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Journal of Child Neurology http://jcn.sagepub.com/ Neuroimaging of Pediatric Brain Tumors: From Basic to Advanced Magnetic Resonance Imaging (MRI) Ashok Panigrahy and Stefan Blüml J Child Neurol 2009 24: 1343 DOI: 10.1177/0883073809342129 The online version of this article can be found at: http://jcn.sagepub.com/content/24/11/1343 Published by: http://www.sagepublications.com Additional services and information for Journal of Child Neurology can be found at: Email Alerts: http://jcn.sagepub.com/cgi/alerts Subscriptions: http://jcn.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav Citations: http://jcn.sagepub.com/content/24/11/1343.refs.html >> Version of Record - Oct 19, 2009 What is This? Downloaded from jcn.sagepub.com at CHILDRENS HOSPITAL on April 14, 2014 Special Issue Article Journal of Child Neurology Volume 24 Number 11 November 2009 1343-1365 # 2009 The Author(s) Neuroimaging of Pediatric Brain Tumors: 10.1177/0883073809342129 http://jcn.sagepub.com From Basic to Advanced Magnetic Resonance Imaging (MRI) Ashok Panigrahy, MD, and Stefan Blu¨ ml, PhD In this review, the basic magnetic resonance concepts used in imaging (MRI) techniques. The second part of this review the imaging approach of a pediatric brain tumor are described will provide an overview of the major advanced MRI tech- with respect to different factors including understanding the niques used in pediatric imaging, particularly, magnetic reso- significance of the patient’s age. Also discussed are other fac- nance diffusion, magnetic resonance spectroscopy, and tors directly related to the magnetic resonance scan itself magnetic resonance perfusion. The last part of the review will including evaluating the location of the tumor, determining provide more specific information about the use of advanced if the lesion is extra-axial or intra-axial, and evaluating the magnetic resonance techniques in the evaluation of pediatric contrast characteristics of the lesion. Of note, there are key brain tumors. imaging features of pediatric brain tumors, which can give information about the cellularity of the lesion, which can Keywords: advanced MR imaging; brain tumors; MRI; then be confirmed with advanced magnetic resonance CT scan ediatric brain tumors are the second most frequent have severe neurological, neurocognitive, and psychoso- malignancy of childhood, exceeded only by leuke- cial sequelae due to either the effects of the tumor or the Pmia, and the most common form of solid tumor. treatment required to control it. Among brain tumor par- There are approximately 2500 new diagnoses per year in ticipants, approximately 35% of all patients are younger the United States, and the incidence of brain tumors has than 5 years and 75% are younger than 10 years. The type increased slightly over the decades. Brain tumors com- of tumors, the overall incidence of brain tumors, and the prise 20% to 25% of all malignancies occurring among risks of poor outcome change with the age. Young children children under 15 years of age and 10% of tumors occur- are at the highest risk because tumors tend to be more malig- ring among 15- to 19-year-old children. Brain tumors are nant in their behavior in this age group. Childhood brain the leading cause of death from cancer in pediatric oncol- tumors display a high pathologic heterogeneity. Whereas ogy. In addition, survivors of childhood brain tumors often most brain tumors in adults are gliomas (70% malignant anaplastic astrocytoma and glioblastoma), a significant por- tion of pediatric brain tumors are other tumor types such as Received June 15, 2009. Accepted for publication June 15, 2009. medulloblastoma, pilocytic astrocytomas, ependymomas, From the Department of Radiology, Childrens Hospital Los Angeles, Los Angeles, California. and others (Table 1). Genetic risk factors for brain tumors include neurofibromatosis types 1 and 2 (pilocytic astrocy- We acknowledge our multidisciplinary neuro-oncology team at CHLA including the neuro-oncologists (including Drs Finlay, Dhall, Epstein, Vil- toma, low-grade gliomas, and ependymoma), Turcot syn- lablanca, and Jubran), the neurosurgeons (Drs Krieger and McComb), drome (medulloblastoma and high-grade glioma), Li- neuroradiologist (Drs Nelson and Jackson), the neurologists (Drs Mitchell Fraumeni syndrome, Gorlin syndrome, and von and Rosser), neuropathologist (Drs Gonzalez and Gilles), and nurse prac- tioners (including Barbara Britt) for their excellent world class care of chil- Hippel-Lindau syndrome (hemangioblastoma). dren with brain tumors. We acknowledge the organizations that support our research including the National Institutes of Health, the Thrasher Research Fund, Ian’s Friends Foundation, and Rudi Schulte Research Basic Differences Between Computed Institute. We also acknowledge Julia Castro for editorial assistance. Tomography and Magnetic Resonance Imaging Address correspondence to: Ashok Panigrahy, Department of Radiology, Childrens Hospital Los Angeles, 4650 Sunset Blvd, MS 81, Los Angeles, CA 90027; e-mail: [email protected]. Usually the first imaging study of a pediatric patient with a brain tumor is computed tomography ([CT] roentgen-ray Panigrahy A, Blu¨ ml S. Neuroimaging of pediatric brain tumors: from basic to advanced Magnetic Resonance Imaging (MRI). J Child Neurol. computed tomography) imaging. With CT imaging, a 2009;24:1343-1365. beam of x-rays is shot straight through the brain. As it 1343 Downloaded from jcn.sagepub.com at CHILDRENS HOSPITAL on April 14, 2014 1344 Journal of Child Neurology / Vol. 24, No. 11, November 2009 Table 1. World Health Organization Grade and Approximate Relative Incidence of the Most Common Pediatric Brain Tumorsa World Health Diagnosis Organization Gradeb Location Relative Frequency Medulloblastoma 4 Posterior fossa 20% Pilocytic astrocytoma 1 Posterior fossa, hypothalamic/third ventricular 20% region, optic nerve, and chiasmal region Astrocytoma Anywhere in the brain 20%-25% Low-grade astrocytoma 2 Anaplastic astrocytoma 3 Glioblastoma 4 Ependymal tumors Mostly posterior fossa 10%-15% Ependymoma 2 Anaplastic ependymoma 3 Choroid plexus tumors Mostly intraventricular, growing out from 3% Papilloma 1 choroid plexus tissue Carcinoma 3 Germ cell tumors Pineal and suprasellar regions, also basal ganglia 3% Pure germinomas Mixed germ cell tumors Craniopharyngioma 1 Sellar region, not a primary brain tumor 4% Other 5%-10% Neuronal and mixed neuronal-glial tumors, etc a. Among the more than 100 subtypes of pediatric brain tumors, medulloblastoma, pilocytic astrocytomas, astrocytomas, and ependymomas constitute more than 80%. Note that the incidence of individual tumors changes with age. b. The 2007 World Health Organization classification of tumors of the central nervous system. comes out the other side, the beam is blunted slightly at which the signal is received and transmitted. The advan- because it hits dense living tissues on the way through. tage of magnetic resonance over CT is the lack of radiation Blunting or ‘‘attenuation’’ of the x-ray comes from the den- exposure. However, younger pediatric patients with brain sity of the tissue encountered along the way. Very dense tis- tumors usually need to be sedated for magnetic resonance. sue like bone or calcification blocks a relatively higher Standard anatomical pre- and post-contrast MRI is the number of x-rays; gray matter blocks some and fluid rela- method of choice to determine tumor size, location, and the tively less. This allows different densities or attenuations status of the bloodÀbrain barrier. This information is often to be created in the brain x-ray detectors positioned around sufficient for diagnosing the tumor type and for making the circumference of the scanners collecting attenuation immediate treatment decisions.1-3 Conventional MRI is readings from multiple angles. A computerized algorithm also essential for assessing the impact of therapy by deter- reconstructs an image of each slice. The advantage of CT mining the completeness of resection, monitoring the size imaging is that it is widely available and as a result is usually of lesions, and detecting recurrent disease. the first imaging study which is performed when a pediatric patient first presents with neurological symptoms that may be related to pediatric brain tumor. Basic Magnetic Resonance Concepts in With magnetic resonance imaging (MRI), protons are Pediatric Brain Tumors placed in a magnetic field and they become capable of receiving and then transmitting electromagnetic energy. Multiple factors are considered to render an accurate The strength of the transmitted energy is proportional to differential in the diagnosis of a pediatric brain tumor the number of protons in the tissue. Signal strength is mod- including the age, location, intra-axial versus extra-axial ified by the properties of each proton’s microenvironment, location, the cellularity of the lesion (T2 signal and appar- such as its mobility and the local homogeneity of the mag- ent diffusion coefficient values), enhancement characteris- netic field. Magnetic resonance signal can be ‘‘weighted’’ to tics, and the amount of perilesional edema as determined accentuate some properties and not others. T1 signal is by fluid attenuated inversion recovery imaging. used mostly for anatomic imaging, evaluating blood prod- In general, intra-axial lesions narrow the cerebrospinal ucts, and contrast imaging. T2 imaging is used to evaluate fluid space and displace
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