Diffusion-weighted imaging and ADC mapping in the differentiation of intraventricular brain tumors Poster No.: C-2652 Congress: ECR 2010 Type: Educational Exhibit Topic: Neuro Authors: M. Gavrilov, T. Stosic-Opincal, S. Lavrnic, D. Grujicic, M. Macvanski, D. Damjanovic; Belgrade/RS Keywords: Magnetic Resonance Imaging, DWI, Brain tumor DOI: 10.1594/ecr2010/C-2652 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.myesr.org Page 1 of 14
Learning objectives To show the role of diffusion-weighted imaging (DWI) in characterizing of intraventricular brain masses and to find a correlation between the different apparent diffusion coefficient (ADC) values and histological analysis of tumors. Background Conventional magnetic resonance (MR) imaging has a number of limitations in the diagnosis of brain tumors. Diffusion-weighted imaging provides information that may reflect tumor cellular density and integrity. ADC values in brain tumors seem to be primarily based on tumor cellularity and nuclear area. Correlation between ADC values and tumor grade seems to be present in some degree but recent studies have demonstrated conflicting results. Imaging findings OR Procedure details Fifteen patients with histologically proved supratentorial and infratentorial intraventricular brain tumors were prospectively evaluated with contrast-enhanced MR imaging and diffusion-weighted imaging. There were 5 ependymomas, 4 subependymomas, 2 medulloblastomas, 1 central neurocytoma, 1 atypical plexus papilloma, 2 meningiomas and one B-cell lymphoma. All MR studies were performed on a 1.5T superconducting system. DWI was performed with b values of 0, 500, and 1000 mm2/s. Mean ADC values were calculated from five different regions of interest (ROI) for every tumor. Regions of interest included only solid parts of the tumor, avoiding cysts and zones of necrosis or haemorrhage. The ADC values of the tumors are shown in Table 1. on page 12 They ranged from 0.46 to 0.68 x 10-3 mm2/s in two patients with medulloblastoma WHO grade IV (Fig. 1 on page 3, Fig. 2 on page 3), in patient with central neurocytoma (Fig. 3 on page 4) ranged from 0.54 to 1.08 x 10-3 mm2/s, in patient with B-cell lymphoma (Fig. 4 on page 5) from 0.73 to 0.97 x 10-3 mm2/s, in two patients with meningioma (Fig. 5 on page 6) from 0.82 to 0.93 x 10-3 mm2/s, in five patients with ependymoma (Fig. 6 on page 7, Fig. 7 on page 8) from 0.83 to 1.01 x 10-3 mm2/s, in atypical plexus papilloma (Fig. 8 on page 9) from 0.88 to 1.24 x 10-3 mm2/s and in subependymoma (Fig.9 on page 10) from 0.98 to 1.31 x 10-3 mm2/s). Comparative overview of DWI images of different intraventricular brain tumors are shown in Fig. 10 on page 11. Page 2 of 14
Images for this section: Fig. 1: Medulloblastoma WHO grade IV in the third ventricle. The lesion has a minimum ADC value 0.46 x 10-3 mm2/s and an average ADC value 0.51 x 10-3 mm2/s. Page 3 of 14
Fig. 2: Medulloblastoma WHO grade IV in the fourth ventricle. The lesion has a minimum ADC value 0.50 x 10-3 mm2/s and an average ADC value 0.57 x 10-3 mm2/s. Page 4 of 14
Fig. 3: Central neurocytoma WHO grade II in the third and lateral ventricles in a 23-yearold female with a history of frontal headache. T2W image show "bubbly" intraventricular mass with heterogeneous signal intensity. Contrast-enhanced T1W MR image shows inhomogenous enhancement. The lesion has a minimum ADC value 0.54 x 10-3 mm2/ s and an average ADC value 0.71 x 10-3 mm2/s. Page 5 of 14
Fig. 4: Intraventricular low-grade B-cell lymphoma in the left trigone. Disease manifested by right-sided mild hemiparesis and headache. T2W axial and coronal MR images show relatively homogenous signal intensity and adjoining edema. T1W contrast-enhanced MR image shows intense enhancement of the tumor. The lesion areas have a minimum ADC value 0.73 x 10-3 mm2/s and a mean ADC value 0.83 x 10-3 mm2/s. Page 6 of 14
Fig. 5: Intraventricular fibroplastic meningioma grade I in the fourth ventricle in patient with internal hydrocephalus. T2W axial and saggital MR images show heterogeneous signal with minimal edema in adjacent cerebellar structures. T1W contrast-enhanced MR image shows intense enhancement of the tumor. The lesion areas have a minimum ADC value 0.82 x 10-3 mm2/s and a mean ADC value 0.87 x 10-3 mm2/s. Page 7 of 14
Fig. 6: Intraventricular ependymoma grade II in the lateral ventricles. Disease manifested by severe headaches, diplopia and incoordination. T2W axial, FLAIR coronal and T1W axial images show heterogeneous signal intensity and large zone of intratumoral hemorrhage. T1W contrast-enhanced MR image shows discrete enhancement of the tumor. The lesion has a minimum ADC value 0.55 x 10-3 mm2/s and an average ADC value 0.59 x 10-3 mm2/s. Page 8 of 14
Fig. 7: Intraventricular ependymoma grade II in the fourth ventricle. Axial T2W and coronal FLAIR images show hyperintense mass in the ventricle without adjacent edema. Contrast-enhanced T1W MR image shows strong inhomogenous enhancement. The lesion has a minimum ADC value 0.83 x 10-3 mm2/s and an average ADC value 0.93 x 10-3 mm2/s. Page 9 of 14
Fig. 8: Atypical choroid plexus papilloma WHO grade II in the third ventricle. The mass has a minimum ADC value 0.88 x 10-3 mm2/s and an average ADC value 0.93 x 10-3 mm2/s. Page 10 of 14
Fig. 9: Intraventricular subependymoma WHO grade I in the lateral ventricles. Images show multiple nodules in the lateral ventricles without noticeable T1W post-contrast enhancement. The lesion has a minimum ADC value 0.98 x 10-3 mm2/s and an average ADC value 1.13 x 10-3 mm2/s. Page 11 of 14
Fig. 10: Intraventricular brain tumors - comparative overview of DWI images (b=1000) A. Intraventricular meningioma B. Low-grade B-cell lymphoma C. Central neurocytoma D. Ependymoma grade II E. Atypical choroid plexus papilloma F. Ependymoma grade II G. Medulloblastoma H. Medulloblastoma Fig. 11: Table 1. Summary of apparent diffusion coefficient (ADC) values of different intraventricular tumors in our series Page 12 of 14
Conclusion Our results suggest that diffusion-weighted imaging with the quanti#cation of ADC values may be helpful in the differentiation of some intraventricular tumors before resection like medulloblastoma and lymphoma, but different tumor grades within same histological types cannot be distinguished. Personal Information Mihail Gavrilov Clinical Center of Serbia Radiology Departmant - Magnetic Resonance Center Pasterova 2 11000 Belgrade,Serbia mihail.gavrilov@gmail.com References 1. Kitis O, Altay H, Calli C, et al. Minimum apparent diffusion coefficients in the evaluation of brain tumors. Euro J Radiol 2005;55:393-400. 2. Schaefer PW, Grant PE, Gonzalez RG. Diffusion-weightedMR imaging of the brain. Radiology 2000;217:331-45. 3. Quadery FA, Okamoto K. Diffusion-weighted MRI of haemangioblastomas and other cerebellar tumors. Neuroradiology 2003;45:212-19. 4. Hochberg F, Baehring J, Hochberg E. Primary CNS lymphoma. Nat Clin Pract Neurol 2007;3:24-35. Page 13 of 14
5. Stadnik TW, Chaskis C, Michotte A, et al. Diffusion-weighted MR imaging of intracerebral masses: comparison with conventional MR imaging and histologic findings. AJNR Am J Neuroradiol 2001;22:969-76. 6. Rowley HA, Grant PE, Roberts TP. Diffusion MR imaging: theory and applications. Neuroimaging Clin N Am 1999;9:343-61. 7. Sagar P, Grant PE. Diffusion-weighted MR imaging: pediatric clinical applications. Neuroimaging Clin N Am2006;16:45-74. 8. Cha S. Update on brain tumor imaging: from anatomy to physiology. AJNR Am J Neuroradiol 2006;27:475-87. 9. Rollin N, Guyotat J, Streichenberger N, et al. Clinical relevance of diffusion and perfusion magnetic imaging in assessing intra-axial brain tumors. Neuroradiology 2006;48:150-59. 10. Sadeghi N, D'Haene N, Decaestecker C, et al. Apparent diffusion coefficient and cerebral blood volume in brain gliomas: relation to tumor cell density and tumor microvessel density based on stereotactic biopsies. AJNR Am J Neuroradiol 2008;29:476-82. Page 14 of 14