Challenges In Neuroradiology

While routine imaging of the brain for metastatic disease or for primary brain tumors is highly developed and considered generally to be quite successful, there remain a number of challenges. One of the most vexing issues is that concerning the nonenhancing brain lesion. As mentioned, these may require the acquisition of an MR spectroscopy in order to detect the lesion. However, such lesions raise perplexing problems. For instance, to what extent can one rely on imaging findings to dictate therapy, if the actual lesion can be detected only by a ratio of metabolites?

Among lesions that are easily seen on MRI, there remain a number of significant challenges. For instance, having detected a small lesion how long should it be watched and when should surgery be performed? This topic is the subject of intense research and it is hoped answers will emerge in the near future.

Therapy is influenced by tumor grade. Perfusion MR, DCE-MRI, and MR spectroscopy can be used to estimate grade based on a constellation of findings. MR results can be added to PET results to further refine the estimate of tumor grade. The coordination of this data and the synthesis of it into a coherent and reproducible algorithm are the subject of current research. Ultimately, bioinformatics, the management of quantitative biologic information combined with available clinical data may prove useful in helping to determine the nature of a lesion.

Even with the numerous techniques available, radiation necrosis is still difficult to differentiate from progressive disease. Perfusion scans, MR spectroscopy, and DCE-MRI have been used in this setting, although none of these techniques is fully satisfactory. Again, multiparametric imaging may provide better answers in the future.

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