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+++ b/docs_md/articles/cisterna-magna-mass_047add0c-7e4f-40a0-9933-8d6fa00a24f7.md
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+---
+title: "Cisterna Magna Mass"
+docid: "047add0c-7e4f-40a0-9933-8d6fa00a24f7"
+authors:
+ - key: "d19354f3-7ff2-495a-ad3f-064122e45602"
+ value: "Bernadette L. Koch, MD"
+ - key: "20008105-51da-4bbf-aba6-e8253b2d9c21"
+ value: "Daniel E. Meltzer, MD"
+breadcrumbs:
+ -
+ name: "Head and Neck"
+ slug: "head-and-neck"
+ treeNodeId: "ed24ed8c-5d57-4629-879b-447b82d2973d"
+ -
+ name: "Differential Diagnosis"
+ slug: "differential-diagnosis"
+ treeNodeId: "40d68862-8975-4dde-ac2b-ebc43ab0fb5c"
+ -
+ name: "CPA-IAC and Posterior Fossa"
+ slug: "cpa-iac-and-posterior-fossa"
+ treeNodeId: "c590eedb-4a3b-4158-a04f-ad880564c992"
+ -
+ name: "Anatomically Based Differentials"
+ slug: "anatomically-based-differentials"
+ treeNodeId: "debfb06c-8656-4f5d-92c1-eaa468185d78"
+ -
+ name: "Cisterna Magna Mass"
+ slug: "cisterna-magna-mass"
+ treeNodeId: null
+category: "Head and Neck"
+documentVersionId: "86b48ea6-d9ea-428a-b5cb-32a58aaf84b2"
+imageCount: 37
+lastUpdated: "07/16/24"
+pageDescription: "Cisterna Magna Mass"
+pageKeywords: "Head and Neck, Differential Diagnosis, CPA-IAC and Posterior Fossa, Anatomically Based Differentials, Cisterna Magna Mass"
+pageTitle: "Cisterna Magna Mass | STATdx"
+enhancedTitle: "Cisterna Magna Mass"
+type: "DDX"
+references: true
+breadcrumbs:
+ - "Head and Neck"
+ - "Differential Diagnosis"
+ - "CPA-IAC and Posterior Fossa"
+ - "Anatomically Based Differentials"
+ - "Cisterna Magna Mass"
+---
+# ESSENTIAL INFORMATION
+
+- ## Key Differential Diagnosis Issues
+
+
+ - Cisterna magna (CM) between medulla (anterior), occiput (posterior) (a.k.a. cerebellomedullary cistern)
+ - Below/behind inferior vermis
+ - Large medullary cistern masses may extend laterally, posteriorly into CM
+ - Most common adult lesions are tonsillar associated
+ - Indirect (secondary effect on tonsil) > direct (lesion in tonsil)
+ - MR and clinical information helps DDx
+- ## Helpful Clues for Common Diagnoses
+
+
+ - **Herniation Syndromes, Intracranial**
+ - Tonsillar herniation most often 2° to posterior fossa (PF) mass effect
+ - Tonsils pushed down into CM
+ - Peg-like configuration of tonsils
+ - Tonsil folia usually oriented horizontally → become vertically oriented when herniated
+ - 4th ventricle may obstruct → obstructive hydrocephalus
+ - **Chiari 1**
+ - Pointed cerebellar tonsils ≥ 5 mm below foramen magnum (FM)
+ - Crowded FM + effaced CSF
+ - ± brainstem compression
+ - ± retroflexed odontoid, horizontal clivus, scoliosis
+ - PF usually normal size
+ - Syrinx in 30-70%
+ - Treatment aim = restore normal CSF flow at FM
+ - **Chiari 2**
+ - Small PF → contents herniates inferiorly through FM and superiorly through widened incisura
+ - Cascade of tissue (vermis, not tonsil) herniates downward through FM
+ - Caudal brainstem herniation with cervicomedullary kink, tectal beaking, falx insufficiency
+ - ± ventriculomegaly, subependymal gray matter heterotopia, &/or polymicrogyria
+ - ~ 100% secondary to open spinal dysraphism, most often myelomeningocele
+ - **Dandy-Walker Continuum**
+ - Dandy-Walker continuum is broad spectrum of cystic PF malformations
+ - 2/3 have associated CNS &/or extracranial anomalies
+ - All may have inner table occipital bone scalloping
+ - Dandy-Walker malformation classic triad
+ - Vermian agenesis/hypogenesis
+ - Cystic dilatation 4th ventricle
+ - Large PF with lambdoid-torcular inversion
+ - ± hydrocephalus
+ - Vermian hypoplasia
+ - Varying degrees of vermian hypoplasia
+ - ± rotation of vermis
+ - No enlargement of PF
+ - Blake pouch cyst
+ - Open 4th ventricle
+ - Elevated tegmentovermian angle
+ - Normal size and morphology of vermis
+ - Mega CM
+ - Enlarged retrocerebellar cistern communicates with normal 4th ventricle
+ - Normal vermis
+- ## Helpful Clues for Less Common Diagnoses
+
+
+ - **Arachnoid Cyst**
+ - Sharply demarcated extraaxial cyst that follows CSF attenuation/signal
+ - FLAIR suppresses; no diffusion restriction
+ - Size varies from few millimeters to giant
+ - Often asymptomatic, found incidentally
+ - Cerebellopontine angle (CPA) location > CM
+ - **Ependymoma**
+ - Anywhere in neuraxis: 2/3 in PF, 1/3 in supratentorial
+ - 3rd most common malignant pediatric brain tumor arising in PF
+ - Heterogeneous T1/T2 signal with mild to moderate enhancement
+ - Soft or "plastic" tumor squeezes out of 4th ventricle foramina into cisterns
+ - Calcification common (50%)
+ - ± cysts, hemorrhage
+ - Sagittal imaging can distinguish origin as floor vs. roof of 4th ventricle
+ - CSF seeding may occur → image entire neuraxis
+ - **Meningioma**
+ - CM rare PF location
+ - CPA, medullary cisterns more common than CM
+ - CM meningiomas usually arise from occipital squamosa
+ - Well-demarcated, lobulated/rounded enhancing mass with dural attachment
+ - Hyperostosis, tumoral calcifications, ↑ vascular markings
+ - **Metastasis**
+ - Linear or nodular meningeal enhancement
+ - MR CSF flow may be helpful establishing location and degree of CSF obstruction
+ - Primary tumors include breast, lung, melanoma, prostate
+ - Lymphoproliferative malignancy = lymphoma and leukemia
+ - Primary CNS tumor seed basal cisterns (drop metastases)
+ - **Image entire neuraxis**
+ - **Intracranial Hypotension**
+ - Sagittal shows brain descent in 40-50%
+ - Caudal displacement of cerebellar tonsils in 25-75%
+ - Diffusely and intensely enhancing dura in 85%
+ - Bilateral subdural fluid collections in 15%
+ - Dural venous sinus may be distended (convex margins)
+ - Enlarged pituitary
+ - Frequently misdiagnosed syndrome of headache caused by ↓ intracranial CSF pressure from spontaneous spinal CSF leak
+- ## Helpful Clues for Rare Diagnoses
+
+
+ - **Subependymoma**
+ - T2-hyperintense lobular, nonenhancing intraventricular mass
+ - When arises from 4th ventricle floor, may extend posteroinferiorly into CM
+ - More common in middle-aged, older adults
+ - 0.7% of intracranial neoplasms
+ - **Epidermoid Cyst**
+ - Congenital inclusion cysts
+ - Lobulated, irregular, CSF-like mass with "fronds" insinuate cistern
+ - FLAIR usually does not completely null; diffusion yields high-signal restriction
+ - 0.2-1.8% of all primary intracranial tumors
+ - CPA cistern (40-50%) > 4th ventricle (17%) > sellar/parasellar (10-15%)
+ - Rare malignant degeneration into squamous cell carcinoma
+ - **Dermoid Cyst**
+ - Fat appearance: Use fat suppression sequence to confirm
+ - With rupture, fat droplets in cisterns, sulci, and ventricles with extensive MR enhancement possible from chemical meningitis
+ - Rare: < 0.5% of primary intracranial tumors
+ - Rupture can cause significant morbidity/mortality
+ - Rare malignant degeneration into squamous cell carcinoma
+ - **Hemangioblastoma**
+ - Intraaxial PF mass with cyst, enhancing mural nodule abutting pia
+ - Classified as 1 of mesenchymal, nonmeningothelial tumors
+ - Familial = von Hippel-Lindau
+ - ≈ 30% of patients with hemangioblastoma have von Hippel-Lindau
+ - 7-10% of PF tumors
+ - **Neurenteric Cyst**
+ - Round/lobulated, nonenhancing, slightly hyperintense to CSF mass
+ - Most intracranial NECs found in PF
+ - Benign malformative endodermal CNS cyst
+ - Part of split spinal cord malformation spectrum; persistent neurenteric canal
+ - Location
+ - Thoracic (42%), cervical (32%)
+ - Others: Lumbar spine, basilar cisterns, brain parenchyma
+ - Anterior medullary, CPA cisterns > CM
+
+## References
+
+# Selected References
+
+1. [Pindrik J et al: Imaging in Chiari I malformation. Neurosurg Clin N Am. 34(1):67-79, 2023](http://www.ncbi.nlm.nih.gov/pubmed/?term=36424066%5Bpmid%5D)
+1. [Paun L et al: Foramen magnum meningiomas: a systematic review and meta-analysis. Neurosurg Rev. 44(5):2583-96, 2021](http://www.ncbi.nlm.nih.gov/pubmed/?term=33507444%5Bpmid%5D)
+1. [Menezes AH et al: Neurenteric cysts at foramen magnum in children: presentation, imaging characteristics, and surgical management-case series and literature review. Childs Nerv Syst. 36(7):1379-84, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=32322975%5Bpmid%5D)
+1. [Abdel Razek AA et al: Magnetic resonance imaging of malformations of midbrain-hindbrain. J Comput Assist Tomogr. 40(1):14-25, 2016](http://www.ncbi.nlm.nih.gov/pubmed/?term=26599961%5Bpmid%5D)
+1. [Dorfer C et al: Ependymoma: a heterogeneous tumor of uncertain origin and limited therapeutic options. Handb Clin Neurol. 134:417-31, 2016](http://www.ncbi.nlm.nih.gov/pubmed/?term=26948369%5Bpmid%5D)
+1. [Louis DN et al: The 2016 World Health Organization Classification of Tumors of the Central Nervous System: a summary. Acta Neuropathol. 131(6):803-20, 2016](http://www.ncbi.nlm.nih.gov/pubmed/?term=27157931%5Bpmid%5D)
+1. [Tao C et al: Prognostic factors affecting the surgical outcome of anterolateral benign tumors in the foramen magnum region. Int J Surg. 33 Pt A:172-6, 2016](http://www.ncbi.nlm.nih.gov/pubmed/?term=27528437%5Bpmid%5D)
+1. [Tian W et al: A quantitative study of intracranial hypotensive syndrome by magnetic resonance. Clin Neurol Neurosurg. 141:71-6, 2016](http://www.ncbi.nlm.nih.gov/pubmed/?term=26745515%5Bpmid%5D)
+1. [Yamahata H et al: Exploitation of simple classification and space created by the tumor for the treatment of foramen magnum meningiomas. World Neurosurg. 87:1-7, 2016](http://www.ncbi.nlm.nih.gov/pubmed/?term=26409077%5Bpmid%5D)
+1. [Cesmebasi A et al: The Chiari malformations: a review with emphasis on anatomical traits. Clin Anat. 28(2):184-94, 2015](http://www.ncbi.nlm.nih.gov/pubmed/?term=25065525%5Bpmid%5D)
+1. [Liao CC et al: Clinical features and surgical outcomes of sporadic cerebellar hemangioblastomas. Clin Neurol Neurosurg. 125:160-5, 2014](http://www.ncbi.nlm.nih.gov/pubmed/?term=25156409%5Bpmid%5D)
+
+
+## Images
+
+
+### Selected Images
+
+
+**Herniation Syndromes, Intracranial**
+*Sagittal T1 C+ MR shows a cystic mass with an enhancing nodule
, consistent with hemangioblastoma, pushing the tonsils inferiorly through the foramen magnum
. Note effaced 4th ventricle
, enlarged foramen of Monro
, and enlarged 3rd
and lateral
ventricles, consistent with obstructive hydrocephalus.*
+
+
+**Herniation Syndromes, Intracranial**
+*Sagittal T1 C+ MR shows a cystic mass with an enhancing nodule
, consistent with hemangioblastoma, pushing the tonsils inferiorly through the foramen magnum
. Note effaced 4th ventricle
, enlarged foramen of Monro
, and enlarged 3rd
and lateral
ventricles, consistent with obstructive hydrocephalus.*
+
+
+**Chiari 1**
+*Sagittal T2 MR in a patient with occipital headaches shows a significantly pointed configuration of a low-lying cerebellar tonsil
to the level of the midposterior ring of C2. Notice also the dorsally tilted dens
, effacement of CSF at the foramen magnum, and associated cervicothoracic syrinx
.*
+
+
+**Chiari 2**
+*Sagittal T2 MR shows a small posterior fossa with extension of the cerebellar peg
through the foramen magnum to the level of C6. The cervicomedullary junction and 4th ventricle
are low-lying and there is mild tectal beaking
and moderate prominence of the massa intermedia
.*
+
+
+**Dandy-Walker Continuum**
+*Sagittal T2 MR demonstrates a markedly enlarged posterior fossa with cystic dilatation of the 4th ventricle
, upward rotation of severely hypoplastic vermis
, markedly enlarged posterior fossa, and elevated torcula.*
+
+
+**Arachnoid Cyst**
+*Sagittal T1WI MR shows a CSF isointense arachnoid cyst
filling the lower posterior fossa, effacing the cisterna magna, flattening the cervicomedullary junction
, and extending caudally into the upper cervical canal.*
+
+
+**Ependymoma**
+*Sagittal T1WI C+ MR shows enhancing tissue extruding through the foramen of Magendie, filling the cisterna magna
. Resultant obstruction has caused enlargement of the cerebral aqueduct
and dilated 3rd ventricle
.*
+
+
+**Meningioma**
+*Sagittal T1WI MR demonstrates dural-based tumor
with significant mass effect compressing and displacing the cerebellum. Note the trapped CSF clefts
. The tumor encroaches on the cisterna magna.*
+
+
+**Metastasis**
+*Axial T1WI C+ MR shows a typical case of primary CNS lymphoma with subependymal tumor spread. Note a posterior fossa mass near the foramen of Luschka
as well as a 2nd dural-based mass
.*
+
+
+**Intracranial Hypotension**
+*Sagittal T1WI C+ MR shows obliteration of the suprasellar cistern
, sagging/fat midbrain with closed angle between the peduncles and the pons
, dural enhancement
, and tonsillar descent
with effacement of the cisterna magna.*
+
+
+**Subependymoma**
+*Sagittal T1WI C+ MR in 40-year-old man shows an enhancing mass at the bottom of the 4th ventricle
filling the cisterna magna.*
+
+
+**Epidermoid Cyst**
+*Sagittal T1WI MR shows a typical case of a large 4th ventricular epidermoid cyst
, which follows CSF intensity but is often slightly brighter and mildly heterogeneous in signal.*
+
+
+**Dermoid Cyst**
+*Axial T2WI MR demonstrates a T2- hyperintense mass
encroaching laterally upon the ventral CSF at the foramen magnum. There was evidence of rupture (not shown) causing recurrent meningitis.*
+
+
+**Hemangioblastoma**
+*Sagittal T1WI C+ MR shows an enhancing vermian mass protruding through the foramen magnum
. An associated cyst
is deforming the 4th ventricle
.*
+
+
+**Neurenteric Cyst**
+*Axial T1WI C+ MR shows a neurenteric cyst encroaching
upon the prepontine cistern. Although most often these are located anteriorly, they may arise posteriorly at the cisterna magnum.*
+
+
+### Additional Images
+
+
+**Chiari 2**
+*Sagittal T1WI MR shows a small posterior fossa with extension of the cerebellar peg
through the foramen magnum to the level of C3. The cervicomedullary junction and 4th ventricle
are low-lying, and there is tectal beaking
.*
+
+
+**Dandy-Walker Continuum**
+*Sagittal T1WI MR demonstrates a markedly enlarged posterior fossa with cystic dilatation of the 4th ventricle
, upwardly rotated hypoplastic vermis
, and low-lying torcular Herophili
.*
+
+
+**Chiari 1**
+*Sagittal T2 MR in a patient with occipital headaches shows a significantly pointed configuration of a low-lying cerebellar tonsil
to the level of the midposterior ring of C2. Notice also the dorsally tilted dens
and effacement of CSF at the foramen magnum.*
+
+
+**Chiari 1**
+*Sagittal T1WI MR shows inferior extension of the peg-like cerebellar tonsils
well below the level of the foramen magnum
, consistent with Chiari 1.*
+
+
+**Herniation Syndromes, Intracranial**
+*Axial T2WI MR at the level of the foramen magnum demonstrates downward tonsillar herniation
secondary to mass affect from brain death.*
+
+
+**Herniation Syndromes, Intracranial**
+*Sagittal T1WI MR shows cerebellar tonsillar herniation
from a large left posterior fossa mass. Note compression of 4th ventricle
. Supratentorial ventricles are enlarged
.*
+
+
+**Chiari 1**
+*Sagittal CINE phase-contrast CSF flow - diastolic shows diminished posterior CSF flow
compared to anterior CSF flow
at the site of tonsillar impaction.*
+
+
+**Chiari 1**
+*Sagittal T2WI MR shows a classic case of Chiari 1 with pointed cerebellar tonsils
protruding through the foramen magnum and effacing the cisterna magna.*
+
+
+**Chiari 2**
+*Sagittal T2WI MR shows a small posterior fossa with caudal descent of cerebellar tonsillar tissue
, elongation of the 4th ventricle
, and cervical cord syrinx
.*
+
+
+**Chiari 2**
+*Axial FSPGR image demonstrates caudally displaced cerebellar tissue
wrapping around the brainstem. This is sometimes referred to as a "creeping cerebellum" due to a small posterior fossa.*
+
+
+**Chiari 2**
+*Sagittal T1WI MR shows caudal descent of cerebellar vermian tissue
and elongated 4th ventricle
as well as callosal dysgenesis
and a small posterior fossa.*
+
+
+**Chiari 2**
+*Sagittal T1 C+ MR shows a small posterior fossa with extension of the vermis through the foramen magnum to the level of C1/2
. The 4th ventricle is small
, and there is tectal beaking
.*
+
+
+**Dandy-Walker Continuum**
+*Axial T2WI MR shows a normal 4th ventricle and vermis; however, there is a prominent retrocerebellar CSF space
, which does not cause compression but does remodel endosteum, leading to mega cisterna magna.*
+
+
+**Arachnoid Cyst**
+*Sagittal T1WI MR demonstrates a CSF-intensity arachnoid cyst remodeling the endosteum
and filling the cisterna magna
.*
+
+
+**Ependymoma**
+*Sagittal T2WI MR shows heterogeneous features of an ependymoma. Focal hyperintense regions correspond to focal necrosis
and hypointense regions correlate to calcification
.*
+
+
+**Ependymoma**
+*Axial T1 C+ MR demonstrates a heterogeneously enhancing ependymoma
containing cystic elements
.*
+
+
+**Ependymoma**
+*Sagittal T1 C+ MR shows an enhancing mass expanding the 4th ventricle
. The mass is also distending the obex
and protruding through the foramen of Magendie into the cisterna magna
.*
+
+
+**Meningioma**
+*Axial T2WI MR demonstrates a posterior fossa meningioma
with significant mass effect upon the cerebellum with interposed trapped CSF clefts
and vessels
.*
+
+
+**Meningioma**
+*Axial T1 C+ MR of a meningioma shows an avidly enhancing, dural-based mass splaying the cerebellar hemispheres, flattening the 4th ventricle
, with dural tail
.*
+
+
+**Metastasis**
+*Coronal T1 C+ MR demonstrates the diffuse enhancement of meningeal carcinomatosis from metastatic xanthoastrocytoma
spread throughout the posterior fossa, folia, and also more cephalad.*
+
+
+**Intracranial Hypotension**
+*Sagittal T1WI MR shows tonsillar descent
and dural thickening
secondary to intracranial hypotension.*
+
+
+**Epidermoid Cyst**
+*Axial DWI MR shows a hyperintense mass
in the midline posterior fossa.*
+
+
+**Hemangioblastoma**
+*Sagittal T1 C+ MR demonstrates a mostly solid hemangioblastoma
involving the cerebellar tonsils and effacing the cisterna magna.*
+
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