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Intracranial Cysts: Radiologic- Pathologic Correlation and Imaging Approach1 REVIEW for RESIDENTS Ⅲ

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Intracranial Cysts: Radiologic- Pathologic Correlation and Imaging Approach1 REVIEW for RESIDENTS Ⅲ Note: This copy is for your personal non-commercial use only. To order presentation-ready copies for distribution to your colleagues or clients, contact us at www.rsna.org/rsnarights. Intracranial Cysts: Radiologic- Pathologic Correlation and Imaging Approach1 REVIEW FOR RESIDENTS Ⅲ Anne G. Osborn, MD Cysts and cystic-appearing intracranial masses have a Michael T. Preece, MD broad imaging and pathologic spectra. The authors review the pathologic findings, origin, radiologic appearance, and differential diagnosis of many different intracranial cysts. A diagnostic algorithm based on most common anatomic locations is presented that helps narrow the differential REVIEWS AND COMMENTARY diagnosis. ௠ RSNA, 2006 1 From the Department of Radiology, University of Utah Medical Center, Salt Lake City, Utah. Received May 13, 2005; revision requested June 17; revision received July 25; accepted September 1; final version accepted De- cember 8. Address correspondence to M.T.P., 266 East 4th Ave #501, Salt Lake City, Utah 84103 (e-mail: [email protected]). ஽ RSNA, 2006 650 Radiology: Volume 239: Number 3—June 2006 REVIEW FOR RESIDENTS: Intracranial Cysts Osborn and Preece ysts are common findings at mag- since the atria typically enlarge to ac- (interventricular foramen) and within netic resonance (MR) and com- commodate the cyst (2,3). the ventricular body, not the atria. Col- Cputed tomographic (CT) brain im- CPCs occur when lipid accumulates loid cysts should not be mistaken for aging. Their histopathologic spectrum is in the choroid plexus from degenerating CPCs since they typically occur only at broad, and differentiation of these cysts and/or desquamating choroid epithe- the foramen of Monro (see below). on the basis of imaging findings alone lium (1). CPCs can be almost entirely can be problematic. In this article, we cystic, nodular, or partially cystic. They will first review the pathologic and im- appear as nodular, yellowish gray Enlarged PVSs aging spectra of nonneoplastic and tu- masses within the glomus of the choroid mor-associated nonneoplastic cysts (Ta- plexus. Most are small, measuring 2–8 Pathologic Findings ble 1). We will discuss the major differ- mm in diameter. Cysts greater than 2 Enlarged PVSs, also known as Virchow- ential diagnoses for each cyst. We will cm are rare. Robin spaces, are pial-lined interstitial then present an algorithmic location- Microscopic analysis of CPCs reveals fluid-filled structures that accompany based diagnostic approach for these neuroepithelial microcysts containing penetrating arteries and veins (Fig 2). cysts. Cystic and necrotic neoplasms, as nests of foamy lipid-laden histiocytes. They do not communicate directly with well as brain abscesses, are excluded Chronic inflammatory lymphocytic and the subarachnoid space (5,6). They are from the discussion. plasma cell infiltrates, cholesterol clefts, common, incidental, “leave me alone” hemosiderin, and peripheral psammo- lesions that should not be mistaken for matous calcium are part of the CPC more ominous disease (5). They fre- Choroid Plexus Cysts spectrum (1). quently appear in the inferior basal gan- glia, clustering around the anterior Pathologic Findings Imaging commissure and surrounding the lentic- Choroid plexus cysts (CPCs) are non- CPCs are iso- to slightly hyperattenu- ulostriate arteries as they superiorly neoplastic epithelial-lined cysts of the ated on nonenhanced CT scans com- course through the anterior perforated choroid plexus (1,2) (Fig 1). They are pared with CSF. Peripheral calcification substance. Other common locations in- the most common of all intracranial is common. The cysts show enhance- clude the midbrain, deep white matter, neuroepithelial cysts, occurring in up to ment that varies from none to striking. and subinsular cortex. They can also be 50% of autopsy cases. Most are bilat- Signal intensity on MR images is vari- found in the region of the thalami, den- eral and located in the lateral ventricu- able. Most are iso- or hyperintense on tate nuclei, corpus callosum, and cingu- lar atria. The third ventricle is a rare precontrast T1-weighted MR images late gyrus (5,6). but reported location (1). Most CPCs compared with CSF and show rim or Microscopically, PVSs consist of a are asymptomatic and are found inci- nodular contrast enhancement. CPCs single or double layer of invaginated pia. dentally, typically in neonates and older are usually hyperintense to CSF on T2- They are typically very small or inappar- adults. Symptomatic lesions are rare weighted images, especially with long ent as they pass through the cortex, en- repetition/short echo time sequences. larging in the subcortical white matter. The majority do not become completely They are typically not associated with gli- Essentials hypointense (suppress) on fluid-attenu- osis in the surrounding parenchyma (5). Ⅲ Cysts are common findings at MR ated inversion-recovery (FLAIR) images and CT brain imaging. and remain slightly or moderately hy- Imaging Ⅲ Enlarged perivascular spaces are perintense to CSF. Two-thirds show re- Prominent PVSs are considered a nor- common incidental “leave me striction (high signal intensity) on diffu- mal variant. Most appear as smoothly alone” lesions that should not be sion-weighted images (1,2,4). Real-time demarcated fluid-filled cysts, typically mistaken for more ominous dis- prenatal ultrasonographic (US) findings less than 5 mm in diameter, and often ease. demonstrate a cyst greater than 2 mm occur in clusters in the basal ganglia or Ⅲ Tumor-associated nonneoplastic surrounded by echogenic choroid. midbrain. They are isointense to CSF at cysts with trapped CSF or inter- stitial fluid occur, usually with be- Differential Diagnosis nign neoplasms. The major differential diagnosis is Ⅲ Diffusion-weighted and FLAIR MR ependymal cyst and villous hyperplasia Published online sequences are helpful in narrow- of the choroid plexus. Ependymal cysts 10.1148/radiol.2393050823 ing the differential diagnosis of do not enhance. Villous hyperplasia is Radiology 2006; 239:650–664 cystic brain lesions. very rare and, when present, enhances Abbreviations: Ⅲ A location-based approach to in- strongly and relatively uniformly. Dis- CPC ϭ choroid plexus cyst tracranial cysts is helpful in estab- turbed CSF flow and pseudolesions can CSF ϭ cerebrospinal fluid lishing an appropriate differential also be seen on US images but are most FLAIR ϭ fluid-attenuated inversion recovery diagnosis. striking around the foramen of Monro PVS ϭ perivascular space Radiology: Volume 239: Number 3—June 2006 651 REVIEW FOR RESIDENTS: Intracranial Cysts Osborn and Preece all sequences, including FLAIR. Most egress is blocked, fluid accumulates and Differential Diagnosis show normal signal intensity in the adja- the PVSs dilate (5). These lesions cause Enlarged PVSs are often mistaken for cent brain; 25% may have a small rim of focal mass effect and occasionally even multiple lacunar infarcts, cystic neo- slightly increased signal intensity. They hydrocephalus. Rarely, so-called giant plasms, and infectious cysts. Lacunar do not enhance, cause focal mass effect, or tumefactive PVSs may be mistaken infarcts can usually be distinguished or restrict on diffusion-weighted im- for more ominous disease (7). from PVSs since many exhibit adjacent ages. In older patients, basal ganglia PVSs sometimes become prominent and sievelike, a condition known as e´tat Table 1 crible´, or cribriform state. Classification of Intracranial Cysts according to Origin or Pathogenesis Occasionally PVSs may become very large and appear bizarre. They are Origin or Pathogenesis Cyst probably caused by the accumulation of Normal and/or variant Choroid plexus (xanthogranuloma), enlarged perivascular spaces interstitial fluid between the penetrating (PVSs), ependymal, neuroglial, pineal vessels and the pia. If interstitial fluid Congenital Arachnoid, colloid, epidermoid, dermoid, neurenteric, Rathke cleft Traumatic and/or vascular infectious Porencephalic, neurocysticercosis, hydatid, other parasitic cysts Tumor-associated nonneoplastic Meningioma (with trapped cerebrospinal fluid [CSF]), Figure 1 schwannoma (with arachnoid cyst), pituitary adenoma (with enlarged PVSs), craniopharyngioma (with enlarged PVSs) Figure 2 Figure 2: (a) Coronal gross slice of autopsied brain with postmortem gas in bilateral enlarged PVSs. (Image courtesy of E. T. Hedley-Whyte, MD, Massachusetts General Hospital, Boston, Mass.) (b) Transverse contrast-enhanced T1-weighted MR image shows typical nonenhancing enlarged PVSs in right basal ganglia. The cluster of variably sized cysts is a common appearance. (c) Transverse T2-weighted Figure 1: (a) Transverse graphic representa- MR image shows multiple bizarre-appearing cysts tion shows multiple cystic masses in the choroid (arrows) in centrum semiovale and subcortical white plexus glomi (arrows). Most CPCs are actually matter of both hemispheres. The cysts vary in size degenerative xanthogranulomas. (Image courtesy and focally expand but otherwise spare the overlying of Amirsys, Salt Lake City, Utah.) (b) Transverse cortex. contrast-enhanced T1-weighted MR image in a healthy 52-year-old man shows bilateral CPCs with peripheral and nodular enhancement (arrows). 652 Radiology: Volume 239: Number 3—June 2006 REVIEW FOR RESIDENTS: Intracranial Cysts Osborn and Preece parenchymal hyperintensity (so-called out cilia, line ependymal cysts. They tricles (8,10). Part or all of a ventricle e´tat lacunaire). Cystic neoplasms rarely have vesicular nuclei and eosinophilic (most
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