SYMPOSIUM NEURORADIOLOGICUM
BOLOGNA 2010
INTRACRANIAL MASSES WITH
PERILESIONAL EDEMA : DIFFERENTIAL
DIAGNOSIS WITH PERFUSION-CT
D. Gadda, P. Simonelli, G. Villa, V. Scardigli, D. Petacchi,
C. Pandolfo, M. Moretti, S. Chiti, G.P. Giordano
Careggi University Hospital - Florence - Neuroradiology
PERILESIONAL EDEMA
Commonly associated with an intracranial mass
Generated by vasogenic effects in the cerebral
parenchyma surrounding the mass for lack or
absence of blood-brain barrier (BBB) inside the
lesion
Extrusion of fluids into the extravascular space
(“wet brain”) around the mass
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PERILESIONAL EDEMA
On Computed Tomography (CT):
- area of low density for the increased fluid content
- not clear differentiation with areas of compressive
ischemia
- possible presence of neoplastic cells and tumoral
neo-angiogenesis inside the perilesional edema
surrounding high grade gliomas (Kelly PJ et al: Imagingbased stereotaxic serial biopsies in untreated intracranial glial neoplasms; J.
Neurosurg.1987 Jun;66(6):865-74 )
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MASS WITH PERILESIONAL EDEMA
Frequently discovered or suspected on a nonenhanced CT (NECT) scan performed for the onset
of stable or rapidly progressive neurological
symptoms
To complete the baseline imaging before MRI a
supplementary contrast-enhanced CT (CECT) scan
is generally indicated: a mass with perilesional
edema is generally contrast-enhancing
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MASS WITH PERILESIONAL EDEMA
- Neoplastic or not?
- If not , is it an abscess?
- Are there contraindications for steroids
administration ( abscess, lymphoma ) ?
- If a neoplasm is suspected, is it primitive (glioma
versus lymphoma for neurosurgical strategy) or
metastatic (need to search for a primitive tumor
when unknown) ?
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MASS WITH PERILESIONAL EDEMA
- Contrast-enhancement alone not specific for
differential diagnosis
- Need for advanced neuroimaging techniques
- CT : Perfusion CT
- MRI : Perfusion MRI, DWI, DTI, Spectroscopy
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GLIOBLASTOMA
Most frequent and aggressive primitive intra-axial
neoplasm (astrocytic tumors WHO Grade IV) 5060% of astrocytic neoplasms, 20,3% CNS
neoplasms (Central Brain Tumor Registry of the United States - 2007 )
Average survival 14 wks NS+Steroids ( Walker MD et al:
Evaluation of BCNU and/or radiotherapy in the treatment of anaplastic gliomas
: a co-operative clinical trial;JNeurosurg 1978;49:333-43 )
, 1 yr
NS+CT+RT
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GLIOBLASTOMA
Perfusion imaging: either glioblastomas and
their surrounding tissue and perilesional
edema show areas of increased rCBV for
neo-angiogenesis
( Lehmann P et
al: Dynamic contrast-enhanced T2*-weighted MR imaging: a
brain-oedema study;JNeuroradiol2009 May 36 (2):88-92
)
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PRIMARY CNS LYMPHOMA
4-7% primitive cerebral neoplasms
Conventional imaging : difficult d.d. vs
GBM or metastases
Perfusion imaging : generally low rCBV,
high permeability
( Schramm P et al: Dynamic CT perfusion imaging of intra-axial brain
tumours: differentiation of high-grade gliomas from primary CNS lymphomas .
European Radiology, vol 20, number 10, 2482-2490, online May 2010)
Careggi University Hospital - Florence - Neuroradiology
MENINGIOMA
Perfusion imaging may help to differentiate
meningiomas from intra-axial tumors in cases
of uncertainty on conventional imaging : high
rCBV and permeability in meningiomas
( Hakyemez B et al: Meningiomas with conventional MRI findings resembling intraaxial
tumors: can perfusion-weighted MRI be helpful in differentiation? Neuroradiology. 2006
Oct;48(10):695-702. Epub 2006 Aug 1 .)
(Cianfoni A, Cha S, Bradley WG, Dillon WP, Wintermark M. Quantitative measurement of
blood-brain barrier permeability using perfusion-CT in extra-axial brain tumors J
Neuroradiol. 2006 Jun;33(3):164-8.)
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CEREBRAL ABSCESS
Conventional imaging : difficult d.d. vs
tumors with cystic or necrotic content
Perfusion imaging : generally low rCBV for
the solid portions of abscesses, high rCBV
for tumors
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PERFUSION CT (PCT)
- Information about regional microvascular
density (CBV), permeability (PS) and blood
flow (CBF)
- Diagnostic and prognostic role when the
possible presence of tumoral neo-angiogenesis
is suspected
- A few-minutes additional time to a CECT study
is needed
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PERFUSION CT (PCT)
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STUDY PURPOSE
Investigating the possible utility of Perfusion
Computed Tomography (PCT) in the differential
diagnosis of the newly-diagnosed intracranial
solitary masses with perilesional edema
Careggi University Hospital - Florence - Neuroradiology
MATERIALS AND METHODS
Retrospective evaluation.
22 consecutive pts with newly diagnosed solitary
masses and PCT prior to surgery or stereotactic
biopsy
Pathology: 10 Glioblastomas (GBM), 5 nonanaplastic meningiomas, 2 lymphomas, 4
abscesses and 1 metastasis from testicular
choriocarcinoma
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MATERIALS AND METHODS
PCT performance:
- 4-slices multidetector CT scanner
- 40 ml c.m. 370mg/mL Iodine
- injection in 18-gauge i.v. line, flow 4 mL/sec
- 45 dynamic scans, 1/sec, 2cm thick coverage
area
- 80 kVp, 108 mAs
- PCT followed by CECT of the whole brain
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MATERIALS AND METHODS
PCT post-processing:
- two-compartmental model (Patlak analysis) for
Cerebral Blood Volume (CBV) and
Permeability Surface Area Product (PS) maps
- maximum-slope model for Mean Transit Time
(MTT) and Time to Peak (TTP) maps
- CBV, PS, MTT values normalized to
contralateral NAWM (rCBV, rPS, rMTT)
- TTP difference in sec with contralateral NA
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MATERIALS AND METHODS
PCT measurements:
- circular ROI placed on the solid portions of the
lesion for CBV-PS, manual ROI for MTT-TTP
- maximum measurements of rCBV and rPS,
mean values of rMTT and TTP were considered
- rCBV and rPS measurements of the lesion and
of the perilesional edema (PE rCBV and rPS)
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MATERIALS AND METHODS
Statistics::
Receiver operating characteristics (ROC) analyses to
compute the area under the curve (AUC) for each
parameter in the differential diagnoses between
biologically aggressive neoplasms (BAN: GBM,
Lymphomas, Metastases) versus slow-growing tumors
(grade I-II neoplasms) and non-neoplastic conditions
(abscesses). ROC analyses to assess which PCT parameters
had the highest predictive value for GBM, meningioma,
abscess and lymphoma.
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RESULTS : BAN vs non-BAN
Lesion
rCBV
Mean (SD)
BIOLOGICALLY
AGGRESSIVE
NEOPLASMS
(BAN) (13 )
NON-BAN ( 9 )
Lesion
rPS
Mean (SD)
Lesion
rMTT
Mean (SD)
Lesion
TTP
Mean (SD)
Edema
rCBV
Mean (SD)
Edema
rPS
Mean (SD)
4.6
(2.35)
16.87
(6.84)
1.08
(0.26)
2.13
(5.28)
1.13
(0.24)
3.81
(2.38)
6.91
(4.58)
30.05
(21.42)
1.35
(0.33)
6.96
(5.37)
0.91
(0.31)
3.20
(2.01)
P-value (Student’s ttest)
0.19
0.10
0.0495
0.0491
0.083
0.53
Area Under Curve
(AUC)
0.658
0.692
0.821
0.842
0.731
0.462
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RESULTS : GBM vs non-GBM
Lesion
rCBV
Mean (SD)
Lesion
rPS
Mean (SD)
Lesion
rMTT
Mean (SD)
Lesion
TTP
Mean (SD)
Edema
rCBV
Mean (SD)
Edema
rPS
Mean (SD)
GLIOBLASTOMAS
(GBM) (10 )
4.71
(1.99)
15.63
(6.39)
1.04
(0.11)
0.49
(1.82)
1.19
(0.20)
4.28
(2.52)
NON-GBM ( 12 )
6.25
(4.41)
27.79
(19.02)
1.32
(0.37)
7.12
(6.18)
0.91
(0.29)
2.97
(1.8)
P-value (Student’s ttest)
0.29
0.056
0.029
0.003
0.02
0.17
Area Under Curve
(AUC)
0.583
0.708
0.817
0.904
0.812
0.667
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RESULTS : MENINGIOMAS
Lesion
rCBV
Mean (SD)
Lesion
rPS
Mean (SD)
Lesion
rMTT
Mean (SD)
Lesion
TTP
Mean (SD)
Edema
rCBV
Mean (SD)
Edema
rPS
Mean (SD)
MENINGIOMAS
(5 )
10.19
(2.7)
43.94
(18.32)
1.38
(0.42)
6.56
(6.1)
0.73
(0.17)
3.47
(1.83)
NONMENINGIOMAS
( 17 )
4.18
(2.42)
15.89
(6.95)
1.14
(0.26)
3.38
(5.6)
1.13
(0.24)
3.59
(2.35)
P-value (Student’s ttest)
0.0001
0.02
0.14
0.28
0.002
0.92
Area Under Curve
(AUC)
0.976
0.988
0.735
0.759
0.912
0.576
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RESULTS : LYMPHOMAS
Lesion
rCBV
Median
Lesion
rPS
Median
Lesion
rMTT
Median
Lesion
TTP
Median
Edema
rCBV
Median
Edema
rPS
Median
LYMPHOMAS
(2 )
2.1
23.94
1.48
11.3
0.76
2.72
NONLYMPHOMAS
( 20 )
5.65
18.28
1.11
1.9
1.06
3.26
P-value
(Mann-Whitney test)
0.08
0.56
0.20
0.1
0.08
0.42
Area Under Curve
(AUC)
0.875
0.625
0.775
0.850
0.875
0.675
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RESULTS : LYMPH vsINTRA-AXIAL
Lesion
rCBV
Median
Lesion
rPS
Median
Lesion
rMTT
Median
Lesion
TTP
Median
Edema
rCBV
Median
Edema
rPS
Median
LYMPHOMAS
(2 )
2.1
23.94
1.48
11.3
0.76
2.72
NON-LYMPH
INTRA-AXIAL
( 15 )
3.54
15.02
1.06
0.9
1.24
3.24
P-value
(Mann-Whitney test)
0.13
0.17
0.13
0.07
0.02
0.45
Area Under Curve
(AUC)
0.833
0.800
0.833
0.900
1.0
0.600
Careggi University Hospital - Florence - Neuroradiology
RESULTS : ABSCESSES
Lesion
rCBV
Median
Lesion
rPS
Median
Lesion
rMTT
Median
Lesion
TTP
Median
Edema
rCBV
Median
Edema
rPS
Median
ABSCESSES
(4 )
1.81
12.99
1.23
7.6
1.07
2.39
NONABSCESSES
( 18 )
5.65
20.27
1.08
1.25
1.04
3.26
P-value (MannWhitney test)
0.06
0.10
0.13
0.12
0.49
0.34
Area Under Curve
(AUC)
0.806
0.764
0.743
0.750
0.611
0.653
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GLIOBLASTOMA
LYMPHOMA
NON-ANAPLASTIC
MENINGIOMA
ABSCESS
GLIOBLASTOMA
rCBV = 5.48
NON-ANAPLASTIC
MENINGIOMA
rCBV = 13.97
LYMPHOMA
rCBV = 1.07
ABSCESS
rCBV = 1.21
GLIOBLASTOMA
rPS = 22.12
LYMPHOMA
rPS = 21.86
2b
NON-ANAPLASTIC
MENINGIOMA
rPS = 37.91
2b
ABSCESS
rPS = 17.31
GLIOBLASTOMA
rMTT = 1.02
NON-ANAPLASTIC
MENINGIOMA
rMTT = 1.3
LYMPHOMA
rMTT = 1.82
ABSCESS
rMTT = 1.68
GLIOBLASTOMA
TTP = - 0.9
LYMPHOMA
TTP = 18.6
NON-ANAPLASTIC
MENINGIOMA
TTP = 3.6
ABSCESS
TTP = 12.1
GLIOBLASTOMA
Edema rCBV = 1.34
NON-ANAPLASTIC
MENINGIOMA
Edema rCBV = 0.8
LYMPHOMA
Edema rCBV =
0.71
ABSCESS
Edema rCBV = 0.95
CONCLUSIONS
PCT useful in d.d. intracranial masses with edema
- TTP, MTT are the best predictors for BAN and GBM
Careggi University Hospital - Florence - Neuroradiology
CONCLUSIONS
PCT useful in d.d. intracranial masses with edema
- TTP, MTT are the best predictors for BAN and GBM
- lesional rCBV is a good predictor for meningioma,
lymphoma, abscess
Careggi University Hospital - Florence - Neuroradiology
CONCLUSIONS
PCT useful in d.d. intracranial masses with edema
- TTP, MTT are the best predictors for BAN and GBM
- lesional rCBV is a good predictor for meningioma,
lymphoma, abscess
- rCBV of the perilesional edema is a good predictor for
GBM, meningioma, lymphoma
Careggi University Hospital - Florence - Neuroradiology
CONCLUSIONS
PCT useful in d.d. intracranial masses with edema
- TTP, MTT are the best predictors for BAN and GBM
- lesional rCBV is a good predictor for meningioma,
lymphoma, abscess
- rCBV of the perilesional edema is a good predictor for
GBM, meningioma, lymphoma
- lesional rPS good predictor for meningioma
Careggi University Hospital - Florence - Neuroradiology
CONCLUSIONS
PCT useful in d.d. intracranial masses with edema
- TTP, MTT are the best predictors for BAN and GBM
- lesional rCBV is a good predictor for meningioma,
lymphoma, abscess
- rCBV of the perilesional edema is a good predictor for
GBM, meningioma, lymphoma
- lesional rPS good predictor for meningioma
- measurement of permeability of perilesional edema is
not useful
Careggi University Hospital - Florence - Neuroradiology
LIMITATIONS
- limited number of cases
Careggi University Hospital - Florence - Neuroradiology
LIMITATIONS
- limited number of cases
- lack of malignant neoplasms such as lymphomas
( 2 cases) and metastases ( 1 case)
Careggi University Hospital - Florence - Neuroradiology
LIMITATIONS
- limited number of cases
- lack of malignant neoplasms such as lymphomas
( 2 cases) and metastases ( 1 case)
- absence of grade III-IV meningiomas , low-grade
ggliomas, oligodendrogliomas or other malignant masses
Careggi University Hospital - Florence - Neuroradiology
THANK
YOU !!
Azienda Ospedaliero-Universitaria di Careggi - Firenze
Neuroradiologia
THANK
YOU !!
Azienda Ospedaliero-Universitaria di Careggi - Firenze
Neuroradiologia