Page 1Brain 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 NEUROANATOMYand DIFFERENTIAL DIAGNOSIS:PART 2 - Infratentorial LesionsPART 2 - Supratentorial Lesions

James G. Smirniotopoulos, M.D.Professor of Radiology, Neurology, and Biomedical InformaticsChairman, Department of Radiology and Radiological SciencesUniformed Services University of the Health Sciences

4301 Jones Bridge RoadBethesda, MD 20814Voice: 301-295-3145FAX: 301-295-3893

DISCLAIMER

The opinions expressed herein are those of the author(s), and are not necessarily representative of the UniformedServices University of the Health Sciences (USUHS), the Department of Defense (DOD); or, the World HealthOrganization (WHO).

Medicine is a constantly changing field, and medical information is subject to frequent correction and revision.Therefore the reader is entirely responsible for verifying the accuracy and relevance of the information containedherein.

Portions Copyright © 1997 - 2006 by James G. Smirniotopoulos, M.D.

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Schematic of Locations

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Schematic of Locations

PATTERN ANALYSIS

Basic Approach

Where is the lesion ?SupratentorialInfratentorial

Where is the lesion ?IntraaxialExtraaxial

How old is the patient ?ChildAdult

PATTERN ANALYSIS

Where is the Lesion?

INTRAAXIALinternal to PIA(brain parenchyma)

EXTRAAXIALexternal to PIA(meninges, nerve sheath)

INTRAVENTRICULARLateralThirdFourth

INTRAAXIAL:

Differential

CORTEXGRAY/WHITE JUNCTIONDEEP WHITE MATTERDEEP GRAY MATTER

INTRAAXIAL:

Differential

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Differential

GliomaMedulloblastomaHemangioblastomaMetastasesInfarct/hematomaAVM/congenitalAbscess/inflammation

EXTRAAXIAL LESIONS

(Location)

SubarachnoidSubduralEpiduralCalvarium (skull base)SubgalealScalp (soft tissues)

EXTRAAXIAL LESIONS

(Differential):

MeningiomaPituitary adenomaCraniopharyngiomaSchwannomaChordomaDermoid/epidermoid, cyst, lipomaHematoma, metastasis, infection

CLASSIC LOCATIONS

Foramen magnumCerebellopontine angleFourth ventricle/CerebellumSella/parasellar/suprasellarBasal ganglia/Third ventricleLateral ventricle/Pineal regionDeep hemispheric/periventricularCortical/subcorticalConvexity

CPA MASSES:

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Differential

S schwannoma (8th >> > 5th)A aneurysm, arachnoid cystM meningioma, metsE 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 No relationship

Heterogeneous if Large Homogeneous Does NOT enhance

Round, Acute Angle Hemisphere, Obtuse Angle Undulating/Serpentine

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*

CHILDHOOD CEREBELLAR/IV:

Differential

Medulloblastoma (PNET)Astrocytoma (usu. Pilocytic)EpendymomaPost fossa cysts

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DEEP CEREBELLAR (ADULT)

MetastasisHemangioblastomaHemorrhage, infarctGlioma (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 adenomaCraniopharyngiomaAneurysm (ICA , etc.)MeningiomaOptic/hypothalamic glioma

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Optic/hypothalamic gliomaChordomaGranuloma, 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 adenomaSELLA NORMAL - NOT pituitaryCa++ - Craniopharyngioma, but...HYPEROSTOSIS - Meningioma ( exp. "blistering" )CLIVUS - Chordoma, mets, NP CaRemember - rule out vascular lesions (aneurysms)

HYDROCEPHALUS

Differential Diagnosis:

Over production of CSF (CPP)Obstruction of CSF flow:

Obstructive/internal hydrocephalusCommunicating/external hydrocephalus

Under reabsorption of CSF: SAHCompensatory:Ex vacuo/enlargement

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THIRD VENTRICLE

Differential:

Colloid cystCraniopharyngiomaHypothalamic and thalamic gliomaCPP, ependymomaBasilar tip aneurysmNeurocytoma

BASAL GANGLIA/THALAMUS:

BILATERAL SYMMETRIC (toxic/metabolic):PUTAMEN - MethanolGLOBUS 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 pellucidumHuntington's Chorea

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Huntington's ChoreaATROPHY

INTRAVENTRICULAR NEOPLASMS:

Ependymoma (and subependymoma)Choroid plexus papillomaSubependymal giant cell astro.MeningiomaColloid cyst (3rd)Dermoid/epidermoidCentral neurocytomaMedulloblastoma (4th)Mets, lymphoma, Germ Cell

PINEAL/QUAD. CISTERN REGION:

"Pinealomas"Germ cell tumorsPineal cell tumors

PineoblastomaPineocytoma

Gliomas (regional)Brainstem, callosum, thalamus

OtherDermoid, lipoma, arachnoid cystMeningiomaVein of Galen malformations

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Vein of Galen malformations

DEEP AND PERIVENTRICULAR:

Glioma (astrocytoma)LymphomaToxoplasmosis, CMVLeukoencephalopathy (WM)Arteriolar sclerosis (HT)Infarcts (lacunar)Hemorrhage

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CONVEXITY (INTRAAXIAL)

Gray-White JunctionHEMATOGENOUS NeoplasmHEMATOGENOUS InfectionHEMATOGENOUS Thrombi (multiple infarcts)INFARCTION/ISCHEMIAVASCULITIS

CEREBRAL INFARCTION

1. Abrupt Onset2. Gray Matter Involved3. Little Mass Effect4. Vascular Wedge

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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 InformaticsChairman, Department of Radiology and Radiological SciencesUniformed Services University of the Health Sciences

4301 Jones Bridge RoadBethesda, MD 20814Voice: 301-295-3145FAX: 301-295-3893

Comment or Questions - Send EMail about this site.

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