IMAGING OF MIDLINE TUMORS OF THE CENTRAL NERVOUS SYSTEM

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IMAGING OF MIDLINE TUMORS OF THE CENTRAL NERVOUS
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F.Z. Belhoussine1, M. Boubbou1, B. Alami1,
K.Moumna2, A.Amarti 2, M.Benzegmout3, S.
Tizniti1
Department of Radiology 1, CHU Hassan II,
Fez. Department of anatomo-pathology2 CHU Hassan
II, Fez. Department of neuro surgery
3 CHU Hassan II, Fez.
NR7
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INTRODUCTION

• The anatomy of the supratentoriel midline
  structures of the brain is complex
• Corpus callosum,
• Third ventricle,
• Trigone,
• Pituitary gland
• Pineal gland,
• Different types of tumors can arise from
  these structures including tumors of the trigone
  and septum, tumors of the falx, third ventricular
  tumors and pinal region tumors.
• These tumors share similar features minimal
  clinical symptoms despite their occasional large
  size, mild non-specific intracranial hypertension
  syndrome, value of MRI for depiction of tumor
  location, stereotactic biopsy, relative
  difficulty of surgical management.

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OBJECTIVES
Illustrate the radiological semiology
encephalic tumors of the midline.
Show the value of MRI in the exploration of these
tumors.
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BACKGROUND

• The anatomy of the supra tentoriel midline
  structures of the brain is complex.
• We can distinguish 4 region
• Sellar and suprasellar region.
• Corpus callosum region.
• Intraventricular region.
• Pineal region.
• Falx region.
• Brain CT is less sensitive to MRI to
  contribute for depiction of tumor location,
  stereotactic biopsy, relative difficulty of
  surgical management.

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BACKGROUND
ANATOMY
Fig B Sagittal Tl MR 4 pineal region , 3
sellar and suprasellar region
Fig A Coronal Tl MR 1 V3 region , 2corpus
callosum region , 5falx region
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BACKGROUND
THE MAIN ETIOLOGIES by REGIONS
Sellar /Suprasellar region
Microadenoma. Macroadenoma. Craniopharyngioma. Metastasis Meningioma
Intraventricular ( third ventricle)
Colloide cyst ( anterior third ventricle). Astrocytomas. Craniopharyngioma. Hypothalamic astrocytoma. Suprasellar germinoma (involve the anterior third ventricular). Posterior third ventricle colloid cyst meningioma choroide plexus papillomas metastases.
Pineal region
Pinealomas. Germinomas. Teratoma. Pineocytomas/ pineoblastoma. Benign cyst
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BACKGROUND
THE MAIN ETIOLOGIES by REGIONS
Trigone and corpus callosum region
Anaplasic astrocytomas. Glioblastomas. Lymphoma. Lipoma Metastases.
Fax region
Meningioma. Metastases. Hemangiopericytoma
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MATERIALS AND METHODS
A retrospective study involving 36 patients
collected for department of radiology and neuro
surgery over 3 years. Median age is 30
years (2- 77 years). In all patients
conventional magnetic resonance imaging in
conjunction with diffusion-weighted imaging (DWI)
was performed. Proton magnetic resonance
spectroscopy (MRS) was added in most cases.
MRI examinations were performed in a single
session on a machine GE 1.5 Tesla.
Conventional MRI included sagittal T1, coronal
T2, axial FLAIR, axial T2 , Diffusion, 3 planes
T1 gadolinium and sequence spectroscopic.
Histological confirmation was performed in all
patients.
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RESULTS
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RESULTS
Sellar /Suprasellar region
SUPRASELLAR MASS ADULT
MRI sagittal section (A) and coronal (D) T2 W1
and coronal T1 without (B) and with gadolinium
(C) showing a sellar and suprasellar mass
isointense T1, T2 discrete, so is raising
homogeneous after contrast. Selected diagnosis
pituitary macroadenoma.
Coronal graphic shows pituitary macroadenoma
(open arrow). Indentation from diaphragma sella
causes "snowman" appearance (curved arrows). Some
cystic degeneration hemorrhage is depicted.
Anapath PITUITARY MACROADENOMA
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RESULTS
SUPRASELLAR MASS CHILD
Sellar /Suprasellar region
MRI in coronal (A) and sagittal (D) T1, coronal
T2 (B) and T1 contrast Cornale (c) objectifying
the presence of a large sellar and suprasellar
process with a heterogeneous isointense T1 (A and
D), discrete hyperintense T2 (B), with
enhancement of heterogeneously after contrast
(C). this process presents an important extension
latérosellaire responsible hydrocephalus upstream.
Sagittal graphic shows a predominantly cystic,
partially solid, suprasellar mass with focal rim
calcifications. Note small intrasellar component
and fluid-fluid level.
Anapath CRANIOPHARYNGIOMA
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RESULTS
Sellar /Suprasellar region
CRANIOPHARYNGIOMA

• Benign dysontogenetic epithelial tumor derived
  from Rathke pouch epithelium.
• Two types Adamantinomatous and papillary.
• Location
• Surgical division of craniopharyngioma into
  three groups Sellar/ Pre chiasmatic /
  Retrochiasmatic.
• Best diagnostic clue
• CT Finding Partially Ca, partially solid,
  cystic
• suprasellar mass in a child.
• MR Finding
• - High signal intensity suprasellar mass on
  pre-contrast T1WI
• - Tl C Solid portions enhance heterogeneously,
  cyst walls enhance strongly.

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RESULTS
Sellar /Suprasellar region
CRANIOPHARYNGIOMA

• Pathology
• Most common pediatric intracranial tumor of
  non-glial origin.
• Approximately 54 of all pediatric
  sellar/chiasmatic region tumors are CPs
• Clinical Issues
• Clinical profile Pediatric patient with morning
  headache, visual defect, short stature.
• Age Bimodal age distribution (peak 5-15 Years
  papillary CP gt SOy).
• 64-96 overall 10 year survival.
• Diagnostic Checklist
• Use NECT to detect Ca if MR diagnosis is in
  question.

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RESULTS
Sellar /Suprasellar region
D
A
Fig A,B, C and D show a sphenoid ridge mass
slightly intense with cortex in axial and
sagittal T1W1(fig A, D) and axial T2W1(Fig
C)witch enhance homogeneously intensely (fig B)
C
AnapathMENINGIOMA
B
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RESULTS
Intraventricular (3rd ventricle)
T2
Axial graphic shows a classic CC at the foramen
of Monro causing mild/moderate
obstructive hydrocephalus. Note fornices and
choroid plexus are elevated, stretched over the
cyst (arrows).
D
A
31 years old. Headaches with visual disturbances
neglected for a year. MRI round lesion of the
anterior third ventricle, although limited in
homogeneous hyperintense T1 and T2, clogging the
holes of Monro, causing a biventricular
hydrocephalus active upstream (FLAIR hyper
intense peri-ventricular).
C
Coronal T1 Flair W1
Anapath COLLOID CYST
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RESULTS
Intraventricular (3rd ventricle)
D
A
Coronal T1W1 Gado
Coronal T1 Flair W1
Axial FSPGR 3D
C
26 years old, Headache, nausea and vomiting, MR
find a mass in the third ventricle, hypo intense
of Gray matter in T1W1, hyper intense to CSF in
Flair and ringlike enhancement of cyst.
AnapathPILOCYTIC ASTROCYTOMA
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Intraventricular (3rd ventricle)
RESULTS
T2
38 years old. Headaches with visual disturbances
and vomiting. MRI Intraventricular Well
delineated, lobulated mass in third ventricle
iso- intense In T1W1, hyper intense in T2W1,
strongly and homogeneously enhanced.
D
A
Typically pediatric tumors, lateral ventricle
In adults, 4th ventricle, third ventricle in
10 Enhancing papillary mass, hydrocephalus
common
C
Coronal T1 Flair W1
Anapath PAPILLOMA
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RESULTS
Ca
Pineal region
T2
Axial CT
Engulfs" calcified pineal gland Intensely
enhancing pineal mass, often homogeneous Often
CSF spread at diagnosis Hyperdense on CT
Typically young male patients
D
SAG T1
SAG T1 Gado
A
SAG T1 GADO
SAG t1
14 years old. Headaches with visual disturbances
and vomiting. MRI pineal region mass arround
the posterior third ventricle with calcifications
in CT, iso- intense In T1W1, hyper intense in
T2W1, Slightly hyperintense flair , causing a
triventricular hydrocephalus active upstream and
homogeneously enhanced.
Axial T2 flair
C
Anapath Germinoma
COR T2
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RESULTS
Pineal region
Round, smooth cystic mass Typically lt 1 cm,
may be up to 2 cm Variable calcification and
cyst fluid No or minimal rim enhancement,
compressed enhancing gland often seen
posteriorly May be indistinguishable from PC on
imaging
T2
D
A
SAG T1 GADO
SAG t1
31 years old. Fainting, convulsive crisis last
year. MRI Round cyst hypo intense T1, hyper
intense T2 without calcifications.
C
PINEAL CYST
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RESULTS
Pineal region
Most epidermoid cysts resemble CSF, not fat
No dermal appendages 4-9x more common than
dermoid Off-midlinegt midline 40-50 in CPA,
10-15 para sellar/middle fossa, 10 diploic
MRI Isointense to CSF except restricts on
diffusion
T2
Axial T2
D
COR T1
COR flair T2
A
SAG T1 GADO
SAG t1
37 years old. Headache. MRI lobular mass
occupating trijimenal region slightly
hyperintense to CSF on T1W1, doesnt completely
null on flair causing triventricular
hydrocephalus active upstream, hyper intense
on T2 , without enhancement.
v4
SAGT1 gado
C
Anapath EPIDERMOID CYST
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RESULTS
Pineal region
SAG T1
Cor T2 flair
Cor T1 gado
14 years old. Headache. .MRI lobular mass
occupating trijimenal region slightly
hyperintense to CSF on T1W1 flair, causing
triventricular hydrocephalus active upstream,
hyper intense on T2 flair, without enhancement.
C
Coronal T1 Flair W1
Anapath ASTROCYTOMA LOW GRADE
Axial SPGR
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RESULTS
Trigone and corpus callosum region

• Periventricular enhancing mass
• Often crosses corpus callosum
• Typically iso-intense/hypointense on T2WI
• Necrosis common in AIDS related lymphoma.
• Intravascular lymphoma may appear diffusely
  infiltrating.

T2
Axial T2
D
COR T1
COR flair T2
A
SAG T1 GADO
SAG t1
v4
55 years old. Headache and memory troubles. MRI
enhancing lesion involving the entire corpus
callosum showing minimal mass effect on the
ventricle. Contrast enhanced axial T1W1.
C
Coronal T1 Flair W1
Anapath LYMPHOMA
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RESULTS
Trigone and corpus callosum region
T2
Axial T2
D
COR T1
A
SAG T1 GADO
SAG t1
55 years old. Headache and memory troubles. MRI
Heterogenous mass involving the entire
corpus callosum . Its hypo intense on T1W1 and
shows heteregenous enhancement lesion involving
the entire corpus callosum showing minimal mass
effect on the ventricle. Contrast enhanced axial
T1W1.
C
Anapath CORPUS CALLOSUM GLIOMA
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CONCLUSION
Tumors of the midline of the brain are
complex and diverse. The magnetic
resonance imaging is of major interest, allowing
a particularly informative topographic analysis,
a diagnostic aid, bringing sometimes a tissue
characterization and support the choice of
treatment, specifying the path and the target in
stereotactic biopsies.
COR T1
A
SAG t1
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COR T1
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SAG t1
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THANKS
COR T1
A
SAG t1
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