Disclosures. Posterior Fossa Masses. I m from the Government. and I here to help! Differential Diagnosis

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1 Posterior Fossa Masses Differential Diagnosis James G. Smirniotopoulos, M.D. Radiology, Neurology, Biomedical Informatics Uniformed Services University Bethesda, Maryland Disclosures No financial disclosures nor conflict of interest to report I m from the Government and I here to help! 2

2 Uniformed Services University 3 Uniformed Services University Military Medical School Just like the service academies 16th largest SOM in the US 165 students in each class Army Navy Air Force Public Health Service Indian Health Service 4

3 The Best Dressed Medical Students BDU Camouflage Uniforms Summer and Winter 5 A More Recent Photo 6

4 Neuroradiology is like Real-estate 7 Three Rules of Neuroradiology: LOCATION LOCATION LOCATION 8

5 9 10

6 PATTERN ANALYSIS Basic Approach Where is the lesion? Intraaxial Extraaxial Intraventricular Where is the lesion? Supratentorial Infratentorial How old is the patient? Child Adult What about Sex? 11 PATTERN ANALYSIS: Location Basic Approach Where is the lesion? Extraaxial Intraaxial Intraventricular Where is the lesion? Supratentorial Infratentorial How old is the patient? Child Adult What about Sex? 12

7 PATTERN ANALYSIS: Location 13 PATTERN ANALYSIS: Basic Approach Where is the lesion? Extraaxial Intraaxial Intraventricular Where is the lesion? Supratentorial Infratentorial How old is the patient? Child Adult What about Sex? 14

8 PATTERN ANALYSIS: Location Basic Approach Where is the lesion? Extraaxial Intraaxial Intraventricular Where is the lesion? Supratentorial Infratentorial How old is the patient? Child Adult What about Sex? 15 PATTERN ANALYSIS: Location Basic Approach Where is the lesion? Extraaxial Intraaxial Intraventricular Where is the lesion? Supratentorial Infratentorial How old is the patient? Child Adult What about Sex? 16

9 PATTERN ANALYSIS: Basic Approach Where is the lesion? Extraaxial Intraaxial Intraventricular Where is the lesion? Supratentorial Infratentorial How old is the patient? Child Adult What about Sex? 17 INTRA-AXIAL: Cortex Gray-white Junction Deep White Matter Deep Gray Matter Glioma Medulloblastoma Hemangioblastoma Metastases Infarct / Hematoma Avm / Congenital Abscess/inflammation 18

10 EXTRA-AXIAL LESIONS: Subarachnoid Subdural Epidural Calvarium (Skull Base) Subgaleal Scalp (Soft-tissues) Meningioma Pituitary Adenoma Craniopharyngioma Schwannoma Chordoma Dermoid / Epidermoid, Cyst, Lipoma Hematoma, Metastasis, Infection 19 Basic Approach Normal Imaging Modality (with/without contrast) Abnormal Location? List of Suspects Profile For Each Suspect 20

11 List of Suspects Match Profile 21 Infratentorial We are here! James G. Smirniotopoulos, M.D. Radiology, Neurology, Biomedical Informatics Uniformed Services University Bethesda, Maryland

12 CLASSIC LOCATIONS Foramen magnum Cerebellopontine angle Fourth ventricle/cerebellum Sella/parasellar/suprasellar Basal ganglia/third ventricle Lateral ventricle/pineal region Deep hemispheric/periventricular Cortical and subcortical Convexity Extraaxial 23 Posterior Fossa Lesions Extraaxial Cerebellopontine Angle Schwannoma Meningioma Epidermoid Inclusion Cyst Intraaxial Cerebellum Pilocytic Astrocytoma Medulloblastoma Ependymoma Hemangioblastoma Intraaxial Pons Astrocytoma 24

13 Posterior Fossa Masses Extraaxial: Schwannoma Meningioma Epidermoid Pontine Astrocytoma Pilocytic astrocytoma Hemangioblastoma Ependymoma Medulloblastoma 25 History: 24 y.o. woman with headache Exam: N/A 26

14 27 28

15 Differential Diagnosis? 29 Differential Diagnosis? Vestibular Schwannoma Ependymoma Diffuse Pontine Astro Vestibular Schwannoma Pilocytic Astro 30

16 DDx Can be difficult Medulloblastoma Ependymoma 31 DDx Can be difficult Medulloblastoma Ependymoma 32

17 DDx Can be difficult Medulloblastoma Ependymoma 33 34

18 35 36

19 37 38

20 39 History: 24 y.o. woman with headache Exam: N/A Findings: Brain MRI (T1W, T2W, T1W+C) demonstrate multiple enhancing lesions; there are bilateral enhancing lesions in the internal auditory canals; there is an enhancing lesion within the right lateral ventricle; there are multiple enhancing lesions along the falx. Differential: Multiple Schwannomas Multiple meningiomas NF-2 Metastatic disease 40

21 Olfactory (I) Optic (II) Oculomotor (III) Trochlear (IV) Trigeminal (V) Abducens (V) Facial (VII) Vestibulocochlear (VIII) 41 Bill s Bar vertical crest Internal Auditory Canal Ant 7 SV Pos crista falciformis C IV 7 is UP 8th Cochlear Sup. Vestibular Inf. Vestibular Coch(lear) is Down 42

22 43 CPA MASSES Differential S A M E Schwannoma (8th >> > 5th) aneurysm, arachnoid cyst meningioma, mets epidermoid, ependymoma, CPP 44

23 CPA MASSES Demographics 7/9 (Schwannoma, 8th > > 5th) 1/9 Meningioma (tentorial/petrous) 1/9 "Other": Epidermoid Cyst (1/18) Mets, aneurysm, etc. Glioma (ependymoma, CPP) Arachnoid cyst Cystadenoma of endolymphatic sac Glomus tumor 45 Vestibular Schwannoma: Inf > Sup IAC origin IAC involved IAC Enlarged (70%) Spherical Mass encapsulated Heterogeneous if large > 20 mm Enhance always 46

24 Intracanalicular Schwannoma Schwannoma begin inside or distal to IAC 47 Cisternal Segment CNS Oligodendrocytes IAC Segment PNS Schwann cells 48

25 SCHWANNOMA 5-10% of All CNS Tumors Benign, Slowly growing F > M (Intracranial), M > F (Spinal) 30's - 60's, w/nf-2 10's - 30's Sensory Nerves (usually): CNN VIII (Inf.Vestibular), V, X Spine: Dorsal Roots Majority (>90%) are Sporadic Multiple in NF-2, Bilat.VIII Pathognomonic 49 Bilateral Vestibular Schwannoma Laryngoscope. 2007;117(12): Data show IVN tumors twice as common as SVN, Bedside (caloric) tests sup. vest. From Laszlo Mechtler, DNI 50

26 NF2 Bilateral Vestibular Schwannoma Arch Otolaryngol Head Neck Surg Feb;112(2):190-4 "A review of histologic and surgical literature demonstrates that the earlier estimate is inaccurate, and that only 50% of vestibular schwannomas originate on the superior branch of the vestibular nerve." Laryngoscope. 2007;117(12): Data show IVN tumors twice as common as SVN, Bedside (caloric) tests sup. vest. nerve J Laryngol Otol Feb;122(2): Inferior vestibular nerve in 139 cases (91.4 per cent), from the superior vestibular nerve in nine cases (6 per cent), From Laszlo from the Mechtler, cochlear DNI nerve in two cases (1.3 per cent) and from the facial nerve in two cases (1.3 per cent). IAC and CPA Mass Lesion 52

27 53 Vestibular Schwannoma 54

28 Young Schwannoma Old Schwannoma Benign Cystic Degeneration 55 56

29 Trigeminal Schwannoma Meckel s Cave Courtesy of Jacqueline A. Bello MD 57 Trigeminal Schwannoma Courtesy Jacqueline A. Bello MD 58

30 NF2 Multiple Schwannomas, two 8th and one 5th 5th 8th 8th From Laszlo Mechtler, DNI 59 axial Meningioma Tentorium or Dura IAC Normal Size Hemispherical Homogeneous Enhance Homogeneously Hyperostosis 15-40% Courtesy of Bob Peyster, MD Dural Tail 70-90% 60

31 Meningioma 61 Tentorial Meningioma 62

32 Tentorial Meningioma Gross Courtesy Tom Naidich, Mt. Sinai, NY 63 Hyperostosis 64

33 Meningioma HYPEROSTOSIS 65 Does Not Enhance Wavy or Undulating Margin 66

34 Epidermoid - CPA 67 CPA Epidermoid Cyst Not exactly isointense to CSF DWI bright: Restricted Diffusion + T2 shine through 68

35 CPA Epidermoid pearly tumor Squamous epithelium, Layers of keratin debris like onion skin 69 Epidermoid - Dry Keratin 70

36 Epidermoid - Dry Keratin 71 T1W Gd FLAIR Epidermoid 72

37 Epidermoid vs. Arachnoid Cyst Epidermoid Cyst CPA most common Extraaxial CPA Lesion IAC Normal Undulating Margin Similar to CSF - but NOT Identical Brighter on PD, FLAIR, DWI, Darker on ADC NO Enhancement Wispy internal layers Arachnoid Cyst Middle fossa common Extraaxial CPA Lesion IAC Normal Rounded Bubble Mass Identical to H2O on CT and all MR sequences T1, PD, T2, FLAIR, DWI,ADC NO Enhancement NO Internal structure 73 Arachnoid Cyst Convex Bubble NOTE: Signal higher in cyst, due to less dephasing from CSF pulsation. 74

38 Quiz #1 75 CLASSIC LOCATIONS Foramen magnum Cerebellopontine angle Fourth ventricle/cerebellum Sella/parasellar/suprasellar Basal ganglia/third ventricle Lateral ventricle/pineal region Deep hemispheric/periventricular Cortical and subcortical Convexity Extraaxial 76

39 % of Brain Tumors Location of Neoplasms Supratentorial Infratentorial Age 77 ADULT - CEREBELLAR/IVth Metastasis Hemangioblastoma Hemorrhage, infarct Glioma Ependymoma Astrocytoma Abscess 78

40 Central Posterior Fossa Mass 79 Central Posterior Fossa Lesion Could be Intraaxial Could be Intraventricular Could be extending from vermis into ventricle Could be extending from ventricle into vermis 80

41 Fourth Ventricle - Schematic Tentorium Straight Sinus Clivus BS Occiput 81 Fourth Ventricle - Schematic Ant/Sup vellum Tentorium Straight Sinus Clivus BS Occiput Post/Inf medullary vellum 82

42 Fourth Ventricle Medullo (PNET) Ant/Sup vellum Tentorium Straight Sinus Clivus BS Choroid Plexus Occiput Post/Inf medullary vellum 83 Fourth Ventricle - Ependymoma Ant/Sup vellum Tentorium Straight Sinus Clivus BS Choroid Plexus Occiput Post/Inf medullary vellum 84

43 Medulloblastoma Ependymoma 85 4 th ventricle Floor vs. Roof (Vermis) Ependymoma Medulloblastoma Courtesy Joe Parisi 86

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