Supratentorial neoplasm in adult

Dr. Prashant PoteJr.IIIDepartment of RadiologyGMC Mumbai & JJ hospital

Supratentorial intra-axial neoplasms

AstrocytomaLow-grade astrocytoma:

Focal or diffuse mass lesion usually located in white matter with low to intermediate signal on T1WI and high signal on T2WI;

with or without mild Gd-contrast enhancement.

Minimal associated mass effect Well-differentiated but infiltrating

neoplasm, slow growth pattern.

Low-grade astrocytoma.

Fig. 1A.18 Low-grade astrocytoma.a Axial T2WI shows a focal mass lesion inleft temporo-occipital region with heterogeneous intermediate to high signal

Fig. 1A.18 b Postcontrast axial T1WIshows a small zone of mild Gd-contrast enhancement in only a small portion of thelesion.

Low-grade astrocytoma

20% involve deep gray matter structures-thalamus, basal ganglia

Ca++ and cysts uncommon. Hemorrhage or surrounding edema

(rare)

Anaplastic astrocytoma

Grade III astrocytoma,malignant astrocytoma, high grade astrocytoma :

Often irregularly marginated lesion located in white matter with low to intermediate signal on T1WI and high signal on T2WI, with or without Gd-contrast enhancement.

DWI: No diffusion restriction is typical

Anaplastic astrocytoma.

a Axial T2WI shows an infiltrativelesion with heterogenous high signal,poorly defined margins with mass effect located in the right frontoparietal region.

b Postcontrast axial T1WI shows irregularGd-contrast enhancement in a portionof the neoplasm.

Glioblastoma multiforme

a Axial T2WI shows a large masslesion with heterogenous high signal containingareas of necrosis, poorly definedmargins, and marked mass effect locatedin the right temporal, frontal, and parietallobes.

b Postcontrast axial T1WI showsprominent irregular Gd-contrast enhancementat the neoplasm.

Glioblastoma multiforme

Above 50 years Most common primary CNS tumor. Highly malignant

neoplasms with necrosis and vascular proliferation Irregularly marginated mass lesion with necrosis or

cyst. Mixed signal on T1WI and heterogeneous high signal on T2WI. Hemorrhage may be associated.

Prominent heterogeneous Gd-contrast enhancement. Can cross corpus callosum- “butterfly glioma” DWI; Lower measured ADC than low grade gliomaso No diffusion restriction typical Elevated maximum rCBV compared to low grade

Brain-brain spread: White matter tracts,carpous

callosum, corticospinal tract Ependymal and subependymal

spread-creeping tm Drop mets in spine

Gliomatosis cerebri

a AxialT2WI shows an infiltrative lesion with heterogenous high signal, poorly defined margins with mass effect located in the leftfrontal lobe extending through the corpuscallosum into the right frontal lobe

Fig. 1A.20b Postcontrast axial T1WIshows no Gd-contrast enhancement atneoplasm.

Gliomatosis cerebri

Diffusely infiltrating glial tumor involving three or more lobes.

Infiltrative lesion with poorly defined margins with mass effect located in the white matter.

Low to intermediate signal on T1WI and high signal on T2WI; usually no Gd-contrast enhancement until late in disease

Gliomatosis cerebri

T2 cor Post contrast T1Cor

Giant cell astrocytoma–Tuberous sclerosis Circumscribed lesion located near

the foramen ofMonro with mixed low to intermediate or high signal on T1WI and on T2WI.

Cysts and/or calcifications may be associated.

Heterogenous or homogenous Gd-contrast enhancement

Subependymal hamartoma near foramen of Monro,occurs in 15% of patients with tuberous sclerosisbelow 20 years of age.

Slow-growing lesions thatcan progressively cause obstruction of CSF flow through the foramen of Monro.

Pleomorphic xanthoastrocytoma Rare type of astrocytoma occurring in young

adults associated with seizure history Supratentorial cortical mass with adjacent

enhancing dural "tail" Cyst and enhancing mural nodule typical

(50-60%) Despite circumscribed appearance, tumor

often infiltrates into brain, VRSs Minimal or no edema is typical Ca++, hemorrhage, frank skull erosion rare

Oligodendroglioma

Axial T2WI shows a lesionwith heterogenous high signal, poorly defined margins with masseffect located in the right temporal lobe.

Postcontrast sagittal T1WI shows equivocalminimal Gd-contrast enhancement at neoplasm

Oligodendroglioma

Usually in adults older than 35 years of age, 85% supratentorial.

Circumscribed lesion with mixed low to intermediate signal on T1WI and mixed intermediate to high signal on T2WI;

areas of signal void at sites clump-like calcification;

heterogenous Gd-contrast enhancement. Involves white matter and cerebral cortex. Can

cause chronic eosion of inner table of calvaria.

Central neurocytoma

Central neurocytoma. a AxialT2WI shows a circumscribed lesion withheterogenous high signal containing cysticzones, involving the septum pellucidumwith extension into both lateral ventricles.

b Postcontrast coronalT1WI shows irregular pattern of Gd-contrastenhancement at neoplasm

Central neurocytoma

Age 20-40 yrs. Bubbly mass in the body or frontal horn of

lateral ventricle attached to septum pellucidum.

Heterogeneous intermediate signal onT1WI; heterogeneous high signal on T2WI.

Calcifications and/or small cysts may be associated. Heterogeneous Gd-contrast enhancement.

Slow growing Tm ,rarely invades

Imaging appearance similar to intraventricular oligodendrogliomas.

Ganglioglioma, ganglioneuroma,gangliocytoma

Axial T2WIshows a lesion with heterogenous high signalcontaining small cystic zones in theanterior right temporal lobe (arrows). NoGd-contrast enhancement was seen associatedwith this lesion (images notshown).

Ganglioglioma, ganglioneuroma,gangliocytoma

Circumscribed tumor; usually supratentorial, often temporal or frontal lobes. Low to intermediate signal on T1WI, intermediate to high signal on T2WI.

Cysts may be present. With or without Gd-contrast enhancement.

Ganglioglioma (contains glial and neuronal elements),

Ganglioneuroma (contains only ganglion cells). Uncommon tumors, below 30 years, seizure presentation, slow-growing neoplasms.

Gangliocytoma (contains only neuronal elements, dysplastic brain tissue). Favorable prognosis if completely resected

Dysembryoplasticneuroepithelial tumor Circumscribed lesions involving the

cerebral cortex and subcortical white matter. Low

signal on T1WI; high signal on T2WI. Small cysts may

be associated. Usually no Gd-contrast enhancement. Benign superficial lesions commonly

located in the temporal or frontal lobes.

Lymphoma

a Axial T2WI shows infiltrating lesions with high signal and mass effect located in the right frontal and temporal lobes with involvement of the corpus callosum (arrows). b, c Postcontrast axial T1WI shows Gd-contrast enhancement at twosites of intra-axial lymphoma (arrows).

Lymphoma Primary CNS lymphoma more common than

secondary, usually occurs in adults older than 40 yearsof age. B cell lymphoma more common than T cell lymphoma

Primary CNS lymphoma: focal or infiltrating lesion

located in the basal ganglia, periventricular regions, posterior fossa/brainstem.

Low to intermediate signal on T1WI; intermediate signal onT2WI. Hemorrhage/necrosis may be associated in immunocompromised patients.

Usually Gd-contrast enhancement. Diffuse leptomeningeal

enhancement is another pattern of intracranial lymphoma.

Hemangioblastoma Circumscribed tumors usually located in the

cerebellum and/or brainstem. Small Gd-contrast-enhancing nodule with or

without cyst (60%), or larger solid lesion with prominent heterogeneous enhancement (40%)

with or without flow voids within lesion or at the periphery.

Intermediate signal on T1WI; intermediate to high signal on T2WI.

Occasionally lesions have evidence of recent or remote hemorrhage.

Rarely occur in cerebral hemispheres; occur in adolescents, young and middle-aged adults.

Lesions are typically multiple in patients with von Hippel-Lindau disease.

Metastases

Circumscribed spheroid lesions in brain that can have various intra-axial locations, often at gray-white matter junctions.

Usually low to intermediate signal on T1WI; intermediate to high signal onT2WI.

Hemorrhage, calcifications, cysts may be associated.

Variable Gd-contrast enhancement, peripheral to nodular enhancement.

Neurocutaneous melanosis

Extra-axial or intra-axial lesions usually less than 3 cm in diameter with irregular margins in the leptomeninges or brain parenchyma/brainstem (anterior temporal lobes, cerebellum, thalami, inferior frontal lobes) with high signal on T1WI secondary to increased melanin.

Gdcontrast enhancement+/- No restriction on DWI, No blooming. Vermian hypoplasia,arachnoid cysts, Dandy-

Walker malformation may be associated.

Neuroectodermal dysplasia with proliferation of melanocytes in leptomeninges associated with large and/or numerous cutaneous nevi.

Maychange into CNS melanoma.

Radiation necrosis Focal lesion with or without associated mass

effect,or poorly defined zone of low to intermediate signal on T1WI and intermediate to high signal onT2WI, with or without Gd-contrast enhancement.

involving tissue (gray matter and/or white matter) in field of treatment.

Usually occurs from 4−6 months to 10 years after radiation treatment.

May be difficult to distinguish from neoplasm. Positron emission tomography (PET) and MR

spectroscopy (MRS), pMR might be helpful for evaluation.

Radiation injury/necrosis

a Axial T2WI shows poorly definedzones of heterogeneous high signal involvingthe cerebral cortex and white matter atthe anterior portions of both temporallobes (arrows). Mild localized mass effect isalso seen

. b Postcontrast axial T1WIshows Gd-contrast enhancement involvingtissue (gray and/or white matter) in thefield of treatment (arrows).

Supratentorial extra-axial mass lesions

a Axial T2WI shows a large, well-circumscribed, extra-axial dural-based lesion at the anterior falx with heterogeneous intermediate to slightly high signal that results in prominent compression of both frontal lobes.

b Postcontrast axial T1WI shows prominent, slightly heterogenous Gd-contrast enhancement

Meningioma

Extra-axial, well-circumscribed, dural-based lesions.

Locations in order of decreasing frequency: supratentorial,infratentorial, parasagittal, convexity, sphenoid ridge, parasellar, posterior fossa, optic nerve sheath, intraventricular.

Intermediate signal on T1WI and intermediate to slightly high signal onT2WI.

Usually prominent Gd-contrast enhancement. Calcifications may be associated.

Most common extra-axial tumor. Usually benign neoplasms, typically occurring in adults above 40 years of age,

in women more commonly than men. Multiple meningiomas seen with

neurofibromatosis type 2. Can result in compression of adjacent brain

parenchyma, encasement of arteries, and compression of dural venous sinuses.

Rarely invasive/malignant.

a Postcontrast coronal GRE) T1WI shows a large, slightly lobulated,prominently enhancing extra-axialdural-based lesion at the tentorium that resultsin prominent compression of the rightcerebral hemisphere superiorly and rightcerebellar hemisphere inferiorly.

. b AxialT2WI shows the large extra-axial lesion tohave heterogeneous intermediate signal(arrows).

Hemangiopericytoma

Extra-axial mass lesions, often well-circumscribed.

Intermediate signal on T1WI and intermediate to slightly high signal on T2WI;

prominent Gd-contrast enhancement (may resemble meningiomas).

Withor without associated erosive bone changes.

Rare neoplasms in young adults sometimes referred to as

angioblastic meningioma or meningeal hemangiopericytoma.

a Postcontrastaxial T1WI shows abnormal curvilineardural enhancement on the right withtwo zones of nodular thickening representingmetastatic breast carcinoma (arrows).

b Axial T2WI shows the two zonesof dural thickening have intermediate signal,which can also be seen with meningiomas(arrows).

Metastatic tumor Single or multiple well-circumscribed or poorly

defined lesions involving the skull, dura, leptomeninges,and/or choroid plexus.

Low to intermediate signal on T1WI and intermediate to high signal on T2WI; usually Gd-contrast enhancement.

Bone destructionand compression of neural tissue or vessels may be present.

Leptomeningeal tumor often best seen on postcontrast images

Metastatic tumor may have variable destructive or infiltrative changes involving single or multiple sites of involvement.

Germinoma

a Sagittal T1WIshows a circumscribed, slightly lobulatedtumor with intermediate signal in thepineal recess (arrows).

Axial T2WI shows the lesionto have heterogeneous, intermediate to high signal with a thin rim of low signal(arrows).

Postcontrast axial T1WIshows prominent Gd-contrast enhancementof tumor (arrows).

Germinoma More common in males than females (10−30

years); Circumscribed tumors. With or without

disseminated disease. Pineal region, suprasellar region, third

ventricle/basal ganglia. Low to intermediate signal on T1WI,

occasionally high signal on T1WI; variable low, intermediate, high signal on T2WI. Gd-contrast enhancement of tumor and

leptomeninges if disseminated

Pituitary macroadenoma.

a Sagittal T1WI shows a pituitarymacroadenoma with intermediate signalmeasuring 18mm in height (arrows).

b Postcontrast coronal T1WIshows prominent enhancement of the lesion,which extends upward into the suprasellarcistern (arrows).

Pituitary macroadenoma

Macro adenomas (>10mm):. Extension into suprasellar cistern with waist at diaphragma sella, with or without extension into cavernous sinus.

Occasionally invades skull base.

Pituitary adenoma

Microadenomas (<10mm): Commonly have intermediate signal on T1WI and T2WI.

Cysts, hemorrhage,necrosis may be associated.

Typically enhance less than normal pituitary tissue–often best seen with dynamic early phase imaging.

Pituitary adenoma Common benign slow-growing tumors

representing approximately 50% of sellar/parasellar neoplasms in adults.

Can be associated with endocrine abnormalities related to oversecretion of hormones(prolactin, nonsecretory type, growth hormone,ACTH, and others).

Prolactinomas: more common in females than males;

growth hormone tumors:more common in males.

Craniopharyngioma

Craniopharyngioma. a SagittalT1WI shows a lobulated lesion withmixed low, intermediate, and high signal inthe sella and suprasellar cistern with d

Fig. 1A.62b Postcontrast sagittal T1WIshows enhancement in portions of the lesion(arrows).

Craniopharyngioma

Circumscribed lobulated lesions; both suprasellar and intrasellar location, less commonly suprasellar or intrasellar only. Variable low, intermediate, and/or high signal on T1WI and T2WI.

With or without nodular or rim Gd-contrast enhancement.

May contain cysts, lipid components, and calcifications.

Usually histologically benign but locally aggressive lesions arising from squamous epithelial rests along Rathke’s cleft.

Occurs in children (10 years) and adults (above 40 years).

Pineal region tumors

• Pineal parenchymal tumors (pineocytoma/blastoma)

• Germ cell tumors (germinoma, teratoma)

Pineocytomas

Pineocytomas can be encountered at any age but mostly occur in young adults in the second decade of life

obstructive hydrocephalus secondary to compression of the tectum of the midbrain and obstruction of the aqueduct

Slow growing and well circumscribed tumours (compared to pineoblastomas which tend to be larger, and less well circumscribed).

They tend to be solid, although focal areas of cystic change, or haemorrhage do occur.

Pineal calcifications tend to be dispersed peripherally.

T1 C+ (Gd): solid components vividly enhance.

Pineoblatoma Pineoblastomas tend to be large poorly

defined masses, with frequent CSF seeding. directly involve adjacent brain structures. The solid component tends to be slightly

hyperdense compared to adjacent brain due to high cellularity.

"exploded" calcification.T1 C+ (Gd): vivid heterogenous

enhancement DWI/ADC restricted diffusion due to dense cellular packing

Pineoblatoma

Pineal germinoma

Germinomas are soft tissue density, enhancing masses.

When present in the pineal region they appear to "engulf" normal pineal tissue

Pineal germinoma

Choroid plexus papilloma.

a Sagittal T1WI shows a circumscribed,slightly lobulated lesion with intermediatesignal located in the atrium of theright lateral ventricle (arrows). Hydrocephalusis also present.

b Postcontrast sagittal T1WIshows prominent Gd-contrast enhancementof the lesion (arrows).

Choroid plexus papillomaor carcinoma Circumscribed and/or lobulated lesions with

papillary projections. Intermediate signal on T1WI and mixed intermediate to high signal on T2WI;

usually prominent Gd-contrast enhancement. May contain calcifications.

Locations: atrium of lateral ventricle (children) more common than fourth ventricle (adults), rarely other locations such as third ventricle.

Associated with hydrocephalus.

Plasmacytoma.

a SagittalT1WI shows a large lesion with low and intermediatesignal involving the nasal cavity,ethmoidal and sphenoidal sinuses, anteriorand mid skull base. The lesion extends intothe anterior cranial fossa, displacing the inferiorportions of the frontal lobes (arrows).

b.Axial T2WI shows the lesionto have mixed intermediate to high signal.The lesion encases portions of the carotidarteries (arrows).

Myeloma/plasmacytoma

Multiple (myeloma) or single (plasmacytoma) wellcircumscribed or poorly defined lesions involving the skull and dura.

Low to intermediate signal on T1WI and intermediate to high signal on T2WI,

usually with Gd-contrast enhancement and with bone destruction.

Myeloma may have variable destructive or infiltrative changes involving the axial and/or appendicular skeleton.

Chordoma

Well-circumscribed lobulated lesions with low to intermediate signal on T1WI and high signal on T2WI;

Gd-contrast enhancement (usually heterogeneous).

Locally invasive associated with bone erosion/destruction,

encasement of vessels and nerves Skull base and clivus common location,

usually in the midline.

Chondrosarcoma

Lobulated lesions with low to intermediate signal on T1WI and high signal on T2WI.

With or without matrix mineralization: low signal on T2WI.

With Gdcontrast enhancement (usually heterogeneous).

Locally invasive associated with bone erosion/destruction, encasement of vessels and nerves.

Skull base and petro-occipital synchondrosis common location, usually off midline.

Osteogenic sarcoma

Sagittal T1WI shows a large destructive lesion involving the skull with intracranial and extracranial soft-tissue components. These have intermediate signal containing irregular zones of low signal, representing matrix mineralization/ ossification.

Postcontrast sagittal T1WI shows prominent enhancement at the soft-tissue portions of the lesion.

Osteogenic sarcoma

Destructive lesions involving the skull base. Low tointermediate signal on T1WI and mixed low, intermediate,high signal on T2WI.

Usually wit matrix mineralization/ossification: low signal on T2WI.

With Gd-contrast enhancement (usually heterogeneous).

Osteogenic sarcoma

Rare lesions involving the endochondral bone-forming portions of the skull base. More common than chodrosarcomas and Ewing sarcoma.

Locally invasive,high metastatic potential. Occurs in children as primary tumors and

adults (associated with Paget disease, irradiated bone, chronic osteomyelitis, osteoblastoma, giant cell tumor, fibrous dysplasia).

Sinonasal squamouscell carcinoma Destructive lesions in the nasal cavity,

paranasal sinuses, nasopharynx. With or without intracranial extension via

bone destruction or perineural spread. Intermediate signal on T1WI and

intermediate to slightly high signal on T2WI;

Mild Gd-contrast enhancement. Large lesions (necrosis and/or hemorrhage may be associated).

Occurs in adults, more common in males than

females, usually above 55 years. Associated withoccupational or other exposure to nickel, chromium, mustard gas, radium, manufacture of wood products.

Adenoid cystic carcinoma

a.Postcontrast FS coronal T1WI shows anenhancing lesion in the nasopharynx extending superiorly through a widened leftforamen ovale (perineural spread) into theleft trigeminal cistern and medial leftmiddle cranial fossa (arrows).

b AxialT2WI shows that the lesion also extends into the sphenoidal and ethmoidal sinuses and has heterogeneous intermediate and high signal (arrows). A left middle ear effusion is also present.

Adenoid cystic carcinoma

Destructive lesions in the paranasal sinuses, nasal cavity, nasopharynx.

With or without intracranial extension via bone destruction or perineural spread.

Intermediate signal on T1WI and intermediate to high signal on T2WI; variable mild, moderate, or prominent Gd-contrast enhancement.

Esthesioneuroblastoma

Tumors also referred to as olfactory neuroblastoma.

Arise from olfactory epithelium in the superior nasal cavity.

Occurs in adolescents and adults, more common in males than

females.

Esthesioneuroblastoma.

After intravenous administration of Gd-DTPA, considerableenhancement of an inhomogeneouslesion (arrow) originating in thenasal vault is seen

Eosinophilicgranuloma Single or mutiple circumscribed soft-tissue

lesions in the marrow of the skull associated with focal bony destruction/erosion with extension extracranially, intracranially, or both.

Lesions usually have low to intermediate signal on T1WI and mixed intermediate to slightly high signal on T2WI, with Gd-contrast enhancement.

With or without enhancement of the adjacent dura.

Eosinophilic granuloma

a Coronal T2WI shows asoft-tissue lesion with mixed intermediateto high signal in the marrow of the skull,associated with focal bony destruction/erosion(arrows).

b Postcontrast FS coronalT1WI shows heterogeneous enhancementof the lesion as well as enhancement ofthe adjacent dura (arrows).

Single lesion: Commonly seen in males more than females (below 20 years).

Proliferation of histiocytes in medullary cavity with localized destruction of bone with extension into adjacent soft tissues.

Multiple lesions: Associated with syndromes such as: Letterer-Siwe disease (lymphadenopathy hepatosplenomegaly), children below 2 years; Hand- Schüller-Christian disease (lymphadenopathy, exophthalmos,diabetes insipidus) children aged 5−10years.