Korean J Radiol.  2017 Feb;18(1):194-207. 10.3348/kjr.2017.18.1.194.

Advanced MRI for Pediatric Brain Tumors with Emphasis on Clinical Benefits

• Goo HW
• Ra YS

• KMID: 2468133
• DOI: http://doi.org/10.3348/kjr.2017.18.1.194

Abstract

Conventional anatomic brain MRI is often limited in evaluating pediatric brain tumors, the most common solid tumors and a leading cause of death in children. Advanced brain MRI techniques have great potential to improve diagnostic performance in children with brain tumors and overcome diagnostic pitfalls resulting from diverse tumor pathologies as well as nonspecific or overlapped imaging findings. Advanced MRI techniques used for evaluating pediatric brain tumors include diffusion-weighted imaging, diffusion tensor imaging, functional MRI, perfusion imaging, spectroscopy, susceptibility-weighted imaging, and chemical exchange saturation transfer imaging. Because pediatric brain tumors differ from adult counterparts in various aspects, MRI protocols should be designed to achieve maximal clinical benefits in pediatric brain tumors. In this study, we review advanced MRI techniques and interpretation algorithms for pediatric brain tumors.

Keyword

Brain tumors; Imaging techniques; Infants and children; Pediatrics; Magnetic resonance imaging; Magnetic resonance spectroscopy; Diffusion-weighted imaging; Perfusion imaging

MeSH Terms

Brain Neoplasms/*diagnosis/diagnostic imaging/pathology
Child
Diffusion Tensor Imaging
Humans
Image Interpretation, Computer-Assisted
Magnetic Resonance Imaging
Perfusion Imaging
Signal-To-Noise Ratio

Figure

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  Fig. 1 3-year-old boy with anaplastic astrocytoma (WHO grade III). A. Axial T2-weighted image shows diffuse pontine tumor with eccentric bulging on left side. B. Axial apparent diffusion coefficient map reveals region with restricted diffusion (arrows) suggesting higher-grade tumor on anterolateral portion of left pons. C. Axial cerebral blood volume map from dynamic susceptibility contrast imaging demonstrates that same region (arrows) also shows increased tumor perfusion. Substantial image distortion is noted along skull base. D. Single-voxel intermediate echo time (144 ms) MR spectroscopy obtained in region shows exceedingly high choline/creatine ratio strongly suggesting high-grade tumor. WHO = World Health Organization

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  Fig. 2 11-year-old boy with pyogenic abscess. A. Axial enhanced T1-weighted image irregular rim-enhancing lesion (arrows) with extensive perilesional edema in right temporo-parietal area. B. On axial apparent diffusion coefficient map, central non-enhancing portions show restricted diffusion (arrows) suggesting pyogenic abscess. Water diffusion should increase in tumor necrosis. C. Single-voxel intermediate echo time (144 ms) MR spectroscopy demonstrates acetate peak (arrow) approximately at 1.9 ppm and amino acids (including alanine approximately at 1.5 ppm)/lipid/lactate peaks strongly suggesting pyogenic abscess.

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  Fig. 3 14-year-old girl with right optic nerve sheath meningioma. Compared with axial diffusion-weighted image using single-shot spin-echo echo-planar sequence (A), image distortion is considerably reduced on axial diffusion-weighted image using single-shot turbo-spin-echo sequence (B). As result, right orbital tumor (arrows) is better delineated without image distortion on turbo-spin-echo diffusion-weighted image (B).

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  Fig. 4 15-year-old girl with anaplastic ependymoma. Three-dimensional (A) and two-dimensional (B) fiber tractographies illustrate that left corticospinal motor fibers (arrows) are intact and displaced anteromedially by heterogeneously enhancing necrotic tumor. Axial susceptibility-weighted image reveals multiple hypointense foci predominantly in peripheral portion of tumor indicating hemorrhage or neovascularity (C). Ktrans map (D) and cerebral blood volume map from dynamic susceptibility contrast imaging (E) show increased values only in anterior and medial peripheral portions of tumor. Therefore, hypointense foci in posterior and lateral portions of tumor on susceptibility-weighted image mainly represent hemorrhagic necrosis. Image distortion on dynamic susceptibility contrast image is pronounced in anterior part of brain (E).

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  Fig. 5 Signal intensity-time curve of dynamic susceptibility contrast imaging. Curve of T1-dominant leakage pattern shows gradual increase above baseline at later dynamics, while curve of T2*-dominant leakage pattern fails to return to baseline.

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  Fig. 6 13-year-old boy with clear cell ependymoma (WHO grade II). A. Axial enhanced T1-weighted image shows heterogeneous solid and cystic tumor with small enhancing portion (arrows) and mild peritumoral edema in peripheral portion of right parietal lobe. B, C. Axial pseudocontinuous arterial spinal labeling image (B) and cerebral blood flow map from dynamic susceptibility imaging (C) reveal increased values in enhancing tumor. D. Signal intensity-time curve of dynamic susceptibility contrast imaging demonstrates T2*-dominant leakage pattern for enhancing tumor showing increased tumor blood flow (region of interest 2), compared with normal-appearing brain regions (regions of interest 1 and 3). WHO = World Health Organization

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  Fig. 7 12-year-old boy with medulloblastoma. A, B. Sagittal fluid-attenuated inversion recovery image (A) and axial enhanced T1-weighted image (B) show lobulated solid tumor probably originating from inferior cerebellar vermis and extruding through foramen of Magendie (arrow). Obstructed hydrocephalus by tumor is noted (A). C. Single-voxel short echo time (40 ms) MR spectroscopy demonstrates small taurine peak (arrow), high choline/creatine ratio, and increased lipid/lactate peaks, strongly suggesting medulloblastoma.

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  Fig. 8 11-year-old boy with tuberous sclerosis. Multiple calcified subependymal nodules appear hypointense and hyperintense on magnitude (A) and phase (B) images of susceptibility-weighted imaging, respectively, which is confirmed by precontrast brain CT (C). In tuberous sclerosis, subependymal giant cell astrocytoma (WHO grade I), characterized by large subependymal mass (> 1 cm) near foramen of Monro showing calcifications, heterogeneous MRI signal intensity, and marked contrast enhancement, may cause obstructive hydrocephalus. WHO = World Health Organization

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  Fig. 9 15-year-old boy with anaplastic oligodendroglioma who underwent intensity-modulated radiation therapy and chemotherapy after tumor resection. A. Axial enhanced T1-weighted image shows irregular rim-enhancing lesions at previous tumor resection site in left frontal lobe (arrowheads) and newly developed enhancing lesions in right frontal lobe (arrow) and anterior corpus callosum (arrow). B, C. Cerebral blood volume map from dynamic susceptibility contrast imaging (B) and Ktrans map (C) demonstrate increased tumor perfusion and vascular permeability in lesions (arrows), respectively. D. Single-voxel intermediate echo time (144 ms) MR spectroscopy acquired in right frontal lesion reveals highly increased Cho/Cr ratio and no discernible NAA peak. These two enhancing lesions were confirmed as recurred tumors rather than radiation necrosis. Cho = choline, Cr = creatine, NAA = N-acetylaspartate

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