Diagnostic Imaging Approach to

a Supratentorial SOL in an Adult

Antoinette Reinders
Dept of Diagnostic and Interventional Radiology
University of the Free State
Aug 2012
 Approach
• Age
• Location
• Intra vs extra axial
• Anatomical compartment
• Midline crossing
• Tumour spread
• Characteristics on CT and MRI
• Spectroscopy
• Calcification/edema/mass effect
• Enhancement
• Differential diagnoses
• “Tumor mimickers”
Brain Tumours

Smithuis R, Montanera W. Brain Tumor – systematic approach. Available from URL:

http://www.radiologyassistant.nl/en
Major Anatomical considerations

Intra •
•
•
Hemispheres (cerebrum/cerebellum)
Brainstem
Sellar/supraseller

axial •
•
Pineal
Ventricular

Extra • Dural based

• Bone tumours
• Nasopharyngeal tumours

axial
 Approach
• Location
– Intra-axial vs Extra-axial

Smithuis R, Montanera W. Brain Tumor – systematic approach. Available from URL:

http://www.radiologyassistant.nl/en
Extra axial tumour

• Smithuis R, Montanera W. Brain Tumor – systematic approach. Available from URL:

http://www.radiologyassistant.nl/en
Intra vs Extra axial

Smithuis R, Montanera W. Brain Tumor – systematic approach. Available from URL:

http://www.radiologyassistant.nl/en
 Approach
• Location
– Grey matter
• Cortical/subcortical
– White matter
– Grey/white matter interface
– Dural surface
• Abut the meninges
– Ventricles
• Foramen of Monroe
• Trigonum of the lateral ventricles
– Pineal gland
– Sella/suprasellar
Robert Wood Johnson University Hospital. Available from URL: http://www.rwjuh.edu/gamma-
knife/gamma-knife-brain-tumor-treatment.aspx
 Approach
• Cross midline
– Glioblastoma Multiforme, Radiation necrosis,
Meningioma, Lymphoma, Epidermoid cyst, MS
• Multifocal disease
– Phacomatoses
• NF1: Optic gliomas, astrocytomas
• NF2: Meningiomas, Ependymomas, Schwannomas,
Choroid plexus papillomas
• TS: Subependymal tubers, Giant cell astrocytomas
• VHL: Hemangioblastomas
 Approach
• Tumour spread
– Subarachnoid seeding
• PNET
• Ependymoma
• GBM
• Lymphoma
• Oligodendroglioma
– WM Tracts
• Astrocytoma
– Pilocytic, Fibrillary, Gemistocytic, Protoplasmic
– Foramina
• Ependymoma
 Tumour Spread

Ependymoma of 4th ventricle Pleomorphic xantoastrocytoma

 Approach
• Characteristics
– MRI
• Edema
• Cystic
• Mass effect
• Fat containing
• Spectroscopy
– CT
• Calcifications
• Haemorrhage
• Homogenous or heterogenous appearance
• Periosteal reaction
Characteristics on CT
 Haemorrhage
Common haemorrhage Not common haemorrhage
Glioblastoma multiforme Germ cell tumours
Metastases Medulloblastoma
•Choroid
•Thyroid
•Bronchus
•Mamma/melanoma
•Renal
Craniopharyngioma Colloid cysts/central neurocytoma
Oligodendrogliomas
Ependymal

Giant cell astrocytomas

Chordoma
Epidermoid/dermoid
Characteristics on MRI
Characteristics on MRI
Diffusion Weighted Imaging

Abscesses, infarcts have

ABNORMAL diffusion –
restriction

Tumours have NORMAL

diffusion – no restriction
 Approach
• Enhancement
– Destruction of BBB in order to enhance
– Homogenous vs heterogenous enhancement
– Enhancement of gliomas = higher grade of
malignancy
• NB in follow up
– Diffusion weighted
• Restricted diffusion in abscesses and not in tumours

Smithuis R, Montanera W. Brain Tumor – systematic approach. Available from URL:

http://www.radiologyassistant.nl/en
 Approach
No Enhancement Patchy Enhancement Homogenous
Enhancement
Low grade astrocytomas Metastases Metastases
Cystic non tumour lesions Oligodendroglioma Lymphoma
•Dermoid GBM Germinoma and pineal
tumours
•Epidermoid Radiation necrosis Pituatary macroadenoma
•Arachnoid cyst Pilocytic astrocytoma
Hemangioblastoma
Gangliocytoma
Meningioma
Schwannoma
 Common things.....
Brain Tumours
Breast
Colon
Lung
Kidney Astrocytoma
Metastases Oligodendroglioma
Melanoma Glial
20%
40%

Meningioma
Schwannoma
Pituitary Non Glial
Pineal 40%
Lymphoma
 Approach
• Differential diagnoses

• Dural based – Meningioma, Dural metastases, Sarcoid,

Haemangiopericytomas, pineoblastoma, lymphoma
• Cortical based – Dural AV malformation, Herpes
encephalitis
• Multifocal disease – Septic emboli, Abscesses and
Multiple Sclerosis
• Sellar - Aneurysm
 Take home points...
• Age of patient
• Location
– Intra vs extra axial
– Crossing midline
– Multifocal disease
• Tumour spread
• Characteristics on CT/MRI
– Calcifications
– Haemorrhage
– Spectroscopy
• Enhancement pattern
• Differential diagnoses
 Cellphones?
“Although our results overall do not indicate an increased risk of glioma in relation to mobile phone
use, the possible risk in the most heavily exposed part of the brain with long-term use needs to be
explored further before firm conclusions can be drawn.”
Int J Cancer. 2007 Apr 15;120(8):1769-75.
Mobile phone use and risk of glioma in 5 North European countries.

Raised risks of glioma with mobile phone use, as reported by one (Swedish) study forming the basis
of the IARC's re-evaluation of mobile phone exposure, are not consistent with observed incidence
trends in US population data, although the US data could be consistent with the modest excess risks
in the Interphone study.
BMJ. 2012 Mar 8;344:e1147. doi: 10.1136/bmj.e1147.
Mobile phone use and glioma risk: comparison of epidemiological study results with incidence trends in the United States.

BMJ. 2012 May 1;344:e3083; author reply e3088. doi: 10.1136/bmj.e3083.

Association of mobile phone use with adult brain cancer remains plausible
Davis DL, Miller AB, Philips A
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• Smithuis R, Montanera W. Brain Tumor – systematic approach.
Available from URL: http://www.radiologyassistant.nl/en
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1505
• Hoon Shin J, Kyu Lee H, Khang SK et al. Neuronal tumors of the
central nervous system: radiologic findings and pathologic
correlation. RadioGraphics 2002; 22:1177-1189
• Robert Wood Johnson University Hospital. Available from URL:
http://www.rwjuh.edu/gamma-knife/gamma-knife-brain-tumor-
treatment.aspx
• Dahnert W. Radiology Review Manual 6th ed. Lippincott Williams &
Wilkins 2007
• Weissleder et al. Primer of Diagnostic Imaging 4th ed. Mosby
Elsevier 2007