Diagnostic Imaging Approach to a Supratentorial SOL in an Adult

1. Diagnostic Imaging Approach to a Supratentorial SOL in an Adult Antoinette Reinders Dept of Diagnostic and Interventional Radiology University of the Free State Aug 2012

2. Approach • Age • Location • Intra vs extra axial • Anatomical compartment • Midline crossing • Tumour spread • Characteristics on CT and MRI • Spectroscopy • Calcification/edema/mass effect • Enhancement • Differential diagnoses • “Tumor mimickers”

3. Brain Tumours Smithuis R, Montanera W. Brain Tumor – systematic approach. Available from URL: http://www.radiologyassistant.nl/en

4. Major Anatomical considerations

5. Approach • Location • Intra-axial vs Extra-axial Smithuis R, Montanera W. Brain Tumor – systematic approach. Available from URL: http://www.radiologyassistant.nl/en

6. Extra axial tumour • Smithuis R, Montanera W. Brain Tumor – systematic approach. Available from URL: http://www.radiologyassistant.nl/en

7. Intra vs Extra axial Smithuis R, Montanera W. Brain Tumor – systematic approach. Available from URL: http://www.radiologyassistant.nl/en

8. Approach • Location • Grey matter • Cortical/subcortical • White matter • Grey/white matter interface • Dural surface • Abut the meninges • Ventricles • Foramen of Monroe • Trigonum of the lateral ventricles • Pineal gland • Sella/suprasellar

9. Robert Wood Johnson University Hospital. Available from URL: http://www.rwjuh.edu/gamma-knife/gamma-knife-brain-tumor-treatment.aspx

11. Approach • Cross midline • GlioblastomaMultiforme, Radiation necrosis, Meningioma, Lymphoma, Epidermoid cyst, MS • Multifocal disease • Phacomatoses • NF1: Optic gliomas, astrocytomas • NF2: Meningiomas, Ependymomas, Schwannomas, Choroid plexus papillomas • TS: Subependymal tubers, Giant cell astrocytomas • VHL: Hemangioblastomas

13. Approach • Tumour spread • Subarachnoid seeding • PNET • Ependymoma • GBM • Lymphoma • Oligodendroglioma • WM Tracts • Astrocytoma • Pilocytic, Fibrillary, Gemistocytic, Protoplasmic • Foramina • Ependymoma

14. Tumour Spread Pleomorphicxantoastrocytoma Ependymoma of 4th ventricle

15. Approach • Characteristics • MRI • Edema • Cystic • Mass effect • Fat containing • Spectroscopy • CT • Calcifications • Haemorrhage • Homogenous or heterogenous appearance • Periosteal reaction

16. Characteristics on CT

17. Haemorrhage

18. Characteristics on MRI

19. Characteristics on MRI

20. Diffusion Weighted Imaging Abscesses, infarcts have ABNORMAL diffusion – restriction Tumours have NORMAL diffusion – no restriction

21. Approach • Enhancement • Destruction of BBB in order to enhance • Homogenous vsheterogenous enhancement • Enhancement of gliomas = higher grade of malignancy • NB in follow up • Diffusion weighted • Restricted diffusion in abscesses and not in tumours Smithuis R, Montanera W. Brain Tumor – systematic approach. Available from URL: http://www.radiologyassistant.nl/en

22. Approach

23. Common things..... Astrocytoma Oligodendroglioma

24. Approach • Differential diagnoses • Dural based – Meningioma, Dural metastases, Sarcoid, Haemangiopericytomas, pineoblastoma, lymphoma • Cortical based – Dural AV malformation, Herpes encephalitis • Multifocal disease – Septic emboli, Abscesses and Multiple Sclerosis • Sellar- Aneurysm

25. Take home points... • Age of patient • Location • Intra vs extra axial • Crossing midline • Multifocal disease • Tumour spread • Characteristics on CT/MRI • Calcifications • Haemorrhage • Spectroscopy • Enhancement pattern • Differential diagnoses

26. Cellphones? “Although our results overall do not indicate an increased risk of glioma in relation to mobile phone use, the possible risk in the most heavily exposed part of the brain with long-term use needs to be explored further before firm conclusions can be drawn.” Int J Cancer. 2007 Apr 15;120(8):1769-75. Mobile phone use and risk of glioma in 5 North European countries. Raised risks of glioma with mobile phone use, as reported by one (Swedish) study forming the basis of the IARC's re-evaluation of mobile phone exposure, are not consistent with observed incidence trends in US population data, although the US data could be consistent with the modest excess risks in the Interphone study. BMJ. 2012 Mar 8;344:e1147. doi: 10.1136/bmj.e1147. Mobile phone use and glioma risk: comparison of epidemiological study results with incidence trends in the United States. BMJ. 2012 May 1;344:e3083; author reply e3088. doi: 10.1136/bmj.e3083. Association of mobile phone use with adult brain cancer remains plausible Davis DL, Miller AB, Philips A

27. Bibliography • Smithuis R, Montanera W. Brain Tumor – systematic approach. Available from URL: http://www.radiologyassistant.nl/en • Koeller KK, Sandberg GD. Cerebral intraventricularNeoplasms: Radiologic-Pathologic correlation. RadioGraphics 2002; 22:1473-1505 • Hoon Shin J, Kyu Lee H, Khang SK et al. Neuronal tumors of the central nervous system: radiologic findings and pathologic correlation. RadioGraphics 2002; 22:1177-1189 • Robert Wood Johnson University Hospital. Available from URL: http://www.rwjuh.edu/gamma-knife/gamma-knife-brain-tumor-treatment.aspx • Dahnert W. Radiology Review Manual 6th ed. Lippincott Williams & Wilkins 2007 • Weissleder et al. Primer of Diagnostic Imaging 4th ed. Mosby Elsevier 2007