CP Angle Tumors

MANJIT KUMAR
2ND YEAR RESIDENT
MDRD, TUTH
Anatomy
• Lies between
– antero-lateral surface of pons & cerebellum and the
posterior surface of petrous temporal bone

• Important structures
– 5th - 8th cranial nerves
– Superior and anteroinferior cerebellar arteries
– Tributaries of sup petrosal veins
– Floccculus of cerebellum
 INTRODUCTION
• Lesions of the CP angle (CPA) are frequent and
represent 6- 10% of all intracranial tumors.
• Acoustic neuromas and menigiomas are the two
most frequent lesions and account for approximately
85 – 90% of all CPA tumors.
• Majority are located primarily in the cistern,
however, may also arise from:
– Internal auditory canal
– Adjacent brain
– 4th ventricle, lateral recess
– Adjacent skull
•The CPA is outlined by the meninges of the
cerebellopontine cistern; thus, in addition to
cerebrospinal fluid (CSF), the CPA contains nerves
and arteries and possibly embryologic remnants.
Each of these structures can be the site of origin of an
unusual CPA lesion.
Masses originating in the CPA are extraaxial and
thus widen the homolateral subarachnoid
cisterns. They displace or encase neurovascular
structures. These lesions can be separated from
the brainstem by a thin CSF layer, and there is
usually no brainstem edema.
• Imaging signs of extraaxial masses

– Enalarged ipsilateral CPA cistern

– CSF cleft between the mass and cerebellum
– Displaced gray-white interface around the mass
– Brainstem rotation
– Compression of 4th ventricle (nonspecific)
Figure 1. Table (a) and drawing (axial
view)(b) show the segmental approach to
diagnosis of unusual lesions of the CPA
based on their site of origin. DNET
dysembryoplastic neuroepithelial
tumor.
 Type of mass Percent
Common Vestibulocochlear schwannoma 75
Meningioma 8-10
Epdermoid 5
Other schwannomas 2-5
Vascular (ectasia, aneurysm, malformations) 2-5
Metastasis 1-2
Paraganglioma 1-2
Ependymoma, Choroid plexus papilloma 1
(primary or extension from 4th ventricle)
Uncommon =/<1
Arachnoid cyst
Lipoma
Dermoid
Exophytic brainstem/cerebellar astrocytoma
Chordoma
Schwannoma
• Benign tumors originating from schwann cells
• Round/lobulated encapsulated tumor
• Two histologic types
– Antoni A – compact interlacing bundles of cells
– Antoni B – loose stroma with widely separated cells

– Very slow growing benign neoplasms

– Don’t undergo malignant change
• 6-8% of all primary intracranial tumors
• CN VIII schwannoma – most common
cerebellopontine angle mass

• Usually occur as isolated lesion

– (multiple in 5%)
• Approx 18% solitary schwannoma occur with
neurofibromatosis

• Arachnoid cysts (in 5-10%) due to trapped CSF

• Age – 5th to 6th decades.
With NF-2 earlier, usu by 3rd decade

• F:M = 1.5-2 : 1

• Clinically- acc. to the nerve involved +

size & extent of tumor
– CN 8 – tinnitus, Vestibular symptom late
– CN 5 – pain paresthesia, masticatory muscle weakness
• Imaging

– Plain film – widening of internal auditory canal

– Angiography – many are hypovascular with mass effect. 1/4th are

hypervascular

– CT
• iso- or hypodense. Calcification/hge uncommmon
• enhance strongly - uniform to heterogenous
• MRI
– Characteristic findings of extraaxial CPA cistern mass
– Cisternal portion larger than intracanalicular portion  ice cream
cone appearance
– Makes acute angle with petrous bone

• T1W – slightly hypointense(2/3rd), isointense

• T2W – hyperintense, cystic degeneration in large lesions

• Intensely enhance after contrast administration.

– Homogenous(with smaller lesion) to heterogenous
• Main differential diagnosis- meningioma

• Meningioma
– hyperosteosis
– Broad base towards dura
– Makes obtuse angle with petrous bone
– Presence of dural tail
– Hyperdense in NCCT + calcification in 20-25%
– Usu isointense in T2WI

• Schwannoma
– Acute angle with petrous bone
– Intracanalicular extension – ice cream cone appearance
– Usu hyperintense in T2WI
 Coronal postgadolinium T1-
weighted MR image demonstrates
three intensely contrast-enhancing
lesions in the posterior cranial
fossa. The large left-sided
lobulated vestibular schwannoma
fills the left cerebellopontine angle
cistern (white arrow); compresses,
indents, and displaces the left
lateral margin of the pons inward;
and extends laterally into the
widened left internal auditory
canal.
A tiny punctate focus of contrast
enhancement in the right petrous
temporal region (arrowhead)
represents a small intracanalicular
vestibular schwannoma.
A third focus of contrast
enhancement abuts and indents
the right lateral margin of the pons
(black arrow); this is a trigeminal
(fifth cranial nerve) schwannoma.
Vestibular
schwannoma. Axial
T1-weighted image of
the posterior fossa and
skull base following
intravenous
administration of
gadolinium. A small
intensely enhancing
intracanalicular ovoid
mass protrudes
slightly medially into
the cerebellopontine
angle cistern on the
patient's right (arrow).
Meningioma arising from the posterior aspect of the right temporal boneA, Axial T2-
weighted MR image demonstrates a large rounded extra-axial tumor mass in the right
side of the posterior fossa with its base on the posterior dura of the right temporal bone.
The mass is slightly hyperintense relative to gray matter and compresses and displaces
the right cerebellar hemisphere posteriorly and medially. A narrow cleft of cerebrospinal
fluid (arrow) separates the medial margin of the tumor from the adjacent compressed
cerebellum and pons. B, Following intravenous administration of gadolinium, an axial
T1-weighted image demonstrates intense homogeneous contrast enhancement of this
large dural-based tumor (arrow).
Epidermoid Cyst (Primary
cholesteatomas)

•Are the third most frequent tumor of the CPA .

• They arise from normal epithelial cells included

during neural tube closure.

•These slow-growing tumors encase and

surround nerves and arteries in the cisterns
rather than displacing them(arachnoid cyst).
• Ectodermal inclusion cyst
• Location - off midline. CPA cistern, basal
subarachnoid space, para/suprasellar
• Age – 20-60 yrs

• Main differential diagnosis – arachnoid cyst

• CT:
hypo/isodense to CSF
irregular lobulated margin
no adjacent bony changes
slight marginal calcification or enhancement after
contrast administration is rarely seen.
• MRI: larger epidermoids appear more homogeneous
than schwannomas of similar size and may mimic CSF
in intensity with high T2 signal and low T1 signal
• FLAIR:
more sensitive than conventional MR for differentiating
epidermoid from arachnoid cyst it supress signal from CSF.
Epidermoid cyst– high signal
Arachnoid cyst– low signal
• Diffusion weighted imaging : Also allows confirmation of
residual postoperative tumor.
– Epidermoid –hyperintense
– Arachnoid – remains hypointense
• ADC maps:
Epidermoid cyst produces lower diffusion coefficient than
arachnoid cyst.
Figure 2. Epidermoid cyst in a 52-year-old woman with epilepsy. (a) Axial T1-weighted
MR image shows an epidermoid cyst with characteristic focal marbling in the left CPA
(arrow). (b) AxialT2-weighted MR image shows the lobulated margins
of the cyst impinging on the pons (arrowhead).
Dermoid Cyst
•Like epidermoid cysts, dermoid cysts result from inclusion
of ectodermal elements during neural tube closure but may
originate a bit earlier .

•Dermoid cysts are midline lesions that rarely invade the

CPA laterally and contain elements from all layers of the
skin. Thus, fat, hair, sebaceous glands, and sweat glands can
be found in addition to squamous epithelium.

•Typically, dermoid cysts have negative attenuation values

on CT scans and high signal intensity on T1-weighted images
due to their fatty content, may have a very suggestive fat-
fluid level, and contain calcifications
 EPIDERMOID DERMOID
LOCATION Off-midline, most Midline, rarely invade CPA
commonly at CPA laterally
CT CSF density, Ca++, no Fat density, Ca ++, no
enhancement enhancement
MRI CSF SI in both T1 and T2 High SI in T1, and
heterogenous SI in T2
Arachnoid Cyst

•Arachnoid cysts are pouchlike intraarachnoid masses of

uncertain origin filled with CSF.

•At CT/MRI their attenuation and signal intesity match

those of CSF almost exactly. These masses have smooth
and rounded edges, displace neurovascular structures,
and erode adjacent bone structures. There is no
calcification or enhancement.

• As described, fluid-attenuated inversion-recovery and

constructive interference in the steady state sequences as
well as diffusion-weighted imaging are helpful in making
the distinction
 EPIDERMOID ARACHNOID CYST
FLAIR Mixed iso-hyper SI Suppressed signal
DWI Hyperintense due to restricted Hypointense due to increased
diffusion diffusion
Encase vessels Displace vessels
Arachnoid cyst in a 27-year-old woman with
headaches. (a) Axial T1-weighted MR image
shows an arachnoid cyst with signal intensity
similar to that of CSF stretching the left
seventh and eighth cranial nerve
complex (arrow). (b) Axial T2-weighted MR
image shows the cyst displacing the vascular
structures of the CPA (arrowheads).
Lipoma
•Lipomas in the CPA are maldevelopmental masses that arise
from abnormal differentiation of the meninx primitiva.
•They are homogeneous fatty lesions surrounding and encasing
normal adjacent neurovascular structures with very dense
adhesions.
• lipomas are rarely symptomatic, and conservative follow-up
is often preferred to aggressive and potentially risky resection
• Lipomas appear as fat ; homogeneously hypoattenuating
with a negative attenuation value on CT scans and as
characteristic and suggestive homogeneous high signal
intensity on T1-weighted images, which decreases on fat-
suppressed images. There is no enhancement after contrast
material administration.
Lipoma in a 7-year-old boy with a
polymalformation syndrome. (a) Axial CT scan
shows a welldefined hypoattenuating lipoma
of the left CPA. (b) Axial T1-weighted MR
image shows that the lipoma has
signal intensity similar to that of subcutaneous
fat.
MR Imaging Characteristics and Suggestive Features of Unusual Lesions Arising from the
Cerebellopontine Cistern
Lesion T1W T2W Enhanchement Features
Epidermoid Hypo Hyper No Hyperintense in DWI

Dermoid Hyper Hypo No Fat & calcification, fat

fluid levels
Arachnoid cyst Hypo Hyper No Isointense to CSF,
hypointense on DWI
Miscellaneous cyst Hypo Hyper No Mimic arachnoid cyst
except for lack of bone
erosion.
Lipoma Hyper Isointense to fat No Matches signal intensity
with subcutaneous fat in
all sequences

Schwannoma Hypo Hyper Yes Follow anatomic course of

nerves.
Aneurysm Hypo Hypo Possible Well circumscribed
hypointense lesion on
T2W images.
Melanoma Hyper Isointense or Yes Spontaneous
hypointense hyperintense lesion on
T1W images.
Lesion T1W T2W Enhancement Features

Cholesterol Hyper Hyper No Hypointense rim

granuloma on T1 & T2

Paraganglioma Hypo Hyper Yes Salt & pepper

appearance

Chondroma Hypo Hyper Variable Origin from

synchondrosis

Chordoma Hypo Hyper Yes Intratumoral

septa

Endolymphatic Variable Hyper Yes Hyperintense

sac tumor cyst on T1 & T2

Pitutary Hypo Hyper Yes Clinical history

adenoma

Apex petrositis hypo Hyper Yes History of otitis

media
Lesion T1W T2W Enhanchement Features
Glioma Hypo Hyper Variable Arises from
brainstem
Choriod plexus Hypo Hyper Intense Extends from
papilloma foramen of
luschka
Lymphoma Hypo Hyper Yes Edema,immuno-
deficiency

Hemangioblasto Hypo Hyper Intense VHL disease,

ma possible cyst
Ependymoma Hypo Hyper Yes Irregular,
heterogenous
medulloblastoma Hypo Hyper Yes Arises from
cerebellar
hemispheres
Dysembroplastic Hypo Hyper Yes Cystic
neuroepithelial component,
tumors bone erosion
Melanoma in a 58-year-old woman with a left cerebellar syndrome. (a) Axial CT scan shows
a hyperattenuating melanoma of the left CPA. (b) Axial T1-weighted MR image shows a well-
defined extraaxial mass at the posterior edge of the petrous bone. The high signal intensity is
suggestive of melanin.
Cholesterol granuloma in a 32-year old man with right trigeminal neuralgia. (a) Axial
T1-weighted MR image shows a cholesterol granuloma at the apex of the right petrous bone
with typical high signal intensity. An additional suggestive feature is the thin hypointense rim
(arrowheads),which represents expanded cortical bone of the petrous apex.
(b) Axial T2-weighted MR image shows that the granuloma has heterogeneous signal
intensity surrounded by a hypointense rim (arrowheads).
Paraganglioma in a 54-year-old woman with right facial nerve palsy, vertigo, and
tinnitus. (a) Axial T2-weighted MR image shows a huge paraganglioma destroying the petrous
bone and invading the right CPA. Massive flow voids (arrowheads) reflect the hypervascularity
of the lesion. Note the thin layer of trapped CSF (arrow) between the mass and the brainstem,
which indicates an extraaxial origin.
(b) Axial T1-weighted MR image shows the suggestive salt-and-pepper appearance of
the paraganglioma.
Brainstem glioma in a 23-year-old man
with vertigo and hypoacusia. Contrast-
enhanced axial T1-weighted MR image shows
an unusual round grade III glioma located in
front of the porus. The tumor demonstrates
central enhancement
Lymphoma in a 34-year-old man with acquired immunodeficiency syndrome, vertigo, and
headaches.
(a) Contrast-enhanced axial T1-weighted MR image shows a round lymphoma mimicking a
vestibular schwannoma in front of the right porus. (b) Axial T2-weighted MR image shows
narrowing of the cisterns and extensive edema, which suggest an intraaxial tumor
Hemangioblastoma in a 28-year-old woman with von Hippel–Lindau disease and vertigo.
(a) Axial T2-weighted MR image shows a solid hemangioblastoma in the left CPA. Note the
vascular pedicle (arrowhead), which appears as a flow void with all sequences. (b) Contrast-
enhanced axial T1-weighted MR image shows homogeneous enhancement of the
hemangioblastoma (arrowhead).
Ependymoma in a 24-year-old woman with vertigo, headaches, and left facial
nerve palsy. (a) Contrast-enhanced axial T1-weighted MR image shows a heterogeneous
ependymoma with a lobulated multicystic component in the left CPA. The tumor invades
the internal auditory canal without widening the porus (arrow). (b) Coronal T2-weighted
MR image shows marked mass effect of the ependymoma on the brainstem
Dysembryoplastic neuroepithelial tumor in a 39-year-old man with mild, longlasting
headaches. (a) Axial T2-weighted MR image shows a large dysembryoplastic neuroepithelial
tumor of the right CPA with a cystic component () associated with a possibly suggestive
bone erosion (arrow). Note the lack of edema. (b) Contrast-enhanced axial T1-
weighted MR image shows enhancing hamartomatous tissue () and possibly suggestive
slight mass effect with a normal left cerebellopontine cistern (arrow).
Conclusions
A large variety of unusual lesions can be encountered
in the CPA and should be differentiated from acoustic
neuromas or meningiomas. A spectrum of unusual CPA
lesions exists and is primarily based on the site of
origin of the masses. Therefore, this characteristic
should be analyzed first. Attenuation at CT, signal
intensity at MR imaging, enhancement, shape and
margins, extent, mass effect, and adjacent bone
reaction are also helpful in establishing the diagnosis.
THANK YOU
 QUESTIONS
1. Imaging finding in schwannoma.
2. Imaging finding in meningioma.
3. Imaging finding in epidermoid cyst.
4. Difference between epidermoid and
arachnoid cyst.
5. Difference between schwannoma and
meningioma.
6. Difference between epidermoid and dermoid
cyst.