1. SYMPOSIUM NEURORADIOLOGICUM BOLOGNA 2010
INTRACRANIAL MASSES WITH PERILESIONAL EDEMA : DIFFERENTIAL DIAGNOSIS WITH PERFUSION-CT
D. Gadda, P. Simonelli, G. Villa, V. Scardigli, D. Petacchi,
C. Pandolfo, M. Moretti, S. Chiti, G.P. Giordano
Careggi University Hospital - Florence - Neuroradiology

2. PERILESIONAL EDEMA Commonly associated with an intracranial mass
Generated by vasogenic effects in the cerebral parenchyma surrounding the mass for lack or absence of blood-brain barrier (BBB) inside the lesion
Extrusion of fluids into the extravascular space (“wet brain”) around the mass
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3. PERILESIONAL EDEMA On Computed Tomography (CT):
- area of low density for the increased fluid content
- not clear differentiation with areas of compressive
ischemia
- possible presence of neoplastic cells and tumoral
neo-angiogenesis inside the perilesional edema
surrounding high grade gliomas (Kelly PJ et al: Imaging-
based stereotaxic serial biopsies in untreated intracranial glial neoplasms; J.
Neurosurg.1987 Jun;66(6): )
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4. MASS WITH PERILESIONAL EDEMA
Frequently discovered or suspected on a non-enhanced CT (NECT) scan performed for the onset of stable or rapidly progressive neurological symptoms
To complete the baseline imaging before MRI a supplementary contrast-enhanced CT (CECT) scan is generally indicated: a mass with perilesional edema is generally contrast-enhancing
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5. MASS WITH PERILESIONAL EDEMA
- Neoplastic or not?
- If not , is it an abscess?
- Are there contraindications for steroids
administration ( abscess, lymphoma ) ?
- If a neoplasm is suspected, is it primitive (glioma
versus lymphoma for neurosurgical strategy) or
metastatic (need to search for a primitive tumor
when unknown) ?
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6. MASS WITH PERILESIONAL EDEMA
- Contrast-enhancement alone not specific for
differential diagnosis
- Need for advanced neuroimaging techniques
- CT : Perfusion CT
- MRI : Perfusion MRI, DWI, DTI, Spectroscopy
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7. GLIOBLASTOMA
Most frequent and aggressive primitive intra-axial neoplasm (astrocytic tumors WHO Grade IV) 50-60% of astrocytic neoplasms, 20,3% CNS neoplasms (Central Brain Tumor Registry of the United States )
Average survival 14 wks NS+Steroids ( Walker MD et al: Evaluation of BCNU and/or radiotherapy in the treatment of anaplastic gliomas : a co-operative clinical trial;JNeurosurg 1978;49: ) , 1 yr NS+CT+RT
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8. GLIOBLASTOMA
Perfusion imaging: either glioblastomas and their surrounding tissue and perilesional edema show areas of increased rCBV for neo-angiogenesis
( Lehmann P et al: Dynamic contrast-enhanced T2*-weighted MR imaging: a brain-oedema study;JNeuroradiol2009 May 36 (2):88-92 )
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9. PRIMARY CNS LYMPHOMA 4-7% primitive cerebral neoplasms
Conventional imaging : difficult d.d. vs GBM or metastases
Perfusion imaging : generally low rCBV, high permeability
( Schramm P et al: Dynamic CT perfusion imaging of intra-axial brain tumours: differentiation of high-grade gliomas from primary CNS lymphomas . European Radiology, vol 20, number 10, , online May 2010)
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10. MENINGIOMA
Perfusion imaging may help to differentiate meningiomas from intra-axial tumors in cases of uncertainty on conventional imaging : high rCBV and permeability in meningiomas
( Hakyemez B et al: Meningiomas with conventional MRI findings resembling intraaxial tumors: can perfusion-weighted MRI be helpful in differentiation? Neuroradiology Oct;48(10): Epub 2006 Aug 1 .)
(Cianfoni A, Cha S, Bradley WG, Dillon WP, Wintermark M. Quantitative measurement of blood-brain barrier permeability using perfusion-CT in extra-axial brain tumors J Neuroradiol Jun;33(3):164-8.)
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11. CEREBRAL ABSCESS
Conventional imaging : difficult d.d. vs tumors with cystic or necrotic content
Perfusion imaging : generally low rCBV for the solid portions of abscesses, high rCBV for tumors
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12. PERFUSION CT (PCT) - Information about regional microvascular
density (CBV), permeability (PS) and blood
flow (CBF)
- Diagnostic and prognostic role when the
possible presence of tumoral neo-angiogenesis
is suspected
- A few-minutes additional time to a CECT study
is needed
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13. PERFUSION CT (PCT)
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14. STUDY PURPOSE
Investigating the possible utility of Perfusion Computed Tomography (PCT) in the differential diagnosis of the newly-diagnosed intracranial solitary masses with perilesional edema
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15. MATERIALS AND METHODS Retrospective evaluation.
22 consecutive pts with newly diagnosed solitary masses and PCT prior to surgery or stereotactic biopsy
Pathology: 10 Glioblastomas (GBM), 5 non-anaplastic meningiomas, 2 lymphomas, 4 abscesses and 1 metastasis from testicular choriocarcinoma
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16. MATERIALS AND METHODS PCT performance:
- 4-slices multidetector CT scanner
- 40 ml c.m. 370mg/mL Iodine
- injection in 18-gauge i.v. line, flow 4 mL/sec
- 45 dynamic scans, 1/sec, 2cm thick coverage
area
- 80 kVp, 108 mAs
- PCT followed by CECT of the whole brain
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17. MATERIALS AND METHODS PCT post-processing:
- two-compartmental model (Patlak analysis) for
Cerebral Blood Volume (CBV) and
Permeability Surface Area Product (PS) maps
- maximum-slope model for Mean Transit Time
(MTT) and Time to Peak (TTP) maps
- CBV, PS, MTT values normalized to
contralateral NAWM (rCBV, rPS, rMTT)
- TTP difference in sec with contralateral NA
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18. MATERIALS AND METHODS PCT measurements:
- circular ROI placed on the solid portions of the
lesion for CBV-PS, manual ROI for MTT-TTP
- maximum measurements of rCBV and rPS,
mean values of rMTT and TTP were considered
- rCBV and rPS measurements of the lesion and
of the perilesional edema (PE rCBV and rPS)
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19. MATERIALS AND METHODS Statistics::
Receiver operating characteristics (ROC) analyses to compute the area under the curve (AUC) for each parameter in the differential diagnoses between biologically aggressive neoplasms (BAN: GBM, Lymphomas, Metastases) versus slow-growing tumors (grade I-II neoplasms) and non-neoplastic conditions (abscesses). ROC analyses to assess which PCT parameters had the highest predictive value for GBM, meningioma, abscess and lymphoma.
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20. RESULTS : BAN vs non-BAN
Lesion
rCBV
Mean (SD)
rPS
rMTT
TTP
Edema
BIOLOGICALLY
AGGRESSIVE
NEOPLASMS
(BAN) (13 )
4.6
(2.35)
16.87
(6.84)
1.08
(0.26)
2.13
(5.28)
1.13
(0.24)
3.81
(2.38)
NON-BAN ( 9 )
6.91
(4.58)
30.05
(21.42)
1.35
(0.33)
6.96
(5.37)
0.91
(0.31)
3.20
(2.01)
P-value (Student’s t-test)
0.19
0.10
0.0495
0.0491
0.083
0.53
Area Under Curve (AUC)
0.658
0.692
0.821
0.842
0.731
0.462
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21. RESULTS : GBM vs non-GBM
Lesion
rCBV
Mean (SD)
rPS
rMTT
TTP
Edema
GLIOBLASTOMAS (GBM) (10 )
4.71
(1.99)
15.63
(6.39)
1.04
(0.11)
0.49
(1.82)
1.19
(0.20)
4.28
(2.52)
NON-GBM ( 12 )
6.25
(4.41)
27.79
(19.02)
1.32
(0.37)
7.12
(6.18)
0.91
(0.29)
2.97
(1.8)
P-value (Student’s t-test)
0.29
0.056
0.029
0.003
0.02
0.17
Area Under Curve (AUC)
0.583
0.708
0.817
0.904
0.812
0.667
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22. RESULTS : MENINGIOMAS
Lesion
rCBV
Mean (SD)
rPS
rMTT
TTP
Edema
MENINGIOMAS (5 )
10.19
(2.7)
43.94
(18.32)
1.38
(0.42)
6.56
(6.1)
0.73
(0.17)
3.47
(1.83)
NON-MENINGIOMAS
( 17 )
4.18
(2.42)
15.89
(6.95)
1.14
(0.26)
3.38
(5.6)
1.13
(0.24)
3.59
(2.35)
P-value (Student’s t-test)
0.0001
0.02
0.14
0.28
0.002
0.92
Area Under Curve (AUC)
0.976
0.988
0.735
0.759
0.912
0.576
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23. RESULTS : LYMPHOMAS
Lesion
rCBV
Median
rPS
rMTT
TTP
Edema
LYMPHOMAS
(2 )
2.1
23.94
1.48
11.3
0.76
2.72
NON-LYMPHOMAS
( 20 )
5.65
18.28
1.11
1.9
1.06
3.26
P-value
(Mann-Whitney test)
0.08
0.56
0.20
0.1
0.42
Area Under Curve (AUC)
0.875
0.625
0.775
0.850
0.675
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24. RESULTS : LYMPH vsINTRA-AXIAL
0.600
1.0
0.900
0.833
0.800
Area Under Curve (AUC)
0.45
0.02
0.07
0.13
0.17
P-value
(Mann-Whitney test)
3.24
1.24
0.9
1.06
15.02
3.54
NON-LYMPH
INTRA-AXIAL
( 15 )
2.72
0.76
11.3
1.48
23.94
2.1
LYMPHOMAS
(2 )
Edema
rPS
Median
rCBV
Lesion
TTP
rMTT
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25. RESULTS : ABSCESSES
Lesion
rCBV
Median
rPS
rMTT
TTP
Edema
ABSCESSES
(4 )
1.81
12.99
1.23
7.6
1.07
2.39
NON-ABSCESSES
( 18 )
5.65
20.27
1.08
1.25
1.04
3.26
P-value (Mann-Whitney test)
0.06
0.10
0.13
0.12
0.49
0.34
Area Under Curve (AUC)
0.806
0.764
0.743
0.750
0.611
0.653
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26. GLIOBLASTOMA
LYMPHOMA
NON-ANAPLASTIC
MENINGIOMA
ABSCESS

27. GLIOBLASTOMA
rCBV = 5.48
LYMPHOMA
rCBV = 1.07
NON-ANAPLASTIC
MENINGIOMA
rCBV = 13.97
ABSCESS
rCBV = 1.21

28. GLIOBLASTOMA rPS = 22.12 LYMPHOMA rPS = 21.86 NON-ANAPLASTIC
MENINGIOMA
rPS = 37.91
ABSCESS
rPS = 17.31 2b

29. GLIOBLASTOMA
rMTT = 1.02
LYMPHOMA
rMTT = 1.82
NON-ANAPLASTIC
MENINGIOMA
rMTT = 1.3
ABSCESS
rMTT = 1.68

30. GLIOBLASTOMA
TTP = - 0.9
LYMPHOMA
TTP = 18.6
NON-ANAPLASTIC
MENINGIOMA
TTP = 3.6
ABSCESS
TTP = 12.1

31. GLIOBLASTOMA
Edema rCBV = 1.34
LYMPHOMA
Edema rCBV = 0.71
ABSCESS
Edema rCBV = 0.95
NON-ANAPLASTIC
MENINGIOMA
Edema rCBV = 0.8

32. CONCLUSIONS PCT useful in d.d. intracranial masses with edema
- TTP, MTT are the best predictors for BAN and GBM
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33. CONCLUSIONS PCT useful in d.d. intracranial masses with edema
- TTP, MTT are the best predictors for BAN and GBM
lesional rCBV is a good predictor for meningioma,
lymphoma, abscess
Careggi University Hospital - Florence - Neuroradiology

34. CONCLUSIONS PCT useful in d.d. intracranial masses with edema
- TTP, MTT are the best predictors for BAN and GBM
lesional rCBV is a good predictor for meningioma,
lymphoma, abscess
rCBV of the perilesional edema is a good predictor for
GBM, meningioma, lymphoma
Careggi University Hospital - Florence - Neuroradiology

35. CONCLUSIONS PCT useful in d.d. intracranial masses with edema
- TTP, MTT are the best predictors for BAN and GBM
lesional rCBV is a good predictor for meningioma,
lymphoma, abscess
rCBV of the perilesional edema is a good predictor for
GBM, meningioma, lymphoma
- lesional rPS good predictor for meningioma
Careggi University Hospital - Florence - Neuroradiology

36. CONCLUSIONS PCT useful in d.d. intracranial masses with edema
- TTP, MTT are the best predictors for BAN and GBM
lesional rCBV is a good predictor for meningioma,
lymphoma, abscess
rCBV of the perilesional edema is a good predictor for
GBM, meningioma, lymphoma
- lesional rPS good predictor for meningioma
measurement of permeability of perilesional edema is
not useful
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37. LIMITATIONS - limited number of cases
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38. LIMITATIONS - limited number of cases
lack of malignant neoplasms such as lymphomas
( 2 cases) and metastases ( 1 case)
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39. LIMITATIONS - limited number of cases
lack of malignant neoplasms such as lymphomas
( 2 cases) and metastases ( 1 case)
absence of grade III-IV meningiomas , low-grade ggliomas, oligodendrogliomas or other malignant masses
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40. YOU !! THANK Azienda Ospedaliero-Universitaria di Careggi - Firenze
Neuroradiologia

41. YOU !! THANK Azienda Ospedaliero-Universitaria di Careggi - Firenze
Neuroradiologia