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Neuroradiology > Primary Non-neoplastic Cysts > Flashcards

Primary Non-neoplastic Cysts Flashcards

1
Q

For anatomy based approach to brain cysts what are features in approach?

A
  • intra-/ extra-axial lesion
    1st step is it intra- or extra-axial
  • if extra-axial
    &raquo_space; supratent or infratentorial
    &raquo_space; midline or off-midline
  • if intra-axial
    &raquo_space; supra- or infratentorial
    &raquo_space; parenchamal or intraventricular
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2
Q

For the following extra-axial cysts which are midline (or preferred midline) or off-midline

Pineal cyst
Rathke cleft cyst
Dermoid cyst
Arachnoid cyst
Tumor-associated cysts (TACs)
A

Pineal cyst Midline
Rathke cleft cyst Midline
Dermoid cyst Preferred Midline
Arachnoid cyst (AC) Preferred Off-Midline
» rare location of midline AC are….
Suprasellar cistern then
Quadrigeminal cistern & velum interpositum
TACs Depend to location of tumor

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3
Q 
Arachnoid cyst (AC) are Off-Midline cyst but midline also occur but rare.
Where are the location of midline AC?
A

> > rare location of midline AC are….
Suprasellar cistern then
Quadrigeminal cistern &
Velum interpositum

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4
Q

What is the most common off-midline extraaxial supratentorial cyst?

A

Arachnoid cyst
(Osborn เล่มเก่าเรียกอีกชื่อว่า leptomeningeal cyst)

！(◎_◎;)

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5
Q

How much % does AC occur in middle cranial fossa?

A

At least 50%

คือจะบอกว่าเปน common location.

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6
Q

Occasionally AC occur over cerebral convexities but where is the most common lobe does it occur?

A

Parietal lobe. ♪( ´▽｀)

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7
Q

The arachnoid cyst and epidermoid cyst are usually have SI same as CSF.

How can we differentiated these tumors?

☆☆☆☆☆☆

A

By FLAIR and Restricted diffusion sequences.
_____________________________________
FLAIR DWI
_____________________________________
AC Complete suppress not restricted
Epidermoid Not completely Restricted
Suppress
DC Not suppress Restricted
_____________________________________

By morphology
AC >> round or oval shape
            Displaced vessels/nerves
EC >> insinuating growth pattern ( เลื้อย )
            Engulf the vessels/nerves

By MRS
AC&raquo_space; ไม่มีเขียนตรงๆ แต่เดาว่า เหมือน CSF
EC&raquo_space; Lactate
DC&raquo_space; Lipid peak

By location
AC, EC preferred off-midline

Enhancement pattern
AC no enh. ||| DC EC mild capsular enhance.

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8
Q

What is TACs, tumor-associated cysts?

A

Extratumoral cysts occur between tumor-brain interface, mass and adjacent cortex.

TACs is still debate in it’s origin, it may be trapped fluid that lined with gliotic brain, arachnoid cyst or obstructed PVSs.

Benign collections of fluid that vary from clear and CSF-like to proteinaceous.

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9
Q

What is leptomeningeal cyst?

A 
leptomeningeal cyst
- AKA "growing fractures"
- Common in age < 3 years old
- most commonly @ parietal lobe
- Manifestation:
  >> enlarging palpable soft tissue mass
- Image appearance
  >> round lucent, scalloping and enlarging calvarial fracture adjacent to post-traumatic encephalomalacia.
- Patho..
  >> fluid and encephalomalacic brain extrude through torn dura and arachnoid and through the enlarging linear calvaria fracture

(；´Д`A

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10
Q

Most of non-neoplastic cysts in the posteror fossa are midline or off-midline?

A

Off-midline

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11
Q

What is the two most common extraaxial posterior fossa cyst?

A

Epidermoid cyst then Arachnoid cyst

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13
Q
  1. Between spinal canal and intracranial NE cyst (neurenteric cyst) what are more common?
  2. For intracranial and spinal NE cyst.
    Where are common location does it occur?
  3. Between spinal canal and intracranial NE cyst (neurenteric cyst) which one is associated anomaly?
  4. What are the other name of NE cyst?
A
  1. Spinal canal
  2. Intracranial NE cyst.
    &raquo_space; Cerebellomedullary cistern (cisterna magna) , midline or slightly off-midline, lying just anterior to the pontomedullary junction.
    Spinal NE cyst.
    &raquo_space; ventral spine.
  3. Spinal neurenteric cyst associated with bone anomaly about 50%. Intracranial NE cyst not associated with bone anomaly.
  4. enterogenous cyst, enteric cyst, endodermal cyst, gastroenterogenous cyst, gastrocytoma, intestinoma, and archenteric cyst.
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14
Q

What is the
“retroclival ecchordosis (EP)” ?

Where is the common location?

What is the analogue of ecchordosis in malignant form?

A 
Gelatinous notochord remnant, can occur anywhere from dorsum sellae to sarcococcygeal region.
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Common location is prepontine cistern
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Chordomas
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15
Q

What is the first, second and third rank of supratentorial intraaxial cyst?

A

1st
Enlarge Virchow-Robin (perivascular) spaces

2nd
Hippocampal sulcus remnant cyst (HSRC)

3rd
Porencephalic cyst

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16
Q

What is the appearance and pathogenesis of “Hippocampal sulcus remnant cyst”?

Does it has any clinical significant?

A

String of small-CSF-like cysts lying in hippocampus just medial to the temporal horn of lateral ventricle.
_____________________________________
Pathogenesis:
incomplete or defective fusion of embryonic cornu ammonis and dentate gyrus
_____________________________________
No clinical significance.

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17
Q

What is the pathogenesis of Porencepalic cyst?

What is the structures lining of Porencepalic cyst between ependyma or gliotic white matter?

Does Porencephalic cyst alway need to communicate with ventricle?

A

Brain destruction (peri- or antenatal insult)

Gliotic white matter

No

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18
Q

Between Porencepalic cyst and Dilated VR space what is the distinctive feature?

A

Surrounding tissue.

Porencepalic cyst
» Gliotic white matter, appear High T2 signal

Dilated VR space
» normal brain parenchyma

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19
Q

What is the most common of all intracranial neuroepithelial cyst?

From Osborn DI neuro, P I 7, 3

A

Choroid plexus cysts
Found up to 50% of autopsy cases.

Σ（ﾟдﾟlll）

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20
Q

Choroid plexus cysts mostly component are?

What is the appearance of CPCs

A

Xanthogranulomas

High T2, not completely suppress with FLAIR
May show moderately high restricted diffusion.

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21
Q

What is the ependymal cyst(EC)?

Where is it location?

What is it appearance in MR?

A

Cyst lined with ependymal cells

Lateral ventricle

Cyst with CSF signal

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21
Q

What is the cyst is almost exclusively develop in Foramen of Monroe, attached to the anterosuperior portion of the 3rd ventricular roof and also wedge into the foramen and straddled by the fornices?

A

Colloid cysts

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22
Q

What is the the cell origin of Colloid cysts between ectoderm, mesoderm and endoderm?

What is the content of Colloid cyst?

What is the clinical significant of Colloid cyst?

A

Endoderm.

Gelatinous material mostly mucin, but may also contain cholesterol crystals, foamy cells or blood product.
====================================
Suddenly obstruct the foramen of Monroe and developed obstructive hydrocephalus.

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23
Q

What is the pathognomonic imaging appearance if Colloid cysts?

What are the peak age incidence of CCs and does it common in children?

A

Hyperdense mass at the Foramen of Monroe. In NCCT, pathognomonic findings.

However it’s density are inversely related with hydration status.
____________________________________
3rd to 4th decade, peak at 40
Rare in children

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24
Q

Between supratentorial and infratentorial intraparenchymal cyst, what is more common?

What is the most common in both entity?

A

Supratentorial is more common.

Supratentorial cyst (intraparenchymal) and Infratentorial cyst, the most common is
>> Dilated PVSs
25
Q

What is the most common location of dilated VR spaces? In supratentorial and infratentorial.

A

Supratentorial is basal ganglia

Infratentorial is in and around dentate nucleus.

26
Q

The clinical problem from dilated PVSs (VR space) is rare but what is the clinical problem?

A

May cause obstructive hydrocephalus and it may be the rare cause of cranial neuropathy.

28
Q

The two most common cytic-like lesion in 4th ventricle is?

A

“encyst” 4th ventricle
As the consequence of SAH or infection →obstructed foramen

Epidermoid cyst.
By incidence at CPA is more far common than 4th ventricle.

29
Q

Please described the imaging appearance of arachnoid cyst in
> CT
> MR
____________________________________

จงบอกตำแหน่งที่เราพบ arachnoid cyst ได้บ่อยตามลำดับ

A 
CT
> non-enhanced cystic with CSF density.
> may hyperdense if hemorrhage.
> bone remodelling, thin and expand bone
MR
> follow CSF SI, FLAIR กดหมด
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Middle cranial fossa (50-60%)
cerebellopontine angle (10%)
Suprasellar (10%)
Misc. (10%) 
(parietal convexity, quadrigeminal cistern)
30
Q

What are the 2 locations of posterior fossa arachnoid cyst and how much these location account for?

A

CPA and cisterna magna

Account for 10%

31
Q

What are the clinical problems of arachnoid cyst?

A

Subdural hemorrhage
» จากที่ไปโตถ่าง bridging vein

Temporal lobe hypoplastic
» จากที่ไปกด เนื้อสมองโดยตรง

Hydrocephalus
» เป็น associate anomalies…
Foramen Monroe stenosis, aqueductal stenosis

Associated syndromic of ACs
» Aicardi syndrome, Pallister-Hall syndrome, Acrocallosal syndrome

32
Q

What are two type of suprasellar arachnoid cyst?

A

Non-communicating = cyst of membrane Liliequist

Communicating = cystic dilatation of interpeduncular cistern

33
Q

Are the arachnoid cyst are almost alway not communicate with normal CSF space?

A

Nooo

The communicating type is exist

34
Q

What are the other name of colloid cyst?

A

Paraphyseal cyst, endodermal cyst

35
Q

What are common location of dermoid cyst?

A

Midline.

Lumbosacral spinal canal is the most common
then followed by
Parasellar →Frontobasal →Posterior fossa region

36
Q

What are the possible etiologies of dermoid?

A

From embryology
1. Sequestration of ectoderm at lines of epithelial fusion/ along course of normal embryonic invagination.

  1. Inclusion of cutaneous ectoderm at time neural tube closure(3rd - 5th week of GA)

——/——/——/——/——/——/——/——/——/

From traumatic implantation after lumbar puncture

36
Q

If the dermoid cyst has tract to skin it will called?

A

Dermal sinus tract

37
Q

What are the extracranial site of dermoid cyst?

A

Spine and orbit

38
Q

What conditioned that we found spreading of fat droplet along subarachnoid/ intraventricular or leptomeningeal space?

A

Ruptured intracranial dermoid cyst

39
Q

How much intracranial dermoid cyst have Ca++?

A

20% capsular calcification

40
Q

Between intradural dermoid and epidermoid cysts what are more common?

A

Epidermoid are far common 4x - 9x

41
Q

What are the most common clinical presentation of dermoid cysts?

what are complication of dermoid cysts?

A

Ruptured cyst (6.9%) →chemical meningitis
Larger cyst →obstuctive hydrocephalus
Suprasellar →visual symptom
Less common hypopituitarism, DI or CN defect
Malignant transformation →SqCCA

42
Q

Between extradural and intradural epidermoid cyst which are more common?

A

Intradural (90%)

  • CPA, 40-50%
  • 4th ventricle, 17%
  • parasellar/ middle cranial fossa, 10-15%
  • cerebral hemisphere, rare 1.5%
  • brain stem, exceeding rare

Extradural (10%)

  • Skull (intradiploicwithin frontal, occipital, parietal and sphenoid bone)
  • Spine
43
Q

What is the rare variant of epidermoid?

How does it occur?

What is it incidence?

A

“dense” epidermoid จะให้ SI ตรงข้ามกับ typical
「ตรงข้ามกับ rare dermoid very high T1 T2」

Secondary from hemorrhage, high protein, saponification of cyst debris to calcium soaps or iron containing pigment.

3% of epidermoid

44
Q

Between AC EC DC, which are able to engulf vessels?

AC, arachnoid cyst
EC, epidermoid cyst
DC, dermoid cyst

A

EC and DC

But DC that engulf vessels are increased risk of ruptured.

AC displace vessels.

45
Q

“Beautiful tumor” referred to what tumor?

A

Epidermoid cyst in gross pathologic appearance.

Also called “mother of pearl”

46
Q

About Neuroglial cyst.
1. What is other name? (1 points)
2. What is the appearance in MR CT? (5 pts)
3. Please give DDx and differentiated features?
(3000 points)

A
  1. Glioependymal cyst
  2. นึกถึง simple cyst ♪(´ε｀ )
    Non-enhancing CSF-like parenchymal cyst with minimal/ no surrounding signal abnormality. ไม่ต่อกับ CSF-space อื่นๆ
3. DDx are
 >> Porencephalic cyst (brain injury in utero)
      Communicate with ventricles.
      Adjacent brain parenchymal abnormal.
 >> Dilated Virchow-Robin space
      มีหลาย  อัน   มีหลายขนาด
 >> Arachnoid cyst
      Most common extraaxial off-midline cyst
      @ Middle cranial fossa
 >> Ependymal cyst
       Intraventricular cyst
 >> Epidermoid cyst
       Not totally suppress on FLAIR 
       Restricted diffusion on DWI
       Insinuated growth pattern
48
Q

Periventricular cyst (PCs), anterior choroid plexus cyst (ACPC), Germinolytic cyst (GC), Connatal cyst (CS), Cystic periventricular leukomalacia (cPVL)

Among these terms what are the..

  1. คำเรียกรวมๆ ของกลุ่มนี้
  2. มีอีกชื่อว่า coarctation of anterior horns
  3. แต่ก่อนมีอีกชื่อว่า paraventricular cyst
  4. May communicate with ventricle, porencephaly.
A
  1. Periventricular cyst
  2. Connatal cyst
  3. Cystic periventricular leukomalacia
  4. Cystic periventricular leukomalacia
49
Q

Periventricular cyst (PCs) ประกอบด้วย…

  • anterior choroid plexus cyst (ACPC)
  • Germinolytic cyst (GC)
  • Connatal cyst (CS)
  • Cystic periventricular leukomalacia (cPVL)

จงบอกตำแหน่งของ cyst เหล่านี้

A
  • Anterior choroid plexus cyst (ACPC)
    » posterior to caudothalamic groove
    » within choroid plexus or protuding into lateral ventricle
  • Germinolytic cyst (GC),
    Nonhemorrhagic subependymal pseudocyst
    » anterior to caudothalamic groove
  • Connatal cyst (CS)
    » at or just below superolateral angle of frontal horns &/or body of lateral ventricle
  • Cystic periventricular leukomalacia (cPVL)
    » at or above superolateral angle of frontal horns
    » along margin of lateral ventricles, anterior to posterior
    » may communicate with ventricle (Porencephaly) or separate by ependyma.
49
Q

What is the most common location of neuroglial cyst (glioependymal) cyst?

A

Frontal lobe

NGC can occur anywhere throughout neuraxis
Intraparenchymal&raquo_space; extraparenchymal

50
Q

When should be suspected systemic cause in subependymal pseudocyst or anterior choroidal cyst?

A

When occur bilateral SEPCs are the marker of systemic disease.
Eg.
- Aneuploidy and multiple congenital anomaly.
- Growth disorder
- TORCH: CMV and rubella
- Intrauterine exposure of cocaine
- Inborn error metabolism

.
When occur unilateral it is low likelihood to associated with anomalie.

51
Q

What cystic lesion have following features ?

  • involved medial temporal lobe, choroid fissure
  • following the CSF
  • spindle shape on Sagittal MR
A

Choroid fissure cyst.

Anatomy: choroid fissure is….
CSF space between fimbriae of hippocampal and diencephalon.

51
Q

What are the characteristic of dilated VR spaces each site?

Basal ganglia
Midbrain
Anterior commissure

A

Basal ganglia is the most common site.
Anterior commissure, PVSs are the clusterred.
Midbrain, the PVSs are giant or tumefactive

52
Q

Are the dilated VR space are lining with ependymal cells? If not what is that cells?

A

No., it is pial cells

53
Q

Please described the most common location, common location and less common location of dilated Virchow-Robin spaces?

A

Most common location is basal ganglia.

Other common location are..
» midbrain, deep white matter, subinsular cortex, extreme capsule

Less common sites are..
» Dentate nucleus, corpus callosum, cingurate gyrus, thalami

54
Q

The dilated VR space can presented with clustered from which give the same appearance as DNET. How can we differentiate these two tumors?

A

DNET, Dysembryonic neuroepithelial tumor.
ชื่อเล่น do not enhance tumor อาจารย์แอร์ตั้ง
จะ involve cortex ด้วย

Dilated VR space never involve cortex

55
Q

What tumor that initially diagnosis as cystic neoplasm?

คําถามบ้ามากกก

A

Dilated VR space

56
Q
  1. What are the most common sign and symptoms of pineal cyst?
  2. What are the rare but serious manifestation condition of pineal cyst?
  3. What are the manifestation of larger (>1 cm) pineal cyst?
A
  1. Clinically silent is the most.
2. Pineal cyst apoplexy..
>> severe headache 
     ("thunderclap" mimic ruptured aneurysm อันนี้ไม่รุ ป้า ออส รู้ได้งัย Σ（ﾟдﾟlll）)
>> Intracystic hemorrhage
>> Acute hydrocephalus
>> Sudden death
3. 
>> Severe headache 50% 
     from aqueduct obstruction or hydrocephalus
>> Parinaud syndrome 10%
     From tectal plate compression
57
Q

What is the appearance of pineal cyst on T1, T2, FLAIR and restriction map?

Does Pineal cyst enhance?
And if it enhance what is it appearance?

A 
T1
>> homo SI 98-99%,
      hetero SI (hemorrhage) 1-2%
>> slightly hyper to CSF vs iso to CSF
     = 55-60% vs 40%

T2
» iso/ slightly hyper SI to CSF
» Multicystic/ septated (20-25%)

FLAIR & DWI
» not suppress and not restricted.
————————————————–
Yesss….

CECT&raquo_space; rim or nodular enhancement
T1+Gd&raquo_space; 90% enhanced thin rim <= 2 mm

Neuroradiology (6 decks)

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