Imaging of Common Adult
and Pediatric Primary Brain Tumors
Humberto Morales, MD, and Mary Gaskill-Shipley, MD
T he primary goals of brain tumor imaging are lesion de-
tection, localization, delineation of extent, and charac-
terization. This information is used to formulate an appropri-
ate differential diagnosis that is extremely helpful for the
referring neuro-surgeons and the neuro-oncologists.1,2 In ad-
dition, imaging studies play a vital role in therapy planning,
such as stereotactic location for surgery or radiotherapy, and
assessing response to therapy.3
This article discusses the imaging characteristics of several
common pediatric and adult primary central nervous system
(CNS) tumors. The review will focus on the initial imaging
diagnostic workup and will give a useful radiological ap-
proach based on age, localization, imaging characteristics,
and relative frequency of brain tumors. Advanced magnetic
resonance (MR) techniques including spectroscopy and per-
fusion can provide additional information of brain tumors.
These techniques will be discussed separately in this supple-
ment.
Classification
The World Health Organization (WHO) classifies primary
brain tumors according to their cellular origin. The major
categories include neuroepithelial tumors, tumors of the me-
ninges, lymphoma and hematopoietic neoplasms, germ cell
tumors, tumors of the cranial and paraspinal nerves, tumors
of the sellar region, metastatic tumors, and cysts and tumor-
like lesions.4,5 Tumors of neuroepithelial origin comprise a sig-
nificant number of primary brain tumors, including astrocyto-
mas, oligodendrogliomas, ependymomas, choroid plexus
tumors, neuronal and mixed neuronal-glial tumors, pineal le-
sions, and embryonal tumors.
Grading of brain tumors is according to the WHO classi-
fication that assigns a grade of 1-4 from benign to malignant,
taking into account the presence of nuclear changes, mitotic
activity, endothelial proliferation, and necrosis. The proto-
typic WHO grade 1 tumor is the pilocytic astrocytoma (PA)
Division of Neuroradiology, University Hospital, Cincinnati, OH.
Address reprint requests to Humberto Morales, MD, Division of Neuroradi-
ology, University Hospital, 231 Albert Sabin Way, Cincinnati, OH
45267. E-mail: moralehc@ucmail.uc.edu
92 0037-198X/10/$-see front matter © 2010 Elsevier Inc. All rights reserved.
doi:10.1053/j.ro.2009.09.006
that has a 90% 5-year survival after resection whereas glio-
blastoma multiforme (GBM) represents one of the most com-
mon WHO grade 4 tumors with a 4% or less survival at 5
years.6
Although the final diagnosis and grading of brain tumors is
determined by histologic analysis, imaging can be very help-
ful in the initial assessment of neoplasms and can, in many
cases, help direct surgical biopsy or treatment. Imaging fea-
tures associated with increasing malignancy include mass
effect, vasogenic edema, enhancement, necrosis, and hemor-
rhage, particularly when astrocytic tumors are compared.7,8
Cerebral blood volume (CBV), which can be calculated from
MR perfusion studies and choline/creatine (Cho/Cr) ratios
based on MR spectroscopy, are relatively elevated in malig-
nant tumors, secondary to increased vascularity and cell pro-
liferation, respectively.8,9 However it is important to note that
some low-grade tumors can demonstrate “aggressive fea-
tures” on imaging. In children, PAs may have a malignant
appearance on conventional imaging, increased metabolism
on positron emission tomographic images, and increased
rCBV and Cho/Cr ratios.10,11 In adults, oligodendrogliomas
often have increased rCBV.12,13
Diagnostic Approach to
Intracranial Tumors Based
on Frequency, Age, Location,
and Imaging Characteristics
The radiologist’s ultimate goal in the initial imaging evalu-
ation of brain tumors should be to provide an appropriate
differential diagnosis that will guide future intervention
and treatment. Accurate diagnosis is based not only on the
radiological appearance of the tumor but also on the pa-
tient’s age and the location and relative incidence of the
lesion (Table 1).14 Each of these factors must be taken into
account.
The yearly incidence of primary brain tumors is 16.5 cases
per 100,000 population or approximately 30,000-35,000
new cases per year. In comparison, intracranial metastases
are much more common with as many as 170,000 cases
reported each year. The overall incidence of primary tumors
Imaging of primary brain tumors 93

Table 1 Diagnostic Approach of Primary Brain Tumors by Age, Location, and Relative Frequency
Pediatric Brain Tumors Adult Brain Tumors
Extraaxial Extraaxial
Rare in pediatric population: schwannoma and meningioma. Convexities
Meningioma, hemangioendothelioma, and
hemangioperycitoma.
Cerebello-pontine angle
Schwannoma, meningioma, and epidermoid.
Intraaxial Intraaxial
Supratentorial Supratentorial
Cortical Cortical
Neuronal and mixed neural-glial (DNET, ganglioglioma) Pleomorphic xanthoastrocytoma.
and pleomorphic xanthoastrocytoma. Corticomedullary
Corticomedullary Oligodendroglioma and fibrillary/anaplastic
Low-grade astrocytoma and S-PNET. astrocytoma
Deep white matter Deep white matter
Fibrillary/anaplastic astrocytoma, supratentorial Glioblastoma and fibrillary/anaplastic
ependymoma, and glioblastoma. astrocytoma
Corpus callosum/periventricular white matter
Glioblastoma, lymphoma, and gliomatosis
cerebri.
Infratentorial Infratentorial
Cerebellar hemisphere Cerebellar hemisphere
Pilocytic astrocytoma (PA) and ATRT. Hemangioblastoma and astrocytoma.
Intraventricular Intraventricular
Fourth ventricle Fourth ventricle
Medulloblastoma/PNET-MB and ependymoma. Subependymoma, choroid plexus papilloma, and
ependymoma.
Lateral ventricle Lateral ventricle
Choroid plexus papilloma, SEGA, meningioma, ependymoma, Meningioma, ependymoma, central neurocytoma,
and choroid plexus carcinoma. and subependymoma.
Third ventricle
Colloid cyst, astrocytoma, and chordoid glioma.
Midline Midline
Suprasellar-chiasmatic-optic Sellar/suprasellar
Craniopharyngioma, PA, germinoma, LCH, hypothalamic Pituitary adenoma, meningioma, and
hamartoma, lipoma, dermoid, and PMA. craniopharyngioma.
Pineal region Pineal region
Germinoma, teratoma, and pineoblastoma. Pineal cyst, pineocytoma, and
Brainstem epidermoid/dermoid.
Tectal glioma, focal/diffuse pontine, and medullary and
midbrain astrocytomas.
Multiple spaces Multiple spaces
Embryonal tumors (PNET, ependymoblastoma, and Malignant meningioma, hemangiopericytoma, and
neuroblastoma), ATRT. lymphoma.
Abbreviations: DNET, dysembryoplastic neuroepithelial tumor; S-PNET, supratentorial primitive neuroectodermal tumor; ATRT, atypical teratoid
rhabdoid tumor; SEGA, subependymal giant cell astrocytoma; LCH, Langerhan’s cell histiocytosis; PMA, pilomyxoid astrocytoma.

increases with age. The pediatric population (0-19 years) has
a low incidence rate of approximately 4.5 cases per 100,000
population/year while the highest occurrence rate is observed
in patients older than 50 years of age, accounting for over 30
cases per 100,000 population/year.6
The location and histology of primary brain tumors vary
with age. Although the most common location for primary
neoplasms in both adults and children is the cerebral hemi-
spheres; brain tumors in children have a special predilection
for the posterior fossa. In comparison, primary tumors lo-
cated in the cerebellum are unusual in adults. Therefore, in
the adult population, a solitary lesion in the posterior fossa is
most commonly a metastasis.
Differentiating between an intra- and extraaxial location of
a mass will significantly alter potential diagnoses. Although
extraaxial primary tumors, such as meningiomas, are com-
mon in adults, they are very uncommon in the pediatric
population. Intraventricular tumors have a very specific dif-
ferential diagnosis, which can vary depending on which ven-
tricle is involved. If a tumor is intraaxial, determination of its
specific location such as cortex, corticomedullary junction,
or white matter lesion will alter possible diagnoses.
94
Figure 1 Distribution of primary brain and central nervous system tumors by histology and age (Modified from CBTRUS
2000-2004). (Color version of figure is available online.)
Different tumor types occur at very different rates at vari-
ous ages (Fig. 1). The most common tumor of childhood is
the PA, followed by medulloblastoma. However, in adult-
hood, the most common tumor is meningioma, followed by
glioblastoma. Oligodendroglioma, which is common in
adults, is very rare in children. Neuronal and mixed neural-
glial tumors are more common in children than in adults
(Table 1). Therefore, correlating the location and character-
istics of a tumor with the age of the patient is crucial in
determining an appropriate differential diagnosis.
Tumors More
Common in Childhood
Pilocytic Astrocytoma (WHO Grade 1)
PA is the most common primary brain tumor in children.
Overall, patients with PA’s have a good prognosis after resec-
tion with a 94% survival rate at 10 years. Common locations
for PA’s include the cerebellum, optic nerve/chiasm/hypotha-
lamic region, or brain stem. Involvement of the cerebral
hemispheres is less frequent.
Pilocytic astrocytomas are typically well-defined lesions
that classically present as a cystic mass with an enhancing
mural nodule, however solid lesions do occur. Significant
vasogenic edema is rare. These are slow growing tumors that
often present due to localized mass effect. Lesions occurring
in the cerebellum may significantly compress the fourth ven-
tricle, making it difficult to identify the tumor’s parenchymal
origin. The main differential diagnosis is between the 2 most
H. Morales and M. Gaskill-Shipley
common pediatric fourth ventricular tumors, medulloblas-
toma (MB), and ependymoma (Fig. 2).15,16
PA’s occurring in the optic nerve/chiasm/hypothalamic re-
gion have been separated into 3 subsets. In the pediatric
population, tumors are divided into 2 types: those associated
with neurofibromatosis type 1 (NF1) and those not associ-
ated with NF1. PA’s in patients with NF1 are usually bilateral
nonenhancing tumors involving the optic nerves and less
commonly, the optic chiasm/hypothalamic region. They
have an indolent course. PA’s in non-NF1 patients usually
involve the chiasm/hypothalamic region. They are typically
solid/cystic enhancing tumors, which are often larger than
PA’s associated with NF1 and have a less indolent course. The
third subset of tumors, which is identified in adults, demon-
strates more aggressive behavior.
As mentioned earlier, PA may demonstrate a false “aggres-
sive appearance” on MR spectroscopy with significant eleva-
tion of Cho/Cr ratios. Recent studies have shown very low
concentrations of Cr in PA’s compared with other pediatric
tumors, as well as diminished quantities of total Cho. There-
fore, the paradoxical increase in Cho/Cr ratios does not nec-
essarily indicate increased cell proliferation.17
Medulloblastoma/
PNET-MB) (WHO Grade 4)
MB or PNET-MB (primitive neuroectodermal tumor-medul-
loblastoma) is a highly cellular, rapidly growing malignant
embryonal tumor. It is the second most common tumor in
children but the most common posterior fossa lesion. These
masses are typically located in the fourth ventricle arising
Imaging of primary brain tumors 95

Figure 2 (A, D) Pilocytic astrocytoma in a 7-year-old girl with headaches, vomiting, and papilledema. (B, E) Medullo-
blastoma in a 3-year-old boy with headaches and vomiting. (C, F) Ependymoma in a 2-year-old girl with vomiting.
(A, B, C) Axial computed tomography (CT) noncontrast images. (A) Isodense complex cystic-solid mass centered in the
mid cerebellum slightly right to midline. Note the mass effect upon the fourth ventricle. (B) Hyperdense predominantly
solid mass centered in the fourth ventricle with small cystic/necrotic areas. An additional small hyperdense lesion is
noted in the suprasellar region. (C) Isodense solid mass in the fourth ventricle with speckled calcifications. (D, E, F)
Axial and sagittal T1 with gadolinium images. (D) Complex mass with peripheral enhancement of the cystic/necrotic
portions causing significant effacement of the fourth ventricle. (E) Solid enhancing mass within the fourth ventricle,
associated with small enhancing lesion in the suprasellar region most consistent with cerebrospinal fluid dissemination.
(F) Lobulated heterogeneous enhancing mass extending out through the floor of the fourth ventricle. Note ventricular
enlargement in all 3 patients secondary to obstructive hydrocephalus (Images courtesy of Dr. Blaise Jones, MD,
Cincinnati Children’s Hospital).

from the superior medullary velum. Involvement of the cer-
ebellar hemispheres is rare, usually occurring in older chil-
dren and adults and typically representing desmoplastic me-
dulloblastomas.18 MBs have a variable prognosis after resection
with a 50% survival rate at 10 years.
MBs are typically isointense on T1 weighted images,
mildly hypointense to cortex on T2 weighted images, and
homogeneously enhance. The desmoplastic variant that has a
better prognosis often demonstrates a different imaging pat-
tern characterized by calcifications and subtotal heteroge-
neous enhancement.19 Diffusion restriction is commonly ob-
served due to the tumor’s dense cellularity.20 Ninety percent
of these lesions are dense on computed tomography (CT),
which can aid in the radiographic diagnosis (Fig. 2). Approx-
imately one-third of MB’s will have subarachnoid dissemina-
tion at the time of presentation; therefore, imaging the entire
neuroaxis is extremely important to evaluate the extent of
disease.
Supratentorial primitive neuroectodermal tumors (S-PNET)
are a subset of tumors genetically distinct from infratento-
rial PNETs (PNET-MB). Though only 6% of PNETs are
supratentorial, they are important hemispheric masses to
consider in newborns and infants. S-PNETs are large, com-
plex hemispheric masses with heterogeneous enhancement
96 H. Morales and M. Gaskill-Shipley

Figure 3 Supratentorial primitive neuroectodermal tumor in a 1-year-old boy. (A) Axial noncontrast CT image shows a
large mass centered in the trigone of the left lateral ventricle extending into the parietal and occipital brain parenchyma.
There are multiple calcifications and enlargement of the left lateral ventricle. Note ventricular drainage catheter tip in
the right frontal horn. (B) Axial T2 image shows a large mass with significant heterogeneous signal. Areas of dark signal
predominantly in the periphery and cortical regions are consistent with calcifications/hemorrhagic staining.
(C) Coronal T1 with gadolinium image shows heterogeneously enhancing mass with solid/cystic components involving
the ventricle and brain parenchyma as well as extending into the dural/extracranial spaces. Involvement of multiple
spaces is an important characteristic of supratentorial primitive neuroectodermal tumor (Images courtesy of Dr. Blaise
Jones, MD, Cincinnati Children’s Hospital).

and minimal peritumoral edema.21 The differential diagnosis
of these lesions includes teratoid or rhabdoid tumors and
ependymomas. Unlike PNET-MB, calcifications, hemor-
rhage, and necrosis are common (Fig. 3). Patients with
S-PNET have decreased survival compared to those with
PNET-MB.
Ependymoma (WHO Grade 2)
Ependymomas are the fourth most common posterior fossa
tumor in the pediatric population.22 They arise from ependy-
mal cells lining the ventricles and are most commonly located in
the fourth ventricle. Unlike medulloblastomas, which originate
superiorly from the medullary velum, ependymomas arise from
the floor of the fourth ventricle (Fig. 2). One-third of ependy-
momas are located supratentorially where they have a
characteristic deep parietal white matter location rather
than intraventricular. They are slow growing tumors with an
overall 60%-70% survival rate at 5 years after resection.
Infratentorial ependymomas typically preset as heteroge-
neous enhancing lesions that often extend out through the
Imaging of primary brain tumors
foramina of Luschka and Magendie into the cisterns. Punc-
tate calcifications occur in approximately 50% of cases,
therefore CT may be helpful in differentiating this tumor
from MB and PA (Fig. 2).23 Ependymomas may also dem-
onstrate cystic transformation, hemorrhage, necrosis, and
edema.
Choroid Plexus Papilloma/
Carcinoma (WHO Grade 1 and 4)
Choroid plexus papillomas (CPP) are intraventricular papil-
lary neoplasms that are derived from the choroid plexus ep-
ithelium. CPP is one of the most common brain tumors in
children below the age of 2 years.24 In the pediatric popula-
tion they are located in the atrium of the lateral ventricle. In
contrast, tumors in adults are typically located in the fourth
ventricle and cerebellopontine angles. CPP is a slowly grow-
ing tumor with a 5-year survival rate close to 100%.
Imaging features include a frond-like lobulated mass with
intense enhancement. Calcifications and hemorrhage are fre-
quently present. Hydrocephalus is very commonly associated
with CPP’s and can be due to either overproduction or ob-
struction of cerebrospinal fluid (CSF).
Choroid plexus carcinomas (CPC) are malignant neo-
plasms that account for approximately 20%-30% of all cho-
roid plexus masses. Most cases occur in children and also
typically arise in the lateral ventricles. CPC’s have a poor
prognosis with a 50% survival rate at 5 years. Imaging find-
ings that can help differentiate CPP from carcinomas include
extension of the lesion beyond the ventricle wall, prominent
vasogenic edema, and mass effect.23 Both CPP’s and CPC’s
can seed the CSF, however metastatic spread is more com-
monly observed with carcinomas.
Figure 4 Dysembryoplastic neuroepithelial tumor in a 10-year-old girl with seizures. (A) Axial fluid attenuated inver-
sion recovery (FLAIR) image shows a cortical lesion in the left temporal lobe, with an incomplete medial rim of
hyperintense signal. (B) Coronal T1 image with gadolinium shows subtle enhancement of the cortical lesion. Note the
“bubbly appearance” with small rounded areas of hypointensity on FLAIR and T1 near the cortex (Images courtesy of
Dr. Blaise Jones, MD, Cincinnati Children’s Hospital).
97
Neuronal and Mixed
Neural-Glial Tumors (WHO Grade 1-2)
Dysembryoplastic neuroepithelial tumors (DNET) and gan-
gliogliomas/gangliocytomas are the most common mixed
neural-glial tumors in children and young adults. These le-
sions are cortical tumors often associated with refractory sei-
zures.
DNET is a benign mixed neural-glial tumor frequently
associated with a background of cortical dysplasia.25 They are
most commonly found in the temporal lobes; however, they
can arise in other areas of the cerebral hemispheres and pos-
terior fossa. On magnetic resonance imaging (MRI), DNETs
typically have a “bubbly” or multicystic appearance. Most
lesions are well defined with no edema and little mass effect.
Enhancement is present in up to 50% of cases and is usually
nodular or ringlike in appearance. Calcification may be
present. A “FLAIR (fluid attenuated inversion recovery)
bright ring” sign has been described with these tumors,
which is a complete or incomplete hyperintense rim that may
be caused by the presence of loose peripheral neuroglial ele-
ments (Fig. 4). This sign may help differentiate these tumors
from other cortical lesions.26
Gangliogliomas (WHO grade 1 or 2) and gangliocytomas
(WHO grade 1) are also cortically based neoplasms. Ganglio-
gliomas are composed of both benign mixed atypical gan-
glion cells and neoplastic glial cells, whereas gangliocytomas
are primarily composed of dysplastic or neoplastic neurons.
Although both lesions are usually benign, rare cases of ma-
lignant degeneration or metastatic spread have been repor-
ted.27 These lesions can be either solid, cystic, or mixed.15
Approximately 50% will present as a cystic mass with a mural
98
nodule. Most lesions demonstrate either solid or heteroge-
neous enhancement. Mass effect and edema are uncommon.
Brainstem Tumors (WHO Grade 1-4)
Most brainstem tumors are gliomas, including fibrillary as-
trocytomas, PAs, and rarely glioblastomas. Eighty percent of
all brainstem gliomas occur in the pediatric population. They
are categorized according to where they develop (pontine,
medullary, and midbrain) and whether they are diffuse or
focal. Prognosis varies greatly depending on the location and
grade of the lesion.
Pontine gliomas are more often diffuse lesions that may
present with cranial nerve palsies and ataxia.28 These lesions
are often high-grade and have a poor long-term prognosis.
Imaging features include expansion of the brain stem with
abnormal T2 prolongation. Enhancement is usually absent.
Tectal gliomas typically have a distinctly benign behavior
compared to other brainstem tumors. Some authors believe
that these tumors are hamartomas; however, other series
have histologically shown these tumors to be low-grade PAs.
Due to their location adjacent to the sylvian aqueduct, these
lesions often present with obstructive hydrocephalus. They
usually do not require treatment beyond CSF diversion such
as third ventriculostomy or shunting.24
Tumors More
Common in Adulthood
Astrocytomas
Gliomas are the most common primary intraaxial mass in
adult population. Astrocytomas account for over half of all
gliomas and can be divided into 2 major categories, infiltra-
tive and noninfiltrative. Infiltrative astrocytomas are much
more common, representing 75% of all lesions. The nonin-
Figure 5 Low-grade astrocytoma in a 35-year-old woman who presented with seizures. (A) Axial T2 weighted image
demonstrates a moderate sized area of hyperintense signal involving the white matter and cortex of the left frontal lobe.
(B) Axial T1-weighted post gadolinium image demonstrates subtle hypointensity within the lesion. No abnormal
enhancement is observed. Note the relative lack of mass effect despite the size of the lesion.
H. Morales and M. Gaskill-Shipley
filtrative subset includes PAs, pleomorphic xanthoastrocyto-
mas, subependymal giant cell astrocytomas, and desmoplas-
tic cerebral astrocytomas of childhood. This section will
primarily focus on the infiltrative type.
Infiltrative astrocytomas range from low-grade lesions to
highly aggressive malignant neoplasms. Grading these tu-
mors is based on several histopathologic features including
cellularity, nuclear atypia, mitotic activity, endothelial prolif-
eration, and necrosis. As described previously several imag-
ing features including mass effect, edema, enhancement, and
necrosis can help predict tumor grade.
Low grade astrocytomas (WHO grade 2) comprise approx-
imately 25% of all gliomas.29 They tend to occur in younger
adults, often in the third and fourth decades of life. Low grade
gliomas are best visualized on MRI and typically present as
nonenhancing well demarcated or ill-defined lesions in the
cerebral hemispheres (Fig. 5). Edema is usually absent. Typ-
ically there is absent or minimal mass effect, a finding which
can be striking given the size of some lesions.
Anaplastic astrocytomas (AA) (WHO grade 3) occur in a
slightly older population and confer a worse prognosis. The
median survival rate for these patients is 2-3 years. Most AA’s
result from dedifferentiation of low grade gliomas, however
some arise de novo.30 Histologically, AA contains gemisto-
cytes and protoplasmic elements but no necrosis. Dissemina-
tion occurs through the white matter tracts. AA’s typically
demonstrate edema and mass effect that helps to differentiate
them from low grade gliomas (Fig. 6). Approximately two-
thirds of AA’s will partially enhance.
GBM (WHO grade 4) is the most aggressive and malignant
form of astrocytoma and is characterized histologically by
necrosis and neovascularity. It is the second most common
tumor in adults after meningioma and usually occurs in pa-
tients older than 50 years of age.6,31 Involvement of patients
Imaging of primary brain tumors 99

Figure 6 Anaplastic astrocytoma in a 48-year-old man with visual abnormalities and headaches. (A) Axial T2-weighted
image shows a large lesion in the right medial occipitoparietal lobes. Surrounding abnormal T2 signal extends into the
right parietal white matter and across the splenium of the corpus callosum. (B) Axial T1-weighted post gadolinium
image demonstrates a nonenhancing, hypointense mass. Note the mass effect and midline shift that helps to differen-
tiate this lesion from a low-grade astrocytoma. One-third of anaplastic astrocytomas will not enhance.

less than 30 years is rare. These tumors have the worst prog-
nosis among primary brain tumors. The median postopera-
tive survival time is 8 months, and the overall 10-year sur-
vival rate in patients older than 45 of age is less than 1.8%.
GBM’s are most commonly located in the supratentorial
white matter. Involvement of the brainstem and cerebellum
is rare; however, these locations are more common in chil-
dren than adults (Fig. 7). On MRI, GBM’s are usually identi-
fied as large heterogeneously enhancing masses with signifi-
cant necrosis, mass effect, and vasogenic edema (Fig. 8).
Hemorrhage of differing stages is often observed. Involve-
ment of the bilateral hemispheres through the corpus callo-
sum (“butterfly glioma”) is a classic presentation.
Surgical resection of GBM’s is nearly always incomplete
due to the highly infiltrative nature of the tumor. Biopsies
taken from around the margins of resection cavities have
demonstrated tumor cells in the surrounding “edema” and
even in normal appearing white matter.32 Surgical resec-
tion and radiation are frequently targeted to the enhancing
(higher grade) portion of the tumor, however the presence

Figure 7 Glioblastoma multiforme in a 5-year-old boy with abnormal gait and vomiting. (A) Axial T2 image shows an
intraaxial mass centered in the right brachium pontis with a central area of necrosis and thick peripheral solid
component. (B) Axial T1 postgadolinium image shows minimal enhancement of the thick peripheral component.
Cerebellar and brainstem glioblastomas are rare, however they are more common in children than adults.
100 H. Morales and M. Gaskill-Shipley

Figure 8 Glioblastoma multiforme in a 59-year-old man who presented with seizures and neurologic deficit. (A) Axial
T2-weighted image demonstrates a mildly hyperintense mass in the lateral right frontal lobe. Note the prominent
surrounding abnormal T2 signal in the adjacent white matter that represents edema and infiltrative tumor. (B) Axial
T1-weighted post gadolinium image shows an irregularly enhancing mass with areas of necrosis.

of tumor cells in the surrounding tissue limits curative
therapy.
Oligodendroglioma (WHO Grade 2)
Oligodendrogliomas are infiltrative gliomas that originate from
oligodendroglial cells. They occur in middle-aged adults and
often present with seizures. Pediatric involvement is rare. Oli-
godendrogliomas may be low grade (WHO grade 2) or anaplas-
tic (WHO grade 3). Similar to astrocytomas, higher grade
oligodendrogliomas demonstrate increased cellularity,
mitotic activity, endothelial hyperplasia, and necrosis. Mixed
oligodendrogliomas contain both features of astrocytomas and
oligodendrogliomas, and can be classified as grade 2 or 3.
Many oligodendrogliomas demonstrate 1p and/or 19q
chromosomal deletions.33 The presence of these chromo-
some losses increases the tumor’s response to radiation and
chemotherapy and improves prognosis. Patients with both
1p and 19q deletions have a median survival time of 8-10
years whereas patient without the deletions have a survival
time of 3-4 years.
Differentiating oligodendrogliomas from astrocytomas on
conventional imaging is often not possible. However, several
imaging features favor the diagnosis of oligodendroglioma,
including cortical involvement, heterogeneous signal, intra-
tumoral cysts, patchy enhancement, and the presence of cal-
cifications34,35 (Fig. 9). Calcifications, which can be seen in

Figure 9 Oligodendroglioma in a 30-year-old man who presents with seizures. (A) Axial T2 FLAIR image shows a large,
mildly heterogeneous left frontal mass involving cortex. Focal areas of hypointense signal represent calcifications that
were confirmed on CT. The lesion is well-defined with no edema and mild mass effect. (B) Axial T1-weighted post
gadolinium image shows patchy enhancement within the lesion.
Imaging of primary brain tumors 101

80% of all oligodendrogliomas, are best demonstrated on CT;
however, gradient imaging can increase MR’s sensitivity. Ol-
igodendrogliomas tend to have higher relative CBVs on MR
perfusion studies compared to other low-grade glial tumors
that is related to a dense capillary network rather than a
higher grade of tumor.13
Pleomorphic
Xanthroastrocytoma (WHO Grade II)
Pleomorphic xanthroastrocytoma (PXA) is a distinct type of
circumscribed astrocytic tumor noted for cellular pleomor-
phism and xanthomatous change. Although usually classified
as WHO grade 2 tumors, they can undergo malignant trans-
formation. PXAs are slow growing lesions that typically
present in the first 2 decades of life. They are usually located
in the cerebral hemispheres with a higher incidence in the
temporal lobes. Recurrence after resection is uncommon and
the survival rate at 10 years is 70%.
Imaging features of PXAs typically include a supratentorial
cortical cystic mass with an enhancing mural node. PXAs are
superficial lesions that involve the leptomeninges as well as
the brain parenchyma. As a result, a “dural tail” may be
present that can help differentiate these neoplasms from
other cortical tumors, such as DNET or ganglioglioma.36
Primary CNS Lymphoma
The vast majority of intracranial lymphomas are primary le-
sions that involve the brain parenchyma. More than 90% are
non-Hodgkin B-cell type. Secondary CNS lymphoma is rare

Figure 10 Primary central nervous system lymphoma in a 62-years-old immunocompetent man. (A) Axial T2-weighted,
(B) T2 FLAIR, and (C) post gadolinium images demonstrate an irregular, homogeneously enhancing mass in the
anterior genu of the corpus callosum extending into the frontal lobes. An additional lesion is noted in the splenium of
the corpus callosum. The lesions are mildly hyperintense on T2 weighted images and are associated with moderate
edema. The multiplicity of lesions, periventricular location, and homogeneous enhancement support the diagnosis of
lymphoma.
102
and often presents with dural or leptomeningeal involve-
ment.
Imaging features and clinical prognosis of primary CNS
lymphoma vary with the patient’s immune status. In immu-
nocompetent patients primary lymphoma typically presents
as solitary or multiple predominantly solid masses in the
basal ganglia and white matter, often periventricular in loca-
tion.37 These are highly cellular tumors that give them a char-
acteristic hyperdensity on CT and homogeneous hypointen-
sity on T2 with strong homogeneous enhancement38 (Fig.
10). Diffusion restriction may be present due to the dense
cellularity of the lesion.39 The administration of corticoste-
roids can modify or annul tumor enhancement, and therefore
should not be administered before initial CT and MR imaging
unless clinically necessary.
In immunodeficient patients, CNS lymphoma tends to
present as multifocal heterogeneous/peripheral enhancing le-
sions with central necrosis.40 These lesions may be indistin-
guishable from infectious etiologies including toxoplasmosis.
However, as in immunocompetent patients, lymphoma in
patients with acquired immunodeficiency syndrome (AIDS)
has a characteristic tendency to involve the ependymal sur-
faces and periventricular white matter.
The incidence of primary CNS lymphoma has tripled over
the past 2 decades, largely due to the increase in patients with
AIDS. However, the incidence of lymphoma is also rising in
the immunocompetent population.38 No environmental or
behavioral factors have been identified to account for this rate
increase.41 In general the prognosis for CNS lymphoma is
poor due to recurrent disease, however it is moderately better
in immunocompetent patients. The median survival time for
AIDS patients with intracranial lymphoma is only 2-6
months.
Hemangioblastoma (WHO Grade 1)
Hemangioblastomas are benign tumors of vascular etiology
that represent approximately 1%-2% of all primary CNS neo-
Figure 11 Hemangioblastoma in a 43-year-old man who presented with headaches. (A, B) Axial T2-weighted and post
gadolinium T1-weighted images demonstrate a large cystic mass with an enhancing mural nodule in the right cerebel-
lum. Marked compression of the fourth ventricle is present.
H. Morales and M. Gaskill-Shipley
plasms. Although rare, hemanagioblastomas are the most
common primary adult intraaxial posterior fossa tumor.42
Over 85% of hemangioblastomas occur in the cerebellar
hemispheres. Less commonly they involve the vermis, me-
dulla, and spinal cord; rare supratentorial lesions have been
reported. Males are more commonly affected than women,
and most patients present within the third to fifth decades of
life. Pediatric involvement is rare.
Most hemangioblastomas occur sporadically, however ap-
proximately 25% are associated with von Hippel-Lindau syn-
drome, an autosomal dominant disease which is also associ-
ated with retinal angiomatosis and visceral tumors involving
the kidneys and adrenal glands.43 Surgical resection is usually
curative, however patients with von Hippel-Lindau syn-
drome often have multiple lesions.
The most common imaging presentation of hemangioblas-
tomas is a well-defined cyst of variable size with an intensely
enhancing mural nodule (Fig. 11). Approximately 25% of
lesions will present as a solid mass without a defined cyst.
Prominent flow voids may be present within the solid por-
tions of the tumor due to the vascular nature of the tumor.
Uncommonly, hemangioblastomas can present as a cyst
without evidence of an enhancing nodule or wall.
Meningioma (WHO Grade 1-3)
Meningiomas arise from arachnoid meningothelial cells and
are the most common benign intracranial neoplasm in adults.
In general, these lesions are slow growing tumors (WHO
grade 1) with a good prognosis, however atypical and ana-
plastic meningiomas (WHO grade 2–3) do occur.44 Aggres-
sive meningiomas can invade the brain parenchyma and will
rarely metastasize to distal sites.
The incidence of meningiomas is highest in middle-aged
women. Meningiomas may occur in multiples, particularly
when associated with neurofibromatosis type 2, and have
been associated with a history of radiation treatment. The
Imaging of primary brain tumors 103

most common location for meningiomas is in the cerebral
convexities. Less common locations include the sphenoid
ridge, olfactory groove, parasellar region, cerebellopontine
angle, and optic nerves. Intraventricular lesions in the adult
population are rare but have a typical presentation in the atria
of the lateral ventricles (Fig. 12).
Meningiomas are most commonly present as extraaxial
masses with prominent homogeneous enhancement and
broad dural attachments. Although the MR signal charac-
teristics of meningiomas on precontrast sequences can
vary, typically they are isointense to brain on T1 weighted
images and isotense to mildly hyperintense on T2
weighted images. This is due to the homogeneous cellu-
larity of the tumor. Tumoral calcifications and hyperosto-
sis of the underlying skull bone are frequent. Edema is
commonly observed in the adjacent brain parenchyma
particularly with masses over the cerebral hemispheres.
The cause of the edema is not fully understood and may be
related to mechanical compression or secretions from the
tumor, however there is no direct correlation between the
presence of edema and the aggressiveness of the lesion or
brain invasion.45 Lesions that can mimic meningiomas in-
clude dural metastases, lymphoma, and hemangiopericy-
tomas.
Meningiomas in the pediatric population are rare, however
when they occur they often have distinct characteristics.
Childhood meningiomas have a male predilection, are more
commonly intraventricular in location compared to adults

Figure 12 Intraventricular meningioma in a 46-year-old woman with headaches. (A) Precontrast axial T2 and (B) T1
weighted images demonstrate an intraventricular mass within the atrium of the right lateral ventricle. The lesion is
hyperintense on the T2 weighted image and isointense on T1. (C) Post gadolinium T1-weighted image shows marked,
homogeneous enhancement of the mass. The signal characteristics, location, and enhancement pattern are typical for
an intraventricular meningioma.
104 H. Morales and M. Gaskill-Shipley

and usually do not have a dural tail.46 These tumors also have
a tendency to malignant transformation.
Central Neurocytoma (WHO Grade 2)
Central neurocytoma is an intraventricular neuronal cell tumor
that typically arises from the septum pellucidum or ventricular
wall. Most lesions are present in the lateral ventricles, however
third ventricular involvement does occur. Histologically, central
neurocytomas resemble oligodendrogliomas, and until recently
were considered “intraventricular oligodendrogliomas.” Neuro-
nal characteristics observed on electron microscopy led to the
reclassification of this lesion in 1982.47
Central neurocytomas occur in young adults and often
present with signs of increased intracranial pressure or hy-
drocephalus due to their intraventricular location. The lesion
typically has a benign course, however more aggressive be-
havior including invasion of the brain and seeding of the CSF
can occur. The survival rate is approximately 81% at 5 years.
On imaging, central neurocytomas are present as hetero-
geneous masses often attached to the septum pellucidum
(Fig. 13). Calcifications and cystic changes are common.48
Solid portions of the tumors demonstrate variable and irreg-
ular enhancement.
Subependymoma (WHO Grade 1)
Subependymoma is an uncommon, benign intraventricu-
lar tumor that typically occurs in middle-aged to older
adults. The most common location for this tumor is the
inferior fourth ventricle followed by the frontal horns of
the lateral ventricles attached to the septum pellucidum.
Subependymomas are usually asymptomatic, however ob-
structive hydrocephalus can occur due to the lesion’s in-
traventricular location.49 Patients with subependymomas
have an excellent prognosis; surgical resection is curative
in most cases.
Imaging features of subependymomas on CT include a
hypodense lobular mass within the fourth or lateral ventri-
cles. On MR these lesions are usually hypo-to isointense on
T1 weighted images and hyperintense on T2 weighted se-
quences. Enhancement is typically absent (Fig. 14).

Figure 13 Central neurocytoma in a 39-year-old man with signs of increased intracranial pressure. (A) Noncontrast CT
scan demonstrates a large heterogeneous, mildly hyperdense intraventricular mass with involvement of the septum
pellucidum. (B) T2-weighted sagittal image shows prominent heterogeneity of the lesion with multiple small cysts.
(C) T1-weighted post gadolinium coronal image demonstrates patchy enhancement. Note the lateral ventricular
dilatation caused by obstruction at the foramen of Monro.
Imaging of primary brain tumors
Figure 14 Subependymoma in an asymptomatic 33-year-old woman. (A) Axial T2 FLAIR image shows a small, well-
defined homogeneous intraventricular mass arising from the septum pellucidum. (B) T1-weighted post gadolinium
coronal image demonstrates no enhancement. The location and lack of enhancement are typical for this benign lesion.
Conclusion
Imaging is a vital step in the initial work-up of brain tumors.
An appropriate differential diagnosis should be based not
only on the radiographic characteristics of the tumor but also
on the age of the patient, location of the lesion, and the
tumor’s relative frequency. Advanced imaging techniques of-
ten can provide complementary information; however, con-
ventional CT and MRI remain the primary tools for neuro-
oncological diagnosis and early detection.
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