Brain Tumour

low grade tumours that enhances

ganglioglioma

pilocytic astrocytoma

signs of extra-axial tumour location

• CSF cleft

• displaced subarachnoid vessel

• cortical grey matter interposition

• displaced/expanded subarachnoid space

• Dural tail

• bony reaction

haemorrhagic brain mets

Melanoma

Renal

Choriocarcinoma/Carcinoid

Thyroid

Multifocal primary brain tumour

lymphoma

multicentric GBM

gliomatosis cerebri

Multifocal primary brain tumour from seeding

medulloblastoma

ependymoma

GBM

Oligodendroglioma

NF1 associated brain tumour

optic glioma

astrocytoma

NF2 associated brain tumour

Schwannomas

Meningiomas

Ependymomas

Tuberous Sclerosis associated brain tumour

subependymal tubers

subependymal giant cell astrocytoma

VHL associated brain tumour

Haemangioblastoma

Cortically based brain tumour

P-DOG

Pleomorphic Xanthroastrocytoma

Dysembryoplastic Neuroepithelial Tumour (DNET)

Oligodendroglioma

Ganglioglioma

Pleomorphic Xanthoastrocytoma

10-20

SUPRATENTORIAL

favors TEMPORAL lobe

cyst with nodule

invades leptomeninges

• dural tail

ENHANCES VIVIDLY

LITTLE peritumoral edema

Dysembryoplastic Neuroepithelial Tumour (DNET)

<20s

cortical grey matter

drug resistant seizure

favors temporal lobe

NO ENHANCEMENT

‘soap bubble appearance’ T2 bright

bright rim sign-FLAIR

Oligodendroglioma

40-50s

IDH mutation

1p19q deletion

calcification 90%

FRONTAL lobe

EXPANDS the cortex

ENHANCES

Ganglioglioma

any age

temporal lobe epilepsy

favors temporal lobe

mixed cystic/solid mass

focal calcification 35%

minimal peritumoral edema

ENHANCES

Intraventricular brain tumour

Ventricular wall

• ependymoma

• medulloblastoma

• subependymal giant cell astrocytoma

• subependymoma(adult)

• central neurocytoma

Choroid plexus

• choroid plexus papilloma

• choroid plexus carcinoma

• xanthogranuloma(adult)

Miscellaneous

• mets

• meningioma

• colloid cyst

ependymoma

bimodal, 6yo & 30 yo

FLOOR of 4th ventricle 70%

toothpaste/plastic tumour

• extends through foramen of lushka and magendie

parenchymal ependymoma 30%

• supratentorial mostly

• cerebellar rarely

calcification 50%

medulloblastoma

bimodal, <10 and 30-40

vermis/ROOF of 4th ventricle

hypercellular

DIFFUSION RESTRICTION

CSF SEEDING

• drop mets(zuckerguss)

• leptomeningeal spreads

associations

• basal cell naevus syndrome (Gorlin)

  • dural calcification

  • odontogenic keratocysts

• turcots syndrome

subependymal giant cell astrocytoma

SEGA

associated with TUBEROUS SCLEROSIS

<20s

lateral wall of lateral ventricle

near foramen of monro

homogenous ENHANCEMENT

calcification common

Subependymoma

associated with tuberous sclerosis

50-60s

4th ventricle > lateral ventricle

NO ENHANCEMENT

FACILITATED DIFFUSIO

Central Neurocytoma

20-40s

most common in this age group

lateral ventricle near foramen of monro

NO IDH mutation/1p19q deletion

numerous cystic area on T2

• bubbly/swiss cheese appearance

• attenuated on FLAIR

Calcification common

can bleed

Choroid Plexus Papilloma

4th ventricle in ADULTS

Trigone in KIDS

Association

• haemangioblastoma

• VHL

Cauliflower like lobulated mass

can be frond-like

homogenous ENHANCEMENT

• heterogenous enhancement suggest carcinoma

Choroid plexus Carcinoma

<5yo

lateral ventricles/trigone

association

• Li-Fraumeni syndrome

HETEROGENOUS enhancement

necrosis

calcification

cysts

CSF SEEDING

• needs entire neural axis imaging

Choroid Plexus Xanthogranuloma

benign

choroid plexus mass

bilateral 70%

T2 Bright

Doesn’t fully attenuate on FLAIR

DIFFUSION RESTRICT

Colloid Cysts

Sudden death - acute onset hydrocephalus

• transependymal edema

  • T2/FLAIR bright

anterior 3rd ventricle

CT hyperdense

Intraventricular Meningioma

30-60s

Trigone 80%

avid homogenous enhancement

calcification 50%

Cerebellopontine angle mass differential

1) vestibular schwannoma

2) Meningioma

3) epidermoid cyst

4) Lipoma

Vestibular Schwannoma

avid heterogenous enhancement

bilateral schwannoma = NF 2

trumpet shaped/ice cream cone IAC

Meningioma

cerebral convexity- most common

avid homogenous enhancement

CT - hyperdense

dural tail

calcification

hyperostosis

Spectroscopy: elevated ALANINE

Epidermoid cyst

congenital/acquired

follows CSF intensity

DIFFUSION RESTRICTS

• white epidermoid - T1 Bright

Dermoid cyst

usually midline

associated with NF 2

favors suprasellar cistern

CONTAINS FAT

CT hypodense & T1 Bright

rupture - fat floats in ventricle

IAC lipoma

association

• sensorineural hearing loss

T1 Bright, fat sat out

Infratentorial brain tumour differential

• Atypical teratoma/rhabdoid tumour(ATRT)

• medulloblastoma

• ependymoma

• juvenile pilocytic astrocytoma

• haemangioblastoma

• ganglioglioma

• diffuse pontine glioma

Atypical teratoma rhabdoid tumour

<6yo

posterior fossa mass

large heterogenous mass

looks like medulloblastoma

calcification common

Juvenile Pilocytic Astrocytoma

10

cerebellum 60%

optic pathway 30%

association

• NF 1

cyst with nodule

enhancing cyst wall

rarely solid cystic/solid

Haemangioblastoma

30-60

associated with

• VON HIPPEL LINDAU

• polycythemia

• renal cell carcinoma

Cerebellum>spinal cord

cyst with nodule

NO CYST WALL ENHANCEMENT

peripheral flow void

Diffuse midline glioma

3-10

favors the pons

NO ENHANCEMENT

FACILITATED DIFFUSION

young adults - spinal cordm

Astrocytoma, IDH-mutant

WHO Grade 2 - diffuse

WHO Grade 3 - anaplastic

little to no enhancement

T2/FLAIR mismatch sign

• Tumour T2 bright, FLAIR iso

Astrocytoma, IDH wiltype

WHO Grade 4 - GBM

deep white matter

Ring enhancement

can CROSS MIDLINE

necrosis

association

• NF 1

• Turcot Syndrome

• Li Fraumeni Syndrome

Gliomatosis Cerebri

20-40

minimal mass effect

MINIMAL ENHANCEMENT

no diffusion restriction

Spectroscopy:

• elevated Cho:Cr & Cho:NAA

FDG-PET: hypometabolism

Brain mets

solitary / multiple

grey-white matter junction

irregular margin

Bright met- Melanoma/Renal/Choriocarcinoma/Carcinoid/Thyroid)

Primary CNS Lymphoma

HIV/AIDS/immunocompromised

EBV

NHL- B cell

favors periventricular white matter

can CROSS MIDLINE

avid homogenous enhancement

periventricular

RESTRICTED DIFFUSION

Spectroscopy: decreased NAA

NM: Thallium Hot

Desmoplastic Infantile Ganglioglioma/Astrocytoma

(DIG)

<2yo

WHO GRADE 1

Rapidly increasing head circumference

SUPRATENTORIAL

CORTEX and MENINGES

• dural tail

large Solid & Cystic mass

AVID ENHANCEMENT

Chordoma

arise from notochord

midline tumour

Sacrum > clivus > C2

destructive heterogenous mass with internal septa

T2 BRIGHT

heterogenous enhancement

Chondrosarcoma

clivus

lateral to midline

T2 bright

arcs and rings matrix(CT)

Dural brain tumour

1) Meningioma

2) Haemangiopericytoma

3) Mets

Dural metastasis

most common primary - breast cancer

prostate

lung

H&N

hematological

Haemangiopericytoma

aka solitary fibrous tumour

lobulated

homogenous enhancement

dural tail

NO CALCIFICATION

NO HYPEROSTOSIS

Skull invasion

ADULT sella/parasella tumour

1) Pituitary adenoma

2) Rathke Cleft Cyst

3) Epidermoid cyst

4) Craniopharyngioma

5) Meningioma

Pituitary Adenoma

most common sella tumour

macroadenoma - >1cm

microadenoma - <1cm

enhances less than normal pituitary

• dynamic contrast enhanced MR

• delayed enhancement compare to normal pituitary

Rathke Cleft Cyst

Incidental finding

between anterior & posterior pituitary

T2 VERY BRIGHT

DO NOT ENHANCE

Craniopharyngioma

Adult: PAPILLARY

Child: ADAMANTINOMATOUS

PAPILLARY type

• solid tumour

• DO NOT CALCIFY

• STRONG ENHANCEMENT

ADAMANTINOMATOUS type

• Cystic

• CALCIFICATION

• T1 & T2 BRIGHT

• Enhancement of the solid parts

CHILD Sella/Parasella tumour

1) Craniopharyngioma

2) Hypothalamic Hamartoma

Hypothalamic Hamartoma

hamartoma of the tuber cinereum

• between pituitary and mammillary body

Gelastic Seizures

T1 & T2 isointense

DO NOT ENHANCE

Pineal tumour

1) Germinoma

2) Pineoblastoma/Pineocytoma

3) Pineal cyst

Parinaud Syndrome

• vertical gaze palsy

Germinoma

aka dysgerminoma/extra-gonadal seminoma

young patients 10-12

precocious puberty

MOST COMMON pineal tumour

‘engulfed’ CENTRAL CALCIFICATION

contains FAT

Heterogenous T1/T2

Pineoblastoma

‘expanded’ CALCIFICATION

highly invasive

heterogenous

AVID enhancement

Trilateral retinoblastoma

• bilateral retinoblastoma

• pineoblastoma

*non-invasive- Pineocytoma

Pineal Cyst

thin cyst wall enhancement

calcification 25%

Diffusion Restriction DDX

Abscess

Lymphoma

Medulloblastoma

GBM

Midline crossing DDX

Lymphoma

GBM

MS

Radiation necrosis

T1 BRIGHT tumour DDX

Fat: Lipoma, dermoid

Melanin: Melanoma

Blood: hemorrhagic mets(MRCT)

Cholesterol: Colloid cyst

Limbic encephalitis primary DDx

LUNG

breast

thymic

testicular