Eur Radiol (2007) 17: 2472–2482

DOI 10.1007/s00330-007-0679-x NEURO

Fabrice Bonneville
Julien Savatovsky
Imaging of cerebellopontine angle lesions:
Jacques Chiras an update. Part 1: enhancing extra-axial lesions

Received: 25 December 2006

Abstract Computed tomography available. A diagnostic algorithm
Revised: 24 April 2007 (CT) and magnetic resonance (MR) based on the lesion’s site of origin,
Accepted: 27 April 2007 imaging reliably demonstrate typical shape and margins, density, signal
Published online: 12 June 2007 features of vestibular schwannomas or intensity and contrast material uptake
# Springer-Verlag 2007 meningiomas in the vast majority of is also proposed. Part 1 describes the
mass lesions in the cerebellopontine different enhancing extra-axial CPA
F. Bonneville (*) . J. Chiras angle (CPA). However, a large variety masses primarily arising from the
Department of Neuroradiology, of unusual lesions can also be en- cerebellopontine cistern and its con-
Pitié-Salpêtrière Hospital, countered in the CPA. Covering the tents, including vestibular and non-
47, Boulevard de l’Hôpital, entire spectrum of lesions potentially vestibular schwannomas, meningioma,
75013 Paris, France
e-mail: fabrice.bonneville@psl.aphp.fr found in the CPA, these articles metastasis, aneurysm, tuberculosis
Tel.: +33-142163596 explain the pertinent neuroimaging and other miscellaneous meningeal
Fax: +33-142163515 features that radiologists need to know lesions.
to make clinically relevant diagnoses
J. Savatovsky
Department of Radiology, Adolphe de in these cases, including data from Keywords Cerebellopontine angle .
Rothschild Fondation, diffusion and perfusion-weighted im- Brain tumours . Magnetic resonance
Paris, France aging or MR spectroscopy, when imaging . Diffusion imaging

Introduction lesions that are challenging to diagnose. In addition to the

computed tomography (CT) and conventional magnetic
The cerebellopontine angle (CPA) cistern is a subarachnoid resonance (MR) imaging characteristics of the different
space containing cranial nerves and vessels bathed in CPA lesions (including anatomic site of origin, shape,
cerebrospinal fluid (CSF). The CPA is bounded by the density, signal and behaviour after contrast media injec-
pons, the anterior aspect of the cerebellum and the petrous tion), these articles also provide data from MR advanced
temporal bone covered by dura mater. It is centred by the techniques such as diffusion-weighted imaging (DWI) and
internal auditory canal (IAC) and extends caudally from the perfusion imaging, as well as MR spectroscopy, when
Vth cranial nerve to the IX-X-XIth cranial nerve complex. available, as they may bring crucial new data that allow
CPA lesions are clinically non-specific and the presenting accurate preoperative diagnosis.
symptoms are not related to the nature of the lesion itself, In this work, we initiate the approach depending on the
but to the nerves or cerebral structures involved with the result of a simple question: does the mass lesion enhance
lesions. Therefore, preoperative diagnosis of a CPA region after contrast administration? If the answer is yes, the site
tumour is mainly based on imaging. Diagnosis may be of origin of the lesion is then determined as it leads to three
difficult because of the wide variety of cell types and different gamuts based on whether the mass originates
origins of such tumours (Fig. 1) [1, 2]. Because vestibular within the CPA cistern itself, the cerebellum or brain stem,
schwannomas account for 70%–80% of all CPA lesions, or the skull base. If the answer is no, then the intrinsic T1
meningiomas 10%–15% and epidermoid cysts 5%, the few signal intensity is crucial: it points toward a cystic lesion if
remaining lesions, which account for less than 1% each, are low, or a lesion with fat or a high protein content if high.
derived from an extraordinarily wide spectrum of unusual Based on all these specific imaging characteristics
 2473

provided for all lesions potentially encountered in the CPA, Demonstration of vessels interposed between the mass
a concise algorithm is proposed to facilitate diagnosis lesion and the brain parenchyma is another sign of the
(Fig. 1). We review in this paper only the different extra-axial origin of the lesion. Such lesions include
enhancing extra-axial lesions appearing as very focal mass schwannomas and a wide spectrum of meningeal mass
lesions located in the CPA, thus excluding diffuse posterior lesions, as well as vascular lesions.
fossa meningeal thickening, while non-enhancing extra-
axial lesions as well as skull base and intra-axial lesions
invading the CPA are discussed in the second part of this Vestibular schwannoma
work.
Vestibular schwannoma (formerly called acoustic neuro-
ma) is by far the most frequent tumour in the CPA,
Enhancing extra-axial lesions originating in the CPA accounting for 70% to 80% of all CPA masses [3]. Most
vestibular schwannomas develop from the Schwann sheath
Extra-axial lesions are theoretically easily recognized in the of the inferior vestibular nerve in the IAC where they grow
CPA: they are separated from the brain parenchyma by a slowly. Then, they smoothly erode the posterior edge of the
cleft of cerebrospinal fluid and may enlarge the cerebel- porus acusticus and may give rise to a round or oval
lopontine cistern. They also push the cranial nerves, the component in the CPA cistern, thus giving the typical “ice
brain stem or the anterior aspect of the cerebellum away. cream on cone” pattern. At CT, schwannomas are usually

Fig. 1 Drawing of a segmental approach to diagnosis of CPA lesions based on gadolinium enhancement, site of origin and key feature
(adapted from reference [1], with permission)
2474

isodense and enhance after contrast administration. On

MRI, they show T1 isointensity and T2 high signal
intensity, but appear as a hypointense filling defect on T2-
weighted high-resolution MR cisternography, and enhance
strongly after gadolinium injection. Enhancement of the
adjacent meninges is possible in vestibular schwannoma
and is not specific to meningiomas [4]. Three different MRI
appearances of the tumoral enhancement are described in
vestibular schwannomas: homogeneous (50–60%), hetero-
geneous (30–40%), and cystic (5–15%) [5–7]. The size of
vestibular schwannomas is correlated to the appearance of
the signal and the gadolinium uptake, and the histological
Antoni subtype: small vestibular schwannomas are usually
homogeneous and histologically composed of Antoni type
A pattern, while heterogeneous and cystic vestibular
schwannomas are larger and harbour Antoni B pattern or
a mix of type A and B [7]. It is noteworthy that vestibular
schwannomas always become heterogeneous in lesions
larger than 25 mm in diameter because of the occurrence of Fig. 3 Post-therapeutic remnant of another large vestibular schwan-
those additional cystic or necrotic components (Fig. 2) [8]. noma in a 44-year-old woman. Axial infra-millimetric heavily T2-
weighted image depicts a focus of high signal intensity in the dorsal
Aside from the classic IAC-CPA schwannomas, small, brain stem (arrow), on the same side of the CPA tumour, presumed
purely intracanalicular schwannomas exist, but may also to result from the degeneration of the vestibular nucleus
present with a dumbbell extension in the cochlea or
vestibule [9]. In contrast, purely intracisternal vestibular
schwannomas, exclusively located in the CPA without IAC normal parenchyma, with apparent diffusion coefficient
involvement, represent a distinct entity because they have a (ADC) values ranging from 1.1 to 1.7×10−3 mm2/s in the
large space to grow in before becoming symptomatic, thus literature and a raised mean ADC value compared to normal
leading to cerebellum, brain stem or fourth ventricle brain (1.4×10−3 mm2/s) [12, 13] (Table 1). It has been
compression rather than hearing loss, and at imaging are postulated that higher ADC may reflect the lower cell
always large, heterogeneous and may show hypervascular- density of Antoni type B schwannomas [13]. However,
ity with possible high flow vessels [10]. Differential though the mean ADC value is significantly higher than in
diagnosis with other CPA lesions is not always simple meningiomas [13], there is a great deal of overlap between
and advanced techniques may solve difficult cases. On 3D them, so DWI does not reliably differentiate these two
fast spin-echo heavily T2-weighted sequence, a small focus entities. On the other hand, the relative tumour blood
of high signal T2 intensity observed in the dorsal brain stem volume [usually expressed as the relative cerebral blood
on the same side of a CPA tumour presumably results from volume (rCBV) in the literature, even for extra-axial
the degeneration of the vestibular nucleus associated with lesions] evaluated with perfusion imaging is significantly
vestibular schwannoma and may therefore be suggestive of lower in vestibular schwannomas than meningiomas [14].
the diagnosis (Fig. 3) [11]. DWI shows the solid component Even if there is an overlap between the rCBV ratios of both
of vestibular schwannomas to be usually isointense to the entities (rCBV ratio = rCBV of the lesion/rCBV of the

Fig. 2 Large vestibular

schwannoma in a 53-year-old
woman presenting with
dizziness, left deafness and long-
lasting headache. a. Contrast-
enhanced axial T1-weighted
image shows typical “ice cream-
on-cone” CPA mass lesion that
heterogeneously enhances. The
component enlarging the porus
of the internal auditory canal is
very suggestive of the diagnosis.
b. Short TE MR spectroscopy
reveals a prominent peak of
myo-inositol, another character-
istic feature of schwannomas
 2475

Table 1 Summary of diffusion, perfusion and MR spectroscopy findings usually observed in the most frequent enhancing extra-axial
cerebellopontine angle lesions
Extra-axial lesions DWI ADC mean (min-max) rCBV ratios mean (min-max) Spectroscopy

Schwannoma Isointense 1.4 (1.1–1.7) 3 (2.2–4.4) Myo-Inositol

Meningioma Variable* 1 (0.7–2.6) 8 (3–18) Alanine
Metastasis Hypo- to isointense (rarely hyperintense) 1.1 (0.8–1.5) 5 (1.3–15) Lipids and choline
Tuberculoma Variable* 1 (0.4–2.64) <1 Lipids
Note: DWI: signal intensity on diffusion-weighted imaging; ADC: apparent diffusion coefficient, values are ×10−3mm2/s; rCBV ratios:
relative cerebral blood volume ratios of the lesion to the normal brain; spectroscopy: characteristic metabolite peaks found at MR
spectroscopy. * Variable: for these lesions, signal intensity on DWI widely ranges from hypo- to hyperintense with no dominating pattern.

normal contralateral white matter), a threshold of 4.4 is the Other cranial nerve schwannomas
highest rCBV ratio reported in schwannomas [14], while the
mean rCBV ratio of typical meningiomas ranges from 6 to 9 Non-vestibular schwannomas are rarely present in the CPA
[14–16]. [1]. If signal intensities and post-contrast behaviours are
Proton MR spectroscopy has rarely been reported in the similar to those of vestibular schwannomas, they are easily
work up of CPA lesions, certainly because of the frequent distinguished from them because they present with different
lipid contamination in spectra of extra-axial lesions symptoms, neuroanatomic locations, shapes and relation-
abutting fatty bony limits of the posterior fossa. However, ships with skull base foramina and canals. Trigeminal
it seems interesting when feasible on large lesions, because schwannoma is the most frequent lesion among non-
it may help in distinguishing schwannomas from menin- vestibular schwannomas. It is located cephalad to vestibular
giomas by depicting a prominent myo-inositol peak in schwannoma, has an anterior-posterior direction in the CPA
schwannomas at 3.55 ppm (Fig. 2), whereas alanine found cistern and may extend into Meckel’s cave and along the
in meningiomas is absent in schwannomas [17]. trigeminal branches. Facial nerve schwannomas involving
Once the diagnosis is made, MRI may be used to CPA/IAC may be difficult to distinguish from vestibular
optimise treatment planning with respect to several features schwannomas because of their similar anatomical location
of the lesion: (i) the size of the tumour, which is assessed and clinical presentation. However, they usually have a
most reproducibly on high-resolution axial slices by dumbbell shape with an extension along the different
measuring the two largest diameters of the extracanalicular segments of the nerve into the temporal bone, as well as a
portion of the tumour, parallel and perpendicular to the suggestive associated round mass projecting up into the
posterior surface of the petrous temporal bone [18]; (ii) the middle cranial fossa due to a component developing at the
distance between the lateral extremity of the intracana- geniculate fossa (Fig. 4) [22]. Finally, glossopharyngeal,
licular portion of the tumour and the fundus because it vagus and spinal accessory nerves schwannomas, also called
affects the hearing prognosis and may modify the surgical jugular foramen schwannomas, may extend cranially with a
approach. This is better demonstrated with the heavily T2- large component coming back up in the CPA, especially
weighed MR cisternography as it clearly depicts the lesion when cystic, and mimic an intracisternal vestibular schwan-
as hypointense within the high-signal of the CSF [19]; noma (Fig. 5). However, a more caudal centre and the
(iii) the intralabyrinthine signal intensity: while normal extension through an enlarged jugular foramen are the key
labyrinthine signal intensities are hyperintense on 3D fast features of the diagnosis [23].
spin-echo T2-weighted images and suppressed on fluid
attenuated inversion recovery (FLAIR) sequence, poor
hearing prognosis may be predicted by a low T2-signal Meningioma
intensity of labyrinth contents compared to the unaffected
ear [20], which probably corresponds to a weakly sup- Meningioma is the most common intracranial extra-axial
pressed signal intensity on FLAIR sequence; (iv) the tumour in adults, but is the second most frequent lesion in
identification of the facial nerve and its position relative to the CPA after vestibular schwannoma, representing 10%–
the vestibular schwannoma. This is sometimes demon- 15% of all tumours in this location [2]. Meningiomas arise
strated by the use of heavily 3D T2-weighted sequence from arachnoid meningothelial cells and grow slowly in the
[21], but is almost certainly better depicted by the ad- CPA, independently from the internal auditory canal. They
ministration of contrast material that amplifies the are usually located at the posterior aspect of the temporal
difference of signal intensities between the lesion and the bone or at the premeatal area, from where they can easily
facial nerve. extend into the IAC, but without enlarging the porus
(Fig. 6) [24, 25]. At CT, meningiomas are hyperdense in
70% of the cases, calcified in about 20% and show a
2476

Fig. 4 Left facial nerve

schwannoma in a 47-year-old
man presenting with left facial
palsy, sensorineural hearing loss
and tinnitus. a. Contrast-en-
hanced axial T1-weighted image
demonstrates a CPA mass mi-
micking a common vestibular
schwannoma, except for the
intralabyrinthine enhancing
component (arrow). b. Contrast-
enhanced coronal T1-weighted
image shows a large infratem-
poral tumoral component, lo-
cated at the geniculate fossa, a
feature suggestive of a facial
schwannoma

frequent adjacent bone reaction including hyperostosis and atypical or malignant meningiomas tend to have lower
enostotic spur [25]. MRI clearly depicts a broad-based ADCs than the benign ones [31]. On the other hand,
dural hemispheric or oval lesion, attached to the petrous lymphomas have low ADCs as well. As previously
dura mater or the inferior aspect of the tentorium. mentioned, dynamic contrast-enhanced perfusion MR im-
Meningiomas are usually isointense with the cortex on all aging finds very high mean rCBV ratios in meningiomas,
sequences, and strongly enhance after contrast injection, ranging from 6 to 9, with even higher rCBV ratios in atypical
often homogeneously. Though not specific to meningiomas meningiomas (Table 1) [14]. Interestingly, this is signifi-
[4], the intense enhancement of the non-neoplastic cantly higher than in schwannomas (mean rCBV ratio=3) or
thickened peritumoral dura, the so-called “dural tail in lymphomas (mean rCBV ratio=1), thus providing another
sign”, is particularly frequent in association with menin- characteristic that allows discrimination between these CPA
giomas and should suggest the diagnosis when observed. lesions [14]. At proton MR spectroscopy, the combination of
This sign, and other conventional MR features, may look elevated glutamate/glutamine and the characteristic pre-
very similar in a wide variety of dural tumoral lesions in the sence of alanine at 1.5 ppm are considered very specific for
CPA, including the different subtypes of meningiomas meningiomas (Fig. 6) [17]. Three-dimensional high-resolu-
(meningothelial, fibrous, transitional, atypical, anaplastic tion T2-weighted sequence should also be performed in the
or clear cell meningiomas [26]), solitary fibrous tumours work up of CPA meningiomas because the neurosurgical
[27], lymphomas [28, 29] or metastases [30], making outcome depends not only on their consistency and size, but
preoperative differentiation difficult. The value of DWI is also on their precise location and relation to the surrounding
still questionable in the differential diagnosis and the neurovascular structures [32]. Similarly, the extent of the
pathological grading of meningiomas, but it seems that involvement of the IAC should be assessed by this sequence

Fig. 5 Jugular foramen schwannoma in a 38-year-old woman. a. IAC. c. Contrast-enhanced coronal T1-weighted image reveals the
Axial T2-weighted image and (b) gadolinium-enhanced axial T1- extent of the schwannoma along the course of the mixed nerves,
weighted image show a cystic lesion exactly located in front of the towards the jugular foramen
 2477

Fig. 6 Left CPA meningioma in a 49-year-old woman with area (arrow), a feature suggestive of a meningioma. b. Contrast-
dizziness and left sensorineural hearing loss. a. Axial T2-weighted enhanced axial gradient echo T1-weighted image shows an intense
image reveals an homogeneous extra-axial hyperintense mass enhancing lesion with even an extension within the IAC. c. Proton
compressing the brain stem and the anterior aspect of the left MR spectroscopy, at long TE=135 ms, shows the characteristic
cerebellar hemisphere away. Note the enostotic spur at the premeatal presence of a negative doublet of alanine observed at 1.5 ppm

because surgery of meningiomas in the CPA involving the appearing mass resembling schwannoma or meningioma
IAC carries an increased rate of cranial nerve morbidity and should make radiologists think of the possibility of a
should therefore require special surgical management [33]. metastasis and examine the lungs and breast carefully [1].
On the other hand, perfusion MR imaging can provide
additional information helpful in distinguishing dural
Metastases metastases from meningiomas, by demonstrating rCBV
ratios usually moderately elevated (often between 1.5
Meningeal metastases from lung or breast cancers, mela- and 5), which may suggest the diagnosis of metastasis,
noma (see below), or more rarely from other cancers, may while meningiomas have higher rCBV ratios (around 8)
invade the CPA. If CPA metastases should be sought when [15], and lymphomas rCBV almost equal to that of the
vertigo or other cranial nerve symptoms appear in a known normal parenchyma (see part II of this work for more
cancer patient [34], however, correct preoperative diagnosis
is frequently difficult in patients in whom a primary tumour
has not been detected at the time of identification of the
lesion in the CPA. At imaging, the presence of multifocal
cerebral lesions is highly suggestive of metastases (Fig. 7),
but CPA metastases may be solitary and mimic benign
tumours of the CPA [30, 35], or be bilateral, mimicking
neurofibromatosis 2 [36]. Metastases from cutaneous
melanomas certainly represent the most frequent aetiology
of melanocytic tumours in the CPA [37]. However, the few
melanocytes normally present in the meninges of the
posterior fossa may uncommonly give rise to benign or
malignant primary melanocytic tumours [1, 38]. An
epidermoid cyst associated with malignant melanocytic
cells has also been the subject of a single case report of an
unusual pigmented tumour in the CPA [39]. Final diagnosis
is usually made by pathological analysis of a dural lesion
resembling meningioma at preoperative imaging [1, 38].
The pigmented nature of this meningioma-like mass could,
however, be suspected if it demonstrates subtle intrinsic
homogeneous T1 high-signal intensity, due to the para- Fig. 7 Intra- and extra-axial metastases in a 69-year-old man with
magnetic effect of the melanin contained in the tumour [1]. lung cancer and intracranial hypertension syndrome. Contrast-
enhanced axial T1-weighted image demonstrates a right IAC-CPA
But except for melanocytic tumours, no imaging charac- lesion that may mimic a small vestibular schwannoma. The
teristic is pathognomonic of the diagnosis of metastases, combination with multiple intra-axial lesions is suggestive of a
but the unusual aggressiveness of an otherwise benign- metastasis
2478

Aneurysm

Vertebrobasilar aneurysms and dolichoectasia account for a

substantial part of non-tumoral lesions of the CPA that can
lead to cranial nerves or brain stem compression [41]. In
this location, and even in the internal auditory canal,
intracranial aneurysms may resemble vestibular schwan-
nomas, especially on CT, because they appear as well-
defined round or oval lesions that intensely enhance after
contrast administration [42]. At MRI, aneurysms without
significant internal thrombus have obvious flow voids and
pulsation artefacts on all spin echo sequences, but
demonstrate iso— to high signal intensities and variable
patterns of gadolinium uptake on T1-weighted images
when intraluminal thrombus is present. However, the
diagnosis should systematically be suspected when round/
oval lesions with low to no signal intensity are seen on T2-
weighted sequence (Fig. 8) [1]. MR angiography should
Fig. 8 Partially thrombosed giant vertebrobasilar aneurysm in a 76- then be performed to confirm the diagnosis and depict the
year-old man with vascular dementia. Axial T2-weighted image
demonstrates a well-defined round hypointense lesion, very parent artery, which could be the postero-inferior cerebellar
suggestive of an aneurysm, that was subsequently confirmed by artery [1], the antero-inferior cerebellar artery [43], the
an MR angiogram (not shown) vertebral artery [44] or the basilar artery itself.

details on lymphomas). On DWI, the majority of necrotic Cavernoma

metastatic lesions will have elevated diffusivity with low
signal and high ADC values [13]. Exceptions are ade- Cavernous malformations can also be encountered in the
nocarcinoma metastases that may mimic abscesses with CPA. Even if most infratentorial cavernomas are located in
restricted diffusivity and high signal on DWI and low ADC the pons, superficial intra-axial cerebellar or even extra-
values. MR spectroscopy shows, in addition to elevated axial cavernomas in the CPA exist and may clinically and
choline, a predominant peak of lipids in metastases, radiologically mimic vestibular schwannomas [45]. MRI
another important finding considered suggestive of the accurately establishes the diagnosis in most cases of intra-
diagnosis [40]. axial cavernomas: they appear as well-circumscribed
lesions with a reticulated core of mixed signal intensity
on T1-weighted images and usually high signal intensity
on T2-weighted images, surrounded by a peripheral rim of
hemosiderin that shows hypointensity on all sequences,

Fig. 9 Right CPA cavernoma in

a 42-year-old woman with
headache. a. Axial T2-weighted
image reveals a typical “pop-
corn” lesion in front of the right
IAC, with a hyperintense core
surrounded by a peripheral rim
of low signal intensity. b. Gra-
dient echo T2-weighted image
at the same level highlights the
hemorrhagic nature of the lesion
 2479

Fig. 10 Tuberculomas in a 31-year-old woman with meningitis and these gathered lesions c. Tuberculomas present with either iso- or
right cerebellar syndrome. a. Axial T2-weighted image reveals, in hypersignal intensities on diffusion-weighted image, but apparent
front of the right IAC, several cerebellar superficial lesions with a diffusion coefficients were always within normal values, similar to
mixture of iso- and hyposignal intensities. b. Contrast-enhanced that of parenchyma
axial T1-weighted image shows peripheral rim enhancement of

with moderate to no enhancement after contrast injection Sarcoidosis

(Fig. 9). Extra-axial CPA cavernomas are different and
arise from the cranial nerves. Most of the reported cases Sarcoidosis involves the nervous system in about 5% of the
had a faint intrinsic increased signal on T1-weighted cases and usually manifests as a granulomatous inflamma-
images, with variable enhancement after gadolinium tion of the meninges and the hypothalamic region. The
administration, and showed more classical central T2 meningeal lesions appear in a diffuse plaque-like pattern,
hyperintensity surrounded by a rim of low signal intensity but infrequent focal dural-based masses have occasionally
[46–48]. The presence of another or multiple intrapar- been reported in the CPA [49–51]. Diagnosis is difficult, but
enchymal hypointense lesions detected by gradient echo can be considered because the sarcoidosis granulomas are
T2-weighted images is a clue that points toward the hyperattenuating at CT, isointense on T1-weighted images,
diagnosis. intensely enhance after contrast media injection and overall
demonstrate a suggestive homogeneous low signal intensity
on T2-weighted images [50].

Fig. 11 Erdheim-Chester disease in a 38-year-old patient with weighted image reveals an enhancing lesion at the stalk. c. Coronal
diabetes insipidus and exophthalmia. a. Contrast-enhanced axial T1- T1-weighted image depicts identical lesions in both intra-conical
weighted image reveals an extra-axial round mass in the left CPA spaces. The combination of granulomatous lesions in the meninges,
that homogeneously enhances. b. Contrast-enhanced coronal T1- the orbits and the sellar area is very suggestive of the diagnosis
2480

Tuberculosis Erdheim-Chester disease

Central nervous system tuberculosis usually manifests as a Erdheim-Chester disease is a rare systemic non-Langerhans
tuberculous basilar meningitis that may be associated with histiocytosis of unknown aetiology that affects multiple
intra-axial tuberculomas or tuberculous abscesses. Solitary organ systems, with a predilection for bones, orbits and
tuberculoma presenting as an extra-axial mass mimicking a brain. Cerebral involvement is caused by a mixed infiltrative
meningioma is, however, a classic but rare circumstance [52] pattern (widespread lesions, nodules or intracerebral masses
that is even more uncommon in the CPA [53]. Superficial of the dentate and pituitary regions) and extra-axial
intraparenchymal tuberculomas, which are more frequent, meningeal masses, with either thickening of the dura
may be difficult to distinguish from extra-axial lesions, and a mater or meningioma-like tumours [58, 59]. Diagnosis of
high degree of suspicion for tuberculosis must be maintained the extra-axial abnormality is challenging if the underlying
when faced with a so-called CPA mass in the presence of risk disorder has not been identified, because the meningeal
factors for tuberculosis. CT and MR imaging findings vary enhancing dural masses may resemble meningiomas [4].
depending on the stage of the disease and the character of the However, the combination of dural lesions with intra-orbital
lesion (i.e., non-caseating, caseating with solid centre or and pituitary masses and osteosclerotic changes of the bones
caseating with necrotic centre) [54]. This may explain why in a patient with a cerebellar syndrome is highly suggestive
cases of tuberculomas with no restricted diffusion and of the diagnosis (Fig. 11).
normal ADC have been reported [55]. Other cases that are
caseating with a solid centre present as ring-enhancing
lesions, with a central T2 hypointensity that parallels a high Conclusion
signal intensity on diffusion-weighted images and a possible
low ADC [56]. The presence of multiple concomitant lesions A wide variety of lesions can be encountered in the CPA. A
with different DWI patterns may finally be a clue for the meticulous analysis of the site of origin, shape, density,
diagnosis of tuberculous lesions (Fig. 10). MR spectroscopy signal intensities and behaviour after contrast media
may also be helpful in reaching the diagnosis of tuberculoma: injection allows a systematic approach to the preoperative
in a case report of a lesion located outside the posterior fossa, diagnosis in the majority of cases. Diffusion and perfusion-
it distinguished an extra-axial tuberculoma from a meningi- weighted imaging, as well as MR spectroscopy may also
oma by depicting elevated lipids peaks at 0.9 and 1.33 ppm provide crucial information that helps radiologists arrive at
and findings characteristic of tuberculomas [57]. Interest- the correct diagnosis non-invasively.
ingly, these peaks detected in the lesion core of tuberculomas
by proton MR spectroscopy also differed distinctively from Acknowledgements We are grateful to David Seidenwurm, MD,
those of the pyogenic brain abscesses [56]. Finally, and for his meticulous and exhaustive review of this manuscript
contrary to tumours, infectious lesions and especially
tuberculomas demonstrate hypoperfusion on MR perfusion
with rCBV ratios usually <1 [14].

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