GeneralClinical Manifestations and Diagnostic Imaging of Brain Tumors
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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