MRS and Perfusion of Brain Tumors
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1 Department of Radiology University of California San Diego MRS and Perfusion of Brain Tumors John R. Hesselink, M.D.
2 MRS & Perfusion of Brain Tumors Tumor histology Degree of malignancy Delineate tumor beyond T2 and enhancing margins Guide biopsy Follow response to therapy
3 Normal MR Spectrum Lipid Lactate NAA Glutamates Creatine Choline Myo-Inositol Lying Lazy No Good Crooks Cheat My Insurance Brian Ross, Huntington Medical Research Institute
4 Normal MR Spectrum 2 GM Hunter s angle WM
5 Metabolite Ratios Normal Abnormal TE 30 msec NAA/Cr 2.0 < 1.5 NAA/Cho 1.6 < 1.2 Cho/Cr 1.2 > 1.5 TE 144 msec NAA/Cho 1.5 < 1.0
6 MRS & Perfusion of Brain Tumors Perfusion (rcbv) elevated in metastases, meningiomas & gliomas (Grades 3 & 4) NAA decreased in tumors that displace or destroy neurons Cho increased in tumors (hypercellularity) Lipids seen in necrotic tumors - indicative of high malignancy Lactate noted in highly cellular malignant tumors that outgrow blood supply Myo-inositol elevated in low-grade gliomas
7 Effect of Echo Time Grade 2 Fibrillary Astrocytoma TE 30 TE 270 Lipids, glutamates & myo-inositol have short T2 and drop out at longer echoes
8 History: 68 y/o man with episodes of severe parietal headaches TE 30 ms 655
9 {Page 2} 3 years later TE 144 ms Dx: Grade 2 fibrillary astrocytoma
10 History: 39 y/o woman with fluctuating visual deficits for several weeks 475
11 {Page 2}
12 {Page 3} TE 30 msec TE 144 msec
13 {Page 4} TE 30 ms Dx: Highly anaplastic astrocytoma
14 MR Spectra Changes with Tumor Grade As malignancy increases: NAA decreases Cr decreases Cho increases Lactate increases Lipids may increase
15 History: 34 y/o man with headache and mental status changes 502
16 {Page 2}
17 1 3 {Page 3} 3 2 Dx: GBM 1 2
18 History: 25 y/o woman with a well-controlled seizure disorder & 3-week history of nausea & headaches 646
19 {Page 2} TE 30 ms
20 {Page 3} 5 months later Dx: Gliomatosis cerebri
21 History: 27 y/o male with a single seizure 708
22 {Page 2} TE 144 ms TE 30 ms Dx: Low-grade fibrillary astrocytoma
23 History: 55 y/o male with nausea, vomiting & increasing somnolence 684
24 {Page 2}.. Vascular permeability Dx: GBM
25 History: 41 y/o man with a right hemiparesis & speech difficulty 621
26 {Page 2}
27 {Page 3} CBV Dx: Primary CNS Lymphoma
28 History: 87 y/o woman on treatment for abdominal lymphoma
29 {Page 2} TE 35 msec Acetate Alanine Lactate Succinate Dx: Abscess (Nocardia & Gram + rods)
30 History: 56 y/o man with new onset of seizures 491
31 {Page 2}
32 {Page 3} γ Glx α & β Glx Alanine Lactate Dx: Meningioma
33 History: 62 y/o woman with facial pain & weakness
34 {Page 2}
35 {Page 3} Dx: Metastases Lung CA
36 ER - History: 78 y/o women with breast cancer
37 {Page 2} CBV Dx: Glioblastoma multiforme
38 History: 42 y/o man with diabetes & a brain mass 495
39 {Page 2}
40 {Page 3} Dx: Tumefactive MS
41 History: 53 y/o woman with 4 days of headache, fatigue, ataxia and poor memory 674
42 {Page 2}
43 {Page 3}
44 {Page 4} Dx: Metastasis Adeno CA Lung & chronic MS
45 History: 41 y/o diabetic with headache, lethargy & inappropriate behavior 606
46 {Page 2}
47 1 3 {Page 3} Ketones (2.2 ppm) Ketones 2 Dx: Streptococcal abscess & diabetic ketoacidosis (venous ph = 7.28)
48 Post-treatment Imaging MRI, Perfusion, MRS & DWI Radiation effect Tumor recurrence Pseudoprogression Pseudoresponse
49 Radiation Temodar Avastin Dexamethasone Grade II Gemistocytic Astrocytoma FLAIR FLAIR T1-Gd Feb 2008 July 2008 Jan 2009 VD -
50 Radiation Temodar Avastin Dexamethasone FLAIR FLAIR T1-Gd Feb 2008 July 2008 Jan 2009 July 2009 Jan 2010
51 July 2009
52 January 2010 Choline map Dx: Radiation effect pseudoprogression
53 Radiation Temodar Avastin D-methasone GBM Choline map FLAIR T2 T1-Gd Apr 2008 Oct 2008 Jan 2009 Apr 2009 July 2009 Sept 2009
54 GBM April 2009 Choline map CBV
55 Radiation Temodar Avastin D-methasone GBM Recurrent GBM pseudoresponse FLAIR T2 T1-Gd Apr 2008 Oct 2008 Jan 2009 Apr 2009 July 2009 Sept 2009
56 History: 53 y/o man with GBM Post-op Baseline 775 -
57 1 year s/p radiation followed by Temodar & Avastin June 2011
58 SWI June 2011 DWI ADC CBV
59 {Page 4} May 2010 Sept 2010 Nov 2010 Feb 2011 May 2011
60 Progressive neurological decline Recurrent GBM Radiation Effect Choline map Aug 2011
61 MRS and Perfusion Glioma Cho / Cr NAA / Cr Metabolites rcbv Grade 4 Very High Very Low Lipid/Lactic Very High Grade 3 High Low Lipid/Lactic High Grade 2 Moderate Moderate mi Low Gliomatosis Cerebri Mild Normal mi Low Ganglioglioma Normal Normal Moderate Lymphoma High Very Low Lipid/Lactic Mild Metastases High Very Low Lipid/Lactic High Meningioma Moderate No NAA Alanine, Glutamates Very High Radiation Necrosis Very Low Very Low Lipid/Lactic Low Tumefactive MS High Low Lipid/Lactic Low Abscess Moderate Very Low Acetate, Alanine, Cytosolic acid, Succcinate Low
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