NAME : Dr. ANGGRAINI DWI S.,dr.,Sp.Rad (K)BORN : PASURUAN, SEPTEMBER 12, 1961

EDUCATION :GP, MEDICAL FACULTY OF AIRLANGGA UNIVERSITY, 1987RADIOLOGIST, AIRLANGGA UNIVERSITY, 1996ATTACH PROGRAM NNI SINGAPORE, 2002NEURORADIOLOGIST CONSULTANT, 2004DOCTOR , MEDICAL FACULTY OF AIRLANGGA UNIVERSITY, 2013

POSITION :STAFF OF DEPT. RADIOLOGY MED. FAC. AIRLANGGA UNIVERSITYHEAD OF DIPLOMA PROGRAM FOR RADIOGRAPHERMEMBER OF NEURORADIOLOGICAL DIVION. MEDICAL FACULTY AIRLANGGA UNIV.MEMBER OF IDIMEMBER OF DKJ FORUM MEMBER OF PDSRIMEMBER OF AONHCRMEMBER OF ASCIOFFICIAL JOURNAL OF INDONESIAN NEURORADIOLOGY OF THE EUROPEAN NEURORADIOLOGY JOURNAL SENIOR CONSULTANT IN NEURORADIOLOGY , SOETOMO HOSPITAL AND SEVERAL HOSPITALS IN SURABAYAHEAD OF RADIOLOGY, HUSADA UTAMA HOSPITALMEDICAL MANAGER, HUSADA UTAMA HOSPITAL

Curriculum Vitae

Differential Diagnosis of Brain Infection, Tumor, Metastatic Process

on CT Scan and MRI

Dr. dr. Anggraini Dwi S.,Sp.Rad.(K)Radiology Dept., Medical Faculty,

Airlangga University/Soetomo Hospital, Surabaya

Clinical findings?

Atlas Scott, 2007

Plain X-ray USG CT Scan MRI PET Scan

Radiation exp. + - ++ - +++

Tissue contrast + ++ ++ +++ -

Calcification + + +++ + -

Hydrocephalus - ++ +++ ++++ -

Contrast - - ++ ++++ -

Uptake rad farm - - - - +++

Metabolite - - - +++ -

Tissue Perfusion - - ++ ++ -

Tissue Diffusion - - - + -

Techniques in Neuroimaging

5

Brain lesion (infection, primary, metastatic):1. Initial recognition and characterization of

the lesion 2. The mechanical effects and structural deformities resulting from intracranial neoplasm

The Most effective Uses of CT in Neuroradiology

Rulling out SAHAcute head traumaFracture of skull, face, orbitsSinusitisSalivary gland calculous diseaseSubtle bony irregularitiesDetection of calcification in lesion

Odontoic lesionDegenerative diseaseCTACT perfusionBony spinal stenosisMR is contraindicatedImmediate postop evaluationTemporal bone disease

MR imaging has the most potential of any imaging technique to allow a complete and accurate diagnosis and initial management strategy to be formulated for a brain tumor

Brain Tumor Imaging with MR: Objectives

Specific DiagnosisNeoplasma VS otherHistology (Grading)

Therapy PlanningLocalize for biopsyDelineate extent or spreadRT portal designGuide minimally invasive surgery - Define peritumoral “eloquent” - Define neuroanatomic pathway involvement

Post TreatmentResidual TumorReccurent tumor VS treatment-related necrosis

Fundamentals of lesion localization and characterization: -The age of the patient -Single or multiple? -Intraaxial or extra axial? -Density/intensity? -Presence of contrast enhancement? -Hemorrhage -Calcification -Necrosis?

Basic protocol brain MRI1. T12. T23. T2FLAIR4. Gre T2*5. DWI6. 2-3 planes post Gad T17. Pefusion CBV• MR Spectroscopy (?)1. DTI (?)2. Functional MRI (?)

Brain Lesions

MedScape, 2011

Multiple Small Ring Enhancing Lesions

Tuberkuloma

CT• Isodense or slight

hyperdense basal cistern• Basal homogenous

meningeal enhancement• Hydrocephalus (C and NC)• Tuberculoma, rim

enhancement, 1/3 with target sign (central calcification)

MRI• Cisternal enhancement ++• Meningeal enhancement

(better in FLAIR than T2), patchy meningitis

• Hydrocephalus (C and NC)• Tuberculoma, rim

enhancement, 1/3 with target sign (central calcification)

Metastatic

CT • Hyperdense, hypodense or

isodense• Small, round zones• Extensive collateral edema• Intratumoral hemorrhage• 80% enhancement,

sometimes a ring

MRI• Detects 2-3x> MRI• Typically hypointense on T1• Hyperintense on T2• Melanoma?• Enhancement: uniform,

punctate, ring• T2FLAIR: perifocal edema• MRS: No Cho↑ at perifocal

edema, NAA↓

Neurosarcoidosis

CT• Leptomeningitis• Suprasellar manifestation

(diabetes incipidus)• Hydrocephalus• Single or multiple

granuloma slightly hyperdense foci up to 1cm

• Up to 60% negative

MRI• T1: iso or hypointense• T2: variable• T1+C: homogenous

enhancement• Pituitary + hypothalamic• Leptomeningeal involv.• Cranial nerve (II,VIII)

Cerebral Abscess

CT•Varies with stage of abscess•Early cerebritis: hypodense•Subacute: ring-like structure•Necrotizing tissue•Gas forming +/-•Enhancing ring: 3-6mm, uniform•Dughter abscess

MRI• Varies with stage of abscess• T1W• T2W• FLAIR• DWI (+) : hypercellularity,

brain ischemia, cellular swelling due to cytotoxic edema

• Central liquefactive necrosis• MRS : NAA, Cho,Cr ↓, LL↑

Multiple Large Enhancing Lesions

Abscess

Metastatic

Glioma

MR Spectroscopy

Tumeactive Demyelinating Lesion

HIV? Toxoplasma?

Unenhanced CT Scan MRI T1 WI

T1 WI T1 WI

T2W axial T2W axial

Enhanced T1W

Before Tx After Tx

Lymphoma?

TDL: tumeactive demyelinating lesion

Metastase

MR SpectroscopyIs there perienhancement infiltrationOver 1 Cho/NAA ?

Low grade neoplasm

LymphomaPerfusion MRIs perfusion over 1,75 rCBV?

Is there necrosisOn CE MRI?•Low grade neoplasm

or•encephalitis

Conventional CE MRIDoes the lesion enhance?

MR SpectroscopyIs the elevation of Cho/NAA over 2,2?

DWI, diffusing facilitated > 1,1/100 mm2/ADC?

Intraaxial Brain Mass

NO YES

NOYES

YES

•TDL or abscess•Abscess

High grade neoplasm

NOYES

NOYES

High grade glioma

YES

YESNO

NO

Diffusion Weighted Image

Diffusion Weighted Image

MR Spectroscopy

MR Spectroscopy

The Peritumoral region (PTR) demonstrated most significant differences in metabolite ratios.

• The Cho/Cr ratio in glioblastomas was significantly higher than that in metastases.

• PCLs significantly elevated Cho/Cr levels were also noted in compared with those in metastases .

• PCLs also demonstrated significantly higher lipids+lactate/Cr levels compared with glioblastomas and metastases.

Proton magnetic resonance spectroscopy in differentiating glioblastomas from primary cerebral lymphomas and brain metastases.Chawla S1, Zhang Y, Wang S, Chaudhary S, Chou C, O'Rourke DM, Vossough A, Melhem ER, Poptani H.

MR Perfusion

Take home message1. CT Scan plays in emergency cases and some

abnormality (blood, calcification, hemorrhage)2. MRI play a better role than CT in differentiate

infection, primary and metastatic tumor3. MR imaging has the most potential of any

imaging technique to allow a complete and accurate diagnosis and initial management strategy to be formulated for a brain tumor

4. Advanced imaging help enhancing the specifity of the lesions

Thank You