Comprehensive Imaging Review of Supratentorial Extra-

axial Lesions; Avoiding Common Pitfalls in Diagnosis and

Management

Poster No.: C-0449

Congress: ECR 2012
Type: Educational Exhibit
Authors: A. Justaniah, S. Erbay, J. E. Small; Burlington, MA/US
Keywords: Education, MR, Neuroradiology brain, Neoplasia
DOI: 10.1594/ecr2012/C-0449

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Learning objectives

• Describe characteristic imaging features of enhancing supratentorial extra-

axial lesions, with solid and cystic components.

• Delineate specific helpful imaging features in an attempt to differentiate

extra-axial lesions with solid and cystic components.

• Incorporate additional helpful clues from other imaging studies.

Background

One of the most critical decisions for intracranial diagnostic interpretation is the
differentiation of intra-axial versus extra-axial lesions. The differential diagnostic
considerations for lesions arising from the brain parenchyma as opposed to those
arising from the extra-axial compartment are widely disparate. Therefore, facility with
differentiation of location, even when the lesion is large, is essential.

Once the extra-axial location of a lesion has been established, the enhancement
characteristics of the lesion help differentiate non-enhancing lesions (e.g. arachnoid
cyst, epidermoid, and neuroglial cyst) from various enhancing lesions, with either solid
or combined solid and cystic components. As extra-axial lesions with solid and cystic
components present the most formidable challenges, we will focus on these lesions.

Imaging findings OR Procedure details

Enhancing Supratentorial Extra-axial Lesions with Solid and Cystic Components:

Meningioma:

It is the most common dural-based enhancing extra-axial lesion. Typically, it is a

slow growing, well-defined, isodense/isointense lesion. Homogeneous or heterogeneous

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enhancement may be seen, with heterogeneity at times secondary to cyst formation or
varying degrees of calcification.

Imaging characteristics such as hyperostosis or a dural tail sign are classic features
of meningioma. However, it is important to note that other dural based processes
may exhibit a dural tail sign. Meningioma has different manifestations including a
plaque-like growth pattern, or may rarely grow in an intra-ventricular location (most
commonly in the trigones of the lateral ventricles). Varying degrees of parenchymal
edema may be seen. Meningioma with cystic and solid components shares these varying
imaging characteristics including vasogenic edema, dural tail sign, compression and
displacement of the parenchyma, as well as infiltration of the adjacent structures including
bone (Fig 1,2,3). Brain parenchymal invasion, however, strongly suggests an atypical or
malignant meningioma.

Metastasis:

Metastasis should be considered when there are multiple lesions in various

compartments. Parenchymal edema tends to be less pronounced in extra-axial
metastasis compared to intra-axial one. Imaging based differentiation between
meningioma and metastasis may be challenging. Close follow up should be considered
if there is known history of primary malignancy elsewhere. Most metastatic lesions are
solid. In rare occasions, cystic metastasis can be seen with enhancing solid component
(Fig 4,5).

Hemangiopericytoma:

Dural based, aggressive, highly vascularized, enhancing, mensenchymal tumor. It

erodes through the adjacent bone. Remember, meningioma causes hyperostosis. Given
its rapid growth, surrounding edema and mass effect are common.

These lesions are generally hyperdense on CT with heterogeneous enhancement.

Cystic and necrotic components can be seen (Fig 6). T1W and T2W isointensity,
with heterogeneous enhancement post gadolinium. Unfortunately, no clear imaging
differentiating features from meningioma. Its aggressiveness mandates surgical
resection and radiation therapy.

Enterogenous Cyst:

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This is a rare extra-axial lesion arising from the endoderm. Although this lesion
is classically cystic, an enhancing rim or small solid nodule has been reported [1]
(Fig 7). It is more common infratentorially. Nevertheless, it may be seen in the
supratentorial compartment. Usually, it has a variable density and intensity. The majority
are hyperdense on CT and heyperintense on T2WI compared to CSF.

Diagnostic Pearls for General Extra-axial Lesions:

Location:

Confirm the lesion as extra-axial by clearly separating it from the adjacent parenchyma
with the help of secondary signs such as the CSF cleft sign (Fig 8), the cortical ribbon
sign, dural tail (Fig 9), and inward displacement of the cortical vessels (Fig 10).

Imaging Appearance:

There is significant overlap between benign and malignant entities in this regard.
Prominent calcification and hyperostosis suggest meningioma (Fig 11).

Growth Pattern:

Slow growth is a characteristic feature of benign meningioma.

Bone appearance:

Adjacent hyperostosis may favor meningioma (Fig 11). Erosions and infiltration may
represent a rapidly growing neoplasm. Bone thickening and enhancement indicates intra-
osseous extension of an extra-axial lesion.

Dural tail:

A non-specific finding that can be associated with variety of extra-axial lesions (Fig 9).

Parenchymal enhancement:

Indicates parenchymal infiltration and represents at least atypical or high-grade

neoplasia. Should the lesion's borders become indeterminate from adjacent parenchyma,
parenchymal invasion should be considered, regardless of parenchymal enhancement.

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Images for this section:

Fig. 6: Surgically proven hemagiopericytoma. Axial T2WI (left) shows left parafalcine
heterogeneous mass with some cystic component. There is mild mass effect without
significant edema. Coronal enhanced T1WI (right) shows left convexity extra-axial mass
with heterogenous enhancement.

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Fig. 7: Surgically proven enterogenous cyst. Axial T1WI (left) demonstrates a left frontal
hyperintense lesion with subtle medial isointense nodule. The hyperintensity within the
cyst is owed to keratin debris and hemosiderin deposition as noted on the spicemen.
Post gadolinium T1WI (right) shows enhancement at the medial lesion nodule (arrows).
Pathologic examination revealed a nodule with granulomatous reaction corresponds to
the enhancing medial nodule.

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Fig. 1: Combined cystic and solid meningioma. Axial T2WI with left anterior solid and
posterior cystic components. Note the mass effect and left-sided edema.

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Fig. 2: Combined cystic and solid meningioma; same patient. Axial pre-(left) and post
(right) gadolinium T1WI demonstrate enhancement of the anterior solid component, as
well as the dura.

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Fig. 3: Combined cystic and solid meningioma; same patient. Sagittal pre-(left) and post
(right) gadolinium T1WI demonstrate enhancement of the anterior solid component, as
well as the dura.

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Fig. 5: Breast cancer metastasis. MRI of the same patient. T2WI (left) demonstrates the
same lesion with central cystic component and surrounding edema. Coronal (middle)
and sagittal T1WI (right) with contrast show solid component enhancement and spared
cystic part.

Fig. 8: Axial T2WI demonstrates CSF at the margin of the lesions (arrows) indicating the
CSF cleft sign in this meningioma.

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Fig. 12: High grade astrocytoma. Theses images facilitate the differentiation between
intra and extra-axial lesions. Coronal T2WI (left) of a left temporal intra-parenchymal
lesion demonstrated by the absence of CSF cleft sign. Sagittal enhanced T1WI (right) of
the same lesion touching the dura without dural tail sign.

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Fig. 9: Coronal T1WI with contrast for the same patient demonstrates dural enhancement
(arrow) in continuation with the lesion (dural tail sign).

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Fig. 10: Coronal T2WI of an extra-axial CSF intensity mass consistent with arachnoid
cyst. Note the right cerebral hemisphere compression rather than expansion and the
inward displacement of the cortical vessels (arrow). A sign of an extra-axial mass origin.

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Fig. 11: Axial CT of the brain shows asymmetric thickening of the right frontotemporal
bone (hyperostosis) secondary to meningioma (arrow), indicating an indolent slow
growth.

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Fig. 4: Breast cancer metastasis. CT without (left) and with (right) contrast demonstrates
an enhancing right frontal dural-based lesion with central hypodense (cystic) component.
This shows how metastasis can present with solid and cystic components.

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Conclusion

All available tools including history, prior studies, and presence of secondary clues aid in
tailoring the differential diagnosis for exta-axial lesions.

Personal Information

References

1. Preece MT, Osborn AG, Chin SS, Smirniotopoulos JG.Intracranial neurenteric cysts:
imaging and pathology spectrum. AJNR Am J Neuroradiol. 2006;27(6):1211-6.

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