eMedicine Specialties > Radiology > Brain/Spine
Choroid Plexus Papilloma: Imaging
Updated: Sep 23, 2008
Radiography
Findings
Plain radiography is not used to investigate choroid plexus papillomas. However, evidence of increased intracranial pressure may be noted. The presence of faint intracranial calcification in appropriate locations, which is observed in 4.1% of patients, may suggest the diagnosis.
Degree of Confidence
Because of the low sensitivity and specificity of plain radiographs, CT scanning and MRI are the imaging studies of choice.
Computed Tomography
Findings
The advent of CT scanning has resulted in improvement in the detection and characterization of all intracranial masses, including choroid plexus papillomas.
In choroid plexus papillomas, these tumors appear as well-marginated round or lobulated solid masses and are isoattenuating or hyperattenuating relative to normal brain parenchyma on nonenhanced scans. In as many as 24% of patients, the tumors may contain foci of calcification, which is readily demonstrated on CT scans, compared with MRI. Choroid plexus papillomas are strongly enhancing after the intravenous administration of contrast material.
In children, choroid plexus papillomas can be heterogeneous in appearance because of the accumulation of CSF, blood, and blood products between the fronds and papillae. A heterogeneous appearance is a possible sign of malignancy. In adults, most choroid plexus papillomas are heterogeneous secondary to cystic and/or calcific degeneration.
Associated findings include hydrocephalus, which may involve the lateral, third, and fourth ventricles to varying degrees.
The presence of irregular margins should raise concerns about malignancy. Choroid plexus papillomas may have limited parenchymal invasion, which makes the distinction of the benign tumor from its malignant counterpart difficult.
Magnetic Resonance Imaging
Findings
Axial T2-weighted magnetic resonance image (repetition time, 2883 ms; echo time, 100 ms) shows a lobulated mass with frondlike papillary projections in the left lateral ventricle. The mass is isointense relative to the cortex and has internal hypointense foci that likely represent prominent vessels. Note the associated hydrocephalus and transependymal cerebrospinal fluid flow.
Axial T1-weighted nonenhanced magnetic resonance image (repetition time, 450 ms; echo time, 20 ms) shows that the mass is predominantly isointense relative to the cortex.
Sagittal T1-weighted contrast-enhanced magnetic resonance image (repetition time, 500 ms; echo time, 12 ms) shows intense heterogeneous enhancement. Note the extension into the third ventricle.
Axial T1-weighted contrast-enhanced magnetic resonance image (repetition time, 500 ms; echo time, 20 ms) demonstrates the strongly enhancing lateral ventricular mass.
Multiplanar imaging, which is possible with MRI, can be used to precisely localize and determine the extent of the choroid plexus papilloma, and thereby aid in surgical planning. MRI also has the advantage of eliminating artifacts of the posterior fossa, which can occasionally be problematic with CT scanning. MRI easily depicts local parenchymal invasion, which is occasionally present. MRI may be useful in distinguishing benign tumors from more aggressive or malignant choroid plexus tumors. Interventricular extension, an ancillary diagnostic sign of choroid plexus papilloma, is readily identified in the coronal plane. For these reasons, consider MRI the test of choice for the diagnosis of choroid plexus papilloma.
Choroid plexus papillomas appear as heterogeneous masses, with or without cystic components; these may have intratumoral signal voids that correspond to a rich vascular supply or low-intensity areas that correspond to calcifications.
On T1-weighted images, choroid plexus papillomas are slightly hypointense relative to gray matter in adults. In children, the masses are isointense. Small areas of high signal intensity are compatible with localized hemorrhagic components.
On T2-weighted images, tumors in both adults and children have high signal intensity, which may approximate the signal intensity of CSF. After the injection of a paramagnetic contrast agent such as gadolinium-diethylenetriamine pentaacetic acid (Gd-DTPA), intense enhancement is observed.
The superior imaging capability of MRI in the examination of the spinal canal may reveal evidence of seeding to the spinal subarachnoid space on rare occasions, particularly with posterior fossa tumors.
Gadolinium-based contrast agents (gadopentetate dimeglumine [Magnevist], gadobenate dimeglumine [MultiHance], gadodiamide [Omniscan], gadoversetamide [OptiMARK], gadoteridol [ProHance]) have been linked to the development of nephrogenic systemic fibrosis (NSF) or nephrogenic fibrosing dermopathy (NFD). For more information, see the eMedicine topic Nephrogenic Fibrosing Dermopathy.
NSF/NFD has occurred in patients with moderate to end-stage renal disease after being given a gadolinium-based contrast agent to enhance MRI or MRA scans. NSF/NFD is a debilitating and sometimes fatal disease. Characteristics include red or dark patches on the skin; burning, itching, swelling, hardening, and tightening of the skin; yellow spots on the whites of the eyes; joint stiffness with trouble moving or straightening the arms, hands, legs, or feet; pain deep in the hip bones or ribs; and muscle weakness. For more information, see the FDA Public Health Advisory or Medscape.
Ultrasonography
Findings
Ultrasonography may be useful in special circumstances, such as in neonates. The availability, portability, accuracy, low cost, and lack of a requirement for sedation make ultrasonography a valuable tool. In many instances, ultrasonography is the examination of choice for initial screening. Ultrasonographic evaluation may also be valuable in the postoperative assessment of the neonatal brain.
In cases of choroid plexus papilloma, real-time ultrasonography demonstrates the presence of hydrocephalus. The tumors themselves appear as heterogeneous, highly echogenic intraventricular masses with irregular borders. Doppler ultrasonographic studies have shown pulsatile intratumoral vascular channels with biphasic flow. Occasionally, intratumoral cysts are identified; these appear as hypoechoic areas and are believed to represent areas of hydropic degeneration.
Angiography
Findings
The blood supply to choroid plexus papillomas is derived from the choroid plexus. An enlarged anterior choroidal artery supplies tumors within the temporal horns of the lateral ventricles, whereas the posterior choroidal arteries supply masses in the atria or posterior horn. Branches of the posterior inferior cerebellar artery may supply tumors in the fourth ventricle.
Angiographic signs may include the presence of many small spiral arteries; a meningioma-type blush with early tumoral circulation and persistent enhancement into the venous phase; displacement of vessels such as the internal cerebral veins; and evidence of ventricular dilatation.
More on Choroid Plexus Papilloma |
| Overview: Choroid Plexus Papilloma |
 Imaging: Choroid Plexus Papilloma |
| Follow-up: Choroid Plexus Papilloma |
| Multimedia: Choroid Plexus Papilloma |
| References |
| Further Reading |
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Further Reading
Management of brain metastases: role of radiotherapy alone or in combination with other treatment modalities.
Program in Evidence-based Care. 2004 Mar 30. 35 pages. NGC:003529
Pre-irradiation evaluation and management of brain metastases.
American College of Radiology. 1999 (revised 2005). 7 pages. NGC:004635
Keywords
choroid plexus papilloma, CPP, choroid plexus neoplasm, choroid plexus tumor, benign intracranial neoplasm, cerebral ventricle neoplasm, brain neoplasm, brain tumor
