The Wave of the Future - Lieberman's eRadiology Learning …eradiology.bidmc.harvard.edu/LearningLab/central/Feltus.pdf · Whitney Feltus, MS IV Gillian Lieberman, MD The Wave of

Whitney Feltus MS IV

Gillian Lieberman MD

The Wave of the Future Glioblastoma Multiforme (GBM)

and Diffusion Tensor Imaging (DTI)


Wake Forest School of Medicine


October 16 2012



Objectives bull Our Patient

bull Overview of GBM ndash The basics

ndash MRI Findings

ndash Treatment

bull Diffusion Tensor Imaging ndash Introduction

ndash How it works

bull Diffusion Tensor Imaging for Treatment of GBM ndash Surgery

ndash Radiation

bull Post-Treatment Evaluation Using DTI ndash Response

ndash Injury

ndash Progression vs Pseudoprogression





ndash MRI Findings

ndash Treatment


ndash How it works


ndash Radiation


ndash Injury




Our Patient Clinical Presentation

bull History of Present Illness A 63 year-old left-handed male from an outside hospital presented to the

emergency department with a 1-week history of slurred speech memory loss and decreased concentration All other review of systems were negative

bull Past Medical History Hepatitis C Appendectomy in (1958) Hernia repair (1985)

bull Family History Non-contributory

bull Social History The patient lives with his wife has two children and works as a manager at manufacturing firm He quit smoking in 2004 and denied use of alcohol

bull Physical Exam Vital signs were stable There were no physical exam findings including neurological deficits

bull Imaging CT scan at OSH revealed 38 cm mass in left frontal lobe

4



Our Patient

Head CT Unlabeled

5 C- axial CT

PACS BIDMC



Our Patient Head CT Labeled

6

4 cm circular

hypodense intra-

axial mass in the

left posterior-

inferior frontal

lobe

Surrounding edema

Right-ward shift of

septum pellucidum

C- axial CT PACS BIDMC



7

Our Patient

Enhancing Mass on CT Angiogram

4 cm ring-enhancing heterogenous mass

C+ axial CTA PACS BIDMC




Our Patient Hospital Course

ndash Admitted to the neurosurgery unit and started

on dexamethasone for cerebral swelling and

dilantin for seizure prophylaxis

ndash Received an MRI of the head for further

evaluation of the lesion and surgical planning

ndash Underwent tumor resection and found to have

biopsy proven glioblastoma multiforme WHO

grade IV

8



Objectives bull Overview of GBM

ndash The basics

ndash MRI Findings

ndash Treatment


ndash How it works


ndash Radiation


ndash Injury




Overview of Glioblastoma Multiforme

Origins Rudolph Virchow

ldquoFather of Pathologyrdquo

German pathologist

First named gliomas in 1830rsquos

One of first to study brain tumors

at the microscopic level

Dr Rudolph Virchow

(13 October 1821 ndash 5 September 1902)

Image adopted from

httpwwwsciencephotocomimage229103350wmH

4220150-Rudolf_Virchow_German_pathologist-

SPLjpg

Andreas M Stark et al (2005)



Spongioblastoma multiforme - 1926

ldquoIt is from this group doubtless that the

generally unfavorable impression

regarding gliomas as a whole has been

gained It is not only the largest single

group in the serieshellipbut at the same time

is one of the most malignanthellipIn the five

unoperated cases the average duration

of life from the onset of symptoms was

only three months which speaks well on

the whole for the average survival period

of twelve months for those surgically

treatedrdquo

Lassman A et al (2005) (May 9 1892 ndash August 10 1973)

Dr Percival

Bailey

Dr Harvey Cushing

(April 8 1869 ndash October 7 1939)

Image adopted from

httpneurosurgeryorgsocietybiophotobailey_percivaljpg

Image adopted from

httpuploadwikimediaorgwikipediacommonsthumbccaHarv

eyCushingJPG220px-HarveyCushingJPG


Origins Spongioblastoma



Overview of Glioblastoma Multiforme Classification Epidemiology Prognosis

Classification

ndash Most common primary brain

and glial tumor

ndash WHO Grade IV astrocytoma

ndash Highly aggressive and invasive

Epidemiology

ndash Incidence 2-3

cases100000yr in the US

and Europe

ndash Malegt Female

ndash 6th or 7th decade

Prognosis

ndash Dismal

ndash Survival

bull Median 14 months with

treatment

bull 5-year 3

ndash Poor Prognostic Indicators

bull Older age

bull Histological features

bull Poor Karnofsky performance

status

bull Unresectable tumors

bull Unmethylated MGMT

promoter

DeAngelis LM et al (2012) Primary and Metastatic Tumors of the Nervous System



Overview of Glioblastoma Multiforme Clinical Presentation

AM Stark et al Surgical Neurology 63 (2005) 162ndash169

SignsSymptoms

- Headache seizures focal

neurological deficits

Tumor Location

- Cerebral hemispheres

(Temporal lobe)

- Bihemispheric across

corpus callosum







Overview of Glioblastoma Multiforme Cell Biology Glial Cells

Glial cell

Support cells in the brain and maintain homeostasis

Image adopted from

httpwwwaccessmedicinecomgolibproxywfubmcedupopupaspxaID=5271176



Overview of Glioblastoma Multiforme Cell Biology Astrocytes

Astrocytes Types

bull Protoplasmic delicate branched in gray matter

bull Fibrous contain glial fibrils usually not branched

Location bull Surround blood vessels and overlay surface of the brain below the pia

Function bull Structural support for blood brain barrier formed by vessels

bull Ion balance (K+) in extracellular space

bull Role in neurotransmission

bull Repair Waxman SG (2010)



Overview of Glioblastoma Multiforme Pathology

Heterogeneous Patterns

Variable micro- and macroscopic findings from

one area of the tumor to the next



Overview of Glioblastoma Multiforme Pathology Gross Anatomy

bull Gross Anatomy

ndash Firm amp white

ndash Soft amp yellow

(necrosis)

ndash Cystic degeneration

ndash Hemorrhage

Image adopted from

httplibrarymedutaheduWebPathjpeg5CNS136jpg

Saunders W B (2009)



Overview of Glioblastoma Multiforme Pathology Microanatomy

bull Poorly differentiated

bull Polymorphic

bull Elongatedirregular

bull Hyperchromatic nuclei

bull Eosinophilic

Vascular proliferation and pseudopalisading necrosis separates GBM from anaplastic astrocytoma

Image adopted from

httpwwwpathpediacomEducationeAtlasHistopathologyb

rain_and_cordglioblastoma_(gbm)aspx

Saunders W B (2009)



Overview of Glioblastoma Multiforme Pathology Microvascular and Endothelial

Proliferation

bull Hypoxia induces

production of VGEF

bull Cells pile up and bulge

into lumen of vessels

(Tufts)

bull Tufts form glomeruloid

body (black arrows)

Image adopted from

httpwwwpathpediacomEducationeAtlasHistopathologybr

ain_and_cordglioblastoma_(gbm)aspxtes4jpg

Saunders W B (2009)



Overview of Glioblastoma Multiforme Pathology Necrosis

bull Hypercellularity and rapid cell turn-over

bull Cells along margin of necrotic tumor form pseudopalisades ndash Palisade = fence or row

of wooden poles

ndash Pseudopalisade = elongated nuclei gathered in a row due to necrosis

Image adopted from

httpwwwpathpediacomEducationeAtlasHistopathology

brain_and_cordglioblastoma_(gbm)aspx

Image adopted from

httpwwwpathpediacomEducationeAtlasHistopathologybrai

n_and_cordglioblastoma_(gbm)aspx Saunders W B (2009)



Overview of Glioblastoma Multiforme Pathology Glial Fibrillary Acidic Protein

bull Intermediate filament (IF) of cells expressed in the CNS and elsewhere

bull Function ndash May play role in

maintaining structure and shape of astrocytes (Eng et al (2000))

ndash Cell communication

ndash Mitosis

bull Good marker for GBM

Image adopted from

httpwwwpathpediacomEducationeAtlasHistopathologybrain_and_cordg

lioblastoma_(gbm)aspx

Saunders W B (2009)



Overview of Glioblastoma Multiforme Pathogenesis Molecular Genetics

bull Gene Amplification bull MDM2

ndash Inhibitor of p53

bull Epidermal growth factor receptor (EGFR)

ndash Stimulation and growth of tumor cells by

raquo Inc tyrosine kinase activity activation of RAS and PI-3 kinase pathways

bull MGMT (DNA repair gene) bull May have methylation of promoter gene

bull Alters responsiveness to DNA alkylating chemotherapy drugs

Saunders W B (2009)




The Diagnosis and Evaluation of GBM

Using Magnetic Resonance Imaging

(MRI)



Overview of Glioblastoma Multiforme MRI An Overview of Magnetic Resonance Imaging

bull MRI is the standard for characterizing brain lesions ndash Gadolinium contrast allows better visualization of active lesions

bull GBM is an aggressive tumor that causes breakdown of the blood brain barrier (BBB)

bull Disruption of the (BBB) allows contrast to leak into tissues

bull Higher grade tumors have a higher degree of enhancement

bull Advanced uses ndash Functional hemodynamic metabolic cellular cytoarchitectural

alterations

ndash Tumor grade using and cellularity using diffusion sequences

ndash Staging amp Prognosis

ndash Evaluate treatment response and tumor progression

25

Cha s et al (2006) Update on Brain Tumor Imaging From Anatomy to Physiology



pre-C axial T1 MRI PACS BIDMC

26

Overview of Glioblastoma Multiforme MRI MRI vs CT


MRI gives

better

visualization of

cellular activity

within the lesion

sharper borders

of tumor for

more precise

measurements

increased

differentiation of

edema vs lesion



The Basics of T1-Weighted Imaging

Fat = hyperintense (bright)

Lesions inflammation fluid collections = hypointense (dark)

27

Overview of Glioblastoma Multiforme MRI T1-Weighted Imaging Overview

Clark J et al (2012) Neuroimaging Diagnosis and Response Assessment in Glioblastoma



MRI Sequence Type T1 Pre-contrast T1 Post-contrast

Function Assess for intratumoral

hemorrhage surrounding

edema (Clark J et al (2012)

To define active lesions

Can detect smaller satellite

lesions

GBM Findings - Hypointense lesion

- Surrounding vasogenic

edema

- Ring-enhancing

heterogeneous lesion

- Central area of necrosis

28

Overview of Glioblastoma Multiforme MRI A Comparison of T1- Weighted Imaging with and without Gadolinium

Contrast




29

Overview of Glioblastoma Multiforme MRI T1-Weighted Imaging of Our Patient Unlabeled

post-C axial T1 MRI PACS BIDMC



30

Overview of Glioblastoma Multiforme MRI T1-Weighted Imaging of Our Patient Labeled

38 cm

homogeneous

hypointense mass

edema Ring-

enhancement

with central

area of

heterogenous

enhancement

Central area

of necrosis Satellite lesion detected





31

Overview of Glioblastoma Multiforme MRI T1-Weighted Imaging of Our Patient

pre-C sagittal T1 MRI PACS BIDMC

Another view of the frontal lobe lesion



bull Basics

ndash Water and fluid are bright

on T2

ndash Used to assess for edema

or infiltrative tumor Clark et al (2012)

bull GBM Findings

ndash Vasogenic edema

ndash Central area of necrosis


MRI T2-Weighted Imaging Overview

Axial T2-Weighted MRI PACS BIDMC

32

Vasogenic Edema

Cystic

necrosis



bull FLAIR Basics

ndash Inversion recovery pulse sequence

ndash Nulls signal from water of CSF and

maintains hyperintensity of T2

ndash Improves lesion detection

T M Simonson et al (1996) Echo-planar FLAIR

imaging in evaluation of intracranial lesions

bull GBM Findings

ndash More hyperintense signaling due to higher

grade of tumor

ndash Surrounding vasogenic edema

(hyperintense)

ndash Central necrosis (hypointense) better

visualized than on T2

Overview of Glioblastoma Multiforme MRI FLAIR (Fluid Attenuated Inversion Recovery)

33

Vasogenic Edema

Cystic

necrosis

Hyperintense

lesion

Satellite lesion

Axial FLAIR MRI PACS BIDMC




MRI Diffusion Weighted Imaging

bull DWI Basics

ndash Measures diffusibility of water molecules in and out of tissues

ndash Areas of decreased diffusion will appear bright

ndash Apparent Diffusion Coefficient (ADC) takes into account direction mainly diffusion of molecules along one vector

bull GBM Findings

ndash Increased areas of cellularity restrict diffusion of water molecules and appear bright on DWI

Schaefer P et al (2000) Diffusion-weighted MR Imaging of the Brain

Axial DWI ndash TRACE MRI

PACS BIDMC

Axial DWI ndash ADC MRI

PACS BIDMC

34

Increased signal

= restricted

diffusion

Satellite lesion

detected




MRI MR Spectroscopy

bull Basics ndash Analysis of chemical composition of brain lesions

ndash Used to distinguish tumors from other lesions and measure cellular activity

bull Measures ndash N-acetylaspartate (NAA)

bull Product of glutamate breakdown

bull Neuronal marker

bull Decreased in astrocytomas due to replacement of viable neuronal tissue by malignant cells

ndash Choline bull Component of cell membranes

bull Increased in astrocytomas due to increased cellularity

ndash Creatinine bull Maintains energy-dependent systems in the brain

bull Decreased in astrocytomas due to increased metabolism

35 Castillo M et al (1996) Clinical Applications of Proton MR Spectroscopy



Overview of Glioblastoma Multiforme MRI MR Spectroscopy Graphs in Normal Brain Tissue vs GBM

Images obtained from Castillo M et al (1996) Clinical Applications of Proton MR Spectroscopy

httpwwwajnrorgcontent1711long

36

MR Spectroscopy Graph of Comparison Case 1 Showing Normal Results MR Spectroscopy Graph of Comparison Case 2 with GBM



Overview of Glioblastoma Multiforme MRI MR Spectroscopy Example in Low-Grade Astrocytoma

Images obtained from Clark J et al (2012) Neuroimaging Diagnosis and Response Assessment in Glioblastoma

httpovidsptxovidcomsp-360bovidwebcgiT=JSampPAGE=fulltextampD=ovftampAN=00130404-201201000-

00006ampNEWS=NampCSC=YampCHANNEL=PubMed

37

MR Spectroscopy Graph of Comparison Case 3




Surgery Radiation and Chemotherapy

for the Treatment of GBM




Treatment Surgery

Does the extent of resection correlate with

increased survival in patients with

glioblastoma multiforme



The effect of extent of resection on time to tumor progression and survival

in patients with glioblastoma multiforme of the cerebral hemisphere

Methods

bull Retrospective study

bull N = 92

bull Measure pre- and post-operative tumor volumes

bull End point variables affecting time to tumor progression and overall

survival

Results

bull Variables that had significant impact on TTP

bull Pre-operative Karnofsky Performance Status (plt05)

chemotherapy (plt05) percent of resection (POR) (plt001)

volume of residual disease(VRD) (plt001)

bull Variables that had significant impact on overall survival

bull Age (plt05) preop KPS (p = 05) postop KPS (plt005) POR

(plt0005) VRD (plt0001)

Keles GE Anderson B Berger MS The effect of extent of resection on time to tumor progression and survival in patients with glioblastoma

multiforme of the cerebral hemisphere Department of Neurosurgery V Koc Foundation American Hospital Istanbul Turkey Surg Neurol 1999

Oct 52(4) 371-9


Treatment Surgery



Images adopted from Keles GE et al(1999) httpwwwsurgicalneurology-onlinecomarticleS0090-3019(99)00103-2abstract


Treatment Surgery



A multivariate analysis of 416 patients with glioblastoma multiforme

prognosis extent of resection and survival

Lacroix M et al (2001)

Methods

bull Retrospective mmultivariate analysis

bull N = 416

bull Volumetric data by MRI collected prospectively

bull End point

bull Predictors of survival age KPS extent of resection degree of necrosis and enhancement on preop MRI

Results bull Survival and extent of resection

bull Resection gt= 98 = median survival 13 months (95 confidence interval [CI] 114-146 months)

bull Resection lt 98 = median survival 88 months (95 CI 74-102 months p lt 00001)

bull Survival and KPS

bull KPS (0-5) and tumor necrosis on MR imaging

bull significantly longer survival in patients with lower scores (1-3) who underwent aggressive resections

bull slightly longer survival with higher scores (4-5)

Lacroix M et al A multivariate analysis of 416 patients with glioblastoma multiforme prognosis extent of resection and

survival Department of Neurosurgery The University of Texas MD Anderson Cancer Center Houston Texas J

Neurosurg 95 190-198 2001


Treatment Surgery



Overview of Glioblastoma Multiforme Treatment Radiation Therapy

bull Improved survival with radiation treatment ndash Kristiansen K et al Cancer 1981 Feb 1547(4)649-52

bull Dose 60 Gy + 10 Gy boost

ndash 2 Gy fx 5dwk for 6 wks

ndash Nelson DF et al NCI Monogr 1988(6)279-84

bull No benefit of whole brain radiation vs limited-volume RT

ndash Shapiro et al J Neurosurg 1989 Jul71(1)1-9

bull No benefit of radiosurgery

ndash Souhami L et al Int J Radiat Oncol Biol Phys 2004 Nov

160(3)853-60




Treatment Chemotherapy

0

10

20

30

40

50

60

70

80

90

1st Qtr 2nd Qtr 3rd Qtr 4th Qtr

East

West

North



The European Organisation for Research and Treatment of Cancer (EORTC) Brain Tumor and

Radiotherapy Groups and the National Cancer Institue of Canada (NCIC) Clinical Trials Group

Radiotherapy plus Concomitant and Adjuvant Temozolomide for Glioblastoma

Randomized multicenter phase III trial to compare radiation therapy alone vs radiation +

temozolomide Stupp R et al (March 2005) NEJM

bull Methods

ndash Phase III Randomized control trial

ndash N = 573 patients from 85 centers randomized with newly diagnosed biopsy

proven GBM

ndash Assignments

bull Radiotherapy alone (fractionated focal irradiation in daily fractions of 2 Gy given

5 dayswk for 6 weeks for total of 60 Gy)

ndash 287 patients

bull Radiotherapy + temozolomide (75 mgm2day 7 daysweek for duration of

radiotherapy + 6 cycles of adjuvant temozolomide 150 ndash 200 mgm2 for 5 days

during each 28-day cycle

ndash 286 patients

ndash End Point overall survival

Overview of Glioblastoma Multiforme Treatment Chemotherapy








bull Results

ndash Median follow-up 28 months

bull Median survival 146 months with

radiation + temozolomide


radiation therapy alone

ndash Unadjusted hazard ratio for death in

radiotherapy + temozolomide =

63(95 CI 052 to 075 Plt001)

ndash 2-yr survival rate = 265 with

Concurrent therapy 104 with

radiotherapy alone




Objectives

bull Diffusion Tensor Imaging

ndash Introduction

ndash How it works

bull Diffusion Tensor Imaging for Treatment of GBM

ndash Surgery

ndash Radiation

bull Post-Treatment Evaluation Using DTI

ndash Response

ndash Injury




Diffusion Tensor Imaging

Image adopted from

http4bpblogspotcom_4ify7vDXrDsTVHNmBs9SbIAAAAAAAAG_05P4rfZn5I60s640brain_2_pathwaysjpg



bull A 2 or 3D view of white

matter fiber tracks

(WMT) in the brain

bull Uses color-coding and

tractography to visualize

tracts extending in

multiple directions

bull Measures diffusion of

water molecules along the

white matter axis to

reconstruct the image

GBM

Rizea RE et al (2012) 3D diffuse tensor imaging important acquisition in diagnostic and preoperative planning of intracranial lesions

Axial Diffusion Tensor MRI PACS BIDMC

Displacement of

surrounding white matter

corticospinal tracks


Introduction



bull Detect of brain injury

ndash Ischemia vs penumbra

ndash Tumor infiltration

ndash Axonal degeneration

bull Define anatomy

ndash Localize eloquent areas of the brain

bull Obtain more precise coordinates of lesions

bull Evaluate for treatment response and side effects


Introduction How is it used




Introduction How does it work

Basic Principles

1 Diffusion

2 Measurement

3 Image reconstruction



bull Not affected by magnetic field of MR

bull No interference with diffusion process

bull High resolution imaging of deep and

superficial organs

Diffusion Tensor Imaging 1 Diffusion Why use diffusion for imaging

Le Bihan D et al (2001)



bull Convenient

bull Easily follows white matter tracts in healthy brain

bull Interact with tissue components

bull Insight to structural and geometric properties of white matter tracts

bull Sum of interactions in a voxel represent distribution and displacement of water molecules


1 Diffusion Why water




Brownian motion Random movement of molecules (gas or liquid) due to collisions in surrounding medium

Movement of molecules also based on temperature or their thermal energy

Fickrsquos first law of diffusion Diffusion occurs down the concentration gradient

Magnitude of diffusion proportional to concentration gradient

Apparent Diffusion Coefficient (ADC) Represents diffusion in one direction (cm2 s or mm2s) High diffusion give low signal

Water exchange (movement) occurs intra- and extracellularly in tissues

Diffusion of water limited by Shape of surrounding structure

Tissue cellularity


1 Diffusion Concepts of Diffusion

De Figueiredo E et al (2011)



Isotropy

Diffusion of molecules EQUALLY

distributed in all directions

ndash Net movement is same

Anisotropy

UNEQUAL distribution

ndash Net movement is not same

Direction of molecules (water) take

into account shape of surrounding

structure

Proportional to elliptical shape (FA)


1 Diffusion Isotropy vs Anisotropy

Image obtained from

httpwwwnaturecomprjournalv58n5f

ullpr2005800ahtml




Apply Brownian motion ndash Restriction of movement

perpendicular to axon

raquo Water will quickly collide with sides of fibers (myelin sheath and endoneurium)

Apply Ficks Principle

ndash Ease of diffusion is parallel (along axis) to axon

White matter tracts are anisotropic in an ellipsoid shape

ndash Get linear movement (vector) of water molecules parallel to axon


1 Diffusion Anisotropy in White Matter

De Figueiredo E et al (2011) Axon

Myelin

Sheath

Water

molecules

Endoneurium



Diffusion is faster

parallel to white

matter tracts



Image adopted from

httpwwwmedumichedulrccoursepagesm1anatomy2010htmlmodulesN

S_overview_moduleFilesfasicleimgjpg



Tensor

Mathematical model describing the linear relationship between vectors scalars and other tensors

Scalar Real number related to vectors in space can be multiplied to produce another vector

Fractional Anisotropy Scalar measurement of anisotropy

- between 0 and 1

- 0 = isotropic 1 = diffusion along one axis and fully restricted in all other directions

Diffusion Tensor Imaging 2 Measurement of Diffusion Quick Definitions

Jellison B J et al (2004)



Diffusion (D) related to direction and

magnitude of diffusion

Direction = Eigenvectors

Principle eigenvector parallel to main

axis of WMT

Magnitude = Eigenvalues (λ1 λ2 λ3)


2 Measurements Diffusion Tensor

Gerstner E R et al (2011) Wang W et al (2009)



Eigenvalues

Used to calculate scalar measurements such as FA p

q L

1 P = pure isotropic diffusion

2 q= pure anisotropic diffusion

3 L = magnitude of diffusion tensor


2 Measurements Eigenvalues




Apply Tensor to White Matter Measurement of diffusivity in at least 6 different directions (ADCrsquos) with same point of origin

Visualized as an ellipsoid

Represented by a 3x3 matrix of numbers (diagonalization) to

ndash Estimate diffusivity in any direction based on diameter (uses xyz axis)

ndash Determine direction of maximum diffusivity (Diffusion Tensor)

Diffusion Tensor Imaging 2 Measurement of Diffusion Diffusion Tensor in White Matter




Diffusion tensor proportional to strength of anisotropy (FA)

Tensor directionality related to integrity of white matter

Reduced anisotropy can be due to disruption of white matter tracts (invading tumor radiation damage)

Diffusion Tensor Imaging 2 Measurement of Diffusion Diffusion Tensor and Axonal Injury


Image Obtained From

httpwwwsciencedirectcomscience_ob=MiamiCaptionURLamp_method=retrieveamp_eid=1-s20-

S0166223612000720amp_image=1-s20-S0166223612000720-

gr3jpgamp_ba=amp_fmt=fullamp_orig=naamp_issn=01662236amp_pii=S0166223612000720amp_acct=C00002969

8amp_version=1amp_urlVersion=0amp_userid=582433ampmd5=b86aca085f84aae5e6cf351b0b77f7cd



Images obtained from

httpwwwcabiatlcomResourcesCourse

tutorialhtmldtihtml

Diffusion Tensor Imaging 3 Image Reconstruction Mean Diffusivity (MD) vs FA

Mean Diffusivity (Tensor Size)

Lower signal with greater

diffusivity water molecules

spread out within a given space

FA (Tensor Shape)

Higher signal with lower

diffusivity and greater flow of

molecules along an axis



bull Measurement in small voxels (18 x 18 x 3mm)

bull Uses echo-planar imaging (fast acquisition)

bull Pulse field gradients applied variation in diffusion

measurements

bull Pulse field gradient = short timed pulse with spatial-dependent field intensity

bull Detect diffusion anisotropy (encoded in MRI signal)

bull Only molecular displacements along direction of the gradient are

visible

Diffusion Tensor Imaging 3 Image Reconstruction Data Acquisition



View of WMT directions in the Brain using 2D or 3D color-

coded maps

Blue = CST (projection or cranial-caudal)

Red = corpus callosum (commissural or medial-lateral)

Green = intrahemispheric (association or anterior-

posterior)

Diffusion Tensor Imaging 3 Image Reconstruction Tractography



Diffusion Tensor Imaging 3 Image Reconstruction Tractography of Corpus Callosum

Image Obtained From httpwwwajnrorgcontent253356fullpdf+html



Diffusion Tensor Imaging 3 Image Reconstruction

Tractography of Corticospinal Tract

Image Obtained From

httpwwwajnrorgcontent253356fullpdf+html



Objectives


ndash Surgery

ndash Radiation


ndash Response

ndash Injury




The patient received a functional MRI (fMRI) and

diffusion tensor imaging

for neurosurgical planning

69

Diffusion Tensor Imaging for the Treatement of GBM




bull Neuronavigation and

Intraoperative MRI

bull Benefits ndash Provides minimally invasive

approach to tumor resection

ndash More precise resection of tumor

ndash Avoid critical structures or

eloquent areas of the brain Li ZX et al (2006)

Image obtained from httpwwwfeaturefilmstorycombrainlab1gif

Diffusion Tensor Imaging for GBM Treatment

Surgical Planning and Resection Current Practice




Surgery Is There Utility of DTI in Surgical Planning

and Resection



Clinical evaluation and follow-up outcome of diffusion tensor imaging-based functional

neuronavigation a prospective controlled study in patients with gliomas involving

pyramidal tracts Wu Js et al (2007) Shanghai China

bull Methods

ndash Prospective Randomized-Controlled Trial

ndash 238 patients initial imaging diagnosis cerebral gliomas

involving pyramidal tract randomized Study (n = 118) and control

(n=120)

ndash Study underwent DTI and 3D MRI fo PT mapping

ndash End points gross total resection post ndashop motor

deterioration 6-month KPS Median survival estimated

hazard ratio


Surgery Is There Utility of DTI in Surgical Planning and Resection






bull Results

ndash Gross total resection (HGG) Control = 333 trial = 744 (plt001)

ndash Post operative motor deterioration Control = 328 trial = 153 (Plt001)

ndash 6-month KPS Control = 74 +28 study = 86 +-20 (plt001) overall 53 +- 32 vs 77+- 27 for HGG (Plt001)

ndash Medial survival

bull Control = 14 months (95 confidence interval 102-178 mo) (p = 048)

bull Study (81 HGG) = 212 months (95 CI 141-283 mo)

ndash Estimated hazard ratio for effect of DTI-based functional neuronavigation

bull 57 representing 43 reduction in risk of death






Surgery The Role of DTI in Surgical Planning

bull Preservation of eloquent areas of brain

ndash Corticospinal tract

bull Ohue S et al (2012)

ndash Language (brocas area wernickes area arcuate

fasciculus

bull Coordinates of tumor

ndash Smaller craniotomy

ndash More gross total resection with 3D planning

bull Survival benefits



3D Diffusion Tensor MRI PACS BIDMC





Tracks

Blue = Cranial-Caudal

(Corticospinal Tract)

Green = Intrahemispheric

projections (Arcuate

Fasciculus)

Red = Communicating

tracts between hemispheres

(Corpus Callosum)

Combined fMRI for

location of eloquent

areas of the brain

(language motor)

76 3D Diffusion Tensor MRI posterior view

PACS BIDMC





bull Problem

ndash Radiation side effects

bull Radiation to normal tissue

bull Radiation necrosis

ndash Cognitive decline seizures personality changes neurological

deficits

ndash Tumor progressionrecurrence after treatment

bull Residual tumor cells

bull Solution

ndash Focus radiation to targeted lesion

ndash More radiation dose to tumor and less to normal tissue


Radiation Therapy




Is There a Role for DTI in Radiation Planning



Diffusion Tensor Imaging Possible Implications for Radiotherapy Treatment Planning

of Patients with High-Grade Glioma

Jena R et al (2005)

bull Methods ndash N = 7 patients with HGG

ndash Compare standard planning with plans based on DTI

ndash Standard plans used 25 cm clinical target volume (CTV) margin added to the GTV

ndash DTI-based plans CTV generated by adding 1 cm margin to the IHV (image-based high-risk volume)

ndash Estimates on normal tissue complication probability (NTCP) calculated

ndash End Point Level of dose escalation that could be achieved using DTI-based plans

bull Results ndash DTI use resulted in non-uniform margins added to the GTV to

encompass areas at high risk tumor involvement

ndash 67 cases IHV encapsulated by standard CTV margin

ndash DTI reduce size of planning-target volume (PTV) (mean 35 range 18-46) in all cases

ndash Resulted in escalation does (mean 67 Gy range 64-74) with NTCP

Jena R Price SJ Baker C et al Diffusion Tensor Imaging Possible Implications for Radiotherapy Treatment Planning of Patients with

High-grade Glioma Department of Oncology University of Cambridge UK Clinical Oncology (2005) 17 581-590


Radiation Therapy The Role of DTI in Treatment Planning



Jena R Price SJ Baker C et al Diffusion Tensor Imaging Possible Implications for Radiotherapy Treatment Planning of Patients with High-

grade Glioma Department of Oncology University of Cambridge UK Clinical Oncology (2005) 17 581-590



Image adopted from

httpacels-cdncomS09366555050020371-s20-S0936655505002037-mainpdf_tid=ba91d3e0-12e5-11e2-a37a-

00000aacb35dampacdnat=1349879046_274507c69f9a08070c8b90335dcb4f14


Gillian Lieberman MD Diffusion Tensor Imaging for GBM Treatment




Image adopted from








Image adopted from





bull DTI could provide more accurate definition

of tumor margins and infiltration

ndash Price SJ et al (2006)

bull Need more randomized studies to evaluate

benefits of using DTI for radiation therapy

treatment planning





Objectives


ndash Response

ndash Injury




Post-Treatment Evaluation of GBM using DTI

Overview

bull What happens after treatment

ndash Response

ndash Radiation-induced damage

ndash Pseudoprogression

ndash Progression

ndash Tumor recurrence



Post-Treatment Evaluation of GBM using DTI Response White Matter Tracts Post-Chemotherapy

Image adopted from httpwwwsciencedirectcomsciencearticlepiiS1053429610000998

Gerstner E R et al (2011)



Radiation-induced injury to

white matter tracts can be

assessed using DTI Nagesh V et al (2008)

Post-Treatment Evaluation of GBM using DTI Radiation-Induced Injury Damage to White Matter Tracts

Image adopted from

httpwwwsciencedirectcomsciencearticlepiiS0360301607037686



Progression vs Pseudoprogression

Pseudoprogression A subacute response to radiation therapy

that can present as increased enhancement or expansion of

the site of the lesion on post-treatment imaging

Hygino da Cruz L et al (2011)

Post-Treatment Evaluation of GBM using DTI Radiation-Induced Injury Necrosis vs Tumor Progression




Radiation-Induced Injury Progression vs Pseudoprogression

Current Limitations of Imaging to Assess

Necrosis vs tumor progression

The imaging characteristics of radiation

injury and tumor infiltration are similar as

radiation can cause breakdown of the blood

brain barrier (BBB) and leakage of contrast

into the resection bed


Image adopted from






Image adopted from


Current Limitations of Imaging to

Assess Necrosis vs Progression

There can be discoordinate

findings between images and

sequences




Use of DTI Post-Radiation ndash Correlation between primary tumor site and area of

progression using water diffusion bull Priya A et al (2008)

ndash Compare differences in ADC and fractional anisotropy

The utility of DTI for GBM post-radiation response is a topic of debate

bull Alexiou G et al (2009)





Summary bull Our Patient

bull Overview of GBM ndash Glioblastoma Multiforme is the most common primary brain tumor

ndash Very aggressive with poor prognosis

ndash There are multiple MRI sequences used to diagnose and evaluate properties of the tumor

ndash Surgical resection and chemoradiation therapy can prolong survival

bull Diffusion Tensor Imaging ndash Model of white matter tracts

ndash Can assess anatomy and damage

bull Diffusion Tensor Imaging for the Treatment of GBM ndash Used in surgery planning and resection

ndash Possible use in radiation planning to improve targeted therapy

bull Post-Treatment Evaluation Using DTI ndash Can possibly assess response to treatment radiation injury and

progression vs pseudoprogression



Acknowledgments

bull Dr Rafael Rojas Neuroradiology Beth Israel Deaconess

bull Dr Gillian Lieberman Radiology Beth Israel Deaconess

bull Dr Michael D Chan Radiation Oncology Wake Forest

bull Claire Odom Department of Radiology Beth Israel

Deaconess

93



References 1 Alexiou G Tsiouris S Kyritsis A et al Glioma recurrence versus radiation necrosis accuracy of current imaging

modalities J Neurooncol (2009) 951ndash11

2 Andreas M Stark Arya Nabavi Hubertus Maximilian Mehdorn Ulrike Bloumlmer Glioblastoma multiformemdashreport of 267

cases treated at a single institution Surgical Neurology Volume 63 Issue 2 February 2005 Pages 162-169 ISSN 0090-

3019 101016jsurneu200401028 (httpwwwsciencedirectcomsciencearticlepiiS0090301904002563)

1 Castillo M Kwock L Mukherji S Clinical Applications of Proton MR Spectroscopy AJNR 171ndash15 Jan 1996

0195-6108961701ndash0001 httpwwwajnrorgcontent1711long

2 Cha s Update on Brain Tumor Imaging From Anatomy to Physiology AJNR Am J Neuroradiol 27475ndash 87

March 2006 httpwwwajnrorgcontent273475shortrss=1ampssource=mfc Accessed October 14 2012

3 Chun Shui Yu Kun Cheng Li Yun Xuan Xun Ming Ji Wen Qin Diffusion tensor tractography in patients with

cerebral tumors A helpful technique for neurosurgical planning and postoperative assessment European Journal of

Radiology - November 2005 (Vol 56 Issue 2 Pages 197-204 DOI 101016jejrad200504010)

4 Clark J et al Neuroimaging Diagnosis and Response Assessment in Glioblastoma Cancer J 201218 26Y31

Lippincott Williams and Wilkins httpovidsptxovidcomsp-

360bovidwebcgiT=JSampPAGE=fulltextampD=ovftampAN=00130404-201201000-00006ampNEWS=NampCSC=YampCHANNEL=PubMed

5 DeAngelis LM Wen PY Chapter 379 Primary and Metastatic Tumors of the Nervous System In Longo DL

Fauci AS Kasper DL Hauser SL Jameson JL Loscalzo J eds Harrisons Principles of Internal Medicine 18th

ed New York McGraw-Hill 2012

6 De Figueiredo E Borgonovi A Doring T Basic Concepts of MR Imaging Diffusion MR Imaging and Diffusion

Tensor Imaging Magn Reson Imaging Clin N Am 19(2011) 1-22 2011

httpwwwaccessmedicinecomgolibproxywfubmceducontentaspxaID=9147519 Accessed October 14 2012

94





References 7 Gerstner E R Sorenson A G Diffusion and Diffusion Tensor Imaging of the Brain Department of Massachusetts General

Hospital Semradonc201010005

8 Gomella LG Haist SA Chapter 15 Imaging Studies In Gomella LG Haist SA eds Clinicians Pocket Reference The Scut

Monkey 11th ed New York McGraw-Hill 2007


9 Hygino da Cruz L Rodriguez I Domingues R Pseudoprogression and Pseudoresponse Imaging Challenges in the Assessment

of Posttreatment Glioma AJNR Am J Neuroradiol 321978ndash85 March 2011


10 Jellison B J Field A S Medow J Diffusion Tensor Imaging of Cerebral White Matter A Pictorial Review of Physics Fiber

Tract Anatomy and Tumor Imaging Patterns AJNR AM J Neuroradiol 25356-369 March 2004

11 Jena R Price SJ Baker C et al Diffusion Tensor Imaging Possible Implications for Radiotherapy Treatment Planning of

Patients with High-grade Glioma Department of Oncology University of Cambridge UK Clinical Oncology (2005) 17 581-

590

12 Keles GE Anderson B Berger MS The effect of extent of resection on time to tumor progression and survival in patients with

glioblastoma multiforme of the cerebral hemisphere Surg Neurol 1999 Oct 52(4) 371-9 httpwwwsurgicalneurology-

onlinecomarticleS0090-3019(99)00103-2abstract

13 Kristiansen K Confirmation of the value of postoperative irradiation and lack of potentiation of bleomycin on survival time a

prospective multicenter trial of the Scandinavian Glioblastoma Study Group (Cancer 1981 Feb 1547(4)649-52)

14 Lacroix M et al A multivariate analysis of 416 patients with glioblastoma multiforme prognosis extent of resection and

survival Department of Neurosurgery The University of Texas MD Anderson Cancer Center Houston Texas J Neurosurg 95

190-198 2001 httpthejnsorgdoiabs103171jns20019520190url_ver=Z3988-

2003amprfr_id=oriridcrossreforgamprfr_dat=cr_pub3dpubmed

15 Lassman A Holland C Glioblastoma Multiforme ndash Past Present and Future US Oncology Review 2005 1(1) 109-111

16 Le Bihan D Mangin J Poupon C Diffusion Tensor Imaging Concepts and Applications Journal of Magnetic Resonance

Imaging 13534-546 (2001) 96



References 17 Li ZX Dai JP Jiang T Li SW Sun YL Liang XL Gao PY Function magnetic resonance imaging and

diffusion tensor tractography in patients with brain gliomas involving motor areas clinical application

and outcome Zhonghua Wai Ke Za Zhi 2006 Sep 1544(18)1275-9

18 Nagesh V Tsien C Chenevert T Radiation-Induced Changes in Normal-Appearing White Matter in Patients With Cerebral Tumors A

Diffusion Tensor Imaging Study Int J Radiation Oncology Biol Phys Vol 71 No 5 pp 1553-1562 2008

19 Nelson DF et al Combined modality approach to treatment of malignant gliomas--re-evaluation of RTOG

7401ECOG 1374 with long-term follow-up a joint study of the Radiation Therapy Oncology Group and the Eastern

Cooperative Oncology Group NCI Monogr 1988(6)279-84

20 Ohue S Kohno S Inoue A et al Accuracy of diffusion tensor magnetic resonance imaging-based tractography for surgery of

gliomas near the pyramidal tract a significant correlation between subcortical electrical stimulation and postoperative

tractography Neurosurgery 2012 Feb70(2) 283-93

21 Price S J Jena R Burnet NG Improved Delineation of Glioma Margins and Regions of Infiltration with Use of Diffusion Tensor

Imaging An Image-Guided Biopsy Study AJNR Am J Neuroradiol 2006 Oct 271969-74

22 Priya A Krishnan Asher I et al Evidence That MR Diffusion Tensor Imaging (Tractography) Predicts the Natural History of Regional

Progression in Patients Irradiated Conformally for Primary Brain Tumors Int J Radiation Oncology Biol Phys Vol 71 No 5 pp 1553-

1562 2008

23 Pieter L Kubben Karlien J ter Meulen Olaf EMG Schijns Marieumll P ter Laak-Poort Jacobus J van

Overbeeke Henk van Santbrink Intraoperative MRI-guided resection of glioblastoma multiforme a

systematic review The Lancet Oncology Volume 12 Issue 11 October 2011 Pages 1062-1070 ISSN

1470-2045 101016S1470-2045(11)70130-9

(httpwwwsciencedirectcomsciencearticlepiiS1470204511701309) Accessed October 14 2012

24 Rizea RE et al 3D diffuse tensor imaging important acquisition in diagnostic and preoperative planning of

intracranial lesions Romanian Neurosurgery (2012) XIX 2 110 ndash 115

httpwwwroneurosurgeryeuatdocRizeaR_3DDiffuse_fpdf Access October 14 2012 97



References 25 Sauders WB Robbins and Cotran Pathologic Basis of Disease Professional Edition 8th ed Elsevier Inc

Philadelphia PA 2009

26 Schaefer P Grant E Gilberto G Diffusion-weighted MR Imaging of the Brain Radiology November 2000

2172 331-345 httpradiologyrsnaorgcontent2172331full

27 Shapiro WR et al Randomized trial of three chemotherapy regimens and two radiotherapy regimens and

two radiotherapy regimens in postoperative treatment of malignant glioma Brain Tumor Cooperative

Group Trial 8001 J Neurosurg 1989 Jul71(1)1-9

28 Souhami L et al Randomized comparison of stereotactic radiosurgery followed by conventional

radiotherapy with carmustine to conventional radiotherapy with carmustine for patients with glioblastoma

multiforme report of Radiation Therapy Oncology Group 93-05 protocol Int J Radiat Oncol Biol Phys

2004 Nov 160(3)853-60

29 T M Simonson et al Echo-planar FLAIR imaging in evaluation of intracranial lesions Radiographics May

1996 163 575-584 httpradiographicsrsnaorgcontent163575long

30 Wang W Steward C E Desmond P M Diffusion Tensor Imaging in Glioblastoma Multiforme and Brain

Metastases The role of pqL and Fractional Anisotropy AJNR AM J Neuroradiol 30203-08 Jan 2009

31 Waxman SG Chapter 2 Development and Cellular Constituents of the Nervous System In Waxman SG

ed Clinical Neuroanatomy 26th ed New York McGraw-Hill 2010

httpwwwaccessmedicinecomcontentaspxaID=5271090 Accessed October 24 2012

32 Zoltan Nagy12 et al Diffusion Tensor Imaging on Teenagers Born at Term With Moderate Hypoxic-

ischemic Encephalopathy Pediatric Research (2005) 58 936ndash940

doi10120301pdr00001865168570261 httpwwwnaturecomprjournalv58n5fullpr2005800ahtml

Date accessed October 14 2012

98





ndash MRI Findings

ndash Treatment


ndash How it works


ndash Radiation


ndash Injury






ndash MRI Findings

ndash Treatment


ndash How it works


ndash Radiation


ndash Injury












4



Our Patient

Head CT Unlabeled

5 C- axial CT

PACS BIDMC




6

4 cm circular

hypodense intra-

axial mass in the

left posterior-

inferior frontal

lobe

Surrounding edema

Right-ward shift of

septum pellucidum




7

Our Patient















grade IV

8




ndash The basics

ndash MRI Findings

ndash Treatment


ndash How it works


ndash Radiation


ndash Injury







German pathologist




Dr Rudolph Virchow


Image adopted from



SPLjpg
















treatedrdquo


Dr Percival

Bailey

Dr Harvey Cushing


Image adopted from


Image adopted from








Classification


and glial tumor



Epidemiology

ndash Incidence 2-3


and Europe

ndash Malegt Female


Prognosis

ndash Dismal

ndash Survival


treatment

bull 5-year 3


bull Older age



status



promoter






SignsSymptoms



Tumor Location


(Temporal lobe)


corpus callosum








Glial cell


Image adopted from





Astrocytes Types

















bull Gross Anatomy



(necrosis)


ndash Hemorrhage

Image adopted from


Saunders W B (2009)





bull Polymorphic



bull Eosinophilic


Image adopted from



Saunders W B (2009)




Proliferation


production of VGEF



(Tufts)


body (black arrows)

Image adopted from



Saunders W B (2009)






of wooden poles


Image adopted from



Image adopted from










ndash Mitosis


Image adopted from



Saunders W B (2009)











Saunders W B (2009)






(MRI)









alterations




25





26



MRI gives

better

visualization of

cellular activity

within the lesion

sharper borders

of tumor for

more precise

measurements

increased

differentiation of

edema vs lesion






27











lesions



edema

- Ring-enhancing



28


Contrast




29





30


38 cm

homogeneous

hypointense mass

edema Ring-

enhancement

with central

area of

heterogenous

enhancement

Central area






31






bull Basics


on T2



bull GBM Findings






32

Vasogenic Edema

Cystic

necrosis



bull FLAIR Basics







bull GBM Findings


grade of tumor


(hyperintense)




33

Vasogenic Edema

Cystic

necrosis

Hyperintense

lesion

Satellite lesion






bull DWI Basics




bull GBM Findings




PACS BIDMC


PACS BIDMC

34

Increased signal

= restricted

diffusion

Satellite lesion

detected




MRI MR Spectroscopy

















36








37










Treatment Surgery








Methods


bull N = 92



survival

Results







(plt0005) VRD (plt0001)



Oct 52(4) 371-9


Treatment Surgery





Treatment Surgery






Methods


bull N = 416


bull End point











Neurosurg 95 190-198 2001


Treatment Surgery












160(3)853-60





0

10

20

30

40

50

60

70

80

90


East

West

North








bull Methods



proven GBM

ndash Assignments



ndash 287 patients




ndash 286 patients










bull Results








63(95 CI 052 to 075 Plt001)



radiotherapy alone




Objectives


ndash Introduction

ndash How it works


ndash Surgery

ndash Radiation


ndash Response

ndash Injury





Image adopted from





matter fiber tracks

(WMT) in the brain



tracts extending in

multiple directions





GBM



Displacement of




Introduction







bull Define anatomy










Basic Principles

1 Diffusion

2 Measurement







superficial organs





bull Convenient

















Tissue cellularity






Isotropy




Anisotropy





structure




Image obtained from


ullpr2005800ahtml














Myelin

Sheath

Water

molecules

Endoneurium



Diffusion is faster

parallel to white

matter tracts



Image adopted from





Tensor




- between 0 and 1










axis of WMT







Eigenvalues


q L























Image Obtained From


S0166223612000720amp_image=1-s20-S0166223612000720-







tutorialhtmldtihtml






FA (Tensor Shape)









measurements




visible





coded maps




posterior)










Image Obtained From




Objectives


ndash Surgery

ndash Radiation


ndash Response

ndash Injury







69






Intraoperative MRI













and Resection






bull Methods




(n=120)




hazard ratio








bull Results



















fasciculus












Tracks





Fasciculus)

Red = Communicating


(Corpus Callosum)

Combined fMRI for


areas of the brain

(language motor)


PACS BIDMC





bull Problem





deficits



bull Solution




Radiation Therapy









Jena R et al (2005)






















Image adopted from








Image adopted from








Image adopted from










treatment planning





Objectives


ndash Response

ndash Injury





Overview


ndash Response



ndash Progression













Image adopted from






















Image adopted from






Image adopted from






sequences


























Acknowledgments





Deaconess

93
























94

















590












Imaging 13534-546 (2001) 96


















1562 2008




1470-2045 101016S1470-2045(11)70130-9

















2004 Nov 160(3)853-60












98





ndash MRI Findings

ndash Treatment


ndash How it works


ndash Radiation


ndash Injury












4



Our Patient

Head CT Unlabeled

5 C- axial CT

PACS BIDMC




6

4 cm circular

hypodense intra-

axial mass in the

left posterior-

inferior frontal

lobe

Surrounding edema

Right-ward shift of

septum pellucidum




7

Our Patient















grade IV

8




ndash The basics

ndash MRI Findings

ndash Treatment


ndash How it works


ndash Radiation


ndash Injury







German pathologist




Dr Rudolph Virchow


Image adopted from



SPLjpg
















treatedrdquo


Dr Percival

Bailey

Dr Harvey Cushing


Image adopted from


Image adopted from








Classification


and glial tumor



Epidemiology

ndash Incidence 2-3


and Europe

ndash Malegt Female


Prognosis

ndash Dismal

ndash Survival


treatment

bull 5-year 3


bull Older age



status



promoter






SignsSymptoms



Tumor Location


(Temporal lobe)


corpus callosum








Glial cell


Image adopted from





Astrocytes Types

















bull Gross Anatomy



(necrosis)


ndash Hemorrhage

Image adopted from


Saunders W B (2009)





bull Polymorphic



bull Eosinophilic


Image adopted from



Saunders W B (2009)




Proliferation


production of VGEF



(Tufts)


body (black arrows)

Image adopted from



Saunders W B (2009)






of wooden poles


Image adopted from



Image adopted from










ndash Mitosis


Image adopted from



Saunders W B (2009)











Saunders W B (2009)






(MRI)









alterations




25





26



MRI gives

better

visualization of

cellular activity

within the lesion

sharper borders

of tumor for

more precise

measurements

increased

differentiation of

edema vs lesion






27











lesions



edema

- Ring-enhancing



28


Contrast




29





30


38 cm

homogeneous

hypointense mass

edema Ring-

enhancement

with central

area of

heterogenous

enhancement

Central area






31






bull Basics


on T2



bull GBM Findings






32

Vasogenic Edema

Cystic

necrosis



bull FLAIR Basics







bull GBM Findings


grade of tumor


(hyperintense)




33

Vasogenic Edema

Cystic

necrosis

Hyperintense

lesion

Satellite lesion






bull DWI Basics




bull GBM Findings




PACS BIDMC


PACS BIDMC

34

Increased signal

= restricted

diffusion

Satellite lesion

detected




MRI MR Spectroscopy

















36








37










Treatment Surgery








Methods


bull N = 92



survival

Results







(plt0005) VRD (plt0001)



Oct 52(4) 371-9


Treatment Surgery





Treatment Surgery






Methods


bull N = 416


bull End point











Neurosurg 95 190-198 2001


Treatment Surgery












160(3)853-60





0

10

20

30

40

50

60

70

80

90


East

West

North








bull Methods



proven GBM

ndash Assignments



ndash 287 patients




ndash 286 patients










bull Results








63(95 CI 052 to 075 Plt001)



radiotherapy alone




Objectives


ndash Introduction

ndash How it works


ndash Surgery

ndash Radiation


ndash Response

ndash Injury





Image adopted from





matter fiber tracks

(WMT) in the brain



tracts extending in

multiple directions





GBM



Displacement of




Introduction







bull Define anatomy










Basic Principles

1 Diffusion

2 Measurement







superficial organs





bull Convenient

















Tissue cellularity






Isotropy




Anisotropy





structure




Image obtained from


ullpr2005800ahtml














Myelin

Sheath

Water

molecules

Endoneurium



Diffusion is faster

parallel to white

matter tracts



Image adopted from





Tensor




- between 0 and 1










axis of WMT







Eigenvalues


q L























Image Obtained From


S0166223612000720amp_image=1-s20-S0166223612000720-







tutorialhtmldtihtml






FA (Tensor Shape)









measurements




visible





coded maps




posterior)










Image Obtained From




Objectives


ndash Surgery

ndash Radiation


ndash Response

ndash Injury







69






Intraoperative MRI













and Resection






bull Methods




(n=120)




hazard ratio








bull Results



















fasciculus












Tracks





Fasciculus)

Red = Communicating


(Corpus Callosum)

Combined fMRI for


areas of the brain

(language motor)


PACS BIDMC





bull Problem





deficits



bull Solution




Radiation Therapy









Jena R et al (2005)






















Image adopted from








Image adopted from








Image adopted from










treatment planning





Objectives


ndash Response

ndash Injury





Overview


ndash Response



ndash Progression













Image adopted from






















Image adopted from






Image adopted from






sequences


























Acknowledgments





Deaconess

93
























94

















590












Imaging 13534-546 (2001) 96


















1562 2008




1470-2045 101016S1470-2045(11)70130-9

















2004 Nov 160(3)853-60












98











4



Our Patient

Head CT Unlabeled

5 C- axial CT

PACS BIDMC




6

4 cm circular

hypodense intra-

axial mass in the

left posterior-

inferior frontal

lobe

Surrounding edema

Right-ward shift of

septum pellucidum




7

Our Patient















grade IV

8




ndash The basics

ndash MRI Findings

ndash Treatment


ndash How it works


ndash Radiation


ndash Injury







German pathologist




Dr Rudolph Virchow


Image adopted from



SPLjpg
















treatedrdquo


Dr Percival

Bailey

Dr Harvey Cushing


Image adopted from


Image adopted from








Classification


and glial tumor



Epidemiology

ndash Incidence 2-3


and Europe

ndash Malegt Female


Prognosis

ndash Dismal

ndash Survival


treatment

bull 5-year 3


bull Older age



status



promoter






SignsSymptoms



Tumor Location


(Temporal lobe)


corpus callosum








Glial cell


Image adopted from





Astrocytes Types

















bull Gross Anatomy



(necrosis)


ndash Hemorrhage

Image adopted from


Saunders W B (2009)





bull Polymorphic



bull Eosinophilic


Image adopted from



Saunders W B (2009)




Proliferation


production of VGEF



(Tufts)


body (black arrows)

Image adopted from



Saunders W B (2009)






of wooden poles


Image adopted from



Image adopted from










ndash Mitosis


Image adopted from



Saunders W B (2009)











Saunders W B (2009)






(MRI)









alterations




25





26



MRI gives

better

visualization of

cellular activity

within the lesion

sharper borders

of tumor for

more precise

measurements

increased

differentiation of

edema vs lesion






27











lesions



edema

- Ring-enhancing



28


Contrast




29





30


38 cm

homogeneous

hypointense mass

edema Ring-

enhancement

with central

area of

heterogenous

enhancement

Central area






31






bull Basics


on T2



bull GBM Findings






32

Vasogenic Edema

Cystic

necrosis



bull FLAIR Basics







bull GBM Findings


grade of tumor


(hyperintense)




33

Vasogenic Edema

Cystic

necrosis

Hyperintense

lesion

Satellite lesion






bull DWI Basics




bull GBM Findings




PACS BIDMC


PACS BIDMC

34

Increased signal

= restricted

diffusion

Satellite lesion

detected




MRI MR Spectroscopy

















36








37










Treatment Surgery








Methods


bull N = 92



survival

Results







(plt0005) VRD (plt0001)



Oct 52(4) 371-9


Treatment Surgery





Treatment Surgery






Methods


bull N = 416


bull End point











Neurosurg 95 190-198 2001


Treatment Surgery












160(3)853-60





0

10

20

30

40

50

60

70

80

90


East

West

North








bull Methods



proven GBM

ndash Assignments



ndash 287 patients




ndash 286 patients










bull Results








63(95 CI 052 to 075 Plt001)



radiotherapy alone




Objectives


ndash Introduction

ndash How it works


ndash Surgery

ndash Radiation


ndash Response

ndash Injury





Image adopted from





matter fiber tracks

(WMT) in the brain



tracts extending in

multiple directions





GBM



Displacement of




Introduction







bull Define anatomy










Basic Principles

1 Diffusion

2 Measurement







superficial organs





bull Convenient

















Tissue cellularity






Isotropy




Anisotropy





structure




Image obtained from


ullpr2005800ahtml














Myelin

Sheath

Water

molecules

Endoneurium



Diffusion is faster

parallel to white

matter tracts



Image adopted from





Tensor




- between 0 and 1










axis of WMT







Eigenvalues


q L























Image Obtained From


S0166223612000720amp_image=1-s20-S0166223612000720-







tutorialhtmldtihtml






FA (Tensor Shape)









measurements




visible





coded maps




posterior)










Image Obtained From




Objectives


ndash Surgery

ndash Radiation


ndash Response

ndash Injury







69






Intraoperative MRI













and Resection






bull Methods




(n=120)




hazard ratio








bull Results



















fasciculus












Tracks





Fasciculus)

Red = Communicating


(Corpus Callosum)

Combined fMRI for


areas of the brain

(language motor)


PACS BIDMC





bull Problem





deficits



bull Solution




Radiation Therapy









Jena R et al (2005)






















Image adopted from








Image adopted from








Image adopted from










treatment planning





Objectives


ndash Response

ndash Injury





Overview


ndash Response



ndash Progression













Image adopted from






















Image adopted from






Image adopted from






sequences


























Acknowledgments





Deaconess

93
























94

















590












Imaging 13534-546 (2001) 96


















1562 2008




1470-2045 101016S1470-2045(11)70130-9

















2004 Nov 160(3)853-60












98



Our Patient

Head CT Unlabeled

5 C- axial CT

PACS BIDMC




6

4 cm circular

hypodense intra-

axial mass in the

left posterior-

inferior frontal

lobe

Surrounding edema

Right-ward shift of

septum pellucidum




7

Our Patient















grade IV

8




ndash The basics

ndash MRI Findings

ndash Treatment


ndash How it works


ndash Radiation


ndash Injury







German pathologist




Dr Rudolph Virchow


Image adopted from



SPLjpg
















treatedrdquo


Dr Percival

Bailey

Dr Harvey Cushing


Image adopted from


Image adopted from








Classification


and glial tumor



Epidemiology

ndash Incidence 2-3


and Europe

ndash Malegt Female


Prognosis

ndash Dismal

ndash Survival


treatment

bull 5-year 3


bull Older age



status



promoter






SignsSymptoms



Tumor Location


(Temporal lobe)


corpus callosum








Glial cell


Image adopted from





Astrocytes Types

















bull Gross Anatomy



(necrosis)


ndash Hemorrhage

Image adopted from


Saunders W B (2009)





bull Polymorphic



bull Eosinophilic


Image adopted from



Saunders W B (2009)




Proliferation


production of VGEF



(Tufts)


body (black arrows)

Image adopted from



Saunders W B (2009)






of wooden poles


Image adopted from



Image adopted from










ndash Mitosis


Image adopted from



Saunders W B (2009)











Saunders W B (2009)






(MRI)









alterations




25





26



MRI gives

better

visualization of

cellular activity

within the lesion

sharper borders

of tumor for

more precise

measurements

increased

differentiation of

edema vs lesion






27











lesions



edema

- Ring-enhancing



28


Contrast




29





30


38 cm

homogeneous

hypointense mass

edema Ring-

enhancement

with central

area of

heterogenous

enhancement

Central area






31






bull Basics


on T2



bull GBM Findings






32

Vasogenic Edema

Cystic

necrosis



bull FLAIR Basics







bull GBM Findings


grade of tumor


(hyperintense)




33

Vasogenic Edema

Cystic

necrosis

Hyperintense

lesion

Satellite lesion






bull DWI Basics




bull GBM Findings




PACS BIDMC


PACS BIDMC

34

Increased signal

= restricted

diffusion

Satellite lesion

detected




MRI MR Spectroscopy

















36








37










Treatment Surgery








Methods


bull N = 92



survival

Results







(plt0005) VRD (plt0001)



Oct 52(4) 371-9


Treatment Surgery





Treatment Surgery






Methods


bull N = 416


bull End point











Neurosurg 95 190-198 2001


Treatment Surgery












160(3)853-60





0

10

20

30

40

50

60

70

80

90


East

West

North








bull Methods



proven GBM

ndash Assignments



ndash 287 patients




ndash 286 patients










bull Results








63(95 CI 052 to 075 Plt001)



radiotherapy alone




Objectives


ndash Introduction

ndash How it works


ndash Surgery

ndash Radiation


ndash Response

ndash Injury





Image adopted from





matter fiber tracks

(WMT) in the brain



tracts extending in

multiple directions





GBM



Displacement of




Introduction







bull Define anatomy










Basic Principles

1 Diffusion

2 Measurement







superficial organs





bull Convenient

















Tissue cellularity






Isotropy




Anisotropy





structure




Image obtained from


ullpr2005800ahtml














Myelin

Sheath

Water

molecules

Endoneurium



Diffusion is faster

parallel to white

matter tracts



Image adopted from





Tensor




- between 0 and 1










axis of WMT







Eigenvalues


q L























Image Obtained From


S0166223612000720amp_image=1-s20-S0166223612000720-







tutorialhtmldtihtml






FA (Tensor Shape)









measurements




visible





coded maps




posterior)










Image Obtained From




Objectives


ndash Surgery

ndash Radiation


ndash Response

ndash Injury







69






Intraoperative MRI













and Resection






bull Methods




(n=120)




hazard ratio








bull Results



















fasciculus












Tracks





Fasciculus)

Red = Communicating


(Corpus Callosum)

Combined fMRI for


areas of the brain

(language motor)


PACS BIDMC





bull Problem





deficits



bull Solution




Radiation Therapy









Jena R et al (2005)






















Image adopted from








Image adopted from








Image adopted from










treatment planning





Objectives


ndash Response

ndash Injury





Overview


ndash Response



ndash Progression













Image adopted from






















Image adopted from






Image adopted from






sequences


























Acknowledgments





Deaconess

93
























94

















590












Imaging 13534-546 (2001) 96


















1562 2008




1470-2045 101016S1470-2045(11)70130-9

















2004 Nov 160(3)853-60












98




6

4 cm circular

hypodense intra-

axial mass in the

left posterior-

inferior frontal

lobe

Surrounding edema

Right-ward shift of

septum pellucidum




7

Our Patient















grade IV

8




ndash The basics

ndash MRI Findings

ndash Treatment


ndash How it works


ndash Radiation


ndash Injury







German pathologist




Dr Rudolph Virchow


Image adopted from



SPLjpg
















treatedrdquo


Dr Percival

Bailey

Dr Harvey Cushing


Image adopted from


Image adopted from








Classification


and glial tumor



Epidemiology

ndash Incidence 2-3


and Europe

ndash Malegt Female


Prognosis

ndash Dismal

ndash Survival


treatment

bull 5-year 3


bull Older age



status



promoter






SignsSymptoms



Tumor Location


(Temporal lobe)


corpus callosum








Glial cell


Image adopted from





Astrocytes Types

















bull Gross Anatomy



(necrosis)


ndash Hemorrhage

Image adopted from


Saunders W B (2009)





bull Polymorphic



bull Eosinophilic


Image adopted from



Saunders W B (2009)




Proliferation


production of VGEF



(Tufts)


body (black arrows)

Image adopted from



Saunders W B (2009)






of wooden poles


Image adopted from



Image adopted from










ndash Mitosis


Image adopted from



Saunders W B (2009)











Saunders W B (2009)






(MRI)









alterations




25





26



MRI gives

better

visualization of

cellular activity

within the lesion

sharper borders

of tumor for

more precise

measurements

increased

differentiation of

edema vs lesion






27











lesions



edema

- Ring-enhancing



28


Contrast




29





30


38 cm

homogeneous

hypointense mass

edema Ring-

enhancement

with central

area of

heterogenous

enhancement

Central area






31






bull Basics


on T2



bull GBM Findings






32

Vasogenic Edema

Cystic

necrosis



bull FLAIR Basics







bull GBM Findings


grade of tumor


(hyperintense)




33

Vasogenic Edema

Cystic

necrosis

Hyperintense

lesion

Satellite lesion






bull DWI Basics




bull GBM Findings




PACS BIDMC


PACS BIDMC

34

Increased signal

= restricted

diffusion

Satellite lesion

detected




MRI MR Spectroscopy

















36








37










Treatment Surgery








Methods


bull N = 92



survival

Results







(plt0005) VRD (plt0001)



Oct 52(4) 371-9


Treatment Surgery





Treatment Surgery






Methods


bull N = 416


bull End point











Neurosurg 95 190-198 2001


Treatment Surgery












160(3)853-60





0

10

20

30

40

50

60

70

80

90


East

West

North








bull Methods



proven GBM

ndash Assignments



ndash 287 patients




ndash 286 patients










bull Results








63(95 CI 052 to 075 Plt001)



radiotherapy alone




Objectives


ndash Introduction

ndash How it works


ndash Surgery

ndash Radiation


ndash Response

ndash Injury





Image adopted from





matter fiber tracks

(WMT) in the brain



tracts extending in

multiple directions





GBM



Displacement of




Introduction







bull Define anatomy










Basic Principles

1 Diffusion

2 Measurement







superficial organs





bull Convenient

















Tissue cellularity






Isotropy




Anisotropy





structure




Image obtained from


ullpr2005800ahtml














Myelin

Sheath

Water

molecules

Endoneurium



Diffusion is faster

parallel to white

matter tracts



Image adopted from





Tensor




- between 0 and 1










axis of WMT







Eigenvalues


q L























Image Obtained From


S0166223612000720amp_image=1-s20-S0166223612000720-







tutorialhtmldtihtml






FA (Tensor Shape)









measurements




visible





coded maps




posterior)










Image Obtained From




Objectives


ndash Surgery

ndash Radiation


ndash Response

ndash Injury







69






Intraoperative MRI













and Resection






bull Methods




(n=120)




hazard ratio








bull Results



















fasciculus












Tracks





Fasciculus)

Red = Communicating


(Corpus Callosum)

Combined fMRI for


areas of the brain

(language motor)


PACS BIDMC





bull Problem





deficits



bull Solution




Radiation Therapy









Jena R et al (2005)






















Image adopted from








Image adopted from








Image adopted from










treatment planning





Objectives


ndash Response

ndash Injury





Overview


ndash Response



ndash Progression













Image adopted from






















Image adopted from






Image adopted from






sequences


























Acknowledgments





Deaconess

93
























94

















590












Imaging 13534-546 (2001) 96


















1562 2008




1470-2045 101016S1470-2045(11)70130-9

















2004 Nov 160(3)853-60












98



7

Our Patient















grade IV

8




ndash The basics

ndash MRI Findings

ndash Treatment


ndash How it works


ndash Radiation


ndash Injury







German pathologist




Dr Rudolph Virchow


Image adopted from



SPLjpg
















treatedrdquo


Dr Percival

Bailey

Dr Harvey Cushing


Image adopted from


Image adopted from








Classification


and glial tumor



Epidemiology

ndash Incidence 2-3


and Europe

ndash Malegt Female


Prognosis

ndash Dismal

ndash Survival


treatment

bull 5-year 3


bull Older age



status



promoter






SignsSymptoms



Tumor Location


(Temporal lobe)


corpus callosum








Glial cell


Image adopted from





Astrocytes Types

















bull Gross Anatomy



(necrosis)


ndash Hemorrhage

Image adopted from


Saunders W B (2009)





bull Polymorphic



bull Eosinophilic


Image adopted from



Saunders W B (2009)




Proliferation


production of VGEF



(Tufts)


body (black arrows)

Image adopted from



Saunders W B (2009)






of wooden poles


Image adopted from



Image adopted from










ndash Mitosis


Image adopted from



Saunders W B (2009)











Saunders W B (2009)






(MRI)









alterations




25





26



MRI gives

better

visualization of

cellular activity

within the lesion

sharper borders

of tumor for

more precise

measurements

increased

differentiation of

edema vs lesion






27











lesions



edema

- Ring-enhancing



28


Contrast




29





30


38 cm

homogeneous

hypointense mass

edema Ring-

enhancement

with central

area of

heterogenous

enhancement

Central area






31






bull Basics


on T2



bull GBM Findings






32

Vasogenic Edema

Cystic

necrosis



bull FLAIR Basics







bull GBM Findings


grade of tumor


(hyperintense)




33

Vasogenic Edema

Cystic

necrosis

Hyperintense

lesion

Satellite lesion






bull DWI Basics




bull GBM Findings




PACS BIDMC


PACS BIDMC

34

Increased signal

= restricted

diffusion

Satellite lesion

detected




MRI MR Spectroscopy

















36








37










Treatment Surgery








Methods


bull N = 92



survival

Results







(plt0005) VRD (plt0001)



Oct 52(4) 371-9


Treatment Surgery





Treatment Surgery






Methods


bull N = 416


bull End point











Neurosurg 95 190-198 2001


Treatment Surgery












160(3)853-60





0

10

20

30

40

50

60

70

80

90


East

West

North








bull Methods



proven GBM

ndash Assignments



ndash 287 patients




ndash 286 patients










bull Results








63(95 CI 052 to 075 Plt001)



radiotherapy alone




Objectives


ndash Introduction

ndash How it works


ndash Surgery

ndash Radiation


ndash Response

ndash Injury





Image adopted from





matter fiber tracks

(WMT) in the brain



tracts extending in

multiple directions





GBM



Displacement of




Introduction







bull Define anatomy










Basic Principles

1 Diffusion

2 Measurement







superficial organs





bull Convenient

















Tissue cellularity






Isotropy




Anisotropy





structure




Image obtained from


ullpr2005800ahtml














Myelin

Sheath

Water

molecules

Endoneurium



Diffusion is faster

parallel to white

matter tracts



Image adopted from





Tensor




- between 0 and 1










axis of WMT







Eigenvalues


q L























Image Obtained From


S0166223612000720amp_image=1-s20-S0166223612000720-







tutorialhtmldtihtml






FA (Tensor Shape)









measurements




visible





coded maps




posterior)










Image Obtained From




Objectives


ndash Surgery

ndash Radiation


ndash Response

ndash Injury







69






Intraoperative MRI













and Resection






bull Methods




(n=120)




hazard ratio








bull Results



















fasciculus












Tracks





Fasciculus)

Red = Communicating


(Corpus Callosum)

Combined fMRI for


areas of the brain

(language motor)


PACS BIDMC





bull Problem





deficits



bull Solution




Radiation Therapy









Jena R et al (2005)






















Image adopted from








Image adopted from








Image adopted from










treatment planning





Objectives


ndash Response

ndash Injury





Overview


ndash Response



ndash Progression













Image adopted from






















Image adopted from






Image adopted from






sequences


























Acknowledgments





Deaconess

93
























94

















590












Imaging 13534-546 (2001) 96


















1562 2008




1470-2045 101016S1470-2045(11)70130-9

















2004 Nov 160(3)853-60












98











grade IV

8




ndash The basics

ndash MRI Findings

ndash Treatment


ndash How it works


ndash Radiation


ndash Injury







German pathologist




Dr Rudolph Virchow


Image adopted from



SPLjpg
















treatedrdquo


Dr Percival

Bailey

Dr Harvey Cushing


Image adopted from


Image adopted from








Classification


and glial tumor



Epidemiology

ndash Incidence 2-3


and Europe

ndash Malegt Female


Prognosis

ndash Dismal

ndash Survival


treatment

bull 5-year 3


bull Older age



status



promoter






SignsSymptoms



Tumor Location


(Temporal lobe)


corpus callosum








Glial cell


Image adopted from





Astrocytes Types

















bull Gross Anatomy



(necrosis)


ndash Hemorrhage

Image adopted from


Saunders W B (2009)





bull Polymorphic



bull Eosinophilic


Image adopted from



Saunders W B (2009)




Proliferation


production of VGEF



(Tufts)


body (black arrows)

Image adopted from



Saunders W B (2009)






of wooden poles


Image adopted from



Image adopted from










ndash Mitosis


Image adopted from



Saunders W B (2009)











Saunders W B (2009)






(MRI)









alterations




25





26



MRI gives

better

visualization of

cellular activity

within the lesion

sharper borders

of tumor for

more precise

measurements

increased

differentiation of

edema vs lesion






27











lesions



edema

- Ring-enhancing



28


Contrast




29





30


38 cm

homogeneous

hypointense mass

edema Ring-

enhancement

with central

area of

heterogenous

enhancement

Central area






31






bull Basics


on T2



bull GBM Findings






32

Vasogenic Edema

Cystic

necrosis



bull FLAIR Basics







bull GBM Findings


grade of tumor


(hyperintense)




33

Vasogenic Edema

Cystic

necrosis

Hyperintense

lesion

Satellite lesion






bull DWI Basics




bull GBM Findings




PACS BIDMC


PACS BIDMC

34

Increased signal

= restricted

diffusion

Satellite lesion

detected




MRI MR Spectroscopy

















36








37










Treatment Surgery








Methods


bull N = 92



survival

Results







(plt0005) VRD (plt0001)



Oct 52(4) 371-9


Treatment Surgery





Treatment Surgery






Methods


bull N = 416


bull End point











Neurosurg 95 190-198 2001


Treatment Surgery












160(3)853-60





0

10

20

30

40

50

60

70

80

90


East

West

North








bull Methods



proven GBM

ndash Assignments



ndash 287 patients




ndash 286 patients










bull Results








63(95 CI 052 to 075 Plt001)



radiotherapy alone




Objectives


ndash Introduction

ndash How it works


ndash Surgery

ndash Radiation


ndash Response

ndash Injury





Image adopted from





matter fiber tracks

(WMT) in the brain



tracts extending in

multiple directions





GBM



Displacement of




Introduction







bull Define anatomy










Basic Principles

1 Diffusion

2 Measurement







superficial organs





bull Convenient

















Tissue cellularity






Isotropy




Anisotropy





structure




Image obtained from


ullpr2005800ahtml














Myelin

Sheath

Water

molecules

Endoneurium



Diffusion is faster

parallel to white

matter tracts



Image adopted from





Tensor




- between 0 and 1










axis of WMT







Eigenvalues


q L























Image Obtained From


S0166223612000720amp_image=1-s20-S0166223612000720-







tutorialhtmldtihtml






FA (Tensor Shape)









measurements




visible





coded maps




posterior)










Image Obtained From




Objectives


ndash Surgery

ndash Radiation


ndash Response

ndash Injury







69






Intraoperative MRI













and Resection






bull Methods




(n=120)




hazard ratio








bull Results



















fasciculus












Tracks





Fasciculus)

Red = Communicating


(Corpus Callosum)

Combined fMRI for


areas of the brain

(language motor)


PACS BIDMC





bull Problem





deficits



bull Solution




Radiation Therapy









Jena R et al (2005)






















Image adopted from








Image adopted from








Image adopted from










treatment planning





Objectives


ndash Response

ndash Injury





Overview


ndash Response



ndash Progression













Image adopted from






















Image adopted from






Image adopted from






sequences


























Acknowledgments





Deaconess

93
























94

















590












Imaging 13534-546 (2001) 96


















1562 2008




1470-2045 101016S1470-2045(11)70130-9

















2004 Nov 160(3)853-60












98




ndash The basics

ndash MRI Findings

ndash Treatment


ndash How it works


ndash Radiation


ndash Injury







German pathologist




Dr Rudolph Virchow


Image adopted from



SPLjpg
















treatedrdquo


Dr Percival

Bailey

Dr Harvey Cushing


Image adopted from


Image adopted from








Classification


and glial tumor



Epidemiology

ndash Incidence 2-3


and Europe

ndash Malegt Female


Prognosis

ndash Dismal

ndash Survival


treatment

bull 5-year 3


bull Older age



status



promoter






SignsSymptoms



Tumor Location


(Temporal lobe)


corpus callosum








Glial cell


Image adopted from





Astrocytes Types

















bull Gross Anatomy



(necrosis)


ndash Hemorrhage

Image adopted from


Saunders W B (2009)





bull Polymorphic



bull Eosinophilic


Image adopted from



Saunders W B (2009)




Proliferation


production of VGEF



(Tufts)


body (black arrows)

Image adopted from



Saunders W B (2009)






of wooden poles


Image adopted from



Image adopted from










ndash Mitosis


Image adopted from



Saunders W B (2009)











Saunders W B (2009)






(MRI)









alterations




25





26



MRI gives

better

visualization of

cellular activity

within the lesion

sharper borders

of tumor for

more precise

measurements

increased

differentiation of

edema vs lesion






27











lesions



edema

- Ring-enhancing



28


Contrast




29





30


38 cm

homogeneous

hypointense mass

edema Ring-

enhancement

with central

area of

heterogenous

enhancement

Central area






31






bull Basics


on T2



bull GBM Findings






32

Vasogenic Edema

Cystic

necrosis



bull FLAIR Basics







bull GBM Findings


grade of tumor


(hyperintense)




33

Vasogenic Edema

Cystic

necrosis

Hyperintense

lesion

Satellite lesion






bull DWI Basics




bull GBM Findings




PACS BIDMC


PACS BIDMC

34

Increased signal

= restricted

diffusion

Satellite lesion

detected




MRI MR Spectroscopy

















36








37










Treatment Surgery








Methods


bull N = 92



survival

Results







(plt0005) VRD (plt0001)



Oct 52(4) 371-9


Treatment Surgery





Treatment Surgery






Methods


bull N = 416


bull End point











Neurosurg 95 190-198 2001


Treatment Surgery












160(3)853-60





0

10

20

30

40

50

60

70

80

90


East

West

North








bull Methods



proven GBM

ndash Assignments



ndash 287 patients




ndash 286 patients










bull Results








63(95 CI 052 to 075 Plt001)



radiotherapy alone




Objectives


ndash Introduction

ndash How it works


ndash Surgery

ndash Radiation


ndash Response

ndash Injury





Image adopted from





matter fiber tracks

(WMT) in the brain



tracts extending in

multiple directions





GBM



Displacement of




Introduction







bull Define anatomy










Basic Principles

1 Diffusion

2 Measurement







superficial organs





bull Convenient

















Tissue cellularity






Isotropy




Anisotropy





structure




Image obtained from


ullpr2005800ahtml














Myelin

Sheath

Water

molecules

Endoneurium



Diffusion is faster

parallel to white

matter tracts



Image adopted from





Tensor




- between 0 and 1










axis of WMT







Eigenvalues


q L























Image Obtained From


S0166223612000720amp_image=1-s20-S0166223612000720-







tutorialhtmldtihtml






FA (Tensor Shape)









measurements




visible





coded maps




posterior)










Image Obtained From




Objectives


ndash Surgery

ndash Radiation


ndash Response

ndash Injury







69






Intraoperative MRI













and Resection






bull Methods




(n=120)




hazard ratio








bull Results



















fasciculus












Tracks





Fasciculus)

Red = Communicating


(Corpus Callosum)

Combined fMRI for


areas of the brain

(language motor)


PACS BIDMC





bull Problem





deficits



bull Solution




Radiation Therapy









Jena R et al (2005)






















Image adopted from








Image adopted from








Image adopted from










treatment planning





Objectives


ndash Response

ndash Injury





Overview


ndash Response



ndash Progression













Image adopted from






















Image adopted from






Image adopted from






sequences


























Acknowledgments





Deaconess

93
























94

















590












Imaging 13534-546 (2001) 96


















1562 2008




1470-2045 101016S1470-2045(11)70130-9

















2004 Nov 160(3)853-60












98






German pathologist




Dr Rudolph Virchow


Image adopted from



SPLjpg
















treatedrdquo


Dr Percival

Bailey

Dr Harvey Cushing


Image adopted from


Image adopted from








Classification


and glial tumor



Epidemiology

ndash Incidence 2-3


and Europe

ndash Malegt Female


Prognosis

ndash Dismal

ndash Survival


treatment

bull 5-year 3


bull Older age



status



promoter






SignsSymptoms



Tumor Location


(Temporal lobe)


corpus callosum








Glial cell


Image adopted from





Astrocytes Types

















bull Gross Anatomy



(necrosis)


ndash Hemorrhage

Image adopted from


Saunders W B (2009)





bull Polymorphic



bull Eosinophilic


Image adopted from



Saunders W B (2009)




Proliferation


production of VGEF



(Tufts)


body (black arrows)

Image adopted from



Saunders W B (2009)






of wooden poles


Image adopted from



Image adopted from










ndash Mitosis


Image adopted from



Saunders W B (2009)











Saunders W B (2009)






(MRI)









alterations




25





26



MRI gives

better

visualization of

cellular activity

within the lesion

sharper borders

of tumor for

more precise

measurements

increased

differentiation of

edema vs lesion






27











lesions



edema

- Ring-enhancing



28


Contrast




29





30


38 cm

homogeneous

hypointense mass

edema Ring-

enhancement

with central

area of

heterogenous

enhancement

Central area






31






bull Basics


on T2



bull GBM Findings






32

Vasogenic Edema

Cystic

necrosis



bull FLAIR Basics







bull GBM Findings


grade of tumor


(hyperintense)




33

Vasogenic Edema

Cystic

necrosis

Hyperintense

lesion

Satellite lesion






bull DWI Basics




bull GBM Findings




PACS BIDMC


PACS BIDMC

34

Increased signal

= restricted

diffusion

Satellite lesion

detected




MRI MR Spectroscopy

















36








37










Treatment Surgery








Methods


bull N = 92



survival

Results







(plt0005) VRD (plt0001)



Oct 52(4) 371-9


Treatment Surgery





Treatment Surgery






Methods


bull N = 416


bull End point











Neurosurg 95 190-198 2001


Treatment Surgery












160(3)853-60





0

10

20

30

40

50

60

70

80

90


East

West

North








bull Methods



proven GBM

ndash Assignments



ndash 287 patients




ndash 286 patients










bull Results








63(95 CI 052 to 075 Plt001)



radiotherapy alone




Objectives


ndash Introduction

ndash How it works


ndash Surgery

ndash Radiation


ndash Response

ndash Injury





Image adopted from





matter fiber tracks

(WMT) in the brain



tracts extending in

multiple directions





GBM



Displacement of




Introduction







bull Define anatomy










Basic Principles

1 Diffusion

2 Measurement







superficial organs





bull Convenient

















Tissue cellularity






Isotropy




Anisotropy





structure




Image obtained from


ullpr2005800ahtml














Myelin

Sheath

Water

molecules

Endoneurium



Diffusion is faster

parallel to white

matter tracts



Image adopted from





Tensor




- between 0 and 1










axis of WMT







Eigenvalues


q L























Image Obtained From


S0166223612000720amp_image=1-s20-S0166223612000720-







tutorialhtmldtihtml






FA (Tensor Shape)









measurements




visible





coded maps




posterior)










Image Obtained From




Objectives


ndash Surgery

ndash Radiation


ndash Response

ndash Injury







69






Intraoperative MRI













and Resection






bull Methods




(n=120)




hazard ratio








bull Results



















fasciculus












Tracks





Fasciculus)

Red = Communicating


(Corpus Callosum)

Combined fMRI for


areas of the brain

(language motor)


PACS BIDMC





bull Problem





deficits



bull Solution




Radiation Therapy









Jena R et al (2005)






















Image adopted from








Image adopted from








Image adopted from










treatment planning





Objectives


ndash Response

ndash Injury





Overview


ndash Response



ndash Progression













Image adopted from






















Image adopted from






Image adopted from






sequences


























Acknowledgments





Deaconess

93
























94

















590












Imaging 13534-546 (2001) 96


















1562 2008




1470-2045 101016S1470-2045(11)70130-9

















2004 Nov 160(3)853-60












98















treatedrdquo


Dr Percival

Bailey

Dr Harvey Cushing


Image adopted from


Image adopted from








Classification


and glial tumor



Epidemiology

ndash Incidence 2-3


and Europe

ndash Malegt Female


Prognosis

ndash Dismal

ndash Survival


treatment

bull 5-year 3


bull Older age



status



promoter






SignsSymptoms



Tumor Location


(Temporal lobe)


corpus callosum








Glial cell


Image adopted from





Astrocytes Types

















bull Gross Anatomy



(necrosis)


ndash Hemorrhage

Image adopted from


Saunders W B (2009)





bull Polymorphic



bull Eosinophilic


Image adopted from



Saunders W B (2009)




Proliferation


production of VGEF



(Tufts)


body (black arrows)

Image adopted from



Saunders W B (2009)






of wooden poles


Image adopted from



Image adopted from










ndash Mitosis


Image adopted from



Saunders W B (2009)











Saunders W B (2009)






(MRI)









alterations




25





26



MRI gives

better

visualization of

cellular activity

within the lesion

sharper borders

of tumor for

more precise

measurements

increased

differentiation of

edema vs lesion






27











lesions



edema

- Ring-enhancing



28


Contrast




29





30


38 cm

homogeneous

hypointense mass

edema Ring-

enhancement

with central

area of

heterogenous

enhancement

Central area






31






bull Basics


on T2



bull GBM Findings






32

Vasogenic Edema

Cystic

necrosis



bull FLAIR Basics







bull GBM Findings


grade of tumor


(hyperintense)




33

Vasogenic Edema

Cystic

necrosis

Hyperintense

lesion

Satellite lesion






bull DWI Basics




bull GBM Findings




PACS BIDMC


PACS BIDMC

34

Increased signal

= restricted

diffusion

Satellite lesion

detected




MRI MR Spectroscopy

















36








37










Treatment Surgery








Methods


bull N = 92



survival

Results







(plt0005) VRD (plt0001)



Oct 52(4) 371-9


Treatment Surgery





Treatment Surgery






Methods


bull N = 416


bull End point











Neurosurg 95 190-198 2001


Treatment Surgery












160(3)853-60





0

10

20

30

40

50

60

70

80

90


East

West

North








bull Methods



proven GBM

ndash Assignments



ndash 287 patients




ndash 286 patients










bull Results








63(95 CI 052 to 075 Plt001)



radiotherapy alone




Objectives


ndash Introduction

ndash How it works


ndash Surgery

ndash Radiation


ndash Response

ndash Injury





Image adopted from





matter fiber tracks

(WMT) in the brain



tracts extending in

multiple directions





GBM



Displacement of




Introduction







bull Define anatomy










Basic Principles

1 Diffusion

2 Measurement







superficial organs





bull Convenient

















Tissue cellularity






Isotropy




Anisotropy





structure




Image obtained from


ullpr2005800ahtml














Myelin

Sheath

Water

molecules

Endoneurium



Diffusion is faster

parallel to white

matter tracts



Image adopted from





Tensor




- between 0 and 1










axis of WMT







Eigenvalues


q L























Image Obtained From


S0166223612000720amp_image=1-s20-S0166223612000720-







tutorialhtmldtihtml






FA (Tensor Shape)









measurements




visible





coded maps




posterior)










Image Obtained From




Objectives


ndash Surgery

ndash Radiation


ndash Response

ndash Injury







69






Intraoperative MRI













and Resection






bull Methods




(n=120)




hazard ratio








bull Results



















fasciculus












Tracks





Fasciculus)

Red = Communicating


(Corpus Callosum)

Combined fMRI for


areas of the brain

(language motor)


PACS BIDMC





bull Problem





deficits



bull Solution




Radiation Therapy









Jena R et al (2005)






















Image adopted from








Image adopted from








Image adopted from










treatment planning





Objectives


ndash Response

ndash Injury





Overview


ndash Response



ndash Progression













Image adopted from






















Image adopted from






Image adopted from






sequences


























Acknowledgments





Deaconess

93
























94

















590












Imaging 13534-546 (2001) 96


















1562 2008




1470-2045 101016S1470-2045(11)70130-9

















2004 Nov 160(3)853-60












98




Classification


and glial tumor



Epidemiology

ndash Incidence 2-3


and Europe

ndash Malegt Female


Prognosis

ndash Dismal

ndash Survival


treatment

bull 5-year 3


bull Older age



status



promoter






SignsSymptoms



Tumor Location


(Temporal lobe)


corpus callosum








Glial cell


Image adopted from





Astrocytes Types

















bull Gross Anatomy



(necrosis)


ndash Hemorrhage

Image adopted from


Saunders W B (2009)





bull Polymorphic



bull Eosinophilic


Image adopted from



Saunders W B (2009)




Proliferation


production of VGEF



(Tufts)


body (black arrows)

Image adopted from



Saunders W B (2009)






of wooden poles


Image adopted from



Image adopted from










ndash Mitosis


Image adopted from



Saunders W B (2009)











Saunders W B (2009)






(MRI)









alterations




25





26



MRI gives

better

visualization of

cellular activity

within the lesion

sharper borders

of tumor for

more precise

measurements

increased

differentiation of

edema vs lesion






27











lesions



edema

- Ring-enhancing



28


Contrast




29





30


38 cm

homogeneous

hypointense mass

edema Ring-

enhancement

with central

area of

heterogenous

enhancement

Central area






31






bull Basics


on T2



bull GBM Findings






32

Vasogenic Edema

Cystic

necrosis



bull FLAIR Basics







bull GBM Findings


grade of tumor


(hyperintense)




33

Vasogenic Edema

Cystic

necrosis

Hyperintense

lesion

Satellite lesion






bull DWI Basics




bull GBM Findings




PACS BIDMC


PACS BIDMC

34

Increased signal

= restricted

diffusion

Satellite lesion

detected




MRI MR Spectroscopy

















36








37










Treatment Surgery








Methods


bull N = 92



survival

Results







(plt0005) VRD (plt0001)



Oct 52(4) 371-9


Treatment Surgery





Treatment Surgery






Methods


bull N = 416


bull End point











Neurosurg 95 190-198 2001


Treatment Surgery












160(3)853-60





0

10

20

30

40

50

60

70

80

90


East

West

North








bull Methods



proven GBM

ndash Assignments



ndash 287 patients




ndash 286 patients










bull Results








63(95 CI 052 to 075 Plt001)



radiotherapy alone




Objectives


ndash Introduction

ndash How it works


ndash Surgery

ndash Radiation


ndash Response

ndash Injury





Image adopted from





matter fiber tracks

(WMT) in the brain



tracts extending in

multiple directions





GBM



Displacement of




Introduction







bull Define anatomy










Basic Principles

1 Diffusion

2 Measurement







superficial organs





bull Convenient

















Tissue cellularity






Isotropy




Anisotropy





structure




Image obtained from


ullpr2005800ahtml














Myelin

Sheath

Water

molecules

Endoneurium



Diffusion is faster

parallel to white

matter tracts



Image adopted from





Tensor




- between 0 and 1










axis of WMT







Eigenvalues


q L























Image Obtained From


S0166223612000720amp_image=1-s20-S0166223612000720-







tutorialhtmldtihtml






FA (Tensor Shape)









measurements




visible





coded maps




posterior)










Image Obtained From




Objectives


ndash Surgery

ndash Radiation


ndash Response

ndash Injury







69






Intraoperative MRI













and Resection






bull Methods




(n=120)




hazard ratio








bull Results



















fasciculus












Tracks





Fasciculus)

Red = Communicating


(Corpus Callosum)

Combined fMRI for


areas of the brain

(language motor)


PACS BIDMC





bull Problem





deficits



bull Solution




Radiation Therapy









Jena R et al (2005)






















Image adopted from








Image adopted from








Image adopted from










treatment planning





Objectives


ndash Response

ndash Injury





Overview


ndash Response



ndash Progression













Image adopted from






















Image adopted from






Image adopted from






sequences


























Acknowledgments





Deaconess

93
























94

















590












Imaging 13534-546 (2001) 96


















1562 2008




1470-2045 101016S1470-2045(11)70130-9

















2004 Nov 160(3)853-60












98





SignsSymptoms



Tumor Location


(Temporal lobe)


corpus callosum








Glial cell


Image adopted from





Astrocytes Types

















bull Gross Anatomy



(necrosis)


ndash Hemorrhage

Image adopted from


Saunders W B (2009)





bull Polymorphic



bull Eosinophilic


Image adopted from



Saunders W B (2009)




Proliferation


production of VGEF



(Tufts)


body (black arrows)

Image adopted from



Saunders W B (2009)






of wooden poles


Image adopted from



Image adopted from










ndash Mitosis


Image adopted from



Saunders W B (2009)











Saunders W B (2009)






(MRI)









alterations




25





26



MRI gives

better

visualization of

cellular activity

within the lesion

sharper borders

of tumor for

more precise

measurements

increased

differentiation of

edema vs lesion






27











lesions



edema

- Ring-enhancing



28


Contrast




29





30


38 cm

homogeneous

hypointense mass

edema Ring-

enhancement

with central

area of

heterogenous

enhancement

Central area






31






bull Basics


on T2



bull GBM Findings






32

Vasogenic Edema

Cystic

necrosis



bull FLAIR Basics







bull GBM Findings


grade of tumor


(hyperintense)




33

Vasogenic Edema

Cystic

necrosis

Hyperintense

lesion

Satellite lesion






bull DWI Basics




bull GBM Findings




PACS BIDMC


PACS BIDMC

34

Increased signal

= restricted

diffusion

Satellite lesion

detected




MRI MR Spectroscopy

















36








37










Treatment Surgery








Methods


bull N = 92



survival

Results







(plt0005) VRD (plt0001)



Oct 52(4) 371-9


Treatment Surgery





Treatment Surgery






Methods


bull N = 416


bull End point











Neurosurg 95 190-198 2001


Treatment Surgery












160(3)853-60





0

10

20

30

40

50

60

70

80

90


East

West

North








bull Methods



proven GBM

ndash Assignments



ndash 287 patients




ndash 286 patients










bull Results








63(95 CI 052 to 075 Plt001)



radiotherapy alone




Objectives


ndash Introduction

ndash How it works


ndash Surgery

ndash Radiation


ndash Response

ndash Injury





Image adopted from





matter fiber tracks

(WMT) in the brain



tracts extending in

multiple directions





GBM



Displacement of




Introduction







bull Define anatomy










Basic Principles

1 Diffusion

2 Measurement







superficial organs





bull Convenient

















Tissue cellularity






Isotropy




Anisotropy





structure




Image obtained from


ullpr2005800ahtml














Myelin

Sheath

Water

molecules

Endoneurium



Diffusion is faster

parallel to white

matter tracts



Image adopted from





Tensor




- between 0 and 1










axis of WMT







Eigenvalues


q L























Image Obtained From


S0166223612000720amp_image=1-s20-S0166223612000720-







tutorialhtmldtihtml






FA (Tensor Shape)









measurements




visible





coded maps




posterior)










Image Obtained From




Objectives


ndash Surgery

ndash Radiation


ndash Response

ndash Injury







69






Intraoperative MRI













and Resection






bull Methods




(n=120)




hazard ratio








bull Results



















fasciculus












Tracks





Fasciculus)

Red = Communicating


(Corpus Callosum)

Combined fMRI for


areas of the brain

(language motor)


PACS BIDMC





bull Problem





deficits



bull Solution




Radiation Therapy









Jena R et al (2005)






















Image adopted from








Image adopted from








Image adopted from










treatment planning





Objectives


ndash Response

ndash Injury





Overview


ndash Response



ndash Progression













Image adopted from






















Image adopted from






Image adopted from






sequences


























Acknowledgments





Deaconess

93
























94

















590












Imaging 13534-546 (2001) 96


















1562 2008




1470-2045 101016S1470-2045(11)70130-9

















2004 Nov 160(3)853-60












98








Glial cell


Image adopted from





Astrocytes Types

















bull Gross Anatomy



(necrosis)


ndash Hemorrhage

Image adopted from


Saunders W B (2009)





bull Polymorphic



bull Eosinophilic


Image adopted from



Saunders W B (2009)




Proliferation


production of VGEF



(Tufts)


body (black arrows)

Image adopted from



Saunders W B (2009)






of wooden poles


Image adopted from



Image adopted from










ndash Mitosis


Image adopted from



Saunders W B (2009)











Saunders W B (2009)






(MRI)









alterations




25





26



MRI gives

better

visualization of

cellular activity

within the lesion

sharper borders

of tumor for

more precise

measurements

increased

differentiation of

edema vs lesion






27











lesions



edema

- Ring-enhancing



28


Contrast




29





30


38 cm

homogeneous

hypointense mass

edema Ring-

enhancement

with central

area of

heterogenous

enhancement

Central area






31






bull Basics


on T2



bull GBM Findings






32

Vasogenic Edema

Cystic

necrosis



bull FLAIR Basics







bull GBM Findings


grade of tumor


(hyperintense)




33

Vasogenic Edema

Cystic

necrosis

Hyperintense

lesion

Satellite lesion






bull DWI Basics




bull GBM Findings




PACS BIDMC


PACS BIDMC

34

Increased signal

= restricted

diffusion

Satellite lesion

detected




MRI MR Spectroscopy

















36








37










Treatment Surgery








Methods


bull N = 92



survival

Results







(plt0005) VRD (plt0001)



Oct 52(4) 371-9


Treatment Surgery





Treatment Surgery






Methods


bull N = 416


bull End point











Neurosurg 95 190-198 2001


Treatment Surgery












160(3)853-60





0

10

20

30

40

50

60

70

80

90


East

West

North








bull Methods



proven GBM

ndash Assignments



ndash 287 patients




ndash 286 patients










bull Results








63(95 CI 052 to 075 Plt001)



radiotherapy alone




Objectives


ndash Introduction

ndash How it works


ndash Surgery

ndash Radiation


ndash Response

ndash Injury





Image adopted from





matter fiber tracks

(WMT) in the brain



tracts extending in

multiple directions





GBM



Displacement of




Introduction







bull Define anatomy










Basic Principles

1 Diffusion

2 Measurement







superficial organs





bull Convenient

















Tissue cellularity






Isotropy




Anisotropy





structure




Image obtained from


ullpr2005800ahtml














Myelin

Sheath

Water

molecules

Endoneurium



Diffusion is faster

parallel to white

matter tracts



Image adopted from





Tensor




- between 0 and 1










axis of WMT







Eigenvalues


q L























Image Obtained From


S0166223612000720amp_image=1-s20-S0166223612000720-







tutorialhtmldtihtml






FA (Tensor Shape)









measurements




visible





coded maps




posterior)










Image Obtained From




Objectives


ndash Surgery

ndash Radiation


ndash Response

ndash Injury







69






Intraoperative MRI













and Resection






bull Methods




(n=120)




hazard ratio








bull Results



















fasciculus












Tracks





Fasciculus)

Red = Communicating


(Corpus Callosum)

Combined fMRI for


areas of the brain

(language motor)


PACS BIDMC





bull Problem





deficits



bull Solution




Radiation Therapy









Jena R et al (2005)






















Image adopted from








Image adopted from








Image adopted from










treatment planning





Objectives


ndash Response

ndash Injury





Overview


ndash Response



ndash Progression













Image adopted from






















Image adopted from






Image adopted from






sequences


























Acknowledgments





Deaconess

93
























94

















590












Imaging 13534-546 (2001) 96


















1562 2008




1470-2045 101016S1470-2045(11)70130-9

















2004 Nov 160(3)853-60












98




Glial cell


Image adopted from





Astrocytes Types

















bull Gross Anatomy



(necrosis)


ndash Hemorrhage

Image adopted from


Saunders W B (2009)





bull Polymorphic



bull Eosinophilic


Image adopted from



Saunders W B (2009)




Proliferation


production of VGEF



(Tufts)


body (black arrows)

Image adopted from



Saunders W B (2009)






of wooden poles


Image adopted from



Image adopted from










ndash Mitosis


Image adopted from



Saunders W B (2009)











Saunders W B (2009)






(MRI)









alterations




25





26



MRI gives

better

visualization of

cellular activity

within the lesion

sharper borders

of tumor for

more precise

measurements

increased

differentiation of

edema vs lesion






27











lesions



edema

- Ring-enhancing



28


Contrast




29





30


38 cm

homogeneous

hypointense mass

edema Ring-

enhancement

with central

area of

heterogenous

enhancement

Central area






31






bull Basics


on T2



bull GBM Findings






32

Vasogenic Edema

Cystic

necrosis



bull FLAIR Basics







bull GBM Findings


grade of tumor


(hyperintense)




33

Vasogenic Edema

Cystic

necrosis

Hyperintense

lesion

Satellite lesion






bull DWI Basics




bull GBM Findings




PACS BIDMC


PACS BIDMC

34

Increased signal

= restricted

diffusion

Satellite lesion

detected




MRI MR Spectroscopy

















36








37










Treatment Surgery








Methods


bull N = 92



survival

Results







(plt0005) VRD (plt0001)



Oct 52(4) 371-9


Treatment Surgery





Treatment Surgery






Methods


bull N = 416


bull End point











Neurosurg 95 190-198 2001


Treatment Surgery












160(3)853-60





0

10

20

30

40

50

60

70

80

90


East

West

North








bull Methods



proven GBM

ndash Assignments



ndash 287 patients




ndash 286 patients










bull Results








63(95 CI 052 to 075 Plt001)



radiotherapy alone




Objectives


ndash Introduction

ndash How it works


ndash Surgery

ndash Radiation


ndash Response

ndash Injury





Image adopted from





matter fiber tracks

(WMT) in the brain



tracts extending in

multiple directions





GBM



Displacement of




Introduction







bull Define anatomy










Basic Principles

1 Diffusion

2 Measurement







superficial organs





bull Convenient

















Tissue cellularity






Isotropy




Anisotropy





structure




Image obtained from


ullpr2005800ahtml














Myelin

Sheath

Water

molecules

Endoneurium



Diffusion is faster

parallel to white

matter tracts



Image adopted from





Tensor




- between 0 and 1










axis of WMT







Eigenvalues


q L























Image Obtained From


S0166223612000720amp_image=1-s20-S0166223612000720-







tutorialhtmldtihtml






FA (Tensor Shape)









measurements




visible





coded maps




posterior)










Image Obtained From




Objectives


ndash Surgery

ndash Radiation


ndash Response

ndash Injury







69






Intraoperative MRI













and Resection






bull Methods




(n=120)




hazard ratio








bull Results



















fasciculus












Tracks





Fasciculus)

Red = Communicating


(Corpus Callosum)

Combined fMRI for


areas of the brain

(language motor)


PACS BIDMC





bull Problem





deficits



bull Solution




Radiation Therapy









Jena R et al (2005)






















Image adopted from








Image adopted from








Image adopted from










treatment planning





Objectives


ndash Response

ndash Injury





Overview


ndash Response



ndash Progression













Image adopted from






















Image adopted from






Image adopted from






sequences


























Acknowledgments





Deaconess

93
























94

















590












Imaging 13534-546 (2001) 96


















1562 2008




1470-2045 101016S1470-2045(11)70130-9

















2004 Nov 160(3)853-60












98




Astrocytes Types

















bull Gross Anatomy



(necrosis)


ndash Hemorrhage

Image adopted from


Saunders W B (2009)





bull Polymorphic



bull Eosinophilic


Image adopted from



Saunders W B (2009)




Proliferation


production of VGEF



(Tufts)


body (black arrows)

Image adopted from



Saunders W B (2009)






of wooden poles


Image adopted from



Image adopted from










ndash Mitosis


Image adopted from



Saunders W B (2009)











Saunders W B (2009)






(MRI)









alterations




25





26



MRI gives

better

visualization of

cellular activity

within the lesion

sharper borders

of tumor for

more precise

measurements

increased

differentiation of

edema vs lesion






27











lesions



edema

- Ring-enhancing



28


Contrast




29





30


38 cm

homogeneous

hypointense mass

edema Ring-

enhancement

with central

area of

heterogenous

enhancement

Central area






31






bull Basics


on T2



bull GBM Findings






32

Vasogenic Edema

Cystic

necrosis



bull FLAIR Basics







bull GBM Findings


grade of tumor


(hyperintense)




33

Vasogenic Edema

Cystic

necrosis

Hyperintense

lesion

Satellite lesion






bull DWI Basics




bull GBM Findings




PACS BIDMC


PACS BIDMC

34

Increased signal

= restricted

diffusion

Satellite lesion

detected




MRI MR Spectroscopy

















36








37










Treatment Surgery








Methods


bull N = 92



survival

Results







(plt0005) VRD (plt0001)



Oct 52(4) 371-9


Treatment Surgery





Treatment Surgery






Methods


bull N = 416


bull End point











Neurosurg 95 190-198 2001


Treatment Surgery












160(3)853-60





0

10

20

30

40

50

60

70

80

90


East

West

North








bull Methods



proven GBM

ndash Assignments



ndash 287 patients




ndash 286 patients










bull Results








63(95 CI 052 to 075 Plt001)



radiotherapy alone




Objectives


ndash Introduction

ndash How it works


ndash Surgery

ndash Radiation


ndash Response

ndash Injury





Image adopted from





matter fiber tracks

(WMT) in the brain



tracts extending in

multiple directions





GBM



Displacement of




Introduction







bull Define anatomy










Basic Principles

1 Diffusion

2 Measurement







superficial organs





bull Convenient

















Tissue cellularity






Isotropy




Anisotropy





structure




Image obtained from


ullpr2005800ahtml














Myelin

Sheath

Water

molecules

Endoneurium



Diffusion is faster

parallel to white

matter tracts



Image adopted from





Tensor




- between 0 and 1










axis of WMT







Eigenvalues


q L























Image Obtained From


S0166223612000720amp_image=1-s20-S0166223612000720-







tutorialhtmldtihtml






FA (Tensor Shape)









measurements




visible





coded maps




posterior)










Image Obtained From




Objectives


ndash Surgery

ndash Radiation


ndash Response

ndash Injury







69






Intraoperative MRI













and Resection






bull Methods




(n=120)




hazard ratio








bull Results



















fasciculus












Tracks





Fasciculus)

Red = Communicating


(Corpus Callosum)

Combined fMRI for


areas of the brain

(language motor)


PACS BIDMC





bull Problem





deficits



bull Solution




Radiation Therapy









Jena R et al (2005)






















Image adopted from








Image adopted from








Image adopted from










treatment planning





Objectives


ndash Response

ndash Injury





Overview


ndash Response



ndash Progression













Image adopted from






















Image adopted from






Image adopted from






sequences


























Acknowledgments





Deaconess

93
























94

















590












Imaging 13534-546 (2001) 96


















1562 2008




1470-2045 101016S1470-2045(11)70130-9

















2004 Nov 160(3)853-60












98










bull Gross Anatomy



(necrosis)


ndash Hemorrhage

Image adopted from


Saunders W B (2009)





bull Polymorphic



bull Eosinophilic


Image adopted from



Saunders W B (2009)




Proliferation


production of VGEF



(Tufts)


body (black arrows)

Image adopted from



Saunders W B (2009)






of wooden poles


Image adopted from



Image adopted from










ndash Mitosis


Image adopted from



Saunders W B (2009)











Saunders W B (2009)






(MRI)









alterations




25





26



MRI gives

better

visualization of

cellular activity

within the lesion

sharper borders

of tumor for

more precise

measurements

increased

differentiation of

edema vs lesion






27











lesions



edema

- Ring-enhancing



28


Contrast




29





30


38 cm

homogeneous

hypointense mass

edema Ring-

enhancement

with central

area of

heterogenous

enhancement

Central area






31






bull Basics


on T2



bull GBM Findings






32

Vasogenic Edema

Cystic

necrosis



bull FLAIR Basics







bull GBM Findings


grade of tumor


(hyperintense)




33

Vasogenic Edema

Cystic

necrosis

Hyperintense

lesion

Satellite lesion






bull DWI Basics




bull GBM Findings




PACS BIDMC


PACS BIDMC

34

Increased signal

= restricted

diffusion

Satellite lesion

detected




MRI MR Spectroscopy

















36








37










Treatment Surgery








Methods


bull N = 92



survival

Results







(plt0005) VRD (plt0001)



Oct 52(4) 371-9


Treatment Surgery





Treatment Surgery






Methods


bull N = 416


bull End point











Neurosurg 95 190-198 2001


Treatment Surgery












160(3)853-60





0

10

20

30

40

50

60

70

80

90


East

West

North








bull Methods



proven GBM

ndash Assignments



ndash 287 patients




ndash 286 patients










bull Results








63(95 CI 052 to 075 Plt001)



radiotherapy alone




Objectives


ndash Introduction

ndash How it works


ndash Surgery

ndash Radiation


ndash Response

ndash Injury





Image adopted from





matter fiber tracks

(WMT) in the brain



tracts extending in

multiple directions





GBM



Displacement of




Introduction







bull Define anatomy










Basic Principles

1 Diffusion

2 Measurement







superficial organs





bull Convenient

















Tissue cellularity






Isotropy




Anisotropy





structure




Image obtained from


ullpr2005800ahtml














Myelin

Sheath

Water

molecules

Endoneurium



Diffusion is faster

parallel to white

matter tracts



Image adopted from





Tensor




- between 0 and 1










axis of WMT







Eigenvalues


q L























Image Obtained From


S0166223612000720amp_image=1-s20-S0166223612000720-







tutorialhtmldtihtml






FA (Tensor Shape)









measurements




visible





coded maps




posterior)










Image Obtained From




Objectives


ndash Surgery

ndash Radiation


ndash Response

ndash Injury







69






Intraoperative MRI













and Resection






bull Methods




(n=120)




hazard ratio








bull Results



















fasciculus












Tracks





Fasciculus)

Red = Communicating


(Corpus Callosum)

Combined fMRI for


areas of the brain

(language motor)


PACS BIDMC





bull Problem





deficits



bull Solution




Radiation Therapy









Jena R et al (2005)






















Image adopted from








Image adopted from








Image adopted from










treatment planning





Objectives


ndash Response

ndash Injury





Overview


ndash Response



ndash Progression













Image adopted from






















Image adopted from






Image adopted from






sequences


























Acknowledgments





Deaconess

93
























94

















590












Imaging 13534-546 (2001) 96


















1562 2008




1470-2045 101016S1470-2045(11)70130-9

















2004 Nov 160(3)853-60












98




bull Gross Anatomy



(necrosis)


ndash Hemorrhage

Image adopted from


Saunders W B (2009)





bull Polymorphic



bull Eosinophilic


Image adopted from



Saunders W B (2009)




Proliferation


production of VGEF



(Tufts)


body (black arrows)

Image adopted from



Saunders W B (2009)






of wooden poles


Image adopted from



Image adopted from










ndash Mitosis


Image adopted from



Saunders W B (2009)











Saunders W B (2009)






(MRI)









alterations




25





26



MRI gives

better

visualization of

cellular activity

within the lesion

sharper borders

of tumor for

more precise

measurements

increased

differentiation of

edema vs lesion






27











lesions



edema

- Ring-enhancing



28


Contrast




29





30


38 cm

homogeneous

hypointense mass

edema Ring-

enhancement

with central

area of

heterogenous

enhancement

Central area






31






bull Basics


on T2



bull GBM Findings






32

Vasogenic Edema

Cystic

necrosis



bull FLAIR Basics







bull GBM Findings


grade of tumor


(hyperintense)




33

Vasogenic Edema

Cystic

necrosis

Hyperintense

lesion

Satellite lesion






bull DWI Basics




bull GBM Findings




PACS BIDMC


PACS BIDMC

34

Increased signal

= restricted

diffusion

Satellite lesion

detected




MRI MR Spectroscopy

















36








37










Treatment Surgery








Methods


bull N = 92



survival

Results







(plt0005) VRD (plt0001)



Oct 52(4) 371-9


Treatment Surgery





Treatment Surgery






Methods


bull N = 416


bull End point











Neurosurg 95 190-198 2001


Treatment Surgery












160(3)853-60





0

10

20

30

40

50

60

70

80

90


East

West

North








bull Methods



proven GBM

ndash Assignments



ndash 287 patients




ndash 286 patients










bull Results








63(95 CI 052 to 075 Plt001)



radiotherapy alone




Objectives


ndash Introduction

ndash How it works


ndash Surgery

ndash Radiation


ndash Response

ndash Injury





Image adopted from





matter fiber tracks

(WMT) in the brain



tracts extending in

multiple directions





GBM



Displacement of




Introduction







bull Define anatomy










Basic Principles

1 Diffusion

2 Measurement







superficial organs





bull Convenient

















Tissue cellularity






Isotropy




Anisotropy





structure




Image obtained from


ullpr2005800ahtml














Myelin

Sheath

Water

molecules

Endoneurium



Diffusion is faster

parallel to white

matter tracts



Image adopted from





Tensor




- between 0 and 1










axis of WMT







Eigenvalues


q L























Image Obtained From


S0166223612000720amp_image=1-s20-S0166223612000720-







tutorialhtmldtihtml






FA (Tensor Shape)









measurements




visible





coded maps




posterior)










Image Obtained From




Objectives


ndash Surgery

ndash Radiation


ndash Response

ndash Injury







69






Intraoperative MRI













and Resection






bull Methods




(n=120)




hazard ratio








bull Results



















fasciculus












Tracks





Fasciculus)

Red = Communicating


(Corpus Callosum)

Combined fMRI for


areas of the brain

(language motor)


PACS BIDMC





bull Problem





deficits



bull Solution




Radiation Therapy









Jena R et al (2005)






















Image adopted from








Image adopted from








Image adopted from










treatment planning





Objectives


ndash Response

ndash Injury





Overview


ndash Response



ndash Progression













Image adopted from






















Image adopted from






Image adopted from






sequences


























Acknowledgments





Deaconess

93
























94

















590












Imaging 13534-546 (2001) 96


















1562 2008




1470-2045 101016S1470-2045(11)70130-9

















2004 Nov 160(3)853-60












98





bull Polymorphic



bull Eosinophilic


Image adopted from



Saunders W B (2009)




Proliferation


production of VGEF



(Tufts)


body (black arrows)

Image adopted from



Saunders W B (2009)






of wooden poles


Image adopted from



Image adopted from










ndash Mitosis


Image adopted from



Saunders W B (2009)











Saunders W B (2009)






(MRI)









alterations




25





26



MRI gives

better

visualization of

cellular activity

within the lesion

sharper borders

of tumor for

more precise

measurements

increased

differentiation of

edema vs lesion






27











lesions



edema

- Ring-enhancing



28


Contrast




29





30


38 cm

homogeneous

hypointense mass

edema Ring-

enhancement

with central

area of

heterogenous

enhancement

Central area






31






bull Basics


on T2



bull GBM Findings






32

Vasogenic Edema

Cystic

necrosis



bull FLAIR Basics







bull GBM Findings


grade of tumor


(hyperintense)




33

Vasogenic Edema

Cystic

necrosis

Hyperintense

lesion

Satellite lesion






bull DWI Basics




bull GBM Findings




PACS BIDMC


PACS BIDMC

34

Increased signal

= restricted

diffusion

Satellite lesion

detected




MRI MR Spectroscopy

















36








37










Treatment Surgery








Methods


bull N = 92



survival

Results







(plt0005) VRD (plt0001)



Oct 52(4) 371-9


Treatment Surgery





Treatment Surgery






Methods


bull N = 416


bull End point











Neurosurg 95 190-198 2001


Treatment Surgery












160(3)853-60





0

10

20

30

40

50

60

70

80

90


East

West

North








bull Methods



proven GBM

ndash Assignments



ndash 287 patients




ndash 286 patients










bull Results








63(95 CI 052 to 075 Plt001)



radiotherapy alone




Objectives


ndash Introduction

ndash How it works


ndash Surgery

ndash Radiation


ndash Response

ndash Injury





Image adopted from





matter fiber tracks

(WMT) in the brain



tracts extending in

multiple directions





GBM



Displacement of




Introduction







bull Define anatomy










Basic Principles

1 Diffusion

2 Measurement







superficial organs





bull Convenient

















Tissue cellularity






Isotropy




Anisotropy





structure




Image obtained from


ullpr2005800ahtml














Myelin

Sheath

Water

molecules

Endoneurium



Diffusion is faster

parallel to white

matter tracts



Image adopted from





Tensor




- between 0 and 1










axis of WMT







Eigenvalues


q L























Image Obtained From


S0166223612000720amp_image=1-s20-S0166223612000720-







tutorialhtmldtihtml






FA (Tensor Shape)









measurements




visible





coded maps




posterior)










Image Obtained From




Objectives


ndash Surgery

ndash Radiation


ndash Response

ndash Injury







69






Intraoperative MRI













and Resection






bull Methods




(n=120)




hazard ratio








bull Results



















fasciculus












Tracks





Fasciculus)

Red = Communicating


(Corpus Callosum)

Combined fMRI for


areas of the brain

(language motor)


PACS BIDMC





bull Problem





deficits



bull Solution




Radiation Therapy









Jena R et al (2005)






















Image adopted from








Image adopted from








Image adopted from










treatment planning





Objectives


ndash Response

ndash Injury





Overview


ndash Response



ndash Progression













Image adopted from






















Image adopted from






Image adopted from






sequences


























Acknowledgments





Deaconess

93
























94

















590












Imaging 13534-546 (2001) 96


















1562 2008




1470-2045 101016S1470-2045(11)70130-9

















2004 Nov 160(3)853-60












98




Proliferation


production of VGEF



(Tufts)


body (black arrows)

Image adopted from



Saunders W B (2009)






of wooden poles


Image adopted from



Image adopted from










ndash Mitosis


Image adopted from



Saunders W B (2009)











Saunders W B (2009)






(MRI)









alterations




25





26



MRI gives

better

visualization of

cellular activity

within the lesion

sharper borders

of tumor for

more precise

measurements

increased

differentiation of

edema vs lesion






27











lesions



edema

- Ring-enhancing



28


Contrast




29





30


38 cm

homogeneous

hypointense mass

edema Ring-

enhancement

with central

area of

heterogenous

enhancement

Central area






31






bull Basics


on T2



bull GBM Findings






32

Vasogenic Edema

Cystic

necrosis



bull FLAIR Basics







bull GBM Findings


grade of tumor


(hyperintense)




33

Vasogenic Edema

Cystic

necrosis

Hyperintense

lesion

Satellite lesion






bull DWI Basics




bull GBM Findings




PACS BIDMC


PACS BIDMC

34

Increased signal

= restricted

diffusion

Satellite lesion

detected




MRI MR Spectroscopy

















36








37










Treatment Surgery








Methods


bull N = 92



survival

Results







(plt0005) VRD (plt0001)



Oct 52(4) 371-9


Treatment Surgery





Treatment Surgery






Methods


bull N = 416


bull End point











Neurosurg 95 190-198 2001


Treatment Surgery












160(3)853-60





0

10

20

30

40

50

60

70

80

90


East

West

North








bull Methods



proven GBM

ndash Assignments



ndash 287 patients




ndash 286 patients










bull Results








63(95 CI 052 to 075 Plt001)



radiotherapy alone




Objectives


ndash Introduction

ndash How it works


ndash Surgery

ndash Radiation


ndash Response

ndash Injury





Image adopted from





matter fiber tracks

(WMT) in the brain



tracts extending in

multiple directions





GBM



Displacement of




Introduction







bull Define anatomy










Basic Principles

1 Diffusion

2 Measurement







superficial organs





bull Convenient

















Tissue cellularity






Isotropy




Anisotropy





structure




Image obtained from


ullpr2005800ahtml














Myelin

Sheath

Water

molecules

Endoneurium



Diffusion is faster

parallel to white

matter tracts



Image adopted from





Tensor




- between 0 and 1










axis of WMT







Eigenvalues


q L























Image Obtained From


S0166223612000720amp_image=1-s20-S0166223612000720-







tutorialhtmldtihtml






FA (Tensor Shape)









measurements




visible





coded maps




posterior)










Image Obtained From




Objectives


ndash Surgery

ndash Radiation


ndash Response

ndash Injury







69






Intraoperative MRI













and Resection






bull Methods




(n=120)




hazard ratio








bull Results



















fasciculus












Tracks





Fasciculus)

Red = Communicating


(Corpus Callosum)

Combined fMRI for


areas of the brain

(language motor)


PACS BIDMC





bull Problem





deficits



bull Solution




Radiation Therapy









Jena R et al (2005)






















Image adopted from








Image adopted from








Image adopted from










treatment planning





Objectives


ndash Response

ndash Injury





Overview


ndash Response



ndash Progression













Image adopted from






















Image adopted from






Image adopted from






sequences


























Acknowledgments





Deaconess

93
























94

















590












Imaging 13534-546 (2001) 96


















1562 2008




1470-2045 101016S1470-2045(11)70130-9

















2004 Nov 160(3)853-60












98






of wooden poles


Image adopted from



Image adopted from










ndash Mitosis


Image adopted from



Saunders W B (2009)











Saunders W B (2009)






(MRI)









alterations




25





26



MRI gives

better

visualization of

cellular activity

within the lesion

sharper borders

of tumor for

more precise

measurements

increased

differentiation of

edema vs lesion






27











lesions



edema

- Ring-enhancing



28


Contrast




29





30


38 cm

homogeneous

hypointense mass

edema Ring-

enhancement

with central

area of

heterogenous

enhancement

Central area






31






bull Basics


on T2



bull GBM Findings






32

Vasogenic Edema

Cystic

necrosis



bull FLAIR Basics







bull GBM Findings


grade of tumor


(hyperintense)




33

Vasogenic Edema

Cystic

necrosis

Hyperintense

lesion

Satellite lesion






bull DWI Basics




bull GBM Findings




PACS BIDMC


PACS BIDMC

34

Increased signal

= restricted

diffusion

Satellite lesion

detected




MRI MR Spectroscopy

















36








37










Treatment Surgery








Methods


bull N = 92



survival

Results







(plt0005) VRD (plt0001)



Oct 52(4) 371-9


Treatment Surgery





Treatment Surgery






Methods


bull N = 416


bull End point











Neurosurg 95 190-198 2001


Treatment Surgery












160(3)853-60





0

10

20

30

40

50

60

70

80

90


East

West

North








bull Methods



proven GBM

ndash Assignments



ndash 287 patients




ndash 286 patients










bull Results








63(95 CI 052 to 075 Plt001)



radiotherapy alone




Objectives


ndash Introduction

ndash How it works


ndash Surgery

ndash Radiation


ndash Response

ndash Injury





Image adopted from





matter fiber tracks

(WMT) in the brain



tracts extending in

multiple directions





GBM



Displacement of




Introduction







bull Define anatomy










Basic Principles

1 Diffusion

2 Measurement







superficial organs





bull Convenient

















Tissue cellularity






Isotropy




Anisotropy





structure




Image obtained from


ullpr2005800ahtml














Myelin

Sheath

Water

molecules

Endoneurium



Diffusion is faster

parallel to white

matter tracts



Image adopted from





Tensor




- between 0 and 1










axis of WMT







Eigenvalues


q L























Image Obtained From


S0166223612000720amp_image=1-s20-S0166223612000720-







tutorialhtmldtihtml






FA (Tensor Shape)









measurements




visible





coded maps




posterior)










Image Obtained From




Objectives


ndash Surgery

ndash Radiation


ndash Response

ndash Injury







69






Intraoperative MRI













and Resection






bull Methods




(n=120)




hazard ratio








bull Results



















fasciculus












Tracks





Fasciculus)

Red = Communicating


(Corpus Callosum)

Combined fMRI for


areas of the brain

(language motor)


PACS BIDMC





bull Problem





deficits



bull Solution




Radiation Therapy









Jena R et al (2005)






















Image adopted from








Image adopted from








Image adopted from










treatment planning





Objectives


ndash Response

ndash Injury





Overview


ndash Response



ndash Progression













Image adopted from






















Image adopted from






Image adopted from






sequences


























Acknowledgments





Deaconess

93
























94

















590












Imaging 13534-546 (2001) 96


















1562 2008




1470-2045 101016S1470-2045(11)70130-9

















2004 Nov 160(3)853-60












98








ndash Mitosis


Image adopted from



Saunders W B (2009)











Saunders W B (2009)






(MRI)









alterations




25





26



MRI gives

better

visualization of

cellular activity

within the lesion

sharper borders

of tumor for

more precise

measurements

increased

differentiation of

edema vs lesion






27











lesions



edema

- Ring-enhancing



28


Contrast




29





30


38 cm

homogeneous

hypointense mass

edema Ring-

enhancement

with central

area of

heterogenous

enhancement

Central area






31






bull Basics


on T2



bull GBM Findings






32

Vasogenic Edema

Cystic

necrosis



bull FLAIR Basics







bull GBM Findings


grade of tumor


(hyperintense)




33

Vasogenic Edema

Cystic

necrosis

Hyperintense

lesion

Satellite lesion






bull DWI Basics




bull GBM Findings




PACS BIDMC


PACS BIDMC

34

Increased signal

= restricted

diffusion

Satellite lesion

detected




MRI MR Spectroscopy

















36








37










Treatment Surgery








Methods


bull N = 92



survival

Results







(plt0005) VRD (plt0001)



Oct 52(4) 371-9


Treatment Surgery





Treatment Surgery






Methods


bull N = 416


bull End point











Neurosurg 95 190-198 2001


Treatment Surgery












160(3)853-60





0

10

20

30

40

50

60

70

80

90


East

West

North








bull Methods



proven GBM

ndash Assignments



ndash 287 patients




ndash 286 patients










bull Results








63(95 CI 052 to 075 Plt001)



radiotherapy alone




Objectives


ndash Introduction

ndash How it works


ndash Surgery

ndash Radiation


ndash Response

ndash Injury





Image adopted from





matter fiber tracks

(WMT) in the brain



tracts extending in

multiple directions





GBM



Displacement of




Introduction







bull Define anatomy










Basic Principles

1 Diffusion

2 Measurement







superficial organs





bull Convenient

















Tissue cellularity






Isotropy




Anisotropy





structure




Image obtained from


ullpr2005800ahtml














Myelin

Sheath

Water

molecules

Endoneurium



Diffusion is faster

parallel to white

matter tracts



Image adopted from





Tensor




- between 0 and 1










axis of WMT







Eigenvalues


q L























Image Obtained From


S0166223612000720amp_image=1-s20-S0166223612000720-







tutorialhtmldtihtml






FA (Tensor Shape)









measurements




visible





coded maps




posterior)










Image Obtained From




Objectives


ndash Surgery

ndash Radiation


ndash Response

ndash Injury







69






Intraoperative MRI













and Resection






bull Methods




(n=120)




hazard ratio








bull Results



















fasciculus












Tracks





Fasciculus)

Red = Communicating


(Corpus Callosum)

Combined fMRI for


areas of the brain

(language motor)


PACS BIDMC





bull Problem





deficits



bull Solution




Radiation Therapy









Jena R et al (2005)






















Image adopted from








Image adopted from








Image adopted from










treatment planning





Objectives


ndash Response

ndash Injury





Overview


ndash Response



ndash Progression













Image adopted from






















Image adopted from






Image adopted from






sequences


























Acknowledgments





Deaconess

93
























94

















590












Imaging 13534-546 (2001) 96


















1562 2008




1470-2045 101016S1470-2045(11)70130-9

















2004 Nov 160(3)853-60












98











Saunders W B (2009)






(MRI)









alterations




25





26



MRI gives

better

visualization of

cellular activity

within the lesion

sharper borders

of tumor for

more precise

measurements

increased

differentiation of

edema vs lesion






27











lesions



edema

- Ring-enhancing



28


Contrast




29





30


38 cm

homogeneous

hypointense mass

edema Ring-

enhancement

with central

area of

heterogenous

enhancement

Central area






31






bull Basics


on T2



bull GBM Findings






32

Vasogenic Edema

Cystic

necrosis



bull FLAIR Basics







bull GBM Findings


grade of tumor


(hyperintense)




33

Vasogenic Edema

Cystic

necrosis

Hyperintense

lesion

Satellite lesion






bull DWI Basics




bull GBM Findings




PACS BIDMC


PACS BIDMC

34

Increased signal

= restricted

diffusion

Satellite lesion

detected




MRI MR Spectroscopy

















36








37










Treatment Surgery








Methods


bull N = 92



survival

Results







(plt0005) VRD (plt0001)



Oct 52(4) 371-9


Treatment Surgery





Treatment Surgery






Methods


bull N = 416


bull End point











Neurosurg 95 190-198 2001


Treatment Surgery












160(3)853-60





0

10

20

30

40

50

60

70

80

90


East

West

North








bull Methods



proven GBM

ndash Assignments



ndash 287 patients




ndash 286 patients










bull Results








63(95 CI 052 to 075 Plt001)



radiotherapy alone




Objectives


ndash Introduction

ndash How it works


ndash Surgery

ndash Radiation


ndash Response

ndash Injury





Image adopted from





matter fiber tracks

(WMT) in the brain



tracts extending in

multiple directions





GBM



Displacement of




Introduction







bull Define anatomy










Basic Principles

1 Diffusion

2 Measurement







superficial organs





bull Convenient

















Tissue cellularity






Isotropy




Anisotropy





structure




Image obtained from


ullpr2005800ahtml














Myelin

Sheath

Water

molecules

Endoneurium



Diffusion is faster

parallel to white

matter tracts



Image adopted from





Tensor




- between 0 and 1










axis of WMT







Eigenvalues


q L























Image Obtained From


S0166223612000720amp_image=1-s20-S0166223612000720-







tutorialhtmldtihtml






FA (Tensor Shape)









measurements




visible





coded maps




posterior)










Image Obtained From




Objectives


ndash Surgery

ndash Radiation


ndash Response

ndash Injury







69






Intraoperative MRI













and Resection






bull Methods




(n=120)




hazard ratio








bull Results



















fasciculus












Tracks





Fasciculus)

Red = Communicating


(Corpus Callosum)

Combined fMRI for


areas of the brain

(language motor)


PACS BIDMC





bull Problem





deficits



bull Solution




Radiation Therapy









Jena R et al (2005)






















Image adopted from








Image adopted from








Image adopted from










treatment planning





Objectives


ndash Response

ndash Injury





Overview


ndash Response



ndash Progression













Image adopted from






















Image adopted from






Image adopted from






sequences


























Acknowledgments





Deaconess

93
























94

















590












Imaging 13534-546 (2001) 96


















1562 2008




1470-2045 101016S1470-2045(11)70130-9

















2004 Nov 160(3)853-60












98






(MRI)









alterations




25





26



MRI gives

better

visualization of

cellular activity

within the lesion

sharper borders

of tumor for

more precise

measurements

increased

differentiation of

edema vs lesion






27











lesions



edema

- Ring-enhancing



28


Contrast




29





30


38 cm

homogeneous

hypointense mass

edema Ring-

enhancement

with central

area of

heterogenous

enhancement

Central area






31






bull Basics


on T2



bull GBM Findings






32

Vasogenic Edema

Cystic

necrosis



bull FLAIR Basics







bull GBM Findings


grade of tumor


(hyperintense)




33

Vasogenic Edema

Cystic

necrosis

Hyperintense

lesion

Satellite lesion






bull DWI Basics




bull GBM Findings




PACS BIDMC


PACS BIDMC

34

Increased signal

= restricted

diffusion

Satellite lesion

detected




MRI MR Spectroscopy

















36








37










Treatment Surgery








Methods


bull N = 92



survival

Results







(plt0005) VRD (plt0001)



Oct 52(4) 371-9


Treatment Surgery





Treatment Surgery






Methods


bull N = 416


bull End point











Neurosurg 95 190-198 2001


Treatment Surgery












160(3)853-60





0

10

20

30

40

50

60

70

80

90


East

West

North








bull Methods



proven GBM

ndash Assignments



ndash 287 patients




ndash 286 patients










bull Results








63(95 CI 052 to 075 Plt001)



radiotherapy alone




Objectives


ndash Introduction

ndash How it works


ndash Surgery

ndash Radiation


ndash Response

ndash Injury





Image adopted from





matter fiber tracks

(WMT) in the brain



tracts extending in

multiple directions





GBM



Displacement of




Introduction







bull Define anatomy










Basic Principles

1 Diffusion

2 Measurement







superficial organs





bull Convenient

















Tissue cellularity






Isotropy




Anisotropy





structure




Image obtained from


ullpr2005800ahtml














Myelin

Sheath

Water

molecules

Endoneurium



Diffusion is faster

parallel to white

matter tracts



Image adopted from





Tensor




- between 0 and 1










axis of WMT







Eigenvalues


q L























Image Obtained From


S0166223612000720amp_image=1-s20-S0166223612000720-







tutorialhtmldtihtml






FA (Tensor Shape)









measurements




visible





coded maps




posterior)










Image Obtained From




Objectives


ndash Surgery

ndash Radiation


ndash Response

ndash Injury







69






Intraoperative MRI













and Resection






bull Methods




(n=120)




hazard ratio








bull Results



















fasciculus












Tracks





Fasciculus)

Red = Communicating


(Corpus Callosum)

Combined fMRI for


areas of the brain

(language motor)


PACS BIDMC





bull Problem





deficits



bull Solution




Radiation Therapy









Jena R et al (2005)






















Image adopted from








Image adopted from








Image adopted from










treatment planning





Objectives


ndash Response

ndash Injury





Overview


ndash Response



ndash Progression













Image adopted from






















Image adopted from






Image adopted from






sequences


























Acknowledgments





Deaconess

93
























94

















590












Imaging 13534-546 (2001) 96


















1562 2008




1470-2045 101016S1470-2045(11)70130-9

















2004 Nov 160(3)853-60












98









alterations




25





26



MRI gives

better

visualization of

cellular activity

within the lesion

sharper borders

of tumor for

more precise

measurements

increased

differentiation of

edema vs lesion






27











lesions



edema

- Ring-enhancing



28


Contrast




29





30


38 cm

homogeneous

hypointense mass

edema Ring-

enhancement

with central

area of

heterogenous

enhancement

Central area






31






bull Basics


on T2



bull GBM Findings






32

Vasogenic Edema

Cystic

necrosis



bull FLAIR Basics







bull GBM Findings


grade of tumor


(hyperintense)




33

Vasogenic Edema

Cystic

necrosis

Hyperintense

lesion

Satellite lesion






bull DWI Basics




bull GBM Findings




PACS BIDMC


PACS BIDMC

34

Increased signal

= restricted

diffusion

Satellite lesion

detected




MRI MR Spectroscopy

















36








37










Treatment Surgery








Methods


bull N = 92



survival

Results







(plt0005) VRD (plt0001)



Oct 52(4) 371-9


Treatment Surgery





Treatment Surgery






Methods


bull N = 416


bull End point











Neurosurg 95 190-198 2001


Treatment Surgery












160(3)853-60





0

10

20

30

40

50

60

70

80

90


East

West

North








bull Methods



proven GBM

ndash Assignments



ndash 287 patients




ndash 286 patients










bull Results








63(95 CI 052 to 075 Plt001)



radiotherapy alone




Objectives


ndash Introduction

ndash How it works


ndash Surgery

ndash Radiation


ndash Response

ndash Injury





Image adopted from





matter fiber tracks

(WMT) in the brain



tracts extending in

multiple directions





GBM



Displacement of




Introduction







bull Define anatomy










Basic Principles

1 Diffusion

2 Measurement







superficial organs





bull Convenient

















Tissue cellularity






Isotropy




Anisotropy





structure




Image obtained from


ullpr2005800ahtml














Myelin

Sheath

Water

molecules

Endoneurium



Diffusion is faster

parallel to white

matter tracts



Image adopted from





Tensor




- between 0 and 1










axis of WMT







Eigenvalues


q L























Image Obtained From


S0166223612000720amp_image=1-s20-S0166223612000720-







tutorialhtmldtihtml






FA (Tensor Shape)









measurements




visible





coded maps




posterior)










Image Obtained From




Objectives


ndash Surgery

ndash Radiation


ndash Response

ndash Injury







69






Intraoperative MRI













and Resection






bull Methods




(n=120)




hazard ratio








bull Results



















fasciculus












Tracks





Fasciculus)

Red = Communicating


(Corpus Callosum)

Combined fMRI for


areas of the brain

(language motor)


PACS BIDMC





bull Problem





deficits



bull Solution




Radiation Therapy









Jena R et al (2005)






















Image adopted from








Image adopted from








Image adopted from










treatment planning





Objectives


ndash Response

ndash Injury





Overview


ndash Response



ndash Progression













Image adopted from






















Image adopted from






Image adopted from






sequences


























Acknowledgments





Deaconess

93
























94

















590












Imaging 13534-546 (2001) 96


















1562 2008




1470-2045 101016S1470-2045(11)70130-9

















2004 Nov 160(3)853-60












98




26



MRI gives

better

visualization of

cellular activity

within the lesion

sharper borders

of tumor for

more precise

measurements

increased

differentiation of

edema vs lesion






27











lesions



edema

- Ring-enhancing



28


Contrast




29





30


38 cm

homogeneous

hypointense mass

edema Ring-

enhancement

with central

area of

heterogenous

enhancement

Central area






31






bull Basics


on T2



bull GBM Findings






32

Vasogenic Edema

Cystic

necrosis



bull FLAIR Basics







bull GBM Findings


grade of tumor


(hyperintense)




33

Vasogenic Edema

Cystic

necrosis

Hyperintense

lesion

Satellite lesion






bull DWI Basics




bull GBM Findings




PACS BIDMC


PACS BIDMC

34

Increased signal

= restricted

diffusion

Satellite lesion

detected




MRI MR Spectroscopy

















36








37










Treatment Surgery








Methods


bull N = 92



survival

Results







(plt0005) VRD (plt0001)



Oct 52(4) 371-9


Treatment Surgery





Treatment Surgery






Methods


bull N = 416


bull End point











Neurosurg 95 190-198 2001


Treatment Surgery












160(3)853-60





0

10

20

30

40

50

60

70

80

90


East

West

North








bull Methods



proven GBM

ndash Assignments



ndash 287 patients




ndash 286 patients










bull Results








63(95 CI 052 to 075 Plt001)



radiotherapy alone




Objectives


ndash Introduction

ndash How it works


ndash Surgery

ndash Radiation


ndash Response

ndash Injury





Image adopted from





matter fiber tracks

(WMT) in the brain



tracts extending in

multiple directions





GBM



Displacement of




Introduction







bull Define anatomy










Basic Principles

1 Diffusion

2 Measurement







superficial organs





bull Convenient

















Tissue cellularity






Isotropy




Anisotropy





structure




Image obtained from


ullpr2005800ahtml














Myelin

Sheath

Water

molecules

Endoneurium



Diffusion is faster

parallel to white

matter tracts



Image adopted from





Tensor




- between 0 and 1










axis of WMT







Eigenvalues


q L























Image Obtained From


S0166223612000720amp_image=1-s20-S0166223612000720-







tutorialhtmldtihtml






FA (Tensor Shape)









measurements




visible





coded maps




posterior)










Image Obtained From




Objectives


ndash Surgery

ndash Radiation


ndash Response

ndash Injury







69






Intraoperative MRI













and Resection






bull Methods




(n=120)




hazard ratio








bull Results



















fasciculus












Tracks





Fasciculus)

Red = Communicating


(Corpus Callosum)

Combined fMRI for


areas of the brain

(language motor)


PACS BIDMC





bull Problem





deficits



bull Solution




Radiation Therapy









Jena R et al (2005)






















Image adopted from








Image adopted from








Image adopted from










treatment planning





Objectives


ndash Response

ndash Injury





Overview


ndash Response



ndash Progression













Image adopted from






















Image adopted from






Image adopted from






sequences


























Acknowledgments





Deaconess

93
























94

















590












Imaging 13534-546 (2001) 96


















1562 2008




1470-2045 101016S1470-2045(11)70130-9

















2004 Nov 160(3)853-60












98






27











lesions



edema

- Ring-enhancing



28


Contrast




29





30


38 cm

homogeneous

hypointense mass

edema Ring-

enhancement

with central

area of

heterogenous

enhancement

Central area






31






bull Basics


on T2



bull GBM Findings






32

Vasogenic Edema

Cystic

necrosis



bull FLAIR Basics







bull GBM Findings


grade of tumor


(hyperintense)




33

Vasogenic Edema

Cystic

necrosis

Hyperintense

lesion

Satellite lesion






bull DWI Basics




bull GBM Findings




PACS BIDMC


PACS BIDMC

34

Increased signal

= restricted

diffusion

Satellite lesion

detected




MRI MR Spectroscopy

















36








37










Treatment Surgery








Methods


bull N = 92



survival

Results







(plt0005) VRD (plt0001)



Oct 52(4) 371-9


Treatment Surgery





Treatment Surgery






Methods


bull N = 416


bull End point











Neurosurg 95 190-198 2001


Treatment Surgery












160(3)853-60





0

10

20

30

40

50

60

70

80

90


East

West

North








bull Methods



proven GBM

ndash Assignments



ndash 287 patients




ndash 286 patients










bull Results








63(95 CI 052 to 075 Plt001)



radiotherapy alone




Objectives


ndash Introduction

ndash How it works


ndash Surgery

ndash Radiation


ndash Response

ndash Injury





Image adopted from





matter fiber tracks

(WMT) in the brain



tracts extending in

multiple directions





GBM



Displacement of




Introduction







bull Define anatomy










Basic Principles

1 Diffusion

2 Measurement







superficial organs





bull Convenient

















Tissue cellularity






Isotropy




Anisotropy





structure




Image obtained from


ullpr2005800ahtml














Myelin

Sheath

Water

molecules

Endoneurium



Diffusion is faster

parallel to white

matter tracts



Image adopted from





Tensor




- between 0 and 1










axis of WMT







Eigenvalues


q L























Image Obtained From


S0166223612000720amp_image=1-s20-S0166223612000720-







tutorialhtmldtihtml






FA (Tensor Shape)









measurements




visible





coded maps




posterior)










Image Obtained From




Objectives


ndash Surgery

ndash Radiation


ndash Response

ndash Injury







69






Intraoperative MRI













and Resection






bull Methods




(n=120)




hazard ratio








bull Results



















fasciculus












Tracks





Fasciculus)

Red = Communicating


(Corpus Callosum)

Combined fMRI for


areas of the brain

(language motor)


PACS BIDMC





bull Problem





deficits



bull Solution




Radiation Therapy









Jena R et al (2005)






















Image adopted from








Image adopted from








Image adopted from










treatment planning





Objectives


ndash Response

ndash Injury





Overview


ndash Response



ndash Progression













Image adopted from






















Image adopted from






Image adopted from






sequences


























Acknowledgments





Deaconess

93
























94

















590












Imaging 13534-546 (2001) 96


















1562 2008




1470-2045 101016S1470-2045(11)70130-9

















2004 Nov 160(3)853-60












98









lesions



edema

- Ring-enhancing



28


Contrast




29





30


38 cm

homogeneous

hypointense mass

edema Ring-

enhancement

with central

area of

heterogenous

enhancement

Central area






31






bull Basics


on T2



bull GBM Findings






32

Vasogenic Edema

Cystic

necrosis



bull FLAIR Basics







bull GBM Findings


grade of tumor


(hyperintense)




33

Vasogenic Edema

Cystic

necrosis

Hyperintense

lesion

Satellite lesion






bull DWI Basics




bull GBM Findings




PACS BIDMC


PACS BIDMC

34

Increased signal

= restricted

diffusion

Satellite lesion

detected




MRI MR Spectroscopy

















36








37










Treatment Surgery








Methods


bull N = 92



survival

Results







(plt0005) VRD (plt0001)



Oct 52(4) 371-9


Treatment Surgery





Treatment Surgery






Methods


bull N = 416


bull End point











Neurosurg 95 190-198 2001


Treatment Surgery












160(3)853-60





0

10

20

30

40

50

60

70

80

90


East

West

North








bull Methods



proven GBM

ndash Assignments



ndash 287 patients




ndash 286 patients










bull Results








63(95 CI 052 to 075 Plt001)



radiotherapy alone




Objectives


ndash Introduction

ndash How it works


ndash Surgery

ndash Radiation


ndash Response

ndash Injury





Image adopted from





matter fiber tracks

(WMT) in the brain



tracts extending in

multiple directions





GBM



Displacement of




Introduction







bull Define anatomy










Basic Principles

1 Diffusion

2 Measurement







superficial organs





bull Convenient

















Tissue cellularity






Isotropy




Anisotropy





structure




Image obtained from


ullpr2005800ahtml














Myelin

Sheath

Water

molecules

Endoneurium



Diffusion is faster

parallel to white

matter tracts



Image adopted from





Tensor




- between 0 and 1










axis of WMT







Eigenvalues


q L























Image Obtained From


S0166223612000720amp_image=1-s20-S0166223612000720-







tutorialhtmldtihtml






FA (Tensor Shape)









measurements




visible





coded maps




posterior)










Image Obtained From




Objectives


ndash Surgery

ndash Radiation


ndash Response

ndash Injury







69






Intraoperative MRI













and Resection






bull Methods




(n=120)




hazard ratio








bull Results



















fasciculus












Tracks





Fasciculus)

Red = Communicating


(Corpus Callosum)

Combined fMRI for


areas of the brain

(language motor)


PACS BIDMC





bull Problem





deficits



bull Solution




Radiation Therapy









Jena R et al (2005)






















Image adopted from








Image adopted from








Image adopted from










treatment planning





Objectives


ndash Response

ndash Injury





Overview


ndash Response



ndash Progression













Image adopted from






















Image adopted from






Image adopted from






sequences


























Acknowledgments





Deaconess

93
























94

















590












Imaging 13534-546 (2001) 96


















1562 2008




1470-2045 101016S1470-2045(11)70130-9

















2004 Nov 160(3)853-60












98




29





30


38 cm

homogeneous

hypointense mass

edema Ring-

enhancement

with central

area of

heterogenous

enhancement

Central area






31






bull Basics


on T2



bull GBM Findings






32

Vasogenic Edema

Cystic

necrosis



bull FLAIR Basics







bull GBM Findings


grade of tumor


(hyperintense)




33

Vasogenic Edema

Cystic

necrosis

Hyperintense

lesion

Satellite lesion






bull DWI Basics




bull GBM Findings




PACS BIDMC


PACS BIDMC

34

Increased signal

= restricted

diffusion

Satellite lesion

detected




MRI MR Spectroscopy

















36








37










Treatment Surgery








Methods


bull N = 92



survival

Results







(plt0005) VRD (plt0001)



Oct 52(4) 371-9


Treatment Surgery





Treatment Surgery






Methods


bull N = 416


bull End point











Neurosurg 95 190-198 2001


Treatment Surgery












160(3)853-60





0

10

20

30

40

50

60

70

80

90


East

West

North








bull Methods



proven GBM

ndash Assignments



ndash 287 patients




ndash 286 patients










bull Results








63(95 CI 052 to 075 Plt001)



radiotherapy alone




Objectives


ndash Introduction

ndash How it works


ndash Surgery

ndash Radiation


ndash Response

ndash Injury





Image adopted from





matter fiber tracks

(WMT) in the brain



tracts extending in

multiple directions





GBM



Displacement of




Introduction







bull Define anatomy










Basic Principles

1 Diffusion

2 Measurement







superficial organs





bull Convenient

















Tissue cellularity






Isotropy




Anisotropy





structure




Image obtained from


ullpr2005800ahtml














Myelin

Sheath

Water

molecules

Endoneurium



Diffusion is faster

parallel to white

matter tracts



Image adopted from





Tensor




- between 0 and 1










axis of WMT







Eigenvalues


q L























Image Obtained From


S0166223612000720amp_image=1-s20-S0166223612000720-







tutorialhtmldtihtml






FA (Tensor Shape)









measurements




visible





coded maps




posterior)










Image Obtained From




Objectives


ndash Surgery

ndash Radiation


ndash Response

ndash Injury







69






Intraoperative MRI













and Resection






bull Methods




(n=120)




hazard ratio








bull Results



















fasciculus












Tracks





Fasciculus)

Red = Communicating


(Corpus Callosum)

Combined fMRI for


areas of the brain

(language motor)


PACS BIDMC





bull Problem





deficits



bull Solution




Radiation Therapy









Jena R et al (2005)






















Image adopted from








Image adopted from








Image adopted from










treatment planning





Objectives


ndash Response

ndash Injury





Overview


ndash Response



ndash Progression













Image adopted from






















Image adopted from






Image adopted from






sequences


























Acknowledgments





Deaconess

93
























94

















590












Imaging 13534-546 (2001) 96


















1562 2008




1470-2045 101016S1470-2045(11)70130-9

















2004 Nov 160(3)853-60












98



30


38 cm

homogeneous

hypointense mass

edema Ring-

enhancement

with central

area of

heterogenous

enhancement

Central area






31






bull Basics


on T2



bull GBM Findings






32

Vasogenic Edema

Cystic

necrosis



bull FLAIR Basics







bull GBM Findings


grade of tumor


(hyperintense)




33

Vasogenic Edema

Cystic

necrosis

Hyperintense

lesion

Satellite lesion






bull DWI Basics




bull GBM Findings




PACS BIDMC


PACS BIDMC

34

Increased signal

= restricted

diffusion

Satellite lesion

detected




MRI MR Spectroscopy

















36








37










Treatment Surgery








Methods


bull N = 92



survival

Results







(plt0005) VRD (plt0001)



Oct 52(4) 371-9


Treatment Surgery





Treatment Surgery






Methods


bull N = 416


bull End point











Neurosurg 95 190-198 2001


Treatment Surgery












160(3)853-60





0

10

20

30

40

50

60

70

80

90


East

West

North








bull Methods



proven GBM

ndash Assignments



ndash 287 patients




ndash 286 patients










bull Results








63(95 CI 052 to 075 Plt001)



radiotherapy alone




Objectives


ndash Introduction

ndash How it works


ndash Surgery

ndash Radiation


ndash Response

ndash Injury





Image adopted from





matter fiber tracks

(WMT) in the brain



tracts extending in

multiple directions





GBM



Displacement of




Introduction







bull Define anatomy










Basic Principles

1 Diffusion

2 Measurement







superficial organs





bull Convenient

















Tissue cellularity






Isotropy




Anisotropy





structure




Image obtained from


ullpr2005800ahtml














Myelin

Sheath

Water

molecules

Endoneurium



Diffusion is faster

parallel to white

matter tracts



Image adopted from





Tensor




- between 0 and 1










axis of WMT







Eigenvalues


q L























Image Obtained From


S0166223612000720amp_image=1-s20-S0166223612000720-







tutorialhtmldtihtml






FA (Tensor Shape)









measurements




visible





coded maps




posterior)










Image Obtained From




Objectives


ndash Surgery

ndash Radiation


ndash Response

ndash Injury







69






Intraoperative MRI













and Resection






bull Methods




(n=120)




hazard ratio








bull Results



















fasciculus












Tracks





Fasciculus)

Red = Communicating


(Corpus Callosum)

Combined fMRI for


areas of the brain

(language motor)


PACS BIDMC





bull Problem





deficits



bull Solution




Radiation Therapy









Jena R et al (2005)






















Image adopted from








Image adopted from








Image adopted from










treatment planning





Objectives


ndash Response

ndash Injury





Overview


ndash Response



ndash Progression













Image adopted from






















Image adopted from






Image adopted from






sequences


























Acknowledgments





Deaconess

93
























94

















590












Imaging 13534-546 (2001) 96


















1562 2008




1470-2045 101016S1470-2045(11)70130-9

















2004 Nov 160(3)853-60












98



31






bull Basics


on T2



bull GBM Findings






32

Vasogenic Edema

Cystic

necrosis



bull FLAIR Basics







bull GBM Findings


grade of tumor


(hyperintense)




33

Vasogenic Edema

Cystic

necrosis

Hyperintense

lesion

Satellite lesion






bull DWI Basics




bull GBM Findings




PACS BIDMC


PACS BIDMC

34

Increased signal

= restricted

diffusion

Satellite lesion

detected




MRI MR Spectroscopy

















36








37










Treatment Surgery








Methods


bull N = 92



survival

Results







(plt0005) VRD (plt0001)



Oct 52(4) 371-9


Treatment Surgery





Treatment Surgery






Methods


bull N = 416


bull End point











Neurosurg 95 190-198 2001


Treatment Surgery












160(3)853-60





0

10

20

30

40

50

60

70

80

90


East

West

North








bull Methods



proven GBM

ndash Assignments



ndash 287 patients




ndash 286 patients










bull Results








63(95 CI 052 to 075 Plt001)



radiotherapy alone




Objectives


ndash Introduction

ndash How it works


ndash Surgery

ndash Radiation


ndash Response

ndash Injury





Image adopted from





matter fiber tracks

(WMT) in the brain



tracts extending in

multiple directions





GBM



Displacement of




Introduction







bull Define anatomy










Basic Principles

1 Diffusion

2 Measurement







superficial organs





bull Convenient

















Tissue cellularity






Isotropy




Anisotropy





structure




Image obtained from


ullpr2005800ahtml














Myelin

Sheath

Water

molecules

Endoneurium



Diffusion is faster

parallel to white

matter tracts



Image adopted from





Tensor




- between 0 and 1










axis of WMT







Eigenvalues


q L























Image Obtained From


S0166223612000720amp_image=1-s20-S0166223612000720-







tutorialhtmldtihtml






FA (Tensor Shape)









measurements




visible





coded maps




posterior)










Image Obtained From




Objectives


ndash Surgery

ndash Radiation


ndash Response

ndash Injury







69






Intraoperative MRI













and Resection






bull Methods




(n=120)




hazard ratio








bull Results



















fasciculus












Tracks





Fasciculus)

Red = Communicating


(Corpus Callosum)

Combined fMRI for


areas of the brain

(language motor)


PACS BIDMC





bull Problem





deficits



bull Solution




Radiation Therapy









Jena R et al (2005)






















Image adopted from








Image adopted from








Image adopted from










treatment planning





Objectives


ndash Response

ndash Injury





Overview


ndash Response



ndash Progression













Image adopted from






















Image adopted from






Image adopted from






sequences


























Acknowledgments





Deaconess

93
























94

















590












Imaging 13534-546 (2001) 96


















1562 2008




1470-2045 101016S1470-2045(11)70130-9

















2004 Nov 160(3)853-60












98



bull Basics


on T2



bull GBM Findings






32

Vasogenic Edema

Cystic

necrosis



bull FLAIR Basics







bull GBM Findings


grade of tumor


(hyperintense)




33

Vasogenic Edema

Cystic

necrosis

Hyperintense

lesion

Satellite lesion






bull DWI Basics




bull GBM Findings




PACS BIDMC


PACS BIDMC

34

Increased signal

= restricted

diffusion

Satellite lesion

detected




MRI MR Spectroscopy

















36








37










Treatment Surgery








Methods


bull N = 92



survival

Results







(plt0005) VRD (plt0001)



Oct 52(4) 371-9


Treatment Surgery





Treatment Surgery






Methods


bull N = 416


bull End point











Neurosurg 95 190-198 2001


Treatment Surgery












160(3)853-60





0

10

20

30

40

50

60

70

80

90


East

West

North








bull Methods



proven GBM

ndash Assignments



ndash 287 patients




ndash 286 patients










bull Results








63(95 CI 052 to 075 Plt001)



radiotherapy alone




Objectives


ndash Introduction

ndash How it works


ndash Surgery

ndash Radiation


ndash Response

ndash Injury





Image adopted from





matter fiber tracks

(WMT) in the brain



tracts extending in

multiple directions





GBM



Displacement of




Introduction







bull Define anatomy










Basic Principles

1 Diffusion

2 Measurement







superficial organs





bull Convenient

















Tissue cellularity






Isotropy




Anisotropy





structure




Image obtained from


ullpr2005800ahtml














Myelin

Sheath

Water

molecules

Endoneurium



Diffusion is faster

parallel to white

matter tracts



Image adopted from





Tensor




- between 0 and 1










axis of WMT







Eigenvalues


q L























Image Obtained From


S0166223612000720amp_image=1-s20-S0166223612000720-







tutorialhtmldtihtml






FA (Tensor Shape)









measurements




visible





coded maps




posterior)










Image Obtained From




Objectives


ndash Surgery

ndash Radiation


ndash Response

ndash Injury







69






Intraoperative MRI













and Resection






bull Methods




(n=120)




hazard ratio








bull Results



















fasciculus












Tracks





Fasciculus)

Red = Communicating


(Corpus Callosum)

Combined fMRI for


areas of the brain

(language motor)


PACS BIDMC





bull Problem





deficits



bull Solution




Radiation Therapy









Jena R et al (2005)






















Image adopted from








Image adopted from








Image adopted from










treatment planning





Objectives


ndash Response

ndash Injury





Overview


ndash Response



ndash Progression













Image adopted from






















Image adopted from






Image adopted from






sequences


























Acknowledgments





Deaconess

93
























94

















590












Imaging 13534-546 (2001) 96


















1562 2008




1470-2045 101016S1470-2045(11)70130-9

















2004 Nov 160(3)853-60












98



bull FLAIR Basics







bull GBM Findings


grade of tumor


(hyperintense)




33

Vasogenic Edema

Cystic

necrosis

Hyperintense

lesion

Satellite lesion






bull DWI Basics




bull GBM Findings




PACS BIDMC


PACS BIDMC

34

Increased signal

= restricted

diffusion

Satellite lesion

detected




MRI MR Spectroscopy

















36








37










Treatment Surgery








Methods


bull N = 92



survival

Results







(plt0005) VRD (plt0001)



Oct 52(4) 371-9


Treatment Surgery





Treatment Surgery






Methods


bull N = 416


bull End point











Neurosurg 95 190-198 2001


Treatment Surgery












160(3)853-60





0

10

20

30

40

50

60

70

80

90


East

West

North








bull Methods



proven GBM

ndash Assignments



ndash 287 patients




ndash 286 patients










bull Results








63(95 CI 052 to 075 Plt001)



radiotherapy alone




Objectives


ndash Introduction

ndash How it works


ndash Surgery

ndash Radiation


ndash Response

ndash Injury





Image adopted from





matter fiber tracks

(WMT) in the brain



tracts extending in

multiple directions





GBM



Displacement of




Introduction







bull Define anatomy










Basic Principles

1 Diffusion

2 Measurement







superficial organs





bull Convenient

















Tissue cellularity






Isotropy




Anisotropy





structure




Image obtained from


ullpr2005800ahtml














Myelin

Sheath

Water

molecules

Endoneurium



Diffusion is faster

parallel to white

matter tracts



Image adopted from





Tensor




- between 0 and 1










axis of WMT







Eigenvalues


q L























Image Obtained From


S0166223612000720amp_image=1-s20-S0166223612000720-







tutorialhtmldtihtml






FA (Tensor Shape)









measurements




visible





coded maps




posterior)










Image Obtained From




Objectives


ndash Surgery

ndash Radiation


ndash Response

ndash Injury







69






Intraoperative MRI













and Resection






bull Methods




(n=120)




hazard ratio








bull Results



















fasciculus












Tracks





Fasciculus)

Red = Communicating


(Corpus Callosum)

Combined fMRI for


areas of the brain

(language motor)


PACS BIDMC





bull Problem





deficits



bull Solution




Radiation Therapy









Jena R et al (2005)






















Image adopted from








Image adopted from








Image adopted from










treatment planning





Objectives


ndash Response

ndash Injury





Overview


ndash Response



ndash Progression













Image adopted from






















Image adopted from






Image adopted from






sequences


























Acknowledgments





Deaconess

93
























94

















590












Imaging 13534-546 (2001) 96


















1562 2008




1470-2045 101016S1470-2045(11)70130-9

















2004 Nov 160(3)853-60












98





bull DWI Basics




bull GBM Findings




PACS BIDMC


PACS BIDMC

34

Increased signal

= restricted

diffusion

Satellite lesion

detected




MRI MR Spectroscopy

















36








37










Treatment Surgery








Methods


bull N = 92



survival

Results







(plt0005) VRD (plt0001)



Oct 52(4) 371-9


Treatment Surgery





Treatment Surgery






Methods


bull N = 416


bull End point











Neurosurg 95 190-198 2001


Treatment Surgery












160(3)853-60





0

10

20

30

40

50

60

70

80

90


East

West

North








bull Methods



proven GBM

ndash Assignments



ndash 287 patients




ndash 286 patients










bull Results








63(95 CI 052 to 075 Plt001)



radiotherapy alone




Objectives


ndash Introduction

ndash How it works


ndash Surgery

ndash Radiation


ndash Response

ndash Injury





Image adopted from





matter fiber tracks

(WMT) in the brain



tracts extending in

multiple directions





GBM



Displacement of




Introduction







bull Define anatomy










Basic Principles

1 Diffusion

2 Measurement







superficial organs





bull Convenient

















Tissue cellularity






Isotropy




Anisotropy





structure




Image obtained from


ullpr2005800ahtml














Myelin

Sheath

Water

molecules

Endoneurium



Diffusion is faster

parallel to white

matter tracts



Image adopted from





Tensor




- between 0 and 1










axis of WMT







Eigenvalues


q L























Image Obtained From


S0166223612000720amp_image=1-s20-S0166223612000720-







tutorialhtmldtihtml






FA (Tensor Shape)









measurements




visible





coded maps




posterior)










Image Obtained From




Objectives


ndash Surgery

ndash Radiation


ndash Response

ndash Injury







69






Intraoperative MRI













and Resection






bull Methods




(n=120)




hazard ratio








bull Results



















fasciculus












Tracks





Fasciculus)

Red = Communicating


(Corpus Callosum)

Combined fMRI for


areas of the brain

(language motor)


PACS BIDMC





bull Problem





deficits



bull Solution




Radiation Therapy









Jena R et al (2005)






















Image adopted from








Image adopted from








Image adopted from










treatment planning





Objectives


ndash Response

ndash Injury





Overview


ndash Response



ndash Progression













Image adopted from






















Image adopted from






Image adopted from






sequences


























Acknowledgments





Deaconess

93
























94

















590












Imaging 13534-546 (2001) 96


















1562 2008




1470-2045 101016S1470-2045(11)70130-9

















2004 Nov 160(3)853-60












98




MRI MR Spectroscopy

















36








37










Treatment Surgery








Methods


bull N = 92



survival

Results







(plt0005) VRD (plt0001)



Oct 52(4) 371-9


Treatment Surgery





Treatment Surgery






Methods


bull N = 416


bull End point











Neurosurg 95 190-198 2001


Treatment Surgery












160(3)853-60





0

10

20

30

40

50

60

70

80

90


East

West

North








bull Methods



proven GBM

ndash Assignments



ndash 287 patients




ndash 286 patients










bull Results








63(95 CI 052 to 075 Plt001)



radiotherapy alone




Objectives


ndash Introduction

ndash How it works


ndash Surgery

ndash Radiation


ndash Response

ndash Injury





Image adopted from





matter fiber tracks

(WMT) in the brain



tracts extending in

multiple directions





GBM



Displacement of




Introduction







bull Define anatomy










Basic Principles

1 Diffusion

2 Measurement







superficial organs





bull Convenient

















Tissue cellularity






Isotropy




Anisotropy





structure




Image obtained from


ullpr2005800ahtml














Myelin

Sheath

Water

molecules

Endoneurium



Diffusion is faster

parallel to white

matter tracts



Image adopted from





Tensor




- between 0 and 1










axis of WMT







Eigenvalues


q L























Image Obtained From


S0166223612000720amp_image=1-s20-S0166223612000720-







tutorialhtmldtihtml






FA (Tensor Shape)









measurements




visible





coded maps




posterior)










Image Obtained From




Objectives


ndash Surgery

ndash Radiation


ndash Response

ndash Injury







69






Intraoperative MRI













and Resection






bull Methods




(n=120)




hazard ratio








bull Results



















fasciculus












Tracks





Fasciculus)

Red = Communicating


(Corpus Callosum)

Combined fMRI for


areas of the brain

(language motor)


PACS BIDMC





bull Problem





deficits



bull Solution




Radiation Therapy









Jena R et al (2005)






















Image adopted from








Image adopted from








Image adopted from










treatment planning





Objectives


ndash Response

ndash Injury





Overview


ndash Response



ndash Progression













Image adopted from






















Image adopted from






Image adopted from






sequences


























Acknowledgments





Deaconess

93
























94

















590












Imaging 13534-546 (2001) 96


















1562 2008




1470-2045 101016S1470-2045(11)70130-9

















2004 Nov 160(3)853-60












98






36








37










Treatment Surgery








Methods


bull N = 92



survival

Results







(plt0005) VRD (plt0001)



Oct 52(4) 371-9


Treatment Surgery





Treatment Surgery






Methods


bull N = 416


bull End point











Neurosurg 95 190-198 2001


Treatment Surgery












160(3)853-60





0

10

20

30

40

50

60

70

80

90


East

West

North








bull Methods



proven GBM

ndash Assignments



ndash 287 patients




ndash 286 patients










bull Results








63(95 CI 052 to 075 Plt001)



radiotherapy alone




Objectives


ndash Introduction

ndash How it works


ndash Surgery

ndash Radiation


ndash Response

ndash Injury





Image adopted from





matter fiber tracks

(WMT) in the brain



tracts extending in

multiple directions





GBM



Displacement of




Introduction







bull Define anatomy










Basic Principles

1 Diffusion

2 Measurement







superficial organs





bull Convenient

















Tissue cellularity






Isotropy




Anisotropy





structure




Image obtained from


ullpr2005800ahtml














Myelin

Sheath

Water

molecules

Endoneurium



Diffusion is faster

parallel to white

matter tracts



Image adopted from





Tensor




- between 0 and 1










axis of WMT







Eigenvalues


q L























Image Obtained From


S0166223612000720amp_image=1-s20-S0166223612000720-







tutorialhtmldtihtml






FA (Tensor Shape)









measurements




visible





coded maps




posterior)










Image Obtained From




Objectives


ndash Surgery

ndash Radiation


ndash Response

ndash Injury







69






Intraoperative MRI













and Resection






bull Methods




(n=120)




hazard ratio








bull Results



















fasciculus












Tracks





Fasciculus)

Red = Communicating


(Corpus Callosum)

Combined fMRI for


areas of the brain

(language motor)


PACS BIDMC





bull Problem





deficits



bull Solution




Radiation Therapy









Jena R et al (2005)






















Image adopted from








Image adopted from








Image adopted from










treatment planning





Objectives


ndash Response

ndash Injury





Overview


ndash Response



ndash Progression













Image adopted from






















Image adopted from






Image adopted from






sequences


























Acknowledgments





Deaconess

93
























94

















590












Imaging 13534-546 (2001) 96


















1562 2008




1470-2045 101016S1470-2045(11)70130-9

















2004 Nov 160(3)853-60












98







37










Treatment Surgery








Methods


bull N = 92



survival

Results







(plt0005) VRD (plt0001)



Oct 52(4) 371-9


Treatment Surgery





Treatment Surgery






Methods


bull N = 416


bull End point











Neurosurg 95 190-198 2001


Treatment Surgery












160(3)853-60





0

10

20

30

40

50

60

70

80

90


East

West

North








bull Methods



proven GBM

ndash Assignments



ndash 287 patients




ndash 286 patients










bull Results








63(95 CI 052 to 075 Plt001)



radiotherapy alone




Objectives


ndash Introduction

ndash How it works


ndash Surgery

ndash Radiation


ndash Response

ndash Injury





Image adopted from





matter fiber tracks

(WMT) in the brain



tracts extending in

multiple directions





GBM



Displacement of




Introduction







bull Define anatomy










Basic Principles

1 Diffusion

2 Measurement







superficial organs





bull Convenient

















Tissue cellularity






Isotropy




Anisotropy





structure




Image obtained from


ullpr2005800ahtml














Myelin

Sheath

Water

molecules

Endoneurium



Diffusion is faster

parallel to white

matter tracts



Image adopted from





Tensor




- between 0 and 1










axis of WMT







Eigenvalues


q L























Image Obtained From


S0166223612000720amp_image=1-s20-S0166223612000720-







tutorialhtmldtihtml






FA (Tensor Shape)









measurements




visible





coded maps




posterior)










Image Obtained From




Objectives


ndash Surgery

ndash Radiation


ndash Response

ndash Injury







69






Intraoperative MRI













and Resection






bull Methods




(n=120)




hazard ratio








bull Results



















fasciculus












Tracks





Fasciculus)

Red = Communicating


(Corpus Callosum)

Combined fMRI for


areas of the brain

(language motor)


PACS BIDMC





bull Problem





deficits



bull Solution




Radiation Therapy









Jena R et al (2005)






















Image adopted from








Image adopted from








Image adopted from










treatment planning





Objectives


ndash Response

ndash Injury





Overview


ndash Response



ndash Progression













Image adopted from






















Image adopted from






Image adopted from






sequences


























Acknowledgments





Deaconess

93
























94

















590












Imaging 13534-546 (2001) 96


















1562 2008




1470-2045 101016S1470-2045(11)70130-9

















2004 Nov 160(3)853-60












98









Treatment Surgery








Methods


bull N = 92



survival

Results







(plt0005) VRD (plt0001)



Oct 52(4) 371-9


Treatment Surgery





Treatment Surgery






Methods


bull N = 416


bull End point











Neurosurg 95 190-198 2001


Treatment Surgery












160(3)853-60





0

10

20

30

40

50

60

70

80

90


East

West

North








bull Methods



proven GBM

ndash Assignments



ndash 287 patients




ndash 286 patients










bull Results








63(95 CI 052 to 075 Plt001)



radiotherapy alone




Objectives


ndash Introduction

ndash How it works


ndash Surgery

ndash Radiation


ndash Response

ndash Injury





Image adopted from





matter fiber tracks

(WMT) in the brain



tracts extending in

multiple directions





GBM



Displacement of




Introduction







bull Define anatomy










Basic Principles

1 Diffusion

2 Measurement







superficial organs





bull Convenient

















Tissue cellularity






Isotropy




Anisotropy





structure




Image obtained from


ullpr2005800ahtml














Myelin

Sheath

Water

molecules

Endoneurium



Diffusion is faster

parallel to white

matter tracts



Image adopted from





Tensor




- between 0 and 1










axis of WMT







Eigenvalues


q L























Image Obtained From


S0166223612000720amp_image=1-s20-S0166223612000720-







tutorialhtmldtihtml






FA (Tensor Shape)









measurements




visible





coded maps




posterior)










Image Obtained From




Objectives


ndash Surgery

ndash Radiation


ndash Response

ndash Injury







69






Intraoperative MRI













and Resection






bull Methods




(n=120)




hazard ratio








bull Results



















fasciculus












Tracks





Fasciculus)

Red = Communicating


(Corpus Callosum)

Combined fMRI for


areas of the brain

(language motor)


PACS BIDMC





bull Problem





deficits



bull Solution




Radiation Therapy









Jena R et al (2005)






















Image adopted from








Image adopted from








Image adopted from










treatment planning





Objectives


ndash Response

ndash Injury





Overview


ndash Response



ndash Progression













Image adopted from






















Image adopted from






Image adopted from






sequences


























Acknowledgments





Deaconess

93
























94

















590












Imaging 13534-546 (2001) 96


















1562 2008




1470-2045 101016S1470-2045(11)70130-9

















2004 Nov 160(3)853-60












98




Treatment Surgery








Methods


bull N = 92



survival

Results







(plt0005) VRD (plt0001)



Oct 52(4) 371-9


Treatment Surgery





Treatment Surgery






Methods


bull N = 416


bull End point











Neurosurg 95 190-198 2001


Treatment Surgery












160(3)853-60





0

10

20

30

40

50

60

70

80

90


East

West

North








bull Methods



proven GBM

ndash Assignments



ndash 287 patients




ndash 286 patients










bull Results








63(95 CI 052 to 075 Plt001)



radiotherapy alone




Objectives


ndash Introduction

ndash How it works


ndash Surgery

ndash Radiation


ndash Response

ndash Injury





Image adopted from





matter fiber tracks

(WMT) in the brain



tracts extending in

multiple directions





GBM



Displacement of




Introduction







bull Define anatomy










Basic Principles

1 Diffusion

2 Measurement







superficial organs





bull Convenient

















Tissue cellularity






Isotropy




Anisotropy





structure




Image obtained from


ullpr2005800ahtml














Myelin

Sheath

Water

molecules

Endoneurium



Diffusion is faster

parallel to white

matter tracts



Image adopted from





Tensor




- between 0 and 1










axis of WMT







Eigenvalues


q L























Image Obtained From


S0166223612000720amp_image=1-s20-S0166223612000720-







tutorialhtmldtihtml






FA (Tensor Shape)









measurements




visible





coded maps




posterior)










Image Obtained From




Objectives


ndash Surgery

ndash Radiation


ndash Response

ndash Injury







69






Intraoperative MRI













and Resection






bull Methods




(n=120)




hazard ratio








bull Results



















fasciculus












Tracks





Fasciculus)

Red = Communicating


(Corpus Callosum)

Combined fMRI for


areas of the brain

(language motor)


PACS BIDMC





bull Problem





deficits



bull Solution




Radiation Therapy









Jena R et al (2005)






















Image adopted from








Image adopted from








Image adopted from










treatment planning





Objectives


ndash Response

ndash Injury





Overview


ndash Response



ndash Progression













Image adopted from






















Image adopted from






Image adopted from






sequences


























Acknowledgments





Deaconess

93
























94

















590












Imaging 13534-546 (2001) 96


















1562 2008




1470-2045 101016S1470-2045(11)70130-9

















2004 Nov 160(3)853-60












98





Methods


bull N = 92



survival

Results







(plt0005) VRD (plt0001)



Oct 52(4) 371-9


Treatment Surgery





Treatment Surgery






Methods


bull N = 416


bull End point











Neurosurg 95 190-198 2001


Treatment Surgery












160(3)853-60





0

10

20

30

40

50

60

70

80

90


East

West

North








bull Methods



proven GBM

ndash Assignments



ndash 287 patients




ndash 286 patients










bull Results








63(95 CI 052 to 075 Plt001)



radiotherapy alone




Objectives


ndash Introduction

ndash How it works


ndash Surgery

ndash Radiation


ndash Response

ndash Injury





Image adopted from





matter fiber tracks

(WMT) in the brain



tracts extending in

multiple directions





GBM



Displacement of




Introduction







bull Define anatomy










Basic Principles

1 Diffusion

2 Measurement







superficial organs





bull Convenient

















Tissue cellularity






Isotropy




Anisotropy





structure




Image obtained from


ullpr2005800ahtml














Myelin

Sheath

Water

molecules

Endoneurium



Diffusion is faster

parallel to white

matter tracts



Image adopted from





Tensor




- between 0 and 1










axis of WMT







Eigenvalues


q L























Image Obtained From


S0166223612000720amp_image=1-s20-S0166223612000720-







tutorialhtmldtihtml






FA (Tensor Shape)









measurements




visible





coded maps




posterior)










Image Obtained From




Objectives


ndash Surgery

ndash Radiation


ndash Response

ndash Injury







69






Intraoperative MRI













and Resection






bull Methods




(n=120)




hazard ratio








bull Results



















fasciculus












Tracks





Fasciculus)

Red = Communicating


(Corpus Callosum)

Combined fMRI for


areas of the brain

(language motor)


PACS BIDMC





bull Problem





deficits



bull Solution




Radiation Therapy









Jena R et al (2005)






















Image adopted from








Image adopted from








Image adopted from










treatment planning





Objectives


ndash Response

ndash Injury





Overview


ndash Response



ndash Progression













Image adopted from






















Image adopted from






Image adopted from






sequences


























Acknowledgments





Deaconess

93
























94

















590












Imaging 13534-546 (2001) 96


















1562 2008




1470-2045 101016S1470-2045(11)70130-9

















2004 Nov 160(3)853-60












98





Treatment Surgery






Methods


bull N = 416


bull End point











Neurosurg 95 190-198 2001


Treatment Surgery












160(3)853-60





0

10

20

30

40

50

60

70

80

90


East

West

North








bull Methods



proven GBM

ndash Assignments



ndash 287 patients




ndash 286 patients










bull Results








63(95 CI 052 to 075 Plt001)



radiotherapy alone




Objectives


ndash Introduction

ndash How it works


ndash Surgery

ndash Radiation


ndash Response

ndash Injury





Image adopted from





matter fiber tracks

(WMT) in the brain



tracts extending in

multiple directions





GBM



Displacement of




Introduction







bull Define anatomy










Basic Principles

1 Diffusion

2 Measurement







superficial organs





bull Convenient

















Tissue cellularity






Isotropy




Anisotropy





structure




Image obtained from


ullpr2005800ahtml














Myelin

Sheath

Water

molecules

Endoneurium



Diffusion is faster

parallel to white

matter tracts



Image adopted from





Tensor




- between 0 and 1










axis of WMT







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Image Obtained From


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tutorialhtmldtihtml






FA (Tensor Shape)









measurements




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coded maps




posterior)










Image Obtained From




Objectives


ndash Surgery

ndash Radiation


ndash Response

ndash Injury







69






Intraoperative MRI













and Resection






bull Methods




(n=120)




hazard ratio








bull Results



















fasciculus












Tracks





Fasciculus)

Red = Communicating


(Corpus Callosum)

Combined fMRI for


areas of the brain

(language motor)


PACS BIDMC





bull Problem





deficits



bull Solution




Radiation Therapy









Jena R et al (2005)






















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treatment planning





Objectives


ndash Response

ndash Injury





Overview


ndash Response



ndash Progression













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Image adopted from






sequences


























Acknowledgments





Deaconess

93
























94

















590












Imaging 13534-546 (2001) 96


















1562 2008




1470-2045 101016S1470-2045(11)70130-9

















2004 Nov 160(3)853-60












98






Methods


bull N = 416


bull End point











Neurosurg 95 190-198 2001


Treatment Surgery












160(3)853-60





0

10

20

30

40

50

60

70

80

90


East

West

North








bull Methods



proven GBM

ndash Assignments



ndash 287 patients




ndash 286 patients










bull Results








63(95 CI 052 to 075 Plt001)



radiotherapy alone




Objectives


ndash Introduction

ndash How it works


ndash Surgery

ndash Radiation


ndash Response

ndash Injury





Image adopted from





matter fiber tracks

(WMT) in the brain



tracts extending in

multiple directions





GBM



Displacement of




Introduction







bull Define anatomy










Basic Principles

1 Diffusion

2 Measurement







superficial organs





bull Convenient

















Tissue cellularity






Isotropy




Anisotropy





structure




Image obtained from


ullpr2005800ahtml














Myelin

Sheath

Water

molecules

Endoneurium



Diffusion is faster

parallel to white

matter tracts



Image adopted from





Tensor




- between 0 and 1










axis of WMT







Eigenvalues


q L























Image Obtained From


S0166223612000720amp_image=1-s20-S0166223612000720-







tutorialhtmldtihtml






FA (Tensor Shape)









measurements




visible





coded maps




posterior)










Image Obtained From




Objectives


ndash Surgery

ndash Radiation


ndash Response

ndash Injury







69






Intraoperative MRI













and Resection






bull Methods




(n=120)




hazard ratio








bull Results



















fasciculus












Tracks





Fasciculus)

Red = Communicating


(Corpus Callosum)

Combined fMRI for


areas of the brain

(language motor)


PACS BIDMC





bull Problem





deficits



bull Solution




Radiation Therapy









Jena R et al (2005)






















Image adopted from








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Image adopted from










treatment planning





Objectives


ndash Response

ndash Injury





Overview


ndash Response



ndash Progression













Image adopted from






















Image adopted from






Image adopted from






sequences


























Acknowledgments





Deaconess

93
























94

















590












Imaging 13534-546 (2001) 96


















1562 2008




1470-2045 101016S1470-2045(11)70130-9

















2004 Nov 160(3)853-60












98












160(3)853-60





0

10

20

30

40

50

60

70

80

90


East

West

North








bull Methods



proven GBM

ndash Assignments



ndash 287 patients




ndash 286 patients










bull Results








63(95 CI 052 to 075 Plt001)



radiotherapy alone




Objectives


ndash Introduction

ndash How it works


ndash Surgery

ndash Radiation


ndash Response

ndash Injury





Image adopted from





matter fiber tracks

(WMT) in the brain



tracts extending in

multiple directions





GBM



Displacement of




Introduction







bull Define anatomy










Basic Principles

1 Diffusion

2 Measurement







superficial organs





bull Convenient

















Tissue cellularity






Isotropy




Anisotropy





structure




Image obtained from


ullpr2005800ahtml














Myelin

Sheath

Water

molecules

Endoneurium



Diffusion is faster

parallel to white

matter tracts



Image adopted from





Tensor




- between 0 and 1










axis of WMT







Eigenvalues


q L























Image Obtained From


S0166223612000720amp_image=1-s20-S0166223612000720-







tutorialhtmldtihtml






FA (Tensor Shape)









measurements




visible





coded maps




posterior)










Image Obtained From




Objectives


ndash Surgery

ndash Radiation


ndash Response

ndash Injury







69






Intraoperative MRI













and Resection






bull Methods




(n=120)




hazard ratio








bull Results



















fasciculus












Tracks





Fasciculus)

Red = Communicating


(Corpus Callosum)

Combined fMRI for


areas of the brain

(language motor)


PACS BIDMC





bull Problem





deficits



bull Solution




Radiation Therapy









Jena R et al (2005)






















Image adopted from








Image adopted from








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treatment planning





Objectives


ndash Response

ndash Injury





Overview


ndash Response



ndash Progression













Image adopted from






















Image adopted from






Image adopted from






sequences


























Acknowledgments





Deaconess

93
























94

















590












Imaging 13534-546 (2001) 96


















1562 2008




1470-2045 101016S1470-2045(11)70130-9

















2004 Nov 160(3)853-60












98





0

10

20

30

40

50

60

70

80

90


East

West

North








bull Methods



proven GBM

ndash Assignments



ndash 287 patients




ndash 286 patients










bull Results








63(95 CI 052 to 075 Plt001)



radiotherapy alone




Objectives


ndash Introduction

ndash How it works


ndash Surgery

ndash Radiation


ndash Response

ndash Injury





Image adopted from





matter fiber tracks

(WMT) in the brain



tracts extending in

multiple directions





GBM



Displacement of




Introduction







bull Define anatomy










Basic Principles

1 Diffusion

2 Measurement







superficial organs





bull Convenient

















Tissue cellularity






Isotropy




Anisotropy





structure




Image obtained from


ullpr2005800ahtml














Myelin

Sheath

Water

molecules

Endoneurium



Diffusion is faster

parallel to white

matter tracts



Image adopted from





Tensor




- between 0 and 1










axis of WMT







Eigenvalues


q L























Image Obtained From


S0166223612000720amp_image=1-s20-S0166223612000720-







tutorialhtmldtihtml






FA (Tensor Shape)









measurements




visible





coded maps




posterior)










Image Obtained From




Objectives


ndash Surgery

ndash Radiation


ndash Response

ndash Injury







69






Intraoperative MRI













and Resection






bull Methods




(n=120)




hazard ratio








bull Results



















fasciculus












Tracks





Fasciculus)

Red = Communicating


(Corpus Callosum)

Combined fMRI for


areas of the brain

(language motor)


PACS BIDMC





bull Problem





deficits



bull Solution




Radiation Therapy









Jena R et al (2005)






















Image adopted from








Image adopted from








Image adopted from










treatment planning





Objectives


ndash Response

ndash Injury





Overview


ndash Response



ndash Progression













Image adopted from






















Image adopted from






Image adopted from






sequences


























Acknowledgments





Deaconess

93
























94

















590












Imaging 13534-546 (2001) 96


















1562 2008




1470-2045 101016S1470-2045(11)70130-9

















2004 Nov 160(3)853-60












98








bull Methods



proven GBM

ndash Assignments



ndash 287 patients




ndash 286 patients










bull Results








63(95 CI 052 to 075 Plt001)



radiotherapy alone




Objectives


ndash Introduction

ndash How it works


ndash Surgery

ndash Radiation


ndash Response

ndash Injury





Image adopted from





matter fiber tracks

(WMT) in the brain



tracts extending in

multiple directions





GBM



Displacement of




Introduction







bull Define anatomy










Basic Principles

1 Diffusion

2 Measurement







superficial organs





bull Convenient

















Tissue cellularity






Isotropy




Anisotropy





structure




Image obtained from


ullpr2005800ahtml














Myelin

Sheath

Water

molecules

Endoneurium



Diffusion is faster

parallel to white

matter tracts



Image adopted from





Tensor




- between 0 and 1










axis of WMT







Eigenvalues


q L























Image Obtained From


S0166223612000720amp_image=1-s20-S0166223612000720-







tutorialhtmldtihtml






FA (Tensor Shape)









measurements




visible





coded maps




posterior)










Image Obtained From




Objectives


ndash Surgery

ndash Radiation


ndash Response

ndash Injury







69






Intraoperative MRI













and Resection






bull Methods




(n=120)




hazard ratio








bull Results



















fasciculus












Tracks





Fasciculus)

Red = Communicating


(Corpus Callosum)

Combined fMRI for


areas of the brain

(language motor)


PACS BIDMC





bull Problem





deficits



bull Solution




Radiation Therapy









Jena R et al (2005)






















Image adopted from








Image adopted from








Image adopted from










treatment planning





Objectives


ndash Response

ndash Injury





Overview


ndash Response



ndash Progression













Image adopted from






















Image adopted from






Image adopted from






sequences


























Acknowledgments





Deaconess

93
























94

















590












Imaging 13534-546 (2001) 96


















1562 2008




1470-2045 101016S1470-2045(11)70130-9

















2004 Nov 160(3)853-60












98








bull Results








63(95 CI 052 to 075 Plt001)



radiotherapy alone




Objectives


ndash Introduction

ndash How it works


ndash Surgery

ndash Radiation


ndash Response

ndash Injury





Image adopted from





matter fiber tracks

(WMT) in the brain



tracts extending in

multiple directions





GBM



Displacement of




Introduction







bull Define anatomy










Basic Principles

1 Diffusion

2 Measurement







superficial organs





bull Convenient

















Tissue cellularity






Isotropy




Anisotropy





structure




Image obtained from


ullpr2005800ahtml














Myelin

Sheath

Water

molecules

Endoneurium



Diffusion is faster

parallel to white

matter tracts



Image adopted from





Tensor




- between 0 and 1










axis of WMT







Eigenvalues


q L























Image Obtained From


S0166223612000720amp_image=1-s20-S0166223612000720-







tutorialhtmldtihtml






FA (Tensor Shape)









measurements




visible





coded maps




posterior)










Image Obtained From




Objectives


ndash Surgery

ndash Radiation


ndash Response

ndash Injury







69






Intraoperative MRI













and Resection






bull Methods




(n=120)




hazard ratio








bull Results



















fasciculus












Tracks





Fasciculus)

Red = Communicating


(Corpus Callosum)

Combined fMRI for


areas of the brain

(language motor)


PACS BIDMC





bull Problem





deficits



bull Solution




Radiation Therapy









Jena R et al (2005)






















Image adopted from








Image adopted from








Image adopted from










treatment planning





Objectives


ndash Response

ndash Injury





Overview


ndash Response



ndash Progression













Image adopted from






















Image adopted from






Image adopted from






sequences


























Acknowledgments





Deaconess

93
























94

















590












Imaging 13534-546 (2001) 96


















1562 2008




1470-2045 101016S1470-2045(11)70130-9

















2004 Nov 160(3)853-60












98



Objectives


ndash Introduction

ndash How it works


ndash Surgery

ndash Radiation


ndash Response

ndash Injury





Image adopted from





matter fiber tracks

(WMT) in the brain



tracts extending in

multiple directions





GBM



Displacement of




Introduction







bull Define anatomy










Basic Principles

1 Diffusion

2 Measurement







superficial organs





bull Convenient

















Tissue cellularity






Isotropy




Anisotropy





structure




Image obtained from


ullpr2005800ahtml














Myelin

Sheath

Water

molecules

Endoneurium



Diffusion is faster

parallel to white

matter tracts



Image adopted from





Tensor




- between 0 and 1










axis of WMT







Eigenvalues


q L























Image Obtained From


S0166223612000720amp_image=1-s20-S0166223612000720-







tutorialhtmldtihtml






FA (Tensor Shape)









measurements




visible





coded maps




posterior)










Image Obtained From




Objectives


ndash Surgery

ndash Radiation


ndash Response

ndash Injury







69






Intraoperative MRI













and Resection






bull Methods




(n=120)




hazard ratio








bull Results



















fasciculus












Tracks





Fasciculus)

Red = Communicating


(Corpus Callosum)

Combined fMRI for


areas of the brain

(language motor)


PACS BIDMC





bull Problem





deficits



bull Solution




Radiation Therapy









Jena R et al (2005)






















Image adopted from








Image adopted from








Image adopted from










treatment planning





Objectives


ndash Response

ndash Injury





Overview


ndash Response



ndash Progression













Image adopted from






















Image adopted from






Image adopted from






sequences


























Acknowledgments





Deaconess

93
























94

















590












Imaging 13534-546 (2001) 96


















1562 2008




1470-2045 101016S1470-2045(11)70130-9

















2004 Nov 160(3)853-60












98




Image adopted from





matter fiber tracks

(WMT) in the brain



tracts extending in

multiple directions





GBM



Displacement of




Introduction







bull Define anatomy










Basic Principles

1 Diffusion

2 Measurement







superficial organs





bull Convenient

















Tissue cellularity






Isotropy




Anisotropy





structure




Image obtained from


ullpr2005800ahtml














Myelin

Sheath

Water

molecules

Endoneurium



Diffusion is faster

parallel to white

matter tracts



Image adopted from





Tensor




- between 0 and 1










axis of WMT







Eigenvalues


q L























Image Obtained From


S0166223612000720amp_image=1-s20-S0166223612000720-







tutorialhtmldtihtml






FA (Tensor Shape)









measurements




visible





coded maps




posterior)










Image Obtained From




Objectives


ndash Surgery

ndash Radiation


ndash Response

ndash Injury







69






Intraoperative MRI













and Resection






bull Methods




(n=120)




hazard ratio








bull Results



















fasciculus












Tracks





Fasciculus)

Red = Communicating


(Corpus Callosum)

Combined fMRI for


areas of the brain

(language motor)


PACS BIDMC





bull Problem





deficits



bull Solution




Radiation Therapy









Jena R et al (2005)






















Image adopted from








Image adopted from








Image adopted from










treatment planning





Objectives


ndash Response

ndash Injury





Overview


ndash Response



ndash Progression













Image adopted from






















Image adopted from






Image adopted from






sequences


























Acknowledgments





Deaconess

93
























94

















590












Imaging 13534-546 (2001) 96


















1562 2008




1470-2045 101016S1470-2045(11)70130-9

















2004 Nov 160(3)853-60












98




matter fiber tracks

(WMT) in the brain



tracts extending in

multiple directions





GBM



Displacement of




Introduction







bull Define anatomy










Basic Principles

1 Diffusion

2 Measurement







superficial organs





bull Convenient

















Tissue cellularity






Isotropy




Anisotropy





structure




Image obtained from


ullpr2005800ahtml














Myelin

Sheath

Water

molecules

Endoneurium



Diffusion is faster

parallel to white

matter tracts



Image adopted from





Tensor




- between 0 and 1










axis of WMT







Eigenvalues


q L























Image Obtained From


S0166223612000720amp_image=1-s20-S0166223612000720-







tutorialhtmldtihtml






FA (Tensor Shape)









measurements




visible





coded maps




posterior)










Image Obtained From




Objectives


ndash Surgery

ndash Radiation


ndash Response

ndash Injury







69






Intraoperative MRI













and Resection






bull Methods




(n=120)




hazard ratio








bull Results



















fasciculus












Tracks





Fasciculus)

Red = Communicating


(Corpus Callosum)

Combined fMRI for


areas of the brain

(language motor)


PACS BIDMC





bull Problem





deficits



bull Solution




Radiation Therapy









Jena R et al (2005)






















Image adopted from








Image adopted from








Image adopted from










treatment planning





Objectives


ndash Response

ndash Injury





Overview


ndash Response



ndash Progression













Image adopted from






















Image adopted from






Image adopted from






sequences


























Acknowledgments





Deaconess

93
























94

















590












Imaging 13534-546 (2001) 96


















1562 2008




1470-2045 101016S1470-2045(11)70130-9

















2004 Nov 160(3)853-60












98







bull Define anatomy










Basic Principles

1 Diffusion

2 Measurement







superficial organs





bull Convenient

















Tissue cellularity






Isotropy




Anisotropy





structure




Image obtained from


ullpr2005800ahtml














Myelin

Sheath

Water

molecules

Endoneurium



Diffusion is faster

parallel to white

matter tracts



Image adopted from





Tensor




- between 0 and 1










axis of WMT







Eigenvalues


q L























Image Obtained From


S0166223612000720amp_image=1-s20-S0166223612000720-







tutorialhtmldtihtml






FA (Tensor Shape)









measurements




visible





coded maps




posterior)










Image Obtained From




Objectives


ndash Surgery

ndash Radiation


ndash Response

ndash Injury







69






Intraoperative MRI













and Resection






bull Methods




(n=120)




hazard ratio








bull Results



















fasciculus












Tracks





Fasciculus)

Red = Communicating


(Corpus Callosum)

Combined fMRI for


areas of the brain

(language motor)


PACS BIDMC





bull Problem





deficits



bull Solution




Radiation Therapy









Jena R et al (2005)






















Image adopted from








Image adopted from








Image adopted from










treatment planning





Objectives


ndash Response

ndash Injury





Overview


ndash Response



ndash Progression













Image adopted from






















Image adopted from






Image adopted from






sequences


























Acknowledgments





Deaconess

93
























94

















590












Imaging 13534-546 (2001) 96


















1562 2008




1470-2045 101016S1470-2045(11)70130-9

















2004 Nov 160(3)853-60












98





Basic Principles

1 Diffusion

2 Measurement







superficial organs





bull Convenient

















Tissue cellularity






Isotropy




Anisotropy





structure




Image obtained from


ullpr2005800ahtml














Myelin

Sheath

Water

molecules

Endoneurium



Diffusion is faster

parallel to white

matter tracts



Image adopted from





Tensor




- between 0 and 1










axis of WMT







Eigenvalues


q L























Image Obtained From


S0166223612000720amp_image=1-s20-S0166223612000720-







tutorialhtmldtihtml






FA (Tensor Shape)









measurements




visible





coded maps




posterior)










Image Obtained From




Objectives


ndash Surgery

ndash Radiation


ndash Response

ndash Injury







69






Intraoperative MRI













and Resection






bull Methods




(n=120)




hazard ratio








bull Results



















fasciculus












Tracks





Fasciculus)

Red = Communicating


(Corpus Callosum)

Combined fMRI for


areas of the brain

(language motor)


PACS BIDMC





bull Problem





deficits



bull Solution




Radiation Therapy









Jena R et al (2005)






















Image adopted from








Image adopted from








Image adopted from










treatment planning





Objectives


ndash Response

ndash Injury





Overview


ndash Response



ndash Progression













Image adopted from






















Image adopted from






Image adopted from






sequences


























Acknowledgments





Deaconess

93
























94

















590












Imaging 13534-546 (2001) 96


















1562 2008




1470-2045 101016S1470-2045(11)70130-9

















2004 Nov 160(3)853-60












98






superficial organs





bull Convenient

















Tissue cellularity






Isotropy




Anisotropy





structure




Image obtained from


ullpr2005800ahtml














Myelin

Sheath

Water

molecules

Endoneurium



Diffusion is faster

parallel to white

matter tracts



Image adopted from





Tensor




- between 0 and 1










axis of WMT







Eigenvalues


q L























Image Obtained From


S0166223612000720amp_image=1-s20-S0166223612000720-







tutorialhtmldtihtml






FA (Tensor Shape)









measurements




visible





coded maps




posterior)










Image Obtained From




Objectives


ndash Surgery

ndash Radiation


ndash Response

ndash Injury







69






Intraoperative MRI













and Resection






bull Methods




(n=120)




hazard ratio








bull Results



















fasciculus












Tracks





Fasciculus)

Red = Communicating


(Corpus Callosum)

Combined fMRI for


areas of the brain

(language motor)


PACS BIDMC





bull Problem





deficits



bull Solution




Radiation Therapy









Jena R et al (2005)






















Image adopted from








Image adopted from








Image adopted from










treatment planning





Objectives


ndash Response

ndash Injury





Overview


ndash Response



ndash Progression













Image adopted from






















Image adopted from






Image adopted from






sequences


























Acknowledgments





Deaconess

93
























94

















590












Imaging 13534-546 (2001) 96


















1562 2008




1470-2045 101016S1470-2045(11)70130-9

















2004 Nov 160(3)853-60












98



bull Convenient

















Tissue cellularity






Isotropy




Anisotropy





structure




Image obtained from


ullpr2005800ahtml














Myelin

Sheath

Water

molecules

Endoneurium



Diffusion is faster

parallel to white

matter tracts



Image adopted from





Tensor




- between 0 and 1










axis of WMT







Eigenvalues


q L























Image Obtained From


S0166223612000720amp_image=1-s20-S0166223612000720-







tutorialhtmldtihtml






FA (Tensor Shape)









measurements




visible





coded maps




posterior)










Image Obtained From




Objectives


ndash Surgery

ndash Radiation


ndash Response

ndash Injury







69






Intraoperative MRI













and Resection






bull Methods




(n=120)




hazard ratio








bull Results



















fasciculus












Tracks





Fasciculus)

Red = Communicating


(Corpus Callosum)

Combined fMRI for


areas of the brain

(language motor)


PACS BIDMC





bull Problem





deficits



bull Solution




Radiation Therapy









Jena R et al (2005)






















Image adopted from








Image adopted from








Image adopted from










treatment planning





Objectives


ndash Response

ndash Injury





Overview


ndash Response



ndash Progression













Image adopted from






















Image adopted from






Image adopted from






sequences


























Acknowledgments





Deaconess

93
























94

















590












Imaging 13534-546 (2001) 96


















1562 2008




1470-2045 101016S1470-2045(11)70130-9

















2004 Nov 160(3)853-60












98










Tissue cellularity






Isotropy




Anisotropy





structure




Image obtained from


ullpr2005800ahtml














Myelin

Sheath

Water

molecules

Endoneurium



Diffusion is faster

parallel to white

matter tracts



Image adopted from





Tensor




- between 0 and 1










axis of WMT







Eigenvalues


q L























Image Obtained From


S0166223612000720amp_image=1-s20-S0166223612000720-







tutorialhtmldtihtml






FA (Tensor Shape)









measurements




visible





coded maps




posterior)










Image Obtained From




Objectives


ndash Surgery

ndash Radiation


ndash Response

ndash Injury







69






Intraoperative MRI













and Resection






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Deaconess

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2004 Nov 160(3)853-60












98





Jena R et al (2005)






















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treatment planning





Objectives


ndash Response

ndash Injury





Overview


ndash Response



ndash Progression













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sequences


























Acknowledgments





Deaconess

93
























94

















590












Imaging 13534-546 (2001) 96


















1562 2008




1470-2045 101016S1470-2045(11)70130-9

















2004 Nov 160(3)853-60












98







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treatment planning





Objectives


ndash Response

ndash Injury





Overview


ndash Response



ndash Progression













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sequences


























Acknowledgments





Deaconess

93
























94

















590












Imaging 13534-546 (2001) 96


















1562 2008




1470-2045 101016S1470-2045(11)70130-9

















2004 Nov 160(3)853-60












98






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treatment planning





Objectives


ndash Response

ndash Injury





Overview


ndash Response



ndash Progression













Image adopted from






















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Image adopted from






sequences


























Acknowledgments





Deaconess

93
























94

















590












Imaging 13534-546 (2001) 96


















1562 2008




1470-2045 101016S1470-2045(11)70130-9

















2004 Nov 160(3)853-60












98






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treatment planning





Objectives


ndash Response

ndash Injury





Overview


ndash Response



ndash Progression













Image adopted from






















Image adopted from






Image adopted from






sequences


























Acknowledgments





Deaconess

93
























94

















590












Imaging 13534-546 (2001) 96


















1562 2008




1470-2045 101016S1470-2045(11)70130-9

















2004 Nov 160(3)853-60












98








treatment planning





Objectives


ndash Response

ndash Injury





Overview


ndash Response



ndash Progression













Image adopted from






















Image adopted from






Image adopted from






sequences


























Acknowledgments





Deaconess

93
























94

















590












Imaging 13534-546 (2001) 96


















1562 2008




1470-2045 101016S1470-2045(11)70130-9

















2004 Nov 160(3)853-60












98



Objectives


ndash Response

ndash Injury





Overview


ndash Response



ndash Progression













Image adopted from






















Image adopted from






Image adopted from






sequences


























Acknowledgments





Deaconess

93
























94

















590












Imaging 13534-546 (2001) 96


















1562 2008




1470-2045 101016S1470-2045(11)70130-9

















2004 Nov 160(3)853-60












98




Overview


ndash Response



ndash Progression













Image adopted from






















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Image adopted from






sequences


























Acknowledgments





Deaconess

93
























94

















590












Imaging 13534-546 (2001) 96


















1562 2008




1470-2045 101016S1470-2045(11)70130-9

















2004 Nov 160(3)853-60












98












Image adopted from






















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Image adopted from






sequences


























Acknowledgments





Deaconess

93
























94

















590












Imaging 13534-546 (2001) 96


















1562 2008




1470-2045 101016S1470-2045(11)70130-9

















2004 Nov 160(3)853-60












98







Image adopted from






















Image adopted from






Image adopted from






sequences


























Acknowledgments





Deaconess

93
























94

















590












Imaging 13534-546 (2001) 96


















1562 2008




1470-2045 101016S1470-2045(11)70130-9

















2004 Nov 160(3)853-60












98





















Image adopted from






Image adopted from






sequences


























Acknowledgments





Deaconess

93
























94

















590












Imaging 13534-546 (2001) 96


















1562 2008




1470-2045 101016S1470-2045(11)70130-9

















2004 Nov 160(3)853-60












98













Image adopted from






Image adopted from






sequences


























Acknowledgments





Deaconess

93
























94

















590












Imaging 13534-546 (2001) 96


















1562 2008




1470-2045 101016S1470-2045(11)70130-9

















2004 Nov 160(3)853-60












98





Image adopted from






sequences


























Acknowledgments





Deaconess

93
























94

















590












Imaging 13534-546 (2001) 96


















1562 2008




1470-2045 101016S1470-2045(11)70130-9

















2004 Nov 160(3)853-60












98

























Acknowledgments





Deaconess

93
























94

















590












Imaging 13534-546 (2001) 96


















1562 2008




1470-2045 101016S1470-2045(11)70130-9

















2004 Nov 160(3)853-60












98
















Acknowledgments





Deaconess

93
























94

















590












Imaging 13534-546 (2001) 96


















1562 2008




1470-2045 101016S1470-2045(11)70130-9

















2004 Nov 160(3)853-60












98



Acknowledgments





Deaconess

93
























94

















590












Imaging 13534-546 (2001) 96


















1562 2008




1470-2045 101016S1470-2045(11)70130-9

















2004 Nov 160(3)853-60












98
























94

















590












Imaging 13534-546 (2001) 96


















1562 2008




1470-2045 101016S1470-2045(11)70130-9

















2004 Nov 160(3)853-60












98

















590












Imaging 13534-546 (2001) 96


















1562 2008




1470-2045 101016S1470-2045(11)70130-9

















2004 Nov 160(3)853-60












98















590












Imaging 13534-546 (2001) 96


















1562 2008




1470-2045 101016S1470-2045(11)70130-9

















2004 Nov 160(3)853-60












98


















1562 2008




1470-2045 101016S1470-2045(11)70130-9

















2004 Nov 160(3)853-60












98













2004 Nov 160(3)853-60












98

Documents

The Wave of the Future - Lieberman's eRadiology Learning …eradiology.bidmc.harvard.edu/LearningLab/central/Feltus.pdf · Whitney Feltus, MS IV Gillian Lieberman, MD The Wave of