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NAME : Dr. ANGGRAINI DWI S.,dr.,Sp.Rad (K)BORN : PASURUAN, SEPTEMBER 12, 1961
EDUCATION :GP, MEDICAL FACULTY OF AIRLANGGA UNIVERSITY, 1987RADIOLOGIST, AIRLANGGA UNIVERSITY, 1996ATTACH PROGRAM NNI SINGAPORE, 2002NEURORADIOLOGIST CONSULTANT, 2004DOCTOR , MEDICAL FACULTY OF AIRLANGGA UNIVERSITY, 2013
POSITION :STAFF OF DEPT. RADIOLOGY MED. FAC. AIRLANGGA UNIVERSITYHEAD OF DIPLOMA PROGRAM FOR RADIOGRAPHERMEMBER OF NEURORADIOLOGICAL DIVION. MEDICAL FACULTY AIRLANGGA UNIV.MEMBER OF IDIMEMBER OF DKJ FORUM MEMBER OF PDSRIMEMBER OF AONHCRMEMBER OF ASCIOFFICIAL JOURNAL OF INDONESIAN NEURORADIOLOGY OF THE EUROPEAN NEURORADIOLOGY JOURNAL SENIOR CONSULTANT IN NEURORADIOLOGY , SOETOMO HOSPITAL AND SEVERAL HOSPITALS IN SURABAYAHEAD OF RADIOLOGY, HUSADA UTAMA HOSPITALMEDICAL MANAGER, HUSADA UTAMA HOSPITAL
Curriculum Vitae
Differential Diagnosis of Brain Infection, Tumor, Metastatic Process
on CT Scan and MRI
Dr. dr. Anggraini Dwi S.,Sp.Rad.(K)Radiology Dept., Medical Faculty,
Airlangga University/Soetomo Hospital, Surabaya
Clinical findings?
Atlas Scott, 2007
Plain X-ray USG CT Scan MRI PET Scan
Radiation exp. + - ++ - +++
Tissue contrast + ++ ++ +++ -
Calcification + + +++ + -
Hydrocephalus - ++ +++ ++++ -
Contrast - - ++ ++++ -
Uptake rad farm - - - - +++
Metabolite - - - +++ -
Tissue Perfusion - - ++ ++ -
Tissue Diffusion - - - + -
Techniques in Neuroimaging
5
Brain lesion (infection, primary, metastatic):1. Initial recognition and characterization of
the lesion 2. The mechanical effects and structural deformities resulting from intracranial neoplasm
The Most effective Uses of CT in Neuroradiology
Rulling out SAHAcute head traumaFracture of skull, face, orbitsSinusitisSalivary gland calculous diseaseSubtle bony irregularitiesDetection of calcification in lesion
Odontoic lesionDegenerative diseaseCTACT perfusionBony spinal stenosisMR is contraindicatedImmediate postop evaluationTemporal bone disease
MR imaging has the most potential of any imaging technique to allow a complete and accurate diagnosis and initial management strategy to be formulated for a brain tumor
Brain Tumor Imaging with MR: Objectives
Specific DiagnosisNeoplasma VS otherHistology (Grading)
Therapy PlanningLocalize for biopsyDelineate extent or spreadRT portal designGuide minimally invasive surgery - Define peritumoral “eloquent” - Define neuroanatomic pathway involvement
Post TreatmentResidual TumorReccurent tumor VS treatment-related necrosis
Fundamentals of lesion localization and characterization: -The age of the patient -Single or multiple? -Intraaxial or extra axial? -Density/intensity? -Presence of contrast enhancement? -Hemorrhage -Calcification -Necrosis?
Basic protocol brain MRI1. T12. T23. T2FLAIR4. Gre T2*5. DWI6. 2-3 planes post Gad T17. Pefusion CBV• MR Spectroscopy (?)1. DTI (?)2. Functional MRI (?)
Brain Lesions
MedScape, 2011
Multiple Small Ring Enhancing Lesions
Tuberkuloma
CT• Isodense or slight
hyperdense basal cistern• Basal homogenous
meningeal enhancement• Hydrocephalus (C and NC)• Tuberculoma, rim
enhancement, 1/3 with target sign (central calcification)
MRI• Cisternal enhancement ++• Meningeal enhancement
(better in FLAIR than T2), patchy meningitis
• Hydrocephalus (C and NC)• Tuberculoma, rim
enhancement, 1/3 with target sign (central calcification)
Metastatic
CT • Hyperdense, hypodense or
isodense• Small, round zones• Extensive collateral edema• Intratumoral hemorrhage• 80% enhancement,
sometimes a ring
MRI• Detects 2-3x> MRI• Typically hypointense on T1• Hyperintense on T2• Melanoma?• Enhancement: uniform,
punctate, ring• T2FLAIR: perifocal edema• MRS: No Cho↑ at perifocal
edema, NAA↓
Neurosarcoidosis
CT• Leptomeningitis• Suprasellar manifestation
(diabetes incipidus)• Hydrocephalus• Single or multiple
granuloma slightly hyperdense foci up to 1cm
• Up to 60% negative
MRI• T1: iso or hypointense• T2: variable• T1+C: homogenous
enhancement• Pituitary + hypothalamic• Leptomeningeal involv.• Cranial nerve (II,VIII)
Cerebral Abscess
CT•Varies with stage of abscess•Early cerebritis: hypodense•Subacute: ring-like structure•Necrotizing tissue•Gas forming +/-•Enhancing ring: 3-6mm, uniform•Dughter abscess
MRI• Varies with stage of abscess• T1W• T2W• FLAIR• DWI (+) : hypercellularity,
brain ischemia, cellular swelling due to cytotoxic edema
• Central liquefactive necrosis• MRS : NAA, Cho,Cr ↓, LL↑
Multiple Large Enhancing Lesions
Abscess
Metastatic
Glioma
MR Spectroscopy
Tumeactive Demyelinating Lesion
HIV? Toxoplasma?
Unenhanced CT Scan MRI T1 WI
T1 WI T1 WI
T2W axial T2W axial
Enhanced T1W
Before Tx After Tx
Lymphoma?
TDL: tumeactive demyelinating lesion
Metastase
MR SpectroscopyIs there perienhancement infiltrationOver 1 Cho/NAA ?
Low grade neoplasm
LymphomaPerfusion MRIs perfusion over 1,75 rCBV?
Is there necrosisOn CE MRI?•Low grade neoplasm
or•encephalitis
Conventional CE MRIDoes the lesion enhance?
MR SpectroscopyIs the elevation of Cho/NAA over 2,2?
DWI, diffusing facilitated > 1,1/100 mm2/ADC?
Intraaxial Brain Mass
NO YES
NOYES
YES
•TDL or abscess•Abscess
High grade neoplasm
NOYES
NOYES
High grade glioma
YES
YESNO
NO
Diffusion Weighted Image
Diffusion Weighted Image
MR Spectroscopy
MR Spectroscopy
The Peritumoral region (PTR) demonstrated most significant differences in metabolite ratios.
• The Cho/Cr ratio in glioblastomas was significantly higher than that in metastases.
• PCLs significantly elevated Cho/Cr levels were also noted in compared with those in metastases .
• PCLs also demonstrated significantly higher lipids+lactate/Cr levels compared with glioblastomas and metastases.
Proton magnetic resonance spectroscopy in differentiating glioblastomas from primary cerebral lymphomas and brain metastases.Chawla S1, Zhang Y, Wang S, Chaudhary S, Chou C, O'Rourke DM, Vossough A, Melhem ER, Poptani H.
MR Perfusion
Take home message1. CT Scan plays in emergency cases and some
abnormality (blood, calcification, hemorrhage)2. MRI play a better role than CT in differentiate
infection, primary and metastatic tumor3. MR imaging has the most potential of any
imaging technique to allow a complete and accurate diagnosis and initial management strategy to be formulated for a brain tumor
4. Advanced imaging help enhancing the specifity of the lesions
Thank You