Department of Radiology University of California San Diego MRS and Perfusion of Brain Tumors John R. Hesselink, M.D.
MRS & Perfusion of Brain Tumors Tumor histology Degree of malignancy Delineate tumor beyond T2 and enhancing margins Guide biopsy Follow response to therapy
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
Normal MR Spectrum 2 GM Hunter s angle 2 1 1 WM
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
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
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
History: 68 y/o man with episodes of severe parietal headaches TE 30 ms 655
{Page 2} 3 years later TE 144 ms Dx: Grade 2 fibrillary astrocytoma
History: 39 y/o woman with fluctuating visual deficits for several weeks 475
{Page 2}
{Page 3} TE 30 msec TE 144 msec
{Page 4} TE 30 ms Dx: Highly anaplastic astrocytoma
MR Spectra Changes with Tumor Grade As malignancy increases: NAA decreases Cr decreases Cho increases Lactate increases Lipids may increase
History: 34 y/o man with headache and mental status changes 502
{Page 2}
1 3 {Page 3} 3 2 Dx: GBM 1 2
History: 25 y/o woman with a well-controlled seizure disorder & 3-week history of nausea & headaches 646
{Page 2} TE 30 ms
{Page 3} 5 months later Dx: Gliomatosis cerebri
History: 27 y/o male with a single seizure 708
{Page 2} TE 144 ms TE 30 ms Dx: Low-grade fibrillary astrocytoma
History: 55 y/o male with nausea, vomiting & increasing somnolence 684
{Page 2}.. Vascular permeability Dx: GBM
History: 41 y/o man with a right hemiparesis & speech difficulty 621
{Page 2}
{Page 3} CBV Dx: Primary CNS Lymphoma
History: 87 y/o woman on treatment for abdominal lymphoma 780-14316798
{Page 2} TE 35 msec Acetate Alanine Lactate Succinate Dx: Abscess (Nocardia & Gram + rods)
History: 56 y/o man with new onset of seizures 491
{Page 2}
{Page 3} γ Glx α & β Glx Alanine Lactate Dx: Meningioma
History: 62 y/o woman with facial pain & weakness 644-2150323
{Page 2}
{Page 3} Dx: Metastases Lung CA
ER - History: 78 y/o women with breast cancer
{Page 2} CBV Dx: Glioblastoma multiforme
History: 42 y/o man with diabetes & a brain mass 495
{Page 2}
{Page 3} 1 1 2 2 Dx: Tumefactive MS
History: 53 y/o woman with 4 days of headache, fatigue, ataxia and poor memory 674
{Page 2}
{Page 3} 2 1 2 1
{Page 4} Dx: Metastasis Adeno CA Lung & chronic MS
History: 41 y/o diabetic with headache, lethargy & inappropriate behavior 606
{Page 2}
1 3 {Page 3} Ketones (2.2 ppm) 3 2 1 Ketones 2 Dx: Streptococcal abscess & diabetic ketoacidosis (venous ph = 7.28)
Post-treatment Imaging MRI, Perfusion, MRS & DWI Radiation effect Tumor recurrence Pseudoprogression Pseudoresponse
Radiation Temodar Avastin Dexamethasone Grade II Gemistocytic Astrocytoma FLAIR FLAIR T1-Gd Feb 2008 July 2008 Jan 2009 VD -
Radiation Temodar Avastin Dexamethasone FLAIR FLAIR T1-Gd Feb 2008 July 2008 Jan 2009 July 2009 Jan 2010
July 2009
January 2010 Choline map Dx: Radiation effect pseudoprogression
Radiation Temodar Avastin D-methasone GBM Choline map FLAIR T2 T1-Gd Apr 2008 Oct 2008 Jan 2009 Apr 2009 July 2009 Sept 2009
GBM April 2009 Choline map CBV
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
History: 53 y/o man with GBM Post-op Baseline 775 -
1 year s/p radiation followed by Temodar & Avastin June 2011
SWI June 2011 DWI ADC CBV
{Page 4} May 2010 Sept 2010 Nov 2010 Feb 2011 May 2011
Progressive neurological decline Recurrent GBM Radiation Effect Choline map Aug 2011
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