Tumors in

Central Nervous System

1) Brain
2) Pituitary
3) Pineal
Brain Tumours
• Growth of abnormal cells in the tissues of the brain
• Commonly located at supratentorial compartment
• And commonly occurs in population older than 15, with 30% are mets lesions
• In population younger than 15, commonly in posterior fossa and rare to have mets
lesions
Classifications
Brain tumors

Primary Secondary/Metastasis

Intra-axial Extra-axial
(Within brain (External to brain Lung (50%)
parenchyma) parenchyma) Breast
Bone
Renal
Astrocytoma Meningioma Colon
Oligodendroglioma
Ependymoma
Astrocytomas
• Arised from astrocytes, account for 70% of all gliomas
Grade 1: Pilocytic Astrocytoma
Lower grade tumours
Grade 2: Low Grade Astrocytoma
Grade 3: Anaplastic Astrocytoma
Higher grade tumours
Grade 4: Glioblastoma Multiforme

• Epilepsy
• Focal brain damage- dysphasia,hemiparesis,personality change
• Raised ICP – headache,vomiting,depression of
conscious level
Lack of capsule and have the potential to spread throughout the CNS
 Lower grade tumors
•Hypodense on CT scan, little or no enhancement
•Hypointense on T1W1, hyperintense on T2W2, minimal enhancement

• Well demarcated, without

necrosis and neovascularity
• Showed clacification (20%),
rarely surrounding edema
• Often cystic

• Nonenhanced CT scan
shows a
heterogeneous, ill-
defined,
hypoattenuating area in
the right temporal lobe.
• Cystic pilocytic astrocytoma of
the hypothalamic region.
• Yellow arrow: cystic part
• Red arrow: solid part
Non enhanced T2-weighted MRI
shows a well-circumscribed area of
increased signal intensity in the left
temporal lobe
 Higher grade tumors

• Common to have necrosis, haemorrhage and neovascularization

• Surrounding white matter edema is very common
• Usually occurs in old age (>40 years old)

•Heterogenous on CT scan
•Isointense or hypointense on T1W1, hyperintense on T2W1
•Ring-like pattern on post-contrast imaging
• Contrast-enhanced (left) and nonenhanced (right) images show a cystic
lesion with thick walls in the left parietal lobe, with thick rim
enhancement on the enhanced image. Moderate surrounding vasogenic
edema causes mass effect on the atrium of the left lateral ventricle.
Axial nonenhanced T1-weighted.
Shows well-defined area of mixed signal intensity in the right parietal lobe extending to the corpus
callosum with adjacent vasogenic edema.
Mixed areas represent hemorrhage
Glioblastoma multiforme
• Large oval mass in the right
frontal lobe with surrounding edema.
• Hypodense
• There is a leftward midline shift and
compression of the right lateral and
third ventricles.
Axial enhanced and coronal enhanced T1-weighted MRI :
heterogeneous enhancement, extensive vasogenic edema, and mass effect
ependymal and subependymal enhancement involving the adjacent lateral ventricle
• T1-weighted axial gadolinium-enhanced • T2-weighted image demonstrates the
magnetic resonance image demonstrates an same lesion as in the previous image,
enhancing tumor of the right frontal lobe
with notable edema and midline shift.
Oligodendrogliomas
• 5-18% of all gliomas
• More common in adults with peak age of 30-50 years old
• 85% are supratentorial, located in frontal lobe
• Grows slowly and showed calcification in 100%, with haemorrhage and cyst occur in 20%

CT scan :
• Generally hypodense or isodense
• Occasionally hyperdense (due to hemorrhage or calcification)
• Reasonably well-demarcated mass

MRI:
• T1 : typically hypointense
• T2 : hyperintense with or without surrounding edema
Contrast-enhanced computed
tomography scan :

Image reveals a calcified

hypoattenuating lesion that is
invading the corpus callosum.

Left frontal oligodendroglioma

Axial T1-weighted MRI

Heterogeneous low signal

intensity in the left frontal
lobe involves the cortex and
white matter.

Low-grade
oligodendroglioma
Axial T2-weighted sequence magnetic resonance image of a low-grade oligodendroglioma. This
image shows heterogeneous high signal intensity in the left frontal lobe and low signal intensity in
the white matter of the right parietal lobe that corresponds to a cavernous hemangioma
 Ependymomas
• Arise from the ependymal lining of the ventricles or the central canal of the spinal cord
• often block CSF passages causing hydrocephalus
• 3-9% of neuroepithelial neoplasms, commonly manifest in children and adolescent (commonly in
posterior fossa - 4th ventricle)
CT scan :
• coarse calcification is common (50%) ; cystic areas (50%)
• solid component isodense to hypodense
• heterogeneous enhancement
• a small proportion can have haemorrhage
MRI:
• T1 - isointense to hypointense relative to gray matter
• T2 :- hyperintense to gray matter
• Heterogenous enhancement for solid components
Non-contrast CT scan. Slight heterogenous mass seen infratentorially. Slightly hyperdense with surrounding
cerebral edema, hydrocephalus due to CSF hinderances.
•Anaplastic ependymoma of the
right lateral ventricle

•T1-weighted axial image

demonstrates a heterogeneous mass
in the right frontal lobe

•Note the bright contrast

enhancement within the neoplasm
and areas of low signal intensity
consistent with calcification.
 Meningioma
• Common extra-axial neoplasm and account 15% of all intracranial tumors
• Peak at 50-60 years old, more common in female
• Arised from arachnoid cap cells, dural fibroblasts and pial cells

CT Scan MRI

• 60% slightly hyperdense to normal • Extra–axial lesion (cortical buckling)

brain,the rest are more isotense • Iso to hypointense to grey matter on
• Intratumoral calcifications may be T1WI
present • Variable intensity on T2WI
• Underlying parenchymal edema • Parenchymal edema more apparent
• Enhance homogeneously and • Enhance homogeneously and
intensely intensely with contrast
• “Dural tail" • “Dural tail"
• Hyperostosis
• Majority lying over the convexities
• CT scan shows a malignant
meningioma in the frontal
convexity.
• A hyperattenuating and
inhomogeneous enhancing mass
with ring-shaped enhancement is
shown
• Causes mass effects compressing
on adjacent brain structure
• Midlined shift
 – Well-circumscribed homogeneously
enhancing meningioma
– Located along the left frontal dural
convexity
– Marked parenchymal edema
– Mass effect with midline shift
– Lack of calcification

Contrast-enhanced axial CT scan obtained in a 59-year-old woman

– Coronal enhanced T1WI
– Meningioma with dural tail, hyperostosis of adjacent bone
and homogeneous enhancement
Metastatic Brain Tumors
Introduction
Intra-axial commonly from •Commonly to be multiple
-Lung, breast, melanoma and colon ca •30% solitary with melanoma, lung ca
Extra-axial, subaracnoid space and dural and breast ca the most likely primary
commonly from
-Breast ca, lymphoma, prostate ca, lung
ca and neuroblastoma
Commonly at supratentorial except
renal cell carcinoma (posterior fossa)
• CT scan
• hypodense

• MRI
– hypointense in T1W1
– Variable signal intensity in T2W1 with marked vasogenic edema
surrounding the lesion
– Intense enhancement with contrast administration (ring or nodular)
Mets from small cell lung CA
a) NECT- frontal hemorrhage with
additional hyperdense lesions
b) CECT- enhancement of hyperdense
lesions
c&d) T1 weighted – multiple enhancing
lesions
e) FLAIR – vasogenic edema surrounding
hemorrhage, but little edema associated
with other lesions
f) T2w- frontal hemorrhage, but no blood
in other lesions
Mets from ovarian CA

a&b) NECT- normal

c&d) CECT- multiple enhanced ill-defined nodules

e&f) T1w contrast MRI- innumberable enhancing

nodules
Solitary Mets from lung CA
a) NECT- hyperdense lesion at right
parietal gray-white matter junction with
surrounding vasogenic edema

b) Contrast T1w MRI- ring enhanced

lesion

c) FLAIR confirms extensive vasogenic

edema
Pituitary tumours
divided into
• macroadenoma (>1cm)
• microadenoma (<1cm)
 common
• macroadenoma 2x more common then microadenoma
 MRI preferred over CT
T1WI and T1WI+C
Normal
Pituitary Microadenoma
T1WI and T1WI+C
 Pituitary macroadenoma

a) T1W and b) T2W – large homogenous T1w-T2w isointense pituitary mass encroaching
cavernous sinus region
Pituitary macroadenoma
Pineal tumour
• Pineal gland is a small structure
located at the posterior of the
3rd ventricle
• CT scan- soft tissue attenuation
with calcification in adulthood
(>10 years)
• MRI- heterogenous due to
calcification and cystic space
Normal

MRI T1WI – normal pineal gland

Pineal Tumour

MRI T1WI contrast - Pineoblastoma

Pineal tumours

Left: Normal CT scan of 3rd ventricle Right: Mass lesion of the pineal region with hyperdense appearance