Brain Tumor Diagnosis by Location

Portions 1999 - 2006 by James G. Smirniotopoulos, M.D. This page was last updated: 01/10/2013 16:30:14

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REGIONAL NEUROANATOMY and DIFFERENTIAL DIAGNOSIS: PART 2 - Infratentorial Lesions PART 2 - Supratentorial Lesions
James G. Smirniotopoulos, M.D. Professor of Radiology, Neurology, and Biomedical Informatics Chairman, Department of Radiology and Radiological Sciences Uniformed Services University of the Health Sciences 4301 Jones Bridge Road Bethesda, MD 20814 Voice: 301-295-3145 FAX: 301-295-3893
DISCLAIMER The opinions expressed herein are those of the author(s), and are not necessarily representative of the Uniformed Services University of the Health Sciences (USUHS), the Department of Defense (DOD); or, the World Health Organization (WHO). Medicine is a constantly changing field, and medical information is subject to frequent correction and revision. Therefore the reader is entirely responsible for verifying the accuracy and relevance of the information contained herein. Portions Copyright 1997 - 2006 by James G. Smirniotopoulos, M.D.

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Schematic of Locations

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Brain Tumor Diagnosis by Location Schematic of Locations PATTERN ANALYSIS Basic Approach Where is the lesion ? Supratentorial Infratentorial Where is the lesion ? Intraaxial Extraaxial How old is the patient ? Child Adult PATTERN ANALYSIS Where is the Lesion? INTRAAXIAL internal to PIA (brain parenchyma) EXTRAAXIAL external to PIA (meninges, nerve sheath) INTRAVENTRICULAR Lateral Third Fourth

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INTRAAXIAL: Differential CORTEX GRAY/WHITE JUNCTION DEEP WHITE MATTER DEEP GRAY MATTER

INTRAAXIAL: Differential http://rad.usuhs.mil/rad/home/locate/locate.html 1/10/2013 4:31:04 PM

Brain Tumor Diagnosis by Location Differential Glioma Medulloblastoma Hemangioblastoma Metastases Infarct/hematoma AVM/congenital Abscess/inflammation EXTRAAXIAL LESIONS (Location) Subarachnoid Subdural Epidural Calvarium (skull base) Subgaleal Scalp (soft tissues) EXTRAAXIAL LESIONS (Differential): Meningioma Pituitary adenoma Craniopharyngioma Schwannoma Chordoma Dermoid/epidermoid, cyst, lipoma Hematoma, metastasis, infection CLASSIC LOCATIONS Foramen magnum Cerebellopontine angle Fourth ventricle/Cerebellum Sella/parasellar/suprasellar Basal ganglia/Third ventricle Lateral ventricle/Pineal region Deep hemispheric/periventricular Cortical/subcortical Convexity CPA MASSES:

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Brain Tumor Diagnosis by Location

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Differential S schwannoma (8th >> > 5th) A aneurysm, arachnoid cyst M meningioma, mets E epidermoid, ependymoma, CPP CPA MASSES Demographics 7/9 (Schwannoma, 8th > > 5th) 1/9 Meningioma (tentorial/petrous) 1/9 "Other": Epidermoid (1/18) Mets, aneurysm, etc. Glioma (ependymoma, CPP) Arachnoid cyst, Cystadenoma FEATURES OF CPA MASSES

Differential Diagnosis of CPA Masses Vestibular Schwannoma Meningioma Related to IAC IAC Enlarged Round, Acute Angle No relationship Epidermoid Cyst No relationship Does NOT enhance Related to Dura/Tentorium Cisternal Mass

Heterogeneous if Large Homogeneous

Hemisphere, Obtuse Angle Undulating/Serpentine

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Brain Tumor Diagnosis by Location

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* CHILDHOOD CEREBELLAR/IV: Differential Medulloblastoma (PNET) Astrocytoma (usu. Pilocytic) Ependymoma Post fossa cysts

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Brain Tumor Diagnosis by Location

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DEEP CEREBELLAR (ADULT) Metastasis Hemangioblastoma Hemorrhage, infarct Glioma (Ependymoma, Astro) Abscess POSTERIOR FOSSA INCIDENCE/LOCATION: Medulloblastoma (1/4 - 1/3) Post. To IVth Brainstem glioma (1/6) Ant. To IVth Ependymoma (1/6) Inside IVth Pilocytic (1/4 - 1/3) Lat. And/or post. IVth ( and these are often a cyst w / nodule ) DRAWING SELLA/PARASELLAR REGION Differential: Pituitary adenoma Craniopharyngioma Aneurysm (ICA , etc.) Meningioma Optic/hypothalamic glioma http://rad.usuhs.mil/rad/home/locate/locate.html 1/10/2013 4:31:04 PM

Brain Tumor Diagnosis by Location Optic/hypothalamic glioma Chordoma Granuloma, e.g., hamartoma, cyst(arachnoid, dermoid/epi) Germ Cell (Germinoma) PITUITARY ADENOMA Sexual Dimorphism paste table SELLA/PARASELLAR Differential Features: CHILD - Craniopharyngioma / Glioma (hypothalamus or optic ) ADULT - Pituitary adenoma SELLA NORMAL - NOT pituitary Ca++ - Craniopharyngioma, but... HYPEROSTOSIS - Meningioma ( exp. "blistering" ) CLIVUS - Chordoma, mets, NP Ca Remember - rule out vascular lesions (aneurysms) HYDROCEPHALUS Differential Diagnosis: Over production of CSF (CPP) Obstruction of CSF flow: Obstructive/internal hydrocephalus Communicating/external hydrocephalus Under reabsorption of CSF: SAH Compensatory: Ex vacuo/enlargement

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Brain Tumor Diagnosis by Location

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THIRD VENTRICLE Differential: Colloid cyst Craniopharyngioma Hypothalamic and thalamic glioma CPP, ependymoma Basilar tip aneurysm Neurocytoma

BASAL GANGLIA/THALAMUS: BILATERAL SYMMETRIC (toxic/metabolic): PUTAMEN - Methanol GLOBUS PALLIDUS - CO Poisoning BILATERAL ASYMMETRIC (hematogenous): INFECTION (TOXO, etc.) UNILATERAL (acquired/neoplastic): THALAMUS GLIOMA (astrocytoma) HYPERTENSIVE HEMATOMA (exclusion) ABOVE FORAMEN OF MONRO Lateral Ventricle/caudate Subependymal Giant Cell Astro. TUBEROUS SCLEROSIS, Enhances & Ca++ Subependymoma (variant of Ependymoma) No Ca++, no enhancement Central Neurocytoma (septum pellucidum) Cyst/Cavum septum pellucidum Huntington's Chorea http://rad.usuhs.mil/rad/home/locate/locate.html 1/10/2013 4:31:04 PM

Brain Tumor Diagnosis by Location Huntington's Chorea ATROPHY

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INTRAVENTRICULAR NEOPLASMS: Ependymoma (and subependymoma) Choroid plexus papilloma Subependymal giant cell astro. Meningioma Colloid cyst (3rd) Dermoid/epidermoid Central neurocytoma Medulloblastoma (4th) Mets, lymphoma, Germ Cell

PINEAL/QUAD. CISTERN REGION: "Pinealomas" Germ cell tumors Pineal cell tumors Pineoblastoma Pineocytoma Gliomas (regional) Brainstem, callosum, thalamus Other Dermoid, lipoma, arachnoid cyst Meningioma Vein of Galen malformations http://rad.usuhs.mil/rad/home/locate/locate.html 1/10/2013 4:31:04 PM

Brain Tumor Diagnosis by Location Vein of Galen malformations

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DEEP AND PERIVENTRICULAR: Glioma (astrocytoma) Lymphoma Toxoplasmosis, CMV Leukoencephalopathy (WM) Arteriolar sclerosis (HT) Infarcts (lacunar) Hemorrhage

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Brain Tumor Diagnosis by Location

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CONVEXITY (INTRAAXIAL) Gray-White Junction HEMATOGENOUS Neoplasm HEMATOGENOUS Infection HEMATOGENOUS Thrombi (multiple infarcts) INFARCTION/ISCHEMIA VASCULITIS

CEREBRAL INFARCTION 1. 2. 3. 4. Abrupt Onset Gray Matter Involved Little Mass Effect Vascular Wedge

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Brain Tumor Diagnosis by Location

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CONVEXITY (EXTRAAXIAL) Differential EPIDURAL (HEMATOMA empyema, mets) (biconvex, acute, limited by sutures) SUBDURAL (HEMATOMA empyema, mets) (Crescentic, subacute, crosses sutures) MENINGIOMA (hyperdense, hemispheric, hyperostosis, homogeneous enhancement) END OF SECTION . This page is maintained by: James G. Smirniotopoulos, M.D. Professor of Radiology, Neurology, and Biomedical Informatics Chairman, Department of Radiology and Radiological Sciences Uniformed Services University of the Health Sciences 4301 Jones Bridge Road Bethesda, MD 20814 Voice: 301-295-3145 FAX: 301-295-3893 Comment or Questions - Send EMail about this site.

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