Presented By

Dr. Shamim Rima

M.PHIL
RADIOLOGY & IMAGING
BSMMU.
 BRAIN TUMOUR

• Primary neoplasms of the central nervous system (CNS)

represent nearly 10% of all tumour reported.

Age Incidence

• Cerebral tumours are predominantly tumours of adult

life With a peak incidence of 13 cases per 100,000
population at age 55-65.
• They are relatively uncommon in infants and children at 2
cases per 1,00,000.
 BRAIN TUMOUR, Contd.

Primary Tumour

Primary intracranial tumour can occur at any age, it is

helpful in deferential diagnosis to know that certain tumor
occur mainly in certain age groups.

Secondary Tumour

These affect mainly the middle aged and elderly, with the
exception of secondary neuroblastoma which occurs
mainly in children.
 BRAIN TUMOUR, Contd.

Location
• In adults supratentorial
tumours out number
posterior fossa tumour by a
ratio of 7 to 3.
• But in children this ratio is

reversed and posterior fossa

tumours are the most
common.
 DIAGNOSTIC IMAGING

• The goals of diagnostic imaging in the Pt. with suspected

intracranial tumour include:

- Detection of the presence of neoplasm

- Localization of the extent of the tumour

- Characterization of the nature of the process

Contd ..
 DIAGNOSTIC IMAGING

 Plain radiography :
Full skull series include the four views
- Lateral projection
- Occipito frontal projection
- Half axial antero posterior (Town’s) Projection
- Sub mento vertical (base) Projection

Contd ..
 DIAGNOSTIC IMAGING:

 CT
- Routine CT examination of the brain and specific area.

- Computed tomography cisternography.

 MRI
- Magnetic resonance diffusion imaging

- Magnetic resonance perfusion imaging.

- Magnetic resonance spectroscopy.

Contd ..
 DIAGNOSTIC IMAGING:

 Functional Imaging techniques

- Single photon emission computed tomography

- Positron emission tomography

 Vascular Imaging

- Conventional intra arterial angiography

- Computed tomography angiography

- MR angiography

- Doppler ultrasound
Contd ..
 CLASSIFICATION
• Brain tumour may be classified in different ways one
of them may be:

Primary neoplasm that derived from normal cellular

constituents

Primary neoplasm that arise from embryologically

misplaced tissue

Secondary neoplasm from extracranial primary sites

that metastasize to the CNS.
Non neoplastic condition that can mimic tumour.

Contd ..
 CLASSIFICATION OF INTRA CRANIAL TUMOURS:

There are several ways of classifying brain tumours:

primary versus secondary

intraxial (arising from the brain parenchyma) versus extra

axial (arising from tissue covering the brain such as dura)
and

various regional classification

> Supratentorial
> Infratentorial
> Intraventricular
> Pineal region
> Sellar region tumours. Contd ..
 CLASSIFICATION ACCORDING TO HISTOLOGY

Primary brain tumours are subdivided into two basic groups:

Tumours of neuroglial origin (Glioma)

Non - glial tumours that are specified by a combination

of putative cell origin and specific location.

Glial tumors (gliomas)

- Astrocytomas

Fibrillary astrocytomas

Benign astrocytoma
Contd ..
 GLIAL TUMORS (GLIOMAS)

Astrocytomas :
Anaplastic astrocytoma
Glioblastoma multiforme

Pilocytic astrocytoma
Pleomorphic xanthoastrocytoma
Subependymal giant cell astrocytoma

Oligodendroglioma

Ependymal tumours

Choroid plexus tumours Contd ..

 NONGLIAL TUMOURS

Neuronal and mixed neuronal-glial tumours

Ganglioglioma
Gangliocytoma

Meningeal and mesenchymal tumours

Meningioma

Hemangiopericytoma

Hemangioblastoma

Fibrous histiocytoma Contd ..

 NONGLIAL TUMOURS

Pineal region tumours

Pineocytoma
Pineoblastoma
Pineal cell tumours
Choriocarcinoma
Teratoma
Germinoma

Germ cell tumours

Contd ..
 Nonglial tumours

Other cell tumours

Benign pineal cysts

Astrocytoma

Embryonal tumours

Neuroblastoma
Primitive neuroectodermal tumours (PNET)

Cranial and spinal nerve tumours

Schwannoma
Neurofibroma
 NONGLIAL TUMOURS

Hemopoetic neoplasm's

Lymphoma
Leukemia
Plasmacytoma

Pituitary tumours

Contd ..
 NONGLIAL TUMOURS

Cysts and tumour like lesions

Rathke cleft cyst

Dermoid cyst
Epidermoid cyst
Colloid cyst
Enterogenous cyst
Neuroglial cyst
Lipoma
Hamartoma
Contd ..
 NONGLIAL TUMOURS Contd.

Local extensions from regional tumours

Craniopharyngioma

Paraganglioma

Chordoma

According to location

Intra axial

Extra axial
 Points Intra axial Extra axial

Within brain Outside brain

Location parenchyma. parenchyma
Contiguity with bone /
Usually not Yes
flax
Bony changes Usually not Yes
Effaced
CSF space Often widened

Corticomedullary buckling No Yes

GM / WM junction Destruction Preservation

External carotid
Internal carotid artery
Vascular supply
artery
 INTRA AXIAL

Primary

Glioma
Atrocytoma
Oligodendroglioma
Ependymal tumour
Lymphoma
Hemangioblastoma
Dermoid , epidermoid (rarely)

Secondary

Metastesis
 INTRA AXIAL Contd.

Infratentoria
l

• Brainstem glioma

• Cerebellar astrocytoma
• Medulloblastoma
• Ependymoma
• Meningioma
• Hemangioblastoma
• Dermoid
 INTRA AXIAL Contd.

Supratentorial

• Meningeoma

• Dermoid
• Epidermoid
• Pitutary adenoma
• Pineal region tumour
• Craniopharyngeoma
• Chordoma
 INTRA AXIAL Contd.

Infratentorial

• Acoustic neuroma

• Meningioma
• Dermoid
• Chordoma
• Glomus jugular tumour
 OTHER CLASSIFICATION

Pediatric brain tumour

Brain stem glioma

Optic pathway glioma

Medulloblastoma
Craniopharyngioma
Neuroblastoma
Cerebellar astrocytoma

Ependymoma
 OTHER CLASSIFICATION

Intraventricular tumour

Ependymoma

Choroid pluxus tumor

Colloid cysts

Meningioma
 CLASSIFICATION – ACCORDING AGE GROUP

YEARS CLASSIFICATION

0-5 Brain Stem Glioma, Optic Nerve Glioma

Medulloblastoma, Cerebellar Astrocytoma,

5-15 Craniopharyngma, Choroid Plexus Papiloma ,
Pinealoma.

15-30 Ependymoma

Glioma, Meningioma, Acoustic neuroma,

30-60
Pitutary Tumour, Hemangioblastoma

60+ Meningeoma, Acoustic Neuroma, Glioblastoma

 CLASSIFICATION ACCORDING TO FREQUENCY

FREQUENCY CLASSIFICATION

Glioma, Metastasis, Meningioma,

Adult Pitutary Tumour, Hemangeoblastoma,
Lymphoma

Astrocytoma, Medulloblastoma,
Child
Ependymoma, Craniopharyngioma
 FREQUENCY OF CEREBRAL TUMOURS

Tumour Frequency

Gliomas 31.4
Metastases 20.3
Meningiomas 15.4
Angiomas 5.9
Pituitary 4.4
Adenomas
Acoustic 1.5
Tumours
Congenital 2.0
Tumours
Miscellanous 12.3
 TUMOUR OF NEUROEPITHELIAL TISSUE

Glioma

Tumours arising from neuroglial cells known as gliomas are

most common intracranial brain tumour which comprises
45%- 65% in a series
2/3rd of all brain tumours are primary neoplasm

Almost ½ of all brain tumours are glioma

¾ th of all gliomas are astrocytic

> ¾ th of all astrocytomas are anaplastic and

GBM
 ASTROCYTIC TUMOUR

Circumscribed Astrocytoma

Juvenile pilocytic astrocytoma

Pleomorphic xanthoastrocytoma
Subependymal giant cell astrocytoma

Diffuse

Low grade astrocytoma

Anaplastic astrocytoma
Glioblastoma multiforme
Gliomatosis cerebri
Gliosarcoma
 WHO CLASSIFICATION

GRADE CLASSIFICATION
Pilocytic astrocytoma
Grade 1
SGCA(subependymal giant cell astrocytoma)

Grade 2 Low grade astrocytoma

Grade 3 Anaplastic astrocytoma

Grade 4 Glioblastoma multiforme

 FEATURES OF LOW GRADE GLIOMA

Age – Younger age group 20-40 yrs

Incidence – 10-20% of astrocytoma

Location – cerebral hemisphere

frontal and parietel lobe
temporal lobe
Histology- low grade malignancy

Presenting Symptom - Seizure

 IMAGING STUDY LOW GRADE GLIOMA

CT

NECT : Iso/hypo
CECT : Little or no enhancement
 IMAGING STUDY LOW GRADE GLIOMA

MRI

T1 : Iso/Hypointense

T2 : Homogenously hyper
 IMAGING STUDY LOW GRADE GLIOMA

PET scan

Fluorodeoxyglucose usually shows reduced uptake

compared to the rest of the brain, indicative of
hypometabolism
 IMAGING STUDY LOW GRADE GLIOMA.

Others

Calcification occurs in 15-20 % cases

No perilesional oedema

No haemorrhage

Mild to moderate mass effect

Most are eventually under go malignant degeneration

 ANAPLASTIC ASTROCYTOMA

It usually occurs in the middle aged patients

Incidence- 20-25%
Locations: cerebral hemispheres
frontal and
temporal lobe

Histology- malignant

Presenting Symptom- Seizure, focal neurological deficit

IMAGING STUDY ANAPLASTIC ASTROCYTOMA

CT

NECT : Iso/hypo In homogenous mixed density

CECT : Enhance strongly, inhomogenously

 IMAGING STUDY ANAPLASTIC ASTROCYTOMA

MRI

T1: Hypo to iso intense

T2 : Heterogenously Hyperintense

As typically enhance strongly

but non uniformly following
contrast administration.
Irregular rim enhancement is
common
 IMAGING STUDY ANAPLASTIC ASTROCYTOMA

OTHER FEATURES

Calcification – uncommon
Oedema- perilesional oedema
common
Haemorrhage may occur

Cystic area may present

Mass effect Common

Histologically malignant
 GLIOBLASTOMA MULTIFORME

Half of all astrocytoma are GBM. It is most common supratentorial

neoplasm in adult. The most common primary brain tumour, it is
also the most malignant astrocytoma
Incidence – 40-50%.
Age- > 50yrs.
Locations- cerebral hemisphere, Frontal and
temporal lobe, White mater
Presenting symptom- Seizure, Focal neurological deficit,
stroke like syndroms
 GLIOBLASTOMA MULTIFORME,cont

Infratentorial glioblastoma multiforme is rare and often

represents subarachnoid dessimination of supra tentorial
origin.

Natural history- spreads rapidly and diffusely

Prognosis- worst prognosis

Median survival is 8 months after operation.

 IMAGING STUDY

Imaging study shows ‘multiforme’ appearance

CT

NECT : In homogenously mixed density lesion

CECT : Enhances strongly, inhomogenously.
Ring enhancing lesion – due to increased cellularity
and neovascularity.
Area of central necrosis shows hypodensity
 T-1 T-1 C T-1 C
MRI

T1: T1 weighted image shows mixed signal mass with

necrosis or cyst formation and thick irregular wall.

Marked but in homogenous contrast enhancement is

present in majority of glioblastoma multiforme. These
tumours are hihgly vascular, haemorrhage of different ages
are often present.
MRI

T2: T2- weighted image shows very heterogenous mass with

mixed signal intensity. Central necrosis is the hall mark.
Haemorrhage , necrosis, oedema are present in GBM

Angiography

A large mass with striking tumours blush, Contrast stasis and

pooling in Bizarre vascular channel is typical
 IMAGING STUDY Contd.

Other features

Calcification uncommon
Oedema abundant
Mass effect more severe
Haemorrhage common
 IMAGING STUDY Contd.

Spread

Through white mater

Sub ependymal seedling
Through CSF
Rarely through haemtogenous route
Extra cerebral metastasis- Lung, Liver, Bone
 PILOCYTIC ASTROCYTOMA

This tumour is of grade –I of WHO grading

Age -most commonly affects the patients in the 2nd decadeof life

Site - 2/3rd of pilocytic astrocytoma occurs in cerebellum.

25-30% in the region of optic nerve , chisma, hypothalmus.
Remainder in the cerebrum.
Generally have benign course because of their lack of invasion and
lack of malignant degeneration

Better prognosis than infiltrating fibrillary and diffuse astrocytoma.

Pathology

Elongated and fibrillated cells often associated with Rosenthal fiber

Eosinophilic granular body common

Microcystic area alternate with pilocytic area

IMAGING STUDY

CT

Slightly hypodese to isodense

Well-definend core in >50%
Cystic component
Mural nodule with contrast enhancement
Calcification seen in 22% cases
Very little or no oedema
Mass effect present –displaces or compresse 4th ventricle
 PILOCYTIC ASTROCYTOMA IMAGING STUDY

MRI

Sharply defined macrocystic mass

Mural nodule easily identifiable
Pronounced contrast enhancement
 OLIGODENDROGLIOMA

Arise from a specific type of glial cell- Oligodendrocyte. These

are typically unencapsulated but well circumscribed focal white
matter tumours that may extent into the cortex and
leptomeninges. Foci of cystic degeneration common Hge,
necrosis uncommon

Incidence - 5-10% of gliomas

Age distribution- 4th to 5th decade
Peak age - 35-45 yrs.
Location - 85% supratentorial
Cerebral hemisphere- mostly frontal
 IMAGING STUDY

X-RAY

Show characteristic
serpigineus calcification.
 IMAGING STUDY- OLIGODENDROGLIOMA

CT
NECT- Prominent mass of calcification. Partially calcified mixed
density hemispheric mass that extends peripherally to the
cortex.

CECT- Mild to moderate contrast enhancement occurs

 IMAGING STUDY- OLIGODENDROGLIOMA

T-1 C
MRI T-1 T-2

Heterogenous signal intensity due to calcification

T1- weighted image shows mixed hypo or iso intensity lesion
T2- weighted image shows hyper intense foci
Absent to slight enhancement is typical
 IMAGING STUDY- OLIGODENDROGLIOMA

Other features

Calcification- occurs in 70-90%, peripherally located, clumped

nodules
Cysts are common
Oedema relatively rare
Peritumoural oedema and contrast enhancement is more
common in anaplastic astrocytoma

Histological feature shows ‘fried egg’ appearance

 EPENDYMOMA

Ependymomas are tumours of the young and are third

most common intracranial tumour of children
Age distribution- 1-5 yrs.
Incidence- 2-8% of gliomas
15% of pediatric brain tumour
Location- 60% infratentorial more common in children.
40% supratentorial more common in adult.
4th ventricle, C-P angle, in or near 3rd ventricle
 IMAGING STUDY- EPENDYMOMA

CT

NECT- Mixed density, isodense or slightly hyperdense

Fine calcification seen in approximately 50% of the
patients.
May have cystic areas

CECT- More than 80% contrast enhancement occurs

 MRI

T1- Heterogenous signal intensity markedly hypointense area

due to calcification
In homogenous enhancement with gadolinium
T2- Iso to hyper intensity

Histological feature shows uniform ependymal cells in pattern of

rosettes, canal or perivascular pseudorosettes
 IMAGING STUDY- EPENDYMOMA

 Other features:
Hydrocephalus if in posterior fossa.
Fine calcification
Headache, nausea, vomiting, papilledema are most
common presentation
 CHOROID PLEXUS PAPILLOMA

Tumours of choroid plexus are rare, accounting for 0.4-0.6%

of all intracranial tumour
Age distribution- > 85% occurs in children
Location in case of children majority of the choroid
plexus tumour occurs in lateral ventricle

In adult most of the choroid plexus

papilloma occurs in 4th ventricle
 IMAGING STUDY CHOROID PLEXUS PAPILLOMA

CT

NECT Iso or hyperdense, 3/4th hyperdense

CECT heterogenous contrast enhancement
 IMAGING STUDY CHOROID PLEXUS PAPILLOMA

MRI
T1 weighted image shows- Predominently isointense
Intensely contrast enhancement occurs

T2 weighted image shows- Iso to hyperintense,

occasionally signal void from the vascular pedicle
 IMAGING STUDY CHOROID PLEXUS PAPILLOMA

Other features

Calcification occurs in 25% cases

Hydrocephalus severe
Drop metastasis common

The imaging differential diagnosis of choroid plexus papilloma

In a child CPCs
papillary ependymoma
medulloblastoma
astrocytoma
In adult patient meningioma
metastasis
 PINEAL TUMOUR

The pineal region is defined as the area of the brain bordered

dorsally by the splenium of corpus callosum and the tela
choroidea
ventrally by the quadrigeminal plate and midbrain tectum
rostrally by the posterior part of 3rd ventricle and
caudally by the cerebellar vermis
 PINEAL TUMOUR , Cont

The pineal region tumours are rare tumour the incidence of

which is 1% of all intra cranial tumour.
Types of pineal region tumour are as follows

Gemcell tumour Germinoma

Teratoma
Embryonal carcinoma
Choriocarcinoma

Pineal cell tumour Pinealoblastoma

Pinealocytoma
 PINEAL TUMOUR , Cont

Tumour of supporting cells and adjacent structure

Astrocytoma
Meningioma
Benign pineal cyst
Haemangioma
Craniopharyngioma

Metastic tumour in the pineal region

 GERMINOMA

This type of germ cell tumour is most common in the pineal region

Incidence 65-72% of all intracranial germ cell tumour

Age distribution 10-30yrs
Consistency is mainly solid, cystic may be present

Radiological study
CT: NECT- slightly hyperdense
Engulfment or displacement of pineal gland is found
CECT- Enhancement occurs strongly and uniformly
 GERMINOMA RADIOLOGICAL STUDY

MRI Nonspecific or variable

homogeneous masses with signal
intensity equal to that of gray matter
T1 hyperintense
homogenous post gd enhancement
T2 heterogenous slight hyperintensity

Other features
Noncapsulated.
Tends to grow slowly by invasion.
More radiosesitive.
Ependymal spread more common.
 TERATOMA

Teratomas derives from all germ layer.

These tumour occur mostly in children below 9yrs. Usually within 1st
two decade.
Origin - two or more germ layers.
Age – Children . Male predominance.
Imaging study :
CT scan- heterogeneous lesion
Contrast CT- Little or no contrast enhancement
Irregular margin
MRI- Nonspecific findings
Teratoma may be –
Mature teratoma
Immature teratoma
Teratoma with malignant transformation.
 PINEO BLASTOMA

This tumour ( PNET) is highly malignant

Age distribution -1st and 2nd decade
Haemorrhage, calcification, necrosis are common in this type
of tumour. Pineoblastoma disseminate through CSF
Histologically similar to medulloblastoma and retinoblastoma

Imaging study
CT hyper dense lesion
contrast enhancement occurs densely
MRI
T 1 weighted image shows hypointense
T 2 weighted image shows mixed intensity
 SELLAR/SUPRASELLAR MASSES

The sellar region is an anatomically complex area composed

of the bony sellaturcica, pituitary gland, and adjacent
structures
Pituitary adenoma
Older classification
Chromophobic
Acido philic
Basophilic
Mixed
New classification
Pituitary microadenoma (size <10mm)
Pituitary macroadenoma (size
>10mm)
 PITUITARY ADENOMA

Pituitary adenoma is benign slow growing neoplasm.

It arises from adenohypophysis (anterior pituitary).
Age and sex- more in adult ( < 10% in children)
Microadenomas are more common than macroadenoma
Pituitary adenoma 75% are endocrinologically active
25% are nonfunctioning, formerly called ‘nonfunctioning
tumour’or chromophobe adenoma, they are now called null
cell adenoma or oncocytoma.
 FUNCTIONING PITUITARY TUMOUR

Prolactinoma
Somatotrophic tumour(GH secreting)
Corticotrophic tumour( ACTH secreting)
Mixed
Others
Radiological features
Area of haemorrhage, necrosis, cyst formation are less common
RI is the most sensitive imaging study for pituitary tumour
T 1 weighted image (non contrast) shows
hypointense to pituitary gland
gland becomes asymmetric
gland becomes covex
superiorly
stalk deviation occurs
depression of sellar floor
 RADIOLOGICAL FEATURES

After contrast (GD- DTPA) dynamic image is required

Rapid sequence coronal single slice of T 1 weighted image of
sella immediately after I.V. bolus administration of contrast
with image obtained consecutively of 10 second interval upto
3 minutes.

Hypo intense tumour over 1st 1-2 minute after injection

On delayed film may mask the presence of tumour
T2 weighted image shows focal mild hyper intensity
 PITUITARY MACROADENOMA

This type of tumour is usually endocrinologically inactive

Incidence- 70-80% ie twice as common as microadenoma

Age distribution of pituitary macroadenoma- 4th to 5th decade of life

Pituitary macroadenoma becomes symtomatic because of their
mass effect- hypo pituitarism, visual problems etc

Macroadenoma secrets hormone sub unit, so clinically inactive

 IMAGING STUDY

X-ray
expansion of sellar cavity
thining of bony cortex
ballooning of sella

CT

Large, homogenously isodense, rounded midline mass

 PITUITARY MACROADENOMA, Cont

Extension
Into the suprasellar cystern forming the figure of eight(8 )
Elevate and compress the optic chiasma and 3rd ventricle
Laterally into the cavernous sinus
May encase the ICA or narrow the vessels
Area of haemorrhage, necrosis, cyst formation are common
which appear as hypodense within the tumour
Acute or subacute haemorrhage causes focal intratumoural
hyperdense area
Hydrocephalus due to obstruction of foramen monro may occur
Calcification is rare
MRI

T 1 weighted image shows hypointense

T 2 weighted image shows hyperintensity

Extension is better visualized after contrast

Both CT and MRI show strong contrast enhancement with

some what inhomogenously
 MENINGEAL AND MESENCHYMAL TUMOUR

Meningiomas
Malignant mesenchymal tumour
Hemangiopericytoma
Hemangioblastoma

Meningiomas
Meningiomas are most common nonglial primary brain tumour
Most common extra axial tumour (13-18%)
Age – adult tumour 40-60yrs
Sex- more in female
Cytogenetics-chromosome 22 is important for pathogenesis of
meningioma
 MENINGIOMAS

Neurofibroma type –II is the major predisposing factor

for meningioma
Origin; Meningioma arises from arachnoid cap cells
In children - > 10% becomes multiple

WHO classification
Typical 88-95%
Atypical 5-7%
Anaplastic 1-2%
Types
globular, flat, compact rounded with invagination of brain
Meningioma enplaque
Multi centric /multifocal
 Location
Cerebral convexity 32-45 %

Parasagital 26%

Sphenoid ridge 20 %
Juxtra sellar 10 %

olfactory groove 10 %

Posterior fossa 10 %

Tentorium
Pineal region

Others optic nerve sheath, intravetrricular

 IMAGE STUDY

X-ray
Hyperostosis
Erosion
Enlarged vascular
channelscalcifications
Tumour
Pneumosinus dilatans
 IMAGE STUDY

CT

70% to 75% hyperdense

20% to 25% calcified
90% enhance strongly , uniformly
10% to 15% cystic areas
60% peritumoral edema
Hemorrhage rare

Area of haemorrhage, necrosis, cyst formation are common

which appear as hypodense within the tumour
 IMAGE STUDY

Angiography
Dual vascular supply common
Sunburst of enlarged dural feeders in tumour

Extension
Into the suprasellar cystern forming the figure of eight(8 )
Elevate and compress the optic chiasma and 3rd ventricle
Laterally into the cavernous sinus
May encase the ICA or narrow the vessels
 IMAGE STUDY -MENINGIOMAS

Area of haemorrhage, necrosis, cyst formation are common

which appear as hypodense within the tumour
Acute or subacute haemorrhage causes focal intratumoural
hyperdense area

Hydrocephalus due to obstruction of foramen monro may occur.

Calcification is rare

MRI
T 1 weighted image shows hypointense

T 2 weighted image shows hyperintensity. Extension is

better visualized after contrast.

Both CT and MRI show strong contrast enhancement with some

what in homogenously
 IMAGE STUDY

Other features:
Cystic degeneration may present,
Calcification, haemorrhage,
Rotational deformity of brain stem,
Present with features of extra axial mass

Neurofibroma:
Schwann cell and fibroblast origin,
Noncapsulated,
Infiltrating, fusiform,
Nerve Sheath Tumour

- Schwannoma
- Neurofibroma
- Malignant nerve sheath tumour

Schwannoma

Benign tumour of schwann cell origin related to cranial nerves.

-90% are solitary
-Multiple Schwannoma are associated with neurofibromatosis type 2
90% of intracranial schwannomas are located in the cerebello
pontine angle originating from VIII cranial nerve- acoustic neuroma.
Age- 40-60 yrs.
Sex- female preponderance
All the cranial nerves except olfactory and optic nerve, are partially
composed of schwann cells so are potentially site for schwannoma

Most arises at the site where axonal sheath switches from glial to
schwanncell origin

Most common – vestibular schwannoma, Trigeminal nerve

schwannoma

Other intracranial sites- infratemporal, jugular foramen and bulb.

Clinical feature depends upon specific nerve involvement and size

Vestibulo-cochlear nerve- Tinnitus, sensory neural hearing

impairment

Trigeminal nerve- Facial sensory impairment, ataxia, exoph

thalmos, diplopia, corneal reflex loss
 RADIOLOGICAL STUDY

Mass causes >2 mmdifference between right and left I.A.C

(Internal acoustic canal)
Erosion and flattening of I.A.C.
I A C > 8mm

CT
NECT - Is to slight hypodense

CECT – Small tumour uniformly enhances

MRI

More sesitive than CT

T 1 weighted image- 2/3rd slightly hypointense, 1/3rd iso

intense
 RADIOLOGICAL STUDY

T 2 weighted image – mild to markedly increased signal intensity.

After contrast- intense enhancement

Homogenous- 62% small

Heterogenous- 22% large

Extension of cerebello pontine angle tumopur into IAC causes ‘cone

ice cream’ appearance
 RADIOLOGICAL STUDY

Other Features

Cystic degeneration may present,

Calcification, haemorrhage,
Rotational deformity of brain stem,
Present with features of extra axial mass

Neurofibroma

Schwann cell and fibroblast origin,

Noncapsulated,
Infiltrating, fusiform
Point Schwannoma Neurofibroma
1. Pathology Schwann cell origin Schwann cell + Fibroblast
Encapsulated Uncapsulated
Focal, Round Infiltrating, Fusiform
Cyst, Hge, necrosis- Rear
common Malignant degeneration- 5
Malignant degeneration to 10%
–not

2. ssociation NF2 NF1

3. Incidence Common Uncommon
4. Age 40-60 Yrs Any age
5. Location Cranial nerve esp. CN cutaneous and spinal nerve
VIII
6. Imaging Sharply delineated Poorly delineated,
Heterogenous infiltrating
T1-70% -Hypo Homogenous
30% -ISO intense T1- mostly ISO intense
T2- Hyper intense T2- Hyper intense
Enhancement- strong Enhancement- moderate
 CEREBELLOPONTINE ANGLE (CPA) CISTERN MASSES

Normal Anatomy

The cerebellopontine angle (CPA) cistern between the anterolateral

surface of the pons and cerebellum and the posterior surface of the
petrous temporal bone. Important structures within the CPA cistern
include the fifth, seventh, and eighth cranial nerves, the superior and
anterior inferior cerebellar arteries, and tributaries of the superior
petrosal veins
 CEREBELLOPONTINE ANGLE (CPA) CISTERN MASSES

Normal Anatomy

The majority of CPA tumours in adults are extraaxial.

Imaging findings that distingush extraaxail from
intraaxail masses include the following:
1.Enlarged CPA cistern.
2.A CSF cleft between the mass and adjacent brain .
3. Brainstem rotation.
4. Displaced cerebellar hemisphere cortex.
 CEREBELLOPONTINE ANGLE (CPA) CISTERN MASSES

Common CPA masses

- Vestubular schwannoma (acoustic neuroma)

- Meningioma
- Epidermoid
- Other schwannoma

Less common

- Arachnoid cyst
- Metastases
- Vascular
- Lipoma
- Dermoid.
 CEREBELLOPONTINE ANGLE (CPA) CISTERN MASSES

Intraventricular Tumour

One tenth of all CNS tumour involve the ventricle.

Imaging characteristics are usually nonspecific; exact location of
the mass and age of the patients are the most helpfull
information in the diagnosis of these lesions
 INTRAVENTRICULAR MASSES IN ADULT

In Lateral Ventricle
- Astrocytoma(anaplastic, glioblastoma)
- Central neurocytoma.
- Subepedymoma.
- Oligodendroglioma.
- Choroid plexus papilloma.
- Meningioma.
- Metastases
Foramen Of Monro/Third Ventricle

- Colloid cyst
- Central neurocytoma
- Astrocytoma
Extrinsic mass- pituitary adenoma, aneurysm, germinoma
 INTRAVENTRICULAR MASSES IN ADULT

Aqueduct/Fourth Ventricle

- Midbrain glioma
- Metastases
- Subependymoma
- Haemangiblastoma
 INTRAVENTRICULAR MASSES IN CHILDREN

1. Lateral ventricle
Choroid plexus tumour.
PNET
Astrcytoma
Ependymoma
2. Third ventricle.
Craniopharyngioma
Subependymoma
Germinoma
3. Fourth ventricle
Pylocytic astrocytoma
Medulloblastoma
Ependymoma
Exophytic tumour
Aqueduct/Fourth Ventricle

- Midbrain glioma
- Metastases
- Subependymoma
- Haemangiblastoma
 COLLOID CYST

A cystic tumour arising from an embryological remnant in the anterior

roof of 3rd ventricle.
It is neuro epithelial cyst comprises 2% of all glioma and 0.5-1% of all
intracranial tumour.
Site- most commonly found in the 3rd ventricle but may in septum
pellucidum.
Age- usually 20-50 years.
Pathogenesis- comprises of fibrous epithelial lined wall filledwith
either mucoid or dense hyaloid substance.
Colloid cyst is slow growing, benign tumour.
It blocks the foramina of Monro causing obstructive hydrocephalus
involving only the lateral ventricle.
Although it is a slow growing benign tumour, there is risk of sudden
death.
 COLLOID CYST

Presentation

Most commonly presents with intermittent acute intracranial

hypertension due to episodic obstruction of foramen Monro.
Most clinically significant cysts are > 1.5 cm in diameter.
Sudden death may occur due to acute blockage of C.S.F flow
resulting herniation

Radiological Findings

Lesion is situated in the anterior 3rd ventricle causing obstruction of

foramen of Monro and dilatation of lateral ventricle
 COLLOID CYST

CT Scan Of Brain

Findings are variable. Most cysts are hyper dense ( 2/3rd ),

1/3rd are isodense.
A well delineated round or ovoid non calcified anterior 3rd
ventricular mass.
Enhancement, following contrast administration is usually absent.

M.R.I.

The most common appearance is a mass that is hyperintense on T1

and hypointense on T2. The signal intensity of colloid cyst vary
widely. Rim enhancement on contrast administration is observed in
some cases
 COLLOID CYST

Rathke Cleft Cyst

Etiology

Primitive stomodial remnant(Rathke pouch).

Pathology:Cyst with variable contents. Columnar, cuboidal or
squamous epithelium

Age and gender

Any age but mostly adult. Female: Male 2-3: 1.

Location

70% both intra sellar and suprasellar, 20-25% intrasellar and

<5% completly suprasellar
 MEDULLOBLASTOMA

Most common malignant pediatric brain tumour.

Incidence: 15-20% of intracranial tumour in children.
Male: Female 2:1.
Age: most in 1st decade. 75% in 4-8 years.
Site: 75% arises in the cerebellar vermis mostly in midline, in
the apex of 4th ventricle.
25% arises in lateral cerebellum.
Highly radiosensitive and moderately chemo sensitive.
Metastasis occur early in the CSF.
Prognosis is very poor
 MEDULLOBLASTOMA

Radiological study

CT scan of brain:
Rounded or ovoid, mainly homogenous iso to slightly hyper dense mass.
Obstructive hydrocephalus is common.
calcification occurs in 15% patients
Moderately strong, relatively homogenous enhancement is seen
following contrast administration. Typical medulloblastoma fills the
4th ventricle and extends through foramen of Magendie in to the
cysterna magna.
T 1 weighted image shows heterogeneous hypointense, cyst in 75-
80%.
T 2 weighted image shows hypo to hyper intense.
Contrast enhancement is variable. Moderately enhancement which
is heterogeneous in nature. Many medulloblastoma shows partial
enhancement following contrast administration.
 CRANIOPHARYNGIOMA

Craniopharyngiomas arise from the squamous epithelial rests along

the involuted hypophyseal Rathke’s duct.
Incidence: 3-5% of primary brain tumour.
50% of pediatric brain tumour.
Age: > 50% in children, peak between 8-12 years.
Location: 70 % combined suprasellar and intrasellar
Imaging study
CT scan of brain-
90% partially cystic,
90% calcification present,
90% nodular or rim enhancement occur
MRI of Brain
Variable signal, most common is hypointense in T 1 weighted image
and hyperintense in T2 weighted image
 INTRACRANIAL METASTASES

Representing 1/4th to 1/3rd of all brain tumour.

Common:
Skull
Leptomeninges
Parenchymal (most common).
Less common:
Dural
Pial
Sub pial
Parenchymal metastases:
Location – any where but most common in cortico medullary
junction ( grey mater- white mater interface).
 INTRACRANIAL METASTASES

Pathology

Welldefined circumscribed nodule of variable size

May be solid partially cystic, filled with mucinous material, necrotic
material, haemorrhagic fluid.

Imaging Study

CT:
NECT- mostly isodense lesion / hyperdense lesion-
Example-Thyroid carcinoma, Lung carcinoma,choriocarcinoma,
malignant melanoma, sarcoma
 INTRACRANIAL METASTASES

Cystic metastasis

Mucin producing tumour adenocarcinoma arising from stomach, small

and large intestine, pancreas, ovary,breast cancer

Cystic and calcified metastasis

Rare- breast carcinoma, lung cancer.

CECT:Most enhance strongly, both solid and ring shaped pattern
are noted

MRI

T 1 weighted image-shows variable features most non

haemorrhagic tumour slightly hyper intense.
Some non haemorrhagic tumour – hyper intense
 INTRACRANIAL METASTASES

MRI

T 2 weighted image - Most are hyper intense with iso intense rim
Some are hypointense on T 2 W image mucin secreting tumour from
adenocarcinoma of G I T.
After contrast, most enhances strongly.

Solid, rim, mixed enhancement are seen.

High dose contrast (0.2-0.3 mmol/kg) normal 0.1 mmol/kg more
sensitive and helpful for identification of early, small, additional
foci.
Thank You