Patterns of Enhancement James G. Smirniotopoulos, M.D. Professor of Radiology and Neurology...
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Patterns of EnhancementJames G. Smirniotopoulos, M.D.
Professor of Radiology and NeurologyChairman, Department of Radiology Uniformed
Services University of the Health Sciences4301 Jones Bridge Road
Bethesda, MD 20814 USA
Voice: 301-295-3145FAX: 301-295-3893
Email: [email protected] us on the WEB at: http://rad.usuhs.mil
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DISCLAIMER
The opinions expressed herein are those of the author(s), and are not necessarily representative of the Uniformed Services University of the Health Sciences (USUHS), the Department of Defense (DOD); or the World Health Organization (WHO). Medicine is a constantly changing field, and medical information is subject to frequent correction and revision. Therefore the reader is entirely responsible for verifying the accuracy and relevance of the information contained herein. Portions copyright 1997-2000 James G. Smirniotopoulos, M.D.
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CONTRAST ENHANCEMENT
•Vascularity
•Permeability
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CONTRAST ENHANCEMENT
•Vascularity–Blood Volume–Blood Flow
•Permeability–Capillary
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CONTRAST ENHANCEMENT
• Any change (increase or decrease) in signal (intensity, density, etc.) over the pre-injection (inhalation, etc.) or normal background pattern, that increases the conspicuity of a lesion or makes the anatomy more visible.
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CONTRAST ENHANCEMENT
– Fill a cavity (BE, Cystogram, Myelogram)– Inject a Vessel (Angiogram, venogram,
bronchogram– Diffusion (from vessel) into Interstitium
CT w/ Iodine– MR w/Gadolinium– "Bodygram" on XU
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CONTRAST ENHANCEMENT
• VASCULAR (intravascular) PHASE(Inc. Blood Flow/Hypervascular)AVM, MENINGIOMA, GBM, ETC.TRUE "LUXURY" PERFUSION HYPEREMIA (TRAUMATIC)
• INTERSTITIAL (extravascular) PHASE (Blood‑brain‑barrier breakdown)Acute inflammation (ms), Neoplasm, Abscess, "granulation" tissue, Ischemia, "luxury" perfusion,Contusion
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CONTRAST ENHANCEMENT
Normal Tissue w/o BBB• DURA (falx and tentorium)• (ARACHNOID ?)• CHOROID PLEXUS• PINEAL GLAND (epiphysis)• PITUITARY GLAND (hypophysis)• CTZ (MEDULLA ‑ AREA POSTREMA)
("Circumventricular Organs")
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Enhancement vs. Edema
ABNORMAL PERMEABILITY(ABBB)
EDEMA ENHANCEMENT
INCREASED VASCULARITY
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CONTRAST ENHANCEMENT -
PhasesVASCULAR BBB
ANGIO(I‑) ++++ ‑
R‑N (Tc+) + (flow) + (static)
C.T. (I‑) + +++
MRI (Gd+) +/‑ +++
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CONTRAST ENHANCEMENT
• Morphologic Patterns– HOMOGENEOUS (SOLID)– HETEROGENEOUS (non‑uniform)– RING (unilocular/multilocular)– SERPENTINE ("GYRIFORM")
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CONTRAST ENHANCEMENT
• Location– SUPERFICIAL (CORTICAL/GYRAL)– GREY‑WHITE JUNCTION– DEEP WHITE MATTER– PERIVENTRICULAR, EPENDYMAL
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CONTRAST ENHANCEMENT
Cortical/Gyriform– Cerebral Ischemia / Infarction– CSF or sub‑pial spread– Meningo‑encephalitis– S.A.H.– Leptomeningeal Malformation (SW)– Meningioangiomatosis (NF2)
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CONTRAST ENHANCEMENT
• Ring LesionCircumferential or peripheral/marginalenhancement, surrounding a centralnon‑enhancing region. In turn, this isoften surrounded by a large area of "edema". May Be Unilocular OrMultilocular.
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CONTRAST ENHANCEMENT
• Contrast leaks into interstitium from vessels without BBB
• Remains localized within millimeters of where it leaks out
• Not "simple diffusion" but rather "BULK FLOW" at a very slow rate
• (Glacier Not River)
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CONTRAST ENHANCEMENT
Diffusion ExperimentSHARK TANK ‑ with volunteer• Flowing Water ‑ rapid movement by "bulk
flow”• Motionless Water ‑ Diffusion (simple
diffusion)• Jell-O, viscous fluid, DB or DT
slow movement by "bulk flow"
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CONTRAST ENHANCEMENT
Ring LesionsM ‑ Metastasis, MSA ‑ Abscess (Also Cerebritis)G ‑ Glioblastoma, GranulomaI ‑ Infarct (Esp. Basal Ganglia)C ‑ Contusion (Rare)A ‑ AIDS (Toxo, Etc.)L ‑ Lymphoma (in Aids)
D ‑ Demyelination (Active)R ‑ Resolving Hematoma Radiation Change (Necrosis)
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CONTRAST ENHANCEMENT
Ring Lesion Features For Infection• ORGANIZED ABSCESS
thin and uniform wall (3‑7mm.)smooth inner margin does not "fill in" on CT, MR?
• CEREBRITIS (infection w/o organization):variable wall (may be smooth) smooth/variable inner marginoften has "fill‑in" on DDD(w/o fluid level)
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CONTRAST ENHANCEMENT-
Abscess• 2 ‑ 4 wks. for ORGANIZED WALL• 2 LAYERS• inner MESENCHYMAL (capillaries,fibroblasts,
collagen)• outer ASTROGLIAL (reactive astrocytes)• WALL facing GM is well formed 3‑5 mm• WALL FACING WM IS THINNER/WEAKER
(Daughter Abscess)Ventricular Spill ("pyocephalus")
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CONTRAST ENHANCEMENT
Ring Lesion Features For NeoplasmNECROTIC NEOPLASM:• thick and irregular wall• shaggy inner margin (usually)• may "fill in" heterogeneously on DDDCYSTIC NEOPLASM:• thin wall +/‑ MURAL NODULE• PART OF WALL MAY NOT ENHANCE
– smooth inner margin– uniform fluid enhancement
or FLUID LEVEL
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CONTRAST ENHANCEMENT-
HematomaEARLY: Hyperdense, round/oval
Homogeneous mass of RBC's Proportional mass effect for volume Edema "Halo", not spreading
LATER: Iso‑/Hypodense, smaller Reactive capillaries form outside Uniform rim of enhancement May see "vasogenic" edema
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CONTRAST ENHANCEMENT- Post-
Operative• RESIDUAL TUMOR
– (left behind)• RECURRENT TUMOR
– (grew back)• INFECTION• NORMAL POSTOPERATIVE CHANGE
– (surgical trauma, healing)• RADIATION Tx.?
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CONTRAST ENHANCEMENT - Surgical Change and/or Residual
Neoplasm?• Surgical Enhancement typically after 24‑48
hrs.(scan early!)may last for months
• In the Operative Bed (mixed w/ residual?) and along the Margins of Resection– thin and uniform in brain (CT/MR)
• LINEAR meningeal/dural enhancement on MR (not lumpy-bumpy)
• Small amts. of air, blood (non‑contrast)
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