P o s t e r i o r Fo s s a Tum o r s

Lara A. Brandão, MDa,b,*, Tina Young Poussaint, MDc

KEYWORDS
 Posterior fossa tumor  Medulloblastoma  Atypical teratoid/rhabdoid tumor
 Cerebellar astrocytoma  Ependymoma  Brainstem glioma

KEY POINTS
 Medulloblastoma is the most common posterior fossa tumor in children.
 Due to high cell density and high nuclear-to-cytoplasmic ratio, medulloblastomas are typically hy-
perdense on computed tomography, isointense to the cerebellar cortex on T2 and present with
restricted diffusion, as well as a very high choline peak and a taurine peak on magnetic resonance
spectroscopy.
 Cerebellar pilocytic astrocytoma is a World Health Organization grade I tumor with a solid portion
that is typically hyperintense to the cerebellar cortex on T2 due to high water content along with low
cell density.
 Extension through the fourth ventricular outflow foramina, although typical, is not entirely pathogno-
monic of ependymoma.
 Brainstem gliomas are usually located in the pons, with diffuse midline glioma H3 K27-mutant the
most common.

INTRODUCTION imaging (DWI), MR spectroscopy (MRS),

perfusion-weighted imaging, and dynamic
Pediatric brain tumors are the leading cause of contrast-enhanced (DCE) studies, increase diag-
death from solid tumors in childhood.1,2 The nostic confidence and help distinguish between
most common posterior fossa tumors in children different histologic tumor types.
are medulloblastoma (MB), atypical teratoid/rhab- Here we discuss the most common posterior
doid tumor (ATRT), cerebellar pilocytic astrocy- fossa tumors in children, including typical imaging
toma (CPA), ependymoma, and brainstem glioma findings on CT, cMR imaging, and advanced MR
(BG). Location, as well as imaging findings on imaging studies.
computed tomography (CT) and conventional
magnetic resonance (cMR) imaging may provide MEDULLOBLASTOMA
important clues to the most likely diagnosis. More-
over, information obtained from advanced MR im- Medulloblastoma (MB), a highly malignant
aging techniques, such as diffusion-weighted neoplasm, is the most common posterior fossa

Funding Sources: None.

neuroimaging.theclinics.com

Conflict of Interest: None.

a
Radiologic Department, Clı́nica Felippe Mattoso, Fleury Medicina Diagnóstica, Avenida das Américas 700,
sala 320, Barra Da Tijuca, Rio De Janeiro, Rio De Janeiro CEP 22640-100, Brazil; b Department of Radiology,
Clı́nica IRM- Ressonância Magnética, Rua Capitão Salomão, Humaitá, Rio De Janeiro, Rio De Janeiro CEP
22271-040, Brazil; c Division of Neuroradiology, Department of Radiology, Boston Children’s Hospital, Harvard
Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
* Corresponding author. Clı́nica Felippe Mattoso, Fleury Medicina Diagnóstica, Avenida das Américas 700, sala
320, Barra Da Tijuca, Rio De Janeiro, Rio De Janeiro CEP 22640-100, Brazil.
E-mail address: [email protected]

Neuroimag Clin N Am 27 (2017) 1–37

http://dx.doi.org/10.1016/j.nic.2016.08.001
1052-5149/17/Ó 2016 Elsevier Inc. All rights reserved.
2 Brandão & Young Poussaint

neoplasm in children, representing 15% to 20% Computed Tomography and Conventional MR

of all pediatric brain tumors and 30% to 40% of Imaging
posterior fossa neoplasms.3–8 Medulloblastomas
On unenhanced CT, the tumor is usually charac-
are classified as embryonal tumors, the largest
terized as hyperdense (Fig. 2), and on T2 images,
group of malignant tumors in the pediatric
as isointense to hypointense compared with gray
population.3
matter (Fig. 3).14 These imaging findings are likely
This highly malignant neoplasm occurs more
secondary to high cell density and high nuclear-to-
frequently in boys, usually before 10 years of
cytoplasmic ratio.2
age.3,9 Although less common, the disease may
The tumor typically may appear heterogeneous
also occur in adults, usually in the third and fourth
on imaging, with findings related to cyst formation
decades of life.9
and hemorrhage on MR, and calcification seen on
Clinical Picture and Treatment CT (see Fig. 3A–C). Intratumoral cyst or necrosis is
observed in 40% to 50% of cases.19
Clinical symptoms and signs are generally brief, MBs typically enhance.4
typically less than 3 months in duration, and reflect Atypical imaging findings, such as high signal in-
the strong predilection of this tumor to arise within tensity compared with the cerebellar cortex on T2,
the cerebellum, most often in the vermis. Symp- as well as no enhancement may be demonstrated
toms may include headache, general malaise, fail- (Fig. 4).18
ure to thrive, vomiting, and clumsiness, among Sometimes the tumor presents with an infiltra-
other presentations that mimic common and tive pattern instead of a solid solitary mass (Fig. 5).
benign childhood pathologies seen in primary Evidence of leptomeningeal metastatic spread
care.10,11 is present in 33% of all cases at the time of diag-
Typically, the treatment strategies for MB are nosis and is well evaluated with contrast-
threefold: maximal safe resection (which may enhanced MR imaging of the brain and the
include cerebrospinal fluid [CSF] diversion), neu- spine.20 MR imaging is more sensitive than CSF
raxis radiotherapy, and chemotherapy.11 studies for the detection of CSF spread of primary
brain tumors.2,4
Location Metastases may be leptomeningeal, dural-
The tumor usually arises at the midline within the based, intraventricular, adherent to the spinal
vermis and exhibits growth into the fourth ventricle roots, or even to the liver (Fig. 6).
(Fig. 1).12–17 Metastasis to the brain parenchyma may bleed,
Less typical locations include nonventricular su- resembling cavernoma (Fig. 7).
perior or inferior vermian tumor, cerebellar hemi-
Diffusion-Weighted MR Imaging
spheric lesions, and extension into the foramina
of Magendie and foramina of Luschka to the cere- Apparent diffusion coefficient (ADC) values are
bellopontine angle (CPA).18 significantly lower in MBs than in all other posterior

Fig. 1. MB: location. (A, B) Contrast-enhanced MR T1 images from a 6-year-old girl presenting with MB in the
midline vermis, with growth into the fourth ventricle and hydrocephalus.
 Posterior Fossa Tumors 3

Fig. 2. MB: CT. A 9-year old boy presenting with headache and vomiting. There is a well-circumscribed solid lesion
in the midline vermis, that occupies the fourth ventricle with hydrocephalus. The lesion is hyperdense on the non-
contrast CT (A) and enhances after contrast injection (B).

fossa tumors (P<.001) related to high cell density Elevation of the Cho peak is useful in distin-
(Fig. 8, see also Figs. 3D, E and 5E).21–23 guishing between MB and L’Hermitte-Duclos dis-
A study by Jaremko and colleagues21 confirmed ease (LDD), as MBs occasionally may present
that diffusion imaging is the single most useful with a laminated appearance, and with no contrast
sequence for differentiating pediatric posterior enhancement, mimicking LDD. The Cho peak is
fossa tumors and that, as expected, diffusion re- typically elevated in patients with MB when
striction is rare in grade 1 tumors and common in compared with patients with LDD.8
grade 4 tumors. The optimal threshold for distin- Desmoplastic MBs may present with no eleva-
guishing MB and juvenile pilocytic astrocytomas tion of the choline in the spectra. In these tumors,
(JPAs), ADC minimum 5 800  10 6 mm2/s, was a huge myo-inositol peak may be seen related to
lower than the threshold of 900  10 6 mm2/s the desmoplastic nature (Lara A. Brandão, MD,
used by Rumboldt and colleagues,22 likely personal communication, 2013) (Fig. 11).
because they used ADC mean rather than ADC
minimum. Taurine
Desmoplastic medulloblastoma, a histologically Spectra with a short echo time (TE) show a signif-
less aggressive subtype with better prognosis icantly elevated taurine (Tau) concentration at
than the classic type, is expected to have less 3.3 ppm in patients with MB when compared
highly restricted diffusion than the classic type. with other tumors (see Fig. 10).24,28–32 Further-
Some of these tumors present with no restricted more, at a TE of 30 ms, the Tau peak projects
diffusion at all (Fig. 9).21 above the baseline; whereas, at a TE of 144 ms,
the Tau peak occurs below the baseline.28
Proton Magnetic Resonance Spectroscopy Tau has been established as an important
biomarker in distinguishing MBs from other com-
Choline mon pediatric brain tumors, such as cerebellar as-
On MRS, MBs usually demonstrate a significant trocytomas.24,28,31,33,34 Higher Tau levels are
elevation of the choline (Cho) peak related to associated with increased cellular proliferation
high cell density and elevated Cho/Cr and Cho/ and tumoral aggressiveness.23,24,28,29,35
N-acetyl-aspartate (NAA) ratios, reflecting its ma-
lignant nature (Fig. 10, see also Figs. 3F and Glutamine and glutamate and alanine
5F).2,24–26 In a study of 60 children with untreated brain tumors,
High Cho has been previously reported as a Panigrahy and colleagues24 measured the highest
characteristic finding of embryonal tumors.12,27 glutamate (Glu) concentrations in pineal germinoma
4

Fig. 3. MB: MR imaging. Same patient as Fig. 1. A 6-year old girl complaining of neck pain, presenting with walking
difficulty and ataxia. There is a well-circumscribed lesion in the midline vermis, with growth into the fourth ventricle.
Some cysts with high signal intensity on T2 (A: coronal and B: axial) as well as some foci of low signal intensity on the
gradient echo (C) that may be related to calcification or blood are demonstrated within the lesion. The solid portion
is isointense to the cerebellar cortex on T2, due to high cell density along with high nuclear-cytoplasmic ratio, also
responsible for the restricted diffusion (D: DWI, E: ADC map) and high Cho peak (F) demonstrated in the lesion. There
is significant enhancement (G: axial T1 with contrast) and no elevation of the blood volume (H: rCBV map) in the perfu-
sion study.

Fig. 4. MB: high signal on T2 and no enhancement. An 8-year old boy presenting with headaches and vomiting. There
is a solid MB within the inferior vermis growing into the fourth ventricle, with no enhancement (A: sagittal, B: axial T1
with contrast) presenting with high signal intensity compared with the cerebellar cortex on T2 (C: axial T2).
 Posterior Fossa Tumors 5

Fig. 5. MB: infiltrative pattern. A 12-year old girl presenting with ataxia, headache, and vomiting. There is a
diffuse infiltrative lesion (A–C: coronal T2), involving the right greater than left cerebellum, infiltrating into
the brainstem. Most of the lesion is hyperintense on T2, with some hypointense areas (arrows in A and B), prob-
ably related to high cell density. The neurosurgeon suspected ADEM (acute disseminated encephalomyelitis). Pa-
thology was consistent with classic MB. There is heterogeneous enhancement (D: sagittal T1 with contrast) as well
as evidence of high cell density and high nuclear-cytoplasmic ratio characterized by restricted diffusion (arrow in
E: ADC map) and high choline on spectra (F).

and in MB (see Fig. 10B). Specifically, the MB, pi- cell turnover and tumor growth, a finding substan-
neal germinoma, and astrocytoma showed mean tiated by a significant positive correlation between
glutamine and glutamate (Glx) concentrations tCho and the Ki67 index.37 Tau is present in both
above the mean in all tumors; whereas, Glx concen- metastatic and localized tumors, although higher
tration was low in both the choroid plexus papilloma levels are typically found in metastatic tumors,
and carcinoma. The quantitation of these metabo- which is consistent with previous findings in neuro-
lites proved useful in separating either MB or astro- blastoma (ie, Tau is a reliable biomarker for more
cytoma from choroid plexus papilloma. Panigrahy aggressive subtypes of neural tumors).37–39 The
and colleagues24 have also reported the highest fact that higher mobile Lip levels are observed in
mean alanine (Ala) concentration among posterior localized tumors may also reflect a higher propor-
fossa tumors in MBs. tion of necrotic tumor in these cases.

Lipids and lactate

Dynamic Susceptibility Contrast and Dynamic
Prominent lipid (Lip) resonances can be observed
Contrast-Enhanced MR Imaging
in some, but not all, spectra of malignant MB (see
Fig. 11B).24,28 There can be variable perfusion and permeability
High lactate (Lac) values are usually found in the characteristics in MB, with some lesions showing
spectra of MB.36 elevated perfusion and permeability and others
not (Fig. 12, see also Fig. 3H).
Magnetic resonance spectroscopy in metastatic
versus localized medulloblastomas Important considerations
Metastatic MBs are characterized by higher total Radiologic-pathologic correlation The World
Cho (tCho), which is consistent with increased Health Organization (WHO) classification system
6 Brandão & Young Poussaint

Fig. 6. MB: metastasis. (A, B) A 26-year-old woman treated for MB at the age of 8. Now presenting with ataxia
and incoordination. Enhancing leptomeningeal metastases are demonstrated surrounding the brainstem, basal
cisterns, temporal lobes, and occipital lobes (A, B: axial T1 with contrast). (C, D) A 20-year-old man treated for
MB 2 years ago. MR imaging shows dural-based metastasis in the temporal and frontal basal regions, isointense
to the cortex on T2 (C: axial) with solid enhancement (D: axial T1 with contrast). Metastasis also may compromise
the ventricular system (E), the spinal roots, which may look thickened (F), as well as the liver (G).

2007 uses histology to classify MBs into 4 major densely packed small round blue cells (basophilic)
groups, including classic, desmoplastic, MB with with a high nuclear-to-cytoplasmic ratio, mitotic
extensive nodularity (MBEN), and large cell/ and apoptotic activity, and may occur in the
anaplastic MB subtypes3,40: midline.3
Elevation of Tau is seen specifically in this histo-
Classic Classic MB represents the most common
logic subtype.
histologic subtype and is composed of sheets of
 Posterior Fossa Tumors 7

Fig. 7. MB: parenchymal metastasis resembling cavernoma. A 7-year-old girl presenting with headaches and
paresthesia on the right. A solid lesion is demonstrated in the left frontal region, which is heterogeneous, hypo-
intense on T2 (A: axial T2), has significant low signal on the gradient echo image (B: axial gradient echo [GRE])
and some enhancement (C: axial T1 with contrast). Lesion was diagnosed as cavernoma. Two months later (D, E:
axial T1 with contrast) dural-based, as well as leptomeningeal metastasis are demonstrated with final diagnosis of
metastatic MB.

Fig. 8. MB-restricted diffusion. Patient diagnosed with MB, presenting with dizziness and nausea in the previous
2 months. There is a solid lesion in the midline vermis, mostly isointense to the cerebellar cortex on T2 (A: axial
T2), presenting with restricted diffusion (B: DWI, C: ADC map).
8 Brandão & Young Poussaint

Fig. 9. MB: no restricted diffusion. A 51-year-old man diagnosed with desmoplastic MB, presenting with head-
aches and nausea in the preceding 3 months. There is an infiltrative lesion compromising most of the cerebellar
parenchyma, presenting with mild high signal intensity on T2 (A: coronal, B: axial T2), and no restricted diffusion
(C: ADC map). The lesion does not enhance (D: axial T1 with contrast).

Fig. 10. MB: MRS. Same patient as in Fig. 8. There is a solid enhancing MB in the cerebellar vermis (A: sagittal T1
with contrast), presenting with very high Cho as well as Tau peak in the spectra (B: MRS). NAA is very low and
there is elevation of Glx as well as presence of Ala and lactate.
 Posterior Fossa Tumors 9

Fig. 11. MB: no elevation of Cho. Patient diagnosed with desmoplastic MB. MRS (A: voxel placement-axial T2)
demonstrates no elevation of the Cho peak (B-curve). The most striking finding is elevation of the myo-
inositol peak (mI).

Desmoplastic This subtype is hypocellular, pre- abundant apoptosis, and a much poorer
sents with lower Tau concentration compared prognosis.3,43,44
with the classic subtype and carries a favorable This is the most aggressive subtype, character-
prognosis.3,41 ized by presence of necrosis.
This histologic subtype is often found in adult
patients with MB, demonstrating a cerebellar Extensively nodular MBENs tend to develop in the
hemispheric mass extending to the overlying vermis in children younger than 3 years in most
meninges, with desmoplastic reaction evoked cases and is frequently represented as a nodular
by prominent leptomeningeal involvement enhancing appearance on CT scans or MR im-
(Fig. 13).19 ages. Prognosis is better than for the classic
MB.19,41
Anaplastic Anaplastic MBs (15%) are character-
ized by marked nuclear pleomorphism, nuclear Molecular subgroups More recently there has
molding, and cell–cell wrapping, and the large been the development of a classification of 4
cell variant (2%–4%) displays a monomorphous main subgroups of MBs based on molecular
population of large cells whose nuclei exhibit profiling.42,45–51
prominent nucleoli.3,42 Both variants are charac- The WNT and SHH groups were named after the
terized by a very high proliferative activity, predominant signaling pathways thought to be

Fig. 12. MB: low blood volume, no significant permeability. Same patient as in Figs. 8 and 10. There is a solid
enhancing MB in the cerebellar vermis (A: axial T1 with contrast), showing no elevation of the blood volume
(B: rCBV map), as well as no significant elevation of the permeability (C: maximum slope of increase map).
10 Brandão & Young Poussaint

Fig. 13. MB: desmoplastic type. A 64-year-old woman presenting with numbness and reduced consciousness.
There is an infiltrative cerebellar lesion in the left cerebellar hemisphere, extending laterally to the cerebellopon-
tine angle, hyperintense on T2 (A, B: axial T2) with a laminated appearance. There is no restricted diffusion,
which may be demonstrated in desmoplastic MBs (C: ADC map). There is nonhomogeneous enhancement in
the lesion, associated with thickening of the adjacent meninges due to desmoplastic reaction (D, E: axial, F: cor-
onal T1 with contrast).

affected in their pathogenesis. Less is known generic names were chosen until they are better
currently regarding the pathogenesis of groups 3 understood.45
(tending to harbor MYC amplification) and 4 (tend- The SHH group has become of increasing
ing to have isochromosome 17q) and therefore interest because of the availability and

Fig. 14. ATRT: CT. ATRT hyperdense on noncontrast CT (A), with enhancement in the contrast-enhanced study (B).
(Courtesy of A. James Barkovich, MD, San Francisco, CA.)
 Posterior Fossa Tumors 11

temporary success of small molecule inhibitors to focus of tremendous efforts to genomically

smoothened (SMO), which is part of the SHH characterize it.53
pathway. What was once thought to be a single disease
For a detailed comprehensive review on the mo- has been divided into multiple, molecularly
lecular subgroups of MB, see the consensus unique subgroups through gene expression
article by Taylor and colleagues.52 profiling. Each subgroup is not only unique in its
MB is the most common malignant brain origin and pathogenesis, but also in the prognosis
tumor in children and, as such, has been the and potential therapeutic options. The molecular

Fig. 15. ATRT: MR imaging. A 5-year-old girl with irritability and hypersexuality, sent to a psychiatrist. There is a
nonhomogeneous lesion presenting with a solid component isointense to the cerebellar cortex on T2 (A: coronal
and B–D: axial). Cysts are demonstrated within and adjacent to the solid component. The lesion is located off
midline and extends to the CPA on the right, which favors ATRT instead of MB. Some low signal intensity foci
are demonstrated within the solid portion, which may be related to blood products (E: axial GRE). There is het-
erogeneous enhancement (F: axial T1 with contrast) and significant restricted diffusion (G: DWI, H: ADC map).
12 Brandão & Young Poussaint

classification system has a potential use in MB is currently stratified into 4 molecular variants
developing prognostic models as well as through the advances in transcriptional profiling.54,55
for the advancement of targeted therapeutic They include sonic hedgehog (SHH), wingless
interventions. (WNT), Group III, and Group IV.

Fig. 16. PA: location and signal on T2. (A, B) A 9-year-old girl presenting with headaches, neck pain, ataxia, and
vomiting. There is a PA in the left cerebellar hemisphere, compressing and displacing the fourth ventricle (A: cor-
onal and B: axial T2). The solid component is hyperintense to the cerebellar cortex on T2. (C, D) Children diag-
nosed with MB. The lesion is located in the midline vermis, filling the fourth ventricle. The solid component of
MB is usually isointense to the cerebellar cortex on T2 (C). Some MBs may present with high signal intensity
on T2 (D), resembling a PA.
 Posterior Fossa Tumors 13

Fig. 17. PA: multinodular/multicystic appearance. PA presenting with multiple enhancing nodules (A: coronal, B:
axial T1 with contrast) hyperintense on T2 (C: axial T2), as well as multiple cystic nonenhancing components.

SHH (sonic hedgehog) medulloblastomas SHH tu- studied and have a very good long-term prognosis
mors are thought to account for 28% of all with overall survivals reaching 90%.51,59,60
medulloblastomas.42 WNT tumors also show a specific age distribu-
They have an intermediate prognosis between tion being almost absent in infants (aged <4 years)
good prognosis WNT tumors and poor prognosis but predominantly affecting children with a peak
group 3 tumors, and may be similar in prognosis incidence of 10 to 12 years.59
to group 4.52,53 SHH MBs show a dichotomous Most (97%) WNT MBs show classic histology;
age distribution being more common in both in- however, rarely, they are phenotypically large
fants (<4 years) and adults (>16 years).56–58 cell/anaplastic3 and may remarkably retain their
Most tumors in this group are of the desmoplas- relatively good prognosis with this phenotype.47
tic subtype, located in the cerebellar hemisphere They tend to occur in the middle cerebellar
more often than in the midline. peduncle/cerebellopontine angle.55
WNT (wingless) medulloblastomas (w10%) WNT Group 3 Group 3 tumors account for 28% of all
tumors are thought to be the rarest subgroup of MBs.
medulloblastoma, accounting for 11% of these tu- They are associated with the worst prognosis of
mors,58 but they have probably been the most all the subgroups and are frequently

Fig. 18. PA: striking solid enhancement. Same patient as in Fig. 16A, B. The solid portion of the PA presents with
striking enhancement. (A) Coronal and (B) axial T1 with contrast.
14 Brandão & Young Poussaint

metastatic.45,51 Group 3 tumors are found in in- Although they frequently metastasize, they still
fants and children but very rarely in adults.52 have an intermediate prognosis compared with
Group 3 MBs are mostly classic or large cell/ the poor prognosis of group 3.11,46,49,55,60
anaplastic morphology.51,52 MYC amplification The vast majority of group 4 MBs have a classic
appears to be highly associated with group 3 tu- histology.
mors and is associated with a worse prognosis.47 All histologic subtypes can present with
The tumors in this subgroup tend to be ill-defined this molecular profile, except the desmoplastic
on imaging.55 one.
These tumors tend to have minimal or no
Group 4 Group 4 MBs are thought to be the most
enhancement.51
common “typical” subgroup of MB, accounting for
approximately 34%,52 and can be thought of Molecular profiling: implications in treatment The
conceptually as being associated with isochromo- identification of different molecular pathways
some 17q.52 Group 4 medulloblastomas rarely involved in the pathogenesis of MBs provides
affect infants (0–3 years) and mainly affect chil- new therapeutic targets for drug
dren, with a peak age of 10 years.52 development.11,46,51,61–63

Fig. 19. PA: peripheral enhancement. (A) Axial T1 with contrast, (B) axial T2: Patient diagnosed with PA. There is a
large round lesion in the right cerebellar hemisphere presenting with marginal enhancement (A) and mild pe-
ripheral edema (B). (C, D) Child diagnosed with right cerebellar abscess presenting with peripheral enhancement
(C: axial T1 with contrast). There is significant diffusion restriction (D: DWI) not typically found in PA.
 Posterior Fossa Tumors 15

Medulloblastomas and associated syndromes Li-Fraumeni Germline mutations of the p-53 tumor
Basal cell nevus syndrome (Gorlin syndrome) This suppressor gene predisposes to different types of
is a rare autosomal dominant disorder with high cancer in patients, especially soft tissue sarcomas.
incidence of neoplasms, notably MB. Ten percent Ten percent of these patients develop MB.67
of these patients will develop MBs, usually
desmoplastic.
Falcine calcification in children with MB may be Key points to remember
a marker for basal cell nevus syndrome.64,65
 MB is the most common posterior fossa tu-
Turcot syndrome Turcot syndrome is associated mor in children
with familial colonic polyposis, with high incidence  MB affects mainly boys before 10 years of age
of brain tumors, such as MB and glioma.66  There is a second peak in adults

Fig. 20. PA: DWI. (A, B) Same patient as Fig. 16A, B. There is no restricted diffusion in the solid component of the
PA (A: DWI and B: ADC map), which helps distinguish PAs from MBs, which typically present with restricted diffu-
sion, due to high cell density (C: DWI and D: ADC map, same patient as Fig. 16C).
16 Brandão & Young Poussaint

 Lesion is often located in the midline vermis  There are imaging features associated with
and presents with hyperattenuation on CT, molecular subgroups: SHH involves the cere-
isointense to hypointense on T2, restricted bellar hemisphere, the WNT pathway involves
diffusion and high Cho and taurine on MRS cerebellar peduncle/CPA cistern, group 3 tu-
 Perfusion and permeability values are variable mors are ill-defined on imaging, and group 4
 Look for CSF spread! tumors have minimal or no enhancement

Fig. 21. Infiltrative rather than well circumscribed PA. A 23-month-old boy with developmental delay, low stature
and low weight for his age. There is a PA infiltrating the left cerebellar hemisphere and vermis, extending ante-
riorly to the left cerebellopontine angle, compressing the fourth ventricle (A: coronal T2, B, C: axial T2). There is
an associated cystic component in the right cerebellar hemisphere. There is striking enhancement in the solid
component (D: axial T1 with contrast) and no restricted diffusion (E: ADC map). MRS (F, G) demonstrates a large
choline peak, along with reduced NAA and Cr, as well as high lipids, very consistent with the diagnosis of PA.
 Posterior Fossa Tumors 17

ATYPICAL TERATOID RHABDOID TUMORS CSF tumor spread.71 Metastasis to the lungs and
abdomen also may be demonstrated.72,73
ATRTs are classified as part of the embryonal tumor
group of central nervous system (CNS) tumors.3
ATRT is a highly malignant CNS neoplasm that
Imaging Findings
most often occurs in children younger than
2 years.68,69 ATRTs represent 1.3% of CNS pri- On unenhanced CT, the tumor is usually charac-
mary brain tumors in the pediatric population, terized as hyperdense (Fig. 14) and on T2 images,
but if one considers only children younger than 3, as isointense to hypointense compared with gray
prevalence rises to 20%.4,70 matter (Fig. 15). These imaging findings are likely
ATRTs are more common in girls than in boys, secondary to high cell density and high nuclear-
with 94% in an intra-axial location.70 A review of to-cytoplasmic ratio and overlap with those
14 histologically confirmed cases of ATRTs described for MBs.
demonstrated equal preference for the supraten- Enhancement is demonstrated in approximately
torial and infratentorial compartments.71 89% of the cases (see Fig. 15F).71
These tumors are aggressive lesions with a Due to high cell density, as well as high nuclear-
dismal prognosis, and a 2-year survival of only to-cytoplasmic ratio, restricted diffusion is typi-
17%. Survival improves if the patient is older cally seen (see Fig. 15G, H).
than 3 years.4 MRS shows elevated Cho and reduced NAA as
Poor prognosis is related to the young age of the well as a prominent Lip peak. However, there are
affected patients as well as the high propensity for no reports in the literature that quantify these

Fig. 22. PA: blood. A 10-year-old girl, presenting with headache and dizziness. There is a PA within the cerebellar
vermis. The solid portion is hyperintense to the cerebellar cortex on T2 (A, B: axial T2) and has no restricted diffu-
sion (C: ADC map). There is nonhomogeneous enhancement in the lesion (D: axial T1 with contrast) and low
signal intensity foci within the solid portion in the gradient echo image (E) related to the presence of blood prod-
ucts, as confirmed after surgical resection.
18 Brandão & Young Poussaint

changes or address the presence or size of Tau CEREBELLAR PILOCYTIC ASTROCYTOMA

peaks.4,36
CPA and MB each constitute approximately 35%
of all posterior fossa masses in children.77
Atypical Teratoid Rhabdoid Tumors Versus
Pilocytic astrocytomas (PAs) are low-grade
Medulloblastoma
(grade I) tumors, most often located in the poste-
The main differential diagnosis for posterior fossa rior fossa (60%), with 40% involving the cere-
ATRT is MB. If the patient is younger than 3 years, bellum and 20% involving the brainstem.4
if tumor is located off midline, extending to the CPA has excellent survival after gross total sur-
CPA, and if blood products are demonstrated in gical resection.2,4,78
the lesion, one should consider ATRT as the Differential diagnosis between PA and MB in the
most likely diagnosis.74 posterior fossa is crucial; the former is a low-grade
However, the precise distinction can be made (WHO grade I) tumor, with excellent prognosis,
only through immunohistochemistry and genetic whereas MB is a grade IV tumor, with poorer
analyses. ATRTs frequently demonstrate deletions prognosis.36,79
of chromosome 22q with inactivation of the INI1/
hSNF5, thought to be a tumor suppressor gene.
Location
Loss of the INI1 gene product is used to diagnose
ATRT, although it is not present in all ATRT Predilection for the cerebellar hemisphere instead
tumors.75,76 of the cerebellar vermis is typically demonstrated.

Fig. 23. PA versus ependymoma: MRS. (A, B) Same patient as Fig. 18 diagnosed with PA. Spectra from the lesion
(A, B) demonstrates very high Cho peak, reduced NAA and Cr peaks, along with presence of lipids and lactate,
typical of PA. (C, D) A 3-year-old boy diagnosed with grade II ependymoma. Spectra from the tumor demonstrates
significant elevation of the mI peak as the most striking finding.
 Posterior Fossa Tumors 19

The lesion displaces and compresses the fourth or hypointense to normal cerebellar paren-
ventricle (Fig. 16A, B), as opposed to what is typi- chyma on T2 images (see Fig. 16C).2,4 Howev-
cally demonstrated in MB that usually compro- er, higher-grade astrocytomas may manifest
mises the cerebellar vermis, filling the fourth lower signal intensity on T2-weighted images,
ventricle (Fig. 16C, D).2,4,79 effectively mimicking MBs.4 On the other
hand, some MBs may present with high signal
intensity on T2, resembling PA (see Fig. 16D).18
Imaging Findings
Cysts associated with PAs are usually larger
CPA often presents with a solid component that than those demonstrated in MBs (compare
is hyperintense to the cerebellar cortex on T2 Fig. 16 A, B vs C).79
due to high water content as well as low cell Some tumors may present with multiple solid
density (see Fig. 16A, B).2,4,79 By contrast, the and/or cystic components (multinodular/multicys-
solid component of MBs is usually isointense tic appearance) (Fig. 17).

Fig. 24. PA: high perfusion blood volumes. (A, B) Same patient as Fig. 18. The solid enhancing PA (A: axial T1 with
contrast) demonstrates high blood volume on the DCE perfusion study (B: rCBV map). (C, D): Same patient as
Fig. 22. The solid enhancing PA (C: axial T1 with contrast) presents with high blood volumes (D: rCBV map).
20 Brandão & Young Poussaint

Despite being low-grade (grade I) tumors, strik- Restricted diffusion

ing solid enhancement is characteristic (Fig. 18). Diffusion is typically not restricted in PAs (see
The amount of gadolinium enhancement matches Fig. 20A, B), because these are low cell density le-
the T2 abnormality.79 sions.21–23 Approximately 7% of these tumors may
Some lesions will present with peripheral present with restricted diffusion.21
enhancement resembling abscesses (Fig. 19).
Diffusion may help in the differential diagnosis in Very high Cho along with presence of lipids
these cases.21 and lactate in the magnetic resonance
The solid component of PAs has higher ADC spectroscopy
values than do other cerebellar tumors, such as Brain metabolites may be useful to suggest
MB and ATRT (Fig. 20).21–23 tumor grade. Among these, Cho is typically related
The typical imaging features described previ- to tumor cell density and, hence, higher Cho/crea-
ously may be useful to suggest the diagnosis tine and Cho/NAA ratios are typically demon-
of a pilocytic tumor and to distinguish this strated in higher grade (grade III) than in lower
tumor from more aggressive tumors, such as grade (grade II) gliomas. However, tCho is not an
MBs. However, the following are some imaging effective or accurate biomarker for grade I PAs.36
findings rarely seen that can be considered Choline is typically very high in pilocytic tumors,
atypical.79 despite the benign clinical course for tumors of this
type (Fig. 23A, B).2,4,26,36,80
Due to the very high Cho peak, the spectral
Infiltrative, rather than well-circumscribed
pattern of PAs may overlap with that from MB
lesion
(see Fig. 10).79 However, the Tau peak, consid-
CPAs are typically well-circumscribed, localized
ered very characteristic of MBs, is not typically
lesions. However, sometimes the tumor may be
demonstrated in PAs.33
infiltrative, presenting with ill-defined margins,
Lipids and lactate are also usually demonstrated
and hence complete surgical resection is very diffi-
in the spectra of PA.26,79
cult (Fig. 21).
The spectral pattern of PAs may be used to
distinguish between these tumors and grade II
Presence of blood products ependymomas (Fig. 23C, D).79
CPAs, despite being grade I (low-grade) tumors
may bleed (Fig. 22). Knowledge of this “unex- High blood volumes in the perfusion study
pected” finding is essential so as not to change Despite being low grade (grade I tumors), PAs may
the diagnosis in these cases. present with high blood volumes on dynamic

Fig. 25. PA: CSF tumor spread. (A, B) An 8-year-old girl treated for PA, now presenting with CSF tumor spread
with multiple ependymal enhancing nodules in both frontal horns (A: axial T1 with contrast) better demon-
strated in the axial T2 fluid-attenuated inversion recovery (FLAIR) with contrast (B). There is also involvement
of the ependyma of the third ventricle and the atrium bilaterally. (C) A 6-year-old boy treated for PA presenting
with CSF spread. Enhancing nodules are demonstrated adjacent to the conus medullaris (C: sagittal T1 with
contrast).
 Posterior Fossa Tumors 21

Fig. 26. Ependymoma in the fourth ventricle. Fourth ventricular mass, extending though the foramina of Luschka
on the left to the left cerebellopontine angle (CPA). (A) Coronal T2, (B, C) axial T1 with contrast.

Fig. 27. Ependymoma in the foramina of Luschka. A 4-year-old boy with ataxia and hearing loss. Ependymoma
growing in the foramina of Luschka on the right, displacing the medulla and pons. Lesion was mistaken for exo-
phytic BG. (A) Coronal T1 with contrast, (B, C) axial T2.

susceptibility contrast studies (Fig. 24).79,81–83

This finding is not related to aggressiveness in
these lesions.

Cerebrospinal fluid spread

Despite the low malignancy grade, PA may spread
via CSF dissemination (Fig. 25).4,79

EPENDYMOMAS
Ependymomas are characterized by perivascular
arrangement of tumor cells.3 These tumors are
most often seen in children younger than 5, with
a second peak in adults in the fourth decade.2,4
Ependymomas are the fourth most common
posterior fossa tumors in children after MB, cere-
bellar astrocytoma, and BG.2,4
There are genetically distinct subgroups
that have been identified by genomic studies
based on locations in classic grade II and Fig. 28. Ependymoma: calcification. Ependymoma
III ependymomas. They are supratentorial located in the fourth ventricle, presenting with multi-
ependymomas with C11 or f95-RELA fusion ple foci of calcification. (Courtesy of A. James Barko-
or YAP1 fusion, infratentorial ependymomas vich, MD, San Francisco, CA.)
22 Brandão & Young Poussaint

with or without a hypermethylated phenotype ependymomas than in any other posterior fossa
(CIMP), and spinal cord ependymomas.84 tumor in children.
Seventy percent of all ependymomas are in the These tumors are heterogeneous on MR imag-
posterior fossa, with 90% involving the ventricular ing (see Fig. 28, see also Fig. 27), reflecting a com-
ependyma (Fig. 26).2 Ependymomas may also bination of solid tumor, cyst, calcification,
spread through the foramina of Luschka and necrosis, edema, or hemorrhage.4
Magendie (Fig. 27). Punctate calcification is The most important imaging finding in identi-
demonstrated in 50% of ependymoma cases on fying an ependymoma is extension of the
CT (Fig. 28).4 Calcification is most often seen in tumor through the fourth ventricular outflow

Fig. 29. Ependymoma: MR imaging. MR imaging after surgical resection of an ependymoma in a 3-year old boy
demonstrates residual tumor in the fourth ventricle, extending through the foramina of Luschka on the left, en-
casing the vertebral and basilar arteries, as well as extending inferiorly through the foramina of Magendie and
foramen magnum. The lesion is isointense to the cerebellar cortex on T2 (A: sagittal, B, C: axial T2) and presents
with a cystic component. High-resolution T2 (D, E) demonstrates encasement of the basilar artery, extension to
the left internal auditory canal (IAC) and to left Meckel cave (arrow in E). There is heterogeneous enhancement
(F) and a punctate hypointensity likely representing calcification is demonstrated within the lesion (arrow in G).
 Posterior Fossa Tumors 23

Fig. 30. Ependymoma: DWI. (A, B) Same patient as Fig. 29. There is mild restricted diffusion in the lesion (A: axial
T2, B: ADC map).

foramina (see Fig. 26; and Fig. 29)4; however, this usually present with no or mild restricted diffu-
feature is not entirely pathognomonic, as some sion (Fig. 30). Jaremko and colleagues21
MBs may extend through the fourth ventricular demonstrated an overlap between ADC values
exit foramina. In addition, they usually show of the classic type (WHO grade 2, one-half of tu-
more bulbous extension and restricted diffusion mors demonstrating restricted diffusion) and
rather than small amounts of tissue through the anaplastic type (WHO grade 3, two-thirds of tu-
foramina that is characteristic of an ependy- mors demonstrating restricted diffusion). Given
moma.4,85 Siderosis86 may be demonstrated the wide histologic and prognostic spectrum of
associated with ependymomas. ependymoma, diffusion characteristics of epen-
dymoma also have a wide range overlapping
other tumor types, such as MB.21,29,87 Because
Diffusion-Weighted Imaging
ependymoma shows no distant disease in
Most ependymomas in the posterior fossa are more than 90% of cases,85 metastasis favors
classic (grade II) ependymomas. These tumors MB.

Fig. 31. Ependymoma: MRS. Same patient as Fig. 26. Classic grade II ependymomas typically demonstrate high mI
in the spectra (A: axial FLAIR, B: spectroscopy).
24 Brandão & Young Poussaint

Magnetic Resonance Spectroscopy Perfusion and Permeability Studies

High myo-inositol (mI) levels are typically demon- Ependymomas generally demonstrate markedly
strated in classic grade II ependymomas.36,81 In elevated relative cerebral blood volume (rCBV)
a study by Harris and colleagues,88 the (Fig. 32) and, unlike many other glial neoplasms,
presence of high mI levels strongly suggested a a poor return to baseline that may be attributable
diagnosis of ependymoma when short TE is used to fenestrated blood vessels and an incomplete
at 1.5 T (Fig. 31 see also Fig. 23C, D). Schneider blood brain barrier (BBB) (see Fig. 32C).89–91 This
and colleagues29 also demonstrated that ependy- behavior, although very characteristic of ependy-
momas are characterized by an elevation in mI and momas, is not entirely pathognomonic and also
Glx. may be demonstrated in other tumors, such as

Fig. 32. Ependymoma: perfusion. Same patient as Fig. 26 diagnosed with ependymoma. There is a solid
enhancing tumor in the fourth ventricle (A: axial T1 with contrast) presenting with significant elevation of
rCBV on perfusion imaging (B: rCBV map) with poor return of the perfusion curve to the baseline (arrows in
C: perfusion curve).
 Posterior Fossa Tumors 25

embryonal tumors (Fig. 33) (Lara A. Brandão, MD, adults too) is characterized by K27M mutations
personal communication, 2013). in the histone H3 gene H3F3A, or less
For the same reason stated previously (fenes- commonly in the related HIST1H3B gene, a
trated blood vessels and an incomplete BBB), diffuse growth pattern, and a midline location
ependymomas tend to present with very high (eg, thalamus, brainstem, and spinal cord). This
permeability (Fig. 34) (Lara A. Brandão, MD, per- newly defined entity is termed diffuse midline
sonal communication, 2013). glioma, H3 K27M–mutant and includes tumors
previously referred to as diffuse intrinsic
pontine glioma.51 Most of these tumors have
BRAINSTEM GLIOMA AND OTHER
poor prognosis but exceptions have been
BRAINSTEM TUMORS
reported.51
One narrowly defined group of tumors primarily The identification of this phenotypically and
occurring in children (but sometimes in molecularly defined set of tumors provides a

Fig. 33. Embryonal tumor: perfusion. Brainstem embryonal tumor presenting with striking enhancement (A: axial
T1 with contrast) and significant elevation of the rCBV on the perfusion study (B: rCBV map) with poor return of
the perfusion curve to the baseline (arrows in C: perfusion curve); similar findings as in ependymomas (see Fig. 32).
26 Brandão & Young Poussaint

Fig. 34. Ependymoma: permeability (DCE study). Same patient as Figs. 26, 31, and 32. There is an enhancing
fourth ventricular ependymoma (A: axial T1 with contrast) with significant elevation of the permeability (B:
maximum slope of increase map, C: curves; region of interest [ROI] 1, from the jugular vein; 2, from the tumor;
3, from the cerebellar white matter; 4, from the cerebellar cortex).
 Posterior Fossa Tumors 27

Fig. 35. BG: MR imaging. A 5-year-old girl presenting with headaches and diplopia. There is a midline diffuse gli-
oma with high signal intensity on T2 (A: axial) expanding the pons, compressing the fourth ventricle and encasing
the basilar artery. There is no enhancement in the lesion (B: axial T1 with contrast).

rationale for therapies directed against the effects Proton MRS and perfusion imaging may be use-
of these mutations. ful in differentiating low-grade (usually focal)
Brainstem tumors represent 10% to 20% of all pontine tumors, which have lower Cho peaks (as
CNS tumors in childhood.2 Most BGs are diffuse well as Cho/Cr and Cho/NAA ratios) and lower
and involve the pons.4 blood volumes, from high-grade tumors in which
Diagnosis is based on the characteristic the Cho/Cr ratio is usually higher (Fig. 38).36
changes on MR imaging of diffuse T2 hyperintense A citrate peak can be demonstrated at approxi-
expansion of the brainstem without biopsy (Figs. mately 2.6 ppm and can be used to follow tumor
35 and 36).2,4 Enhancement is typically absent progression (Fig. 39).95–97 Reduced citrate levels
(see Fig. 35B) or restricted to a small portion of may indicate malignant transformation of these tu-
the lesion (Fig. 36D). mors, or may be related to chronic administration
Five-year survival is related to location, with of steroids, RT, and/or chemotherapy.96 Although
midbrain lesions having the best outcome the citrate signal is most prominent and most often
(72%–100% of patients alive in 5 years) and pontine observed in diffuse midline gliomas of the pons, it
lesions having the worst (18% alive in 5 years).92 Tu- is also noted in other common pediatric brain tu-
mor extension also influences survival, with diffuse mors and in the developing brain of infants
lesions having the worst survival rates (18%–20%) younger than 6 months.97
and focal lesions having the best (56%–199%).92 Some studies suggest that MRS might be a use-
ful early predictor of disease progression in BGs,
Diffusion-Weighted Imaging preceding clinical and radiological deteriora-
Areas of restricted diffusion may be demonstrated tion.95,98,99 Metabolic changes indicative of malig-
within a pontine glioma, indicating higher cell den- nant transformation include increased levels of
sity and the best place for biopsy (Fig. 37).79 tCho, decreased metabolite ratios of NAA/tCho
ADC measurements in these tumors are closely and Cr/tCho, and increased levels of Lips. In addi-
related to prognosis and survival with lower ADC tion, a significant reduction in the “apparent” cit-
values associated with poorer survival.92,93 rate levels also may be associated with
malignant transformation.97
Magnetic Resonance Spectroscopy
Perfusion and Permeability Studies
Single-voxel MRS (SV-MRS) or multivoxel spec-
troscopy (chemical shift imaging) can be used to Available literature suggests that at least a
evaluate BGs.36,94 subset of diffuse midline gliomas of the pons
28 Brandão & Young Poussaint

Fig. 36. BG: MR imaging. A 4-year-old girl presenting with headaches in the previous 3 months, strabismus, and
ataxia. There is a midline diffuse glioma with high signal intensity on T2 (A: sagittal, B: coronal, C: axial T2) ex-
panding the pons, compressing the fourth ventricle and encasing the basilar artery. A small area of enhancement
is demonstrated in the lesion (arrow in D: axial T1 with contrast).

is histologically low grade (WHO grade II) at Treatment considerations

initial clinical presentation, but rapidly evolves Radiation therapy is the most used therapy for BGs,
into high-grade neoplasms, with most found with very good response in some patients, espe-
to be glioblastoma at postmortem cially in those with low cell density tumors (Fig. 41).
examination.96,99–105 Enlargement of a pontine glioma during radia-
Perfusion and permeability are related to tumor tion therapy plus chemotherapy and or immuno-
grade, with areas of higher blood volumes and therapy is not necessarily related to treatment
higher permeability indicating aggressiveness failure and may represent pseudoprogression
and the best site for biopsy (Fig. 40).81 especially with immunotherapy treatments.106,107
 Posterior Fossa Tumors 29

Fig. 37. BG: DWI. Same patient as Fig. 36. An area of restricted diffusion is demonstrated in the lateral portion of
the lesion (arrow in A: DWI, B: ADC map) indicating high cell density.

Fig. 38. Focal versus diffuse BG: MRS. (A, B) Focal BG presenting with more preserved NAA and higher mI than the
infiltrative more aggressive pontine glioma (C, D). Cho/Cr and Cho/NAA ratios are also higher in the diffuse gli-
oma versus the focal less aggressive one.
30 Brandão & Young Poussaint

Fig. 39. BG: MRS. Same patient as Figs. 36 and 37. MRS (A: voxel, B, curve) shows high Cho along with citrate peak
in 2.6 ppm.

Other brainstem tumors Posterior fossa gangliogliomas (PF GGs) occur

Tumors in the midbrain and medulla are most often less often than supratentorial gangliogliomas (ST
PAs on histology, with a better prognosis than the GGs).108
diffuse midline glioma.2,4 On imaging, PF GGs are most often infiltrative
Ganglioglioma is another diagnostic consider- and expansile solid masses with dorsal predomi-
ation for tumors located in the brainstem. nant “paintbrush” enhancement (Fig. 42).

Fig. 40. BG: perfusion and permeability. Same patient as Fig. 36. An area of high rCBV is demonstrated in the
lateral portion of the lesion (arrow in A: rCBV map). There is no significant elevation of the permeability (B:
maximum slope of increase map).
 Posterior Fossa Tumors 31

Fig. 41. BG: good response to RT. Same patient as Fig. 35. A 5-year-old boy presenting with headaches and
diplopia, diagnosed with diffuse midline glioma of the pons (A: axial T2). There is no restricted diffusion in
the lesion, indicating low cell density (B: ADC map). After RT (C: axial T2) the lesion is smaller and less hyperin-
tense, indicating therapeutic response.

Fig. 42. Brainstem ganglioglioma. A 5-year-old boy presenting with hypotonia. There is an infiltrative expansile
ganglioglioma at the cervicomedullary junction, with an exophytic component in the left foramina of Luschka,
hyperintense on T2 (A: sagittal, B: coronal, C: axial T2) with no restricted diffusion (D: ADC map). There is dorsal
linear enhancement, as well as multiple enhancing nodules within the lesion (E: sagittal, F: coronal T1 with
contrast).
32 Brandão & Young Poussaint

PF GGs are not amenable to gross total resec-  ETANRT (embryonal tumors with abundant
tion, and have worse progression-free survival neuropil & true rosettes) with variable
and mortality, compared with ST GGs.107 numbers of rosettes, small blue cells
These tumors can be grade I or II and have a  Ependymoblastoma (diagnosis removed from
higher propensity to CSF spread than PA.109 WHO 2016)
If there is evidence of high cell density within
the tumor, with restricted diffusion and high Cho These are usually large bulk tumors in the supra-
in the spectra, one should consider embryonal tu- tentorial compartment, but also may be found in
mor in the differential diagnosis (Figs. 43 and the posterior fossa.
44).110 They are usually heterogeneous and can have
little edema for their size.
A small percentage of pontine gliomas may be
EMBRYONAL TUMOR WITH MULTILAYERED diagnosed as ETMR.
ROSETTES C19MC-ALTERED Prognosis is dismal despite radiation therapy.
A new entity, embryonal tumor with multilayered
rosettes (ETMR) C19MC-altered, was recently SUMMARY
described in children younger than 3 years.51
The spectrum of morphologic patterns in this Pediatric brain tumors are the most common solid
entity includes the following: tumor in children and the leading cause of death in

Fig. 43. ATRT. There is a heterogeneously enhancing lesion in the midbrain (A: sagittal T1 with contrast) mainly
hypointense on T2 (B: axial) with restricted diffusion (C: ADC map) and high Cho on MR spectra (D), suggesting
high cell density.
 Posterior Fossa Tumors 33

Fig. 44. Embryonal tumor. Same patient as Fig. 33, diagnosed with embryonal tumor. A 13-year-old girl with
headaches, ataxia, and diplopia. There is a solid lesion centered in the medulla, hypointense on T2 (A: sagittal,
B: axial T2) extending to the left cerebellopontine angle (arrow in B), presenting with significant enhancement
(C: axial T1 with contrast). Restricted diffusion is demonstrated (D: DWI, E: ADC map), indicating high cell density.

this patient population. The primary objective of 5. Najel BJ, Palmer SL, Reddick WE, et al. Abnormal
this article was to offer a detailed overview of the hippocampal development in children with medul-
most common brain tumors affecting the posterior loblastoma treated with risk-adapted irradiation.
fossa in children. The respective imaging features AJNR Am J Neuroradiol 2004;25:1575–82.
on CT, cMR imaging, and advanced MR imaging 6. Khong P, Kwong DL, Chan GC, et al. Diffusion-
studies, may help suggest the most likely diag- tensor imaging for the detection and quantification
nosis leading to early and appropriate treatment. of treatment-induced white matter injury in children
with medulloblastoma: a pilot study. AJNR Am J
Neuroradiol 2003;24:734–40.
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