Typical and Atypical MR Imaging

Features of Intracranial
Epidermoid Tumors

David F. KaIImes1 OBJECTIVE. We categorized the MR imaging characteristics of intracranial epidetmoid tumors.
James M. Provenzale2 MATERIALS AND METHODS. MR images from 23 cases of intracranial epidermoid to-

Harry J.CIoft1 mors were reviewed retrospectively. Signal intensities of tumor relative to surrounding
structures were noted, as were the internal architecture of the tumors and the presence and
Roger E. McClendon3
degree of hydrocephalus.
RESULTS. Seventeen (74%) of 23 cases of intracranial epidermoid tumors were revealed
as slightly hyperintense relative to CSF on Il-weighted MR images. Nineteen (95%) of 20
American Journal of Roentgenology 1997.169:883-887.

cases were hyperintense relative to CSF on proton density-weighted MR images. Fifteen (65%)
of 23 cases were isointense to CSF on 12-weighted MR images, whereas the remaining eight
cases (35%) were hyperintense to CSF on 12-weighted MR images. One (4%) of 23 cases
showed signal intensity that was isointense to CSF on all pulse sequences. Fifteen (65%) of 23
cases showed heterogeneous signal characteristics on either TI -weighted or proton density-
weighted MR images, or both. Eight (35%) of 23 cases showed a rim of hyperintensity on pro-
ton density-weighted MR images. Five (33%) of the 15 cases that received gadolinium showed
rim enhancement. Five (22%) of 23 cases were multilocular, with different regions of tumors
showing highly variable imaging characteristics. Two (9%) of 23 cases showed high signal in-
tensity on 12-weighted MR images in the adjacent brain parenchyma. Two (9%) of 23 cases
showed mild hydrocephalus. Six (43%) of 14 tumors that either originated in or secondarily in-
volved the cerebellopontine angle also extended into the ipsilateral Meckel’s cave.
CONCLUSION. On 11-, proton density-, and 12-weighted MR images intracranial epi-
dermoid tumors usually showed heterogeneous signal intensity that was hyperintense to CSF.
On all spin-echo pulse sequences epidermoid tumors with signal characteristics isointense to
CSF were unusual. Hydrocephalus, even in the selling of marked displacement and compres-
sion of the brainstem, was not usually seen on MR imaging. Meckel’s cave was often involved
secondarily with epidermoid tumors that involved the cerebellopontine angle.

E pidermoid
nants
tumors
of ectodermal
represent
tissues
rem-
mis-
high
weighted
signal intensity
images, rim
on proton
enhancement,
density-
and
placed during embryogenesis [1] lack of edema in adjacent brain parenchyma
and account for approximately 0.3% of intra- [6, 1 1-14]. Several authors have noted that
cranial tumors [2]. These lesions have attracted epidermoid tumors may have signal intensity

Received November 25, 1996;accepted after revision

much attention in the radiology literature, espe- characteristics similar to those of CSF on all
March 24, 1997. cially since the advent of MR imaging. Vim- spin-echo pulse sequences, making it difficult
1 Department of Radiology, Box 170, University of Virginia ous signal-intensity patterns have been to distinguish these tumors from arachnoid
Health Sciences Center, Lee St., Charlottesville, VA 22908. reported, ranging from hypo- to hyperintense cysts [14-16]. These same authors suggest
Address correspondence to 0. F. Kalimes. on both Ti- and 12-weighted spin-echo im- the application of sequences such as diffu-
2Department of Radiology, Duke University Medical ages [3-1 1]. The most commonly reported sion-weighted, fast imaging with steady-state
Center, Durham, NC 27710.
characteristics of epidermoid tumors include precession or steady-state free precession im-
3Department of Pathology, Duke University Medical heterogeneously low signal intensity on 11- aging to differentiate epidermoid tumors
Center, Durham, NC 27710.
weighted images and high signal intensity on from arachnoid cysts. The apparent diffusion
AJR 1997;169:883-887 proton density- and 12-weighted images [6, coefficient of epidermoid tumors is less than
0361-803X197/1693-883 1 1]. Other imaging features occasionally de- that ofCSF within arachnoid cysts ( 151. allow-
© American Roentgen Ray Society scribed in epidermoid tumors include a rim of ing distinction between these lesions. In the

AJR:169, September 1997 883

 Kallmes et al.

case of steady-state imaging, either fast imag- copy. Consensus was attained by these readers in all
Wacterlsda of
ing with steady-state precession or steady- cases. The signal intensity of the tumors was com-
idsrmoM Tumors
state free precession, epidermoid tumors pared with that of surrounding structures, such as

show hyperintensity to CSF, most likely be- CSF, white matter, and gray matter (Table I). The
presence of heterogeneous signal intensity within
cause the bulk flow of the surrounding CSF
the tumors was specifically noted. Tumors were
leads to dephasing, with resultant loss of sig-
considered to be multilocular if different regions
nal intensity I 161. within the tumor exhibited markedly differenl sig-
Even though many studies have described nal-intensity characteristics on a single pulse se-
the MR imaging characteristics of epidermoid quence. For multilocular tumors, only the largest
tumors, detailed information of their appear- single region was included in the table. Tumors that
ance on high-field-strength (1.0 1 or greater) were isointense to CSF on all pulse sequences were
MR scanners is relatively scarce. Indeed, specifically noted. The presence and degree of hy-
many of the series regarding typical imaging drocephalus was noted. Also noted was the pres-
ence of hyperintensity within the adjacent brain
characteristics were based on studies obtained
parenchyma on proton density- or T2-weighted im-
on MR scanners of less than 0.5 1 [8, 9, 11].
ages. suggesting edema or gliosis. Proton density-
Many of these same series not only fail to re-
weighted images were scrutinized for the presence
port proton density-weighted findings but also of a hyperintense rim of signal intensity around the
do not precisely qualify the tumor’s signal in- periphery of the tumors. When available, the pres-
tensity relative to surrounding structures such ence, degree, and morphology of contrast enhance-
as gray matter, white matter, or CSF [10, 1 1]. ment within the tumors was noted. For tumors that
We report data from a series of 23 intracra- either originated in or secondarily involved the cer-
epidermoid tumors, most of which were ebellopontine angle (CPA), direct involvement of
American Journal of Roentgenology 1997.169:883-887.

nial
imaged using high-field-strength MR scanners. the ipsilateral Meckel’s cave was also noted. Such
involvement was defined as expansion of the ipsi-
We specifically detail spin-echo signal-intensity
lateral Meckel’s cave, with material isointense to
characteristics, as well as morphologic appear-
the portion of the epidermoid tumor closest to
ances, to define the findings most frequently
Meckel’s cave itself. Involvement of the ipsilateral
seen in intracranial epidermoid tumors. aty-weighted images,1.. eighted images.
internal auditory canal was also noted.
acpA = epidermoid tumors originating in or secondarily
Of the 23 cases included, TI- and 12-weighted
involving the cerebellopontine angle.
images were available in all cases, and proton den- bpercentages for Meckel’s cave involvement include only
Materials and Methods sity-weighted images were available in 20 cases
cerebellopontine angle tumors.
Cases were identified by computer searches at (87’/c). The cohort included 13 males and 10 fe-
three institutions. All cases were pathologically males who were 3-60 years (mean, 41 years). Gad-
proven. Two board-certified radiologists with sub- olinium-enhanced images were available in IS [General Electric Medical Systems. Milwaukee,
specialty training in neuroradiology concurrently (65%) of 23 cases. Sixteen studies were obtained WI] and three with a Magnetom I .5-1 scanner [Sie-
viewed the available spin-echo images on hard with 1.5-1 scanners (13 with a Signa 1.5-1 scanner mens Medical Systems. Iselin, NJ]). Four studies

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Fig. 1.-40-year-old man with epidermoid tumor originating in right cerebellopontine angle (CPA).
A, Axial Ti-weighted MR image shows right CPA epidermoid tumor displacing pons (P) to left. Tumor is of heterogeneous signal intensity, nearly identical to that of CSF within
occipital horn of left lateral ventricle (arrow).
B, Proton density-weighted MR image at same level as A shows heterogeneous signal intensity that is predominantly isointense to gray matter. Arrows delineate extent of tumor.
C. Axial T2-weighted MR image at same level as A and B shows signal intensity within tumor to be isointense to CSF. Basilar artery is displaced to left (open arrow). Cranial nerve
V (curvedarrow) traverses midportion of epidermoid tumor.

884 AJR:i69, September 1997

 were obtained with a Magnetom 1 .0-T scanner slightly hypointense relative to gray matter, 1C and 2C). Fifteen (65%) of 23 cases were
(Siemens Medical Systems). Three studies were ob- whereas five (22%) of 23 cases were isointense isointense to CSF on T2-weighted images,
tinned with a Technicare 0.6-1 scanner (General to CSF (Figs. IA and 2A). In one of the latter whereas the remaining eight cases (35%) were
Electric Medical Systems). Tl-weighted images hyperintense to CSF.
cases, the epidermoid tumor was also isointense
used TRIFE of 500/15, proton density-weighted
to CSF on proton density- and 12-weighted im- Concerning internal architecture, 15 (65%)
images used 2000/20, and T2-weighted images
ages (Fig. 3). A single case showed high signal of 23 cases showed heterogeneous signal-in-
used 2000/80. Fourteen tumors involved the CPA.
Three cases were located in the pineal region. Two intensity on TI-weighted images, similar to that tensity characteristics on either Il-weighted
cases each were located in the suprasellar cistern, of subcutaneous fat. or proton density-weighted images (Figs. 1,

fourth ventricle, and the region of the sylvian fis- In 19 (95%) of 20 cases, proton density- 2, and 4). On Il-weighted images, the heter-
sure. Eight cases had already undergone partial re- weighted images showed that the epidermoid ogeneity was usually manifested as thin, ir-
section. None of the patients had indwelling tumors were hyperintense relative to CSF regular, curvilinear regions of hyperintensity
ventricular shunts at the time of the MR imaging. (Fig. I B); 12 (63%) of these 19 cases showed relative to the remainder of the tumor.
isointensity to gray matter. The remaining A rim of hyperintensity on proton density-
Results seven (37%) of these 19 cases showed hyper- weighted images was shown in eight (35%) of
In 17 (74%) of 23 cases, Ti-weighted im- intensity to gray matter. 23 cases.
ages showed that the epidermoid tumors On 12-weighted images, all 23 cases Five (33%) ofthe 15 cases that underwent
were slightly hyperintense relative to CSF and showed iso- or hyperintensity to CSF (Figs. gadolinium-enhanced imaging showed rim

i;
American Journal of Roentgenology 1997.169:883-887.

Fig. 2.-36-year-o$d woman with left sylvian epidermoid tumor. Short straight arrow corresponds to region 1, long straight arrow to region 2, and curved arrow to region 3.
A, Axial gadolinium-enhanced Ti-weighted MR image shows three distinct patterns of signal intensity. In region 1, heterogeneous signal intensity similar to that of CSF is seen
within interpeduncular cistern. In region 2, signal intensity is nearly isointense to CSF. In region 3, signal intensity is markedly hyperintense to CSF. Rim enhancement is seen
along ventromedial aspect of tumor.
B, In an axial proton density-weighted MR image-region 1 shows signal intensity hyperintense to CSF. Region 2 shows signal intensity similar to CSF, and region 3 shows signal
intensity markedly hyperintense to CSF.
C, Axial T2-weighted MR image shows signal intensity is similar to CSF in each region.

A B C

Fig. 3.-29-year-old man with epidermoid tumor in region of pineal gland. Straight arrow denotes tumor and curved arrow points to lateral ventricles.
A, Axial Ti-weighted MR image shows that signal intensity within tumor (straight arrow) is isointense to CSF within trigones of lateral ventricles (curved arrow).
B, Axial proton density-weighted MR image shows that signal intensity within tumor is isointense to CSF.
C, Axial T2-weighted image shows that signal intensity within tumor is isointense to CSF.

AJR:169, September 1997 885

 Kalimes et al.

enhancement (Fig. 2A). None of these cases able, because many of the tumors displaced echo pulse sequences. is relatively unusual.
showed complete circumferential enhance- and deformed the sylvian aqueduct and fourth However, tumors that exhibited signal intensi-
ment. One of these five cases also showed en- ventricle (Figs. 4 and 5). ties relatively similar to CSF on one or two
hancement within the tumor, which was Concerning Meckel’s cave involvement, pulse sequences were frequent in our series.
limited to a thin, curved line (Fig. 2A). six (43%) of 14 tumors that involved the CPA Furthermore, the assessment of signal intensity
Five (22%) of 23 cases were multilocular, in also extended into the ipsilateral Meckel’s is subjective and, thus, subject to interobserver
which different regions of the tumors showed cave (Fig. 6). None of these tumors extended variability. As such, given the surgical corn-
highly variable imaging characteristics (Fig. 2). into the ipsilateral internal auditory canal. plexity associated with these lesions, advanced
Surrounding parenchymal signal-intensity imaging techniques such as fast imaging with
abnormalities were seen in two cases that steady-state precession, steady-state free pre-
had CPA involvement manifested as small Discussion cession, or diffusion-weighted imaging may
foci of increased signal intensity on proton This report represents the largest single Se- be useful in certain patients.
density- and 12-weighted images in the ad- ries to our knowledge detailing the MR imag- Hyperintense rims of signal intensity on
jacent brain parenchyma. One case showed ing characteristics of intracranial epidermoid proton density-weighted images have been
high signal intensity in the middle cerebellar tumors. Our data confirm earlier reports re- featured prominently in prior reports on in-
peduncle. and the other showed high signal garding the most common spin-echo imaging tracranial epidermoid tumors [6]. Most inves-
intensity within the pons. characteristics of these tumors. That is, most tigators have claimed that CSF entrapped
Twenty-one (91%) of 23 cases showed no epidermoid tumors show heterogeneous sig- within fronds of the tumor periphery is the
hydrocephalus. Two (9%) of 23 cases showed nal intensity slightly hyperintense to CSF on cause of this hyperintensity. However, CSF is
evidence of hydrocephalus. This was remark- Il-weighted images, hyperintense to CSF on hypointense rather than hyperintense on pro-
proton density-weighted images, and iso- or ton density-weighted images, so entrapped
American Journal of Roentgenology 1997.169:883-887.

hyperintense to CSF in 12-weighted images. fluid cannot explain the hyperintense rim. At
Previous authors have correlated the spin- any rate, this finding was present in less than
echo imaging characteristics with the pathol- half of the cases in our series; therefore, the
ogy of the tumors, especially regarding the absence of this hyperintense rim should not be
relative composition of keratin and choles- used as a criterion against the presence of an
terol [5]. Cholesterol within epidermoid tu- epidermoid tumor in a particular case.
mors is in the solid state and, thus, does not The striking lack of hydrocephalus even in
contribute to II shortening [51. Slight II hy- the face of marked mass effect on the sylvian
perintensity relative to CSF may result from aqueduct and fourth ventricle has been de-
protein or debris within the tumors 1161. 11 scribed [171. The physiology that allows persis-
shortening also contributes to the hyperinten- tent passage of CSF through bulky tumors and
sity of many epidermoid tumors relative to compressed ventricles and aqueducts is un-
CSF on long IR sequences (i.e., proton den- clear. Epidermoid tumors grow slowly, insinu-
sity- and 12-weighted images), because it en- ating themselves within cisternal spaces while
hances the rate of regrowth of longitudinal deforming adjacent structures. This slow rate
Fig. 4-29-year-old man with epidermoid tumor origi- magnetization with a resultant increase in sig- of growth may allow them to displace struc-
nating within right cerebellopontine angle. Ti-weighted nal intensity on long TR sequences. tures markedly without causing hydrocephalus.
MR image shows that tumor (straight arrow) distorts Our data suggest that the “isointense epider- Parenchymal signal-intensity changes adja-
midbrain and displaces aqueduct of Sylvius. No hydro-
cephalus is seen, as evidenced by nondilated temporal moid tumor,” with signal-intensity characteris- cent to the epidermoid tumors were unusual in
horns of lateral ventricles (curved arrows). tics identical to those of CSF on all three spin- our cases. Even in the two cases that showed the

Fig. 5-3-year-old girl with pon-

tomedullary epidermoid tumor that
secondarily involves cerebellopon-
tine angle.
A, On sagittal Ti-weighted MR image,
signal intensitywithin tumor is slightly
hyperintense to CSF.
B, Axial T2-weighted MR image,
shows tumor markedly distorts brain-
stem and compresses fourth ventricle
(straightarrow). No hydrocephalus is
seen, as evidenced by slitlike tempo-
ral horns of lateral ventricles (curved
arrows).

886 AJR:169, September 1997

 MR Imaging Features of Intracranial Epidermoid Tumors

similar involvement can be seen in a variety 5. Gualdi G, Di Biasi C, Trasimeni G, Pingi A, Vig-
of CPA tumors. Nonetheless, such a finding nati A, Mains G. Unusual MR and CT appearance
ofan epidermoid tumor. AJNR 1991:12:771-772
should be considered relatively typical for
6. Tampieri D, Melanson D. Ethier R. MR imaging of
epidermoid tumors that involve the CPA. No-
epidermoid cysts. AJNR 1989:10:351-356
tably, none of these tumors showed involve- 7. Newton DR. Larson TC, Dillon WP, Newton TH.
ment of the ipsilateral internal auditory canal. Magnetic resonance characteristics of cranial epi-
The most common differential diagnosis dermoid and teratomatous tumors (abstr). AJNR

considered in the setting of suspected epider- 1987;8:945

8. Vion-Dury J, Vincentelli F. Jiddane M, et al. MR
moid tumors in virtually any intracranial loca-
imaging of epidermoid cysts. Neurnradiologv
tion is that of arachnoid cysts, which almost
1987:29:333-338
always have a signal intensity isointense to CSF 9. Horowitz B, Chtal M. James R, Bryan RN. MR of
on all spin-echo pulse sequences. Other less intracranial epidermoid tumors: correlation of in
common considerations include, depending on vivo imaging with in vitro C-l3 spectroscopy.
location, craniophaiyngiomas, Rathke’s cleft AJNR 1990: 1 1:299-302
10. Panagopoulos K. El-Aouzi M, Chisolm H. Jolesz
cysts, and tumors that tend to form cystic corn-
FA, Black PM. Intracranial epidernoid tumors.
Fig. 6.-33-year-old man with epidermoid
tumor origi- ponents, including pilocytic astrocytomas, he-
nating within left cerebellopontine angle. Coronal T2-
weighted MR image shows expansion of Meckel’s cave
on left (curved arrow) relative to right-sided Meckel’s
mangioblastomas,
In conclusion,
and gangiogliomas.
most intracranial epidermoid
II .
Arch
Steffey
MR
Neural

imaging
1990:47:813-816
DJ. De Filipp GJ. Spera
of primary
1. Gabrielson
epidermoid tumors.
TO.
J
cave (straightarrow). tumors have heterogeneous signal intensity that Comput Assist Tomogr 1988; 12:438-440
is hyperintense to CSF on 11-, proton density-, 12. Rubin G, Scienza R, Pasqualin A. Craniocerebral

signal-intensity changes, the extent of paren- and T2-weighted images. Epidermoid tumors epidermoids and dermoids. Acta Neurnehir 1989:
97: 1-16
American Journal of Roentgenology 1997.169:883-887.

chymal abnormality was minor. The circum- with signal-intensity characteristics isointense
13. Gao P. Osborn AG. Smirniotopoulos JG. Harris CP
stances that allow passage of CSF through to CSF on all spin-echo pulse sequences are un- Epidermoid tumor of the cerebellopontine angle.
apparently compromised cisterns and aqueducts usual. Hydrocephalus, even in the setting of AJNR 1992:13:863-872
may also allow the brain parenchyma to func- marked displacement and compression of the 14. ‘flen RD. MacFall J, Heinz R. Evaluation of com-
tion normally despite significant compression. brainstem, is unusual. Meckel’s cave is often in- plex cystic masses of the brain: value of steady-
Meckel’s cave was secondarily involved in volved secondarily in the setting of epidermoid state free procession MR imaging. AiR 1992:159:
1049-1055
nearly one half of tumors involving the CPA tumors within the CPA.
15. Tsuruda J, Chew W, Moseley M, Norman D. Dif-
in our series. This finding is not surprising,
fusion-weighted MR imaging ofthe brain: value in
because Meckel’s cave is contiguous with the differentiating between extraaxial cysts and epider-
subarachnoid space of the prepontine cistern. References moid tumors.AJR 1990:155:1059-1065
Primary epidermoid tumors of Meckel’s cave 1. McLendon RE. Epidermoid and dermoid tumors. 16. SakamotoY, Takahashi M. UshioY. Korogi Y. Visi-
have been reported [18], but, to our knowl- In: Wilkins RH, Rengachary 55, eds. Neurosur- bility of epidermoid tumors on steady-state free
gery, 2nd ed. New York: McGraw-Hill, 1996: procession images. AJNR 1994:15:1737-1744
edge, only a single case of secondary involve-
959-963 17. Rosarlo M, Becker DH, Conley FK. Epidermoid
ment of Meckel’s cave with an epidermoid
2. Conley FK. Epidermoid and dermoid tumors: din- tumor involving the fourth ventricle. Neurosurgery
tumor has been reported in the radiology liter- ical features and surgical management. In: Wilkins 1981:9:9-13
ature [l9J. The frequency of this finding has RH, Rengachary 55. eds. Neumsurger 2nd ed. 18. Miyazawa N, Yamazaki H, Wakao T. Nukui H.
been underestimated; indeed, a recent report New York: McGraw-Hill, 1996:971- 977 Epidermoid tumors of Meckel’s cave: case report
included images of two epidermoid tumors 3. Ishikawa M, Kikuchi H, Asato R. Magnetic reso- and review of the literature. Neuro.curgerv 1989:
nance imaging of the intracranial epidermoid. Acta 2:951-955
originating in the CPA, both of which showed
Neumchir 1989;lOl:l08-l 11 19. Gentry LR, Jacoby CG, Turski PA, Houson LW,
enlargement of the ipsilateral Meckel’s cave
4. Latack JT, Kartush Kemink JL, Graham MD,
JM, Strother CM, Sacketi JE Cerebellopontine angle-
but no mention of tumor involvement was Knake JE. Epidermoidomas of the cerebellopon- petromastoid mass lesions: comparative study of
made in the text [16]. The significance of tine angle and temporal bone: CT and MR aspects. diagnosis with MR imaging and CT. Radiology
Meckel’s cave involvement is unclear, and Radiology 1985;l57:36l-366 1987; 162:5 13-520

AJR:169, September 1997 887