cysts are hyperintense, similar to fat on T1WIs and are
heterogeneous on T2WI.
• Chemical shift artefact is present similar to lipomas.
• However, dermoids are less lobulated than lipomas, and displace
blood vessels and neural structures, in contrast to encasement of
these structures by lipomas.
• Growth can lead to rupture of the cyst, causing a chemical meningitis.
Imaging findings vary.
• Fat-like leptomeningeal and intraventricular deposits are diagnostic of
a ruptured dermoid cyst.
Arachnoid Cyst
• Arachnoid cysts are congenital, benign, intra-arachnoid CSF filled
lesions.
• Mostly these are supratentorial lesions and about 70% are present in
the middle cranial fossa anterior to the temporal poles.
• Infratentorial arachnoid cysts account for only 10% of arachnoid cysts
and a vast majority of these are located in the CPA.
• Typically arachnoid cysts are asymptomatic.
• However they can compromise cranial nerve functions by stretching
them or rarely present with spontaneous or traumatic intracystic
hemorrhage.
• CT usually shows a well-defined, nonenhancing lesions with CSF
density.
• Large lesions may be associated with mass effect and bone
remodeling.
• On MR, these lesions have intensity on T1-weighted and T2-weighted
images, similar to CSF.
• As they come into contact with vascular structures (e.g., basilar
artery), they displace these structures, rather than surrounding them
Arachnoid cyst in a 27-year-old woman
with headaches. (a) Axial T1-weighted
MR image shows
an arachnoid cyst with signal intensity
similar to that of CSF stretching the left
seventh and eighth cranial nerve
complex (arrow).

(b) Axial T2-weighted MR image shows

the cyst displacing the vascular
structures of the
CPA (arrowheads).
Arachnoid cyst: Axial T2WI shows a
well-defined extra-axial cyst in
superior cerebellar cistern
which is isointense to the CSF on
T1WI (A), T2WI (B) and Flair (C).
The lesion is dark on DWI (D)
suggesting
increased diffusion.
Imaging
• At neuroimaging, arachnoid cyst is hypodense on CT and follows CSF
signal intensity on all MRI sequences including DWI, and do not
enhance after gadolinium administration
• Complete suppression of signal intensity on FLAIR sequence and the
lack of diffusion restriction differentiate arachnoid cyst from
epidermoid cyst
Cerebellopontine Angle/Internal Auditory
Canal Lipomas
• Lipomas represent mesodermal inclusions and are rare CPA/IAC
lesions.

• Characteristically, these lesions are hyperintense on T1WI and show

signal suppression on fat-sat images.
• On CT, detection of a small lipoma, especially an intracanalicular
lipoma, may be difficult.
• On T1-weighted MR images, these lesions are characteristically
hyperintense.
• The signal fades on T2-weighted images and if a fat-suppression
technique is utilized.
• On high-quality images one may observe that cranial nerves traverse
the substance of a lipoma
T1
. (a) Axial CT scan shows a
welldefined
hypoattenuating lipoma of
the left CPA.

(b) Axial T1-weighted MR

image shows that the lipoma
has signal intensity similar
to that of subcutaneous fat.
Metastatic Disease
• CPA metastatic disease is rare and may be leptomeningeal or parenchymal
(brainstem, cerebellum).
• Meningeal metastases may be diffuse, nodular or mass-like.
• Parenchymal lesions are exophytic brainstem or cerebellar hemispheric
lesions mimicking CPA masses.
• With large lesions, it may be difficult to differentiate meningeal from
parenchymal metastases.
• Primary tumors usually are from breast, lungs, melanomas, and prostate.
They usually present as an unexplained and progressive cranial nerve palsy.
• Melanomas have a predilection to involve the IAC.
 Endolymphatic Sac Tumor
• Endolymphatic sac tumors arise from the endolymphatic sac located in the distal
portion of the vestibular aqueduct and are papillary adenomatous tumors.
• tumors are frequent in von Hippel–Lindau disease, but may also occur sporadically.
• At CT, the tumor causes destruction of the retrolabyrinthine petrous bone, has
geographic or moth-eaten margins, and intratumoral spiculated or reticulated bone .
• At MR imaging, these tumors are heterogeneous on both T1 and T2WIs with foci of
hyperintensity due to subacute hemorrhages and hypointensity due to calcification
or hemosiderin.
• Presence of T1- and T2-hyperintense blood-filled cysts and protein-filled cysts may
suggest the diagnosis
• Enhancement is heterogeneous after gadolinium administration.
• Vascular flow-voids are seen within the tumor or peritumoral region in tumors more
than 2 cm in size.
ELST. A 54-year-old woman
with a mass in the right
temporal bone extending into
the CPA consistent with an
ELST. (A) Lytic changes in
the retrolabyrinthine
temporal bone
and central calcific spicules
are seen on CT.

(B) T1-enhanced MRI with

shows heterogenous
enhancement of this
lobulated lesion.
VASCULAR LESIONS OF CP ANGLE
• These include aneurysms and vascular malformations.
• Aneurysms may arise from the anterior inferior cerebellar artery or its adjacent
parts of vertebrobasilar system.
• They may be partially thrombosed or completely patent.
• At times, an aneurysm may be mistakenly diagnosed as a tumor, especially on CT.
• MR, however, usually is diagnostic.
• Angiography confirms the diagnosis
• An arteriovenous malformation and a cavernous malformation may present as
masses in CP angles.
• Their radiological appearance is identical to these lesions occurring elsewhere.
Endolymphatic sac tumor: Axial
CT scan (A) shows a well-
defined retrolabyrinthine mass
in right
petrous bone with intratumoral
bony spicules. The mass is
heterogeneously hyperintense
on fat-saturated T1WI (B)
and T2WI (C) and shows
heterogeneous enhancement
(D).
Facial Nerve Schwannomas
• Schwannomas may arise anywhere along the course of the facial
nerve from the CPA to the stylomastoid foramen.
• The facial nerve schwannoma arising in the IAC or CPA may be
difficult to differentiate from vestibular schwannoma.
• The presence of enhancing component extending along the
labyrinthine segment of the facial nerve to the geniculate ganglion
suggests the diagnosis of a facial nerve schwannoma over a vestibular
schwannoma.
Facial schwannoma.
Axial T1-weighted magnetic resonance
image at the level of the internal auditory
canal shows a soft-tissue mass (arrow)
along the course of the tympanic segment
of the facial nerve.
facial schwannoma. Coronal contrast-
enhanced T1-weighted magnetic
resonance image shows a schwannoma
(arrow) involving the mastoid segment
of cranial nerve VII.
• Trigeminal schwannomas may present with pain and numbness in
trigeminal distribution.
• Facial schwannomas may present an appearance suggesting Bell’s
palsy. They have radiological features similar to vestibular
schwannomas
• Schwannomas also may arise from ninth, tenth, eleventh, and twelfth
cranial nerves.
. (5) Schwannoma in a 34-year-old man with right
trigeminal neuralgia.
Contrast material–enhanced axial T1-weighted MR image
shows a homogeneous, enhanced, dumbbell-shaped right
trigeminal schwannoma involving the cisternal part of the
nerve and Meckel cave.

• (6) Schwannoma in a 52-year-old woman with left ear

pain.
• (a) Gadolinium-enhanced coronal T1-weighted MR
image shows an enhancing schwannoma of the ninth,10th,
and 11th cranial nerves in the lowest part of the CPA.
• (b) Coronal T2-weighted MR image shows the extent of
the schwannoma along the course of the nerves (arrows)
and beneath the normal left internal auditory canal
(arrowheads).
• (c) Axial CT scan shows smooth erosion of the skull base
and especially the jugular foramen by the schwannoma.
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