Tumors and Vascular Tumors and Vascular diseases of the Braindiseases of the Brain

April 3, 2008April 3, 2008

Jennifer Villa Frabizzio, Jennifer Villa Frabizzio, M.D.M.D. Abington Memorial HospitalAbington Memorial Hospital Radiology Group of Abington, PCRadiology Group of Abington, PC

Board Certified in Diagnostic Board Certified in Diagnostic Imaging with Added Qualifications Imaging with Added Qualifications in Neuroradiologyin Neuroradiology

Topics for DiscussionTopics for Discussion

NeuroimagingNeuroimagingThen and NowThen and Now

NeuroanatomyNeuroanatomy Vascular and Nonvascular Vascular and Nonvascular

Vascular DisordersVascular DisordersDiagnosis and TreatmentDiagnosis and Treatment

TumorsTumorsPrimary and Metastatic DiseasePrimary and Metastatic Disease

Neuroimaging- ThenNeuroimaging- Then

Standard RadiographStandard Radiograph

PneumoencephalographyPneumoencephalography

Direct Cerebral AngiographyDirect Cerebral Angiography

PneumoencephalograhPneumoencephalograhyy Introduced in 1919 by American Surgeon Introduced in 1919 by American Surgeon

Dandy WalkerDandy Walker Primary method of Neurodiagnosis used late Primary method of Neurodiagnosis used late

until late 1970’s early 1980’suntil late 1970’s early 1980’s Lumbar puncture performed in sitting Lumbar puncture performed in sitting

positionposition Patient placed in somersault chair with head Patient placed in somersault chair with head

suspended in harnesssuspended in harness CSF removed and 10-15 mls of air introducedCSF removed and 10-15 mls of air introduced Patient is tilted upside down and 50-60 mls Patient is tilted upside down and 50-60 mls

more air introducedmore air introduced

PneumonecephalograpPneumonecephalography cont.hy cont. Air outlined brainstem structures and supra Air outlined brainstem structures and supra

tentorial structures to diagnose masses, tentorial structures to diagnose masses, tumors and cerebral atrophytumors and cerebral atrophy

Very time consuming, could take from one to Very time consuming, could take from one to two hours to performtwo hours to perform

Following the procedure patients invariably Following the procedure patients invariably developed severe headache and maybe a developed severe headache and maybe a feverfever

Sampling of CSF post procedure showed high Sampling of CSF post procedure showed high protein and white blood cells, which seemed to protein and white blood cells, which seemed to be a response to the airbe a response to the air

Symptoms would usually resolve within 48hrsSymptoms would usually resolve within 48hrs

Direct Cerebral Direct Cerebral ArteriographyArteriography Pioneered in 1927 by Dr. Egas MonizPioneered in 1927 by Dr. Egas Moniz Needle was inserted directly into the Needle was inserted directly into the

common carotid artery in the neck and common carotid artery in the neck and contrast material injectedcontrast material injected

Rapid series of radiographs were taken Rapid series of radiographs were taken of the skull in numerous projectionsof the skull in numerous projections

Currently studies are preformed by Currently studies are preformed by inserting a catheter into the femoral inserting a catheter into the femoral arteryartery

Remains as gold standard for imaging Remains as gold standard for imaging arterial and venous structuresarterial and venous structures

Neuroimaging-NowNeuroimaging-Now

Computed Axial TomographyComputed Axial Tomography– CAT SCANCAT SCAN

Magnetic Resonance ImagingMagnetic Resonance Imaging– MRIMRI

Computed Computed TomographyTomography From Greek tomos (slice) and graphein (to write)From Greek tomos (slice) and graphein (to write) Generation of three dimensional images for a series of Generation of three dimensional images for a series of

two dimension Xrays taken around a single axis of two dimension Xrays taken around a single axis of rotationrotation

Computer generated images produce an axial imageComputer generated images produce an axial image Early CT scans in early 1970’s had single slice, Early CT scans in early 1970’s had single slice,

allowing imaging of the brain in four minutesallowing imaging of the brain in four minutes Modern state of the art scanners can have up to 200 Modern state of the art scanners can have up to 200

slices and can image the whole body in 30 secondsslices and can image the whole body in 30 seconds Iodine base contrast material in injected in an arm Iodine base contrast material in injected in an arm

vein to optimize visualization of vessels and solid vein to optimize visualization of vessels and solid organsorgans

Uses ionizing radiation to obtain images, and should Uses ionizing radiation to obtain images, and should be used with caution in pregnant or pediatric patientsbe used with caution in pregnant or pediatric patients

CT cont.CT cont.

Advanced techniquesAdvanced techniques CT angiography and venography CT angiography and venography – Contrast rapidly injected into an arm vein and timed Contrast rapidly injected into an arm vein and timed

to visualize arteries and veinsto visualize arteries and veins– Has become first line minimally invasive procedure Has become first line minimally invasive procedure

to image the intracerebral vasculature and coronary to image the intracerebral vasculature and coronary arteriesarteries

CT perfusionCT perfusion– Rapid imaging of the brain after contrast injection Rapid imaging of the brain after contrast injection

followed by computer post processing can generated followed by computer post processing can generated area in the brain at risk for strokearea in the brain at risk for stroke

Magnetic Resonance Magnetic Resonance Imaging (MRI)Imaging (MRI) Powerful magnetic field used to align hydrogen atoms Powerful magnetic field used to align hydrogen atoms

in the bodyin the body Radiowaves are activated that alter the alignment of Radiowaves are activated that alter the alignment of

this magnetization, allow for the atoms to relax at this magnetization, allow for the atoms to relax at different rates according to their chemical compositiondifferent rates according to their chemical composition

These signals are manipulated to reconstruct images These signals are manipulated to reconstruct images of the bodyof the body

Greater soft tissue contrast than CTGreater soft tissue contrast than CT No ionizing radiationNo ionizing radiation Must be extremely careful to remove all metal from Must be extremely careful to remove all metal from

patientspatients Contraindicated in patients with pacemakersContraindicated in patients with pacemakers

MRI cont.MRI cont.

Advanced techniquesAdvanced techniques– MR AngiographyMR Angiography

detection of moving molecules done without detection of moving molecules done without the injection of contrast to visualize flowing the injection of contrast to visualize flowing bloodblood

excellent to visualize head and neck excellent to visualize head and neck vesselsvessels

– Gadolinium based contrast agent is injected Gadolinium based contrast agent is injected into an arm vein, mixed with flowing blood and into an arm vein, mixed with flowing blood and allows for visualization of vessels especially in allows for visualization of vessels especially in the chest and abdomenthe chest and abdomen

MRI cont.MRI cont.

Diffusion imagingDiffusion imaging– For visualization of acute stroke, damaged For visualization of acute stroke, damaged

cells swell and cause restricted diffusioncells swell and cause restricted diffusion MR spectroscopyMR spectroscopy

– Separating the chemical composition of Separating the chemical composition of brain lesions into different peaks to brain lesions into different peaks to determine chemical compositiondetermine chemical composition

Functional MRIFunctional MRI– Using changes in blood flow to monitor Using changes in blood flow to monitor

neural activityneural activity

NeuroimagingNeuroimaging

NonvascularNonvascular

NeuroimagingNeuroimaging

VascularVascular

Vascular diseasesVascular diseases

StrokeStrokeTrauma/Intracranial HemorrhageTrauma/Intracranial HemorrhageAneurysmAneurysmArteriovenous MalformationsArteriovenous Malformations

StrokeStroke

Acute episode leading to a Acute episode leading to a neurologic deficitneurologic deficit– 80% are due to ischemia (either 80% are due to ischemia (either

thrombotic or embolic)thrombotic or embolic)– 20% other 20% other

Transient ischemic attack (TIA)Transient ischemic attack (TIA)– Focal events that resolve in 24hrsFocal events that resolve in 24hrs

Stroke cont.Stroke cont.

Of the 80%, three quarters are due to Of the 80%, three quarters are due to atherosclerotic disease or occlusion of atherosclerotic disease or occlusion of vessels.vessels.

Diagnosis can be made by both CT and Diagnosis can be made by both CT and MRI, as well as the advanced images MRI, as well as the advanced images techniquestechniques– MRI is more sensitive, it can age strokes and MRI is more sensitive, it can age strokes and

can detect an acute stroke within thirty can detect an acute stroke within thirty minutes.minutes.

– CAT scan can detect a stroke within 6 hrs, and CAT scan can detect a stroke within 6 hrs, and is useful to determine if there is underlying is useful to determine if there is underlying hemorrhagehemorrhage

71 year old white 71 year old white femalefemale

Found by husband in the bathroom on Found by husband in the bathroom on the floor, unable to move left side of her the floor, unable to move left side of her bodybody

Brought by EMS to AMH and had a CAT Brought by EMS to AMH and had a CAT scanscan

Cont.Cont.

Admitted to intensive care Admitted to intensive care CAT scan performed 6 hrs later CAT scan performed 6 hrs later

after worsening of symptomsafter worsening of symptoms

Cont.Cont.

Patient continues to deteriorate, Patient continues to deteriorate, despite supportive measuresdespite supportive measures

CAT scan performed 24 hrs after CAT scan performed 24 hrs after admissionadmission

No improvementNo improvement CAT scan performed 12 hrs later, CAT scan performed 12 hrs later,

48 hrs after admission48 hrs after admission

19 year old white male 19 year old white male

Found unconscious in dorm room Found unconscious in dorm room by roommate after drinking all by roommate after drinking all night at a fraternity partynight at a fraternity party

Friends had seen him take some Friends had seen him take some pills, found later to be valium pills, found later to be valium (benzodiazepine-tranquilizer)(benzodiazepine-tranquilizer)

Anoxic brain injuryAnoxic brain injury

Lack of blood flow to the brain Lack of blood flow to the brain affects deep grey matter affects deep grey matter structures and can cause structures and can cause irreversible damageirreversible damage

Can also be seen in near Can also be seen in near drowning, carbon monoxide drowning, carbon monoxide poisoningpoisoning

Intracranial Intracranial HemorrhageHemorrhage Non TraumaticNon Traumatic

– Hypertension (most common)Hypertension (most common)– TumorTumor– otherother

TraumaticTraumatic– Epidural and subdural HematomasEpidural and subdural Hematomas– Hemorrhagic contusionsHemorrhagic contusions

Hemorrhage cont.Hemorrhage cont.

Hypertensive type most common Hypertensive type most common in small arteries off of the middle in small arteries off of the middle cerebral arterycerebral artery

High mortality depending on size High mortality depending on size and locationand location

81 year old black male81 year old black male

Found at breakfast with difficulty Found at breakfast with difficulty speakingspeaking

Brought to AMH by sonBrought to AMH by son Ran out of blood pressure Ran out of blood pressure

medicine last weekmedicine last week Vital signs in ERVital signs in ER Blood pressure 210/80Blood pressure 210/80 CAT scan upon arrivalCAT scan upon arrival

Cont.Cont.

ICU Staff was unable to control ICU Staff was unable to control blood pressure, symptoms blood pressure, symptoms worsenedworsened

Hemorrhage cont.Hemorrhage cont.

TraumaticTraumatic– Subdural hematomasSubdural hematomas

Common in the elderly or in children Common in the elderly or in children due to child abusedue to child abuse

Tearing of bridging veins along the edge Tearing of bridging veins along the edge of the brainof the brain

Can grow large and may need Can grow large and may need neurosurgical evacuationneurosurgical evacuation

Hemorrhage cont.Hemorrhage cont.

Epidural hematomaEpidural hematoma– Mostly due to injury to the middle Mostly due to injury to the middle

meningeal artery, superficial vessel meningeal artery, superficial vessel that runs along the skullthat runs along the skull

– Commonly associated with skull Commonly associated with skull fracturesfractures

– Large ones are neurosurgical Large ones are neurosurgical emergenciesemergencies

AneurysmsAneurysms

Most common type is the berry or Most common type is the berry or saccular aneurysm saccular aneurysm – Are usually congenital or degenerative Are usually congenital or degenerative – Focal outpouching of a arteryFocal outpouching of a artery– Occur in specific locations along the Circle Occur in specific locations along the Circle

of Willisof Willis– Once diagnosed, the risk of rupture is Once diagnosed, the risk of rupture is

1.3% per year1.3% per year– A ruptured aneurysm requires urgent A ruptured aneurysm requires urgent

diagnosis and treatment, due to a high risk diagnosis and treatment, due to a high risk of rebleeding and 50% mortalityof rebleeding and 50% mortality

Aneurysms cont.Aneurysms cont.

Patients present with “worst Patients present with “worst headache of life” and can have headache of life” and can have varying stages of consciousnessvarying stages of consciousness

CAT scan of the brain show CAT scan of the brain show diffuse subarachoid hemorrhage, diffuse subarachoid hemorrhage, “crab of death”“crab of death”

Aneurysms cont.Aneurysms cont.

TreatmentTreatment Conventional-crainiotomy and Conventional-crainiotomy and

aneurysm clippinganeurysm clipping Neurointerventional-intravascular Neurointerventional-intravascular

coilingcoiling

Arteriovenous Arteriovenous Malformations (AVM)Malformations (AVM) Network of arteries connected directly Network of arteries connected directly

to veins with no intervening brain to veins with no intervening brain tissue or capillariestissue or capillaries

Can hemorrhage because of high flow Can hemorrhage because of high flow statestate

TreatmentTreatment– Endovascular coilingEndovascular coiling– GlueGlue– Stereotactic RadiosurgeryStereotactic Radiosurgery

58 year old female 58 year old female

MVA, crashed car into a tree MVA, crashed car into a tree because she “blacked out”because she “blacked out”

Arrives at AMH with headache, Arrives at AMH with headache, bruising but awakebruising but awake

CAT scan performedCAT scan performed

Brain TumorsBrain Tumors

Primary brain tumors are 70% of Primary brain tumors are 70% of all intracranial neoplasmsall intracranial neoplasms

The remaining 30% represent The remaining 30% represent metastases from primary tumors metastases from primary tumors elsewhere in the body, common elsewhere in the body, common ones include lung and breast ones include lung and breast cancercancer

MRI with Gadolinium in the MRI with Gadolinium in the modality of choice for diagnosismodality of choice for diagnosis

Brain tumors cont.Brain tumors cont.

Primary Brain TumorsPrimary Brain Tumors– 80% are gliomas, the most aggressive 80% are gliomas, the most aggressive

is the Gliomblastoma Multiforme (GBM)is the Gliomblastoma Multiforme (GBM)– 20% are all others, which include 20% are all others, which include

meningiomas from the brain surface, meningiomas from the brain surface, nerve sheath tumors and lymphomanerve sheath tumors and lymphoma

– Treatment is a combination of surgery, Treatment is a combination of surgery, radiation and chemotherapyradiation and chemotherapy

Thank youThank you

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jvfrabizzio@amh.orgjvfrabizzio@amh.org

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