Department of Radiology 1 CHU Hassan II Fez Department of anatomopathology2 CHU Hassan II Fez Department of neuro surgery 3 CHU Hassan II Fez FZ Belhoussine 1 M Boubbou ID: 799983
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IMAGING OF MIDLINE TUMORS OF THE CENTRAL NERVOUS SYSTEM
Department of Radiology 1, CHU Hassan II, Fez.
Department of anatomo-pathology2 CHU Hassan II, Fez.
Department of neuro surgery 3 CHU Hassan II, Fez.
F.Z. Belhoussine1, M. Boubbou1, B. Alami1, K.Moumna2, A.Amarti 2, M.Benzegmout3, S. Tizniti1
NR7
Slide2IMAGING OF MIDLINE TUMORS OF THE CENTRAL NERVOUS SYSTEM
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INTRODUCTION:
The
anatomy
of the
supratentoriel
midline
structures of the
brain
is
complex:Corpus callosum, Third ventricle, Trigone,Pituitary glandPineal gland,… Different types of tumors can arise from these structures including tumors of the trigone and septum, tumors of the falx, third ventricular tumors and pinal region tumors. These tumors share similar features: minimal clinical symptoms despite their occasional large size, mild non-specific intracranial hypertension syndrome, value of MRI for depiction of tumor location, stereotactic biopsy, relative difficulty of surgical management.
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OBJECTIVES:
Illustrate the radiological semiology encephalic tumors of the midline.
Show the value of MRI in the exploration of these tumors
.
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BACKGROUND:
The anatomy of the supra tentoriel midline structures of the brain is complex.
We can distinguish 4 region:
Sellar
and
suprasellar
region.
Corpus callosum region.
Intraventricular
region.
Pineal region.
Falx
region. Brain CT is less sensitive to MRI to contribute for depiction of tumor location, stereotactic biopsy, relative difficulty of surgical management.
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BACKGROUND:
ANATOMY
:
Fig
B:
Sagittal
Tl
MR ; 4: pineal region , 3:
sellar
and
suprasellar
region
34B125AFig A: Coronal Tl MR ; 1: V3 region , 2:corpus callosum region , 5:falx region
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BACKGROUND:
THE MAIN ETIOLOGIES by REGIONS
:
Sellar
/
Suprasellar
region
Microadenoma
.
Macroadenoma
.
Craniopharyngioma.MetastasisMeningiomaIntraventricular ( third ventricle)Colloide cyst ( anterior third ventricle).Astrocytomas.Craniopharyngioma.Hypothalamic astrocytoma.Suprasellar germinoma (involve the anterior third ventricular).Posterior third ventricle: colloid cyst; meningioma; choroide plexus papillomas; metastases.Pineal region:Pinealomas.Germinomas.Teratoma.Pineocytomas
/ pineoblastoma.
Benign cyst
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BACKGROUND:
THE MAIN ETIOLOGIES by REGIONS
:
Trigone
and corpus callosum region
Anaplasic
astrocytomas
.
Glioblastomas
.
Lymphoma
.LipomaMetastases.Fax regionMeningioma.Metastases.Hemangiopericytoma
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MATERIALS AND METHODS :
A retrospective study involving 36 patients collected for department of radiology and
neuro
surgery over 3 years.
Median age is 30 years (2- 77 years).
In all patients conventional magnetic resonance imaging in conjunction with diffusion-weighted imaging (DWI) was performed.
Proton magnetic resonance spectroscopy (MRS) was added in most cases.
MRI examinations were performed in a single session on a machine GE 1.5 Tesla.
Conventional MRI included:
sagittal T1, coronal T2, axial FLAIR, axial T2 *, Diffusion, 3 planes T1 gadolinium and
sequence
spectroscopic. Histological confirmation was performed in all patients.
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RESULTS :
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RESULTS :
Sellar
/
Suprasellar
region
MRI sagittal section (A) and coronal (D) T2 W1 and coronal T1
without
(B) and
with
gadolinium (C)
showing a sellar and suprasellar mass isointense T1, T2 discrete, so is raising homogeneous after contrast.Selected diagnosis: pituitary macroadenoma.Coronal graphic shows pituitary macroadenoma (open arrow). Indentation from diaphragma sella causes "snowman" appearance (curved arrows). Some cystic degeneration & hemorrhage is depicted.Anapath : PITUITARY MACROADENOMASUPRASELLAR MASS ADULT
A
B
C
D
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RESULTS :
Sellar
/
Suprasellar
region
MRI in coronal (A) and sagittal (D) T1, coronal T2 (B) and T1
contrast
Cornale
(c)
objectifying the presence of a large sellar and suprasellar process with a heterogeneous isointense T1 (A and D), discrete hyperintense T2 (B), with enhancement of heterogeneously after contrast (C). this process presents an important extension latérosellaire responsible hydrocephalus upstream.Sagittal graphic shows a predominantly cystic, partially solid, suprasellar mass with focal rim calcifications. Note small intrasellar component and fluid-fluid level.Anapath : CRANIOPHARYNGIOMASUPRASELLAR MASS CHILDAB
C
D
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RESULTS :
Sellar
/
Suprasellar
region
CRANIOPHARYNGIOMA
Benign
dysontogenetic
epithelial tumor derived from
Rathke pouch epithelium.Two types: Adamantinomatous and papillary. Location:Surgical division of craniopharyngioma into three groups: Sellar/ Pre chiasmatic / Retrochiasmatic. Best diagnostic clue:CT Finding: Partially Ca++, partially solid, cystic suprasellar mass in a child.MR Finding: - High signal intensity suprasellar mass on pre-contrast T1WI- Tl C+: Solid portions enhance heterogeneously, cyst walls enhance strongly.
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RESULTS :
Sellar
/
Suprasellar
region
CRANIOPHARYNGIOMA
Pathology
:
Most common pediatric intracranial tumor of
non-glial
origin.Approximately 54% of all pediatric sellar/chiasmatic region tumors are CPs Clinical Issues:Clinical profile: Pediatric patient with morning headache, visual defect, short stature.Age: Bimodal age distribution (peak 5-15 Years papillary CP > SOy).64-96% overall 10 year survival.Diagnostic Checklist:Use NECT to detect Ca++ if MR diagnosis is in question.
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RESULTS :
Sellar
/
Suprasellar
region
Anapath
:MENINGIOMA
Fig
A,B, C and D show a
sphenoid
ridge mass slightly intense with cortex in axial and sagittal T1W1(fig A, D) and axial T2W1(Fig C)witch enhance homogeneously & intensely (fig B)ABDC
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RESULTS :
Intraventricular
(3
rd
ventricle
)
A
D
C
31 years old. Headaches with visual disturbances neglected for a year. MRI: round lesion of the anterior third ventricle, although limited in homogeneous
hyperintense T1 and T2, clogging the holes of Monro, causing a biventricular hydrocephalus active upstream (FLAIR hyper intense peri-ventricular).Coronal T1 Flair W1 T2Anapath: COLLOID CYSTAxial graphic shows a classic CC at the foramen of Monro causing mild/moderate obstructivehydrocephalus. Note fornices and choroid plexus are elevated, stretched over the cyst (arrows).
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RESULTS :
Intraventricular
(3
rd
ventricle
)
Anapath
:PILOCYTIC
ASTROCYTOMA
26
years old, Headache, nausea and vomiting, MR find a mass in the third ventricle, hypo intense of Gray matter in T1W1, hyper intense to CSF in Flair and ringlike enhancement of cyst. ADCAxial FSPGR 3DCoronal T1W1 Gado+Coronal T1 Flair W1
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RESULTS :
Intraventricular
(3
rd
ventricle
)
A
D
C
38 years old. Headaches with visual disturbances and vomiting. MRI:
Intraventricular Well delineated, lobulated mass in third ventricle iso- intense In T1W1, hyper intense in T2W1, strongly and homogeneously enhanced.Coronal T1 Flair W1 T2Anapath: PAPILLOMA • Typically pediatric tumors, lateral ventricle• In adults, 4th ventricle, third ventricle in 10%• Enhancing papillary mass, hydrocephalus commonSAG t1
COR T1 GADO +
COR T2 flair
SAG T1 GADO +
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RESULTS :
Pineal
region
A
D
C
14 years old. Headaches with visual disturbances and vomiting. MRI: pineal region mass
arround
the posterior third ventricle with calcifications in CT,
i
so- intense In T1W1, hyper intense in T2W1, Slightly hyperintense flair , causing a triventricular hydrocephalus active upstream and homogeneously enhanced.T2Anapath: Germinoma•Engulfs" calcified pineal gland• Intensely enhancing pineal mass, often homogeneous• Often CSF spread at diagnosis• Hyperdense on CT• Typically young male patientsSAG t1SAG T1 GADO +Ca+Axial CT
SAG T1
SAG T1 Gado+
Axial T2 flair
COR T2
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RESULTS :
Pineal
region
A
D
C
31 years old.
Fainting, convulsive crisis last year. MRI: Round cyst hypo intense T1, hyper intense T2 without calcifications
.
T2
PINEAL CYST •Round, smooth cystic mass• Typically < 1 cm, may be up to 2 cm• Variable calcification and cyst fluid• No or minimal rim enhancement, compressed enhancing gland often seen posteriorly• May be indistinguishable from PC on imagingSAG t1SAG T1 GADO +COR T1SAG T1AXIAL T2
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RESULTS :
Pineal
region
A
D
C
37 years old. Headache.
MRI: lobular mass
occupating
trijimenal region slightly hyperintense to CSF on T1W1, doesn’t completely null on flair causing triventricular hydrocephalus active upstream, hyper intense on T2 , without enhancement.T2 Anapath: EPIDERMOID CYSTSAG t1SAG T1 GADO +v4COR T1COR flair T2
Axial T2
SAGT1 gado +
• Most
epidermoid
cysts resemble CSF, not fat
• No
dermal
appendages
• 4-9x more common than
dermoid
• Off-
midline
>
midline
: 40-50% in CPA, 10-15%
para
sellar
/middle
fossa
, 10%
diploic
• MRI:
Isointense
to CSF
except
restricts
on diffusion
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RESULTS :
Pineal
region
C
14 years old. Headache.
.MRI: lobular mass
occupating
trijimenal
region
slightly hyperintense to CSF on T1W1 flair, causing triventricular hydrocephalus active upstream, hyper intense on T2 flair, without enhancement.Coronal T1 Flair W1 Anapath: ASTROCYTOMA LOW GRADECor T2 flairCor T1 gado+ SAG T1 Axial SPGR
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RESULTS :
Trigone
and corpus
callosum
region
A
D
C
55 years old. Headache and memory troubles.
MRI: enhancing lesion involving the entire corpus
callosum showing minimal mass effect on the ventricle. Contrast enhanced axial T1W1.Coronal T1 Flair W1 T2 Anapath: LYMPHOMASAG t1SAG T1 GADO +v4COR T1COR flair T2Axial T2•Periventricular enhancing mass•Often crosses corpus callosum•
Typically iso-intense/hypointense
on T2WI• Necrosis common in AIDS related lymphoma.
Intravascular lymphoma may appear diffusely infiltrating.
Axial flair T1
Axial T2
Axial T1 Gado +
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RESULTS :
Trigone
and corpus
callosum
region
A
D
C
55 years old. Headache and memory troubles.
MRI:
Heterogenous mass involving the entire corpus callosum . It’s hypo intense on T1W1 and shows heteregenous enhancement lesion involving the entire corpus callosum showing minimal mass effect on the ventricle. Contrast enhanced axial T1W1.T2 Anapath: CORPUS CALLOSUM GLIOMA SAG t1SAG T1 GADO +COR T1Axial T2
Coronal T1 Flair W1
Sagittal T1
TDM axial C+
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CONCLUSION :
A
SAG t1
COR T1
Tumors of the midline of the brain are complex and diverse.
The magnetic resonance imaging is of major interest, allowing a particularly informative topographic analysis, a diagnostic aid, bringing sometimes a tissue characterization and support the choice of treatment, specifying the path and the target in stereotactic biopsies.
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BIBLIOGRAPHY :
A
SAG t1
COR T1
1-
A.Osborn
,
S.Blaser
,
K.Salzman
. Diagnostic Imaging :Brain.
2- Tumeurs cranio encéphalique de la ligne médiane. C.Delmaire; JY.Gauvrit; EL Hajj; G.Soto.Ares; JR2006, 87: 764- 78.3- Tous en selle sur l’hypophyse. R.Richard, C. Vandendries, F. Benoudiba, N. Hocine, M. Adoui, G. Nasser, D. Ducreux. SFR 2011.4- Imagerie des tumeurs de la région pinéale : à propos de 26 cas S. Belkacem, M. Fikri, J. Faik Ouahab, N. Ech-Cherif El Kettani, MR. El Hassani, M. Jiddane . SFR2011 .5- Aide au diagnostic des lésions kystiques intracrâniennes .Y Alaoui Lamrani, M Maâroufi, I Kamaoui, N Hammas, H Ammor, L Benjelloun, M Boubbou, N Sqalli Houssaini, A Amarti, S Tizniti. SFR 2011.
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A
SAG t1
COR T1
THANKS