Dima A Hammoud and Martin G Pomper

Brain tumor imaging has four main goals, namely, evaluating lesion extent, estimating tumor grade, identifying associated complications, and defining a comprehensive differential diagnosis. It assesses the relationship of the lesion to various brain structures and identifies associated findings, such as increased intracranial pressure, impending herniation, hydrocephalus, hemorrhagic transformation, and mass effect. A comprehensive differential diagnosis is usually established based on the patient's age, tumor location, and specific imaging findings.

Cross-sectional imaging with computed tomography (CT) or magnetic resonance imaging (MRI) is necessary for accurate brain tumor characterization. Plain film imaging has virtually no role. Before the advent of CT scan and MRI, imaging techniques, such as pneumoencephalography and plain film X-rays of the skull, were the only options for neurosurgeons in the preoperative evaluation of brain tumors. Cross-sectional imaging has significantly facilitated the task of pre-operative evaluation and planning of brain tumor surgery.

CT, the patient will need further imaging, usually with contrast-enhanced MRI for adequate evaluation. Patients with contraindications to MRI, such as severe claustrophobia, a pacemaker, or severe obesity may have to undergo a contrast-enhanced CT scan instead of MRI.

One of the advantages of CT is its ability to depict hemorrhagic and calcific findings, which could narrow the differential diagnosis of a detected lesion in certain cases (Figure 27.1). It also provides information about bony lesions, such as metastatic disease to the skull and hyperostotic changes associated with meningiomas. Detailed anatomy of the base of the skull, provided by CT imaging, can provide precious information in specific cases, such as intracranial extension of nasopharyngeal tumors and metastatic disease. Currently, CT is not routinely used in the evaluation of patients with brain tumors either pre- or postoperatively, with few exceptions.

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