244 lines
22 KiB
Markdown
244 lines
22 KiB
Markdown
---
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title: "Quadrigeminal Cistern Mass"
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docid: "828ddbbf-3daf-45b9-8dce-2ab3582fddaa"
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authors:
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- key: "f184750a-90b4-47a7-907b-23b05d70357a"
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value: "Chang Yueh Ho, MD"
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breadcrumbs:
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-
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name: "Brain"
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slug: "brain"
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treeNodeId: "6d8829f1-14d7-45af-8675-255189aa526a"
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-
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name: "Differential Diagnosis"
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slug: "differential-diagnosis"
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treeNodeId: "a7fdd139-664e-4bb8-8d18-400e4733ff60"
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-
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name: "Sella/Juxtasellar, Pineal Region"
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slug: "sellajuxtasellar-pineal-region"
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treeNodeId: "5e38b9c1-3137-47e3-aa83-1fc82cb4099a"
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-
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name: "Anatomically Based Differentials"
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slug: "anatomically-based-differentials"
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treeNodeId: "7a51b2ca-8fee-4c16-aff3-b7189f68ea60"
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-
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name: "Quadrigeminal Cistern Mass"
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slug: "quadrigeminal-cistern-mass"
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treeNodeId: null
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category: "Brain"
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documentVersionId: "f1b37d5a-a0fe-4dbb-9e53-9f3a204d6cec"
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imageCount: 31
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lastUpdated: "01/27/23"
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pageDescription: "Quadrigeminal Cistern Mass"
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pageKeywords: "Brain, Differential Diagnosis, Sella/Juxtasellar, Pineal Region, Anatomically Based Differentials, Quadrigeminal Cistern Mass"
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pageTitle: "Quadrigeminal Cistern Mass | STATdx"
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enhancedTitle: "Quadrigeminal Cistern Mass"
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type: "DDX"
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references: true
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breadcrumbs:
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- "Brain"
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- "Differential Diagnosis"
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- "Sella/Juxtasellar, Pineal Region"
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- "Anatomically Based Differentials"
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- "Quadrigeminal Cistern Mass"
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---
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# ESSENTIAL INFORMATION
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- ## Key Differential Diagnosis Issues
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- Quadrigeminal cistern (QC) lesions are smaller subset of pineal region masses
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- Bounded by quadrigeminal plate, splenium, vermis, & tentorial margin
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- Contents: Pia, pineal gland, caudal internal cerebral veins, vein of Galen, posterior cerebral artery, posteromedial choroidal arteries, CNIV
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- Masses arising from QC itself (& its contents) < < those from nearby structures
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- ## Helpful Clues for Common Diagnoses
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- **Leptomeningeal Metastases**
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- From primary CNS or non-CNS neoplasms
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- Linear &/or nodular enhancing lesions
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- Image entire neuraxis
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- ## Helpful Clues for Less Common Diagnoses
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- **Cyst of Velum Interpositum**
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- Axial MR/CT shows triangular-shaped CSF space between bodies of lateral ventricles
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- Follows CSF on all sequences
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- Mimics arachnoid cyst of QC
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- Splays & elevates fornix
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- Inferiorly displaces internal cerebral veins
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- **Medial Atrial Diverticulum**
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- Massive hydrocephalus causes dehiscence of fornix → diverticula of inferior medial atrial wall
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- Creates subarachnoid cyst that may herniate medial to occipital lobe into QC
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- **Arachnoid Cyst**
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- Sharply demarcated extraaxial cyst that follows CSF
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- May be eccentric
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- Elevates internal cerebral veins
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- **Neurocysticercosis**
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- Cystic lesion isointense to CSF; may see discrete, eccentric scolex
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- Basal cistern cysts may be racemose
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- **CNS Tuberculoma**
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- Ring-enhancing abscess without central ↓ diffusion
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- ## Helpful Clues for Rare Diagnoses
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- **Lipoma**
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- Well-delineated, lobulated, extraaxial mass with fat attenuation/intensity
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- Ca⁺⁺ varies from none to extensive
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- **Epidermoid Cyst**
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- Lobulated, irregular, CSF-like mass
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- Incomplete FLAIR suppression; diffusion restriction
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- Surface ectoderm rests included with neural tube closure
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- **Dermoid Cyst**
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- Fat containing: MR fat suppression or negative HU
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- May rupture with sulcal fat & chemical meningitis
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- **Vein of Galen Malformation**
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- Misnomer: Arteriovenous fistula draining into enlarged median prosencephalic vein
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- Dilated arteries feeding into large midline venous pouch
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- Look for prominent flow voids & phase artifact
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## References
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# Selected References
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1. [Silva MA et al: Surgical management of quadrigeminal cistern arachnoid cysts: case series and literature review. J Neurosurg Pediatr. 29(4):427-34, 2022](http://www.ncbi.nlm.nih.gov/pubmed/?term=34996040%5Bpmid%5D)
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1. [Smith AB et al: From the archives of the AFIP: lesions of the pineal region: radiologic-pathologic correlation. Radiographics. 30(7):2001-20, 2010](http://www.ncbi.nlm.nih.gov/pubmed/?term=21057132%5Bpmid%5D)
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## Images
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### Selected Images
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**Leptomeningeal Metastases**
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*Axial T1 C+ MR shows abnormal leptomeningeal enhancement <img src='img/arrows/CS.png'/> in the quadrigeminal cistern in this child with a primary tumor in the spinal cord. This was a glioneuronal tumor at resection.*
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**Leptomeningeal Metastases**
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*Axial T1 C+ MR shows abnormal leptomeningeal enhancement <img src='img/arrows/CS.png'/> in the quadrigeminal cistern in this child with a primary tumor in the spinal cord. This was a glioneuronal tumor at resection.*
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**Medial Atrial Diverticulum**
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*Sagittal T2 MR in a child with hydrocephalus shows markedly enlarged ventricles. The left lateral ventricle herniates through the medial wall of the atria, through the quadrigeminal plate cistern <img src='img/arrows/CS.png'/> and compresses the cerebellum inferiorly below the tentorium <img src='img/arrows/CC.png'/>.*
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**Arachnoid Cyst**
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*Sagittal T2 MR shows a large cyst centered in the quadrigeminal cistern with mass effect on the cerebellum inferiorly <img src='img/arrows/CS.png'/>, which elevates the flow voids of the internal cerebral veins <img src='img/arrows/CC.png'/>.*
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**Neurocysticercosis**
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*Axial T1 C+ MR shows abnormal leptomeningeal enhancement <img src='img/arrows/CS.png'/> in the right suprasellar cistern with nonenhancing racemose cysts <img src='img/arrows/CC.png'/> in the left ambient and quadrigeminal plate cistern. This patient had a history of neurocysticercosis.*
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**CNS Tuberculoma**
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*Axial T1 C+ MR shows multiple ring-enhancing lesions in the parenchyma and basal cisterns. Note the nodular enhancement in the ambient and quadrigeminal plate cistern <img src='img/arrows/CS.png'/> in this patient with CNS tuberculosis.*
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**Lipoma**
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*Axial T2 FS MR shows a tectal mass projecting into the quadrigeminal plate cistern with signal loss <img src='img/arrows/CS.png'/>. This is consistent with a tectal lipoma. Intracranial lipomas are typically midline and can be associated with malformations, particularly the corpus callosum.*
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**Epidermoid Cyst**
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*Axial DWI trace MR shows a hyperintense mass in the left quadrigeminal cistern <img src='img/arrows/CS.png'/>. This followed CSF on T1 and T2 but had incomplete FLAIR suppression. Epidermoid cysts are from inclusion of surface ectoderm during neural tube closure with midline predominance.*
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**Vein of Galen Malformation**
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*Sagittal T2 HASTE MR shows a large, hypointense mass in the quadrigeminal cistern from a large flow void of the mesencephalic vein <img src='img/arrows/CS.png'/>. Note dilated straight sinus <img src='img/arrows/CO.png'/> and superior sagittal sinus. The mass causes cerebellar tonsil herniation <img src='img/arrows/CC.png'/>.*
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### Additional Images
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**Leptomeningeal Metastases**
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*Axial T1 C+ MR demonstrates typical leptomeningeal (pia and arachnoid) metastases <img src='img/arrows/WS.png'/> involving quadrigeminal cistern as well as other structures via subarachnoid spread.*
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**Cyst of Velum Interpositum**
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*Axial FLAIR MR shows a cavum velum interpositum as a CSF isointense mass <img src='img/arrows/WS.png'/>, which suppresses completely on FLAIR.*
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**Arachnoid Cyst**
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*Sagittal T1WI MR shows a CSF intensity arachnoid cyst in the superior vermian cistern <img src='img/arrows/BS.png'/> extending into and expanding the quadrigeminal cistern <img src='img/arrows/WS.png'/>.*
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**Neurocysticercosis**
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*Axial T1 C+ MR shows multiple nonenhancing cysts in the quadrigeminal cistern <img src='img/arrows/WS.png'/> and in the atrium of the right lateral ventricle <img src='img/arrows/WC.png'/>.*
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**Lipoma**
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*Sagittal T1WI MR demonstrates a hyperintense, well-circumscribed lipoma <img src='img/arrows/BS.png'/> in the quadrigeminal cistern.*
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**Epidermoid Cyst**
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*Axial DWI MR shows a multilobulated epidermoid <img src='img/arrows/WS.png'/> extending into the quadrigeminal cistern <img src='img/arrows/WO.png'/>, which restricts on diffusion.*
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**Dermoid Cyst**
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*Axial NECT shows a typical, hypodense, fat-containing, ruptured dermoid <img src='img/arrows/WS.png'/>. Fat droplets, also with negative HU, are present throughout the subarachnoid space <img src='img/arrows/WO.png'/>.*
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**Dermoid Cyst**
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*Sagittal T1WI MR shows a ruptured quadrigeminal cistern dermoid <img src='img/arrows/WO.png'/> as well as fat droplets throughout the subarachnoid space <img src='img/arrows/WS.png'/> and ventricular fat-fluid levels <img src='img/arrows/BS.png'/>.*
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**Vein of Galen Malformation**
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*Axial T1 C+ MR shows a very prominent phase artifact <img src='img/arrows/WS.png'/> from a quadrigeminal cistern vein of Galen malformation <img src='img/arrows/WO.png'/> with dural arteriovenous fistulae <img src='img/arrows/WC.png'/>.*
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**Leptomeningeal Metastases**
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*Sagittal T1 C+ MR shows typical leptomeningeal (pia and arachnoid) metastases <img src='img/arrows/WS.png'/> in the quadrigeminal cistern as well as widespread throughout the cerebellar folia.*
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**Cyst of Velum Interpositum**
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*Sagittal T1WI MR reveals a well-defined cavum velum interpositum <img src='img/arrows/BS.png'/>, isointense with CSF, displacing the internal cerebral veins inferiorly <img src='img/arrows/BO.png'/> and compressing the quadrigeminal cistern <img src='img/arrows/WC.png'/>.*
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**Arachnoid Cyst**
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*Sagittal T1WI MR shows an arachnoid cyst compressing the vermis inferiorly <img src='img/arrows/WO.png'/>, widening the quadrigeminal cistern <img src='img/arrows/WC.png'/>, and extending into velum interpositum <img src='img/arrows/WS.png'/>.*
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**Neurocysticercosis**
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*Sagittal STIR MR reveals multiple hyperintense cysts in the quadrigeminal cistern <img src='img/arrows/WS.png'/> and basal subarachnoid spaces <img src='img/arrows/WO.png'/>.*
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**Lipoma**
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*Sagittal T2WI MR demonstrates a fat intensity lipoma <img src='img/arrows/BS.png'/> within the quadrigeminal cistern displacing the vermis, which suppressed with T1 fat suppression (not shown).*
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**Epidermoid Cyst**
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*Axial T1WI MR demonstrates a lobulated CSF-like epidermoid <img src='img/arrows/BS.png'/> within the quadrigeminal cistern.*
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**Vein of Galen Malformation**
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*Sagittal T1WI MR demonstrates a prominent flow void within the quadrigeminal cistern from a vein of Galen malformation <img src='img/arrows/WS.png'/> as well as associated fistulae <img src='img/arrows/WO.png'/>.*
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**Leptomeningeal Metastases**
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*Coronal T1 C+ FS MR shows diffuse leptomeningeal enhancement involving the cerebellar folia <img src='img/arrows/CS.png'/>, right temporal lobe <img src='img/arrows/CO.png'/>, and structures surrounding the quadrigeminal plate cistern <img src='img/arrows/CC.png'/>. This patient had a history of lung cancer.*
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**Cyst of Velum Interpositum**
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*Axial T2WI FS MR shows a cyst between the thalami and splaying the internal cerebral veins <img src='img/arrows/CS.png'/>. Cysts of the cavum velum interpositum arise superior to the quadrigeminal cistern, but very large cysts may extend into or efface the quadrigeminal cistern.*
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**Arachnoid Cyst**
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*Sagittal T1 C+ MR shows a cyst dorsal to the normally enhancing pineal gland <img src='img/arrows/CS.png'/>. There is mass effect on the superior vermis <img src='img/arrows/CO.png'/>. This arachnoid cyst follows CSF on all sequences.*
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**Neurocysticercosis**
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*Axial T1 C+ FS MR shows leptomeningeal enhancement along the right suprasellar cistern extending along the right middle cerebral artery <img src='img/arrows/CS.png'/>. Multiple cysts with enhancing rim extend along the right ambient cistern to the quadrigeminal cistern <img src='img/arrows/CO.png'/>. Racemose neurocysticercosis presents with multiple extraaxial cysts.*
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**Medial Atrial Diverticulum**
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*Axial FLAIR MR shows medial bowing of the medial margin of the left atria of a dilated lateral ventricle, effacing the quadrigeminal plate cistern <img src='img/arrows/CS.png'/>. The medial atrial wall is a weak point for pulsion diverticula from massive hydrocephalus.*
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**Lipoma**
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*Axial T2WI FS MR shows loss of signal in a quadrigeminal cistern mass <img src='img/arrows/CS.png'/>. There was hyperintense T1 signal on T1WI, consistent with a lipoma. Lipomas are maldifferentiation, and persistence of the meninx primitiva and typically occur midline intracranially.*
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**Epidermoid Cyst**
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*Axial DWI b = 1000 MR shows a mass with uniform decreased diffusion arising in the quadrigeminal plate cistern. This lesion has a cystic appearance on T1 and T2 sequences (not shown) and was an epidermoid cyst at surgery.*
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