Extra axial lesions

Meningioma
Hemangiopericytoma
Meningial metastasis
Schwannoma
Arachnoid cyst
Dermoid cyst
Epidermoid cyst
Signs of extra axial
location
CSF cleft
Gray white matter buckling
Broad dural base(dural tail)
Displaced subaracnoid vessels
Displace and expand subaracnoid space
Bony reaction
Broad dural base

Grey white matter

buckling
CSF cleft
• There is a CSF cleft (yellow arrow).
• The subarachnoid vessels that run on the surface of the
brain are displaced by the lesion (blue arrow).
• There is gray matter between the lesion and the white
matter (curved red arrow).
• The subarachnoid space is widened because growth of
an extra-axial lesion tends to push away the brain
broad dural base or a dural tail of enhancement as is
typically seen in meningiomas.

There is hyperostosis in the adjacent bone and the

lesion enhances homogeneously
MENINGIOMA
Location
Supratentorial (90%):
 Para sagittal/convexity (45%),
 sphenoid ridge (15-20%),
 olfactory groove (5-10%),
 parasellar (5-10%)

Infratentorial (8-10%): CPA most common

inside the dura:
Intraventricular, optic nerve sheath, pineal region
outside the dura: Paranasal sinus (most
common), nasal cavity, parotid, skin, calvarium
 Convexity Parafalcine

Sphenoid Ridge Olfactory Groove and sella

Posterior Fossa Cerebellopontine angle
Morphology
 Extra-axial mass with broad-based dural
attachment
Two basic morphologies
 Globose = globular, well-demarcated
neoplasm with wide dural attachment
 En plaque = sheet-like extension covering
dura without parenchymal invagination
En plaque
WHO grading
Common meningioma = WHO grade 1
very slow-growing tumors account for
75%
 Atypical meningioma = WHO grade 2
Usually slow-growing but can recur.
Malignant meningioma = WHO grade 3
More malignant, faster-growing.
Radiographic Findings
Radiography:
Hyperostosis,
irregular cortex,
tumoral calcifications,
 increased vascular
markings
 CT Findings
 NECT
 Hyperostosis, irregular cortex,
tumoral calcifications,
increased vascular markings
 Sharply circumscribed smooth mass
abutting dura
 Hyperdense (70-75%), iso- (25%),
hypo- (1-5%)
 Calcified (20-25%): Diffuse, focal,
sandlike, sunburst, globular, rim
 Necrosis, cysts, hemorrhage (8-23%)
 Rare lipoblastic subtype ~ negative
Hounsfield
 Brain cysts & trapped pools of CSF
common
 Peritumoral hypodense vasogenic
edema (60%)
 CECT: > 90% enhance
homogeneously & intensely
 MR Findings
TlWI
o Usually iso- to slightly hypointense with cortex
o Necrosis, cysts, hemorrhage (8-23%)
o Best to visualize gray matter "buckling“
T2WI
o Variable; sunburst pattern may be evident
o Best to visualize trapped hyperintense CSF
clefts (80%) &
Axial T1 C+ MR
vascular flow voids (80%) Axial Tl C+ MR shows
demonstrates
• FLAIR: Hyperintense peritumoral edema, heterogeneous
dural "tail" dural-based
enhancing
• T2* GRE: Best sensitivity for calcification mostly
• DWI: DWI, ADC maps ,variable in appearancehomogeneousl mass of
• Tl C+ cerebellopontine
y enhancing
o > 95% enhance homogeneously & intensely angle extending into
mass with
o Dural "tail" (35-80% of cases ): Non-specific the
o En plaque: Sessile thickened enhancing dura cortical
internal auditory
buckling.
canal but
Note dural
without obvious
"tail" (arrow).
widening.
Angiographic Findings
 "Sunburst or radial"
appearance with
prolonged vascular
"stain"
 DSA: "Mother-in-law"
sign ~ comes early, stays
late
 Dural vessels supply
lesion core
 Pial vessels (ACA, MCA,
PCA) may supply
periphery when
parasitized
 Venous phase vital to
evaluate sinus
involvement
 ATYPICAL AND MALIGNANT
MENINGIOMA
 Dural based lesion locally invasive with areas of
necrosis & marked brain edema.
CT Findings
NECT
 Hyperdense with minimal or no calcification
 Marked perifocal edema & bone destruction
CT "Triad" of Malignant meningima
 Extracranial mass, osteolysis, & intracranial .
tumor
CECT
 Enhancing tumor mass
 Prominent pannus or tumor, extending away from
mass termed "mushrooming"
 MR Findings
TlWI
 Indistinct tumor margins
 Extending tumor
interdigitating with brain
FLAIR :
 Marked peritumoral edema
DWI
 Markedly hyperintense on DWI
 Marked decrease in ADC
 Correlates with histopathology
T1 C+ Sagittal T1 C+ MR
Axial
 Enhancing tumor mass shows enhancing
FLAIRMR
 Plaque like & may extend into tumor
demonstrates
brain, skull, scalp involving the scalp,
hyperintense
skull, &
tumor
underlying brain.
"mushrooming"
with hypointense
inwards
Brain edema
deforming
HEMANGIOPERICYTOMA
"angioblastic Location
Supratentorial: Occipital
meningioma,“ region most common
Lobular
Typically involve falx,
enhancing extra- tentorium, or dural sinuses
axial mass with
Rarely from skull base,
dural attachment, cranial nerve,
+/- skull erosion intraventricular
involvement
 May mimic
meningioma, Dural "tail" commonly
seen, approximately 50%
but without Ca+
+ or hyperostosis
 CT Findings
NECT:
Hyperdense extra-axial mass
with surrounding edema
 Low density cystic or
necrotic areas are common
 Calvarial erosion may be Axial CECT shows an
seen aggressive
appearing, lobular
 No Ca++ or hyperostosis extra-axial mass with bone
erosion
CECT: (arrow), central
Strong, heterogeneous necrosis, and surrounding
edema,
enhancement typical of
hemangiopericytoma
 MR Findings
TlWI
 Heterogeneous mass,
isointense to gray matter
 Flow voids may be seen
T2WI
 Heterogeneous isointense
mass
 Prominent flow voids are
common
 Surrounding edema, mass
effect typical Axial T1 C+ MR shows
 Hydrocephalus may be seen an avidly enhancing
Tl C+
mass
 Marked enhancement, often
With areas of low
signal
heterogeneous
 Dural "tail" may seen
intensity representing
necrosis
And extension through
the
Schwannoma
 Benign encapsulated Location
nerve sheath tumor
composed of
All cranial nerves (exceptions:
differentiated neoplastic Olfactory, optic
schwann cells nerves) have myelinated
 Cranial nerve schwann cell sheaths are
schwannoma: Slow- sites for intracranial
growing schwannomas
extra-axial mass
98% arise from cranial nerves
 Displaces ("buckles") (predominately sensory)
cortex 90% arise from CN 8 (vestibular
 CSF-vascular "cleft" portion)
10% other (5% CN 5; 7; motor
between tumor, brain nerve
 Cyst with nodule schwannomas rare in absence
of NF2)

1-2% intracerebral
CT Findings

NECT
 Noncalcified extra-axial mass
 Iso/slightly hyperdense compared to brain
 May enlarge bony foramina (lAC, foramen
ovale, facial nerve canal)
 Parenchymal:
Well-delineated hypodense cyst +
isodense nodule,
variable Ca++
CECT: Strong, uniform enhancement
MR Findings
TlWI
 Usually iso-, sometimes
mixed iso/hypointense
 Less common: Intra tumoral
cyst (occasionally have fluid-
fluid level), hemorrhage
 Marginal arachnoid cyst
T2WI
 Hyperintense (nodule may
be isointense) Axial T2WI MR in a
 Surrounding edema Axial T1 C+ MR with fat
patient with
common suppression shows the
Tl C+
diplopia shows
orbital apex mass
 Enhances strongly a lobulated, well-
enhances
 Cranial nerve schwannoma: delineated
strongly but
2/3 solid; 1/3 ring or mass at the orbital
inhomogeneous heterogeneously.
apex that
 Parenchymal schwannoma: Schwannoma of
Nodule enhances strongly
expands superior
abducens
 Identify even small sized orbital
nerve was found at
lesion fissure (curved
surgery
arrow),
extends posteriorly
Meningeal metastases
Meningeal metastases may involve the
pachymeninges (dura mater),
leptomeninges (arachnoid and pia mater)
or both.
 Carcinomatosis of the dura mater,
common in carcinoma of the breast,lung,
melanoma
 CT Findings
NECT
 Any: May find hemorrhagic
hyperdensity
 Sub-galeal space: Relative dense lesion
CECT
 Skull M: Enhancing mass centered in
bone with osseous destruction, lacking
'benign" sclerotic border
 Most are lytic; a few sclerotic (e.g., Axial CECT shows
prostate) diffuse, bilateral,
 DM & LM: Both may appear as leptomeningeal
enhancing biconvex metastases.
masses displacing brain Morphology is
 DM characterized by calvarial smooth rather
involvement than nodular
 Carcinomatosis: CT is insensitive,
however
hydrocephalus may be early sign
MR
Findings
TlWI
 SM: Hypointense marrow
lesion
 DM & LM: Most masses
hypointense to gray matter
 Sub-galeal space: Relative
hypointense lesion
T2WI Axial Axial TIC+ MR:
 SM: Hyperintense marrow Tl C+ MR: Carcinomatosis
lesion; dura usually intact Enhancing skull w/tumor along
 DM between skull &
metastasis folial pia
elevated hypointense dura
 DM & LM: Most
involves both (white arrow) &
hyperintense relative to underlying dura also
gray matter and subarachnoid/
FLAIR overlying scalp. CSF coating
 Diffuse hyperintense to
Superior ventricle (black
CSF
sagittal sinus is arrow),
occluded by cranial nerves
invasion (arrow). (open black
Fat-saturation arrows), brain
ARACHNOID CYST
Intra-arachnoid CSF-filled sac that does not
communicate with ventricular system
Sharply demarcated round/ovoid extra-axial
cyst that follows
CSF attenuation/signal
Location

50-60% middle cranial fossa (MCF)

10% cerebellopontine angle (CPA)

10% suprasellar arachnoid cyst (SSAC),

variable types
10% miscellaneous

(convexity,quadrigeminal)
CT Findings
NECT
 Usually CSF density
 Hyperdense if
intracyst hemorrhage
present
 May expand,
thin/remodel bone
CECT: Doesn't
enhance
 CTA: Posterior
displacement of MCA
in middle cranial
fossa
 CT: Cisternography
may demonstrate
communication with
subarachnoid space
MR Findings
TlWI
 Sharply-marginated extra-
axial fluid collection
 isointense with CSF
 "Mickey mouse ears"
appearance on coronal scans =
SSAC plus lateral ventricles
T2WI: Isointense with CSF
 PD Isointense with CSF
 FLAIR: Suppresses completely
with FLAIR
 T2* GRE: No blooming unless Axial FLAIR MR shows Axial
hemorrhage present (rare) an extra-axial DWl MR
 DWI: No restriction
cystic-appearing mass in shows no
 T1 C+: Doesn't enhance
 MRA: Cortical vessels
the restriction.
displaced away from calvarium middle cranial fossa Presumptive
 MRV: Can demonstrate (arrows). diagnosis is
anomalies of venous drainage The temporal lobe arachnoid cyst.
is hypoplastic with Epidermoid
posteriorly displaced cyst would not
temporal horn. suppress
DERMOID CYST
congenital inclusion cysts
Location
 Most often in sellar/parasellar/frontonasal
region
 Posterior fossai midline vermis & 4th
ventricle
 Intraventricular within tela choroidea in
lateral, 3rd, or 4th ventricles
 Extracranial sites = spine, orbit
 Ruptured: Subarachnoid/intraventricular
spread of contents
 CT Findings
NECT
 Round/lobulated, well-
delineated, cystic mass
 Fat hypodensity
 20% capsular Ca++
 With rupture, droplets of
fat disseminate in cisterns,
may cause fat-fluid level Axial NECT shows
within ventricles hypodense, fat-containing
 Skull/scalp dermoid
pineal region dermoid
expands diploe (black arrow) which has
 Frontonasal: Bifid crista ruptured.
galli, large foramen cecum Fat droplets are present
+ sinus tract throughout subarachnoid
CECT: Generally no space (white arrows
enhancement
 MR Findings
 TlWI
 Unruptured: Hyperintense on Tl WI
 Ruptured: Droplets very hyperintense
on Tl WI
 Fat suppression sequence confirms
Fat-fluid level in cyst, ventricles
common
 Rare "dense" dermoid: Very
hyperintense on Tl WI
 T2WI Axial T1WI MR of Axial T2WI MR
 Unruptured: Heterogeneous, from ruptured dermoid ruptured dermoid
hypo- to hyperintense on T2WI
 Ruptured: Typically hyperintense (black arrow). Fat (black
droplets on T2WI droplets are arrow) contents
 Rare "dense" dermoid: Very present dispersed in
hypointense on T2
 With hair: Fine curvilinear hypointense throughout subarachnoid space
elements subarachnoid W ventricular fat-
 Tl C+: With rupture: Extensive MR
enhancement possible from chemical
space (white fluid levels,
meningitis arrows) with associated with
ventricular fat- chemical shift
fluid levels artifact
EPIDERMOID CYST
CSF-like mass insinuates cisterns,
encases nerves/vessels
Lobulated, irregular, "cauliflower-like"
mass with "fronds
Location
90% intradural, primarily in basal cisterns
Cerebellopontine angle (CPA) = 40-50%
Fourth ventricle = 17%
Para sellar/middle cranial fossa = 10-15%
Rarely in cerebral hemispheres = 1.5
 CT Findings
NECT
 Round/lobulated mass
 > 95% hypodense, resembling
CSF
 10-25% Ca++
 Intradiplioc epidermoid: Bony
erosion with sharply

corticated margins
 Rare variant = "dense"
epidermoid ,Secondary to Axial CECT shows non-
hemorrhage, high protein,
saponification of cyst debris to
enhancing, off-midline,
calcium soaps or iron- CSF isodense
containing pigment
CECT: Usually none although epidermoid within
margin of cyst may
show minimal enhancement
quadrigeminal cistern
 MRI
 TlWI
 Often (75%) slightly
hyperintense to CSF
 Lobulated periphery may be
slightly hyperintense
than the center
 Uncommonly
Sagittal T1 WI MR
 hyperintense to brain ("white
epidermoid") due to high demonstrates CSF
triglycerides & unsaturated
fatty acids isointense
 hypointense to CSF ("black
epidermoid
epidermoid") due to Presence
of solid crystal cholesterol & expanding the fourth
keratin Lack of triglycerides
& unsaturated fatty acids ventricle.
T2WI:
Often iso
(65%) to
slightly
hyperintense
(35%) to CSF
Very rarely
hypointense
Axial T2WI MR Axial T2WI MR
due to
calcification, shows nearly CSF shows
viscous isointense nearly CSF
secretions, epidermoid isointense
iron pigments
expanding the epidermoid within
fourth ventricle. left
Axial DWl MR shows restricted
diffusion within left anterior
middle cranial fossa epidermoid.
Tl C+
Usually none although margin of cyst may
show
Minimal enhancement (35%)
With malignant degeneration changes into
enhancing tumor
 Epidermoid Dermoid

content Squamousepithelial cells, Hair,fat,sweat glands

keratin,choelesterol
location Off midline Mid line
CPA most common Spinal canal most common
Parasellar,middle fossa Parasellar ,post fossa
Rupture Rare common

Age Mean 40 years Younger adults

CT density CSF density May have fat

Ca++ Uncommon common

Enhancement Occasionaly periphrally none

MRI CSF like signals Proteinaceous fluid

other 5-10 times more

commoner than dermoid
 Cerebello Pontine Angle
tumor
meningioma schwannoma epidermoid

Epicenter Dural based IAC CPA

CT Hyper/iso dense iso hypo

Ca++ frequent none occasional

Int.aco.canal normal widended normal

T2w relative to 50%isodense hyper hyper

Gr M
Enhancement dense dense none
Reference
DI Brain
Neuro imaging osborn
Grainger
THANK U