MRI OF BRAIN METASTASIS. Dr P. AGUETTAZ Hôpital Privé Clairval Marseille
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1 MRI OF BRAIN METASTASIS Dr P. AGUETTAZ Hôpital Privé Clairval Marseille
2 Purpose To avoid a few common pitfalls when imaging patient suspected of brain metastasis 1. Does hyperintensity on post contrast T1 weighted imaging always traduce gadolinium uptake? 2. Are all enhancement synonymous of brain metastasis? 3. Does measurement increase always represent tumor progression?
3 Brain metastasis Semeiology is simple and reproductible BM Appear usually as : Intra axial mass With sometimes calcifications, or haemorrhage Enhanced after gadolinium injection Surrounded with oedema Typical sub-cortical location
4 Brain Metastasis
5 Brain Metastasis
6 Does hyperintensities on post gadolinium T1 weighted imaging represent always contrast enhancement?
7 Post Gd hyperintensities = contrast uptake? This question could be or should be trivial if all suspected patients were explored in a proper way
8 Post Gd hyperintensities = contrast uptake?
9 Post Gd hyperintensities = contrast uptake?
10 Post Gd hyperintensities = contrast uptake? THIRD VENTRICULE FLOOR LIPOMA
11 Post Gd hyperintensities = contrast uptake?
12 Post Gd hyperintensities = contrast uptake?
13 Post Gd hyperintensities = contrast uptake? HAEMORRHAGIC CAVERNOMA with DVA
14 Post Gd enhancement = metastasis? Once you re sure that the hyperintensity on post contrast T1 weighted imaging is related to Gd enhancement, you still have a few things to do Avoid the easy association of Evolutive cancer + Brain contrast enhancement = Brain metastasis
15 Post Gd enhancement = metastasis?
16 Post Gd enhancement = metastasis? Another Cavernoma! Up to 25% of cavernoma will show enhancement! Association with an DVA strongly suggest the diagnosis
17 Post Gd enhancement = metastasis?
18 Post Gd enhancement = metastasis? Unusual presentation on both post Gd T1 and FLAIR Consider DWI! ACUTE ISCHEMIC LESION
19 Post Gd enhancement = metastasis? Courtesy Of S. Grand, CHU Grenoble
20 Post Gd enhancement = metastasis? RIGHT TEMPORAL ABSCESS DWI +++ Courtesy Of S. Grand, CHU Grenoble
21 Post Gd enhancement = metastasis?
22 Post Gd enhancement = metastasis? ISOLATED LESION JUXTAVENTRICULAR FAINT CONTRAST ENHANCEMENT PERIPHERIC DIFFUSION RESTRICTION MS
23 Post Gd enhancement = metastasis?
24 Post Gd enhancement = metastasis? Metastasis?
25 Post Gd enhancement = metastasis? Metastasis AMYGDALO-HIPPOCAMPIC CORTICAL THICKENING GB WITH INTRA TUMORAL HAEMORRHAGE
26 Post Gd enhancement = metastasis? Metastasis Abcess GB Ischemia Contusion (post traumatic) Demyelination : MS, ADEM Radionecrosis
27 Increase in size = tumor progression? BM Progression Defined as An increase in longest diameter of more than 20%
28 Increase in size = tumor progression?
29 Increase in size = tumor progression? PRE CK 12 MONTHS FU Disease progression or Radionecrosis?
30 Increase in size = tumor progression? CBV Map NO RESIDUAL NEOANGIOGENESIS RADIONECROSIS
31 Increase in size = tumor progression? PRETREATMENT DURING Ttt Metastastic melanoma Treated by Ipilimumab In Lin, Lancet Oncol 2015
32 Increase in size = tumor progression? 6 WEEKS AFTER COMPLETION OF TTT Pseudoprogression under immunotherapy In Lin, Lancet Oncol 2015
33 Increase in size on FU imaging Very common situation (SRS+++) Could be very tough, consider : 1. Increase in volume > 65% associated with recurrence 2. Assessment of boundaries on T1Gd and T2 Mismatch is in favor of RN 3. Perfusion Imaging (MRI or CT) Residual CBV elevation strongly suggests recurrence 4. MR Spectroscopy More difficult to use than in glioma FU Elevated Choline compared with contralateral white matter suggests recurrence
34 Increase in size on FU imaging DESPITE THOSE TOOLS, DISTINGUISH RECCURENCE FROM RADIONECROSIS REMAINS SOMETIMES A CHALLENGE!
35 Take Home Messages 1. Hyperintensities on post Gd T1 do not represent always gadolinium uptake Spontaneously Hypertintense in T1 weighted imaging : Melanine Fat Blood products Fluid with high protein concentration (colloid or mucinous cyst)
36 Take Home Messages 1. Hyperintensities on post Gd T1 do not represent always gadolinium uptake Spontaneously Hypertintense in T1 weighted imaging : Melanine Fat Blood products Fluid with high protein concentration (colloid or mucinous cyst) DON T FORGET TO EXPLORE YOUR PATIENT IN A PROPER AND COMPLETE WAY! and TO BROWSE THE DIFFERENTIALS DIAGNOSIS
37 Take Home Messages 2. Gd enhancement is not always synonymous of metastasis, even in the context of a extra cerebral metastastic neoplasia Metastasis Abcess GB Ischemia Contusion Demyelination Radionecrosis
38 Take Home Messages 3. Increase in size doesn t always mean disease progression Be very cautious after SRS+++ Don t forget the available tools to deal with this tricky situation (PWI+++)
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