It is simple analysis for a case with signs of cerebellar dysfunction

1. Cerebellar cyst: A case on MRI
Dr Rekha khare
MD. Radiology

2. Case presentation
• A young asian man about 22year came for MRI
• Clinical presentation was in favor of
Cerebellar dysfunction :
Ataxia/ incordination/ gait disturbance
Headache

3. Investigations
• His routine lab investigations Blood & Urine were with
in normal limit
• MRI findings in different sequences:
A large left cerebellar cystic mass with non
enhanced wall. Cyst is with a small mural
nodule vividly enhanced and with flow voids.
Cyst is crossing midline and compressing IV
ventricle so causing dilatation of 3rd and lateral
ventricle
Impression: left cerebellar cyst crossing midline
and causing hydrocephalus

4. T2 sequence axial

5. T2 axial contd.

6. T2 axial contd.

7. T1 sequence axial

8. T1 axial contd.

9. T1 axial contd.

10. Flair sequence

11. Flair contd.

12. Flair contd.

13. GRE sequence

14. GRE contd…

15. GRE contd.

16. T2 sequence sagittal

17. T2 sagittal contd.

18. T2 sagittal contd.

19. T2 sagittal contd.

20. T1 sequence with contrast

21. T1 with contrast contd.

22. T1 with contrast contd.

23. D/D Cerebellar cyst
• Haemangioblastoma
• Astrocytoma
• Sub acute infarction
• Vascular lesion
• Adult Meduloblastoma – rare much more solid
• Metastasis –usually old with primary

24. Haemangioblastoma
Cushing and Bailey introduced the term
Haemangioblastoma in 1928
Clinical symptoms:
Headache-70%
Hydrocephalus /ICH- 50%
Cerebellar dysfunction- 50-60%
altered mental state-10%
Polycythemia due to erythropoietin production
occurs in 5-40%
SYMPTOMS DEPENDS ON ANATOMIC LOCALIZATION

25. Haemangioblastoma
• It accounts for 1% of all intracranial tumor, in
isolation in 80% but is linked with
Von Hippel Lindau syndrome
• Most common in cerebellum
• In adult between 30-65% earlier withVHL
• Male : Female :: 1.3- 2.6

26. Site Haemangioblastoma
• Intracranial – 87-97%
95%------ posterior fossa
85% ----- cerebellar hemisphere
10% -----cerebellar vermis
5% -------medulla
5% -------supratentorial
Rarely up to CP angle
• Spinal – 3-13%

27. Histo-pathology Haemangioblastoma
• Mural nodule with cyst wall not demonstrating
tumor involvement in most cases
• Fluid of cyst often xanthochromatic
• Micro-vascular tumor composed of thin walled
vessels with surrounding stroma of connective
tissue

28. Haemangioblastoma on CT
• Cyst with nonenhancing wall
• Vividly enhanced mural nodule often has
prominent serpentine flow voids
• Calcification is not a feature
• Relatively mild edema and mass effect
** Mistaken for a low density glioma or gliomatous cyst
unless the mural nodule is identified in post enhanced
scan

29. Haemangioblastoma on MRI
• T1- Fluid filled cyst
Hypo intense to isointense mural nodule
vividly enhancing
• T2- Fluid filled cyst like CSF
Hyper intense mural nodule , flow voids due
to enlarged vessels at the periphery to cyst

30. Haemangioblastoma on angiography
• Enlarged feeding arteries often dilated draining
veins are demonstrated with dense tumor blush
centrally

31. Von-Hippel Lindau disease
• It is autosomal dominant hereditary syndrome
first described in 1926 by
Arvid Vilhelm Lindau
• Patient may present with--
1. cerebellar dysfunction- ataxia and in
coordination with or without hydrocephalus
2. Long H/O minor neurological problem or
sudden exacerbation

32. VHL contd…..
• VHL includes retinal angiomatosis, CNS
haemangioblastoma and various visceral tumors most
commonly involving the kidneys and adrenal gland
• This syndrome is classified as PHAKOMATOSIS
although it does not include any cutaneous
manifestation.
• It’s dominating mode of transmission compels
performing alerts screening of family members of patient
diagnosed with VHL

33. Diagnostic work up VHL
• Family history
• Detailed funduscopy
• Haematocrit & RBC count
• MRI with contrast
• Arteriography with DSA
• Spinal Angiography if spinal lesion on MRI
• Urine for Metanephrine- if +ve then 24 hrs VMA
• Abdominal CT scan esp. for pancreas, renal and
suprarenal

34. Vascular lesion
• Arterio -venous malformation
• Cavernoma
Both with or without bleed, confirmed on
Angiography

35. Astrocytoma
• Pilocytic astrocytoma- in children
• GBM - in adults
• Ependymoma

36. Pilocytic astrocytoma on MRI
Iso-Hypointense solid component compared to
adjacent brain on T1 and significantly Hyper
intense solid component on T2

37. Ependymoma on MRI
• Typically heterogenous mass in all modalities
Area of necrosis, calcification, cystic changes
and hemorrhage frequently seen

38. Diagnosis of our case
• On the basis of MRI imaging and clinical
picture most suggestive diagnosis of our case is
Haemangioblastoma
• Patient has been referred to specialist

39. Brain Tumor: Systemic approach
For analysis of potential brain tumor
Questions that need to be answered
1. Age of the patient
2. Localization- intra versus extra axial
Which anatomical compartment
Mid line crossing
3. CT or MRI- calcification, fat, cystic
4. Contrast enhancement
5. Effect on surrounding structure- mass effect, edema
6. Solitary or multiple
7. Pseudotumour

40. References
• Haemangioblastoma-Central nervous system
Dr Bruno Di Muzio and Dr Frank Gaillard et al
radiopaedia.org/article/
• Haemangioblastoma: Medscape Reference
emedicine.medscape.com/article
• Haemangioblastoma:
wikipedia.org/wiki/haemangioblastoma
• Brain tumor: systemic approach Robin Smithnis
and Walter Montanera Radiology Assistant

41. References contd…..
• Haemangioblastoma: Neuroradiology
neuroradiology.ws/haemangioblastoma.htm
• Cerebellar haemangioblastoma: An unusual
cause of syncope
eradiology.bidmc.harvard.edu/learning
lab/mohamed.pdf
• Tumors of uncertain histogenesis-
haemangioblastoma Text book of Radiology
and Imaging vol 2 David Sutton

42. Have a good time