Eur Radiol (2005) 15: 468–484

DOI 10.1007/s00330-004-2555-2 NEURO

G. Wilms
Ph. Demaerel
Intra-axial brain tumours
S. Sunaert

Received: 7 July 2004

Revised: 11 October 2004
Accepted: 14 October 2004
Published online: 31 December 2004
# Springer-Verlag 2004
G. Wilms (*) . P. Demaerel .
S. Sunaert
Department of Radiology, U.Z.
Gasthuisberg,
Herestraat 49,
3000 Leuven, Belgium
e-mail: guido.wilms@uz.kuleuven.ac.be
Tel.: +32-1634-8781
Fax: +32-1634-8765
Abstract The radiological diagnosis diffusion tensor imaging and spec-
and differential diagnosis of intra- troscopy will further enhance the
axial tumours no longer relies on CT value of the radiological studies.
scan and routine MR sequences alone.
Standard multiplanar imaging has to Keywords Brain neoplasms .
be combined with fMRI to allow the Diagnosis . Computed tomography .
exact anatomic location of the lesion Magnetic resonance imaging .
and precise determination of the ex- Comparative studies
tension of the tumour. Perfusion and
diffusion MR is becoming more and
more important in the differential
diagnosis of cerebral mass lesions and
in the grading and typing of gliomas.
More sophisticated techniques such as

Introduction A routine MR examination of the brain starts with a long

Neuroradiology plays a key role in the diagnosis and pre-
operative set-up of patients with brain tumours. State-of-
the-art imaging requires a standardised imaging protocol,
careful and systematic study of the images and finally an
attempt at characterisation of the lesion.
Imaging protocols for the study of (intra-axial) brain
tumours
In modern neuroradiology, magnetic resonance (MR) is
the method of choice to study lesions of the brain. Since
computed tomography (CT) is more widely available, it can
be used as a first screening method if a patient is suspected
of having an intracranial mass lesion. Routinely, precon-
trast and postcontrast CT is performed. Nevertheless, if on
plain CT a mass lesion is evident, one might consider not
giving IV-contrast for economic and medical reasons and
immediately going to MR [1, 2].
TR/long TE (T2-weighted) sequence, a short TR/short TE
(T1-weighted) sequence and a fluid-attenuated (FLAIR)
sequence. These images are mostly performed in the trans-
verse direction, but for specific locations other incidences
can be used. Gadolinium-enhanced series are routinely per-
formed in the transverse, coronal and sagittal plane, com-
pleted if necessary by more selective slices. We routinely
include diffusion weighted imaging (DWI) in our imaging
protocol for the study of intracranial mass lesions, since
it can have important differential diagnostic implications
[3, 4]. Perfusion CT or MR, although not routinely used
in most centres, can offer valuable information on tumoral
vascularity and grading and should be included in the
imaging protocol [5–7]. If the tumour is situated in an
eloquent area, functional MR (fMRI) will better locate the
lesion and define its relations to the functional areas [8, 9].
In institutions where 3-T equipment is available, the use
of diffusion tensor imaging for the study of white matter
invasion of brain tumours is under investigation [10–12].
For the study of vessel displacement and to assess gross
tumour vascularity, magnetic resonance angiography (MRA)

has replaced catheter angiography, which is only performed in
extra-axial tumours [13, 14]. MR spectroscopy is only per-
formed in selective cases, mainly for the differential diagnosis
between tumours and non-tumoural mass lesions.
Fig. 1 Comparison CT-MR for detection of brain metastasis in a
patient with breast carcinoma. a Contrast-enhanced CT scan: no
lesions are seen. The fourth ventricle is deformed but without evi-
dent underlying cause. b T2-weighted MR image at the same level,
performed the next day: numerous metastatic lesions in both tem-
poral poles, cerebellar hemispheres and in the brain stem
469
Fig. 2 Entrapment of the temporal horn by a pilocytic astrocytoma.
Sagittal gadolinium-enhanced MR image: dilatation of the temporal
horn by the presence of a huge partially cystic, partially solid mass
How to examine the images of a patient with a cerebral mass
lesion?
Today, with the availability of CT and MRI, the radiological
diagnosis of a brain tumour includes more than the simple
identification of an intracranial mass. The diagnosis of a
brain tumour includes multiple steps that have to be care-
Fig. 3 Uncal herniation. Coronal gadolinium-enhanced MR image:
herniation of the uncus (arrow) in the hiatus tentorii. Notice hypo-
intense aspect of the uncus pointing to infarction
470

fully examined. These steps are: detection, evaluation of its
effect on the brain and the ventricles, localisation especially
with regard to eloquent areas and definition of the extent
of the tumour. Finally the type and grade of the tumour
have to be described, together with its differential diagno-
sis, especially with non-tumoural lesions.
The first and of course limiting step is the detection of
an intracerebral mass. This will first depend on the volume
of the lesion: smaller lesions will be more easily missed than
larger ones. Nowadays with appropriate techniques and
proper clinical suspicion, very small lesions such as tiny
metastases or microadenomas of the hypophysis can be
detected with CT. Detection will depend on the difference in
CT characteristics, meaning the atomic number or radio-
density. Tumours such as low grade glioma, metastasis or
lymphoma can be almost isodense with the surrounding
brain on CT (Fig. 1a). Artefacts in the posterior fossa or on
the highest slices can mask subtle lesions [15].
With MRI, detection will depend on the difference in
MRI characteristics, such as T1, T2, proton density, flow,
etc. It is known that the sensitivity for pathological con-
ditions is higher with MR than with CT. Lesions producing
little or no change in CT density tend to be more con-
spicuous on MR (Fig. 1b) [15]. This is due to the high
sensitivity of MR for changes in water content, almost in-
variably present in or accompanying brain tumours, leading
to hyperintensity on T2-images and FLAIR images. Isoin-
tensity of a lesion is extremely infrequent with higher field
magnets and, if seen, is rarely present on all sequences.
Small metastasis, though, still can be missed if only a
screening transaxial T2-weighted sequence is performed.
If contrast medium is administered, detection will de-
pend on the difference in vascularity and on the damage to

Fig. 4 Use of fMRI and diffu-

sion tension imaging in the
preoperative setup of a brain
tumour. Thirty-one-year-old
male right-handed patient pre-
senting with seizures. MR-im-
aging revealed a low-grade
tumoral mass in the left supra-
marginal and angular gyri.
A fMRI during a verbal fluency
task depicts a left lateralized
language, with Wernicke’s area
in the middle temporal gyrus
and Broca in the inferior frontal
gyrus. Both eloquent areas are at
distance of the lesion. B Diffu-
sion tensor imaging with fibre-
tracking depicting the arcuate
bundle between Wernicke and
Broca. The bundle seems to be
displaced medially by the mass
effect of the lesion and its
middle part is adjacent to the
tumour border

Fig. 5 Extension of low-grade astrocytoma between lobes. Coronal
gadolinium-enhanced MR image: tumour extends from the frontal to
the temporal lobe
the blood-brain barrier. Since the mechanisms of enhance-
ment are the same with CT and MRI, there will be a similar
sensitivity for both techniques. Nevertheless, MRI will pick
up smaller foci of contrast enhancement by its higher spa-
tial resolution, or by the absence of artefacts or volume-
Fig. 6 Extension of germinoma in a patient with diabetes insipidus.
Sagittal gadolinium-enhanced MR image: huge mass in the pineal
region with impression on the posterior third ventricle. Smaller
seeding lesion in the infundibulum (arrow). This lesion is the cause
of the diabetes insipidus
471
Fig. 7 Hemangioblastoma. Transverse T2-weighted MR image:
presence of numerous flow-voids (arrows) in and around the tu-
mour, pointing to high-flow intratumoural arteriovenous shunts.
Notice anterior displacement of the medulla oblongata
averaging from the overlying bone, especially if background
suppression is enhanced by magnetic transfer prepulses
[16, 17].
The second step is the evaluation of the effect of the
tumour on the brain and the ventricles. This includes
the presence of hydrocephalus or of isolation of parts of
the ventricular system, evaluation of midline shift, herni-
ation of the cingulate gyrus under the falx, of the uncus
through the incisura tentorii and of the cerebellar tonsils
through the foramen magnum, and the compression and
displacement of functional brain tissue [18]. The evaluation
of the impact of the tumour on brain and ventricles is im-
portant for several reasons. First of all, in the acute setting,
the presence of hydrocephalus, midline shift and herniation
can frequently better explain the actual clinical condition of
the patient rather than the exact type or location of the
tumour. Therefore, almost invariably it will be more im-
portant to perform ventricular drainage or decompression
of an isolated “trapped” temporal horn (Fig. 2), rather than
actually to remove the tumour at a stage where little is
known about its histology. Associated brain herniation,
especially of the uncus through the tentorial incisura, can
cause secondary ischemic lesions and can largely deter-
mine the final prognosis of the patient (Fig. 3).
The next step is the localization of the tumour. It has to be
determined if the lesion is intra-axial or extra-axial, supra-
or infratentorial and intraventricular or extraventricular.
Also of concern is the localisation in specific brain struc-
tures such as the hypophysis, the pineal gland or the brain
stem, localisation with regard to functional brain regions
and localisation with regard to vascular structures. To obtain
this information, multiplanar MR is without a doubt of
utmost importance.
Both for the understanding of the symptoms of the patient
and for preoperative planning, it is tremendously important
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Fig. 8 Cystic anaplastic astrocytoma grade 3. a Transverse T2-
weighted MR image: the intensity of the cyst is higher than that of
the cerebrospinal fluid in the ventricles and the subarachnoid spaces.
b FLAIR-MR image: unlike the cerebrospinal fluid in the ventricles
and the subarachnoid spaces, the fluid in the cyst is not attenuated
due to its high protein content
Fig. 9 Ependymoma grade 2 of the fourth ventricle in a 2-year-old
child. Coronal and sagittal gadolinium-enhanced MR images: inho-
mogeneously enhancing tumour filling up the entire fourth ventricle.
The tumour extends through the foramen of Magendie to the fora-
men magnum (large white arrows) and through the foramina of
Luschka (black arrows) to the inferior cerebellar peduncle. There is
marked compression of the brainstem. In the most inferior aspect of
the tumour the brainstem seems clearly invaded (arrowheads)
to determine in which anatomic and functional region the
tumour is situated. Morphologically, this is performed by
the study of the location of the tumour with regard to an-
atomic fissures and sulci, such as the Sylvian (sensory and
motor speech), Rolandic (sensorimotor cortex) or calcarine
(visual cortex) fissures.
Functional MR nowadays plays a major role in the
localisation of a brain tumour or any other operative lesion,
with regard to functional brain tissue, by the actual visual-
isation of functional activity of motor function, speech or
visual activity (Fig. 4) [8, 9]. This activation can be present

Fig. 10 Primary non-Hodgkin’s lymphoma of the brain. a Trans-
verse and b sagittal gadolinium-enhanced MR images: presence of
multiple small nodular enhancing lesions along the walls of the ven-
tricles. The lesions are present along the fourth ventricle, the third
ventricle and the left temporal horn
in the tumour itself, at its edges, or can be displaced by the
mass. The exact distance between the eloquent area and the
tumour can be determinant in the assessment of the opera-
bility of the tumour. Lack of cooperation by the patient
because of tumour symptoms (paresis, aphasia, blindness)
will of course interfere with this method.
Finally, the tumour has to be located with regard to
vascular structures. Here, the display of the cortical venous
anatomy will have important implications for the deter-
mination of the surgical approach. While formerly this was
done with angiography, the combination of surface imag-
473
Fig. 11 Brain abscess: diagnosis with DWI. a Transverse gadoli-
nium-enhanced MR image: multilocular ring-enhancing lesion. b
Diffusion-weighted MR image: The lesions are hyperintense on this
sequence, pointing to restricted diffusion. This is seen in abscesses
due to the presence of necrotic debris and pus
ing and magnetic resonance angiography now offers the
required anatomical information to the surgeon. In the same
way, arterial encasement, invasion or occlusion of the
major vessels, such as, for example, the carotid artery and
the middle cerebral artery in cavernous sinus lesions, is
easily diagnosed by MRA [13].
The next step is the determination of the extent of the
tumour. This answers the question whether or not the lesion
474

is confined to one lobe or extends over a fissure to an-
other lobe (for instance, a frontotemporal lesion) (Fig. 5),
if the tumour involves the brain stem, basal ganglia, crosses
the midline, extends through the incisura tentorii, through
the foramen magnum or seeds to specific anatomic areas. In
this regard, the metastasis of pineoblastoma to the infun-
dibulum of the hypophysis is a pathognomonic finding in
a patient with diabetes insipidus (Fig. 6). Here too, mul-
tiplanar imaging with MRI, with depiction of the ana-
tomic relations in the axial, coronal and sagittal planes, is
mandatory.
The final step in the examination of patients with a
cerebral mass lesion is the differential diagnosis or the
specification of the nature of the lesion. We have to dif-
ferentiate between primary and metastatic lesions, menin-
gioma and neurinoma, lymphoma and metastasis, benign
and malignant character, glioma and other kinds of brain
tumours. This differential diagnosis is based on CT or MR
characteristics (density-intensity), extension or localisation,
contrast enhancement and classical signs [19, 20].
The first is the CT density of the lesion or the intensity
on MR. The presence of calcification can point to oligo-
dendroglioma or ependymoma. Flow voids because of
hypertrophic draining veins or hypervascularity can sug-
gest hemangioblastoma (Fig. 7). The signal from cystic
components, such as hyperintense cholesterol-containing

Fig. 12 Low-grade diffuse in-

filtrating astrocytoma grade 2.
Evolution. a Transverse T2-
weighted MR image: presence
of a markedly hyperintense le-
sion (arrow) in the left insular
area. The lesion is well-delin-
eated and has minimal mass
effect, with slight inward dis-
placement of the lentiform
nucleus. b Transverse gadolini-
um-enhanced MR image: ab-
sence of enhancement (arrow).
c Transverse T2-weighted MR
image: evolution after 5 years of
conservative, mainly anti-epi-
leptic treatment. The lesion (ar-
rows) now is considerably larger
and is inhomogeneous, with
evidence of necrosis. There is
midline displacement. d Trans-
verse gadolinium-enhanced MR
image: now focal enhancement
can be seen within the tumour.
There is deviation of the midline
to the right
 475

cysts in craniopharyngioma, can be diagnostic. MRI can be

very helpful in the specification of tumour necrosis and the
differentiation between cystic versus non-cystic and hem-
orrhagic versus non-hemorrhagic neoplasms. The identifi-
cation of cystic areas on MRI also requires careful scrutiny
of lesion intensity relative to CSF on all of the three rou-
tinely obtained images: short TR/TE, long TR/short TE and
long TR/long TE. If a lesion is exactly isointense to CSF on
all three of these sequences, then one can state very con-
fidently that the lesion is cystic. Tumour cysts, however,
can also be of slightly higher intensity than pure CSF due
to highly proteinaceous debris (Fig. 8). Finally, the recog-
nition of fat in a tumour, by negative density on CT and the
short T1 and short T2 on MRI, is of utmost value in the
diagnosis of lipoma, teratoma and dermoid cysts.
The second point to allow differential diagnosis is the
location and the extension of the tumour. Some tumours,
such as craniopharyngioma, show typical suprasellar loca-
tion and extension. Midline masses in the posterior fossa in
children are very hard to differentiate from one another. In
cases of ependymoma, very frequently we will see that the
tumour extends not only through the foramen of Magendie
to the cisterna magna, but also through the lateral foramina
of Lushka to the cerebellopontine angle (Fig. 9) [21, 22]. In
astrocytoma, the most common glial neoplasm with calci-
fication, it is not uncommon to identify cortical involve-
ment by these tumours with thickening of the cortical
mantle. This can mimic cortical infarction, but in astrocy-
toma the lesion does not follow a vascular territory. In
patients with temporal lobe epilepsy, diffusely hyperin-
tense lesions in the uncus of the temporal lobe frequently
correspond to ganglioglioma. Multiple contrast-enhancing
nodules over the hemispheres can correspond to multifocal
glioblastoma, to metastasis or to lymphoma. If the lesions
are situated adjacent to the ventricles, lymphoma is highly
probable (Fig. 10).
A third factor of interest is the degree of contrast en-
hancement. Classically, it is said that with a higher degree
of malignancy, contrast enhancement will increase. During
the evolution of a lesion, we frequently will see not only
that there is an increase in the oedema, but also in contrast
enhancement. This can be a sign of anaplastic transforma-
tion of the tumour. Nevertheless, striking changes in the
contrast enhancement of a lesion, without any change in the
degree of malignancy at biopsy, are seen in oligoden-
drogliomas [23]. On the other hand, in some series, malig-
nancy was found at biopsy in non-enhancing lesions in up Fig. 13 Oedema and contrast enhancement in glioblastoma. a
Transverse T2-weighted image: the peritumoural oedema shows
to 40% of gliomas [20, 24, 25]. Perfusion MR in these cases fingerlike extension along white matter tracts. The arrow points to
can show tumour hypervascularity, reflecting the malignant the “core” of the lesion. b Transverse gadolinium-enhanced image:
nature of the lesion. the enhancement of the tumour (arrow) is ringlike with nodular
Finally, the differential diagnosis has to be made with formation on its walls
non-tumoral lesions, such as abscesses, multiple sclero-
sis, radionecrosis, infarction, aneurysms, etc. Here, DWI,
perfusion MR and MR-spectroscopy are important (Fig. 11)
[3, 26, 27].
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Fig. 14 Importance of perfusion MR in tumour grading. Thirty-
four-year-old female patient presenting with a histologically proven
oligodendroglioma grade 3 in the right frontal lobe, and a second
focal lesion in the right temporal pole, with “gliosis” as histological
diagnosis. Dynamic contrast-enhanced T2* MR perfusion imaging
was performed at 3T with a GE-EPI perfusion sequence with a
temporal resolution of 1.5 s and injection of 0.1 mmol/kg gabo-
The radiological diagnosis of intra-axial brain tumours
Here, we will discuss the imaging aspects of the most fre-
quent intra-axial tumours: the neuro-epithelial tumours, the
embryonal tumours and the metastases.
The World Health Organisation (WHO) Classification
of Brain Tumours was profoundly changed in 1993 and
was updated recently in 2000 [28, 29]. For the typing and
grading of brain tumours, no longer only standard patho-
logical features are used, but besides information on immu-
nohistochemistry and genetics, imaging findings are taken
into account.
The most important change concerned the large group of
the astrocytic tumours, accounting for more than 60% of
primary brain tumours. Here, a distinction is made between
diffusely infiltrating and circumscribed astrocytomas, re-
ferring to both gross pathological and imaging features.
The diffusely infiltrating astrocytomas are at least grade 2
and have an inherent tendency for anaplastic progression.
Circumscribed astrocytomas are benign, and malignant
transformation is extremely rare.
Low grade astrocytomas are hypodense on CT and have
long T1 and T2 on MRI. Classically, there is no contrast
enhancement. The diffusely infiltrating character is reflect-
ed in a replacement rather than a displacement of brain
structures leading to a mass-effect that is less then expected
benate dimeglumine (MultiHance) at an injection rate of 4 ml/s.
Time-to-bolus arrival (T0), time-to-peak (TTP), regional cerebral
blood volume (NI), regional cerebral perfusion (index) and mean-
transit-time (MTT) maps were calculated. Perfusion characteristics
of the frontal grade 3 oligodendroglioma show markedly increased
rCBV and rCBF within most of the tumour A. The temporal area of
gliosis has normal to slightly decreased rCBV and rCBF B
from the tumour volume and by crossing the borders of the
cerebral lobes (Fig. 12a, b).
Progressive malignant transformation is characterised by
a progressive increase in tumoral necrosis, intratumoral
haemorrhage and peritumoural oedema, with appearance of
contrast enhancement. In this way the low-grade astrocyto-
ma becomes anaplastic and finally displays the very “mul-
tiform” aspect of glioblastoma multiforme (Fig. 12c, d)
[20, 24]. It has to be stressed that in some gliomas anaplastic
transformation is not translated into an increase of contrast
enhancement [25].
The peritumoural vasogenic oedema is typically “finger-
like”, dissecting white matter tracts (Fig. 14a). This oede-
ma reflects the break-down of the blood-brain barrier, but
is also related to angiogenesis, as proven by the presence
of vascular endothelial growth factors (VEGF). There-
fore, oedema is more pronounced in malignant tumours
[30, 31].
Tumoral contrast enhancement is mostly anarchic, areas
of homogeneous enhancement alternating with ringlike
bands of enhancement with nodular formations in the wall
(Fig. 13b). It reflects both the blood-brain barrier break-
down, but also is correlated with tumoral angiogenesis.
This “malignant hypervascularity” has been known for a
long time from angiography, but is now easily demon-
strated by perfusion CT or MRI [5–7] (Fig. 14a). Demon-

Fig. 15 Midline suprasellar pilocytic astrocytoma in a 4-year-old
child. Study performed after ventriculo-external drainage for hydro-
cephalus. a Sagittal and b coronal gadolinium-enhanced MR images:
partially cystic partially solid, strongly enhancing suprasellar tumour
stration of hypervascularity in non-enhancing lesions is a
sign of malignancy. It is noteworthy that the areas of maxi-
mal perfusion do not necessarily correspond to the areas of
maximal enhancement, which offers perspectives for guid-
ed tumour biopsy. Finally, it has to be stressed that the
tumour not only may extend beyond the margins of en-
hancement, but even outside the T2-hyperintense area.
Again, this is confirmed by perfusion CT or MRI. Resec-
477
tion of the enhancing area, therefore, is not sufficient to
assure the cure of the patient. Diffusion-weighted imaging
can be of interest in diffusely infiltrating tumours by dem-
onstrating displacement or invasion of white matter tracts
(Fig. 14b).
Circumscribed astrocytomas have a different, more
focal, aspect, different locations and prognosis than dif-
fusely infiltrating astrocytomas. The most frequent lesions
are pilocytic astrocytomas that develop in young patients
[32, 33]. They occur in the cerebellum, where they typically
present on imaging studies as cysts with an enhancing
nodule or supratentorially in the midline (chiasm, hypo-
thalamus, third ventricle) where they appear more solid,
but variations in imaging features are frequent (Fig. 15).
Despite atypical imaging features, suggesting malignant
transformation, the lesions almost always remain grade 1
(Fig. 16).
Oligodendrogliomas have very distinct imaging features,
but careful correlation of CT and MR images is necessary.
Typical for the tumour are its cortical location with a
diffusely infiltrating aspect and heavy streaky calcifications
[34]. On MR, the aspect of these calcifications can be very
atypical and can be confused with haemorrhage. It recently
has been shown that the appearance of contrast enhance-
ment on follow-up studies does not necessarily reflect
Fig. 16 Grade 1 pilocytic astrocytoma with “aggressive“ imaging
aspects. Transverse gadolinium-enhanced MR image: the tumour
shows intense but inhomogeneous enhancement and has marked
mass-effect as evident by the displacement of the third ventricle.
Despite this aggressive aspect, histology disclosed grade 1 pilocytic
astrocytoma
478

Fig. 17 Oligodendroglioma
grade 2: CT and MR-aspect of
calcifications. Enhancement in
a low-grade lesion. a Contrast-
enhanced CT scan: space-
occupying lesion in the left
parieto-occipital area with ante-
rior displacement of the calci-
fied choroid plexus of the left
lateral ventricle. Presence of
dense streaky calcifications
(arrow) in the lesion. Moderate
enhancement of the dorsal as-
pect of the lesion. b Transverse
T2-weighted MR image: the
lesion is inhomogeneously hy-
perintense. The calcifications
are seen as hypointense streaks
(arrows). c Transverse T1-
weighted MR image: The
tumour now shows overall hy-
pointense signal. Calcification
(arrows) is seen as markedly
hyperintense foci. d Transverse
gadolinium-enhanced MR
image: the posterior part of the
tumour is inhomogeneously en-
hancing (arrow). In the anterior
part some small foci of en-
hancement are seen (arrow-
heads)

malignant transformation, as in astrocytic tumours (Fig. 17)
[23].
Ependymomas originate from the ependymal or sub-
ependymal cells that line the ventricular walls and the
central canal of the spinal cord. Ependymomas are mul-
tilobulated, well-demarcated, frequently calcified masses
that are by definition intraventricular in location [22]. Most
cases occur in the fourth ventricle. They occur most fre-
quently in children from 1 to 5 years of age. In adults they
occur in the 3rd decade and are supratentorial. In the
supratentorial compartment, extraventricular locations are
common (Fig. 18). On non-contrast CT ependymomas are
isodense with calcification in 50%. Enhancement is mild
to moderate. On MR ependymomas are hyperintense on
T2 WI and iso- to hypointense on T1 WI. Calcification
can be less conspicuous than on CT, whereas cysts and
small hemorrhagic foci are better demonstrated on MRI.
Enhancement is moderate. Fourth ventricular ependymo-
mas fill up the fourth ventricle and show lateral extension
to the cerebellopontine angle cisterns. This is considered
as a major differential diagnostic feature with medullo-
blastoma.
Neuronal and mixed neuronal-glial tumours are a rela-
tively new group of lesions, based on the detection by new
immunohistochemical techniques of neuronal elements in
some primary brain tumours. Therefore, in our opinion, it
is a specific responsibility for the (neuro-) radiologist to
mention these tumours in the differential diagnosis, so that
 479

partial complex epileptic seizures. On imaging studies a

Fig. 18 Adult ependymoma grade 3. Transverse gadolinium-en-
hanced MR image: presence of a multicystic ring-enhancing lesion
in the left tempero-occipital region. Tumour seems partially located
within the lateral ventricle. Lesion cannot be differentiated from
malignant glioma
the appropriate stainings and immunohistological exam-
inations should be performed. These lesions all are grade 1
and have neuronal besides glial elements and occur in
young patients. Gangliogliomas are a frequent cause of
well-delineated cortical cyst with an enhancing nodule in
the temporal lobe is typical [35–37].
Dysembryoblastic neuro-epithelial tumours (DNETs) are
multinodular cortical tumours with thinning of the over-
lying bone [38, 39]. They are often associated with cortical
dysplasia (Fig. 19).
Central neurocytoma is typically located in the lateral
ventricles with broad attachment to the septum pellucidum.
They are multicystic lesions, possibly calcified, with var-
iable enhancement (Fig. 20). If the appropriate staining or
immunohistochemical examinations are not performed the
lesion will be mistaken for an oligodendroglioma [40, 41].
The concept of PNET or primitive neuroepithelial tu-
mours refers to the embryonal tumours [42]. This concept
is based on the assumption that a number of cerebral mass
lesions show a common origin from multipotential neuro-
epithelial cells, which may undergo malignant transforma-
tion. This leads to tumours at various levels of the CNS,
with identical histology, morphology and biological be-
haviour. They include supratentorial PNETs in the cerebral
hemispheres (neuroblastoma) and the pineal gland (pine-
oblastoma) and infratentorial PNETs, the medulloblastoma
(PNET-MB). Medulloblastoma is the most common pae-
diatric central nervous system malignancy and the most
common primary tumour of the posterior fossa in children
[42–45]. It arises classically from the vermis or velum
medullare. The high nuclear-cytoplasmatic ratio is ref-
lected on CT by a high density on unenhanced CT scan and
hyperintensity on FLAIR MR images. The malignant as-

Fig. 19 Dysembryoplastic
neuro-epithelial tumour.
a Transverse T2-weighted
MR-image: in the left parieto-
occipital region a strongly hy-
perintense lesion is seen. There
are some more hypointense
strands in the mass giving rise to
a gyriform pattern. There is no
oedema around the lesion. The
lesion is predominantly located
in the cerebral cortex and causes
a bulging of the surface of the
brain. The overlying bone is
thinned and eroded. b Transverse
gadolinium-enhanced MR
image: There are some spots of
focal enhancement within the
lesion. Notice again the cortical
location, the bulging of the sur-
face of the brain and the erosion
of the bony skull
480

Fig. 20 Central neurocytoma.

a Transverse T2-weighted MR
image: lesion in the left lateral
ventricle broadly attached to the
septum pellucidum. Notice
small intratumoural cysts.
b Transverse gadolinium-
enhanced MR image: moderate
and homogeneous enhancement

pect of the tumour on gross pathology with cyst formation,
haemorrhage and calcification is reflected by its heteroge-
neous aspect on imaging studies (Fig. 21a, b). Invasion
of the brain stem and extension through the foramen of
Magendie towards the cisterna magna and the spinal sub-
arachnoid space is well demonstrated by MRI. Evidence of
leptomeningeal spread is evident in one-third to one-half
of the patients (Fig. 21c) [46, 47]. Imaging of the spinal
canal therefore is part of the routine preoperative imaging
protocol of children with tumours of the posterior fossa.

Fig. 21 Medulloblastoma in a 5-year-old child. a Sagittal gadolin-
ium-enhanced MR image: huge tumour, originating from the inferior
vermis with upward displacement of the fourth ventricle. Clear
invasion of the brain stem (arrows). Notice seeding to the spinal
subarachnoid space. b Transverse gadolinium-enhanced MR image:
The tumour extends to the inferior cerebellar peduncles, being most
pronounced on the right (arrow). c Sagittal gadolinium-enhanced
MR image of the spinal canal: presence of a large seeding lesion on
the surface of the spinal cord

Fig. 22 Desmoplastic medulloblastoma in a 34-year-old patient.
Sagittal gadolinium-enhanced MR image: presence of a mass in the
superior vermis. The tumour abuts the undersurface of the tentorium
and extends towards the hiatus tentorii (arrowheads). The aqueduct
and fourth ventricle (arrows) are anteriorly and inferiorly displaced.
There is overall intense enhancement of the tumour, with evidence
of small cystic components. The lesion has a multilobulated aspect
Fig. 23 Cerebellar metastasis from mucinous adenocarcinoma of
the sigmoid colon. Transverse T2-weighted MR image: The lesion
shows marked hypo-intensity pointing to T2-shortening
481
Fig. 24 Metastases from malignant melanoma. Transverse T1-
weighted MR image: multiple spontaneously hyperintense noduli
over both cerebral hemispheres. T1-shortening is due to the para-
magnetic effect of melanin and/or the presence of blood-degradation
products
The desmoplastic variant of medulloblastoma would arise
from the external granular layer. These tumours typically
occur in older patients and are often off-midline (Fig. 22)
[48].
The relative incidence of intracerebral metastases is ra-
pidly growing and now approaches nearly 50% of all brain
neoplasms [49]. This is due to the growing effectiveness
of therapies for malignant tumours and increasing de-
tection with the new imaging modalities. Most frequent
are metastases from lung cancer and breast cancer, from
malignant melanoma, from gastro-intestinal and genito-
urinary primaries. They can be solitary or multiple. On
imaging studies enhancement can be solid or ring-like.
Important peritumoural oedema is frequent. Brain metas-
tases frequently present with short T2 [50]. This is seen in
metastases from mucoid neoplasms of the GI-tract (Fig. 23)
and in hemorrhagic metastases from lung carcinoma or
renal carcinoma. Metastases from malignant melanoma
typically present with short T1 and T2 due to the presence
of paramagnetic melanin (Fig. 24). Perfusion MR shows
promising results in differentiating metastases from dif-
ferent primaries from each other and in the differentiation
between glioma and metastasis [51, 52]. In the presence
of multiple enhancing lesions in the brain, the differential
diagnosis has to be made between metastases, multifocal
482
Fig. 25 Primary non-Hodgkin’s
lymphoma of the brain and
DWI. a Transverse gadolinium-
enhanced MR image: homoge-
neously enhancing lesions in the
paraventricular region and the
corpus callosum. b Transverse
diffusion-weighted MR image:
The lesions appear hyperintense.
The restricted diffusion is
related to the high cellularity
of the lesions
glioblastoma and lymphoma. Besides the distribution of the
lesions, unilateral in glioblastoma, periventricular in lym-
phoma, the study of the perfusion of these lesions seems
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