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Findings

Expansile mass involving the tectum

Isointense on T1WI

Hyperintense on FLAIR and T2WI

No enhancement post gad

Compression of the aqueduct

Flow void across third ventriculostomy

Differential diagnosis

Tectal Glioma

Congenital aqueductal stenosis

Brainstem encephalitis

Demyelinating disease

Brainstem hamartoma in NF1

Other brainstem gliomas

Diagnosis – Tectal Glioma

MR findings

Can have high signal on T1WI due to calcification

Majority have focal high T2 signal

High signal on Flair

Calcifications result in signal drop out on T2 GRE

Variable enhancement pattern

Congenital aqueductal Stenosis

No expansion of the tectum. No abnormal T2/Flair signal.

“funnel shaped” aqueduct on sagittal imaging.

Brainstem encephalitis

Differentiated based on clinical findings

Acute clinical course

Discussion

Clinical symptoms are a result of hydrocephalus

Macrocrania

Headache

Even small lesions result in obstruction of the aqueduct.

Tectal gliomas have a benign clinical course.

Hydrocephalus is generally successfully controlled with endoscopic third ventriculostomy.

80% 5 yr progression-free survival.

Progression or dissemination extremely rare.

Wellons JC 3rd, Tubs RS, Banks JT, Brabb B, Blount JP, Oakes WJ, Grabb PA: Long-term control of hydrocephalus via endoscopic third ventriculostomy in children with tectal plate gliomas. Neurosurgery 51(1):63-7, 2002.