How do you differentiate based on MRI with and without contrast of the brain a stroke vs. a brain tumor? Can GBM IV in its early stage present or mask as a massive hemm. stroke? If so, how does a neurologist or neuro radiology come to the conclusion which one it is or not?
can someone explain to me...
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An acute infarction should present with a pattern of restriction on diffusion weighted imaging (hyperintensity) that ordinarily correlates with a pattern on adjusted diffusion coefficient imaging (hypointensity).
Brain tumors can present with a variety of clinical symptoms and signs - generally chronic in nature. MR imaging should show vasogenic edema surrounding a mass.
The clinical pictures are normally different.
Brain tumors are chronic. Strokes are acute.
Computed tomography imaging should show the difference between hemorrhage and mass lesion.
Perhaps a Radiologist could be more clear than myself?
Brain tumors can present with a variety of clinical symptoms and signs - generally chronic in nature. MR imaging should show vasogenic edema surrounding a mass.
The clinical pictures are normally different.
Brain tumors are chronic. Strokes are acute.
Computed tomography imaging should show the difference between hemorrhage and mass lesion.
Perhaps a Radiologist could be more clear than myself?
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Whenever you have a major intraparenchymal hemorrhage, you have the possibility that it masks some underlying 'badness'. This can be an:
- AVM whose draining veins are compressed/masked by the hematoma
- met or GBM masked by large hematoma
- ....
Most of the time, things are pretty clear. It looks like 'tumor with hemorrhage' 'infarct with hemorrhage' or 'AVM with hemorrhage'. At times, you can't tell, and that is when you have to give a differenttial.
- AVM whose draining veins are compressed/masked by the hematoma
- met or GBM masked by large hematoma
- ....
Most of the time, things are pretty clear. It looks like 'tumor with hemorrhage' 'infarct with hemorrhage' or 'AVM with hemorrhage'. At times, you can't tell, and that is when you have to give a differenttial.
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Cerebral infarction represents cytotoxic edema VS GBM vasogenic with cytotoxic features as well.
MRI- hyperacute/acute/subacute stroke appears hyperintense (white) on diffusion weighted imaging (DWI) and hypointense on apparent diffusion coefficient (ADC) map. GBM will have features of mainly vasogenic edema which is iso to hyperintense on DWI and slightly hyperintense on ADC with areas of hemorrhagic necrosis (also well differentiated on T1 and T2).
T2: vasogenic edema is confined to white matter
Patterns of enhancement:significant non-homogeneous contrast enhancement for GBM. In subacute stroke (mainly MCA infarcts) some leptomeningeal enhancement may occur at 3-4 days lasting about a week due to pial collateral development. By and large, most strokes do not enhance (unless sometimes related to vasculitis).
Presence of Blood on imaging: can occur in strokes due to reperfusion injury and also GBM due to hemorrhagic necrosis, but pattern and presence of contrast enhancement is useful.
Intracerebral hemorrhage: has a thin rim of perihematomal edema which is vasogenic. In case of intratumoral bleed, the size of vasogenic edema is significantly more. Pattern of contrast enhacement will help differentiate primary ICH, tumor related bleed, AVM related bleed etc.
MRI- hyperacute/acute/subacute stroke appears hyperintense (white) on diffusion weighted imaging (DWI) and hypointense on apparent diffusion coefficient (ADC) map. GBM will have features of mainly vasogenic edema which is iso to hyperintense on DWI and slightly hyperintense on ADC with areas of hemorrhagic necrosis (also well differentiated on T1 and T2).
T2: vasogenic edema is confined to white matter
Patterns of enhancement:significant non-homogeneous contrast enhancement for GBM. In subacute stroke (mainly MCA infarcts) some leptomeningeal enhancement may occur at 3-4 days lasting about a week due to pial collateral development. By and large, most strokes do not enhance (unless sometimes related to vasculitis).
Presence of Blood on imaging: can occur in strokes due to reperfusion injury and also GBM due to hemorrhagic necrosis, but pattern and presence of contrast enhancement is useful.
Intracerebral hemorrhage: has a thin rim of perihematomal edema which is vasogenic. In case of intratumoral bleed, the size of vasogenic edema is significantly more. Pattern of contrast enhacement will help differentiate primary ICH, tumor related bleed, AVM related bleed etc.
I appreciate all three of your responses. I have a general understanding from what you all said. Does contrast enhancement always accurately differentiate the presence of blood on imaging between stroke/ reperfusion injury vs. GBM / hem. necrosis? Besides the experience of the neuroradiologist and neurologist to differentiate between the two; does fresh blood vs blood of 2-3 weeks duration play a role regarding hyper and hypointense on diffusion and stating whether it is a stroke or GBM?
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The presence of enhancement doesn't help you to differentiate, the pattern of enhancement does.
The diffusion restriction changes over time, so does the basic T1/T2 signal pattern of extravascular blood. So yes, knowing the time of insult is helpful to determine whether the signal pattern is consistent with an ischemic insult (e.g. a week out you wouldn't expect it to show much diffusion restriction).
f_w, can the pattern of enhancement at times be difficult to differentiate stroke from tumor or vice versa? Can the most experienced neuroradiologist / neurologist miss a tumor calling it a stroke when presented with massive hemmorhage and edema and say for example 2 1/2 weeks of patient presenting w/ all classical symptoms of brain tumor?
In other words, can clinical competency or incompetency of the diagnostician occur or are these more often than usual?
Thanks.
In other words, can clinical competency or incompetency of the diagnostician occur or are these more often than usual?
Thanks.
Without saying much at the moment, can you please answer my aforementioned question? Mistakes I am sure do occur in any field of medicine / specialty/ healthcare. There is nothing secret about this. My question to you doc is does this happen often when presented in ER's ? can the pattern of enhancement be so difficult or deceiving at times from differentiating stroke from tumor?
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Speaking generally, yes, misdiagnosis can and does occur.
However, if you are concerned about misdiagnosis in a specific "real-life" situation, this is not the optimal place to pursue it further.
However, if you are concerned about misdiagnosis in a specific "real-life" situation, this is not the optimal place to pursue it further.
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Agree with neurologist.
Closing.
Closing.
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