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Free Content Common and Uncommon Features of Central Nervous System Lymphoma on Traditional and Advanced Imaging Modalities

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Central nervous system (CNS) lymphoma can occur in isolation as a primary CNS neoplasm or can show systemic lymphoma involvement. Primary CNS lymphomas in patients who are immunocompetent are typically hyperattenuated on CT and iso- to hypointense relative to gray matter on T1- and T2-weighted images. On postcontrast scans, strong homogeneous enhancement is common. Most primary CNS lymphomas contact a CSF surface (either the ventricular ependyma or the pia). Advanced MR imaging may help to differentiate primary CNS lymphomas from other brain lesions. Typical primary CNS lymphomas are highly cellular tumors without necrosis; the lesions are hyperintense on diffusion-weighted images and hypointense on apparent diffusion coefficient maps. The relative cerebral blood volume ratios of primary CNS lymphomas are much lower than those of high-grade gliomas and metastases. On MR spectroscopy, elevated choline as well as a decreased N-acetylaspartate peak and high lipid peak are observed. Unlike high-grade gliomas, hemorrhages and calcifications are rare. Unusual imaging features of primary CNS lymphomas include patchy, streaky, or no enhancement; hemorrhage; necrosis; and calcifications. In patients who are immunocompromised, primary CNS lymphomas show central necrosis and peripheral enhancement. Systemic lymphomas can involve the CNS: two-thirds of patients with secondary CNS lymphoma present with leptomeningeal spread, and one-third present with parenchymal disease. An accurate diagnosis of CNS lymphoma is crucial for proper management and prognosis in both patients who are immunocompetent and those patients who are immunocompromised. The imaging features described herein may allow earlier recognition of CNS lymphoma and thus facilitate optimal treatment.

Learning Objective: Recognize common and uncommon types of primary CNS lymphomas in patients who are immunocompetent and patients who are immunocompromised as well as variation in the appearance of secondary CNS lymphoma on MRI and to describe characteristic imaging findings by using advanced imaging techniques.
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Keywords: ADC = apparent diffusion coefficient; AIDS = acquired immunodeficiency syndrome; CNS = central nervous system; CSF = cerebrospinal fluid; CT = computed tomography; DSC = dynamic susceptibility contrast-enhanced; DWI = diffusion-weighted imaging; FLAIR = fluid attenuated inversion recovery; MRI = magnetic resonance imaging; MRS = magnetic resonance spectroscopy; NHL = non-Hodgkin lymphoma; PCNSL = primary central nervous system lymphoma; PWI = perfusion-weighted imaging; SWI = susceptibility-weighted imaging; T1WI = T1-weighted imaging; TDL = tumefactive demyelinating lesion; rCBV = relative cerebral blood volume

Document Type: Research Article

Publication date: 01 November 2017

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  • Neurographics is the peer-reviewed, bimonthly educational journal of the American Society of Neuroradiology. The journal comprises articles selected from material presented at the ASNR Annual Meeting. Neurographics also publishes other high-quality submissions that are primarily educational and have a high emphasis on a pictorial approach. Neurographics offers CME credit for reading review articles and completing quiz-based self-assessment activities. CME credit for review articles may be claimed up to 3 years after an article's publication date. Visit https://members.asnr.org/webcast/content/course_list.asp?src=Neurographics to view all available CME courses.
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