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Intraaxial Brain Masses: MR Imaging–based Diagnostic Strategy—Initial Experience¹

¹ From the Departments of Radiology (R.N.A., J.K., J.H.W., R.L.W., H.P., E.R.M.) and Neurosurgery (D.M.O., K.D.J.), University of Pennsylvania School of Medicine, 3400 Spruce St, Dulles 2, Philadelphia, PA 19104; and Department of Nuclear Medicine, Medical University of Gdansk, Gdansk, Poland (J.K.). Received March 17, 2006; revision requested May 17; revision received July 31; accepted August 29; final version accepted November 1. Address correspondence to E.R.M. (e-mail: Elias.Melhem{at}uphs.upenn.edu).

View larger version (22K): [in this window] [in a new window] [Download PPT slide]   Figure 1: Flowchart illustrates order of methods used to diagnose and differentiate intraaxial masses. Each method provides an answer to a specific question, which is used as a discriminator to distinguish lesions. 1.1/100MM2/ADC = 1.1 x 10–3 mm2/sec, ADC = apparent diffusion coefficient, CE = contrast material enhanced, Cho = choline, NAA = N-acetylaspartate, r/CBV = relative cerebral blood volume, TDL = tumefactive demyelinating lesion.

View larger version (32K): [in this window] [in a new window] [Download PPT slide]   Figure 2: Strategy and flow diagram proposed by Al-Okaili et al (61) and modified on basis of present study data. Diagram of participants consists of several nodes, or questions. It is validated by using data from our patients with common intraaxial masses. Patient data are listed and color coded on the top to determine discriminative accuracy. Numbers within color-coded boxes indicate the number of patients with that particular lesion. Data from 111 patients start at the top, but data from only 40 patients continue to the bottom because some patients did not undergo one or more of the pertinent studies. 1.1/100mm2/ADC = 1.1 x 10–3 mm2/sec, Ch = choline, High GN = high-grade primary brain neoplasms, Low GN = low-grade primary brain neoplasms, >Peri-lesion Ch/NAA = Cho/NAA ratio around lesion. (Adapted and reprinted, with permission, from reference 61.)

View larger version (50K): [in this window] [in a new window] [Download PPT slide]   Figure 3: Transverse MR images of right frontal region lymphoma in 69-year-old woman. With proposed strategy, this would be lymphoma because of enhancement, restricted diffusion, and absence of necrosis. A, Fluid-attenuated inversion-recovery (10 000/120; inversion time, 2200 msec; field of view, 220 mm; matrix, 256 x 256; section thickness, 5 mm; intersection gap, 0 mm; number of signals acquired, two) and, B, contrast-enhanced T1-weighted spin-echo (600/11; field of view, 220 mm; matrix, 256 x 256; section thickness, 5 mm; intersection gap, 0 mm; number of signals acquired, one) transverse images demonstrate enhancing mass (*) with hyperintense surrounding edema (arrowheads). C, ADC map and, D, diffusion-weighted image (10000/118; b values, 0 and 1000 sec/mm2) show restricted diffusion where lowest ADC obtained was 0.86 x 10–3 mm2/sec.

View larger version (121K): [in this window] [in a new window] [Download PPT slide]   Figure 4: Transverse MR images of left frontal region pathologically proved TDL in 40-year-old woman. Lesion was correctly classified because of enhancement and facilitated diffusion but no substantial elevation of perfusion. A, Fluid-attenuated inversion-recovery (10 000/120; inversion time, 2200 msec; field of view, 220 mm; matrix, 256 x 256; section thickness, 5 mm; intersection gap, 0 mm; number of signals acquired, two) and, B, contrast-enhanced T1-weighted spin-echo (600/11; field of view, 220 mm; matrix, 256 x 256; section thickness, 5 mm; intersection gap, 0 mm; number of signals acquired, one) transverse images demonstrate enhancing mass (*). C, Diffusion-weighted image and, D, ADC map (10 000/118; b values, 0 and 1000 sec/mm2) show facilitated diffusion where the lowest ADC obtained was 1.67 x 10–3 mm2/sec. E, Perfusion image (2000/75; field of view, 240 mm; section thickness, 5 mm; number of signals acquired, one) through mass (highest measured rCBV value = 1.57).

View larger version (121K): [in this window] [in a new window] [Download PPT slide]   Figure 5: Transverse MR images of right frontal region glioblastoma multiforme in 69-year-old man. Lesion was correctly classified as high-grade primary tumor because of enhancement, restricted diffusion, necrosis, and elevated perfusion. A, Fluid-attenuated inversion-recovery (10 000/120; inversion time, 2200 msec; field of view, 220 mm; matrix, 256 x 256; section thickness, 5 mm; intersection gap, 0 mm; number of signals acquired, two) and, B, contrast-enhanced T1-weighted spin-echo (600/11; field of view, 220 mm; matrix, 256 x 256; section thickness, 5 mm; intersection gap, 0 mm; number of signals acquired, one) transverse images demonstrate enhancement (*) with hyperintense surrounding edema (arrowheads) and necrotic component (arrow). C, Diffusion-weighted image and, D, ADC map (10 000/118; b values, 0 and 1000 sec/mm2) show restricted diffusion where the lowest ADC obtained was 0.88 x 10–3 mm2/sec. E, Perfusion image (2000/75; field of view, 240 mm; section thickness, 5 mm; number of signals acquired, one) shows regions of elevated rCBV with measured ratios above 2.97.

View larger version (82K): [in this window] [in a new window] [Download PPT slide]   Figure 6: Transverse MR images of right frontal region anaplastic astrocytoma in 74-year-old man. Lesion is high-grade primary neoplasm because of enhancement, facilitated diffusion, elevated perfusion, and evidence of infiltration. A, Fluid-attenuated inversion-recovery (10 000/120; inversion time, 2200 msec; field of view, 220 mm; matrix, 256 x 256; section thickness, 5 mm; intersection gap, 0 mm; number of signals acquired, two) and, B, postcontrast T1-weighted spin-echo (600/11; field of view, 220 mm; matrix, 256 x 256; section thickness, 5 mm; intersection gap, 0 mm; number of signals acquired, one) transverse images demonstrate enhancing mass (*) with hyperintense surrounding edema (arrowheads). C, Diffusion-weighted image and D, ADC map (10 000/118; b values, 0 and 1000 sec/mm2) show facilitated diffusion where lowest ADC obtained was 1.4 x 10–3 mm2/sec. E, Perfusion image shows elevated rCBV of 2.65 (2000/75; field of view, 240 mm; section thickness, 5 mm; number of signals acquired, one). F, G, Multivoxel spectroscopic (1000/144; field of view, 240 mm; section thickness, 5 mm) images show evidence of infiltration. Boxes 15 and 16, which are beyond the enhancing lesion portion, show Cho/NAA ratio of more than 1.