Normal Imaging Anatomy of Brain
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Normal Imaging Anatomy of Brain
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anterior cerebral artery and n1iddle cerebral artery
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posterior cerebral artery
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anterior and posterior con1n1unicating arteries
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Normal In1aging Anatomy of Brain
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Basic Features of Brain Lesions
Hydrocephalus
The ter111 h)1drocephalus is derived fron1 the Greek \Vore.ts
"hydro" n1eaning \Vater and "ccphalus" n1caning head
As the nan1e in11Jlies" it is a condition in ,vl1ich the 1Jri111ary
characteristic is excessive accun1ulation l)f tl u id in the brain
The excessive accun1ulation of C~SF results in an abnor111al
,vidcning of spaces in the brain called ventricles
This \videning creates p~)tentially har111f'ul pressure
tissues of the brain
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Norn1al CSF no,,, passage
Lateral \ I - (Fora1r1ina of
Mo11ro) - Third \ 1 (1\queduct of Syl,1 it1s) Fourtl1 V - (Median
ape1tt1re & Luscl1ka
Fora111i11a) - Subaracl111oid
SJJace - (Arach11oid
Granulations) - S11perior SS
Normal
Hydrocephalic
fi'A nAM.
Basic Features of Brain Lesions
Hydrocephalus
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~on-con1n1unicating
Communicating
Flgu~e 19. Hydrocephalus
In hydrooephalus, the basilar cisterns (A, a,ro,v) aie effaced, as are
the sulcl fCJ. The lateral and thftid ventricle are enlarged {a).
@1
2007 Joshua BrurJer:
Basic Features of Brain Lesions
Hydrocephalus
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Obstructive hydrocephalus
C'SF-tl<.)\V obstruction ulti111atcly 11rcvcnting ( "SF fron1 tlo\ving
int(.l sulJarachn<.)id space
Secondary to congenital.. infectious <.)r tun1or (iiscases
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Non-Comm unicating Hydrocepha lus:
Axial CT scans. Note the massive
enlargement of the lateral and third
ventricles. Th is patte rn is one of noncommunicating (obstructive)
hydrocephalus, which occurs from
impaired drainage through the
cerebral aqueduct which connects the
third and fourth ventricles .. In this
case, the cause of the hydrocephalus
was likely the intraventricular
hemorrhage associated with
premature birth, with subsequent
scarring and gliosis of the cerebral
aqueduct.
Basic Features of Brain Lesions
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Communicating Hydrocephalus
• Enlargement of lateral, 3 rd , and 4 th ventricles
- Note sulcal effacement, temp horns, rounded 3 rd ,
and enlarged 4 th
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Aqueduct stenosis - obstructive hydrocephalu
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• The ventricles are
prominent, with a
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sulci. There is abnormal
high signal intensity on the
FLAIR scans in the
immediate periventricular
region, consistent with
interstitial edema due to
increased ventricular
pressure. On the postcontrast scans there is
diffuse mild enhancement
of the leptomeninges,
consistent with meningitis .
Basic Features of Brain Lesions
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C\1usc(.I llv. N<.lrn1al A !!ing and diseases
Di ffusc,l brain atrtlphy and ltlcalizc(.t l1rain atrtlphy
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• Different grading
systems of cerebral
atrophy (seen as
decreased size
of gyri and
secondary
increased size
of sulci ):
- Medial temporal
lobe atrophy (MTA)
- Posterior atrophy
(PA)
- Frontal cortical
atrophy (fGCA)
• Brain atrophy in a child
with B 12 deficiency and its
reversal by B 12 treatment.
A 6-month-old girl of
vegetarian parents had
serum B 12 of 92 pmol/L
and serious neurological
impairment. MRI of the
brain showed marked
atrophy, especially in the
fron:tal and temporal lobes
(A). After 5 months of daily
treatment with B 12, there
was regressi,o n of atrophy
and neurological signs
were normal (B).
Basic Features of Brain Lesions
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, Structure departed ti·(Jlll ntlrn1al ptlsititlll due ttl intracranial lesion
, C'tllllllltlnlv. ftlund in tun1ors . hen1attln1a . int~1rctitlll . abscess . etc
Basic Features of Brain Lesions
, Displacctl t)r Ct)n1prcssc(I ,·cntric le
, Narrtl\\·ing llr tlcclusillll tlf ipsilateral ccrcl1ral sulcus and cistern
, Shilt ,Jr n1idline structures
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Vent r icu Ia r tli Iat at it) n cause <l by ( ·SF r> at h\,·a y obstruct ill ll
NEURO-ONCOLOGY



Primary tumor
brain
spinal
Secondary tumor
brain
spinal
Paraneoplastic syndrome
Imaging for Brain Tumors

Skull X-rays:



Rarely necessary.
Useful in demonstrating calcification, erosion, or hyperostosis
CT:

Most widely used for diagnosis of brain tumors
Will detect >90% of tumors, but might miss:






More sensitive than MRI for detecting acute hemorrhage,
calcification, and bony involvement
MRI:
tumors




Small Tumors (<0.5 cm)
Tumors Adjacent to bone (pituitary adenomas, clival tumors, and
vestibular schwannomas)
Brain Stem Tumors
Low Grade Astrocytomas
Nowadays the “golden standard” for diagnosis and follow-up of most brain
More sensitive than CT scans
Can detect small tumors
Provides much greater anatomic detail
Especially useful for visualizing skull base, brain stem, & posterior fossa
tumors
MRI brain T1 vs T2
Epidemiology
Infratentorial vs Supratentorial
Tumors
infratentorial
MENINGIOMA1,2,3

Epi:




Facts:




Arise from arachnoidal cap cell type from the
arachnoid membrane
Usually non-invasive
Associated with NF-2
Location:




2nd most common primary brain tumor after
gliomas, incidence of ~ 6/100,000
Usual age 40-70
F>M
Parasagittal region
Sphenoid wing
Parasellar region
Presentation:


Asymptomatic
Symptomatic: focal or generalized seizure or
gradually worsening neurologic deficit

On Imaging

CT:



MENINGIOMA
isodense or hypodense,
homogenous extra-axial
mass with smooth or
lobulated, clearly
demarcated contours which
enhance homogenously and
densely with contrast
Frequently have areas of
calcification and produce
hyperostosis of adjacent
bone.
– MRI
• Isointense with gray matter on
T1 images
• Enhance with contrast – often
with enhancing dural trail
extending from the tumor
attachment
GLIOMAS
Arise from Glial Cells

Astrocytomas
Astocytomas fall on a gradient that ranges from benign to
malignant
Benign
Low Grade Pilocytic
Astocytomas

Malignant
Diffuse Low Grade
Astrocytomas
Oligodendrogliomas
Glioblastoma
multiforme
Diffuse Low Grade Astrocytoma

Epi:



Facts:



Frontal Region
Subcortical white matter
Cyst
Presentation:




Widely Infiltrate surrounding tissue
Location:


15% of Astrocytomas
Young Adults
Seizures
Headache
Slowly progressive neurologic deficits
On Imaging:


T1 weighted
T2 weighted
CT: Well circumscribed, non enhancing, hypodense or isodense lesion
MRI: MRI more sensitive than CT – useful for identification and establishing extent



T1 image shows abnormal areas of decreased signal
T2 image shows abnormal areas of increased signal
Usually no enhancement
High Grade glioma: Glioblastoma

Epi:



Facts:





May arise de novo or evolve from a low-grade glioma
Tumor infiltrates along white matter tract and can cross corpus callosum
Poor Prognosis
Can look like a butterfly lesion
Location:



The 2-nd place of primary brain tumor in adults
Age of presentation: 40-60, M>F
Frontal & Temporal Lobes
Basal Ganglia
Presentation:



Seizures,
Headache
Slowly progressive neurologic deficits
High Grade glioma: Glioblastoma

On Imaging: Variable

CT:




Hypodense or Isodense
Central hypodense area of necrosis surrounded by thick enhancing rim
Surrounding edema
MRI:


T1 image shows low signal intensity
T2 image shows high signal intensity
High Grade glioma: Glioblastoma
Treatment: steroids
surgical removal
radiotherapy
chemotherapy (temozolomide)
anticonvulsive drugs
Survival
OLIGODENDROGLIOMA




Epi:
 5-10% of primary brain tumors
 Mean age of onset 40 years
Facts:
 Distinguished pathologically from astrocytomas by the
characteristic “fried egg” appearance.
 Arises from Myelin
Location:
 Superficially in Frontal Lobes
Presentation:
 Seizures most common
 Headache
 Slowly progressive neurologic deficits
OLIGODENDROGLIOMA

On Imaging:

CT:



Well circumscribed, hypodense lesions with heavy calcification
Cystic degeneration is common but hemorrhage & edema are uncommon
MRI:


Hypointense or isointense on T1-weighted images
Hyperintense on T2-weighted images with variable enhancement
OLIGODENDROGLIOMA
Treatment:
Surgical excision
radiation therapy
anticonvulsive drugs
The median survival over 7 years
.
INFRATENTORIAL TUMORS









Choroid plexus papillomas
Cerebellar astrocytomas
Medulloblastomas
Hemangioblastomas
Ependymomas
Brainstem gliomas
Schwannomas
Pituitary adenomas
Craniopharyngiomas
CEREBELLAR ASTROCYTOMA

Epi:
Most often occurs in childhood
Facts:
 Most potentially curable of the astrocytomas
Location:
 Posterior Fossa
Presentation:
Cyst
 Headaches
 Nausea/Vomiting
 Gait Unsteadiness
 Posterior head tilt with caudal tonsillar herniation
On Imaging:
 CT or MRI:
 Tumor arising from vermis or cerebellar hemispheres
 Large cyst with single enhancing mural nodule





MEDULLOBLASTOMAS

Epi




Facts





Primitive neuroectodermal tumors (PNET)
Soft, friable tumors, often necrotic
Can metastasize via CSF tracts
Highly radiosensitive
Location


Represent 7% of primary brain tumors
2nd most common posterior fossa tumor in children
70% of patients are diagnosed prior to age 20 with peak incidence
between 5-9 years of age;
About 75% arise within the cerebellar vermis
Presentation


Most frequently present with signs of intracranial pressure
Cranial nerve deficits may also occur
MEDULLOBLASTOMAS

Imaging


MRI reveals a contrastenhancing midline or
paramedian tumor which
often compresses the 4th
ventricle;
Gadolinium enhancement will
most likely be heterogeneous
and may show evidence of
necrosis, hemorrhage, or
cystic change;
EPENDYMOMAS

Epi




Facts



Derived from primitive glia
Overall survival at 10 years is 45-55%
Presentation


Accounts for 10% of CNS lesions;
Male=Female
Median age at diagnosis is 5 years old
Most patients present with symptoms of increased intracranial pressure
Location



Typically arise within or adjacent to the ependymal lining of the
ventricular system.
In children, 90% are intracranial with 60% arising in posterior fossa
(4th ventricle is the most common infratentorial site)
Most common spinal cord glioma (in adults, 75% arise within spinal
cord);;
EPENDYMOMA

Imaging



Usually well demarcated
with frequent areas of
calcification, hemorrhage,
and cysts;
CT: Appear hyperdense
with homogeneous
enhancement
MRI: ependymomas have a
hypointense appearance on
T1 and are hyperintense on
T2;
SCHWANNOMAS

Epi





Facts



Unilateral in 90% of cases (R=L);
Bilateral acoustic neuromas are diagnostic of NF-2;
Presentation






Female>male
Median age at diagnosis is 50
Account for 80-90% of cerebellopontine angle tumors
Comprise 8% of intracranial tumors in adults; rare in children (except with NF-2)
Patients may present with asymmetric sensorineural hearing loss, tinnitus
Fluctuating unsteadiness while walking, vertigo (although only 1% of patients
with vertigo had schwannomas);
If CN V nerve is affected, facial numbness, pain, and hyperesthesia may be
present;
If CN VII is affected, facial paresis may be present.
Tumor progression may lead to compression of brainstem or cerebellum leading
to ataxia, tonsil herniation, and hydrocephalus
Location

Arise from vestibular division of CN VIII; majority benign
SCHWANNOMAS

Imaging


MRI: with gadolinium is
more sensitive in detection
of Schwannomas (when
compared to CT); it can
detect tumors as small as
1-2 mm; seen as
enhancing lesion in the
region of CPA;
Fine-cut CT through
internal auditory canal can
detect large or medium
tumors.
Sella/suprasellar
In this region it is important to keep the possibility of an
aneurysm in the differential diagnosis
PITUITARY ADENOMAS

Epi



Facts


Most common tumors of pituitary gland
Represent 8% of primary brain tumors
Out of pituitary adenomas, prolactinomas are the most
common;
Presentation


May cause hypopituitarism and visual field defects;
Patients should have endocrine, radiographic, and
ophthalmologic assessments.
PITUITARY ADENOMAS

Imaging:



Plain x-ray may show an
enlarged sella turcica;
CT scan will detect only large
adenomas; it will show a
large hyper- or isodense
lesion;
MRI is the imaging of choice;



Microadenomas (lesions <1
cm) will be seen as a low
intensity lesions on T1;
Gadolinium will enhance the
normal gland that is
adjacent to adenoma
Macroadenomas will appear
as isointense on T1 and will
enhance uniformly with
gadolinium
BRAINSTEM GLIOMAS

Epi
Male=Female
 Account for 10-20% on all CNS tumors
 More common in children (account for 20% of all intracranial neoplasms under the
age 15);
 In children, median age at diagnosis is 5-9 years of age.
Facts
 NF-1 is the only known risk factor
 Mostly benign (but range from benign to very aggressive);
 Long term survival for low-grade gliomas is near 100%.
Location
 In peds, 80% arise in pons, with 20% arise in medula, midbrain, and
cervicomedulary junction;
Presentation
 Most patients with low-grade brainstem gliomas have a long history of minor signs
and symptoms;
 May present with neck pain or torticollis;
 Medulary tumors may present with cranial nerve palsies, dysphagia, nasal speech
and apnea, n/v, ataxia,or weakness;
 May cause “locked-in” syndrome
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BRAINSTEM GLIOMAS
•
Imaging
– MRI is the method of choice to
image those tumors (brainstem
glioma appears isodense on CR
and can be missed);
– Appear isointense or hypointense
on T1 images, hyperintense on
T2, and inhance uniformly and
brightly with IV contrast;
4th ventricle
 In
adults tumors in the 4th
ventricle are uncommon.
 Metastases,
followed by
hemangioblastomas, choroid
plexus papillomas and dermoid
and epidermoid cysts.
Metastatic tumors
Parenchymal meta – most common
masses in the in supratentorial and
infratentorial spaces (more supra)
 50% solitary, 50% multiple, 20% 2
lesions
 Origin – lung, (50%), breast (15%)
melanoma(11%), kidney, GIT
 Cystic meta- ovary, breast, GIT
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Hemorrhagic meta
 Breast
 Choriocarcinoma
 lung
 Melanoma
 RCC
 Thyroid
 retinoblastoma
Secondary tumors-MTS
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Lung cancer (NSCCa)
Breast cancer
Melanoma
Kidney
Thyroid
Carcinomatous Meningitis
(Meningeal Carcinomatosis)
Dissemination of tumor cells throughout the meninges
and ventricles.
5 percent of cases of adenocarcinoma of breast, lung, and
gastrointestinal tract; melanoma; childhood leukemia;
and systemic lymphoma.
Manifestations:
Polyradiculopathies (particularly of the cauda equina), multiple cranial
nerve palsies, and a confusional state.
Treatment
Radiation therapy to the symptomatic areas (cranium, posterior fossa,
or spine),
Intraventricular/intratecal methotrexate
Multiple brain tumors can be seen
in phacomatoses:
Neurofibromatosis II: meningiomas,
ependymomas, optic nerve gliomas,
choroid plexus papillomas
 Tuberous Sclerosis: subependymal
tubers, intraventricular giant cell
astrocytomas, ependymomas
 von Hippel Lindau:
hemangioblastomas
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