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A.Prof Frank Gaillard et al.

Oligodendrogliomas are intracranial tumours that account for 5-25% of all gliomas and 5-10% of all primary
intracranial neoplasms. They are identified on histological grounds and by 1p19q codeletion.
On imaging these tumour commonly present as a round or oval sharply marginated mass involving the cortex
or subcortical white matter, with low attenuation on CT, hypointense compared to gray matter on T1 and
hyperintense compared to gray matter on T2-weighted MRI images. The attenuation or signal can be
eventually heterogeneous due to calcification, cystic degeneration and hemorrhage.

These are usually tumours of middle-aged adults, occurring most commonly in the 4 th and 5th decades of life.
Oligodendroglioma is considered the third most common glioma accounting for 2%5% of primary brain tumors
and 5%18% of all glial neoplasms 8.

Clinical presentation
Due to their usual cortical involvement, presentation is most frequently as a result of seizures.

Gross appearance
Generally, oligodendrogliomas are well-circumscribed, gelatinous, gray masses. They are usually calcified (7090%: one of the most frequently calcifying tumours), less often with focal haemorrhage. 20% of these tumours
are cystic, and they can often expand a gyrus and remodel the skull. They can occur essentially anywhere,
including intraventricularly where they are difficult to distinguish from central neurocytomas on light microscopy.

Microscopic appearance and classification

Oligodendroglioma (WHO grade II/low grade):
Sheets of regular cells with spherical nuclei containing finely granular chromatin surrounded by a halo of
cytoplasm "fried egg" appearance under light microscope. Typically contains a delicate network of
anastomosing capillaries giving it a so called "chicken wire" appearance 6. These tumours are slowly growing.

Anaplastic oligodendroglioma (WHO grade III/high grade)

Increased cellular density, mitotic activity, microvascular proliferation and necrosis. Nuclear anaplasia is also
Anaplastic oligodendrogliomas make up 20-50% of all oligodendrogliomas. When necrosis is present in an
anaplastic tumours then they are considered WHO Grade IV lesions and referred to a GBM with
oligodendroglioma component.

Oligoastrocytomas, a tumour of mixed oligodendroglioma and astrocytoma cell populations have historically
been variably reported depending on local practice. As of the 2016 update to the WHO classification of CNS
tumours, to make the diagnosis genomic evidence of both astrocytic and oligodendroglial components will be
required to make the diagnosis, and as such they are likely to become rare.

Molecular genetics and subclassification:

1p/19q chromosome loss: excellent response to radiation and chemotherapy

1p/19q chromosome intact: refractory to radiation and chemotherapy


Radiographic features
Non contrast CT
Tumours are of mixed density (hypodense to isodense). High-attenuation areas within the tumour are likely
from calcification (70-90% of oligodendrogliomas are calcified) or, less commonly, haemorrhage. Calcification
can be located centrally, peripherally or they can be ribbon-like 4. The overlying skull may show pressure

Post contrast CT
50% of oligodendrogliomas enhance: degree of enhancement is extremely variable (no enhancement to

Tumours in which 1p/19q is intact show more homogenous signal on T1 and T2 images and have sharper
borders than tumours with 1p/19q deletions. Calcification and haemorrhage are difficult to distinguish on MR.
Peritumoral vasogenic oedema is minimal.

T1: typically hypointense

T2: typically hyperintense (except calcified areas)

T2*: calcium seen as areas of "blooming"

T1 C+ (Gd): contrast enhancement is common but it is not a reliable indicator of tumour grade, with
only 50% of oligodendrogliomas enhancing to a variable degree, and usually heterogeneously


typically no diffusion restriction

DWI can be used to help differentiate oligodendrogliomas (generally lower grade) from
astrocytomas (generally higher grade); astrocytomas have higher ADC values probably because of their
higher cellularity 5

MR perfusion: increased vascularity "chicken wire" network of vascularity results in elevated relative
cerebral blood volume (rCBV) of grade II vs grade III on PWI; PWI has a sensitivity of 95% and PPV or 87%

for distinguishing grade II from grade III oligodendrogliomas 1; a threshold of 1.75, rCBV above this
threshold demonstrate more rapid tumour progression 1

C-Methionine studies can be used to differentiate oligodendrogliomas from anaplastic oligodendrogliomas.
FDG uptake of oligodendrogliomas is similar to normal white matter. FDG uptake of anaplastic
oligodendrogliomas is similar to normal gray matter.

Treatment and prognosis

As mentioned earlier response to radiochemotherapy and hence prognosis depends significantly on presence
or absence of 1p19q gene deletion 2,7.
Treatment is surgical, with adjuvant radiotherapy and chemotherapy. Although they are macroscopically well
delineated, infiltration is present at their margins and local recurrence is common. Five years survival rate
ranges around 50-75%.

Differential diagnosis
General imaging differential considerations include:



dysembryoplastic neuroepithelial tumour (DNET)

pleomorphic xanthoastrocytoma (PXA)

cerebritis/herpes simplex (HSV) encephalitis

cerebral ischaemia/infarction

cerebral arteriovenous malformation (AVM)

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Cases and Figures

Case 1: typical MRI

Case 2: typical CT

Case 3: anaplastic

Case 4: anaplastic

Case 5: MRS

Case 6: perfusion

Case 7

Case 8

Case 9

Case 11

Case 10

Case 12

Case 13

Case 14

Case 15

Case 16

Imaging Differential Diagnosis