MENINGIOMA

An important advantage of MRI in the imaging of meningiomas is its superior resolution of different types of soft tissue, multiplanar capability, and 3-dimensional (3-D) reconstruction (see the images below).[17, 18]
Parasagittal meningioma. A: Nonenhanced Sagittal T1-weighted magnetic resonance image (MRI) shows a solid dural isointense mass with bone invasion and compression against the parietal cortex. B: Contrast-enhanced sagittal T1weighted MRI demonstrates partially intense enhancement of the tumor. C: Coronal T2-weighted image shows isointense mass meaning hard tissue. This finding is observed on fibroblastic meningiomas. D: Contrast-enhanced T1-weighted axial

MRI shows hyperintense image located within the bony marrow.

A: Noncontrast angio-magnetic resonance image

(MRI) on lateral view demonstrates occluded superior sagittal sinus due to meningioma invasion. B: MRI reconstruction shows sagittal venous obstruction and 3-dimensional (3-D) appearance of the tumor.

MRI can demonstrate tumor vascularity, arterial encasement, venous sinus invasion, and the relationship between the tumor and surrounding structures. This modality is particularly advantageous in depicting the juxtasellar area and the posterior fossa and in demonstrating the rare presence of disseminated disease via the CSF. The multiplanar capability is often the best means to visualize the broad contact of tumors to the meninges, tumor capsules, and meningeal contrast enhancement adjacent to the tumor. [26, 27, 28] See the following images.
Brain meningioma. Nonenhanced T1-weighted sagittal magnetic resonance image demonstrates a typical parasagittal meningioma. A homogeneous, long-T1, round mass with thin capsule is present. The tumor is attached to the left sagittal

dura. Mass effect is noted against the ventricular trigone.

Brain meningioma. Nonenhanced axial magnetic resonance

image demonstrates a typical parasagittal meningioma. T1-weighted image shows a homogeneous, long-T1, round mass

with thin capsule. The tumor is attached to the left side of the falx. Mass effect is noted on the adjacent gyri.

Brain

meningioma. Coronal T2-weighted magnetic resonance image demonstrates a typical parasagittal meningioma. Isointense and inhomogeneous tumor without peripheral edema indicates a more fibrous and harder character (ie, a fibroblastic

meningioma).

Brain meningioma. Contrast-enhanced T1-weighted axial magnetic resonance image demonstrates a

typical parasagittal meningioma. A homogeneous, enhancing, globose mass is depicted.

Brain meningioma. Contrast-

enhanced T1-weighted coronal magnetic resonance image shows a typical parasagittal meningioma. A homogeneous, enhancing, globose mass is depicted.

On nonenhanced T1-weighted images, most meningiomas have no signal intensity difference compared with cortical gray matter. Fibromatous meningiomas may be more hypointense than the cerebral cortex. Meningiomas are hyperintense on T2-weighted images, and T2-weighted images also show the extent of edema. See the images below.

Multiple meningiomas. A: Sagittal T1-weighted magnetic resonance image (MRI) demonstrates posterior fossa and parietal meningiomas. B: Gadolinium enhancement on sagittal T1-weighted MRI shows intense enhancing of the masses. C: T2-weighted coronal MRI shows stable hypointense appearance of the posterior mass after endovascular embolization.

Malignant and multiple meningiomas. A 47-year-old white male underwent gamma knife surgery due to left convexity meningioma, followed by microsurgical removal of the tumor in 2001. A, B: Four years later, in 2005, MRI showed a stable residual parietal/occipital mass. The left sigmoid sinus is occluded. C, D: One small right frontal meningioma also underwent radiosurgery at the same time. Edema and intense enhancing after gadolinium injection is demonstrated.

On MRI and CT, meningiomas exhibit the same enhancement appearance after the injection of contrast medium. Intense enhancement is seen in 85% of tumors. A ring appearance may represent a capsule. Meningiomas have a collar of thickened, enhancing tissue that surrounds their dural attachment; this is also known as a dural tail. This sign represents thickened dura, which may be either reactive or neoplastic. A dural tail occurs in approximately 65% of meningiomas and 15% of other peripheral tumors; therefore, it is a good predictor of lesion identity. Although this radiographic feature is not specific for meningiomas, it is highly suggestive of the diagnosis. Histologic subtypes may have different MRI appearances, but this does not suffice for a histologic diagnosis by using MRI. Hyperintensity on T2-weighted images indicates soft-tumor consistency and microhypervascularity. This is seen more often in aggressive, angioblastic, or meningothelial tumors. T2-weighted signal intensity is best correlated with both the histology and consistency of the meningioma. Generally, low-intensity portions of the tumor on T2-weighted images indicate a more fibrous and harder character (eg, fibroblastic meningiomas), whereas higher-intensity portions indicate a softer character (eg, angioblastic tumor).[29, 30, 31] A typical meningioma is a homogeneous, markedly enhancing extra-axial mass. It may show meningeal cysts, ring enhancement, fatty transformation, and en plaque morphology. Malignant meningiomas may invade the calvarium and cerebral parenchyma (1%). Most meningiomas can be diagnosed by MRI.[17, 18, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41] MRS reveals lactate in embolized areas of the meningioma immediately after embolization. Lipids are not observed before the third day after embolization and are always associated with avascular and soft tissue at the time of surgery.

Gadolinium warning
Gadolinium-based contrast agents (gadopentetate dimeglumine [Magnevist], gadobenate dimeglumine [MultiHance], gadodiamide [Omniscan], gadoversetamide [OptiMARK], gadoteridol [ProHance]) have been linked to the development of nephrogenic systemic fibrosis (NSF) or nephrogenic fibrosing dermopathy (NFD). For more information, see the eMedicine topic Nephrogenic Systemic Fibrosis. The disease has occurred in patients with moderate to end-stage renal disease after being given a gadolinium-based contrast agent to enhance MRI or MRA scans.

NSF/NFD is a debilitating and sometimes fatal disease. Characteristics include red or dark patches on the skin; burning, itching, swelling, hardening, and tightening of the skin; yellow spots on the whites of the eyes; joint stiffness with trouble moving or straightening the arms, hands, legs, or feet; pain deep in the hip bones or ribs; and muscle weakness. For more information, see the FDA Public Health Advisory or Medscape.

Degree of confidence
In general, the sensitivity and specificity of MRI are high in the diagnosis of meningiomas. MRI has proved to be superior in delineation of the tumor and its relation with surrounding structures. However, MRI is unreliable for recognition of tumor calcification, and acute hemorrhage is often difficult to image with this modality.

False positives/negatives
False-negative findings of tumor calcium must be considered. Delineation of acute hemorrhage into tumor with conventional sequences is a disadvantage of MRI and may generate false findings.

ASTROCYTOMA
MRI has increased the sensitivity and specificity in imaging astrocytomas. With the advent of the new techniques (MRS, perfusion-weighted imaging, and diffusion-tensor imaging), specificity has further improved.[6, 7, 8]
Magnetic resonance spectroscopy

MRS allows cerebral metabolites to be assessed by suppressing the signal of water and by interrogating for entities, including NAA, Cho, creatine (Cr), lactate, and lipids. The 2 main MRS techniques are single-voxel spectroscopy (shown in the image below) and chemical-shift imaging.[9,
10]

Single-voxel spectroscopy is

used to detect the signal from a single region during 1 measurement. Chemicalshift imaging uses additional phase-encoding pulses to obtain signals.
Normal pattern on single-voxel magnetic resonance spectroscopy (MRS) of 4 key molecules show relative heights and typical values. N-acetylaspartate (NAA) peaks at 2.0 ppm (tallest peak). Creatine (Cr) peaks at 3.0 ppm. Choline (Cho) peaks at 3.2 ppm. Myo-inositol

(MI) peaks at 3.6 ppm.

Image show no evidence of recurrence in a 37-year-old woman with

a history of grade 3 astrocytoma who underwent resection 7 years ago. Coronal contrastenhanced T1-weighted, diffusion-weighted, and apparent diffusion coefficient (ADC) imaging were initially performed, followed by multivoxel magnetic resonance spectroscopy (MRS) and perfusion imaging. Because findings on cross-sectional imaging were not conclusive, additional studies were performed. MRS shows low levels of N-acetylaspartate (NAA), creatine (Cr), and choline (Cho) in an area of encephalomalacia, with a normal spectrum in the rest of the brain. Perfusion imaging shows no increased activity in the area of concern. These findings are compatible with gliosis.

With cerebral gliomas, MRS is used to assess the spectral pattern, metabolite intensities, and ratios to help grade the tumor and/or predict treatment response (see the image below). MRS can also help in evaluating for tumoral recurrence and treatment response. The intensity of NAA is correlated with neuronal density and viability. Cho is involved in the turnover of cell membranes and neurotransmitters. Cr serves as a reserve for high-energy phosphates in the cytosol of neurons. Cerebral lactate is always abnormal and indicates ineffective cellular oxidative metabolism. Free lipids are present in areas of necrosis. Compared with normal tissues, cerebral gliomas consistently show lowered NAA intensity, elevated Cho (indicating increased membrane metabolism), and a stable or reduced Cr concentration. An Ins peak is described in certain low-grade tumors.
Perfusion-weighted imaging

Perfusion-weighted imaging involves several image acquisitions during the first pass of a bolus of contrast agent. This method allows the imager to determine the relative cerebral blood volume (rCBV). In general, the greater the rCBV, the higher the grade of tumor. Lack of notable flow indicates a nonneoplastic etiology with abnormal signal intensity, such as demyelination. Of note, mixed oligodendrogliomas can have low rCBV. Besides the prognostic information it

provides, perfusion-weighted imaging can increase the yield of brain biopsy and help in differentiating recurrent neoplasm from radiation necrosis.
Diffusion-tensor imaging

Diffusion-tensor imaging is an experimental sequence that allows the imager to evaluate the structure and orientation of the white matter tracts. This sequence takes advantage of the fact that myelin restricts diffusion of water molecules in directions perpendicular to the fiber orientation. This sequence can help in determining whether neoplasm involves white matter pathways, improving the precision of surgical planning and the placement of radiation ports.
Functional MRI

Although not used in the diagnosis of astrocytomas, functional MRI (fMRI) deserves mention because it can be an important part of presurgical planning. A blood oxygendependent sequence is applied as the patient performs various tasks involving motor, sensory, visual, auditory, and language functions. Increased blood flow to a part of the brain is correlated with increased metabolic activity. The results are used to determine whether tumor involves vital structures (eloquent areas), a finding that may possibly affect surgical decisions.
Astrocyte characteristics on MRI

Low-grade astrocytomas are typically hyperintense on T2-weighted images. On T1-weighted images, most low-grade astrocytomas are hypointense relative to white matter. Contrast enhancement may be absent or, at best, mild. Exceptions include the mural nodule of pilocytic astrocytoma and the strong heterogeneous enhancement of pleomorphic xanthoastrocytomas. Astrocytomas are often associated with enhancement of the adjacent dura and meninges, giving the dural-tail appearance. MRS may show an elevated Cho peak and decreased NAA peak. An elevated Cho-Cr ratio or a depressed NAA-Cr ratio suggests tumor. This holds true for all high-grade tumors and many, but not all, low-grade

tumors. (Some low-grade tumors may not have an elevated Cho peak.) Perfusion MRI studies fail to demonstrate increased rCBV. Grade III astrocytomas often invade structures without destroying them, causing their ill-defined borders. The mass is inhomogeneous and bright on T2-weighted images. Surrounding edema and/or tumor infiltration is usually appreciated. Enhancement is usually seen. Perfusion MRI demonstrates increased relative cerebral flow volume. Grade IV astrocytomas (GBM) are usually discovered as bulky disease, and necrosis is a hallmark of this grade. These lesions usually enhance peripherally, in a nodular and irregular manner, and they cause a large amount of mass effect and edema. These tumors often cross the corpus callosum, giving them a typical butterfly shape. Areas of hemorrhage and necrosis are common, and spectroscopy demonstrates high Cho, high lactate, high lipid, and low NAA values. Shortecho time (TE) studies demonstrate an absent or low myo-inositol peak. Perfusion studies demonstrate elevated rCBV. See MRI images of brain astrocytomas below.
Pilocytic astrocytoma in a 20-year-old man. Top row (left to right), sagittal, coronal, and axial contrast-enhanced T1-weighted MRIs. Bottom row: Axial fluid-attenuated inversion recovery (FLAIR), diffusion, and apparent diffusion coefficient (ADC) images. Note the cystic mass with an intensely enhancing mural nodule in the inferior cerebellar vermis, as well as the mass effect on the brainstem, upper cervical cord, cerebellum, and fourth ventricle. Grade II

astrocytoma in a 30-year-old man. Nonenhanced T2-weighted MRI shows a well-circumscribed area of increased signal intensity in the left temporal lobe. Grade II astrocytoma. Left, Fluid-

attenuated inversion recovery (FLAIR) image demonstrates an area of increased signal intensity in the parietooccipital region. Right, Perfusion MRI demonstrates decreased relative cerebral blood volume (rCBV), consistent with a low-grade neoplasm. The final pathologic diagnosis was a grade II astrocytoma. Grade III astrocytoma in a 33-year-old woman. Top row (left to

right), Axial nonenhanced and contrast-enhanced T1-weighted, proton densityweighted, and

fluid-attenuated inversion recovery (FLAIR) MRIs. Bottom row (left to right), Sagittal nonenhanced and contrast-enhanced T1-weighted MRIs, axial diffusion-weighted images, and axial apparent diffusion coefficient (ADC) map. T1-weighted images demonstrate a well-defined area of mixed signal intensity in the right parietal lobe extending to the corpus callosum with adjacent vasogenic edema. Mixed areas represent hemorrhage. Contrast-enhanced images show minimal enhancement of the lesion. Also appreciated is dural enhancement secondary to previous intervention. Grade III astrocytoma in a 71-year-old man. Top row (left to right),

Axial nonenhanced and contrast-enhanced T1-weighted, proton densityweighted, and fluidattenuated inversion recovery (FLAIR) MRIs. Bottom row (left to right), Sagittal nonenhanced and contrast-enhanced T1-weighted MRIs, axial diffusion-weighted images, and axial apparent diffusion coefficient (ADC) map. Images show a cystic, well-defined lesion in the left parietal region with surrounding vasogenic edema and a thick rim enhancement on enhanced images. Diffusion and ADC images shows no evidence of acute restriction.

Recent studies

In a study, Bing et al concluded that first-pass perfusion MRI is a quick and useful way to differentiate between pilocytic astrocytomas and

hemangioblastomas. They also maintained that the maximum rCBV (rCBVmax), defined as the ratio between the CBVmax in tumor tissue and the CBV in healthy, contralateral white matter, is indicative of the tumor type. Because pilocytic astrocytomas and hemangioblastomas can present the same

morphologic characteristics on conventional MRI sequences, the authors studied 11 patients with pilocytic astrocytomas and 8 with hemangioblastomas, who underwent first-pass perfusion MRI to differentiate the tumors.[11] The investigators found that the difference between the rCBVmax of pilocytic astrocytomas (rCBVmax = 1.19 0.71, range 0.6-3.27) and that of hemangioblastomas (rCBVmax = 9.37 2.37, range 5.38-13) was significant. The first-pass curve crossed the baseline, corresponding to vascular permeability problems in pilocytic astrocytomas and hemangioblastomas

EPENDYMOMA

MRI has supplanted CT scanning as the diagnostic modality of choice in the workup and follow-up observation of intracranial neoplasms, including

ependymoma. The most appropriate role for MRI in the treatment of ependymoma is in the detection of tumor and direction of its resection and/or irradiation. MRI is used to monitor ongoing treatment and to survey for recurrence. Although the MRI findings can be of great help in narrowing the differential diagnosis of brain tumors, final diagnosis is achieved through histologic sampling. Solid portions of ependymoma are typically isointense to hypointense relative to white matter on short recovery time/echo time (TR/TE) T1-weighted images. The tumor is hyperintense to white matter on long TR/TE T2-weighted images. As many as 50% of ependymomas demonstrate signal heterogeneity, which may indicate calcification,
7, 8]

necrosis,

methemoglobin,

hemosiderin,

or

tumor

vascularity.[6,

For example, hyperintense foci on both T1- and T2-weighted

images suggest methemoglobin in subacute hemorrhage of 1-4 weeks in age, whereas hypointense foci on both T1- and T2-weighted images suggest hemosiderin, calcium, or necrosis. See the images below.
Fourth-ventricle ependymoma in a 63-year-old man with headaches. T1-weighted sagittal image demonstrates an oval, fourth ventricular tumor with hypointense signal. Moderate obstructive hydrocephalus of the lateral and third ventricles is noted. Fourth-ventricle

ependymoma. T1-weighted coronal postgadolinium image in the same patient as in the previous image. Homogeneous enhancement of a fourth ventricular mass is noted, with extension downward through the foramen of Magendie. Pathologic analysis demonstrated

subependymoma.

Punctate calcific foci are difficult to diagnose prospectively but are present in as many as 45% of ependymomas.[8, 9] See the following images.
Anaplastic brain parenchymal ependymoma in a 5-year-old girl with seizures. T1-weighted axial image demonstrates a heterogeneous mass in the right frontal lobe. Note the bright

contrast enhancement within the neoplasm and areas of low signal intensity consistent with calcification. Anaplastic parenchymal ependymoma in the same patient as in the previous

image. T2-weighted axial image shows heterogeneous high signal intensity in the tumor and adjacent vasogenic edema, with low-signal-intensity calcifications. There was no connection with the lateral ventricle noted on imaging or at the time of surgery. Pathologic analysis demonstrated malignant (anaplastic) ependymoma.

Cystic changes result in high signal intensity on T2-weighted MRIs, as shown in the images below.
Anaplastic ependymoma of the lateral ventricle in an 8-week-old girl with hydrocephalus. Gadolinium-enhanced coronal T1-weighted image demonstrates a large anaplastic

ependymoma of the left lateral ventricular roof. Note the cystic component, mass effect, and subfalcine herniation. Anaplastic ependymoma of the lateral ventricle in the same patient as

in the previous image. Gadolinium-enhanced axial T1-weighted image demonstrates a large anaplastic ependymoma of the left lateral ventricular roof. Note the cystic component, mass effect, and subfalcine herniation.

Signal heterogeneity is a feature useful in distinguishing ependymoma from the more homogeneous medulloblastoma. Calcification and hemorrhagic foci are more typical of ependymoma than medulloblastoma. Additionally, ependymomas are more apt to extend through the foramina of Luschka and Magendie, hence the term plastic ependymoma (see the following images). Similarly, choroid plexus papilloma is more homogeneous than ependymoma and lacks the typical irregular margins and surrounding edema of ependymoma.
Ependymoma arising from the fourth ventricle in a 50-year-old woman with a history of dizziness and nausea, progressive over several years. A lobulated mass on this proton density weighted sagittal image arises from the fourth ventricle and extends distally through the foramen of Magendie. Pathologic analysis demonstrated cellular ependymoma. Note the hydrocephalus. Fourth-ventricle ependymoma in the same patient as in the previous image. A lobulated mass on this proton densityweighted coronal image arises from the fourth ventricle and

extends distally through the foramen of Magendie. Pathologic analysis demonstrated cellular ependymoma.

Enhancement with gadolinium is useful in differentiating tumor from adjacent vasogenic edema and normal brain parenchyma. Without intravenous contrast enhancement, T2-weighted images are more reliable in differentiating tumor margins than are T1-weighted images.[9] Some reports describe ependymomas that cause displacement of the vein of the lateral recess of the fourth ventricle on cerebral arteriography.[9] This vein normally courses from the transverse and lateral supratonsillar veins along the anterior and lateral aspect of the superior pole of the cerebellar tonsil. It then courses lateral to the cerebellopontine angle, over the brachium pontis, to join the petrosal vein. Ependymoma expanding the fourth ventricle and its lateral recesses can displace this vein posteriorly and laterally. Supratentorial ependymomas can differ in appearance from intraventricular ependymomas. Supratentorial ependymomas are more commonly located in the brain parenchyma than infratentorial ependymomas, which are often

intraventricular. Swartz and colleagues reported that 83% of supratentorial ependymomas were located in the parenchyma.[10] Supratentorial ependymomas tend to be larger than infratentorial ependymomas, with 94% being larger than 4 cm in one study.[11] In addition, supratentorial extraventricular ependymomas are often extraventricular and more often have a cystic component, with or without a mural nodule. In these cases, the differential diagnosis includes ganglioglioma, pleomorphic xanthoastrocytoma, and pilocytic astrocytoma. In the posterior fossa, medulloblastoma and cerebellar astrocytoma can mimic the appearance of an ependymoma.[5] Gadolinium-based contrast agents (gadopentetate dimeglumine [Magnevist], gadobenate dimeglumine [MultiHance], gadodiamide [Omniscan],

gadoversetamide [OptiMARK], gadoteridol [ProHance]) have been linked to the development of nephrogenic systemic fibrosis (NSF) or nephrogenic fibrosing

dermopathy (NFD). For more information, see the eMedicine topic Nephrogenic Fibrosing Dermopathy. NSF/NFD has occurred in patients with moderate to end-stage renal disease after being given a gadolinium-based contrast agent to enhance MRI or MRA scans. Characteristics include red or dark patches on the skin; burning, itching, swelling, hardening, and tightening of the skin; yellow spots on the whites of the eyes; joint stiffness with trouble moving or straightening the arms, hands, legs, or feet; pain deep in the hip bones or ribs; and muscle weakness.

HEMANGIOBLASTOMA
MRI with gadolinium enhancement is the best study for screening, with the highest sensitivity and specificity compared with CT and nonenhanced MRI. Large studies are necessary to achieve a high degree of confidence; however, the advantages are obvious.[8, 12, 13, 18] Intracranial hemangioblastomas can manifest as 3 morphologic patterns based on the macroscopic pathology. These are well correlated with the MRI findings and include the following[19, 9] :

Cyst with a small mural nodule Solid mass with a central cystic component Solid tumor without a cystic component A cyst with a small mural nodule is the most common presentation. Cystic fluid surrounding the nodule is hyperintense on T1-weighted images and hyperintense on T2-weighted images. Characteristics of the fluid vary slightly related to protein content. The mural nodule is isointense on T1-weighted images and demonstrates high signal on T2-weighted images. After the administration of gadolinium-based contrast medium, the nodule shows prominent enhancement and the cyst does not enhance (see the image below).[19]

Coronal and axial T1-weighted gadolinium-enhanced MRIs show a large cyst with a peripheral intense enhancing mural nodule.

Solid masses with a central cyst behave similarly; therefore, the different morphologic patterns have been postulated to be part of the natural history of a solid tumor that develops a cystic component around or within it (see the images below).[20, 21]
Patient with von Hippel-Lindau disease. T1-weighted gadolinium-enhanced MRI shows an enhancing nodule. Coronal T2-weighted MRI shows a small high-signal-intensity cyst. Patient with von Hippel-Lindau disease (same patient as in previous image at 1-year follow-up). Coronal T1-weighted gadolinium-enhanced MRI shows an enhancing nodule that has grown in size adjacent to a low-signal-intensity cyst. T2-weighted MRI shows a cystic area that has increased in size, with high-signal-intensity characteristics.

Solid hemangioblastomas occur less frequently than the other patterns (see the image below). The lesion is isointense or hypointense on T1-weighted images and hyperintense on T2-weighted images. Transition from a solid tumor to a classic cystic tumor with a small mural nodule has been reported. Occasionally, signal in solid tumor components can be heterogeneous on T1-weighted images, with areas of increased signal within the solid portion. These regions may represent lipid in the stromal cells or methemoglobin from hemorrhage.[10]
Sagittal (top left) and coronal (top right) T1-weighted gadolinium-enhanced MRI images in a patient with von Hippel-Lindau disease presenting with 2 infratentorial hemangioblastomas. The larger tumor shows with cystic central areas. Bottom left, T1-weighted MRI shows that both lesions have low signal intensity. Bottom right, Abdominal axial image of the same patient shows multiple cysts in the pancreas.

Commonly (60-69%), hemangioblastomas have associated internal or peripheral serpentine signal voids, which represent dilated afferent and efferent vessels.[22]Therefore, the presence of a peripheral cyst with a mural nodule surrounded by signal voids is characteristic of hemangioblastoma.[9] Pathologic

dilated vessels can be demonstrated as hyperintense structures on flowenhanced gadolinium studies. MRI with intravenous contrast enhancement shows enhancing nodules well because of their vascularity (see the image below).[19]
Sagittal T1-weighted gadolinium-enhanced MRI shows a homogeneous intense enhancing tumor in the cistern magna.

False-negative results can be seen with small lesions (< 5 mm) and with delayed imaging because of the early enhancement of the lesions. False-positive findings are rare, and most false-positive findings lead to an inadequate diagnosis. For solid and multiple enhancing lesions, metastases are the most important differential diagnosis; supratentorial lesions are more common in metastases. The visualization of associated abnormal vessels helps in differentiating hemangioblastomas from other cystic lesions. Gadolinium-based contrast agents (gadopentetate dimeglumine [Magnevist], gadobenate dimeglumine [MultiHance], gadodiamide [Omniscan],

gadoversetamide [OptiMARK], gadoteridol [ProHance]) have been linked to the development of nephrogenic systemic fibrosis (NSF) or nephrogenic fibrosing dermopathy (NFD). For more information, see the Medscape Reference topicNephrogenic Fibrosing Dermopathy. NSF/NFD has occurred in patients with moderate to end-stage renal disease after being given a gadolinium-based contrast agent to enhance MRI or MRA scans. NSF/NFD is a debilitating and sometimes fatal disease. Characteristics include red or dark patches on the skin; burning, itching, swelling, hardening, and tightening of the skin; yellow spots on the whites of the eyes; joint stiffness with trouble moving or straightening the arms, hands, legs, or feet; pain deep in the hip bones or ribs; and muscle weakness.