Microneurosurgery, Volume IV A CNS Tumors Surgical

Anatomy, Neuropathology, Neuroradiology, Neurophysiology,

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 Current Neuroimaging with CT and MRI 197

SinglePhoton Emission Computed Tomography Magnetic Resonance Angiography

Singlephoton emission computed tomography (SPECT) is a low- Magnetic resonance angiography (MRA) exploits the fact that
costtechnique of imaging the three-dimensional distribution of cerebral arteries are routinely visible on spin-echo images, due to
radioisotopes.The technique uses the same kinds of gamma-emit- the flow-void phenomenon. MRA techniques rely on special
tingisotopesroutinelyemployed in most hospital nuclear medi- pulse sequences (sensitive to flow) and on sophisticated proces-
cinedepartments,and does not require the availability of an sing of the data to give images similar to standard contrast cathe-
on-sitecycIotron (necessary for PET). SPECT scanning permits ter angiograms. The major present applications for MRA are
the creation of multiplanar tomograms that measure local cere- screening for atherosclerotic disease of the extracranial and
bralbloodvolume,localcerebral blood flow,blood-brain barrier major intracranial vessels around the circle of Willis. MRA can be
abnormalities,and other cerebral metabolic parameters. used as a screening test for intracranial aneurysms in asympto-
matic patients (e. g., family members of patients who have had
aneurysms). Recent improvements in the sensitivity and resolu-
CurrentTrends tion of MRA have been impressive enough for us to use it in the
evaluation of certain intracerebral tumors to help decide which of
Neuroimaginghas continued to evolve to become a comprehen- these merit additional study by selective cerebral arteriography.
sivediscipline that investigates and displays both normal and Although intrinsic and extrinsic tumor vessels can be routinely
abnormal, structural and functional anatomy in the central visualized, MRA is of little value in precisely identifying the feed-
nervoussystem. Of future importance will be the integration of ing vessels, and certainly provides no information about the qual-
noninvasivetechniques that precisely demonstrate, to resolutions ity (e. g., fragility) of these feeding arteries (see Fig. 3.14, 3.49,
of 1-3 mm, both structural and functional areas of the brain 3.48).
together.

Echo-planar MRI
Magnetic Encephalography
Echo-planar MRI technology involves the production of ultrafast
Magneticencephalography (MEG) has shown how this precise MRI images (1-2 seconds). It has been used to study real time
localizationcan be achieved in the somatosensory and motor CSF dynamics and blood flow in vessels and, in addition, may ulti-
areasof the cortex. No doubt the same precision will be achieved mately prove beneficial in the utilization of MRI for the evalua-
withthethreemajorarea componentsof speech.Of more immedi- tion of cerebral metabolic processes. Unfortunately, it is not inex-
ate usefulnessare techniques that allow the noninvasive assess- pensive to adapt it to present MRI imaging capabilities. The need
mentof alterations in the vascular and CSF systems in and around for a high-strength magnet (3.0 Tesla or more) and some uncer-
cerebraltumors,such as magnetic resonance angiography (MRA) tainties about the long-term safety may inhibit further clinical
andechoplanar MRI. development. Future development of fast T2 imaging techniques
(3-4 minutes) may prove to have more widespread applicability
than echo-planar MRI.

CurrentNeuroimaging with CT and MRI

Whilemanyof the problemsof tumor detect~on,localization,and how current neuroimaging can be better utilized. Detailed infor-
pathologicalcharacterization were solved for extrinsic tumors by mation on these topics and specific lesion characteristics are well
the advent of high-resolution CT and MR imaging, especially reviewed in the literature (Kazner et al. 1988, Bradley et al. 1990)
afterthe introduction of nonionic contrast agents, the pathophysi- and in current textbooks (Brant-Zawadzki and Norman 1987,
ologicalsignificance of many of the changes seen on MR with Orrison 1989, Higer and Just 1989, Grossman 1990, Chakeres
intrinsictumors remains uncertain. For neurosurgeons, the sensi- 1991, Dietemann 1993).
tivityofcurrent CT and MR in localizing pathology is truly impres- A higher level of gray /white matter contrast is obtainable
sive.yet the lack of pathological specificity has been a disappoint- with MRI when compared with CT. The degree of anatomical
ment.The cIinical history and examination are, and will remain, detail shown on the three orthogonal planes is greater with MRI.
vital discriminatorsin narrowing the differential diagnosis. To MRI offers increased sensitivity with earlier detection of
makethe best use of current neuroimaging techniques, close dis- smaller lesions in areas previously difficult to image with CT. MRI
cussionsbetween neuroradiologists, neurosurgeons, and neu- provides higher-resolution detail of the posterior fossa and skull
ropathologistsare more important than ever. Hopefully, parallel base. MRI does not have the problems of bone-volume averaging
developmentsby these associated specialists willlead to a better and beam-hardening artifacts that contribute to the false-nega-
understandingof tumor pathophysiology (Table 3.2). tive results obtained with CT in these regions. This increased sensi-
It is not the intention of this chapter to provide a com- tivity of MRI over CT extends to the evaluation of head trauma
pendiumof intracranial pathologies and their various radio- (Han 1984).
graphic characteristics,but rather to stimulate critical analysesof
 1

198 3 Neuroradiology

Table3.2 Current neuroimaging (CT and MRI)capabilities Comparison of CT with MRI

General aspects
Morphologicalchanges During its development, it was predicted that MRI wouldhave
Neoplasms: primary and metastatic three advantages over CT, namely, that (a) MRI scanning usesno
vascular lesions: aneurysm, AVM,ischemia, hematomas ionizing radiation, (b) it requires no moving parts to perform a
Inlectious diseases scan, and (c) multiplanar (axial transverse, coronal, and sagittal)
White-matterdisease: MS, leukodystrophies, encephalopathies
tomograms are easily obtained, since the scanning mechanismis
CSF system (hydrocephalus, secondary atrophy)
Congenital anomalies entirely electronic (Holland et al. 1985). The ability of MRI tomo-
Traumatic lesions graphy to directly produce coronal and sagittal, as well as axial
Location01the lesion transverse, images has shown itself today to be the best meansof
Extrinsic precise lesion assessment (Table 3.3).
Intrinsic(neocerebral, neocerebE¡Jllar,limbic-paralimbic, central In Chapter 2, the importance of identifying the subgyral,
nuclei, and intraventricular) gyral, or lobar peduncular origin of the primary location of many
Postoperative morphological changes (local and remote) intrinsic brain tumors is stressed. Tumors in these locations distort
Hematoma the normal morphology of the brain and make localization diffi-
Edema cult. MRI has made this localization much easier. Neurosurgeons,
Inlarction
CSF hygroma and hydrocephalus in particular, are most grateful for the specific anatomicallocaliza-
Completeness 01surgery tion that current MRI, when properly used, is able to provide.
Residual or recurrent pathological tissue Sagittal and axial MRI provides excellent extrinsic tumor imaging
Special aspects: secondary lunctional changes detail. Coronal MRI imaging is the most useful image plane inpre-
CSF dynamics operative localization and surgical planning for intrinsic tumors,
Hemodynamics as the white-matter peduncular architecture of most gyri can be
Biologicalbehaviour 01the lesi.on most favorably recognized in this planeoFor the frontal and tem-
Progressive
Regressive
poral gyri, on the other hand, the horizon~al or sagittal viewsare
Inactive more helpful. Careful analysis of pre-gadolinium and post-
Parenchymal dynamics gadolinium TI MRI scans in three planes will nearly alwayspro-
Atrophyand related degenerative changes vide the precise anatomical information that is a prerequisite for
Tissue intensity changes: perilesional changes preoperative surgical planning.
? Biochemical metabolic interactions
? Inliltration01tumor cells
Posttreatment effects: surgery, chemotherapy, or radiatio-
therapy MR Image Selection
Unlike CT, MR allows an almost infinite number of manipula-
tions to obtain a diagnostic image and to vary the contrast on
images. The choice of independent tissue variables that provide
the best contrast on diagnostic evaluations include pro ton density,
T ¡-weighted, Tz-weighted, and "flow" -weighted images.The selec-
tion of which pulse sequences to use in the evaluation of anysus-
pected pathology is important not only in eliminating false nega-
Table 3.3 Comparison 01 CT with MRI tives and in maximizing sensitivity, but is also vital for subsequent
CT MR correct interpretation. With an initial (diagnostic) study of a sus-
pected tumor, all three types of main sequences (proton density,
Technique First to directly Direct images 01CNS T,-weighted, and Tz-weighted images) need to be obtained before
image CNS a study can be regarded as complete. In reality, it is useful to
Sensitivity Limited Éxcellent
Specilicity Fair Moderate regard each set of images as totally different imaging methods (as
Spatial resolution High Very high, in three different as MRI is from CT), each with its own advantages, dis-
planes advantages, and limitations. Therefore, at least three completely
Soft-tissue contrast 1) Moderate 1) Excellent different sets of MRI images have to be interpreted using differ-
High-resolution High-resolution
ent criteria. In addition to being fully aware of technical variables
images 01bone images 01bone
Poor gray-white marrow, CSF and limitations, it is especially important for neurosurgeons to
neuroanatomy spaces, gray- realize that artifacts and distortions of real anatomy, especiallyat
white anatomy, and interfaces, can be significant (Pusey et al. 1986, Kelly 1987).
most gross neu- (Table 3.6).
ropathology With MRI the differences between T,-weighted and
2) Limited pathologi- 2) Moderate patho-
cal sensitivity logical sensitivity Tz-weighted images in various normal and pathological tissues
Blood-brain barrier Intravenous con- Intravenous are greater than the variations in proton density. The selectionof
evaluation trast uselul gadolinium very various pulse sequences is used to "weight" the images toward TI
uselul or Tz data. This forms the basis for the increased sensitivityof
Functional capabili- Poor Limited
MRI.
ties
The choice of image sequence parameters can still be criti-
Developed by Ho cally important in lesion detection (Table 3.4). Some convexity
 Current Neuroimaging with CT and MRI 199

meningiomas without secondary parenchymal changes can Table 3.4 Interpretation of T1-weighted and T2-weighted MR images
escape detectionunlessappropriate TI and T2sequences are per- (alter Orrison, Introduction to Neuroimaging, Boston: Little, Brown, 1989,
p.87)
formed. MRI may underrepresent or overrepresent tissues at
s betweenCSFand brain parenchyma.The width of sulci
interface MR appearance Typical causes
is commonly exaggerated, and adjacent gyral surfaces under-
White
represented. Anatomical resolution is best with TI images, and
'Increased signal (short) T,W Fat
pathologicalsensitivity greatest with T2 sequences. Image inter- Normal white matter
pretationfollows hnes similar to those used in CT interpretation. Paramagnetics
Detailedanalyses of geometric factors and 2 tissue contrast fac- Lymphoma
torsare crucial. Chronic hematoma
Increased signal (long) T2W H20
CSF

ContrastMRI Paramagnetics
Edema
Inflammation
Doubts about the sensitivity of CT in identifying tumors Infarcts
promptedAmbrose to develop a contrast agent. The comparison Neoplasms
of contrast with noncontrast scans enabled CT to demonstrate Multiple sclerosis
Normal gray matter
tumorneovascularization and alterations in the blood-brain bar- Lymphoma
rier.MRI carne into clinical use before a suitable contrast agent Chronic hematoma
hadbeen developed. The hope was that, with its increased sensitiv- Black or gray
Decreased signal (long) T1W Ca2+
ity over CT and with suitably chosen T2 sequences, a contrast Blood or CSF flow
agentwould not be needed. This was not the case. Since 1986, H20
MRI with paramagnetic contrast agents such as Gd-DTPA has CSF
increasedthe sensitivity for detection of CNS lesion to a higher Edema
leve\.Forexample,compared to a noncontrasted scan, MRI with Inflammation
Gd identifies 15% more metastatic tumors. Contrast MRI is of Neoplasms
Normal gray matter
greathelp in differentiating tumor from perilesional changes. The Lymphoma
useofcontrast studies is of major importance when one considers Decreased signal (short) T2W Ca2+
that over 50% of patients with intracranial neoplasms have few Blood or CSF
Fat
localizingsigns and normal neurological examinations.
White matter
Lymphoma
Acute hematoma
Usefulnessof MRI in Distinguishing
VascularMass Lesions from Tumors White: increased signal = short T1' long T2
Black: decreased signal = long T" short T2

Although
this work focuses on brain tumors, vascular lesions can
sometimespresent as mass lesions. The noninvasive differentia-
tionbetween these two types of pathology is important. MRI is
ableto provide far more useful information on the structural and Failure of MRI to Detail Surgical Pathophysiology
temporal changes associated with hemorrhage and infarction
thanCT is.Sometimes even the underlying pathological vascular Two other important considerations must be integrated in the syn-
lesioncan be determined (e. g., AVM or cavernomas). MRI can thesis of the final surgical strategy. First, the pathology of the
identify changes associated with subarachnoid hemorrhage, tumor, and second, its functional effects (Iocally, globally and sys-
aneurysm,angioma, and occlusive vascular disease. Ischemia, temically). Unfortunately, these are the two areas where MRI,
infarction,hematoma (epidural, subdural, intraparenchymal, and even with its exquisite sensitivity, has failed to live up to early
interventricular)can also be evaluated. expectations. This failure has been a particular disappointment
and a frustration to surgical decision-making. For many tumors,
the specific MR imaging parameters that precisely define
Functional Studies pathology (consisten<;y, vascularity, adherence, and extension or
infiltration) are yet to be determined. The maximum MRI resolu-
MRI candefine functional relations between normal and abnor- tion attainable at present is down to 0.3 mm.The benefits from
mal tissues better than previous studies. By itself, though, its lack this degree of detail need to be exploited with a more precise cor-
of specificity remains a limitation, especially when attempting to relation with tumor morphology and histology, and with a better
differentiate neoplasms from other disease processes. Current physiological undestanding of the peritumoral changes seen so
workis aimed at to increasing our functional knowledge of brain well on T2 images. Closer cooperation between neurosurgeons,
tumors. Sodium-gated MRI may provide more information neuropathologists, and neuroradiologists in correlating pathologi-
regardingtumor grade and local extension. MRI is very sensitive cal findings, radiological images, and surgical findings will help
in displayingperilesional changes, of uncertain significance and determine those specific additional MRI sequences that may best
conflictinginterpretation. This problem will be further examined answer these questions of profound surgical interest.
below.
200 3 Neuroradiology

Future Correlation 01 MRI demonstrated in white matter, depending on the direction in

with Functionallmaging which pulsed gradients were applied. These effects enabled
specific white-matter tracts to be identified, depending on the
Curiously, the ability of MRI to detail brain morphology, and direction of their fibers. The technique may have application ina
developments in the understanding of functional localization wide range of neurological diseases, and results in better localiza-
within the brain, come nearly 100 years after the same topics split tion of lesions and improved detection of disease (Doran et al.
the neuroscience community. Psychiatrists, behavioral psycholo- 1990,Fazekaset al. 1991,Marshall et al. 1988).
gists, and neuropharmacologists are now increasingly interested
in MRI correlations of morphology and higher cerebral functions.
Certainly, neurologists and neurosurgeons continue to be inter- Recent MRllmprovements
ested in new neuroimaging techniques that can precisely correlate
specific functional are as (e. g., speech areas) with tumor location Three-dimensional MRI technology will soon be available. The
on MRI. The precise assessment of epileptogenic foci around most recent MRA quality and detail is impressive. Hopefully,visu-
mass lesions, whether tumor or vascular, is of crucial concern in alization of the brain parenchyma and blood vessels in three
microsurgical decision-making, and for the prognosis of a seizure dimensions will supply the surgeon with a more realistic viewof
disorder. Very promising is the use of pulsed magnetic field internal CNS pathology and its relationships to surrounding struc-
gradient spin-echo technique, as changes in signal intensity can be tu res.

The Application of Neuroimaging Capabilities to CNS Tumors

Lesion Morphology (Structural Changes) associated mass effect. Interstitial edema is seen around the ven.
tricJes in association with hydrocephalus, and is a result of the
cr and MRI provide images reflecting changes in the mor- increased hydrostatic forces driving fluid into the periventricular
phology of the CNS parenchyma. These advanced neuroimages space. Cytotoxic edema is demonstrated in conjunction with
can identify changes in CNS structures resulting from vascular ischemia and infarction.
occlusive disease, hemorrhage, infection, degenerative disease, In additio~ to an identification of edema, newer techniques.
and neoplasm. The effects of these processes on the surrounding incJuding gradient echo technology, can identify flow voidssignify-
CNS can be seen as well, although their significance remains ing peritumoral vessels. Intratumoral vessel identification usually
unclear (e. g., perilesional changes). MRI and CT provide instant supports the diagnosisof a malignant lesionoGradient echo tech-
information concerning the size, site, extension, shape, and num- niques can identify tumor caJcification, a finding uncommon in
ber of lesions and secondary changes. high-grade lesions unless the tumor has been transformed froma
CT was the first study to provide direct images of the brain, low-grade one. Though MRI and CT can provide important struc-
cisterns, and ventricles. The effects of tumor, incJuding edema, tural information as to the nature of the lesion preoperatively.
mass effect, midline shift, and cerebral herniation, conld be MRI is much better at identifying hemorrhage within a tumor.
readily seen. The addition of iodinated contrast, which demon- The tumors most commonly associated with intratumoral hemor-
strates disruption of the blood-brain barrier, allowed for rhage are high grade gliomas and metas tases from hyperne-
increased tumor detection. Previous noncontrasted scans that phroma, melanoma, thyroid carcinoma, and choriocarcinoma.
showed a pool of edema were frequently seen to "light" up, dem-
onstrating a previously unrecognized tumor. Combined with cJini-
cal information (particularly the age of the patient and the length Lesion Location (Topography)
of the history), the current images quickly suggest whether a
tumor is most likely to be primary or secondary. Not only do the structural images of lesions help to identify them
MRI is an even more sensitive method of determining struc- on CT and MRI, but their location also plays an important role in
tural abnormalities than CT. (CT has now become the second determining the differential diagnosis. CT and MRI are usually
most sensitive test for identifying CNS neoplasms). The introduc- able to determine if a tumor is extrinsic, intrinsic, transitional, or
tion of Gd-DTPA with MRI provides the most sensitive test yet intraventricular. MRI is very effective in demonstating the mor-
for identifying CNS abnormalities. Tz-weighted sequences on phology of tumor-associated herniation as related to the CNS
MRI are particularlygood at demonstrating edema. . compartments. The common CNS compartments visible on MRI.
The common forms of brain edema are vasogenic, hydro- and involved in herniation syndromes, are listed in Table 3.5.The
static (interstitiai) and cytotoxic. Vasogenic edema is the most subarachnoid spaces (incJuding suJci, fissures, and cisterns) are
common type identified, and is that frequently associated with the most common sites involved in brain-tumor herniation. and
white matter edema. It is manifested as an increased T2 signal these areas are well delineated on MRI.
around areas of abnormal blood brain barrier. Typically, this is As a result, it is possible to describe the topography of a
seen along white-matter tracts, as it tends to spare gray-matter herniation of brain tissue or tumor (or both) precisely from an
structures. In higher-grade tumors, vasogenic edema can be space- expanding intracranial neoplasm. This subarachnoidal herniation
occupying, and thus be responsible for a large amount of the may be related to direct compression by the tumor, or bordering
 The Application of Neuroimaging Capabilities to CNS Tumors 201

gyri(or folia), with compression of neighboring compartments. Precise localization of lesions with respect to extrinsic and
Extrinsicand intrinsic tumors commonly compress the surround- intrinsic location enables the neurosurgeon to correlate the sur-
ingsu1ci(and fissures) as an initial manifestation of herniation. face topographical anatomy in vivo to that represented on MRI
Theinvolvedsu1ciare usually compressed and displaced by a dislo- and thus to precisely plan the opera tive approach.
catedneighboring gyrus (or the tumor itself, or both). With a
knowledgeof the topography of the gyrus involved, one can antici-
patethe su1ciand gyri involved. Other Diseases
It is important to note that precise structurallocalization of
everybrain tumor and its associated herniation should be CT and MRI are also helpful in the identification of lesions other
attemptedon the basis of neuroimaging. However, this informa- than tumors and vascular abnormalities. Those lesions that
tionshould no! be used to diagnose the patient's clinical condi- frequently enter into the differential diagnosis are: infectious
tion.Many examples are provided at the end of this chapter, dem- processes, the sequelae of AIDS, parasites, and granulomas.
onstrating the uncertain and confusing lack of correlation These can be suspected on the basis of their structural changes
betweenthe topography of CNS tumors (and associated effects) and location, and in correlation with the history. Certain patho-
andthe patient's clinical status. gens have a predilection for certain areas. For example, toxoplas-
Certain tumors have a propensity for certain locations. Pri- mosis has a predilection for the central nuclear areas in the adult
maryCNS B-celllymphoma is commonly found in close proxim- and the periventricular region (with ca1cifications) in the neonate.
¡tyto deep central nuclei. Metastases tend to be multiple and Cysticercosis may appear as a ca1cified mass with surrounding low
appearat the gray-white junction. Metastatic breast, lung, and attenuation, and it may enhance with contrast (as a ring or in a
occasionallyprostate tumors, have a propensity to deposit on the homogeneous pattern). The presence of multiple ca1cifiedmasses,
dura. in the proper setting, in the cortical and subcortical regions should
Neuroimaging (MRI and CT) frequently demonstrates aro use suspicion of an infectious etiology.
osseousherniation of tumor (or brain) that may occur through CT and MRI have been useful in identifying white-matter dis-
arachnoidal granulations, with partial or full-thickness bony ease. The plaques of multiple sclerosis are often identified on
destruction.In addition, bony erosion may be seen (primarily in MRI, as increased periventricular signal'in the deep white matter.
meningiomas)in the parasellar region, middle fossa (into the pter- Leukodystrophies have certain additional characteristics, includ-
ygopalatinefossa), sphenoid bone, mastoid, clivus, and calvarium. ing abnormal decreased signal intensity in the central nuclei and
Tumorsmay grow into the bone surrounding the dural sinuses thalamus, correlating with an increase in trace metals or iron in
(cavernous,superior sagittal, petrosal, transverse, sigmoid, and these gray-matter structures.
torcular),and the foramina and fissures (cribriform plate, optic'
foramen,superior and inferior orbital fissures, foramen ovale and
foramenrotundum Meckel's cave, acoustic foramen, jugular fora- Ventricular Abnormalities
men,and occipital foramen. Finally, tumor expansion may be seen
into the mucosal sinuses (frontal, sphenoethmoidal and maxil- Morphological changes depicting abnormalities within the CSF
lary)(Table3.5). system can be readily identified with CT and MRI. Interpretation
of additional changes, seen better on MRI, can usually determine
whether the cause of the hydrocephalus is obstructive in nature or
due to a reabsorption problem.
Table3.5 Common compartments involved in herniation syndromes
Subarachnoid
Postoperative Morphological Changes
Sulcal(cerebral, cerebellar)
Cisternal(basal)
Parachiasmatic, parasphenoidal, subtentorial, paramesen- One of the great advantages of the CT and MRI era is the possi-
cephalic, parapontine, parabulbar, cisterna magna bility of noninvasive postoperative imaging. This capability has
Fissural been of life-saving benefit to individual patients, and has had long-
Sylvian,interhemispheric, transverse, cerebello-mesencephalic, term consequences in reducing postoperative morbidity in follow-
cerebellDpontine,cerebellomedullary
ing up pathological processes and in monitoring different thera-
Durall septal pies. As outlined in Chapter 4, our understanding of the way
Tentorial(cerebral downwards, cerebellar upwards)
Sublalcial
tumors alter neurophysiological mechanisms and upset the inte-
gration of the central nervous system is still incomplete. In
Ventricular
patients with an unexpected postoperative course, CT provides
Lateral(Irontal, corpus, trigone, occipital, temporal)
Thirdventricle (inleroanterior, middle, posterior) quick and usually reassuring information. Life-threatening hema-
Aqueduct tomas (either focal or remote) and hydrocephalus can be swiftly
Fourthventricle diagnosed and treated. Infarction and delayed subdural collec-
Osseous tions can be identified. CT in the first 1-5 postoperative days is
Arachnoidalgranulations clearly more pragmatic than MRI (less costly, and less disturbing
Calvarial for the patient). The adequacy of therapy, including completeness
Duralsinus
of tumor removal, is far better assessed by MRI 3-4 weeks after
Foramenand lissures (11,111,
V, VII-VIII, IX-XI, and occipital foramen)
surgery, when many operative changes (edema, small hema-
Mucosalsinus (frontal, ethmoidal, sphenoidal)
tomas) have subsided. At later intervals, serial MRI scans provide
Duralsinus
Intravascular
information regarding residual or recurrent pathological tissue,
or the effects of additional treatments.

J..
202 3 Neuroradiology

FunctionalChanges Table 3.6 Difficulties and limitations of neuroimaging

Differential diagnostic difficulties
In addition to the structural information provided, CT and MRI Process: neoplasm, vascular, infectious, degenerative
have proved useful in yielding information on secondary Between neoplasms: meningioma, glioma, metastasis, ete.
functional changes. The functional CNS dynamics of CSF and Between vascular lesions: cavernoma, venous angioma, telan-
blood can be assessed with CT and MRI. In addition, the biologi- giectasia, microangioma, cryptic angioma, ete.
Necrotie tumor parenchyma, cyst, old hematoma
cal behavior of lesions (aneurysms, angiomas, neoplasms, hema-
tomas, abscesses, infections) can be followed. Progressive, regres- Topographic difficulties
Extrinsic: epidural, intradural, subdural, or mixed
sive, or inactive processes can be diagnosed by comparing serial
Intrinsic: expanding lobar concepts to the subgyral, gyral,lobar,
scans over time. Combined with the clinical history, the nature of or hemispheric peduncle
parenchymal dynamics (including atrophy and degenerative 1. Neocerebral, neocerebellar
changes) can be interpreted. T)1e tissue-intensity changes seen 2. Transitional: Limbic (septal areas, substantia innomi-
with MRI have specific characteristics related to various constitu- nata, amygdala, hippocampus)
Paralimbic (temporal pole,
ents at different times (e. g., phases of blood breakdown within a fronto-orbital, anterior insula, eingulate,
lesion over time). Perilesional edema, metabolic biochemical parahippocampal)
interactions, and perilesional infiltration of tumor cells are other 3. Central gray matter a) Basal ganglia (eaudate, putamen,
parenchymal dynamic changes that await more intense investiga- pallidum)
tion by MRI and MRS. b) Central nuciei (thalamus, meta-,
epi-, sub-, and hypothalamus)
c) Brainstem (mesen-, meten-, myel-
encephalon)
Difficulties and Limitations 4. Intraventricular (lateral ventricle, 111, aqueduet and IVven-
of Neuroimaging trieles)
Paraxiallesions: parasellar, ehiasmal, tentorial,peduncu-
lar, pineal, pontine, bulbar
Even with the optimal use of CT and MRI, neurosurgeons have Herniation-infiltration .
come to recognize significant limitations and difficuIties with Subfaleial, subtentorial, parachiasmal, parapineal
regard to differential diagnosis, topography, extent of lesion, peri- Borderline
lesional changes, adherence, and cleavage planes (Table 3.6). In Extension of Lesion
over 90% of cases, the CT and MRI images provide us with a clear - Expansion
differential diagnosis. However, it is important to remember that - Infiltration
these images are merely electronic shadows (different gray-scale Perilesional changes (hYPodensity, hyperdensity, or hypo- or hyper-
shades) presented on a macroscopic, inanimate, two-dimensional intensity)
framework. This is far different from the complex, living, four- Edema, isehemia, infaretion
Metabolic ehanges
dimensional milieu that really exists; it should not be overlooked Infiltrationby tumor
that the fourth dimension is time, and the pictures in front of us Seattered tumor cells
provide only a static image at a fixed point in time.
Cleavage-no cleavage
It is sometimes difficuIt to differentiate between neoplasm, Adherenee between tumor and peritumoral struetures
vascular lesion, infection, and degenerative disease. The ability to Arteries, veins, sinuses Infiltration
distinguish lesion type solely on the basis of image characteristics Dura, araehnoidea, pia Invasion
is inconsistent. Even the same type of lesion can appear Parenchyma Adherenee
Ependyma Gliosis
completely different. It can be especially challenging to differen- Plexus { Membrane formation
tiate a neurinoma from a meningioma or, less commonly, a
meningioma from a glioma. "Butterfly" lesions may reflect glio-
blastoma, lymphoma, progressive muItifocal leukoen- Detailed lesion construction
cephalopathy, or other uncommon processes. A single contrast- Neoplasms
enhancing lesion may represent a glioma, abscess, Iymphoma, 1. Homogenous or heterogenous
metastatic or anoaItogether different process. Certain morphologi- 2. Cyst: fluid or tumor tissue
3. Consisteney: soft or hard
cal characteristics seen on CT, such as calcification, may not be vis- 4. Vaseularity
ible on MRI. Small meningiomas not producing edema can be - Ouantitative:
missed on MRI, aIthough the use of gradient echo techniques and - Oualitative:
the use of contrast has helped overcome this problem. Still, the
diagnosis is inaccurate in 10% of cases.
Certain vascular lesions, including cavernomas, microan- active and bled, but destroyed itself in the process (autodestruc-
giomas, telangiectasias, and cryptic angiomas cannot be distin- tion), or it may be inactive (dormant). Deciding these questions
guished on MRI. In addition, these lesions can mimic tumors, and with any rational certitude on one set of MRI images is not
vice versa. This lack of neuroimaging spedficity is a problem that possible.
neurosurgeons are frequcntly confronted with. Other tests are of In the posterior fossa, CT images are often degraded by bone-
no help, but the patient expects a firm recommendation. Com- volume averaging, whereas MRI permits better tumor localiza-
pounding this diagnostic uncertainty is the question of the patho- tion, and may allow tumor consistency interpretation. The resolu-
logical or behavioral activity of vascular mass lesions. If the lesion tion detail with the soft tissues is also higher with MRI. Overall.
is active (enlarging, demonstrating a propensity to bleed) manage- the routine use of sagittal, coronal, and axial MRI images pro-
ment is straightforward. However, the lesion may have been vides more precise localizing detail than CT. As we plan OUT opera-
 The Application of Neuroimaging Capabilities to CNS Tumors 203

tiveapproaches, we wish we had a greater understanding of the Tumors can be either circumscribed, semicircumscribed, or, less
topography and real nature of each individual lesion, but this commonly, diffuse. MRI signal and CT intensity changes are often
informationremains incomplete. unable to define cIear tumor boundaries with any confidence.
Often, "irregularly shaped" tumors appear diffuse and inopera-
ble, yet, at surgery, an oddly shaped but well circumscribed lesion
Topographic
Difficulties is found that can be removed with only a moderate degree of diffi-
culty. In the early or intermediate phases of growth, gliomas tend
Extrinsic.In spite of advances in neuroimaging, it sometimes to expand within one segment of one gyrus, or within one part of a
remainsdifficult to determine whether a lesion is extrinsic or central nucIeus, or within one section of the ventricular system.
intrinsic.If it is extrinsic, even with the use of contrast it is often Based on normal anatomical knowledge, it is consistently reward-
unclearwhether the lesion is extradural, intradural, subdural, sub- ing to make a formulation of the anatomical origin of a lesion and
arachnoid,or mixed, as cIear identification of the dura itself is then, during surgery, find its center in just that location. In the
frequentlyjust not possible (see Cases 3.5, 3.7, 3.11, 3.12, 3.28, early phase of growth, only 1% of gliomas, are in our experience
3.31,3.32). truly diffuse (and in less than 0.1% of them there is gliomatosis).
Most commonly, a lesion that appears to be infiltrative due to its
lotrinsic.The localization of intrinsic tumors can be just as prob- peculiar shape is, upon removal, expansive, compressing and dis-
lematic.This was especially true when using the traditional torting adjacent structures, but is not in fact infiltrative.
"lobar"view of the brain, which is far too broad and prevents a
criticaland more detailed analysis of the likely site of tumor Peritumoral Changes
originoOur current concepts (see chapter 1) define the tumor loca-
tionbetter, and have important surgical implications. In addition to our present limitations in defining tumor bound-
Intrinsiclesions should be thought of in gyral concepts, after aries, the extension of the tumor is often difficult to determine. In
subdivisioninto one of the neocerebral / cerebellar, limbic, central a review of many preoperative images, the difference between
nuclearor intraventricular tumor categories. We have to be more tumor expansion that compresses normal structures and frank
precise inourevaluationof intrinsictumor location, realizingthat infiltration is obscure. Tumor infiltration 'is vicariously inferred
thefocalsurgicaland functional anatomy may be quite distinct. In from the T2 peritumoral changes on MRI associated with tumors
planningsurgicalresection, it is very important not to consider all (These changes, generally, are bright are as on TTweighted images
tumorsin one lobe as being of the same category. It is essential for that irregularly circumscribe mass lesions with finger-like projec-
thesurgeonto attempt to describe the location of a tumor as refer- tions extending into surrounding parenchyma) (Table 3.7 and Fig.
ableto a specificgyrus or subgyrus, as most glial tumors arise from , 2.9, p. 148).
a segmentof only one gyrus (see Cases 2.1-2.14). In addition, the Trittmacher et al. (1988) identified two types of peritumoral
assumptionthat the superimposition of a tumor on the underlying changes on MRI. Type I occurs characteristically around benign
anatomymust reflect infiltration of the lesion may give a false tumors such as meningiomas. It is localized on MRI to the region
impressionof the true topography of the lesiono Infiltration may immediately around the tumor, and persists indefinitely (hyperin-
be "overread" unless the real anatomy of a tumor is understood. tense area) on MRI. It is believed by many that this type of
Forexample,the anatomical distortions of three contiguous gyri peritumoral change represents the permanent effects of severe
bya tumor,which is in fact arising in only one should not be neces- edema, ischemia, and necrosis (with subsequent MRI changes)
sarilyregarded as tumor infiltration of all three. "Overcalling" the related to longstanding tumor compression of the surrounding
extentofmalignantinfiltrationand "underreading" the tru~ ana- brain.
tomicallocationof a tumor can seriously distort surgical planning, Type 11 occurs with both extrinsic and intrinsic tumors, and
andlead to intraoperative surprises. can be localized or diffuse on neuroimaging. It is distinguished by
its tendency to spread throughout the ipsilateral hemisphere, and
Paraxial.Paraxiallesions can also pose a problem in location. In
often it is quite irregular in outline. This type of peritumoral
many instances, parase llar, parachiasmal, paratentorial, para-
change tends to resolve on postoperative MRI over 8-12 weeks,
peduncular,parapineal, parapontine, and parabulbar lesions are but may persist (even diffusely) indefinitely in some situations fol-
notsharplyseen on CT and MRI. Again, superimposition of nor-
lowing tumor removal. The etiology of this type of peritumoral
mal and abnonnal structures may cause a paraxial lesion to
change is not well understood.
appearinfiltrating (see Cases 3.5, 3.32. 5.9-5.11). Some authors favor the proposal that glial tumors tend to
lo addition to a false appearance of infiltration, herniation of
spread along white-matter tracts, incIuding association, projec-
cerebraltissue is often so distorted that it may be misinterpreted.
tion, and commissural fibers. It is suggested that tumor proteins
Thedegree of herniation, whether subfalcial, subtentorial, para-
disrupt the blood-brain barrier, and that the abnormal vessel
chiasmal,parapineal, or latero-orbitofrontal, can easily be under- walls allow tumor cells to escape and proliferate in the surround-
estimatedor missed (see Case 5.17).
ing white matter. It is concIuded that this process is represented
Bouodaries.Extrinsic tumors are usually well circumscribed by these T2 changes.
pathologicalentities and, with the vast majority of virgin (i. e. not In theory, since gliomas have a higher water content than nor-
previouslyoperated) tumors, the tumor boundaries can be seen mal brain, proton imaging sensitivity should reflect this on the TI
adequatelyon CT or MRI. Deciding whether there is true dural or and T2images. Tumors in general have prolonged TI and T2relaxa-
venoussinusinvolvement,or both, can be a major problem in a tion times (TR) that produce less signal with a short TR (e. g., TI)
smallnumber of cases. and an increased signal intensity with a longer TR (e. g., T2).
Preoperative imaging of intrinsic tumors however, does not These changes are directly related to a change in the water con-
reliablyprovide the surgeon with precise tumor boundaries. tent of both the tumor and the peritumoral area. Clearly, these
204 3 Neuroradiology

Table 3.7 Perilesional changes (hypodensity, hyperdensity, or ocelusions in the distribution of the venous drainage of the deep
intensity) white matter that are demonstrated as peritumoral changes on
Severe changes Minor changes No changes imaging. We have witnessed glioblastomas without peritumoral
changes on preoperative MRI that intraoperatively proved to be
Tumors Tumors Tumors encapsulated tumors without evidence of thrombosed veins.
Metastasis Acoustic neurinoma Craniopharyngioma
Glioblastoma
Meningiomas with Type 11 perilesional changes on MR
Low-grade astrocy- Epidermoid, der-
Glioma toma moid almost inevitably have arachnoidal-pial reactions, with incorpora-
(High grade --+Iow Oligodendroglioma Chondroma, chor- tion of leptomeningeal vessels (both arteries and veins), leading
grade) Ependymoma doma to marked adherence and adhesive lobar changes and making
Meningioma Pinealoma Pituitary adenoma microsurgical removal difficult (see Cases 3.43, 3.45 on p.236).
Pineoblastoma Neurocytoma Optic glioma
Meningiomas without such perilesional changes on MRI do not
Ganglioneurocy- Plexus papilloma
toma Ganglioglioma show such intense adherent and adhesive reactions (see Cases
Lipoma 3.42, 3.44, 3.46 in pp. 235-238).
Infection Vascular lesions Subependymoma Other etiologies resulting in Type 11 peritumoral changes
Abscess Giant aneurysms (Tuberous sclerosis) might inelude other types of edema, or the effects of treatment by
Parasites Large cavernomas Colloid cyst
Echinococcus surgery, chemotherapy, radiation, or a combination of these
Vascular lesions modalities.
Toxoplasmosis
AVM We have coneluded that the peritumoral increased signal
White-matter diseases Other angiomas intensity is a nonspedfic finding (see cases 3.52-3.57 in
Progressive multifocal Hemangioblastoma pp. 243-245). This is confirmed by a number of studies demon-
leukoencephalopathia
Multiple scierosis
strating that T2 changes do not correlate with malignancy in
Ischemia Infections, parasites biopsy-proved specimens of correlative material. It remains for
Infection (e. g., cysticercosis) newer techniques to elarify this, in conjunction with pathological
Radionecrosis Chronic subdural proof. Some help may come from new techniques, including PET
hematomas
Trauma
and Na-MRI that show promise, especially in distinguishing radia-
tion necrosis from recurrent tumor.

Cleavage

characteristics are not specific for tumors, and the diagnosis of Extrinsic tumors. Some tumors have a elear line of demarcation
tumor infiltration may be incorrect. around them that allows for easy surgical removal in a specified
In the early and intermediate phases of glial tumor growth, eleavage planeoPreoperative imagingcan often demonstratethis.
our experience suggests that the Type 11changes are not represen- Other tumors do not reflect this on imaging, but still can be
tative of frank infiltration. Later stages of the same process may readily shelled out. Others, with a seemingly elear interface
have even more striking T2 changes, which at this advanced stage between the parenchyma and tumor on preoperative imaging,
do indeed reflect true tumor infiltration. It is fair to say that opera- may be densely adherent and extremely difficult to resect. This
bility should never be based solely on this identification of per- problem of immense practical importance is a biologicalone,for
ilesional T2changes. They can be very misleading. In fact, a com- which CT and MRI provide the surgeon with no real usefulinfor-
parison of noncontrast and contrast high-resolution CT scans has mation. The distinct planes of the pia, arachnoid, and dura, and
given a better idea of the true extent of certain large tumors with whether these planes have been compromisedby adherencereac-
extensive perilesional changes than TI and T2 MRI views. tions, cannot be gathered from even the best neuroimagingstud-
In our experience, tumors (even high-grade gliomas) tend to ies (Figs. 3.1, 3.2). Many adherent tumors can be carefully peeled
remain local processes in their early and intermediate phases of off normal structures. Others may be more difficult to remove
growth. Moreover, the appearance of the many of the Type 11 ("adhesive" ones). These are tightly adherent to normal brain,as
perilesional changes remind us more of the patterns of deep if tissue adhesive had been applied (like a stamp to an envelope).
venous drainage observed by Hassler (1966), Wolf and Huang Even the most careful attempts to remove these tumors result in
1964), and others. Although venous drainage has been studied the removal of normal parenchyma. Unfortunately, only limited
extensively, there are not enough combined studies of white-mat- preoperative information regarding tumor adhesiveness can be
ter deep venous drainage correlated to CT and MRI in the neu- obtained from present neuroimaging modalities.
ropathological state to draw firm conelusions (Fig. 1.96). The biological activities of extrinsic tumors frequently lead
We have identified venous thrombosis during glioblastoma to a reactive arachnoiditis, triggering a variably intense reaction
resection, and note the positive correlation between this finding between the pia and arachnoid layers (and often involving the
and the degree of marked T2perilesional changes on the preopera- dura). This "arachnoiditis" gives rise to pseudocapsule formation.
tive films.In these cases, the distribution of these marked T2peri- prominent near dural contact areas of the tumor boundary, but
lesional changes corresponded very well with the venous patterns petering out at parenchymalboundaries.Meningiomaswith signif-
detailed by Hassler, Wolf, and Huang. Even small superficial sub- icant peritumoral changes on T2 images tend to be extremely
palliallesions may demonstrate these deep venous patterns, per- adherent at the interface between the brain parenchyma and local
haps representing engorgement and obstruction of the centripetal vasculature (Table 3.8). The plane around an extrinsic tumor, and
and centrifugal valveless venous system secondary to thrombosis. its relationship to the dura, arachnoid, and pia, is often unclearon
The increased water content may be secondary to small venous present imaging due to pseudocapsule formations. The tumor
 The Application of Neuroimaging Capabilities to CNS Tumors 205

Dura mater
Arachnoid

Interarachnoidal Trabeculae
(subarachnoidal)
space Pia
Subpial space -5 Limitans membrane

Cortex

Perivascular space

Blood vessel a

Fig,3,1 Note the position 01the subarachnoid

(reallyan interarachnoidal)vessel within a pial
sleeve(Irom Hutchings and R. O. Weller, J Neuro-
surg1986; 65: 323, Fig, 9, See also Krisch et al.,
CellTissue Res 1983; 228:597 -640)
a The dura, arachnoid, and piallayers
OrangeDura
BlueArachnoid
GreenPia
YellowLimitans membrane
b Subarachnoid hemorrhage
e Leptomeningitis

interfacewith arteries,veins,and dural sinuses is frequently even Table 3,8 Membranes of tumor and pseudocapsule formation
lessclear.On present CT or MRI studies, we rarely see individual around the tumor
cranialnerves and their relationships with skull base tumms. They Dural Pituitary adenoma, meningioma, chordoma, chon-
are only discovered during surgical exploration (which is drama, glomus tumor
frequentlydifficult). Arachnoidal Craniopharyngioma, pinealoma, germinoma, tera-
In the sellar region, MRI and CT can demonstrate displace- toma, neurinoma, dermoid epidermoid, optic glioma,
cyst
mentof the pituitary stalk, especially on coronal views and thin- Arachnoid pia Meningioma, craniopharyngiomá, etc,
sectionreconstruction. In some cases, extrinsic tumors can be Gliosis Glioma, cavernoma, metastases, angioblastoma,
definedin relation to the pituitary stalk and gland. medulloblastoma, meningioma
Ependymal Ependymoma, subependymoma, plexus papilloma,
Intrinsictumors. A cleavage plane is even more difficult to iden- changes intravenous glioma
tify whendealingwithan intrinsictumor. Tumor relationships to
arteries,veins, and glial surfaces are often vague and ill defined.
Gliosis,as distinct from tumor or perilesional edematous changes,
isnot readily seen on MRI. Even when a cleavage plane is iden-
tified,the lesion may still be difficult to extirpate due to unde-
tectedand unsuspected adherence or adhesiveness.
 206 3 Neuroradiology

.',

--J
'
~~~,flr ~, ..
.
';
."

~
"

.
."
.,., ...,,

a
o @ 0) @
Fig.3.2 The demarcation of CNS neoplasms:-the spectrum of a Epidurallesion (i. e., chordoma, chondroma)
possible effect on surrounding tissue planes. Vessels within the area 1 No adherence to the underlying dura
are purposely excluded, in order to emphasize the pathological 2 Adherence to the dura
changes within the leptomeningeallayers 3 Penetration through the dura, with adherence to the arachnoidlayer
Orange Tumor 4 Infiltration into the arachnoid and piallayer with disruption of the limi-
Yellow Dura tans membrane
Blue Arachnoid
Green Pia
Red Glia limitans
Gold Cortex
1 No adherence to surrounding structures, excellent cleavage plane, 3 Penetration through surrounding structures, no cleavage plane
total demarcation 4 Infiltration into surrounding structures, severe adherence
2 Adherence to surrounding structures, fair to poor cleavage plane,
poor demarcation

b
o 0) @
b Intradurallesion (i. e., meningioma) 3 Penetration through the dura with adherence to the arachnoid layer
1 No adherence to the encasing dura 4 Infiltration into the dura, arachnoid, pia and limitans layers
2 Adherence to the dura

e
0' @ 0) @
e Subdurallesion (i. e., meningioma, adenoma) 3 Penetration through the arachnoid with adherence to the piallayer
1 No adherence to the underlying arachnoid 4 Infiltration into the dura, arachnoid, pia, and limitans layers
2 Adherence to the dura
r---

d
o @ 0) @
d Intra-arachnoid lesion (i. e., craniopharyngioma, optic glioma, 2 Adherence to the overlying arachnoid and dura
epidermoid, neurinoma) 3 Penetration through the arachnoid with adherence to the piallayer
1 No adherence to the surrounding arachnoid 4 Infiltration into the arachnoid, pia, and limitans layers
 Summary 207

.~
CD @ o @
e Subpial-subcorticallesion (i. e., glioma) 3 Penetration through the ependymallayer into the underlying ventricle
1 No adherence to the surrounding white matter 4 Infiltration into the surrounding white matter
2 Adherence to the overlying cortex, limitans, and pia layers

DetailedLesion Reconstruction mining whether a lesion should be aspirated stereotactically or

attacked directly.
Neoplasms may be homogeneous or heterogeneous on imaging, Only limited information regarding the vascularity of a
but tfUetumor consistency (soft or hard) and viscosity cannot be lesion can be obtained from present neuroimaging. Gradient echo
determined until surgery. Cysts associated with tumors may techniques can usefully demonstrate flowing blood. Flow voids on
appear isodense and yet may contain hematoma, CSF, solid MRI usually indica te vessel patency. CT, MRI, and angiography
tumortissue,or tumor fluid (or a combination of all these) CT can together may readily show whether a lesion is hypovascularized
identify the density of a specific area and can shed light on the or hypervascularized, but no other inforrriation regarding its quali-
presenceof calcium, blood, CSF, and other dense materials. MRI tative and quantitative vascular aspects can be ascertained from
canprovide general information as to the true composition of cys- preoperative images. No information regarding tumor vessel
ticlesions.Usually, the contents of a cyst have a higher protein con- fragility is obtainable. Thus, tumor vascularity is understood only
tentthan CSF, so an increased sign~l compared to CSF is seen on in gross terms prior to surgery. However, MRA is now improving
Tb while a decreasedsignal is seen on TI' However, neither MRI rapidly, and may provide answers to this crucial aspect of opera-
nor CT can accurately elucidate the true composition of a lesion tive planning.
preoperatively.This, of course, has considerable impact in deter-

Summary

Plainradiographs of the skull (in the initial assessment and some- the neuroanatomical conceptsof tumor topography using a sec-
timesin the follow-up of certain extrinsic tumors involving the toral architectural arrangement, permit accurate interchanges
skull),chestradiographs, and plain spine radiographs, where indi- between neurosurgeons, neuroradiologists, neuropathologists,
cated,continue to be important in preoperative evaluation. neurophysiologists,and anyone else interested in CNS neoplasm
Pneumoencephalography, myelography, and cerebral and patients.
spinal angiography were the mainstay of neuroimaging until Noninvasive scanning methods with CT and MRI allow for
twenty years ago. Although uncomfortable, invasive, and the identification of small or occult lesions with great accuracy.
associatedwitli some morbidity, myelography and angiography Small avascular lesions lacking tumor blush and mass effect,
are still excellent studies for the diagnosis of pathologicallesions. which were often missedpreviously,are now readily detected.CT
Angiographyis essential in selected patients with tumors close to, and MRI provide us with excellent images representing in-vivo
or involving,major arteries or routes of venous drainage. Present CNS structures and related pathological changes. They deliver
dayMRA can help in the evaluation of these patients. immediate, noninvasive images of the CNS parenchyma and
Cerebral aneurysms are a disease of the intra-arachnoidal craniospinal bony axis in triplanar views.
spaces, while AVMS involve not just the intra-arachnoidal space, The technologies of CT and MRI are quite distinct. CT uses
but alsothe cortex and white matter. The mainstay of neurodiag- ionizing radiation to produce an image based on the numerical
nosticevaluation of these conditions has been angiography. Intrin- differences in electron densities in the CNS and surrounding tis-
sicCNStumors, on the other hand, are almost exclusively a white- sues. Thus, in describing CT changes attributed to lesions, one
matterdisease.As a result, for gliomas white-matter imaging stud- uses terms dealing with density as related to the brain parenchyma
ies(suchasCT and MRI) are paramount. The precise localization (hyperdense, isodense, hypodense).
01intrinsic gliomas is critical for the best operative approach to MRI, on the other hand, is more complex, based on mobile
thelesion(with a minimum of risk) and for the correlation of surgi- hydrogen protons which, when exposed to radiofrequency waves
cal findingswith neuropathological studies. We have found that in a strong magnetic field, generate signal differences during their
208 3 Neuroradiology

relaxation phase. Therefore, the images generated are described The significance of peritumoral changes with different
in terms of image intensity, i. e., bright, hyperintense, hypointense, tumors is uncertain. Clearly, peritumoral changes do not repre-
etc. MRI is more sensitive than CT, and is the current gold stan- sent tumor penetration into cerebral adjacent tissues by gliomas.
dard for detecting CNS lesions. The occurrence and significance of tumor infiltration as related to
Present-day neuroimaging has reduced those lesions in peritumoral changes remain uncertain. Neuroimaging has
which the nature of the lesion remains largely speculative down to resolved many of the problems in tissue differentiation, but the
between 5 and 10% of cases. The nature of the majority of CNS excellent resolution of MRI raises new questions about
lesions is diagnosed correctiy as being of a vascular, inflammatory, pathophysiological interpretation, especially with regard to peri-
autoimmune, degenerative, or neoplastic nature. In general, the tumoral changes. In addition, it is important to avoid clinicalinter-
differential diagnosis is excellent, but in individual cases uncer- pretations of neuroimaging studies, especially with regards to
tainty remains. Commonly, a glioma cannot be ruled out in favor herniation syndromes.
of an unusual presentation of a.more benign tumor (neurinoma, The interpretation of cystic changes seen well on MRI can be
meningioma, epidermoid, etc.), or an infrequentiy encountered difficult (i. e., a real tumor cyst, hemorrhagic fluid, a hematoma,
lesion (chronic granulomatous processes, such as tuberculosis or or solid tumor tissue?). The qua lity of vascularization of a tumor
sarcoid, hamartoma, abscess, or infarct). This lack of specificity is unpredictable with MRI. MRA shows some promise in this
provided by preoperative MRI scans is of ongoing concern to neu- respect, but at present only helps us decide which tumors merit
rosurgeons. further study by arteriography.
Triplanar MRI is superb in its anatomical resolution. It is The concept of sectoral white-matter structure brings
probably only in less than 5% of patients that a precise topographi- together the disciplines of neuroanatomy, neuroradiology, neu-
cal diagnosis cannot be made. Certainly, extrinsic and intrinsic rophysiology, and neuropathology in relation to intrinsic brain
tumors can be readily distinguished. Despite the high quality of tumors. The network of connections in the cerebral cortex, basal
neuroanatomical detail brought about by modern neuroimaging, ganglia, and spinal cord have been areas of intense research
new mapping techniques arestill necessary to better formulate effort. However, the white-matter subsystem of the cerebrum
precise surgical approaches. For example there is still no reliable (and cerebellum) is much less studied. Perhaps this conceptual
way to identify the sulci (so clear on neuroimaging) at surgery. architectural plan will encourage future generations of specialists
Current neuroimaging, despite its 1.0 mm resolution capac- in these disciplines to "map" this largely unexplored continent.
ity and exquisite sensitivity, has been unable to provide answers to MRI has provided the basic framework of the white matter,to
many areas of critical surgical and pathological interest. The layer which we now need to add the fine detail.
of origin of extrinsic tumors is often very difficult to determine. It is important to constantiy keep in mind the fact that cur-
MRI is poor at demonstrating the dura as a separate stucture in rent high-resolution pictures only complement the clinician's
cases of tumors occupying the epidural, subdural, or sub- skill, in formulating an accurate differential diagnosis, based on a
arachnoid spaces. As a result, it is clear that MRI can rarely pro- complete history and physical examination. The belief of some
vide information on cleavage planes, the degree of any arachnoidi- that the history and physical examination are rendered superflu-
tis, or the degree of adherence or adhesiveness, or both (except ous by present neuroimaging sophistication is dangerous, and
for meningiomas with perifocal hyperintensity, in which MRI pre- undermines the benefits these images provide. Decisions on treat-
dicts severe adherence between the tumor surface, arachnoid, and ment must remain clinical judgments, considerably aided by care-
pia) (Table 3.9). fui evaluation of the detail provided by modern imaging.
The major disadvantages of MRI include extended scan
times and confinement in a claustrophobic space. It remains prob-
Table 3.9 Interpretrative cautions in the neuroimaging of tumórs
(CT,MRI) lematic to scan critically ill ventilator-dependent patients.Other
limitations include: remote scanner locations, minimal support
Oislocation effect of the mass
staff, and lack of nonferromagnetic monitoring equipment and
Magnification effect ventilators.
Superimposition effect (parachiasmal, ínsula, Sylvian fissure, transverse
Future MRI advances will no doubt shorten scan times,
fissure)
making the use of MRI in critically ill (and immediately postopera-
Hypodensity, hyperdensity or -intensity
Edema tive) patients worthwhile. Routine three-dimensional imageswill
Scattered tumor cells be come readily available. MRA will improve to the point where
True tumor infiltration the detail is sufficient for preoperative tumor planning eventually
Metabolic changes obviating the need for arteriography in most patients. Echo-
Radionecrosis
Hematoma planar MR with perfusion and diffusion imaging will eventually
Infarction help our understanding of the dynamic consequences of tumors
and their effects on the CSF system. MRS will advance suffi-
Boundaries
Bone, dura, sinuses Infiltration cientiy to provide preoperative pathological information as well
Arteries, veins and sinuses Invasion as standardized monitoring of treatment effects. MEG appears
Dura, arachnoid and pia Adherence very promising for functional localization. Other further
Parenchyma Adhesiveness
advances in neuroimaging technology will provide neurosurgeons
Ependyma Gliosis
Choroíd plexus { Membrane formation with increasingly precise and dynamic information relating to
tumor topography and pathophysiologic characteristics.
 Conclusions . Cases 209

Conclusions

Greatadvances have been made in the neuroradiographic visual- The following 59 cases are presented to illustrate and further
izationof CNS tumors, but we must be carefu!! The precise locali- elucidate the discussed difficulties of differential diagnosis.
zationof intrinsic tumors on neuroimaging must not be described
iniobarterms (what lobe?), but in terms of what part of a gyrus Case
(anterior,middle, or posterior) and which sector (or, in the case of 3.1-3.9 Diagnostic difficulties between intrinsic and extrinsic
a centralganglion and central nudei, which section). Neuroimag- tumors in parachiasmatic area.
ing studies cannot reliably provide information as to which 3.10-3.13 Differential diagnostic difficulties between menin-
tumorsare diffuse and which are circumscribed. We must be care- gioma and other tumors.
fuinot to make judgments on the basis of neuroimaging regard- 3.14 Difficulties concerning the origin of intraventricular
ing: localization, construction, extension, peritumoral changes, tumors.
andherniation. Neuroimaging provides an exact diagnosis in 90% 3.15-3.21 Difficulties with tumors in parapineal areas, their pre-
or more instances (retrospectively), but prospectively, in a given cise location and tumor type.
individualpatient, be careful. The combination of information 3.22-3.33 Difficulties concerning tumor localization and type in
fromMRI, PET, and SPECT (and other new technologies) will be the posterior fossa.
helpfulin these respects. 3.34-3.41 Radiological difficulties between neoplastic, infective,
degenerative and traumatic disease processes.
3.42-3.57 Problems associated with perilesional changes.
Cases 3.58-3.59 White matter changes.

DiagnosticDifficultiesbetweenIntrinsicand
Extrinsic
Tumorsin the ParachiasmaticArea

b
Case3.1 A 52 year-old a
lemalewith a one-year his-
lory01pelil mal seizures,
progressing lo diminished
memoryand mental slug-
gishness. MRI views (T1):
a coronal, b sagittal.
There is a well-delineated
lesion in the superior ante-
riorpart of the right septal
region.Origin? Postopera-
tiveviews(2 weeks post-
operalively):e coronal,
d sagittal. The tumor
(oligodendroglioma,
grade11) arasefromthe
righlside ofthe paratermi-
nal gyrus. Following trans-
callosalremoval, the
palient remains neurologi-
callynormal.
210 3 Neuroradiology

Case 3.2 A 3-year-old female who complained of headaches fol-

lowing a fall from her bed. MRI views: a horizontal (spin-echo),
b coronal (spin-echo), e sagittal (T,). There is a large, well-circum-
scribed lesion, with erosion of the sella and calcifications extending
from the infrasellar into the suprasellar region. Not the displacement
of the ventricular system but little ventriculomegaly (though the
mass extends to the foramen of Momo). Postoperative views
(3 weeks postoperatively): d sagittal (T,), e coronal (T1).The tumor
(craniopharyngioma) was entirely epidural, pushing the dura
upwards to the foramen of Momo (Iike an adenoma). This illustrates
the point that the dura is not visible on neuroimaging. The child
e remains neurologically normal following pterional removal.
 Cases 211

II

,\
b

e d
Case3.3 A 48-year-old man, with progressive headaches over peritoneal shunt. Two large pathological vessels terminated in the
severalmonths, recent weight gain (25 pounds), impotence, and an tumor, and a meningioma was assumed (a, b). The tumor was
unsteadygait. MRIimages (T1): a sagittal, b corona!. There is a well- removed using a combined approach. The patient remains neuro-
circumscribed lesion in the area of the third ventricle, with obstruc- logically normal, with intact visual fields. He needs substitution ther-
tive hydrocephalus. Postoperative views: e sagittal, d corona!. This apy.
tumor (craniopharyngioma) was treated elsewhere by a ventricular