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Mechanism for contrast enhancement in CNS tumors: Intratumoral Hemorrhage vs. Benign Intracranial
- Formation of capillaries with deficient blood-brain Hematomas
barrier rather than the destruction of blood-barrier
is presumed as the mechanism for tumor • Intratumoral hemorrhage:
enhancement. - Markedly heterogenous, related to:
- The capillaries of metastatic tumors to the brain o Mixed stages of blood
has no blood-brain barrier since these tumors o Debris-fluid (intracellular-extracellular
come from elsewhere and not from the brain. blood) levels
o Edema + tumor + necrosis with blood
Type of enhancement: - Identification of nonhemorrhagic tumor
- immediate or delayed component
- evanescent or persistent - Delayed evolution of blood breakdown products
- dense and homogenous - Absent, diminished, or irregular
- minimal or irregular ferritin/hemosiderin
- Persistent surrounding high intensity on long TR
Note: Lack of tumor enhancement do not signify images (i.e., tumor/edema) and mass effect,
lack of tumor. even in late stages
• Benign hemorrhage:
Effects of Tumor Necrosis on Signal Intensity: - Shows expected signal intensities of acute,
subacute or chronic blood, depending on stage of
Short relaxation Hemorrhage hematoma
times Liberation of cellular iron - No abnormal nonhemorrhagic mass
Release of free radicals - Follows expected orderly progression
Proteinaceous debris - Regular complete ferritin/hemosiderin rim
Prolong Cystic change with - Complete resolution of edema and mass effect in
relaxation times increased water chronic stages
Contrast
enhancement Variable; irregular Common; irregular Common; irregular Uncommon
INTRAVENTRICULAR MASSES
Tumor type Typical location Intensity characteristics on T2- Contrast enhancement
weighted images **
Central neurocytoma Lateral Isointense to gray matter Usually dense
(attached to septum
pellucidum)
Prognosis >90% 10-yr 50% 5-yr survival 65-70% 5-yr <1-2% 5-yr survival
(estimated survival) survival survival
Enhancement of adjacent meninges Cortex between mass and (edematous) white matter
Displacement of brain from skull Dura (meninges) between (epidural) mass and brain
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• Cardiac tumors the CT scanner is the most accurate but this would
• Congenital HD, ex.: right to left shunt depend on the cooperation of the facility operators.
Watershed Infarction Once the patient data is deleted from the memory
• Boundary zone infarct file of the system, the direct volume measurement can
no longer be applied on the data in the hard copy
• Internal carotid stenosis or occlusion
(film).
• Systemic hypotension
• Embolic events
In older model CT Scan where volume
measurement is not available, an alternative method
Hemorrhagic Infarction:
is possible by using the area of the hemorrhage:
• Hemorrhagic transformation results to petechial Volume in cubic cm =
hemorrhage or frank hematoma Area x slice thickness (millimeters) 1000
• Anticoagulant therapy
• Thrombolytic agents ABC/2 Method
• More common in cardioembolic strokes • Kothari, et. al., has developed a simple bedside
• Larger cardioembolic strokes are more likely to method of ICH volume determination with the
bleed following formula:
ICH volume = (A x B x C)/ 2
Temporal Evolution of Infarction on CT Scan:
0 – 4 hrs. Normal to subtle hypodensity
± sulcal effacement
• Step 1: The largest dimension of the
hemorrhage is determined in the
1 – 7 days Mass effect peaks at 3 – 4 days
series of CT slices, then the largest diameter of
the hematoma is measured and labeled – A
1 – 8 weeks Contrast enhancement
Days to Hypodensity • Step 2: On the same slice, the largest diameter
months/ yrs of hemorrhage 90o to A is determined and
Weeks to Atrophy labeled – B.
years • Step 3: “C” or the cephalocaudal dimention of
the hemorrhage is determined by comparing the
Acute to Subacute Infarction Changes: rest of the CT slices to the largest hemorrhage on
• Vasogenic Edema that later on wanes the scan.
• Enhancement -(Luxury perfusion) o If the hemorrhage area is 75 % of the
• Petechial hemorrhage largest hemorrhage area =
one (1) slice for determining C
Hypertensive Hemorrhage o If the area was 25 to 75% of the slice
• In hypertensives, hyalinization within the walls of where the hemorrhage was largest, the
small cerebral vessels results in slice is considered as one-half a
Microaneurysms hemorrhage slice
that are less than 1.0 mm in size, o If the area was less than 25 % of the
(Charcot & Bouchard), largest hemorrhage, this is not
that tend to arise from perforating vessels that considered as a hemorrhage slice.
will later on bleed.
Some of the Causes of ICH: When the CT slice thickness is smaller than
Hypertension the table movement, as will be commonly
Amyloid Vasculopathy encountered in CT slices of the posterior fossa,
Aneurysm there will necessarily be the presence of inter-
A-V malformation slice gaps.
Neoplasm
Coagulation disorders, e.g. hemophilia To remedy this, use the table movement
Aticoagulants measurement for thickness of the slice instead of
Vasculitis the actual slice thickness to calculate for volume.
Drug abuse e.g. cocaine
Trauma (A x B x C ) ÷ 2 = Volume in cc
Idiopathic A = 4.0 cm
B = 2.6 cm
• Hypertension accounts for 40-50% of deaths from C = 2.5 cm
non-traumatic hemorrhage in an autopsy series.
• In young (less than 40 y/o) normotensive (4.0 x 2.6 x 2.5) ÷ 2 = 13 cc
patients, cause remains unknown but cryptic
AVM is a suspect. Actual computation directly done in the CT scan = 13.3 cc
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