Tuberous Sclerosis with SGCA

14 yr old male child has seizures and mental retardation. MRI shows non enhancing cortical  hyperintensities on T2 and FLAIR.  In addition, a large intensely and heterogenously enhancing intraventricular, foramen of Monroe Space occupying lesion with obstructive hydrocephalus  with calcification. Features possibly  represent  cortical tubers with subependymal giant cell astrocytoma. Case submitted by-Dr MGK Murthy.

Tuberous sclerosis for the Radiologist

Synonym:  Bournveilles disease. Genetic disease – mutation of TSC1and TSC2, which encode for proteins hamartin and Tuberin (act as tumour growth suppressive factors )

Dignostic  criteria=   11 Major criteria and 9 minor criteria

Brain lesions

Tubers- triangular in shape with apex towards ventricles  and look hyperintense on T2. It may subside with age , but histopathology will still reveal it. Represents neuronal migration disorder. Other MR findings –Radial white matter tracts hyperintense on  T2. Heterotopic grey matter-Subependymal  nodules—abnormal  swollen glial cells and bizarre multinucleated cells . These could turn in to subependymal giant cell astrocytoma (SGCA). Ventricular enlargement

MDR Tuberculomas Mimicking Brain Tumour.

This is a case of 19 year old male with rapidly increasing lesion(despite ATT)  in the parieto-occipital region and extensive edema which was initially diagnosed as mitotic etiology but later on histopathology and surgical evaluation turned out to be tuberculomas, possibly multidrug resistant tuberculomas.

Atypical teratoid/rhabdoid tumors-MR

Primary atypical teratoid/rhabdoid tumors (AT/RTs) are rare malignant intracranial neoplasms, usually occurring in young children. They were termed "AT/RT" because they contain nests or sheets of rhabdoid tumor cells as well as varying proportions of primitive neuroectodermal tumor (PNET) cells, mesenchymal spindle-shaped tumor cells, and/or epithelial-type tumor cells. As reported in the literature this patient had MR imaging signal-intensity characteristics  as nonhomogeneous, secondary to the heterogeneous cellular populations in these tumors as well as the frequent presence of necrosis, hemorrhage, and/or calcifications.

OPTIC CHIASMATIC GLIOMA

Optic nerve glioma (also known as optic pathway glioma) is the most common primary neoplasm of the optic nerve. In 66% of NF-1 patients with optic nerve glioma, the growth involves the intraorbital optic nerve. In the absence of NF-1, the optic chiasm is most commonly involved, as is, less often, the intraorbital optic nerve. Optic nerve glioma may involve various portions of the retrobulbar visual pathway, including the optic nerve, chiasm, tracts, and radiations. Malignant lesions can invade the hypothalamus, basal ganglia, and internal capsule directly, or they may spread to the leptomeninges or subpial surfaces. On T1-weighted images, optic nerve gliomas are usually isointense to the cortex and hypointense to white matter. Invariably, the lesions are hypointense to orbital fat. On T2-weighted images, lesions demonstrate a mixed appearance that is isointense to hyperintense relative to white matter and the cortex. Following contrast administration, intense enhancement is common.

Intraventricular Epidermoid-MRI

INTRAVENTRICULAR EPIDERMOID-MRI
Epidermoids represent 0.2-1% of all intracranial masses. They arise from inclusion of epithelial remnants trapped during 3-5 weeks of fetal life (remember that choroid plexus are also formed from invagination of ectodermal tissues).
Intraventricular epidermoids are more in 4th ventricle followed by lateral ventricles.
More common in middle age; very rare in children
If ruptured, aseptic meningitis occurs.
Long T1 and T2 are due to keratin in solid crystalline state. Epidermoids have restricted ADC and complex FLAIR signal, unlike arachnoid cysts.

FINDINGS
An expansive intraventricular lesion in lateral ventricle, iso-intense on T1-weighted image and hypo-intense on T2-weighted image with few cystic areas, demonstrating restricted diffusion suggestive of INTRAVENTRICULAR EPIDERMOID. Differential diagnosis includes Intraventricular Neurocytoma and Oligodendrogliomas but calcification is hallmark for their diagnosis. Case by- Teleradiology Providers

Ependymoma-MRI

Intracranial ependymomas are typically isodense on unenhanced CT scans with minimal to moderate enhancement upon contrast administration. Calcification can be noted on unenhanced CT scans in approximately one half of cases. Cyst formation is common in these tumors, and foraminal spread can be observed in posterior fossa lesions through the foramina of Luschka and Magendie. On precontrast and postcontrast MRI, tumors often appear heterogeneous secondary to necrosis, hemorrhage, and calcification. Variable signal intensity is noted on T1- and T2-weighted images although intracranial ependymomas are usually hypointense to isointense on T1-weighted images and hyperintense compared with gray matter, on T2-weighted images.

Dr.Sumer K Sethi, MD
Sr Consultant Radiologist ,VIMHANS and CEO-Teleradiology Providers
Editor-in-chief, The Internet Journal of Radiology
Director, DAMS (Delhi Academy of Medical Sciences)

Multiple Arachnoid Cysts-CT

Arachnoid cysts are CSF-filled intraarachnoidal collections. They are most commonly located in the middle cranial fossa followed by suprasellar and quadrigeminal cisterns, posterior fossa, cerebral convexities, and interhemispheric fissure. This is an exceptional case with the coexistence of multiple arachnoid cysts in three different locations.

Glioblastoma Multiforme-MRI

These are post gd images of a biopsy proven case of GBM showing characteristic non-homogenous enhancement, necrotic areas, spread along white matter tracts and perilesional edema.

Teleradiology Providers

Supratentorial Hemangioblastoma-MRI

This tumour originate from the vascular system usually during middle-age and is associated with other diseases such as polycythamia and pancreatic cysts. MR shows typical mural nodule enhancing with areas of restrction on DW with suggestion of bleed on T1.

Case by Dr MGK Murthy, MD

Sr Consultant Radiologist

Teleradiology Providers

Multicentric Glioblastoma Multiforme-MRI

The actual incidence of true multicentric glioblastoma multiforme (GBM) varies between 2.4 and 4.9% of all GBMs. True multicentric tumors are described as widespread lesions in different lobes or hemispheres, which cannot be explained by spreading along the cerebrospinal fluid or blood pathways. We present here a case of multicentric GBM identified with MRI. This is a 73 yr old man, Look at the spread across the corpus callosum and along the white matter tracts in the posterior limb of the internal capsule and into cerebral peduncle.

Dr.Sumer K Sethi, MD
Sr Consultant Radiologist ,VIMHANS and CEO-Teleradiology Providers
Editor-in-chief, The Internet Journal of Radiology
Director, DAMS (Delhi Academy of Medical Sciences)

Distal Facial Neuroma-A Rare Case Report

The presentation of facial nerve neuroma tends to be insidious and depends on the location and extent of the lesion. Slowly progressive or sudden facial weakness, often preceded by facial twitching, is a common presenting complain. Bone-targeted high-resolution CT of the temporal bone is believed to be superior to MRI. Enlargement of the facial nerve suggests involvement of a neoplastic process.4 MRI is complementary, providing information about the nerve itself. Abnormal enhancement indicates the presence of the tumor. High-resolution CT should be performed first to visualize the facial canal followed by MRI to demonstrate the actual tumor. In this case of insidious facila nerve palsy we see mass in the external auditory canal, hypotympanum and descending facial nerve canal.

Dr.Sumer K Sethi, MD
Sr Consultant Radiologist ,VIMHANS and CEO-Teleradiology Providers
Editor-in-chief, The Internet Journal of Radiology
Director, DAMS (Delhi Academy of Medical Sciences)

Epidermoid Tumour- Suprasellar location-CT

Here is a case of epidermoid tumour in the suprasellar location and it appeared bright on DWI.

Dr.Sumer K Sethi, MD
Sr Consultant Radiologist ,VIMHANS and CEO-Teleradiology Providers
Editor-in-chief, The Internet Journal of Radiology
Director, DAMS (Delhi Academy of Medical Sciences)

Optic chiasmatic-hypothalamic glioma-MRI

These are post gadolinium MRI images of the Optic chiasmatic-hypothalamic glioma extending along the posterior optic nerves and posterior optic pathways.

Dr.Sumer K Sethi, MD

Sr Consultant Radiologist ,VIMHANS and CEO-Teleradiology Providers

Editor-in-chief, The Internet Journal of Radiology

Director, DAMS (Delhi Academy of Medical Sciences)

Glioma MRS

This is classical MR spectroscopy findings of thalamic glioma.

Epidermoid cyst of the pineal region

Epidermoid cysts constitute 0-2-1% of intracranial tumours and are generally found at the base of the brain. They rarely occur in the pineal region,in this case of a 17yr old girl, T1, T2, FLAIR and diffusion weighted images have been provided lesion was very bright on DWI and show no significant post gadolinium enhancement.

Teleradiology Providers