General
Clinical Manifestations and Diagnostic Imaging of Brain Tumors

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Introduction

The clinical manifestations of intracranial tumors are myriad and most often referable to the anatomic area of the brain involved or adjacent structures. Some anatomic regions, particularly right frontal, may allow a tumor to reach substantial size while remaining clinically silent. In contrast, small lesions in critical areas (eg, cerebral aqueduct or primary motor cortex) are more likely to present early.

The initial diagnosis of intracranial tumors is most reliably and efficiently made by imaging. Particularly in the acute setting, noncontrast computed tomography (CT) is often the first imaging modality used. In virtually all instances, the identification of an abnormality on noncontrast CT (or in the setting of persistent clinical symptoms) is followed by magnetic resonance imaging (MRI) before and after contrast administration (usually a gadolinium chelate). The use of contrast-enhanced CT scan is, in many centers, restricted to those patients who cannot safely be placed in the magnet.

The value of MRI in defining the preoperative diagnosis, precise anatomic localization for operative planning, detection of response to therapy, discernment of tumor progression, and recognition of treatment-related side effect is based on both the high spatial resolution (<1 mm3) and the large range of tissue characteristics that may be measured.1

This article discusses both the clinicoanatomic features and imaging characteristics of brain tumors, including the use of dynamic susceptibility-weighted, T1 dynamic, diffusion, functional, and diffusion tensor imaging.

Section snippets

Imaging techniques

Because imaging is central to the diagnosis and management of intracranial tumors, this article summarizes the predominant imaging techniques used.

Low-Grade Diffuse Fibrillary Astrocytomas (World Health Organization Grade II)

The average age at diagnosis of a low-grade astrocytoma is 34 years, although the range of ages is wide.47 Astrocytomas of low-grade histopathology become progressively less common with increasing age, such that, by age 45 years, a nonenhancing mass lesion is more likely to be high grade than low grade.48 There is an inverse correlation between increasing age at diagnosis and the time to progression from low to high grade.49

Low-grade diffuse fibrillary astrocytomas (LGA; World Health

Primary Central Nervous System Lymphoma

Primary central nervous system lymphomas (PCNSL) are non-Hodgkin B-cell lymphomas that arise in the brain and eye (intraocular lymphoma). PCNSL has become more common in the past decades, at least in part because of an increase in cases in immunocompetent patients of older age. Peak age incidence is in the sixth and seventh decades. Synchronous systemic (ie, extra-central nervous system [CNS]) sites of disease are uncommon and suggest CNS metastasis rather than a primary neoplasm. The tumor

Metastatic disease

Although systemic cancers usually involve the central and peripheral nervous system through direct metastasis or by compression of neural tissue by metastatic disease, other mechanisms including ischemic stroke, venous thrombosis, side effects of therapy, infection, paraneoplastic neurologic syndromes, and metabolic derangements are not rare and often have important imaging manifestations.

SCLC has the highest incidence among all cancers of paraneoplastic neurologic syndromes, but clinically

Recurrent glioma

Distinguishing between early recurrence/pseudoprogression (ER/PP), recurrent tumor (RT)/delayed treatment effect (DTE), and true response (TR)/pseudoresponse (PR) has become increasingly complex because of the effects of antiangiogenic therapy on conventional (in particular) postcontrast imaging. This issue is critical for patient care, and is most often resolved by serial MRI and biopsy, potentially missing an earlier opportunity to change therapy and adding additional invasive procedures.

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References (119)

  • J. Ambrose et al.

    Computerized transverse axial tomography

    Br J Radiol

    (1973)
  • A.M. Cormack

    Recollections of my work with computer assisted tomography

    Mol Cell Biochem

    (1980)
  • J. Broder et al.

    Increasing utilization of computed tomography in the adult emergency department, 2000-2005

    Emerg Radiol

    (2006)
  • A.J. Wilson et al.

    A comparison of computed tomography and magnetic resonance brain imaging in HIV-positive patients with neurological symptoms

    Int J STD AIDS

    (2010)
  • M. Brant-Zawadzki et al.

    Primary intracranial tumor imaging: a comparison of magnetic resonance and CT

    Radiology

    (1984)
  • W.W. Orrison et al.

    Comparison of CT, low-field-strength MR imaging, and high-field-strength MR imaging. Work in progress

    Radiology

    (1991)
  • P.C. Lauterbur

    Image formation by induced local interactions: examples employing nuclear magnetic resonance

    Nature

    (1973)
  • B. Albayrak et al.

    Intra-operative magnetic resonance imaging in neurosurgery

    Acta neurochirurgica

    (2004)
  • M. Knauth et al.

    Intraoperative MR imaging increases the extent of tumor resection in patients with high-grade gliomas. AJNR

    American journal of neuroradiology

    (1999)
  • D. Croteau et al.

    Correlation between magnetic resonance spectroscopy imaging and image-guided biopsies: semiquantitative and qualitative histopathological analyses of patients with untreated glioma

    Neurosurgery

    (2001)
  • G.S. Harrington et al.

    Intrasubject reproducibility of functional MR imaging activation in language tasks

    AJNR Am J Neuroradiol

    (2006)
  • D.G. Norris

    Principles of magnetic resonance assessment of brain function

    J Magn Reson Imaging

    (2006)
  • L.S. Medina et al.

    Role of functional MR in determining language dominance in epilepsy and nonepilepsy populations: a Bayesian analysis

    Radiology

    (2007)
  • A. Bizzi et al.

    Presurgical functional MR imaging of language and motor functions: validation with intraoperative electrocortical mapping

    Radiology

    (2008)
  • J. Hirsch et al.

    An integrated functional magnetic resonance imaging procedure for preoperative mapping of cortical areas associated with tactile, motor, language, and visual functions

    Neurosurgery

    (2000)
  • M.I. Ruge et al.

    Concordance between functional magnetic resonance imaging and intraoperative language mapping

    Stereotact Funct Neurosurg

    (1999)
  • I. Kane et al.

    Comparison of 10 different magnetic resonance perfusion imaging processing methods in acute ischemic stroke: effect on lesion size, proportion of patients with diffusion/perfusion mismatch, clinical scores, and radiologic outcomes

    Stroke

    (2007)
  • E.A. Knopp et al.

    Glial neoplasms: dynamic contrast-enhanced T2*-weighted MR imaging

    Radiology

    (1999)
  • E.S. Paulson et al.

    Comparison of dynamic susceptibility-weighted contrast enhanced MR methods: recommendations for measuring relative cerebral blood volume in tumors

    Radiology

    (2008)
  • M. Law et al.

    Comparing perfusion metrics obtained from a single compartment versus pharmacokinetic modeling methods using dynamic susceptibility contrast-enhanced perfusion MR imaging with glioma grade

    AJNR Am J Neuroradiol

    (2006)
  • M. Law et al.

    Perfusion magnetic resonance imaging predicts patient outcome as an adjunct to histopathology: a second reference standard in the surgical and nonsurgical treatment of low-grade gliomas

    Neurosurgery

    (2006)
  • L.S. Hu et al.

    Optimized preload leakage-correction methods to improve the diagnostic accuracy of dynamic susceptibility-weighted contrast-enhanced perfusion MR imaging in posttreatment gliomas

    AJNR Am J Neuroradiol

    (2010)
  • M.H. Lev et al.

    Glial tumor grading and outcome prediction using dynamic spin-echo MR susceptibility mapping compared with conventional contrast-enhanced MR: confounding effect of elevated rCBV of oligodendrogliomas

    AJNR Am J Neuroradiol

    (2004)
  • T. Sugahara et al.

    Correlation of MR imaging-determined cerebral blood volume maps with histologic and angiographic determination of vascularity of gliomas

    AJR Am J Roentgenol

    (1998)
  • R.G. Whitmore et al.

    Prediction of oligodendroglial tumor subtype and grade using perfusion weighted magnetic resonance imaging

    J Neurosurg

    (2007)
  • M. Law et al.

    Glioma grading: sensitivity, specificity, and predictive values of perfusion MR imaging and proton MR spectroscopic imaging compared with conventional MR imaging

    AJNR Am J Neuroradiol

    (2003)
  • M. Law et al.

    Gliomas: predicting time to progression or survival with cerebral blood volume measurements at dynamic susceptibility-weighted contrast-enhanced perfusion MR imaging

    Radiology

    (2008)
  • H.B. Larsson et al.

    Measurement of brain perfusion, blood volume, and blood-brain barrier permeability, using dynamic contrast-enhanced T(1)-weighted MRI at 3 tesla

    Magn Reson Med

    (2009)
  • R. Awasthi et al.

    Discriminant analysis to classify glioma grading using dynamic contrast-enhanced MRI and immunohistochemical markers

    Neuroradiology

    (2012)
  • T.F. Patankar et al.

    Is volume transfer coefficient (K(trans)) related to histologic grade in human gliomas?

    AJNR Am J Neuroradiol

    (2005)
  • A. Xyda et al.

    Brain volume perfusion CT performed with 128-detector row CT system in patients with cerebral gliomas: a feasibility study

    Eur Radiol

    (2011)
  • P.W. Schaefer et al.

    Diffusion-weighted MR imaging of the brain

    Radiology

    (2000)
  • L. Chang et al.

    MR spectroscopy and diffusion-weighted MR imaging in focal brain lesions in AIDS

    Neuroimaging Clin North Am

    (1997)
  • A. Hilario et al.

    The added value of apparent diffusion coefficient to cerebral blood volume in the preoperative grading of diffuse gliomas

    AJNR Am J Neuroradiol

    (2012)
  • C.H. Toh et al.

    Differentiation of brain abscesses from necrotic glioblastomas and cystic metastatic brain tumors with diffusion tensor imaging

    AJNR Am J Neuroradiol

    (2011)
  • T.J. Byrnes et al.

    Diffusion tensor imaging discriminates between glioblastoma and cerebral metastases in vivo

    NMR Biomed

    (2011)
  • S. Lu et al.

    Peritumoral diffusion tensor imaging of high-grade gliomas and metastatic brain tumors

    AJNR Am J Neuroradiol

    (2003)
  • J.M. Provenzale et al.

    Peritumoral brain regions in gliomas and meningiomas: investigation with isotropic diffusion-weighted MR imaging and diffusion-tensor MR imaging

    Radiology

    (2004)
  • S. Saksena et al.

    Predicting survival in glioblastomas using diffusion tensor imaging metrics

    J Magn Reson Imaging

    (2010)
  • J.I. Berman et al.

    Diffusion-tensor imaging-guided tracking of fibers of the pyramidal tract combined with intraoperative cortical stimulation mapping in patients with gliomas

    Journal of Neurosurgery

    (2004)
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