Brain Tumor Diagnosis by Location
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Portions © 1999 - 2006 by James G. Smirniotopoulos, M.D. This page was last updated: 01/10/2013 16:30:14
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REGIONAL NEUROANATOMY and DIFFERENTIAL DIAGNOSIS: PART 2 - Infratentorial Lesions PART 2 - Supratentorial Lesions James G. Smirniotopoulos, M.D. Professor of Radiology, Neurology, and Biomedical Informatics Chairman, Department of Radiology and Radiological Sciences Uniformed Services University of the Health Sciences 4301 Jones Bridge Road Bethesda, MD 20814 Voice: 301-295-3145 301-295-3145 FAX: 301-295-3893 301-295-3893 DISCLAIMER The opinions expressed expressed herein herein are those of the author(s), author(s), and are not necessarily necessarily representative representative of the Uniformed Uniformed Services Services University University of the Health Sciences Sciences (USUHS), (USUHS), the Department Department of Defense (DOD); or, the World Health Organization (WHO). Medicine Medicine is a constantly constantly changing changing field, and medical information information is subject to frequent correction correction and revision. revision. Therefore Therefore the reader is entirely responsible responsible for verifying verifying the accuracy and relevance of the information information contained contained herein. Portions Portions Copyright Copyright © 1997 - 2006 by James G. Smirniotopoulo Smirniotopoulos, s, M.D.
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Schematic of Locations
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Brain Tumor Diagnosis by Location
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Schematic of Locations PATTERN ANALYSIS
Basic Approach Where is the lesion ? Supratentorial Infratentorial Where is the lesion ? Intraaxial Extraaxial How old is the patient ? Child Adult PATTERN ANALYSIS
Where is the Lesion? INTRAAXIAL internal to PIA (brain parenchyma) EXTRAAXIAL external to PIA (meninges, nerve sheath) INTRAVENTRICULAR Lateral Third Fourth
INTRAAXIAL:
Differential CORTEX GRAY/WHITE JUNCTION DEEP WHITE MATTER DEEP GRAY MATTER
INTRAAXIAL:
Brain Tumor Diagnosis by Location
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Differential Glioma Medulloblastoma Hemangioblastoma Metastases Infarct/hematoma AVM/congenital Abscess/inflammation EXTRAAXIAL LESIONS
(Location) Subarachnoid Subdural Epidural Calvarium (skull base) Subgaleal Scalp (soft tissues) EXTRAAXIAL LESIONS
(Differential): Meningioma Pituitary adenoma Craniopharyngioma Schwannoma Chordoma Dermoid/epidermoid, cyst, lipoma Hematoma, metastasis, infection CLASSIC LOCATIONS
Foramen magnum Cerebellopontine angle Fourth ventricle/Cerebellum Sella/parasellar/suprasellar Basal ganglia/Third ventricle Lateral ventricle/Pineal region Deep hemispheric/periventricular Cortical/subcortical Convexity CPA MASSES:
Brain Tumor Diagnosis by Location
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Differential S schwannoma (8th >> > 5th) A aneurysm, arachnoid cyst M meningioma, mets E epidermoid, ependymoma, CPP CPA MASSES
Demographics 7/9 (Schwannoma, 8th > > 5th) 1/9 Meningioma (tentorial/petrous) 1/9 "Other": Epidermoid (1/18) Mets, aneurysm, etc. Glioma (ependymoma, CPP) Arachnoid cyst, Cystadenoma FEATURES OF CPA MASSES
Differential Diagnosis of CPA Masses Vestibular Schwannoma Meningioma
Epidermoid Cyst
Related to IAC
Related to Dura/Tentorium Cisternal Mass
IAC Enlarged
No relationship
Heterogeneous if Large Homogeneous Round, Acute Angle
No relationship Does NOT enhance
Hemisphere, Obtuse Angle Undulating/Serpentine
Brain Tumor Diagnosis by Location
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* CHILDHOOD CEREBELLAR/IV:
Differential Medulloblastoma (PNET) Astrocytoma (usu. Pilocytic) Ependymoma Post fossa cysts
Brain Tumor Diagnosis by Location
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DEEP CEREBELLAR (ADULT)
Metastasis Hemangioblastoma Hemorrhage, infarct Glioma (Ependymoma, Astro) Abscess POSTERIOR FOSSA
INCIDENCE/LOCATION: Medulloblastoma (1/4 - 1/3) Post. To IVth Brainstem glioma (1/6) Ant. To IVth Ependymoma (1/6) Inside IVth Pilocytic (1/4 - 1/3) Lat. And/or post. IVth ( and these are often a cyst w / nodule ) DRAWING SELLA/PARASELLAR REGION
Differential: Pituitary adenoma Craniopharyngioma Aneurysm (ICA , etc.) Meningioma O tic h othalamic lioma
Brain Tumor Diagnosis by Location
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Optic/hypothalamic glioma Chordoma Granuloma, e.g., hamartoma, cyst(arachnoid, dermoid/epi) Germ Cell (Germinoma) PITUITARY ADENOMA
Sexual Dimorphism paste table SELLA/PARASELLAR
Differential Features: CHILD - Craniopharyngioma / Glioma (hypothalamus or optic ) ADULT - Pituitary adenoma SELLA NORMAL - NOT pituitary Ca++ - Craniopharyngioma, but... HYPEROSTOSIS - Meningioma ( exp. "blistering" ) CLIVUS - Chordoma, mets, NP Ca Remember - rule out vascular lesions (aneurysms) HYDROCEPHALUS
Differential Diagnosis: Over production of CSF (CPP) Obstruction of CSF flow: Obstructive/internal hydrocephalus Communicating/external hydrocephalus Under reabsorption of CSF: SAH Compensatory: Ex vacuo/enlargement
Brain Tumor Diagnosis by Location
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THIRD VENTRICLE
Differential: Colloid cyst Craniopharyngioma Hypothalamic and thalamic glioma CPP, ependymoma Basilar tip aneurysm Neurocytoma
BASAL GANGLIA/THALAMUS:
BILATERAL SYMMETRIC (toxic/metabolic): PUTAMEN - Methanol GLOBUS PALLIDUS - CO Poisoning BILATERAL ASYMMETRIC (hematogenous): INFECTION (TOXO, etc.) UNILATERAL (acquired/neoplastic): THALAMUS GLIOMA (astrocytoma) HYPERTENSIVE HEMATOMA (exclusion) ABOVE FORAMEN OF MONRO
Lateral Ventricle/caudate Subependymal Giant Cell Astro. TUBEROUS SCLEROSIS, Enhances & Ca++ Subependymoma (variant of Ependymoma) No Ca++, no enhancement Central Neurocytoma (septum pellucidum) Cyst/Cavum septum pellucidum
Brain Tumor Diagnosis by Location
Huntington's Chorea ATROPHY
INTRAVENTRICULAR NEOPLASMS:
Ependymoma (and subependymoma) Choroid plexus papilloma Subependymal giant cell astro. Meningioma Colloid cyst (3rd) Dermoid/epidermoid Central neurocytoma Medulloblastoma (4th) Mets, lymphoma, Germ Cell
PINEAL/QUAD. CISTERN REGION:
"Pinealomas" Germ cell tumors Pineal cell tumors Pineoblastoma Pineocytoma Gliomas (regional) Brainstem, callosum, thalamus Other Dermoid, lipoma, arachnoid cyst Meningioma
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Brain Tumor Diagnosis by Location
Vein of Galen malformations
DEEP AND PERIVENTRICULAR:
Glioma (astrocytoma) Lymphoma Toxoplasmosis, CMV Leukoencephalopathy (WM) Arteriolar sclerosis (HT) Infarcts (lacunar) Hemorrhage
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Brain Tumor Diagnosis by Location
CONVEXITY (INTRAAXIAL)
Gray-White Junction HEMATOGENOUS Neoplasm HEMATOGENOUS Infection HEMATOGENOUS Thrombi (multiple infarcts) INFARCTION/ISCHEMIA VASCULITIS
CEREBRAL INFARCTION 1. Abrupt
Onset 2. Gray Matter Involved 3. Little Mass Effect 4. Vascular Wedge
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Brain Tumor Diagnosis by Location
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CONVEXITY (EXTRAAXIAL)
Differential EPIDURAL (HEMATOMA empyema, mets) (biconvex, acute, limited by sutures) SUBDURAL (HEMATOMA empyema, mets) (Crescentic, subacute, crosses sutures) MENINGIOMA (hyperdense, hemispheric, hyperostosis, homogeneous enhancement) END OF SECTION
. This page is maintained by: James G. Smirniotopoulos, M.D. Professor of Radiology, Neurology, and Biomedical Informatics Chairman, Department of Radiology and Radiological Sciences Uniformed Services University of the Health Sciences 4301 Jones Bridge Road Bethesda, MD 20814 Voice: 301-295-3145 FAX: 301-295-3893 Comment or Questions - Send EMail about this site.
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