The Different Faces of Central Nervous Metastasis

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DIII-490; No. of Pages 15 ARTICLE IN PRESS

Diagnostic and Interventional Imaging (2014) xxx, xxx—xxx
CONTINUING EDUCATION PROGRAM: FOCUS. . .
The different faces of central nervous

system metastases
S. Grand a,∗, C. Pasteris b,
A. Attye a, J.-F. Le Bas a, A. Krainik a
a
Neuroradiology and MR University Clinic, Grenoble University Hospital, CS10217, 38043
Grenoble Cedex 9, France
b
Radiotherapy University Clinic, Grenoble University Hospital, CS10217, 38043 Grenoble
Cedex 9, France
KEYWORDS Abstract Cerebral metastases are the commonest central nervous system tumors. The MR
Metastases; assessment should include T1-weighted images with and without enhancement and T2/FLAIR
Central nervous images. They usually appear as multiple lesions with nodular or annular enhancement and
system tumors; are surrounded by edema. They are hypervascularized and have no restriction of their diffu-
Conventional sion coefficient in their necrotic area and contain lipids on 1H spectroscopy. Metastases can
imaging; be distinguished from primary tumors by the lack of malignant cell infiltration around the
Advanced imaging tumor. Stereotactic radiotherapy may temporarily increase tumor volume, although this is not
of adverse oncological value. Less commonly, spinal disease may be asymptomatic and should
be examined by MR.
© 2014 Published by Elsevier Masson SAS on behalf of the Éditions françaises de radiologie.
Changes in oncology treatments are leading to increased survival of cancer patients and
improved quality of survival, even in those with metastases. The diagnostic and treatment
approach to cerebral metastases is becoming an increasingly common problem.
Intracranial metastases
Epidemiological findings
Cerebral metastases (CM) have become a public health problem. They have increased in
incidence in recent years because of improved oncology treatments in parallel with the
advances in medical imaging, which now offers optimal screening for CM.
Smedby [1] reported a doubling in the incidence of CM in Sweden between 1987 and
2006, without a doubling in cases of related primary malignancy.
∗ Corresponding author.
E-mail address: [email protected] (S. Grand).
http://dx.doi.org/10.1016/j.diii.2014.06.014
2211-5684/© 2014 Published by Elsevier Masson SAS on behalf of the Éditions françaises de radiologie.
Please cite this article in press as: Grand S, et al. The different faces of central nervous system metastases. Diagnostic
and Interventional Imaging (2014), http://dx.doi.org/10.1016/j.diii.2014.06.014
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2 S. Grand et al.
This incidence depends on the histological type of the pri- CM may also be silent and found in the routine staging
mary cancer: 20% for lung cancer, 7% for melanoma, 6.5% for assessment for a primary tumor.
renal cancer, 5.1% for breast cancer and 1.8% for colorectal
cancer [2]. Imaging CM
The prevalence of CM in patients suffering from cancer
is estimated to be 10%. Radiological investigations may form either part of the rou-
Cerebral involvement requires circulating tumor cells to tine staging assessment for a known malignancy or are used
adhere to the cerebral endothelium resulting in invasion of when a metastases is discovered as the presenting feature
the parenchyma and then in situ growth. Some prolifera- of cancer. Although computed tomography is still used to
tion factors for CM are specific to the tumor cells and others screen for CM, MR clearly appears to be the most sensitive
depend on the environment. Blood flow, for example, influ- detection investigation.
ences the site of CM. Intraparenchymal metastasis (Fig. 1), which are the
Cerebral hemisphere disease is the most common (80%) most common, usually appear as nodular images which are
and the CM are located preferentially in the white matter — hypointense on T1-weighted and hyperintense on T2/FLAIR
grey matter junction. This is followed by cerebellar (15%), images, with annular or nodular enhancement surrounded
then brain stem involvement (3%). by ‘‘finger gloves’’ edema which is often disproportionate
In this context, we shall also consider spread of central to the size of the lesion itself (Fig. 2).
nervous system tumors through cerebrospinal fluid. Whilst First-pass perfusion findings show a cerebral blood vol-
these metastases are well known for medulloblastoma or ume ratio (rCBV= CBV metastases /CBV healthy white matter ), which
ependymoma and require routine screening in these diag- is raised [3] to 2 or above. Average values depend on the
noses, they are also classically seen with high-grade gliomas imaging sequence used, the power of magnetic field and the
with periventricular ependymal enhancement and a blurring presence of blood and calcifications impeding the perfusion
of the subarachnoid spaces at the base of the cranium. study because of multiple magnetic susceptibility artifacts.
On 1 H spectroscopy (Fig. 3), a metastasis displays
Clinical aspects increased choline and reduced N-acetylaspartate (NAA) res-
onance whereas large amount of lipids (resonances centered
The predominant clinical feature is headache initially in the at 0.9 and 1.3 ppm) and lactate (a doublet centered at
morning and becoming permanent, and may be combined 1.3 ppm), particularly if necrosis is present.
with raised intracranial pressure. Neurological deficit and Diffusion-weighted images are used to examine tumor
deterioration of higher functions may also be the presenting cellularity and exclude a possible pyogenic abscess
features of secondary disease. (Fig. 4), as intraparenchymal disease may take on different
Figure 1. Enhanced T1 axial MR (a, b, c) and cerebral blood volume mapping (d): showing multiple rounded lesions with massive contrast-
enhancement. These are hypervascular on the cerebral blood volume mapping, suggesting secondary disease.
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The different faces of central nervous system metastases 3
Figure 2. Left anterior frontal metastasis from a lung cancer, annular in appearance after contrast-enhancement (a) surrounded by a
very large amount of finger glove edema clearly visible on FLAIR MR (b). The extent of the edema is a usual finding in metastases.
Figure 3. Single right cerebellar metastasis surrounded by edema (a and b) containing large amount of lipids shown on a long TE
spectroscopy view as positive resonance centered at 1.3 ppm and by another resonance centered at 0.9 ppm.
appearances depending on whether tit are nodular or more hyperintense on unenhanced T1-weighted images (Fig. 5) as
or less necrotic and cystic. a result of melanin deposition or hemorrhage. Hemorrhagic
Some appearances may point towards the origin of the metastases are often associated with choriocarcinoma
primary malignancy. Metastases from melanoma may be and renal cancer. Cystic appearances are often seen in
Figure 4. Metastases may take on all guises: in this case a cystic appearance of a very slight peripheral enhancement on the enhanced
image (a); the lesions are very hyperintense on T2-weighted images (b), with an increase in the diffusion coefficient (c) excluding the
possibility of infectious causes.
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4 S. Grand et al.
adenocarcinoma metastases (lung, colon and breast, etc.).

Very hypervascular tumors on perfusion imaging points
towards lesions secondary to a melanoma or renal adeno-
carcinoma [4].
A sudden neurological deficit is occasionally explained by
hemorrhage within a metastases (Fig. 6).
Meningeal metastases (Fig. 7) account for approximately
10% of intracranial metastases. These complicate both solid
tumors, leukemias and lymphomas. The typical appearance
is one of gyriform enhancement producing a sheet like
appearance in the meninges. These lesions are seen both
in the convexity and in the base of the cranium and may
cause hydrocephalus (Fig. 8) by blocking the subarachnoid
spaces. Another nodular form is seen with spread of tumor
cells along the cerebrospinal fluid.
Dural metastases (Fig. 9) are rarer and usually involve
bone disease extending to the dura mater. In some cases
the dual disease predominates, occasionally resulting in an
incorrect diagnosis of meningioma. Spectroscopy is useful
Figure 5. Metastases from a melanoma may be hyperintense here as in meningiomas the spectrum contains only choline
on an unenhanced T1-weighted view: a ‘‘shower’’ of nodular whereas lipid resonances are seen with metastases (Fig. 10).
micrometastases.
Regardless of site, the vault and the base of the cra-
nium must be examined to look for related bony metastases.
Figure 6. Sudden onset neurological deficit in a 65-year-old man with no past history. The patient was suspected clinically of having
a cerebrovascular accident and investigated with a view to thrombolysis. His assessment showed a hematoma on the T2-weighted echo-
gradient image (a) surrounded by a large amount of edema on FLAIR MR (b). CT at 24 hours (c) showed a slightly hyperdense lesion casting
doubt on the diagnosis of hypertensive hematoma on the 3D T1-weighted enhanced echo-gradient axial view (d) performed after the
computed tomography the lesion enhances peripherally. This is a single metastasis from a lung adenocarcinoma presenting with hemorrhage
within the tumor.
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Figure 7. Meningeal disease in the cerebellum complicating breast cancer, clearly visible on these 2 enhanced T1-weighted images (a and
b).
Figure 8. Female patient followed up for breast cancer with lung and liver metastases presenting with headaches. The FLAIR image (a)
shows ventricular dilatation with signs of transependymal resorption. The T1-weighted axial views with fat suppression after gadolinium (b
and c) show meningeal carcinomatosis at the base of the cranium with slight enhancement of the superior vermis and the two auditory-facial
nerve bundles.
Figure 9. Bulky left, parieto-occipital bone metastasis with extension subcutaneously and to the dura mater appearing as an enhancing
mass (a) with clearly demarcated borders and no underlying edema on the T2-weighted image (b).
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6 S. Grand et al.
Figure 10. Acute epilepsy in a patient with a past history of ethmoid carcinoma. Bulky left anterior extra-parenchymal frontal mass
pushing back the cerebral parenchyma on the T2-weighted coronal view combined with bilateral involvement of the white matter following
treatment (a), with massive contrast-enhancement on the enhanced T1-weighted axial view (b) with enhancement remote from the dura
mater. Spectroscopy shows lipid resonance is centered at 1.3 and 0.9 ppm, excluding a diagnosis of meningioma and supporting a diagnosis
of metastasis.
Whilst this investigation is ‘‘reflex’’ in computed tomogra- The investigation protocols firstly involve a T1-weighted,
phy, it is occasionally omitted in MR investigations (Fig. 11). unenhanced sequence in order to recognize hemorrhagic
metastases, which are hyperintense without enhancement,
or metastases from a primary melanoma, which contain
Investigation protocol melanin and may occasionally by hyperintense.
A contrast-enhanced series must be taken. The standard
The current preferred technique to investigate cerebral dose is 0.1 mmol/kg of gadolinium complex, or 0.2 ml/kg.
metastases is magnetic resonance imaging. This has two Using a double dose is more expensive but better identi-
different aims: fies small metastases as it has been known for many years
In known malignancy, the purpose of MR is to identify [5] that a double or even triple dose improves detection
and locate all of the secondary disease for optimal patient of small lesions. The merits of the double dose was further
management. The development of stereotactic radiosurgery highlighted in 2010 by KIM [6] who compared dimeglutamine
(Gamme knife or Cyber knife) or arc-therapy (linear accel- gadopentate (Magnevist® ) and gadobutrol (Gadovist® ), both
erator) techniques enables local high dose irradiation to a used at double doses, whereas the molecular concentration
maximum of 3 lesions under 3 cm in size. This approach in Gadovist® is already twice that of Magnevist® .
therefore changes management of secondary disease, which It is important to leave an interval between contrast
until now has involved panencephalic irradiation with or injection and image acquisition [5] in order to allow the con-
without chemotherapy. trast medium time to diffuse before recording the images.
In unknown malignancy, the aim of MRI is to make a pos- This is particularly a crucial factor when a T1-weighted vol-
itive diagnosis of secondary disease, which may be difficult ume image is recorded.
with a single lesion and is discussed in the ‘‘Differential For this reason it is recommended that a T2/FLAIR
diagnoses’’ paragraph. sequence be taken after gadolinium enhancement in order
Figure 11. Staging assessment for a melanoma with left inferior cerebellar metastasis (a). Note the right parietal bone involvement which
enhances (b) and is seen clearly on computed tomography (c).
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to allow a few minutes before the T1-weighted image is Advanced imaging has a role in diagnostic difficulties,
taken. particularly to identify a single mass in a patient with no
This is performed from a volume acquisition usually in past history of malignancy.
echo-gradient mode, which provides good contrast between
the white and grey matter and is available on most machines Differential diagnoses
or from a spin echo volume acquisition. This sequence is
reported to have some advantages in detecting secondary Metastases versus malignant glioma
diseases [7]. Both of these malignant tumors are extremely similar
Many sequences are currently being developed to opti- morphologically and both appear as contrast-enhancement
mize detection of small peripheral lesions including a 3D spin which is usually annular or nodular surrounded by a large
echo ‘‘blood sequence’’ in order not to confuse peripheral amount of edema (Fig. 13). Both tumors have an increased
vascular enhancement with a small metastasis [8]. rCBV on perfusion imaging and increased choline with lac-
FLAIR images detect small cortico-subcortical lesions tate and lipid present on spectroscopy.
(Fig. 12). Discriminating between the two tumors is particularly
A FLAIR series after gadolinium enhancement has also difficult when the lesion is single and the patient has no
raised hopes in identifying meningeal disease, helping to known past history of malignancy.
reduce the T1-weighted relaxation time for image enhance- Some subtle appearances suggest a glial tumor. These
ment due to the removal of the cerebrospinal fluid image include a hyperintensity infiltrating the cortex on FLAIR
signal and the lack of enhancement of normal cortical ves- imaging [12]. Extension to the corpus callosum or opti-
sels. cal tract also points towards a glial tumor. Analysis of the
Finally, Singh [9] highlighted that enhanced T1-weighted region around the tumor is the most appropriate method to
images were more sensitive than enhanced FLAIR to detect indicate one or other of these two causes. The hyperinten-
meningeal metastases. sity on FLAIR imaging around the contrast-enhancement in
Some people [10] recommend an enhanced T1-weighted gliomas reflects both edema, the presence of tumor cells and
series with fat suppression rather than an enhanced FLAIR tumor capillaries (infiltration around the lesion) whereas the
series. More recently one group [11] has highlighted the hyperintensity on FLAIR imaging around a metastases only
utility of 3D sequences after gadolinium. reflects vasogenic edema (edema around the lesion).
Figure 12. FLAIR images are particularly useful to identify cortico-subcortical lesions. In the initial assessment of a patient followed up
for lung cancer a small left subcortical insular hyperintensity is seen on FLAIR MR (a) very slightly enhancing on the image with contrast.
(b). The early repeat shows an increase in volume of the lesion on the FLAIR (c) view and contrast uptake, this time annular, after contrast
injection (d).
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8 S. Grand et al.
Figure 13. Around a contrast enhancing annular metastasis (a), edema around the lesion is only visible on FLAIR MR, with no tumor
infiltration (b). Conversely, around a left frontal glioblastoma which is also necrotic and cystic (c), tumor infiltration is present at its
posterior margin (arrow) and ‘‘finger gloves’’ edema is seen around the lesion (d).
This difference is seen on both perfusion and spec- involves examining the texture of different tissues by
troscopy imaging. The rCBV ratio surrounding the lesion extracting parameters such as entropy and homogeneity etc.
around malignant gliomas is greater than around metas- from a perfusion series. This complex approach appears to
tases and in the same way the Cho/Cr ratio is higher around be promising and merits being developed.
malignant gliomas than around metastases [13]. An increase
in myoinositol around a malignant glioma has also been Metastases versus cerebral abscess
reported more recently [14]. According to Opstad [15], a Ebisu [19] has shown the importance of diffusion-weighted
detailed analysis of lipids in the form of a ratio centered at sequences to distinguish abscesses from necrotic-cystic
1.3 ppm and resonances centered at 0.9 ppm may differen- tumors as abscesses have a lower diffusion coefficient than
tiate metastases from malignant gliomas. tumors (Fig. 14).
Cha [16] has examined perfusion curves using two param- This technique is of course not pathognomonic for the
eters: peak height and percentage signal recovery. The peak diagnosis of cerebral abscess although it is very relevant with
height correlates closely with cerebral blood volume and is a sensitivity and specificity of 96% to distinguish cerebral
higher around a high-grade lymphoma than around metas- abscesses from non-abscess space occupying lesions. It has
tases. The percentage recovery of signal intensity is lower a positive predictive value of 98% and a negative predictive
around a metastasis than around a glioblastoma reflect- value of 92%.
ing the highly patent micro vessels. Recently, Ducreux [17] The diffusion-weighted technique in particular may fail
reported the utility of a dynamic T2-weighted echo-gradient with false positives such as hemorrhagic metastases and
sequence, which shows an increased rCBV and permeabil- false negatives when antibiotic therapy has been started or
ity abnormalities (examined by measuring the R2*) in the in fungal abscesses.
close peritumor tissue in gliomas and not in metastases. In these situations it may be useful to use spectroscopy,
In practice, the finding of hyperperfused areas on which demonstrates the presence of an amino acid peak
the cerebral blood volume mapping (obtained from a centered at 0.9 ppm in pyogenic abscesses [20].
first-pass perfusion sequence) beyond the area of contrast- Castillo [21] proposed diffusion tensor imaging to avoid
enhancement argues in favor of a malignant glioma rather the need for ADC analysis.
than a secondary disease. Mapping of the anisotropic fraction shows the presence
Multiparametric MR approaches [18] are developing of a hyperintense ring in 84.6% of metastases and in only
to distinguish high-grade gliomas from metastases. This 13.3% of abscesses. In parallel, the extent of anisotropism
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Figure 14. The liquid component of cystic metastases (a) have a raised diffusion coefficient on the corresponding mapping (b). Conversely,
the liquid component of multiple pyogenic abscesses (c) has a reduced ADC on mapping (d). The diffusion-weighted views are therefore
fundamental to distinguish multiple metastases from abscesses.
measured by various indicators relating to the differences Lymphoma is highly cellular and has a low diffusion coef-
between the specific values of the tensor may point towards ficient: the malignant blood vessels are patent, fenestrated
one or other cause. and the rCBV is slightly higher, close to 1 passing well above
More simply, studying the capsule of the lesion may help the first-pass curve baseline on investigations performed at
to distinguish between malignant tumors and abscesses. 1.5 Tesla (Fig. 15) [24]. It passes above the baseline less
Abscesses have a capsule, which is rich in collagen and often at 3 T [25].
poorly vascularized with a rCBV of close to 1 [22] often The typical spectrum is that of a choline peak combined
passing above the first-pass curve baseline. with lipid resonances centered at 1.3 and 0.9 ppm outside of
Finally, susceptibility imaging [23] used for abscesses necrotic areas [26,27]. These lipid resonances are believed
shows two concentric rings, one hyperintense and the to be due to the presence of numerous macrophages con-
other hypointense around the collection. An external thin taining lipid droplets.
complete hypointense capsule believed to represent para- The advanced techniques are particularly useful to iden-
magnetic free radical deposits from macrophages and the tify primary or secondary meningeal lymphomas.
internal hyperintense ring reflecting the granulomatous tis- The diagnosis may be difficult in immunosuppression, as
sues, which are usually present between the necrotic centre lymphomatous masses in this situation may appear multiple
of the abscess and the fibrous collagen capsule. and necrotic and can take on appearances very similar to
Although none of these techniques is specific to identify secondary disease. Here again, perfusion findings are very
infection, the diagnosis can often be made appropriately contributive in order to distinguish lymphoma from metas-
because of the wide range of techniques available. tasis.
Metastases versus lymphoma Treatment follow-up

Primary cerebral lymphoma appears typically as a homo-
geneous band, which is hyperdense on unenhanced CT, The treatment follow-up for a cerebral metastasis usually
hypointense on T1-weighted imaging in the cortex and more raises no problem if the patient has received chemo- and/or
hypointense on T2-weighted imaging with massive contrast panencephalic radiotherapy as the fall in tumor volume
uptake. Whilst a single deep lesion in the corpus callosum (RECIST criteria) reflects a positive response to treatment.
requires little discussion, multiple sites benefit from being A more difficult problem arises in following up metas-
examined by diffusion-weighted and perfusion images in tases, which have been irradiated by radiosurgery. Increased
order to distinguish these from metastases. early resolving contrast-enhancement has been shown to
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10 S. Grand et al.
Figure 15. Multiple periventricular lesions with massive contrast-enhancement (a and b), with a cerebral blood volume ratio of 1.5 on
the perfusion curve (c) and particularly, major patency abnormalities seen by the baseline passing above the first-pass curve (reference
ROI, yellow curve, lymphoma ROI blue curve). This is a primary central nervous system lymphoma.
be present in 12% of cases [28]. This appearance is seen or outside of the CNS. MR is the only investigation which
particularly in young people and if chemotherapy has been should be used to investigate for these. A recent article
combined with radiosurgery. [32] has reviewed the clinical and radiological features of
Patel [29] examined the tumor volume of 516 metas- 55 patients: spinal signs were the presenting feature of the
tases treated by radiosurgery over 3 years and showed that malignancy in 20% of cases although in 8% the metastases
a third of the lesions increased in size during their follow- were asymptomatic. Lesions enhanced with contrast in 98%
up. This increase in volume begins from 6 weeks after the of cases, multiple lesions were present in 20% of cases and
radiosurgery and can last for up to 15 months afterwards. similarly to cerebral metastases they had extensive edema
Size criteria may therefore not be sufficient to distin- spreading over more than 3 vertebral segments. Concom-
guish radionecrosis from recurrence of tumor. Histologically, itant bone metastases are common and must be looked
necrotic reactions have been found associated with inflam- for.
mation, gliosis effects and demyelination. The main differential diagnosis is with a primary CNS
Kano [30] proposes that T1-weighted contrast- tumor. Rykken [31] described two appearances which
enhancement be compared to the appearance of the pointed towards metastatic disease (other than pri-
lesion on T2-weighted imaging. If the margins of the tumor mary CNS malignancy). The ‘‘ring sign’’ (a complete
defined from T1-weighted imaging cut through the margins or incomplete enhancement ring outside of the cen-
of the T2 image of the tumor, the appearance suggests tral contrast-enhancement) and the ‘‘flame sign’’ (poorly
tumor recurrence whereas if contrast-enhancement over- defined enhancement in the upper or lower pole of the lesion
laps the image abnormalities which then are blurred on looking like a spark) (Fig. 16).
T2-weighted imaging, the appearance should rather suggest
radionecrosis. Epidural, subdural and meningeal metastases
Perfusion imaging also has a role in monitoring malignant
glioma. A raised rCBV suggests progressive tumor whereas a Investigation with enhancement should include the roots of
relatively low ratio suggests radionecrosis. the cauda equina and the end of the dural sac and should
not stop at the conus medullaris (Figs. 17, 18 and 19).
Meningeal disease appears as nodular contrast uptake
Spinal metastases along the axis of the spine and cauda equina nerve roots.
The dura mater may be involved either in isolation or may
Intraspinal metastases [31] complicate bone metastases and often appears as a spindle-
shaped lesion which compresses the spinal cord to a greater
Spinal metastases are poorly understood and may occur or lesser extent. Concomitant bone metastases must be
as a complication of an initial tumor located either inside looked for routinely.
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Figure 16. Intraspinal metastasis from a breast cancer. Note the flame appearance of contrast-enhancement in the upper pole of the
lesion (a) and the considerable edema around the lesion on the T2-weighted image (b).
Figure 17. Left posterior epidural metastases from a lung adenocarcinoma. Contrast-enhancement is heterogeneous on the T1-weighted
sagittal view (a), and the mass is pushing the spinal cord forwards on the T2-weighted axial view (b).
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12 S. Grand et al.
Figure 18. ‘‘Hazy’’ images seen on T2-weighted imaging (a), created by the cerebrospinal fluid hyperintensity on T2, enhancing on the
T1-weighted view with fat suppression (b) reflecting meningeal metastases from a breast cancer.
Figure 19. Contrast-enhancement which is subdural (a) and bilobulated (b) representing extension of a medulloblastoma.
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Conclusion
• The peritumor environment must be analyzed in
Cerebral metastases are varied in appearance and should detail to differentiate primary tumors from cerebral
always be considered in patients with a past history of metastases.
malignancy or with multiple lesions. Advances in treatment • Diffusion-weighted imaging distinguishes metastases
options make an optimal radiological assessment essential, from multiple pyogenic abscesses.
occasionally using advanced techniques. Knowledge of the • The flame sign and the ring sign help to distinguish
treatment regimens used is required to interpret post radio- intraspinal metastases from a primary malignancy.
chemotherapy findings. Spinal lesions (apart from extension
of bone metastases) are often missed and very rarely looked
for routinely, whereas they may be asymptomatic.
Clinical case
TAKE-HOME MESSAGES A seventy-seven-year-old female patient was hospitalized
for a first attack of epilepsy. Clinical examination revealed
• Any cerebral lesion should suggest a metastasis in a right breast mass (Fig. 20).
patients with a past history of malignancy.
• Cerebral metastases are often multiple but may
be single. MR is the most sensitive investigation to Questions
diagnose these.
• Perfusion, diffusion and spectroscopy distinguish What do you think of this MR? What diagnosis would
metastases from non-malignant structures you make from examination of the FLAIR and enhanced
(abscesses, granulomatosis, etc.). T1-weighted appearances and the perfusion and diffusion-
weighted images?
Figure 20. Axial FLAIR view (a), ADC mapping (b), T1-weighted enhanced axial view (c and d) and CBV mapping (e).
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14 S. Grand et al.
Answer 3D fluid-attenuated inversion recovery and magnetization-

prepared rapid acquisition of gradient echo sequences in
Multifocal glioblastoma relation to conventional postcontrast T1-weighted images for
the evaluation of leptomeningeal diseases at 3 T. AJNR Am J
There are several parietal lesions grouped in clusters, which Neuroradiol 2010;31:868—73.
are heterogeneous with a necrotic centre and increased dif- [12] Tang YM, Ngai S, Stuckey S. The solitary enhancing cerebral
fusion coefficient, which excludes the diagnosis of cerebral lesion: can FLAIR aid the differentiation between glioma and
abscess. The lesions are hypervascular and in particular, metastasis? AJNR Am J Neuroradiol 2006;27:609—11.
the perfusion-weighted abnormalities go beyond the T1- [13] Law M, Cha S, Knopp EA, Johnson G, Arnett J, Litt AW. High-
weighted contrast-enhancement, particularly anteriorly. grade gliomas and solitary metastases: differentiation by using
These appearances primarily suggests a malignant glioma perfusion and proton spectroscopic MR imaging. Radiology
rather than secondary disease, despite the breast mass. 2002;222:715—21.
[14] Wijnen JP, Idema AJ, Stawicki M, Lagemaat MW, Wesseling P,
Wright AJ, et al. Quantitative short echo time 1H MRSI of the
peripheral edematous region of human brain tumors in the
Disclosure of interest differentiation between glioblastoma, metastasis, and menin-
gioma. J Magn Reson Imaging 2012;36:1072—82.
The authors declare that they have no conflicts of interest [15] Opstad KS, Murphy MM, Wilkins PR, Bell BA, Griffiths JR, Howe
concerning this article. FA. Differentiation of metastases from high-grade gliomas
using short echo time 1H spectroscopy. J Magn Reson Imaging
2004;20:187—92.
[16] Cha S, Lupo JM, Chen MH, Lamborn KR, McDermott MW, Berger
References MS, et al. Differentiation of glioblastoma multiforme and single
brain metastasis by peak height and percentage of signal inten-
[1] Smedby KE, Brandt L, Backlund ML, Blomqvist P. Brain metas- sity recovery derived from dynamic susceptibility-weighted
tases admissions in Sweden between 1987 and 2006. Br J Cancer contrast-enhanced perfusion MR imaging. AJNR Am J Neuro-
2009;101:1919—24. radiol 2007;28:1078—84.
[2] Barnholtz-Sloan JS, Sloan AE, Davis FG, Vigneau FD, Lai P, [17] Lehmann P, Saliou G, de Marco G, Monet P, Souraya SE, Bru-
Sawaya RE. Incidence proportions of brain metastases in niau A, et al. Cerebral peritumoral edema study: does a single
patients diagnosed (1973 to 2001) in the Metropolitan Detroit dynamic MR sequence assessing perfusion and permeability can
cancer surveillance system. J Clin Oncol 2004;22:2865—72. help to differentiate glioblastoma from metastasis? Eur J Radiol
[3] Hakyemez B, Erdogan C, Bolca N, Yildirim N, Gokalp G, Parlak 2012;81:522—7.
M. Evaluation of different cerebral mass lesions by perfusion- [18] Mouthuy N, Cosnard G, Abarca-Quinones J, Michoux N.
weighted MR imaging. J Magn Reson Imaging 2006;24:817—24. Multiparametric magnetic resonance imaging to differenti-
[4] Kremer S, Grand S, Berger F, Hoffmann D, Pasquier B, ate high-grade gliomas and brain metastases. J Neuroradiol
Remy C, et al. Dynamic contrast-enhanced MRI: differ- 2012;39:301—7.
entiating melanoma and renal carcinoma metastases from [19] Ebisu T, Tanaka C, Umeda M, Kitamura M, Naruse S, Higuchi
high-grade astrocytomas and other metastases. Neuroradiology T, et al. Discrimination of brain abscess from necrotic or cystic
2003;45:44—9. tumors by diffusion-weighted echo planar imaging. Magn Reson
[5] Yuh WT, Tali ET, Nguyen HD, Simonson TM, Mayr NA, Fisher Imaging 1996;14:1113—6.
DJ. The effect of contrast dose, imaging time, and lesion size [20] Grand S, Passaro G, Ziegler A, Esteve F, Boujet C, Hoffmann
in the MR detection of intracerebral metastasis. AJNR Am J D, et al. Necrotic tumor versus brain abscess: importance of
Neuroradiol 1995;16:373—80. amino acids detected at 1H MR spectroscopy — initial results.
[6] Kim ES, Chang JH, Choi HS, Kim J, Lee SK. Diagnostic yield Radiology 1999;213:785—93.
of double dose gadobutrol in the detection of brain metasta- [21] Toh CH, Wei KC, Ng SH, Wan YL, Lin CP, Castillo M. Differentia-
sis: intraindividual comparison with double dose gadopentetate tion of brain abscesses from necrotic glioblastomas and cystic
dimeglumine. AJNR Am J Neuroradiol 2010;31:1055—8. metastatic brain tumors with diffusion tensor imaging. AJNR
[7] Kato Y, Higano S, Tamura H, Mugikura S, Umetsu A, Murata Am J Neuroradiol 2011;32:1646—51.
T, et al. Usefulness of contrast-enhanced T1-weighted samp- [22] Holmes TM, Petrella JR, Provenzale JM. Distinction between
ling perfection with application-optimized contrasts by using cerebral abscesses and high-grade neoplasms by dynamic
different flip angle evolutions in detection of small brain susceptibility contrast perfusion MRI. AJR Am J Roentgenol
metastasis at 3 T MR imaging: comparison with magnetization- 2004;183:1247—52.
prepared rapid acquisition of gradient echo-imaging. AJNR Am [23] Toh CH, Wei KC, Chang CN, Hsu PW, Wong HF, Ng SH, et al.
J Neuroradiol 2009;30:923—9. Differentiation of pyogenic brain abscesses from necrotic
[8] Park J, Kim J, Yoo E, Lee H, Chang JH, Kim EY. Detection of small glioblastomas with use of susceptibility-weighted imaging.
metastatic brain tumors: comparison of 3D contrast-enhanced AJNR Am J Neuroradiol 2012;33:1534—8.
whole-brain black-blood imaging and MP-RAGE imaging. Invest [24] Cotton F, Ongolo-Zogo P, Louis-Tisserand G, Streichenberger N,
Radiol 2012;47:136—41. Hermier M, Jouvet A, et al. Diffusion and perfusion MR imaging
[9] Singh SK, Leeds NE, Ginsberg LE. MR imaging of leptomeningeal in cerebral lymphomas. J Neuroradiol 2006;33:220—8.
metastases: comparison of three sequences. AJNR Am J Neu- [25] Mauz N, Krainik A, Tropres I, Lamalle L, Sellier E, Eker O, et al.
roradiol 2002;23:817—21. Perfusion magnetic resonance imaging: comparison of semio-
[10] Galassi W, Phuttharak W, Hesselink JR, Healy JF, Dietrich logic characteristics in first-pass perfusion of brain tumors at
RB, Imbesi SG. Intracranial meningeal disease: comparison of 1.5 and 3 Tesla. J Neuroradiol 2012;39:308—16.
contrast-enhanced MR imaging with fluid-attenuated inversion [26] Harting I, Hartmann M, Jost G, Sommer C, Ahmadi R, Hei-
recovery and fat-suppressed T1-weighted sequences. AJNR Am land S, et al. Differentiating primary central nervous system
J Neuroradiol 2005;26:553—9. lymphoma from glioma in humans using localized proton
[11] Fukuoka H, Hirai T, Okuda T, Shigematsu Y, Sasao A, Kimura magnetic resonance spectroscopy. Neurosci Lett 2003;342:
E, et al. Comparison of the added value of contrast-enhanced 163—6.
+Model
[27] Tang YZ, Booth TC, Bhogal P, Malhotra A, Wilhelm T. Imag- [30] Kano H, Kondziolka D, Lobato-Polo J, Zorro O, Flickinger JC,
ing of primary central nervous system lymphoma. Clin Radiol Lunsford LD. T1/T2 matching to differentiate tumor growth
2011;66:768—77. from radiation effects after stereotactic radiosurgery. Neuro-
[28] Huber PE, Hawighorst H, Fuss M, van Kaick G, Wannen- surgery 2010;66:486—91 [discussion 491-2].
macher MF, Debus J. Transient enlargement of contrast uptake [31] Rykken JB, Diehn FE, Hunt CH, Eckel LJ, Schwartz KM, Kauf-
on MRI after linear accelerator (linac) stereotactic radio- mann TJ, et al. Rim and flame signs: postgadolinium MRI
surgery for brain metastases. Int J Radiat Oncol Biol Phys findings specific for non-CNS intramedullary spinal cord metas-
2001;49:1339—49. tases. AJNR Am J Neuroradiol 2013;34:908—15.
[29] Patel TR, McHugh BJ, Bi WL, Minja FJ, Knisely JP, Chiang [32] Rykken JB, Diehn FE, Hunt CH, Schwartz KM, Eckel LJ, Wood CP,
VL. A comprehensive review of MR imaging changes following et al. Intramedullary spinal cord metastases: MRI and relevant
radiosurgery to 500 brain metastases. AJNR Am J Neuroradiol clinical features from a 13-year institutional case series. AJNR
2011;32:1885—92. Am J Neuroradiol 2013.

The Different Faces of Central Nervous Metastasis

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DIII-490; No. of Pages 15 ARTICLE IN PRESS

CONTINUING EDUCATION PROGRAM: FOCUS. . .

The different faces of central nervous

adenocarcinoma metastases (lung, colon and breast, etc.).

Metastases versus lymphoma Treatment follow-up

Answer 3D ﬂuid-attenuated inversion recovery and magnetization-

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