Intracranial

Masses:
A Radiologic Approach

RAJ PATEL, MS4

1

Clinical Presentation

Generalized

Headaches-dull and constant. The classic early morning

headaches appears to be uncommon.

Tend to be worse at night and may awaken patient from sleep

Seizures

Syncope

Cognitive dysfunction

Focal

Weakness

Sensory loss

Aphasia

Visual spatial dysfunction

Imaging Modalities

CT +/- contrast

Quick scan time appropriate for emergent

imaging

Low soft tissue delineation limits diagnostic

capability

Beam-hardening artifact : can miss

structural lesions, esp in posterior fossa

MR +/- gadolinium

Procedure of choice for imaging brain tumors

Sensitive for edema

Sensitive for small tumors near bone

Role of imaging

Diagnosis

Ddx: tumor vs. infection vs. vascular

Clinical complications: parenchyma compromise, mass effects

Treatment

Treatment planning

Localization for therapeutic modalities: EBRT, stereotactic surgery

Evaluation

Post-treatment surveillance

Tumor recurrence

Analysis of Potential Brain Tumor

Age of patient

Localization

Intra vs extra-axial

Anatomical compartment

Does is cross midline?

CT and MRI characteristics

Calcifications, fat, cystic components

Signal intensity on T1, T2, DWI

Contrast enhancement

Effect on surrounding structures

Mass effect-edema

Solitary vs multiple

Age distribution

Lesion Enhancement
Metastases

always enhance due to tumor neo-vessels,

which lack a BBB.

Low

grade primary tumors may not enhance. They may

form near normal CNS capillaries with an intact BBB.

Degree

grade.

of enhancement does not correlate with histological

MRI Signals
Most

brain lesions are hypointense on T1 and hyperintense

on T2.

Tumors hypointense on T2-weighted

Metastases containing desiccated mucin (GI adenocarcinomas)

Hypercellular tumors (lymphoma, medulloblastoma, germinoma, and some glioblastomas)

Tumors hyperintense on T1-weighted

Metastatic melanoma

Fat containing tumors, such as dermoid or teratoma

Hemorrhagic metastasis (renal cell, thyroid, choriocarcinoma, and melanoma)

Brain neoplasm
Extra axial

Solitary
mass

Meningioma
Schwannoma

Supratentori
al
Gliomas
Oligodendroglioma

Infratento
rial
Hemangiobla
stoma

Multiple
masses
Location

Pineal
Germ cell
tumor
Pineal cyst
Pineocytoma
Pineoblastom
a

Metastasis

Intraventricu
lar
Subependymoma
Choroid plexus
papilloma
Colloid cyst

Skull
base
Chordoma
Chondrosarco
ma
Lymphoma
Myeloma
Paraganglioma

Sella
Pituitary
adenoma
Chraniopharyn
gioma
Dermoid
Rathkes Pouch
cyst

Emergent complications of brain

tumors

Hemorrhage, Hydrocephalus, and Herniation

CT is a good screening method to evaluate for these complications

Hemorrhage

Most common primary tumor is a glioblastoma

Hemorrhagic metastasis: melanoma, renal cell carcinoma, thyroid

carcinoma, and choriocarcinoma.

Hydrocephalus

Herniation

10

Posterior fossa tumors have increased risk by effacting the 4 th ventricle

Overall mass effects secondary to vasogenic edema and tumoral mass
may contribute to brain herniation.

MR characteristics
of adult tumors
Brain metastasis

11

Common primaries are

lungs, breast, renal cell and
melanoma.

Usually located at greywhite junction

>50% of mets present as

solitary lesions.

CT characteristics:

Prominent vasogenic edema

Enhancement of mass with

contrast is variable

MR characteristics of
adult tumors

Brain metastasis

T1: typically iso to

hypointense
If

hemorrhagic: can
have intrinsic high
signal

12

T1+C: ring-enhancing
lesions

T2: typically
hyperintense (can be
altered by hemorrhage).

Melanoma Metastasis

T1 weighted:

Intrinsic high signal due to paramagnetic properties of

melanin

Can also have high signal due to hemorrhage.

T2 weighted:

13

Typically hypointense

Diffusion Weighted Imaging

14

MR characteristics of adult
tumors
Glioblastoma
Usually

occurs after 40, peak incidence of

65-70 yo.

Grade

IV Astrocytoma

Worst

prognosis

Infiltrative,

can involve WM tract and cross

midline.
T1:

hypo to isointense mass within WM with

central heterogeneous signal

Ring enhancement common,

irregular and nodular, often around necrosis

T1+C:
T2:

15

hyperintense, surrounded by edema.

MR characteristics
of adult tumors
Hemangioblastoma

16

Peak incidence around 30-60, earlier

in VHL

Cystic mass w/ enhancing mural

nodule

T1: hypo/iso-intense mural nodule.

CSF signal cyst

T1 C+: nodule enhances, cyst does

not

T2:

Nodule enhancement

Flow voids (signal loss) especially at

periphery.

Hemangioblastoma Angiogram

17

MR characteristics of
adult tumors
Pituitary adenoma

18

Microadenoma <10mm (pts seek

treatment 2/2 hormone excess)

Macroadenoma >10mm

Usually causes mass effect rather

than endocrine dysfunction

Bony sella often enlarged

Extra-Axial Tumors

19

Signs of extra-axial location

Displaced subarachnoid
vessels

Cortical grey between mass

and white matter

Mass displaces and expands

subarachnoid space

Broad Dural base

Hyperostosis

White matter buckling sign

CSF cleft sign

MR characteristics of adult tumors

Meningioma

20

W>M, 2:1 ratio

Arise from arachnoid cap cells

Dural tail seen 60-70% of the time

T1: isointense to grey matter

T1 C+: intense, homogenous enhancement.

T2: variable (isointense to grey matter ~50%)

MR characteristics of adult tumors

Schwannoma

21

5th-6th decade, earlier if

assoc. with NF2

CN VIII most commonly

involved

Ice cream cone appearance

T1: isointense or hypointense

T1 C+: intense enhancement

T2: hyperintense

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22

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