NON NEOPLASTIC

CYSTS IN CNS
BY DR L.JONES
2ND YEAR POST GRADUATE
MODERATOR:DR RABIYA MAM
ASSOCIATE PROFESSER
DEPARTMENT OF RADIODIAGNOSIS
 Parenchymal cysts
Enlarged perivascular
spaces
Hippocampal sulcus
remnants
Neuroglial cysts
Scalp cysts
Sebaceous cysts
Extra axial cysts
Porencephalic cyst
Arachnoid cyst

Intraventricular cyst
Choroid fissure cyst
Epidermoid cyst
Dermoid cyst
Neurenteric cyst
Pineal cyst
Non neoplastic tumour associated cysts
Choroid plexus cyst
Colloid cyst
Ependymal cyst
FOUR KEY ANATOMY-BASED QUESTIONS
Is the cyst extra- or intraaxial?
Is the cyst supra- or infratentorial?
If the cyst is extraaxial, is it midline or off-midline?
If the cyst is intraaxial, is it in the brain parenchyma or
inside the ventricles?
EXTRA AXIAL
CYSTS
Extra axial cysts are between the skull and brain
most of them lie within the arachnoid membrane or in the subarachnoid space.
Determine the location: supra vs infratentorial ,
midline vs off midline
Arachnoid cyst :
Arachnoid cyst is also known as meningeal cyst ,it is a CSF containing cyst lined by a layer of flattened arachnoid cells.
Etiology :
endomenings fail to merge and remain separated
forms a duplicated arachnoid
CSF is secreted by cells in the cyst wall and
accumulates between the layers
Location
supratentorial :
Middle cranial fossa,anteromedial to the temporal bone
cysts found over cerebral convexities,predominantly over the frontal lobes
Other suprasellar,quadrigeminal cisterns
Infratentorial :
mostly CPA cistern (2nd most common cystic CPA mass)
less common in cisterna magna
most common non neoplastic intracranial cyst
All ages children and young adults
Headaches is common in symptomatic arachnoid cysts
When large, causes obstructive hydrocephalus.
Imaging :
isodense to CSF in CT and MR.
FLAIR and DWI are best sequences to distinguish cystic appearing intracranial masses from one another
Differential diagnosis:
Epidermoid cyst
Enlarged suarachnoid spaces
Loculated subdural hygroma /hematoma
Porencephalic cyst
Rarely neurenteric cyst
Large midline posterior fossa AC is isodense with
CSF on NECT . The unilocular AC compresses and
displaces vermis and brainstem anteriorly. The
cyst suppresses completely on FLAIR and no
restriction on DWI
Choroid fissure cyst :
The choroid fissure is a C shaped infolding of CSF between the fornix (outer margin) and thalamus (inner margin) to the interventricular foramen of Monroe
It forms medial wall of lateral ventricle and attachment site for choroid plexus
A CSF containing cyst can form anywhere along the choroid fissure .
It is subtype of arachnoid cyst
On imaging :
It follows CSF density /signal intensity in all sequences
Axial T1WI FS in the same case
shows a well- shows that the
delineated CSF- cystic mass has the
likemass medial identical signal
to the left intensity as CSF in
temporal horn. the adjacent
cisterns
Epidermoid cyst:
Spinal –acquired
Intra cranial –congenital in origin
Etiology :
congenital inclusion cyst
epithelial remnants in neural tube
outer surface of an EC is often shiny resembling mother of pearl
insunates in /around the CSF cisterns
encases vessels/cranial nerves
multiple Cauliflower like excrescences are typical
Cyst is filled with Waxy, creamy or flaky contents

Graphic image shows

a multilobulated

epidermoid cyst within

prepontine cistern

encasing the basilar

Microscopically
squamous epithelium +keratin debris ,solid cholesterol
no dermal appendages
Epidemiology
0.2% -1.8% of primary intracranial tumors
peak age 20 -60 yrs
symptomatic epidermoid cysts rare in children
General features :
resembles CSF on imaging ,irregular frond like excrescences and an insinuating growth pattern in CSF cisterns
encases ,displaces vessels and cranial nerve
CPA cistern is the most common site
CT
hypodense,calcification is present in 10-20%.
MR
slightly hyperintense to CSF on T1W1 and T2WI
Does not suppress on FLAIR
Restricts ( bright )on DWI
T2WI shows a FLAIR demonstrates The mass restricts
lobulated, irregular that the lobulated, on DWI. This is a

hyperintense mass cauliflower-like mass classic epidermoid

in the right CPA does not suppress. cyst.
and basilar
cisterns. The CSF
looks "dirty."
DIFFERENTIAL
DIAGNOSIS
ARACHNOID CYST(suppresses on FLAIR)restricts on DWI
Others
inflammatory cysts(neurocysticercosis)
neurenteric cyst
Dermoid cyst
A dermoid cyst is benign cystic mass with mature squamous epithelium , keratinous material ,and adnexal structures
Usually(hair follicles and sebaceous and sweat glands)
Extra axial
Midline > off midline
Suprasellar > posterior fossa > frontonasal region
Grows slowly, usually asymptomatic until rupture
Imaging
NECT
hypodense ca+ in 20%
fatty droplets in cisterns if ruptured
MRI
Heterogeneously hyperintense on T1W1
Heterogenously hyperintense on FLAIR
Ruptured dermoid cyst bloom on T2GRE
Ruptured DC is Axial NECT in a 20y man with severe
heterogeneous fat
containing midline mass headaches shows a very hypodense mass in
with ventricular fat-fluid
level and fat droplets in the prepontine cistern.
SASs
T1WI in the same case
demonstrates T1 C+ FS shows that the mass

suppresses completely and does

that the mass is heterogeneously
not enhance. This
hyperintense.
is dermoid cyst without evidence
Differential diagnosis
epidermoid cyst
lipoma
craniopharyngioma
Teratoma may resemble dermoid cyst but most commonly occurs in the pineal gland and is much
more heterogenous on imaging than the typical dermoid cyst
Dermoid verses
epidermoid cyst
Both dermoid and epidermoid contains squamous epithelium + keratin debris
Only dermoid contains fat ,dermal appendages
Clinical issues
dermoid cysts commonly rupture
imaging :
DC behaves mostly like fat
most often midline,supra or juxtasellar
Epidermoid cyst more like CSF
most often midline
most common in posterior fossa (Cp angle cistern)
Axial T1WI
Sagittal T1WI in the
shows dermoid same case nicely
cyst as shows hyperintense
droplets from the
Heterogeneously ruptured dermoid along
hyperintense the sylvian fissure sulci
paramedian
Droplets from
T2* shows that the
the ruptured droplets exhibit blooming
dermoid in and appear as punctate
hypointensities in the left
the left sylvian sylvian fissure
fissure are
hyperintense on
FLAIR
Neurenteric cyst
Neurenteric cyst are rare endodermal derived developmental CNS lesions. They are more common in spine than in brain.
Also called enterogenous cyst, enteric cyst, endodermal cyst, and neuroendodermal cyst
In brain almost 75% occurs in Posterior fossa
All most all are extraaxial & midline
supratentorial & anterior to pontomedullary junction
IMAGING :

NCCT : iso/slightly hyperdense to CSF

CECT : no enhancement
MRI :
T1WI : iso/slightly hyperintense to CSF
PD, T2WI : hyperintense to CSF(>90%) & does not suppress on FLAIR
DWI : mild or no restriction
Differential diagnosis
epidermoid,arachnoid cysts
Rare ecchordosis physaliphora
Sagittal graphic Axial T2WI shows
shows a classic Saggital T1wI of that the mass is
neurenteric neurenteric cyst well delineated.It
cyst .Intracranial shows a is
neurenteric cysts are hyperintense ovoid Heterogeneously
most often found midline mass infront hypointense to
near the of medulla CSF,suggesting
inspissated
midline, anterior to contents. More
the brainstem. typically NE cysts
Pineal cyst
A pineal cyst is a benign glial cells lined, fluid containing cyst within the pineal gland parenchyma
Structures from top to bottom is famous VIP
Fornix, velum interpositum, internal cerebral veins, and pineal gland
Usually < 1cm - 4.5cm, unilocular > multicystic
Wall contains attenuated pineal parenchyma
Fluid clear to yellowish
Clinical issues
Common
23% of normal MR scans,,25-40%of autopsies
Occur at any age,more commom in adults
Usually asymptomatic ,found incidentally
Thunderclap headache may mimics the symptoms of aneurysmal subarachnoid hemorrhage.
pineal apoplexy can result in acute intraventricular obstructive hydrocephalus
Imaging:
shows Ca++ with in the cyst wall
Fluid slightly hyperintense to CSF on MR
Rim,nodular,or cresentic enhancement
Differential diagnosis:
Normal pineal gland,pineocytoma
Coronal NECT ina 49y Axial FLAIR in the same
woman with chronic case shows that the fluid
headaches shows a in the pineal cyst does
large cystic pineal not compress completely
gland with thick rim
calcification .
Sagittal T2WI in a 17y girl Small pineal cyst is seen with
with sudden onset of severe hemorrhage

headache, visual difficulties "blooming" on T2* ﬈, with rim

shows a large pineal cyst and nodular enhancement on
with blood-fluid level T1,c+F
indicating hemorrhage
PARENCHYMAL
CYSTSEnlarged
perivascular spaces
Also know as Virchow robin spaces
Found around penetrating blood vessels
Lined by pia,filled with interstital fluid
Do not communicate directly with subarachnoid spaces
Pathology:
Normal pvss common <2cm
Gaint tumefactive pvss up to 9cm reported
Basal ganglia ,subcortical WM most common
 (Top) T2WI shows perivascular
Graphic shows normal PVSs along
spaces ſt
penetrating arteries in the basal
clustered around the anterior
ganglia ﬈ and commissure ﬇.
subcortical white matter ISF-filled VRSs suppress on FLAIR
Imaging
Often bizzare looking
Occurs in clusters
Variably sized cysts
Follow CSF Basal ganglia PVSs can become
very

prominent in older patients a

condition

termed "état criblé" or cribriform

state.
Neuroglial cyst
Also known as glioependymal cysts or neuroepithelial cysts
They are benign fluid containing cavities buried within the cerebral white matter.
Location
Frontal lobe most common site
They often lie adjacent to but do not communicate directly with the cerebral ventricles
They are solitary unilocular cysts
They contain CSF like fluid
They are less than 1%,occurs in all age groups
Asymptomatic found incidentally
Imaging
Smooth,round or ovoid fluid cointaining cysts
CT imaging
Ngcs are fluid density,typically resemble CSF do not contain calcifications,and do not hemorrhage
MR imaging
Most NGCs are iso or slightly hyperintense to CSF
They usually suppress on FLAIR,do not restrict and do not enhance ,the parenchyma surrounding an NGC is usually normal or may show minimal gliosis
Differential diagnosis
Enlarged perivascular space
Porencephalic cyst
Arachnoid cyst
Epidermoid cyst
Ependymal cyst
Proven neuroglial cyst in the right
MR shows a small presumed right
parietal
occipital lobe does not enhance
on CECT
neuroglial cyst . The cyst follows
CSF on all
follows CSF on T2/FLAIR does not
restrict
sequences and has been stable
Porencephalic cysts
Porencephaly literally means hole in the brain
They are usually congenital or acquired CSF filled parenchymal cavities that usually
communicate via a pore with the subaracnoid space
These are end result of a destructive process like trauma,infection ,vascular insult,surgery.
A few inherited syndromes ex(autosomal dominant familial porencephaly).
Clinical issues
2.5%of congenital brain lesions
These are deep,uni or bilateral ,smooth walled cavities or excavations within brain parenchyma.
Presentation
Spastic hemiplegia
Pschomotor retardation
Most porencephalic cysts remain stable for many years, ocassionally cyst will continue to sequester fluid and expand ,causing mass effect
CT:
Sharply marginated,smooth walled . CSF filled cavities that usually communicate directly with the adjacent ventricle
The ipsilateral ventricle is often enlarged secondary to volume loss in the adjacent parenchyma
Porencephalic cyst does not enhance
MR:
Follow CSF signal intensity on all sequences
These cysts suppress completely on FLAIR,although there is often a rim of hyperintense gliotic or spongiotic white matter around the cyst
No restriction on DWI is present
Autopsy specimen NECT MR scans show a
shows a typical posttraumatic porencephalic
porencephalic cyst
as a CSF-filled cyst extending from the surface
cavity that of the temporal lobe to the
extends from the
brain surface to
the ventricular temporal horn of the lateral
ependyma ventricle. The cyst contains CSF
Differential diagnosis
Cystic encephalomalacia
A porencephalic cyst with surrounding reactive gliosis must be distinguished from spongiosis,a process that represents tissue loss with formation of
empty areas in the brain
Gliosis is a low to medium cellularity lesion that is hyperintense on T2WIand does not suppress on FLAIR.spongiosis is T2hyperintense but suppress on
FLAIR
Hydranencephaly-means water on the brain is the congenital lesion in which most of the supratentorial developing brain has destroyed by arterial
occlusion.
INTRAVENTRICULA
R CYSTSChoroid plexus
cysts
One of the most common type of intracranial cysts.
These are non neoplastic noninflammatory cysts of the choroid plexus
Etiology; congenital
Aicardi syndrome
Trisomy 18
Acquried
They are more common ,lipid that accumulates from desquamating ,degenerating choroid plexus epithelium coalesces into macrocysts and provokes a xanthomatous
response.
Bilateral ,usually multiloculated
Clinical features
m/c intracranial cyst
m/c in fetus/infants,older adults
CT:
Iso/mildly hyperdense
Calcification common
MR:
Iso/mildly hyperintense to CSFon T1WI
Hyperintense on PD/T2W1,FLAIR signal is variable
Variable enhancement(usually thin rim),nodular patterns occur in 25 to 50%
Bright on DWI but isointense on ADC
Differential diagnosis:
m/c ependymal cyst
Cystic metastasis
Multiple cystic Choroid plexus cysts are usually
masses are in bilateral
choroid
and hyperintense compared with
plexus glomi; in CSF and are
adults, it increases
with age.Most are often very bright on DWI
degenerative
xanthogranulomas
Colloid cyst
Colloid cyst are paraphyseal cysts,probably derived from ectopic elements in diencephalic roof.
They are unilocular,mucin cointaining cysts that are almost always found wedged into the top of third ventricle at the foramen of monro.
Size varies from a few millimeters upto 3cm ,smooth walled spherical or ovoid cyts that have a gelatinous material in the centre with variable viscosity.gross hemorrhage is rare.
Contains fibrous capsule
Clinical issues
1%of all intracranial tumours,15-20% of intracranial masses
Asymptomatic,found incidentally
Headache m/c symptom
Sudden obstruction can cause coma,death
Imaging
CT :2/3 hyperdense
1/3 iso dense to hypodense
Usuall do not enhance
MR:
Signal intensity varies with sequence ,cyst contents
Typical T1hyper reflects the cholesterol concentration T2 hypointense
Inspissated content shows T2hypointense
approximately 25% demonstrate mixed hypo and hyperintensity (Black hole effect)
Do not suppress on FLAIR
Generally do not enhance
Thin peripheral rim enhancement may occur
No restriction on DWI
 Less common
Most common
Metastasis
Ectatic basilar artery
Subependymoma
CSF flow artifact Pituitary
macroadenoma

Craniopharyngioma

Rare but important

Low grade
astrocytoma

Lymphoma
Autopsy specimen NECT scan shows hyperdense
demonstrates obstructive colloid cyst that is

hydrocephalus and a large hyperintense on T1WI st,

gelatinous-appearing hypointense on T2WI ﬈, with
colloid cyst with a densely mixed
fibrotic inspissated center
Lesion is located within the signal intensity on FLAIR
foramen of Monro
Ependymal cyst
Also called glioependymal cyst or neuroepithelial cyst
1% intracranial cyst
Solitary usually unilocular,they may cause ventricular asymmentry
Most asymptomatic,discovered incidentally,headache and cognitive dysfunction are common,large ependymal cysts occasionally causes obstructive hydrocephalus and increased intracranial pressure
All ages,but usually <40 yrs
Imaging
Density signal intensity =CSF
No enhancement ,no diffusion restriction,constructive interference in a steady state (ciss)may be necessary to delineate the cyst wall.
Differential diagnosis
m/c choroid cyst Uncommon :Epidermoid cyst
Arachnoid cyst
Cystic metastasis
Graphic image T2WI in the same
showing Axial NECT of
ependymal cyst case shows that the
ependymal cyst of
the lateral shows a CSF-
containing mass unilocular ependymal
ventricle as a CSF- cyst is exactly like
containing simple displacing the
calcified choroid CSF.
cyst that displaces
the choroid plexus plexus around it
Note distinct cyst
around it.
Scalp cystsTrichilemmal
(sebaceous)cyst:
Although the term sebaceous cyst is commonly used,it doesn’t contain sebaceous material .
Such cysts called as trichilemmal cysts .These cysts are proliferating are known as pillar
(turban)tumors.
These cysts are derived from the outer root sheath of hair follicles.
Most commonly occur in elderly women.
CT :
These are solid,cystic or mixed that are hyperdense compared with subcutaneous fat.
Calcification is common .
MRI:
These are generally isointense with brain and muscle on T1WI,
inhomogeneously hypointense on T2WI
TCs do not suppress on FLAIR
blooming foci on T2*(GRE,SWI)are caused by calcifications .
Axial T1WI in Most of the larger The cysts are
the hypointense
cysts appear quite compared with
same case the brain on
shows that hypointense on FLAIR.
the well- T2WI.
delineated The patients
scalp One of the smaller acute infarct is
REFERENCES
OSBORN BRAIN IMAGING ,PATHOLOGY AND
ANATOMY 2ND EDITION
RADIOLOGY ASSISTANT
THANK YOU