INTRA-AXIAL

1. Supratentorial
2. Infratentorial
I. Low grade astrocytoma
Types of Gliomas
 Astrocytoma
o astrocytes
 Oligodendrogliomas
o oligodendrocytes
 Ependymomas
o ependymal cells
 Choroid plexus pappilomas/carcinomas

Astrocytoma Subtypes
1. Low grade astrocytoma
2. Anaplastic astrocytoma
3. Glioblastoma multiforme

Astrocytoma
- 25 – 30% of adult cerebral hemispheric gliomas Post contrast T1-weighted axial shows no enhancement
- 30% of gliomas in children
- in adults, the peak age of incidence is 20-50 years old Bilateral Thalamic Glioma (Astrocytoma)
- the histopathologic classification of glial tumors is based on the
prevalent cell type present and the grading of the tumor by the most
malignant portion present
- On MR:
o Relatively homogeneous masses without much peritumoral
edema
o The margins of the lesion are often clearly defined on MR
o Low grade astrocytomas not infrequently involve both the white
matter and adjacent cortex
 This appearance may stimulate an infarct. If the lesion does
not conform to a vascular territory or there is marked
enhancement, tumor should be suspected
 Occasionally, a follow-up scan is necessary in order to
differentiate a tumor from an infarct Obstruction of 3rd ventricle; hydrocephalus
o contrast enhancement is variable in astrocytomas
o generally, higher grade tumors demonstrate more marked II. Anaplastic
- necrosis, vascular proliferation, and cyst formation common
enhancement than lower grade tumors, but there are many
- significant edema and inhomogenicity
exceptions
o low grade astrocytomas often show no or minimal enhancement; MR Characteristics
no edema - considerable inhomogenicity
o calcification is not uncommon in low grade astrocytomas (seen - hypointensity on T1
in approximately 20% of cases on CT) - hyperintensity on T2
o CT detects calcification much better than MR - surrounding edema
- most show gadolinium enhancement
A 22-year old male with headache
45-year old male complaining headache

There is a large amount of vasogenic edema in superior fronto-parietal-

occipital hemisphere. After contrast administration, there is an irregular
ringlike structures.
The abnormal signal involves both white matter and cortex, but does not
conform to an expected vascular distribution suggesting tumor rather than III. GBM
infarct. - a highly malignant type of astrocytoma
- the most common and most malignant glioma
 - account for 15-20% of primary CNS neoplasms in adults, and
are rare in children
- Glioblastoma multiforme occurs most commonly between ages
40-60 and is rare in childhood.
- Glioblastoma most commonly arises in the frontal and temporal
lobes, but may occur in any region of the brain and can spread
rapidly.
- It commonly crosses the corpus callosum to involve both
cerebral hemispheres. Glioblastoma may also spread through the
ventricles and subarachnoid space.
S/Sx
- elevated intracranial pressure are usually present (headache,
nausea, vomiting, papilledema, visual disturbances)
- headache and seizure are the most common presentation
- focal deficits may result from local invasion of the tumor
- intracranial hemorrhage may result in acute onset of symptoms Subependymal Giant Cell Astrocytoma
DDx - common locations: lateral ventricle attached to caudate head
- arteriovenous malformations - associations: most patients have tuberous sclerosis, of those with TS,
- other astrocytomas 6-16% will develop this tumor
- abscess - demographics: children, young adults (first two decades)
- CNS lymphoma - histology: large cells that variously resemble astrocytes, although
- cavernous malformation may express neuronal markers
- oligodendroglioma - radiology: usually seen with other features of tuberous sclerosis
- metastasis (cortical tubers, calcified subependymal tubules, white matter
streaks). May obstruct foramen of Monroe and cause hydrocephalus.
53-year old male with superior quadrant visual loss and dizziness Enhancement and calcification are both common.

Glioblastoma Multiforme (GBM)

Oligodendroglioma
Bakit wala nito? Sige, pagtyagaan ang notes:
- 90% with calcification
- relatively avascular
- ring enhancement

INFRATENTORIAL
• cerebellar astrocytoma
• medulloblastoma
• ependymoma

Juvenile Pilocytic Astrocytoma

• the most common astrocytomas in children
• occur most often in patients younger than 25 years old
• astrocytoma is the most common and most malignant
glioma
• astrocytomas are responsible for 50 % of primary
pediatric CNS tumors
• accounts for 80-85% of cerebellar astrocytomas and
60% of optic gliomas
• JPAs usually present in older-aged children as opposed
to medulloblastomas
• most frequently arises in the cerebellar hemispheres,
along the optic tracts, and around the third ventricle,
but may also be found in the cerebral hemispheres or
anywhere else astrocytes are present
• usually well-demarcated lesions associated with cyst • complications include hydrocephalus, secondary to
formation compression of the CSF pathways, and leptomeningeal
• usually indolent lesions and rarely transform to a high- dissemination, with subsequent weakness from spinal
grade malignancy cord compression

Signs and Symptoms Imaging

• related to obstructive hydrocephalus and mass effect • the diagnostic test of choice is MRI with and without
including nausea, vomiting, visual disturbances, gandolium
headache, irritability, ataxia • t1-weighted images typically demonstrate a
hypointense lesion while
Differential Diagnosis • t2-weighted images reveal a hyperintense mass with
• other astrocytomas, brain metastases, ependymoma, surrounding edema
oligodendroglioma, medulloblastoma, high-grade • the tumor contrast enhances homogeneously on
glioma gandolium administration
• leptomeningeal dissemination occurs in up to 40% of
Case patients and so pre-surgical spinal MRI should also be
• 7 ½ y/o with nausea, vomiting, and headache obtained

• Precontrast solid and cystic portions of centrally

positioned cerebellar mass. Postcontrast showed a
solid portion enhancing

Case
• 12 y/o presenting with 2-mo history of headache

Medulloblastoma
• primarily a pediatric tumor with a peak age of
incidence of 3-5 years
• 15% of childhood brain tumors
• Only 0.4-1% of adult brain tumors
• the tumor most commonly arises in the posterior fossa
of the brain between the brainstem and the cerebellum
although supratentorial origins have been reported
• in children, the most common site affected is the
cerebellar vermis while in adults the lateral
hemispheres of the cerebellum are most often involved
• patient presentation can be attributed to increased
intracranial pressure (ICP) and cerebellar dysfunction
• Hypointense posterior fossa mass in the region of
cerebellar vermis extending exophytically into 4th
• increased ICP causes headache, nausea and vomiting,
ventricle. The 3rd ventricle and aqueduct show
and cranial nerve VI palsy
dilatation secondary to obstructive hydrocephalus.
• cerebellar symptoms are due to midline infiltration
MR post-gandolium mass shows heterogeneous
causing progressive truncal ataxia enhancement
 • 5 y/o male

Differential Diagnosis
• ependymoma
• pilocytic astrocytoma

Ependymoma
• accounts for 2-6% of intracranial mass
• common locations: 4th ventricle for children and
cerebral hemispheres for adults
• CT: lesion appear heterogeneous on imaging, exhibit
heterogeneous enhancement, and are usually well
defined with lobulated margins Brainstem Gliomas
• make up almost 10% of intracranial tumors in children
• three distinct anatomic locations
• pontine, tectal, and cervicomedullary
• age: average is 7 years of age; ¾ being > 20 years old

Signs and Symptoms

• tectal: macrocrania, headaches
• focal tegemental mesencephalic: hemiparesis
• diffuse intrinsic pontine glioma: ataxia, headache,
bulbar signs, nausea and vomiting, multiple cranial
nerve palsies

CT findings
• gliomas appear as hypoattenuating masses at CT with
variable enhancement depending on the glioma

Case
• 12 y/o male with flu-like symptoms

Cerebellar Hemangioblastoma
• accounts for 2% of all intracranial tumors
• occurs during the 3rd-4th decade of life
• 60% appear as cystic masses with a peripheral
enhancing nodule
• most common locations: cerebellar hemispheres, CNS Infections
vermis, medulla
Sorry, blurred. Hindi kaya ng katawang tao ko ang pagdecipher. I didn’t
include the pictures – kamusta naman para siyang MRI ng unstable
patient. Yeba!

CNS Infections
- common in children usually in newborns
Congenital CMV
- most common of TORCH infections
- transplacental transmission in up to 50% of maternal infections
with 5-10% of fetuses symptomatic
- neonatal symptoms include hepatosplenomegaly, jaundice,
psychomotor retardation, chorioretinitis, and deafness. Mental
retardation and deafness in 20%.
- Intracranial involvement depends on time of infection and can
include migrational anomalies, cerebellar hypoplasia, and
intracranial calcifications (periventricular).
- Leading cause of brain disease and deafness in children
- 90% of infected neonates demonstrate asymptomatic or
subclinical involvement.
Herpes encephalitis
HSV 2
- accounts for 80-90% of neonatal and almost all congenital
infections
Herpes encephalitis
- most common cause of sporadic viral encephalitis
- predilection for temporal lobes
In adults, HSV 1
- accounts for 95% of all fatal cases of sporadic encephalitis and
usually results from reactivation of the latent virus
MRI is preferred for imaging and follow-up studies of herpes
encephalitis
T2 weighted MRI
- hyperintensity corresponding to edematous changes in the
temporal lobes, inferior frontal lobes, and insula with a
predilection for medial temporal lobes
- foci of hemorrhage occasionally can be observed on MRI
- spares basal ganglia
- in the adult form, a predilection for the limbic system –
temporal lobe, cingulated gyrus, or subfrontal region is
characteristic on MR examination, early findings of edema as
evidenced by decreased signal on T1 weighted imaging and
increased signal on T2 weighted imaging may be found
- the edema often extends into the insular cortex with sparing of
the putamen
Neurocystercosis
- caused by tapeworm Taenia solium
- involving CNS, muscles, heart tissue
- Acute Vs Chronic Phase (hindi na kaya ng powers ko basahin
kasi super blurred, pinasadahan lang ni doc ‘to kaya eto lang
din ang notes ko…)
Acute Chronic
Focal seizures Calcifications
Bacterial Meningitis
- CT findings of bacterial meningitis are commonly nonspecific
and even normal in the majority of cases
- In severe cases, noncontrast evaluation may show abnormal
ill-defined filling of the subarachnoid spaces with isoattenuating
material which may show diffuse enhancement after contrast
Brain Abscess
- Common primary sources of infection include sinusitis, otitis,
and dental abscesses.
- CT: a ring-enhancing mass lesion with a hypodense center,
often surrounded by a substantial amount of edema
Toxoplasmosis
- 10% of AIDS patients, up to 40% of CNS infections in AIDS
- up to 70% seropositivity in general population
- clinical: HA (di ko alam bakit HA), fever, lethargy, focal
neurologic deficit
- necrotizing encephalitis with this walled abscess formation
- 3-4 cm lesions, small lesions solid enhancement larger ring-
enhancing
- locations: BG, WM, CM jen (what the?!)
- major ddx in AIDS = lymphoma
o helpful distinguishing factors: no spread across corpus
callosum, larger number of small lesions, response to
antibiotic
Subdural empyema
- essentially collections of pus located between the dura and
leptomeninges
- they are most commonly the result of direct extension
secondary to sinus infection (frontal most common), but may
also result from meningitis with organisms entering the
subdural space through dural sinus or bridging veins.
And since I was inspired…
The wrong news, on the wrong page
On June 5, 2008, newspapers in Manila carried the front-page headline:
“Obama makes history.”
First of all, the headline was not specific and it was wrong. It should have
read: “Obama makes US history.” He and US Sen. Hillary Clinton did not
make history in the Philippines or in the world. There have been and
there still are many black and women presidents in the world. The
Philippines already has had two women presidents. The Americans
should be exposed for being white supremacists, hypocrites and male
chauvinists.
That historical event in the United States did not deserve front-page
space in Philippine news.
We Filipinos should stop thinking that we are Americans because we are
not. Americans are actually laughing at us for being copycats and
parasites—both behaviors feed on the American superego and
superiority complex.
The Americans will be devastated if Filipinos become like the Iranians.
Even their neighbors, the Mexicans, could not care less about them; the
Mexicans don’t want to talk to them. Their excuse: just like the French’s,
“no speak English,” and they are succeeding. Half of California and the
Western states are now Spanish-speaking. It is Montezuma’s revenge.
The Mexicans would never do what Filipino officials did for an American
rapist.
The media should stop glamorizing US Ambassador Kristie Kenney. She
is not our fairy godmother. She actually helped fund the Jemaah
Islamiyah and Abu Sayyaf with the super generous rewards (from P50
million to P500 million) to informers of terrorists. Of course, the booty is
shared with the Abu Sayyaf. This is happening right under the noses of
Philippine military and government officials. As every Filipino knows,
these terrorist groups have been menacing our country, not the United
States.
American political and humanitarian activities in Southern Mindanao and
Sulu are actually making the peace process with the Muslims more
difficult. The Americans are dividing our country just like what they did in
Vietnam and what they’re doing now in Iraq. The obvious reason: so that
Filipinos will continue to be dependent politically, economically and
militarily on the United States. It serves America’s geopolitical interests in
Asia.
The Americans have been raping the sovereignty of our nation by direct
interference in our country’s internal affairs and Filipinos seem to be
enjoying this. There are many examples: The US intelligence agencies
control the access to the websites of Philippine government agencies like
the Department of Health and even the Philippine Senate; this I
discovered recently. These blatant, illegal intrusions are just the tip of the
iceberg.
If Senator Obama wins the presidency of the United States, I suggest
putting that news in the middle of the classified ads.
BERNARDO D. MORANTTE JR., M.D., 23 Mt. Fairweather St., Filinvest
1, Quezon City
Camera Men: Lisa, Eisa, Romy
Camera by: Pril
Transcribers: Pril, Shia, Romy, and Geli
Notes by: Geli