Imaging of Brain Tumors REVIEW ARTICLE


By Justin T. Jordan, MD, MPH, FAAN; Elizabeth R. Gerstner, MD C O N T I N U UM A U D I O
I NT E R V I E W A V A I L AB L E
ONLINE

ABSTRACT
OBJECTIVE: This article focuses on neuroimaging as an essential tool for CITE AS:
CONTINUUM (MINNEAP MINN)
diagnosing brain tumors and monitoring response to treatment. 2023;29(1, NEUROIMAGING):
171–193.

LATEST DEVELOPMENTS: Neuroimaging is useful at all stages of brain tumor

Address correspondence to
care. Technologic advances have improved the clinical diagnostic Dr Justin T. Jordan, 55 Fruit St,
capability of neuroimaging as a vital complement to history, examination, Yawkey 9E, Boston, MA 02114,
and pathologic assessment. Presurgical evaluations are enriched by novel JTJordan@mgh.harvard.edu.
imaging techniques, through improved differential diagnosis and better RELATIONSHIP DISCLOSURE:
surgical planning using functional MRI (fMRI) and diffusion tensor imaging. Dr Jordan has received personal
The common clinical challenge of differentiating tumor progression from compensation in the range of
$0 to $499 for serving as a
treatment-related inflammatory change is aided by novel uses of perfusion consultant for Atheneum
imaging, susceptibility-weighted imaging (SWI), spectroscopy, and new Partners, EM Partners, GLG
Pharma, and Guidepoint Global,
positron emission tomography (PET) tracers.
LLC; in the range of $500 to
$4999 for serving as a
ESSENTIAL POINTS: Using the most up-to-date imaging techniques will facilitate consultant for Creative
Educational Concepts, LLC, and
high-quality clinical practice in the care of patients with brain tumors. Texas Health Resources; and in
the range of $5000 to $9999 for
serving as a consultant for
Children’s Tumor Foundation,
Navio Theragnostics, Inc, and
Recursion and on a scientific
INTRODUCTION advisory board for Recursion.

M
Dr Jordan has stock in The
ore than 120 types of brain tumors are recognized by the Doctor Lounge and Navio
World Health Organization (WHO) Classification of Tumors Theragnostics, Inc, has received
of the Central Nervous System. Symptoms are determined by publishing royalties from
Elsevier, and has
tumor location and tend to develop quickly with malignant noncompensated relationships
tumors and more insidiously with nonmalignant tumors. With as a board member with ABA
the increasing availability of nervous system imaging for symptom evaluation, Academy, Neurofibromatosis
Northeast, Neurofibromatosis
neurologists are often on the front lines of brain tumor identification. Thus, Continued on page 193
neurologists should be familiar with the neuroimaging findings associated with
tumors to appropriately triage and refer patients. This article describes how UNLABELED USE OF
specific imaging techniques may aid in characterizing intraaxial brain tumors PRODUCTS/INVESTIGATIONAL
USE DISCLOSURE:
(those arising from cells in the brain), as well as distinguishing tumor growth
Drs Jordan and Gerstner discuss
from treatment-associated imaging changes. Imaging of extraaxial tumors the unlabeled/investigational
(those arising from nerves, meninges, or other structures outside the brain use of mitogen-associated
parenchyma) is addressed in a separate article; refer to “Imaging of Skull Base protein kinase (MAPK) pathway
with MAP-ERK kinase (MEK)
Tumors” by Wenya Linda Bi, MD, PhD,1 in this issue of Continuum. inhibitors for the treatment of
This year in the United States, approximately 25,000 primary malignant MAP kinase-altered tumors and
various MRI and positron
tumors and 62,000 nonmalignant tumors of the nervous system will be emission tomography (PET)
diagnosed, and approximately 17,000 people will die as a result of nervous techniques not approved for the
system tumors.2 Glioblastoma is the most commonly occurring malignant imaging of brain tumors.

primary brain tumor in adults, and meningioma is the most common © 2023 American Academy
nonmalignant intracranial tumor.2 of Neurology.

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IMAGING OF BRAIN TUMORS

Neuroimaging is crucial when a brain tumor is suspected. Anatomic MRI with

a gadolinium-based contrast agent is the current standard in such cases. CT may
be used in urgent evaluations or where MRI is not safe or feasible but is
substantially less sensitive for tumor detection and less specific for tumor
discrimination. TABLE 7-13 compares the utility of different diagnostic modalities
and sequences for tumor imaging. Not all intraaxial mass lesions are tumors,
however, and neurologists should keep in mind a broader differential diagnosis
that may include abscess, stroke, or inflammatory lesions as well as tumor.
Specific signal characteristics on neuroimaging may further refine the
differential diagnosis, although neuroimaging alone is generally not sufficient to
confirm a tumor diagnosis. Additional diagnostic evaluation requirements are
generally determined based on neuroimaging results.

INITIAL IMAGING
Head CT or brain MRI is usually the first step in the evaluation of a patient who
presents with neurologic symptoms suggestive of a mass lesion. Although MRI is
more sensitive for identifying central nervous system (CNS) tumors, CT is
typically faster, cheaper, and more widely available so is often the first screening test
for a brain tumor. CT can also quickly exclude other possibilities such as ischemic
stroke or intraparenchymal hemorrhage. However, contrast-enhanced MRI is the
current gold standard for diagnosis and long-term management of CNS tumors.
MRI capitalizes on the magnetization properties of protons in the water
molecules within tissue. A powerful magnetic field is applied to align the

TABLE 7-1 Tumor Imaging Modalitiesa

Imaging technique Role in brain tumor imaging

CT Mass effect, herniation, hydrocephalus, hemorrhage, calcifications

Precontrast and postcontrast Enhancement characteristics (eg, homogeneous, heterogeneous, rim), necrosis,
T1-weighted imaging extent of tumor that is enhancing

T2-weighted or fluid-attenuated Peritumoral edema, infiltrative or nonenhancing tumor

inversion recovery (FLAIR)

Diffusion-weighted imaging Low apparent diffusion coefficient in hypercellular portions of tumor,

postoperative devitalized tissue

Diffusion tensor imaging Tractography for surgical planning

Susceptibility-weighted imaging (SWI) Blood products, calcifications, microhemorrhages

Perfusion imaging Tumor vascularity and permeability

Magnetic resonance spectroscopy Metabolic profile for differentiating tumor from other pathologies, including
oncometabolite 2-hydroxyglutarate measurement

Functional MRI (fMRI) Preoperative functional mapping

Positron emission tomography (PET) Increase uptake of amino acid tracers in active, higher-grade tumors

CT = computed tomography; MRI = magnetic resonance imaging.

a
Modified with permission from Baig MA, et al, Continuum (Minneap Minn).3 © 2016 American Academy of Neurology.

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normally randomly oriented protons into one plane.4 This alignment is then KEY POINTS
perturbed by an externally applied radiofrequency pulse. After some
● Approximately 25,000
tissue-specific time, the protons relax into their resting orientation and, in doing primary malignant brain
so, emit radiofrequency energy that is collected and processed through Fourier tumors are diagnosed each
transformation to create a corresponding image. By varying the sequence of year in the United States.
radiofrequency pulses applied, different imaging sequences are created that are
● Glioblastoma is the most
sensitive to different aspects of molecular behavior within different tissue types.
common malignant primary
Thus, MRI provides excellent contrast between different CNS tissues such as intracranial brain tumor in
gray matter, white matter, CSF, and pathologic tissue within a tumor. adults.

MRI SEQUENCES ● Keeping a broad

differential diagnosis is
MRI provides excellent insight into brain pathology by allowing evaluation of the important for mass lesions,
brain in multiple ways to expose different physiologic and anatomic changes. including abscesses,
strokes, or inflammatory
T1-Weighted and T2-Weighted Sequences disease.
T1-weighted, T2-weighted, and fluid-attenuated inversion recovery (FLAIR)
● Although CT may show
sequences are the most common anatomic sequences used for brain tumor acute changes such as
diagnosis and response assessment. Typically, brain tumors are hypointense on stroke or hemorrhage,
T1-weighted images and hyperintense on T2-weighted images, reflecting the gadolinium-enhanced MRI is
the preferred imaging
increased water content in tumor and surrounding vasogenic edema. Notable
modality for brain tumors.
exceptions include tumors that have calcification (eg, oligodendrogliomas) or old
blood products or melanin. FLAIR is a type of T2-weighted pulse sequence that ● T1-weighted,
suppresses the signal from CSF and is most useful in assessing the extent of T2-weighted, and
nonenhancing tumor, vasogenic edema, or gliosis. Imaging patterns for some of fluid-attenuated inversion
recovery (FLAIR) sequences
the most common intraaxial brain tumors are outlined in TABLE 7-2.3 are critical to diagnosing and
treating patients with brain
Diffusion-Weighted Imaging tumors.
Diffusion-weighted imaging uses MR sequences sensitive to the intrinsic random
● Diffusion-weighted
(brownian) movement of water molecules. Reduced diffusivity, or increased
imaging may be helpful to
anisotropy, refers to a limitation in the free movement of water molecules in detect ischemic strokes,
tissue. Because tumors have increased cellularity relative to surrounding normal hypercellularity within
brain tissue, they tend to have more restricted diffusion; this can be quantitated tumors (especially
lymphomas and high-grade
by the apparent diffusion coefficient (ADC), which measures the diffusion of
gliomas), and perioperative
water molecules measured in square millimeters per second. In tumor imaging, devitalized tissues.
ADC values are typically inversely correlated with cellularity: low ADC values
imply increased cellularity and restricted diffusion, as seen in higher-grade
tumors or lymphomas. However, the tumor microenvironment can be quite
variable, with a mix of tumor cells, edema, and necrosis, making the ADC less
specific for tumor grading. Recent studies have suggested that the ADC may help
predict response to antiangiogenic treatment.5,6
Diffusion tensor imaging is an extension of diffusion-weighted imaging and
allows for visualization of the direction of water motion, thus providing
information on the orientation and anisotropy of white matter tracts in the brain.
Knowing where the white matter tracts are in relation to a brain tumor has been
helpful in surgical planning to reduce surgical morbidity.

Susceptibility-Weighted Imaging
Susceptibility-weighted imaging (SWI) is a sequence that is sensitive to
paramagnetic and diamagnetic compounds that distort the local magnetic field.
In the setting of a brain tumor, SWI is used to detect blood products or

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IMAGING OF BRAIN TUMORS

TABLE 7-2 MRI Characteristics of Common Brain Tumorsa

Type of brain tumor MRI characteristics

Pilocytic astrocytoma T1-weighted images: hypointense cystic component, isointense solid component
T2-weighted images: hyperintense cystic component, hyperintense solid component
Postgadolinium images: heterogeneous enhancement of solid component and wall of
cystic component

Isocitrate dehydrogenase T1-weighted images: hypointense mass

(IDH)–mutated
T2-weighted images: hyperintense mass, presence of surrounding hyperintense
astrocytoma
edema increases with grade; fluid-attenuated inversion recovery (FLAIR) imaging may
be relatively hypointense (T2-FLAIR mismatch sign)
Diffusion restriction: unlikely
Postgadolinium images: likelihood and amount of heterogeneous enhancement
increases with grade

IDH-mutated and T1-weighted images: hypointense mass, may extend to include cortex
1p/19q-codeleted
T2-weighted images: heterogeneously hyperintense
oligodendroglioma
Postgadolinium images: enhancement unlikely in grade 2, may be heterogeneous in
grade 3

IDH wild-type glioblastoma T1-weighted images: hypointense mass; hyperintense blood products may be
present
T2-weighted images: hyperintense mass with extensive surrounding hyperintense
edema; may be hypointense centrally because of necrosis
Diffusion restriction: infrequent
Postgadolinium images: heterogeneous enhancement, often ringlike with central
nonenhancing necrotic region

H3 K27–altered diffuse T1-weighted images: hypointense mass in brainstem or thalami or spinal cord
midline glioma
T2-weighted images: hyperintense, heterogeneous
Postgadolinium images: rim enhancement with central necrosis

Lymphoma of the central T1-weighted images: hypointense to isointense mass, often multifocal; hyperintense
nervous system blood products may be seen in immunocompromised patients
T2-weighted images: hypointense to isointense, may have hyperintense surrounding
edema
Diffusion restriction: often present
Postgadolinium images: for immunocompetent patients, homogeneous
enhancement; for immunocompromised patients, rim enhancement with central
necrosis

Central nervous system T1-weighted images: isointense to hypointense (except mucinous lesions, which are
metastasis hyperintense)
T2-weighted images: heterogeneously hyperintense (except mucoepidermoid type,
which are hypointense); usually surrounded by hyperintense edema
Diffusion restriction: may be present, especially in very small lesions
Postgadolinium images: enhancement usually rimlike

MRI = magnetic resonance imaging.

a
Modified with permission from Baig MA, et al, Continuum (Minneap Minn).3 © 2016 American Academy of Neurology.

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calcifications. The presence of a microhemorrhage within a brain tumor can be KEY POINTS
associated with higher-grade gliomas and can be seen following radiation therapy,
● Susceptibility-weighted
potentially reflecting radiation vasculopathy.7 Calcifications can be seen in imaging is helpful to identify
lower-grade meningiomas or oligodendrogliomas, as these entities are more calcifications in low-grade
indolent in nature. Different MRI vendors have different names for these tumors or hemorrhage in
sequences, and there are differences in how the images are acquired, making typically higher-grade
tumors.
comparisons across vendors challenging. For example, a gradient recalled echo
(GRE) sequence provides similar information as an SWI sequence but is acquired ● Perfusion imaging may
at lower spatial resolution so it can be less sensitive to microhemorrhages. help visualize vascularity
and help distinguish
Perfusion Imaging between low- and
high-grade tumors, as well
Perfusion imaging is used to evaluate tumor vascularity and blood-brain barrier as between tumor growth
permeability. Both contrast-dependent approaches (eg, dynamic susceptibility and inflammatory changes.
contrast imaging) and non–contrast-dependent approaches (eg, arterial spin
labeling) exist. In dynamic susceptibility contrast imaging, the most common ● MR spectroscopy
that measures
approach, kinetic analysis of the passage of the contrast bolus through tissue 2-hydroxyglutarate may aid
enables calculation of several physiologic biomarkers, including cerebral blood in diagnosing an isocitrate
volume (CBV), cerebral blood flow, and mean transit time. Cerebral blood dehydrogenase (IDH)-
volume is typically elevated in higher-grade tumors because of the increase in mutated tumor and may
improve monitoring of
angiogenesis and correlates with tumor grade and response to therapy.8,9
treatment response.
Perfusion imaging is increasingly being used clinically in the management of
brain tumors, and recent consensus guidelines include recommendations on how
best to perform it in an effort to standardize this technique (FIGURE 7-1).10

MR Spectroscopy
MR spectroscopy is used to measure metabolites in the brain. Tumors have a
characteristic appearance with an increase in the choline peak, a decrease in the
N-acetylaspartate (NAA) peak, increased choline-to-creatine ratio, and, in
high-grade glioma, a lactate peak. MR spectroscopy has been used to help with
tumor diagnosis, for example, to distinguish tumors from other pathologic
processes and to track tumor response to treatment. A new MR spectroscopy
technique has been developed that can measure the oncometabolite
2-hydroxyglutarate (2HG), which is present in isocitrate dehydrogenase
(IDH)–mutated gliomas.11 With this approach, a tool that potentially reflects
tumor burden more accurately than just contrast dye leakage on postcontrast
sequences is available. Studies have suggested that 2HG can be used as a
marker of tumor response to treatment.12,13 Measuring 2HG with MR
spectroscopy is still a research technique but holds great promise for improving
our ability to diagnose tumors (particularly if in a surgically inaccessible location)
and for interpretation of tumor response to treatment (FIGURE 7-2).

Functional MRI
Functional MRI (fMRI) is a technique that reflects brain metabolic activity by
measuring blood oxygenation changes within blood vessels in the brain.
Increased brain activity leads to increased blood flow and oxygen extraction from
the blood, resulting in an increase in deoxyhemoglobin. Because
deoxyhemoglobin is paramagnetic, a change occurs in the blood oxygen
level-dependent (BOLD) contrast signal, thus highlighting active areas of the
brain depending on the task the patient is performing. fMRI is primarily used by
neurosurgeons preoperatively to help them plan a maximal safe surgical

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IMAGING OF BRAIN TUMORS

FIGURE 7-1
Isocitrate dehydrogenase (IDH) wild-type glioblastoma. A, Axial postcontrast T1-weighted
MRI of a newly diagnosed tumor shows heterogeneous enhancement. B, Perfusion imaging
shows elevated cerebral blood volume in the left frontal tumor (arrow). C, Axial postcontrast
T1-weighted MRI 2 months after chemoradiotherapy shows evidence of pseudoprogression
by increased enhancement in the left frontal tumor. D, Perfusion imaging shows no increase in
cerebral blood volume.

resection. fMRI helps identify eloquent parts of the brain, such as cortical areas
important in speech and white matter tracts important in motor function.

NEW IMAGING APPROACHES

Although MRI has been the backbone of brain tumor diagnosis and monitoring
response to treatment, there is increasing interest in using positron emission
tomography (PET) to monitor tumor response. Because of high physiologic
glucose metabolism within the normal brain, 18F-fludeoxyglucose has poor
diagnostic accuracy for gliomas and therefore has a limited role. Alternatively,
amino acid PET tracers (eg, 3,4-dihydroxy-6-18F-fluoro-L-phenylalanine,
fluoroethyl-L-tyrosine, or 18F-fluciclovine) are being explored because of low
background noise in normal brain tissue. The uptake of amino acid tracers into
the tumor cells is mediated via the L-amino acid transporter system, which is
overexpressed in neoplastic cells but not in non-neoplastic cells, making amino
acid tracers more tumor-specific. These tracers are still under clinical
development in the United States but are more widely used in Europe. Indeed,
the Response Assessment in Neuro-Oncology (RANO) working group and the
European Association for Neuro-Oncology have recommended incorporating

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 KEY POINTS

● Functional MRI is useful

for determining the
anatomic location of brain
activity for various tasks
such as speaking or motor
function and may help
surgical planning.

● Amino acid positron

emission tomography (PET)
tracers may aid in
distinguishing tumor growth
from inflammatory changes.

FIGURE 7-2
Isocitrate dehydrogenase (IDH) wild-type glioblastoma with pseudoprogression following
chemoradiotherapy. A, Axial postcontrast T1-weighted MRI demonstrates heterogeneous
enhancement in the corpus callosum that developed 8 weeks after chemoradiotherapy.
B, Single-voxel (arrow) MR spectroscopy without an elevated choline, creatine, or
N-acetylaspartate (NAA) peak, supporting a diagnosis of pseudoprogression.
Figure courtesy of Eva Ratai, PhD.

amino acid PET scans into the management of brain tumors to aid in the
diagnosis and monitoring of tumor response.14
Other approaches on the horizon that are intended to explore physiologic
changes in brain tumors include chemical exchange-dependent saturation
transfer imaging, which can measure tumor pH, and hyperpolarized carbon-13
MRI, which can measure dynamic changes in different cellular metabolic
pathways. Lastly, deep-learning algorithms and radiomics are increasingly
pervasive in medical imaging. In the setting of brain tumors, deep-learning
algorithms and radiomics have been explored in the noninvasive differentiation
of tumor types, predicting tumor mutation status, tumor segmentation, and
assessing treatment response.15-18 These techniques have been challenging to
deploy universally, however, because of methodologic errors, small data sets,
and lack of external validation cohorts.

COMMON CLINICAL CONUNDRUMS

Despite the increasing sophistication of MRI, several clinical conundrums remain
in which MRI may be misleading or not definitive.

True Tumor Progression Versus Treatment-Related Changes

Differentiating true tumor progression from treatment-related changes, both of
which may present with an increase in contrast enhancement, can be challenging
on routine anatomic MRI sequences. This clinical conundrum can occur early
after radiation treatment with or without chemotherapy (pseudoprogression),
months to years later (radiation necrosis), or after immunotherapy. Studies have
suggested that elevated cerebral blood volume on perfusion imaging, increased
uptake on amino acid PET, low ADC, or the classic MR spectroscopy spectrum of
elevated choline, a decrease in NAA, and an increased choline-to-creatine ratio
favor progressive tumor.19 Unfortunately, no single imaging technique is perfect
in differentiating tumor progression from treatment-related changes. Part of the

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IMAGING OF BRAIN TUMORS

challenge has been establishing ground truth to validate an imaging biomarker.

In particular, with pseudoprogression or inflammatory change following
immunotherapy, pathologic examination can show a heterogeneous mix of
tumor cells and treatment-related changes and is subject to sampling error, that
is, what is evaluated under the microscope may not be representative of any
tissue left behind.
Although this conundrum is classically associated with postcontrast images, it
also extends to nonenhancing tumors that are seen best on T2-weighted
and FLAIR images. With nonenhancing tumors treated with radiation, there can
be a slow progression of FLAIR hyperintensity that reflects gliosis and scarring
from radiation that is hard to distinguish from slow, infiltrative tumor growth.
Often, active surveillance is employed at the onset of such changes, using the
pace of growth or morphologic changes (eg, with a more masslike, expansile
appearance) to determine the likelihood of true tumor growth. In IDH-mutated
gliomas, 2HG MR spectroscopy holds particular promise to help distinguish
tumor growth versus gliosis, as tumor growth would be associated with elevated
2HG. However, MR spectroscopy can fail when 2HG concentrations are very
low, as may occur in tumors with low cellularity.

Pseudoresponse
Another clinical conundrum occurs in the setting of antiangiogenic therapy,
such as bevacizumab. Bevacizumab targets vascular endothelial growth factor
(VEGF) on the tumor blood vessels, thereby closing the blood-brain barrier
and decreasing contrast leakage into the tumor region. This reduction in
enhancing disease is known as pseudoresponse and is often accompanied by
an initial reduction in FLAIR hyperintensity related to restricted extravasation
of fluid and inflammatory cells (CASE 7-1). However, active tumors still need a
rich blood supply, and when angiogenesis is blocked, the tumors may ultimately
co-opt native brain blood vessels with an intact blood-brain barrier, resulting in a
later increase in nonenhancing tumor burden with more masslike expansile
FLAIR hyperintensity but relatively less contrast enhancement.

MONITORING TUMOR RESPONSE TO TREATMENT

The RANO criteria are the most commonly used criteria to monitor tumor response
to treatment (TABLE 7-3). The criteria were created by expert consensus
primarily for the standardization of clinical trial outcomes, and different criteria
exist for most tumor types (eg, RANO criteria for high-grade glioma, low-grade
glioma, meningiomas, brain metastases, and leptomeningeal disease).20-22

TUMOR-SPECIFIC IMAGING CHARACTERISTICS

More than 120 recognized nervous system tumor types exist, and neurologists
will certainly encounter some of the most common of these in routine clinical
practice. Understanding imaging characteristics of these tumors may aid in triage
for subspecialty consultation, diagnostic considerations, and monitoring for
treatment response. The tumor types that are most likely to be seen in routine
clinical practice are reviewed below.

Pilocytic Astrocytoma
Pilocytic astrocytoma (WHO grade 1) is a nonmalignant tumor arising from glial
cells, primarily in the pediatric population (median age, 11 years).2 These tumors

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are well demarcated, are most frequently located in the posterior fossa, and often KEY POINTS
cause positional headache or ataxia. The classic histologic finding of Rosenthal
● Pseudoprogression in
fibers remains a diagnostic hallmark of these tumors, and more recently a high-grade gliomas is often
KIAA1549-BRAF gene fusion has been identified in approximately 70% of associated with increased
pilocytic astrocytomas as well.23 Pilocytic astrocytomas may be curable with contrast enhancement and
complete resection alone, although unresectable or progressive tumors may hyperintensity on
T2-weighted and FLAIR
require additional treatments such as radiotherapy or chemotherapy; emerging
images and is caused by
evidence suggests a role for targeting the mitogen-associated protein kinase inflammatory change.
pathway with MAP-ERK kinase (MEK) inhibitors.24
On imaging, pilocytic astrocytomas are generally well-circumscribed cystic ● Distinguishing tumor
lesions with a heterogeneously enhancing mural nodule. The contents of the progression from
inflammatory change is a
cyst are usually isointense to CSF signal on all sequences, except in the case frequent challenge, and a
of very proteinaceous cystic contents, in which case the signal may be thorough evaluation may
hyperintense to CSF on certain sequences. Additional differential incorporate perfusion MRI,
considerations for cystic tumors are listed in TABLE 7-4.3 amino acid positron
emission tomography, or MR
A notable subgroup of pilocytic astrocytomas arise in the optic pathway, and spectroscopy.
these are found in roughly 15% of patients with neurofibromatosis type 1 (NF1).
These are almost exclusively diagnosed in children, and consensus ● Lower-grade tumors may
recommendations exist for ophthalmologic screening of patients with NF1 exhibit inflammatory
radiation change through
during early childhood as a preferred screening strategy.25 Imaging may show
slow progression of
FLAIR hyperintensity with expansion or tortuosity of optic nerves, chiasm, optic hyperintensity on FLAIR
tracts, or even the hypothalamus. Contrast enhancement is variable, often images.
patchy or absent. Any such finding in a patient with NF1 should prompt
consideration of an optic pathway glioma. Importantly, in many patients, ● Drugs targeting vascular
endothelial growth factor
NF1-associated optic pathway gliomas may remain static or even decrease in size (VEGF) such as bevacizumab
spontaneously. Diagnostic tissue sampling is generally not required, and may reduce enhancement
treatment is indicated only for symptomatic tumors. and hyperintensity on FLAIR
images temporarily for
high-grade gliomas, a
Subependymal Giant Cell Astrocytoma phenomenon known as
Subependymal giant cell astrocytomas (SEGAs) are histologically benign tumors pseudoresponse.
found almost exclusively in patients with tuberous sclerosis complex, occurring
in 5% to 20% of these patients. These tumors are well demarcated and generally ● Based on expert
consensus, the Response
found in the periventricular space, although they may extend into the
Assessment in
intraventricular space and even cause obstructive hydrocephalus. The foramen Neuro-Oncology criteria
of Monro is the classic location for SEGA development. provide a standardized
The differentiation between non-neoplastic subependymal nodules and framework for monitoring
brain tumor treatment
SEGAs can be difficult on imaging. A size cutoff of 1 cm or larger has
response.
been posed as more likely to reflect SEGA than a subependymal nodule. CT may
show an intraventricular mass that is isodense or slightly hypodense ● Despite their
to gray matter, often with internal calcification. MRI may show an enhancing nonmalignant behavior,
mass that is hyperintense on T2-weighted images and has calcified components. pilocytic astrocytomas
present as heterogeneously
Although intervention is not warranted for all SEGAs, surgical intervention enhancing nodules with
may be necessary for obstructive hydrocephalus, and mammalian/mechanistic adjacent cystic structures.
target of rapamycin (mTOR) inhibitors such as everolimus may be used to
stabilize or even shrink tumors in many patients. ● Subependymal giant cell
astrocytomas are a classic
feature of tuberous sclerosis
Grade 2 to 4 IDH–Mutated Astrocytoma complex and are generally
It is now understood that IDH1 and IDH2 mutations are the molecular drivers of found near the foramen
most gliomas referred to historically as “low grade,” which are generally less of Monro.
aggressive than IDH wild-type tumors (historically called “high grade”). These

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IMAGING OF BRAIN TUMORS

CASE 7-1 A 55-year-old right-handed man presented with increasing headaches

and confusion for 2 months’ duration. MRI of the brain, with and without
contrast, revealed a right temporal rim-enhancing mass with surrounding
fluid-attenuated inversion recovery (FLAIR) hyperintensity (FIGURE 7-3).
An open biopsy was performed, and pathologic evaluation confirmed
isocitrate dehydrogenase (IDH) wild-type glioblastoma. The patient was
treated with radiation and both concurrent and adjuvant temozolomide.
Following completion of this therapy, the patient had an increase in
heterogeneous enhancement and surrounding FLAIR hyperintensity, as
well as clinical decline. Bevacizumab therapy was initiated, and
follow-up MRI showed reduced contrast enhancement and reduced
vasogenic edema, consistent with pseudoresponse to vascular
endothelial growth factor (VEGF)–directed therapy. The patient also had
clinical benefit at this time.

COMMENT This case exemplifies the pattern of heterogeneous enhancement and

marked surrounding T2 or FLAIR hyperintensity that is classically seen with
glioblastoma, as well as the reversal of these findings with the use of
bevacizumab (pseudoresponse).

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FIGURE 7-3
Imaging of the patient in CASE 7-1 with isocitrate dehydrogenase (IDH) wild-type
glioblastoma. Before treatment, axial postcontrast T1-weighted MRI (A) shows a
rim-enhancing right temporal lesion, and fluid-attenuated inversion recovery (FLAIR) (B)
shows surrounding vasogenic edema. Six months after completion of standard radiation
therapy and chemotherapy, axial postcontrast T1-weighted MRI (C) shows increased
heterogeneous enhancement, and FLAIR image (D) shows marked increase in surrounding
vasogenic edema. After initiation of bevacizumab, axial postcontrast T1-weighted MRI (E)
shows reduced enhancement, and FLAIR image (F) shows reduced hyperintensity, consistent
with pseudoresponse to vascular endothelial growth factor (VEGF)–directed therapy.

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IMAGING OF BRAIN TUMORS

IDH-mutated tumors are more common in younger adults, and median overall
survival for IDH-mutated grade 2 astrocytoma is generally more than 10 years,
compared with 5 to 10 years for grade 3 tumors and about 3 years for grade
4 tumors.26
CT of these tumors generally identifies a diffuse hypodensity with mass effect
but with infrequent enhancement, especially in lower grades. MRI may show a
lesion that is hypointense on T1-weighted images and hyperintense on
T2-weighted images, often with expansion of underlying parenchyma. A
T2-FLAIR mismatch sign may be present, with T2 hyperintensity but relative
hypointensity on FLAIR imaging thought to stem from spatial differences in the
cellularity and microenvironment of these tumors (FIGURE 7-4).27,28 Gadolinium
enhancement is infrequent in grade 2 tumors but increasingly common in grade 3
and 4 tumors, with the possible appearance of central necrosis and increasing
vasogenic edema in higher grades as well. As noted previously, MR spectroscopy
may be able to detect 2HG, the oncometabolite derived from IDH mutations, and
may aid in diagnosis or treatment monitoring.

Grade 2 to 3 IDH–Mutated and 1p/19q-Codeleted Oligodendroglioma

Oligodendrogliomas are molecularly defined as having both an IDH mutation
and codeletion of chromosome arms 1p and 19q. The average age at diagnosis is in
the fifth decade of life, and seizures are the presenting symptom in two-thirds of
patients.29 Approximately 60% of oligodendrogliomas have a frontal lobe
location.30 Studies of prognosis for oligodendrogliomas are confounded by the
inclusion of other tumor types, including IDH wild-type tumors, which is a
byproduct of the rapidly evolving understanding of glioma biology and
molecularly driven tumor distinctions. Using retrospective molecular
stratification of prior data, oligodendrogliomas are generally considered to have a
favorable response to radiation therapy and chemotherapy, with overall patient
survival of more than 10 years.27
CT of oligodendrogliomas generally shows a diffuse, hypodense lesion
involving both the cortex and subcortical white matter. Calcifications are
commonly seen but are not diagnostic. MRI reveals a mass that is hypointense on
T1-weighted images and hyperintense on T2-weighted images with contrast
enhancement in a small minority of grade 2 oligodendrogliomas but in greater

TABLE 7-3 Response Assessment in Neuro-oncology Criteriaa

Complete response Partial response Stable disease Progressive disease

Contrast enhancement No enhancement ≥50% decrease <50% decrease to <25% increase ≥25% increase

FLAIR Stable or decrease Stable or decrease Stable or decrease Stable or increase

New lesion No No No Present

Corticosteroid dose None Stable or decrease Stable or decrease Not applicable

Clinical status Stable or improved Stable or improved Stable or improved Worsened

FLAIR = fluid-attenuated inversion recovery.

a
Patient must meet all criteria to be categorized as having complete or partial response or having stable or progressive disease.

182 FEBRUARY 2023

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than 70% of grade 3 oligodendrogliomas.31 MR spectroscopy may identify
elevated 2HG (FIGURE 7-5).

IDH Wild-Type Glioblastoma

The most recent iteration of the WHO classification of tumors of the CNS
specifies that the term glioblastoma can be applied only to IDH wild-type tumors
(ie, this term can no longer be applied to astrocytic tumors with IDH mutations).
Glioblastomas may affect adults at any age but are more common in older adults,
and the time from symptom onset to diagnosis is less than 3 months in most
patients.32 Treatment includes a combination of surgical resection, radiation
therapy, and chemotherapy. Prognosis is better with younger age, better
performance status, greater extent of resection, and presence of MGMT
promoter methylation. Median overall survival for WHO grade 4 IDH wild-type
glioblastoma is about 8 months (15 to 18 months with radiation therapy and
chemotherapy), and the 5-year survival rate is 6.8% in the United States.2
Imaging of IDH wild-type glioblastoma generally reveals a supratentorial
space–occupying mass with prominent surrounding edema. Satellite lesions may
be present, as well as evidence of diffuse spread along white matter tracts,
sometimes causing bilateral involvement. On MRI, these tumors are generally
hypointense on T1-weighted images and hyperintense on T2-weighted images
and demonstrate heterogeneous enhancement that is sometimes in the pattern of
irregular rim enhancement with evidence of central necrosis (CASE 7-1).
Intratumoral blood products are not uncommon, affecting SWI as well as
potentially causing foci of intrinsic T1 hyperintensity.

H3 K27–Altered Diffuse Midline Glioma

Diffuse midline glioma is an infiltrative glioma that generally arises in the
brainstem in pediatric patients (especially the pons, as in diffuse intrinsic pontine
glioma) or the thalami or spinal cord in adults. These tumors carry an overall
poor prognosis, with less than 10% of individuals surviving 2 years or longer.
MRI of diffuse midline glioma shows rim enhancement surrounding central

Cortical Masses With Cystic and Nodular Componentsa TABLE 7-4

Gliomas
◆ Pilocytic astrocytoma
◆ Isocitrate dehydrogenase (IDH) wild-type glioblastoma (rare)
Glioneuronal tumors
◆ Ganglioglioma
◆ Pleomorphic xanthoastrocytoma
Other
◆ Hemangioblastoma
◆ Central nervous system metastasis

a
Modified with permission from Baig MA, et al, Continuum (Minneap Minn).3 © 2016 American Academy of
Neurology.

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IMAGING OF BRAIN TUMORS

FIGURE 7-4
World Health Organization grade 2 isocitrate dehydrogenase (IDH)-mutated astrocytoma. A,
Axial fluid-attenuated inversion recovery (FLAIR) MRI of the brain shows relative
hypointensity within the right frontal mass compared to the T2-weighted images. B, Axial
T2-weighted MRI shows hyperintensity (T2-FLAIR mismatch sign). C, Axial postcontrast
T1-weighted MRI shows no abnormal enhancement associated with the tumor.

necrosis in most patients, with poorly defined margins of non–contrast-

enhancing portions with heterogeneous FLAIR signal.33 Specifically, diffuse
intrinsic pontine glioma presents as a tumor arising from the pons with FLAIR
hyperintensity involving greater than 50% of the ventral pons. The basilar artery
may become encased by tumor.

Ependymoma
With an evolving understanding of the molecular and epigenetic features of
ependymal tumors, the current iteration of the WHO classification of CNS

FIGURE 7-5
World Health Organization grade 2 isocitrate dehydrogenase (IDH)-mutated, 1p/19q
codeleted oligodendroglioma. A, Axial fluid-attenuated inversion recovery (FLAIR) MRI
reveals a discrete focus of hyperintensity including both insular cortex and subcortical white
matter. B, Axial postcontrast T1-weighted MRI shows no abnormal enhancement.

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tumors distinguishes a total of 10 ependymoma subtypes across 3 main anatomic KEY POINTS
compartments (ie, supratentorial, posterior fossa, and spine). Although
● IDH-mutated
prospective data focused on molecular subtype–specific treatment determination astrocytomas commonly
are not yet available, the classification distinctions highlight the heterogeneous exhibit the T2-FLAIR
nature of ependymal tumor biology. mismatch sign, in which
Imaging of ependymal tumors varies primarily by location, not necessarily T2-weighted images show a
hyperintense tumor but the
by molecular subtype. Supratentorial ependymomas generally demonstrate
tumor is less hyperintense
heterogeneous enhancement with internal cysts, calcification, or both. SWI may on FLAIR images.
show evidence of internal hemosiderin, and diffusion restriction may be present
in the case of hypercellular tumor. Posterior fossa tumors are primarily found ● Oligodendrogliomas
filling the fourth ventricle, with occasional extension into the foramen of Luschka commonly present with
seizures, extend to the
or Magendie. Enhancement patterns are variable in these tumors, and internal cortex, and may reveal
cysts and calcifications may be seen (FIGURE 7-6). Spinal ependymomas are internal calcification.
intramedullary and enhancing and often have internal cystic change, with less
frequent calcification, blood products, or even necrosis. Sixty percent of spinal ● Glioblastoma is generally
characterized by a
ependymomas are associated with syrinx. Myxopapillary ependymomas are supratentorial mass lesion
nearly exclusively found at the conus medullaris or filum terminale. Finally, with heterogeneous
subependymomas are very well demarcated, hypointense to isointense on enhancement and
T1-weighted images, and hyperintense on T2-weighted images; may have internal surrounding hyperintensity
on T2-weighted and FLAIR
calcification or cystic change; and occasionally show small foci of enhancement.
3 images; some intratumoral
TABLE 7-5 summarizes the differential diagnosis for intraventricular masses. hemosiderin and satellite
lesions may exist.
Lymphoma of the Central Nervous System
Primary diffuse large B-cell lymphoma of the CNS accounts for only about 3% of ● H3 K27–altered diffuse
midline glioma is an
all brain tumors, and the peak incidence is during the fifth to seventh decades of aggressive tumor that may
life, with a slight male predominance.2 These tumors are distinguished from arise from any midline
immunodeficiency-associated CNS lymphomas, whose frequency has declined structure such as thalamus,
as therapies for human immunodeficiency virus (HIV) infection have improved, brainstem, or spinal cord.
although they may still be seen with other immunodeficiencies or ● Ependymomas may arise
immunosuppressive therapies. As CNS lymphoma is a diffuse disease, surgery in the supratentorial space,
plays little role beyond achieving a diagnosis. Instead, methotrexate-based infratentorial space, or
chemotherapy regimens are the standard induction therapy approach, with spinal cord and have varying
molecular differentiation.
consolidation options ranging from high-dose chemotherapy with or without
autologous stem cell transplant to low-dose whole-brain radiation therapy. ● Central nervous system
Overall survival is about 3 years according to most published studies, although lymphomas in
age is an important factor in prognosis, and some patients (especially younger immunocompetent patients
ones) may be cured. are homogeneously
enhancing, whereas
Imaging patterns are different between primary (or secondary) CNS immunosuppressed patients
lymphoma and immunodeficiency-associated CNS lymphoma. In present with rim-enhancing
immunocompetent individuals, MRI demonstrates one or more homogeneously lesions with occasional
enhancing lesions, often with associated restricted diffusion (related to tumor necrosis or hemorrhage.
hypercellularity).34 Nearly 80% of lesions are close to the ventricular ependyma ● Nearly 80% of central
or meningeal surface, and frequent involvement of the basal ganglia, thalamus, nervous system lymphoma
or corpus callosum occurs. Although perilesional edema may be present, it is lesions are close to the
generally less prominent than in gliomas or metastases (CASE 7-2). ventricular ependyma or
meningeal surface, and
Immunodeficiency-associated CNS lymphoma, on the other hand, is more
frequent involvement of the
likely to present with multifocality and rim enhancement of lesions (rather than a basal ganglia, thalamus, or
homogeneous enhancement pattern). Lesions are less likely to be adjacent to corpus callosum occurs.
ependyma or meningeal surfaces35 and may be associated with increased edema,
or even hemorrhage or necrosis.

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IMAGING OF BRAIN TUMORS

KEY POINTS

● Although
hemangioblastomas may be
sporadic, evaluation for
underlying von
Hippel-Lindau syndrome is
important.

● Imaging of the entire

neuraxis and spinal fluid
sampling are necessary
for patients with
medulloblastoma because
of the high rate of
disseminated disease.

FIGURE 7-6
World Health Organization grade 3 posterior fossa ependymoma. A, Axial fluid-attenuated
inversion recovery (FLAIR) MRI reveals a hyperintense mass arising from the fourth ventricle
(not shown is associated noncommunicating hydrocephalus). B, Axial postcontrast
T1-weighted MRI shows heterogeneous enhancement of the fourth ventricular mass.

Hemangioblastoma
Hemangioblastomas are histologically benign tumors that are highly vascular and
most frequently arise in the cerebellum. Accounting for less than 2% of all CNS
tumors, hemangioblastomas are usually sporadic tumors but may be associated
with von Hippel-Lindau syndrome (in which case the tumors are usually
multiple and widespread).36 Sporadic hemangioblastomas may be surgically
eradicated, whereas those presenting in the setting of von Hippel-Lindau
syndrome may be resected individually or treated with belzutifan (hypoxia-
inducible factor 2 alpha inhibitor), which has been recently approved by the US
Food and Drug Administration (FDA).
Tumors are generally cystic in nature, with a solid mural nodule that appears
as isointense on T1-weighted images and hyperintense on T2-weighted images,
and often contain serpentine flow voids.37 The solid portion of the tumor is
generally brightly enhancing, whereas the cyst does not enhance. For individuals
with von Hippel-Lindau syndrome, imaging of the entire spine and examination
of the retina are also recommended.

Medulloblastoma
Medulloblastomas are a type of embryonal tumor that can present at any age but
are most common in childhood, with a greater incidence in males than in
females.2 In children, medulloblastomas account for nearly 20% of intracranial
tumors, whereas in adults they account for less than 1%.2 Notably,
medulloblastomas may be seen as part of several inherited cancer predisposition
syndromes, including Gorlin syndrome (associated with SUFU and PTCH1
germline mutations), Li-Fraumeni syndrome (associated with TP53 germline
mutations), familial adenomatous polyposis (associated with germline APC
mutations), and others.38 Medulloblastomas are molecularly categorized into

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the four primary classifications of wingless and INT-1(WNT)-activated, sonic
hedgehog (SHH)-activated and TP53 wildtype, SHH-activated and TP53-
mutated, and non-WNT/non-SHH, highlighting the heterogeneity of these
tumors both biologically and prognostically. Arising from the fourth ventricle,
medulloblastomas are isointense to hypointense on T1-weighted images and
isointense on T2-weighted images with avid enhancement with gadolinium and
frequent restricted diffusivity. In children, the tumor more often arises from the
vermis, whereas in adults it tends to occur laterally in the cerebellar hemispheres.
Imaging of the entire neuraxis should be pursued because of the elevated risk
of disease dissemination.39 Treatment for medulloblastomas involves surgical
resection followed by a combination of craniospinal radiation therapy and
chemotherapy.

Ganglioglioma
A glioneuronal neoplasm, ganglioglioma is a histologically benign,
well-demarcated, and relatively slow-growing tumor. Most common in the

Intraventricular Massesa TABLE 7-5

Lateral ventricles
◆ Supratentorial ependymoma
◆ Subependymoma
◆ Subependymal giant cell astrocytoma
◆ Central neurocytoma
◆ Choroid plexus papilloma (especially in children)
◆ Choroid plexus carcinoma
◆ Meningioma
◆ Metastasis
◆ Glioblastoma (very rare)
Third ventricle
◆ Colloid cyst
◆ Central neurocytoma
◆ Meningioma
◆ Metastasis
Fourth ventricle
◆ Posterior fossa ependymoma
◆ Metastasis
◆ Rosette-forming glioneuronal tumors
◆ Epidermoid cyst
◆ Choroid plexus papilloma (especially in adults)
◆ Meningioma

a
Modified with permission from Baig MA, et al, Continuum (Minneap Minn).3 © 2016 American Academy of
Neurology.

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IMAGING OF BRAIN TUMORS

CASE 7-2 A 70-year-old right-handed woman presented to the hospital with

memory and mood changes. MRI of the brain, with and without contrast,
revealed multifocal homogeneously enhancing masses with associated
restricted diffusion and surrounding vasogenic edema (FIGURE 7-7).
CTs of the chest, abdomen, and pelvis revealed no other lesions. A
biopsy of one of the enhancing intracranial lesions was obtained, which
confirmed diffuse large B-cell lymphoma, consistent with primary central
nervous system lymphoma. The patient was treated with induction
chemotherapy consisting of high-dose methotrexate and rituximab, with
remarkable radiographic and clinical improvement. She subsequently
underwent high-dose thiotepa-based chemotherapy followed by
autologous stem cell rescue. Cranial imaging since then confirms a
complete response to therapy with no residual or recurrent disease.
Persistent hyperintensity on T2-weighted and fluid-attenuated inversion
recovery (FLAIR) images most likely represents gliosis.

COMMENT This case demonstrates the utility of comprehensive MRI, including

diffusion-weighted and apparent diffusion coefficient images as well as
postgadolinium images, in the evaluation of central nervous system
lymphoma.

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FIGURE 7-7
Imaging of the patient in CASE 7-2 with primary central nervous system lymphoma. Before
treatment, axial postcontrast T1-weighted MRI shows multifocal homogeneously enhancing foci
(A, arrows), axial fluid-attenuated inversion recovery (FLAIR) MRI shows hyperintensity
associated with the lesions and surrounding the lesions (vasogenic edema) (B), and axial
apparent diffusion coefficient (ADC) image indicates hypointensity consistent with restricted
diffusion (C, arrowheads). After 2 months of high-dose methotrexate-based therapy, axial
postcontrast T1-weighted MRI shows stark reduction in enhancing foci (D, arrow), axial FLAIR
MRI shows reduced hyperintensity (E), and axial ADC image shows reduced restricted diffusion
(F, arrowhead). After additional methotrexate-based therapy and then high-dose
chemotherapy with autologous stem cell transplant, axial postcontrast T1-weighted MRI shows
no residual contrast enhancement (G), axial FLAIR MRI shows some small residual hyperintensity
consistent with gliosis (H), and axial ADC image shows no residual restricted diffusion (I).

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IMAGING OF BRAIN TUMORS

adolescent years, gangliogliomas may present in any location throughout the

CNS, and supratentorial tumors are frequently associated with seizures.
Prognosis is generally very good, with the extent of resection serving as its
primary driver. Imaging of gangliogliomas often demonstrates a mix of solid and
cystic components with a variably enhancing mural nodule, and calcification
may occasionally be observed.40

Pleomorphic Xanthoastrocytoma
Generally arising in the temporal lobes, pleomorphic xanthoastroctyomas are
rare, intermediate-grade tumors (WHO grades 2 and 3) typically diagnosed in
children and young adults. Recurrences are common for these tumors, often with
malignant progression. The extent of resection is the primary driver of prognosis,
with a 5-year overall survival of 90% for grade 2 tumors and 57% for grade 3
tumors.41 On imaging, pleomorphic xanthoastroctyomas are usually cystic,
cortically located tumors. CT shows variable tumor density with relative hypodensity
of associated cysts. MRI shows the solid tumor to be either isointense or hypointense
to gray matter on T1-weighted images, with hyperintensity or mixed signal on
T2-weighted images. Contrast enhancement of the solid portion of the tumor is
moderate to strong. Surrounding edema, if present, may be minimal.

Central Neurocytoma
Central neurocytomas are WHO grade 2 tumors arising intraventricularly,
typically attached to the septum pellucidum near the foramen of Monro.42 These
tumors are usually diagnosed in the third decade of life and have a favorable
clinical course, which is positively affected by complete resection. On CT, central
neurocytomas show mixed solid and cystic structures with frequent calcification,
whereas on MRI a characteristic soap-bubble appearance on T2-weighted images
is caused by the multicystic structure. With well-defined margins, these tumors
demonstrate heterogeneous enhancement, and sometimes vascular flow voids
are also present.42

Central Nervous System Metastatic Disease

Brain metastases are far more common than primary brain tumors and are
increasing in incidence as improved systemic cancer therapies lead to longer
postdiagnosis survival.43 Brain metastases are located in the cerebral hemispheres
in 80% of cases, especially in end-arterial border zone locations and at the
junction of cortex and subcortical white matter. It is more common to have
multiple brain metastases than a single brain metastasis, and it is relatively rare
that the brain is the only site of metastasis in the body. Although the
development of brain metastases was historically considered an end-stage
event, outcomes are now more variable (and frequently more favorable) as a
result of the advent of targeted systemic therapies and immunotherapies. The
most common sources of brain metastases include small cell lung cancer,
non–small cell lung cancer, breast cancer, colorectal cancer, renal cancer, and
melanoma.43 A brain metastasis may be the first tumor identified in a patient with
widespread malignancy; therefore, some patients may warrant imaging of the
body (chest, abdomen, pelvis) when metastatic brain tumor is highly suspected.
Brain metastases have a variable appearance on MRI but are often isointense to
hypointense on T1-weighted images with hyperintensity on T2-weighted images.
Some tumors, especially those arising from renal cell carcinoma, melanoma,

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choriocarcinoma, or papillary thyroid cancer, may show blood products, and KEY POINTS
other tumors may show restricted diffusion (especially in small, new
● Pleomorphic
metastases). Peritumoral edema may be prominent in many cases. After xanthoastrocytoma
gadolinium injection, enhancement is often seen in a heterogeneous or rimlike classically presents as a
pattern with central necrosis. In patients with a differential diagnosis including cystic, cortically located
metastasis versus glioblastoma, perfusion imaging may differentiate pure tumor with an enhancing
nodule.
vasogenic edema from infiltrative glioma in hyperintensity surrounding the
tumor on T2-weighted or FLAIR images, thus aiding in presurgical diagnosis.44 ● Brain metastases are
usually multiple and within
the cerebral hemispheres,
CONCLUSION especially in end-arterial
border zone locations and at
Imaging of brain tumors aids tremendously in diagnosis as well as longitudinal the junction of cortex and
monitoring of treated individuals. MRI with gadolinium is the preferred imaging subcortical white matter.
modality. Contrast enhancement is seen when there is breakdown of the
blood-brain barrier and in highly vascular tumors. Although contrast enhancement ● Very small metastatic
tumors may present as foci
is seen with many malignant tumors, it is not always indicative of malignancy. For of restricted diffusion
instance, not only is contrast enhancement present in subacute ischemic infarctions, before growing to show
acute demyelination, and other non-neoplastic entities, but it is also seen in various definitive enhancing tumors.
benign tumors such as pilocytic astrocytoma. Restricted diffusion may be indicative
● Imaging is an essential
of hypercellularity in some tumors but can also be present in ischemic infarctions
tool for diagnosing and
and abscesses. Perfusion imaging shows variability in relative cerebral blood monitoring intracranial brain
volume, which may be a proxy for angiogenesis and has been associated with tumors.
tumor grade. Cerebral blood volume may also aid in differentiation of tumor
recurrence or treatment effect. Finally, MR spectroscopy can be helpful in
evaluating tumor versus demyelination and may also be useful in studying
IDH-mutated tumors, specifically through quantitative 2HG analysis.
Structural and functional imaging modalities provide valuable insight into the
biology of nervous system pathologies, especially neoplasms. Because imaging is
the primary noninvasive tool for disease evaluation and monitoring,
incorporation of up-to-date imaging techniques is essential for the modern
neuro-oncology practice.

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DISCLOSURE
Continued from page 171 compensation in the range of $500 to $4999 for
serving on a data safety monitoring board for
Network, and the United Council for Neurologic Midatech Pharma PLC and in the range of $50,000
Subspecialties that is relevant to AAN interests or $99,999 for serving as an officer or member of the
activities. The institution of Dr Jordan has received board of directors for the Gerstner Family
research support from The Burke Foundation, the Foundation. The institution of Dr Gerstner has
Department of Defense, and the National Institutes received research support from the National Cancer
of Health. Dr Gerstner has received personal Institute.

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