mri imaging hypothalamus dr ahmed esawy

Dr Ahmed Esawy

بسم اهلل الرحمن الرحيم

Dr Ahmed Esawy

Dr. Ahmed Abdallah Eisawy

MBBS M.Sc MD

Dr Ahmed Esawy

HYPOTHALAMUS

MRI

IMAGING

Dr Ahmed Esawy

the hypothalamus is a portion of the brain that

contains a number of small nuclei with a variety of

functions.

One of the most important functions of the

hypothalamus is to link the nervous system to

the endocrine system via the pituitary

gland (hypophysis).

The hypothalamus is located below the thalamus, just

above the brainstem and is part of the limbic system

Dr Ahmed Esawy

The hypothalamus is involved in the following

control systems:

• body temperature

• autonomic nervous system

• emotional and food behavior

• endocrine (via the pituitary)

• circadian rhythm.

Dr Ahmed Esawy

The hypothalamus is a portion of the brain near the third

ventricle, located below the thalamus and above the

brainstem.

The anterior boundary of the hypothalamus is determined by

the line connecting, the lamina terminalis and the optic chiasm

at its lower border and the anterior commissure above .

The lower limit of the hypothalamus is formed by the

infundibulum, the tuber cinerum and the mamillary bodies

(from front to back ).

superior: an imaginary line drawn between the anterior and

posterior commissures

The posterior limit is represented by a straight line joining the

mamillary bodies and the posterior commissure.

Dr Ahmed Esawy

(a) Drawing shows the hypothalamus (outlined with a dashed line) below an imaginary line between the anterior commissure (AC) and the posterior commissure (PC). The anterior boundary of the hypothalamus is the lamina terminalis (LT), which extends between the optic chiasm (OC) and the anterior commissure. The posterior boundary is imprecise; it is indicated by a line that extends between the mamillary bodies (MB) and the posterior commissure. The floor of the hypothalamus is formed by the infundibular stalk (IS), the tuber cinereum (TC), and the mamillary bodies. The major tracts related to the hypothalamus, the mamillothalamic tract (MT) and the postcommissural fornix (PF), are also shown.

Dr Ahmed Esawy

(c) On a sagittal contrast material–enhanced MR image,the infundibular stalk and

pituitary gland show normal homogeneous enhancement, which reflects their lack of a

blood-brain barrier

Dr Ahmed Esawy

Dr Ahmed Esawy

(b) Sagittal T1-weighted MR image clearly demonstrates the anatomy of the

hypothalamus. Note the high-signal-intensity area (arrowhead) representing the

posterior pituitary gland.

AC anterior commissure, IS infundibular stalk, LT lamina terminalis, MB mamillary

bodies, OC optic chiasm, PC posterior commissure, TC tuber cinereum.

Dr Ahmed Esawy

MRI of the Brain (hypothalamus):

T1-weighted sagittal cut. .

1, Anterior commissure.

2, Corpus callosum.

3, Third ventricle.

4, Cerebellum.

5, Pons.

6, Pituitary gland.

Dr Ahmed Esawy

(a) median eminence (b), mamillary bodies

The major hypothalamic tracts and nuclei (circled) are arranged symmetrically about the

floor and lower medial surface of the third ventricle and include the arcuate nucleus

A), anterior commissure(AC), dorsomedial nucleus (DM), lateral nucleus (L), lateral preoptic nucleus(LPO), mamillary bodies(MB), medial preoptic nucleus(MPO) posterior nucleus (P), paraventricular nucleus (PV), suprachiasmatic nucleus (SC), supraoptic nucleus (SO), and ventromedial nucleus (VM). The arcuate nucleus is located at the base of the infundibulum. F fornix, ME median eminence, MT mamillothalamic tract, OC optic chiasm, OT optic tract

Coronal T1-weighted MR images obtained at the level of (from rostral to caudal) the optic chiasm

Dr Ahmed Esawy

Coronal T1-weighted MR images obtained at the level of (from rostral to caudal) the optic chiasm

(c) show the various hypothalamic structures

lateral nucleus (L), F fornix, mamillary bodies(MB), MT mamillothalamic

, posterior nucleus (P), paraventricular nucleus (PV)

Dr Ahmed Esawy

MRI of the Brain (hypothalamus):

T1-weighted axial cut. .

1, Anterior commissure.

2, Putamen.

3, Third ventricle.

4, Corpus callosum.

Dr Ahmed Esawy

MRI of the Brain (hypothalamus):

T1-weighted coronal cut. .

1, Anterior commissure.

2, Caudate nucleus.

3, Corpus callosum.

4, Lateral ventricle.

5, Third ventricle.

Dr Ahmed Esawy

MRI of the Brain (hypothalamus):

T1-weighted axial cut. .

1, Infudibulum.

2, Cerebral aqueduct.

3, Midbrain.

4, Substantia nigra.

Dr Ahmed Esawy

MRI of the Brain (hypothalamus):

T1-weighted coronal cut. Image .

1, Infudibulum.

2, Caudate nucleus.

3, Corpus callosum.

4, Lateral ventricle.

5, Pituitary gland.

Dr Ahmed Esawy

MRI of the Brain (hypothalamus):

T1-weighted sagittal cut. Image .

1, Mammillary body.

2, Corpus callosum.

3, Third ventricle.

4, Cerebellum.

5, Midbrain.

6, Pons.

7, Pituitary gland.

Dr Ahmed Esawy

MRI of the Brain (hypothalamus):

T1-weighted axial cut. Image .

1, Mammillary body.

2, Cerebral aqueduct.

3, Superior colliculus.

Dr Ahmed Esawy

MRI of the Brain (hypothalamus):

T1-weighted sagittal cut.

1, Posterior commissure.

2, Midbrain.

3, Pituitary gland.

4, Récessus optique.

5, Corpus callosum.

Dr Ahmed Esawy

mammillary bodies

• are a pair of small round bodies, located on the undersurface of the brain, that form part of the limbic system.

• They are located at the ends of the anterior arches of the fornix,

• named mammillary for their resemblance to two breasts.

• They consist of two groups of nuclei, the medial mammillary nuclei and the lateral mammillary nuclei.

• Neuroanatomists have often categorized the mammillary bodies as part of the hypothalamus

Dr Ahmed Esawy

tuber cinereum

• is a hollow eminence of gray matter situated between the mammilary bodies behind, and the optic chiasma in front.

• The tuber cinereum is part of the hypothalamus

• A prominence of the base of the hypothalamus, extending ventrally into the infundibulum and pituitary stalk

• tuber cinereum Layer of gray matter in the hypothalamus that also forms part of the floor of the third ventricle.

Dr Ahmed Esawy

(a) Drawing shows the hypothalamus (outlined with a dashed line) below an imaginary line between the anterior commissure (AC) and the posterior commissure (PC). The anterior boundary of the hypothalamus is the lamina terminalis (LT), which extends between the optic chiasm (OC) and the anterior commissure. The posterior boundary is imprecise; it is indicated by a line that extends between the mamillary bodies (MB) and the posterior commissure. The floor of the hypothalamus is formed by the infundibular stalk (IS), the tuber cinereum (TC), and the mamillary bodies. The major tracts related to the hypothalamus, the mamillothalamic tract (MT) and the postcommissural fornix (PF), are also shown.

Dr Ahmed Esawy

Locations of Hypothalamic Nuclei with

Respect to the Medial-Lateral and

Rostral-Caudal Axes

. Lateral Area Medial Area Region*

Lateral preoptic nucleus,

lateral nucleus,

part of supraoptic

nucleus

Medial preoptic nucleus,

supraoptic nucleus,

paraventricular nucleus,

anterior nucleus,

suprachiasmatic nucleus

Anterior

Lateral nucleus, lateral

tuberal nuclei

Dorsomedial nucleus,

ventromedial nucleus,

arcuate nucleus

Tuberal

Lateral nucleus Mamillary nuclei,

posterior nucleus

Posterio

*The rostral-caudal axis divides the hypothalamus into anterior, tuberal, and

posterior regions.

Dr Ahmed Esawy

Classification of Hypothalamic Lesions

• Developmental abnormalities

Craniopharyngioma, germinoma,hamartoma, lipoma , dermoid and epidermoid cysts, arachnoid cyst, RCC, colloid cyst

• Primary tumors of the CNS

Hypothalamic-chiasmatic glioma, ganglioglioma, choristoma, perisellar meningioma

• Vascular tumors

Hemangioblastoma, cavernoma

• Systemic tumors affecting the CNS

Metastasis, lymphoma, leukemia

• Inflammatory and granulomatous diseases

LCH, lymphocytic infundibuloneurohypophysitis, sarcoidosis, Wegener granulomatosis, tuberculosis, syphilis, encephalitis

• Lesions arising from surrounding structures

Suprasellar pituitary tumor, ectopic posterior pituitary (EPP), aneurysms

Dr Ahmed Esawy

Classification of Hypothalamic Lesions

Lesions Pathologic Process

Craniopharyngioma, germinoma,

hamartoma, lipoma, dermoid and

epidermoid cysts, arachnoid cyst, RCC,

colloid cyst

Developmental abnormalities

Hypothalamic-chiasmatic glioma,

ganglioglioma, choristoma, perisellar

meningioma

Primary tumors of the CNS

Hemangioblastoma, cavernoma Vascular tumors

Metastasis, lymphoma, leukemia Systemic tumors affecting the

CNS

LCH, lymphocytic

infundibuloneurohypophysitis,

sarcoidosis, Wegener

granulomatosis, tuberculosis, syphilis,

encephalitis

Inflammatory and granulomatous

diseases

Suprasellar pituitary tumor, ectopic

posterior pituitary (EPP), aneurysms

Lesions arising from surrounding

structures

Dr Ahmed Esawy

Characteristic Anatomic Locations and Key MR

Imaging Features of Hypothalamic Lesions

Key MR Imaging Features Location Lesion

Solid and cystic components (solid:

heterogeneous enhancement; cystic:

variable signal intensity [T1 hyperintensity]),

calcification

Along suprasellar

portion of

stalk

Craniopharyngioma

Solid; iso- to hypointense with T1-weighted

sequences, iso- to hyperintense with T2-

weighted sequences relative to gray matter;

contrast enhancement; may be associated

with pineal infiltration

Upper part of

infundibulum

Germinoma

Solid, sometimes with cysts; isointense with

T1-weighted sequences, iso- to

hyperintense with T2-weighted sequences

relative to gray matter;

no contrast enhancement or calcification

Tuber cinereum Hamartoma

Dr Ahmed Esawy

Characteristic Anatomic Locations and Key MR

Imaging Features of Hypothalamic Lesions

Key MR Imaging Features Location Lesion

Heterogeneous signal intensity similar to

that of fat

Tuber cinereum Osteolipoma

Lobulated borders, isointense with T1-

and T2-weighted sequences relative to

CSF, hyperintense with FLAIR and

diffusion-weighted sequences, no

contrast enhancement

Parasellar Epidermoid cyst

Solid, inhomogeneous signal intensity

similar to that of fat

Suprasellar,

hypothalamic

(midline)

Dermoid cyst

Isointense relative to CSF, no contrast

enhancement

Suprasellar Arachnoid cyst

Dr Ahmed Esawy

Characteristic Anatomic Locations and Key MR

Imaging Features of Hypothalamic Lesions

Key MR Imaging Features Location Lesion

Smooth walls with variable signal

intensity, no solid component or

calcification

Supra- or intrasellar RCC

Solid; hypointense with T1-weighted

sequences,hyperintense with T2-

weighted sequences;

moderately heterogeneous contrast

enhancement

Hypothalamic-chiasmic Glioma

Isointense with T1- and T2-weighted

sequences,

variable contrast enhancement

Infundibulum Choristoma

Isointense with T1- and T2-weighted

sequences,

intense homogeneous contrast

enhancement,

dural tail

Suprasellar (rarely in stalk) Meningioma

Dr Ahmed Esawy

Characteristic Anatomic Locations and Key MR

Imaging Features of Hypothalamic Lesions

Key MR Imaging Features Location Lesion

Cyst with enhancing mural nodule Hypothalamus Hemangioblastoma

Intense contrast enhancement,

bone destruction

without marked sellar enlargement

Stalk, hypothalamus Metastatic disease

Intense contrast enhancement,

associated intraand

extracranial lesions

Stalk LCH

Leptomeningeal contrast

enhancement, associated

intra- and extracranial lesions

Stalk, suprasellar cistern Sarcoidosis

Isointense relative to brain, strong

enhancement,

may contain cystic component or

hemorrhage;

sellar enlargement

Intrasellar center causing

upward displacement of

optic chiasm

Suprasellar pituitary

adenoma

Blood products, residual patent

lumen, phase

artifact

Suprasellar Suprasellar

aneurysm

Dr Ahmed Esawy

Dr Ahmed Esawy

Dr Ahmed Esawy

Dr Ahmed Esawy

Adamantinomatous craniopharyngioma in a 12-year-old boy

Dr Ahmed Esawy

a Girl, 6-year-old, short stature, reduction of the visual field:

craniopharyngioma with predominant cystic component, thin wall calcifications seen on

CT, spontaneous hypersignal on T1 weighted images in relation with high cholesterol

concentration within the cyst.

Dr Ahmed Esawy

boy, 5-year-old: short stature, headache and vomiting; craniopharyngioma

with hydrocephalus, ‘‘egg-shell’’ calcification on CT,spontaneous T1 hyperintense

cystic part on MRI

Dr Ahmed Esawy

Girl 9-year old, visual disturbance since several months, papillary edema on

fundoscopy:craniopharyngioma with predominantly cystic component,peripheral rim

enhancement after contrast injection.

Dr Ahmed Esawy

Boy, 4-year-old, vomits since 2 weeks, palsy of the right 6th nerve:

craniopharyngioma with T1 isointense cystic component,

intra sellar solid component.

localized MR spectroscopy within the cyst demonstrates a doublet

lactate peak

Dr Ahmed Esawy

Papillary craniopharyngioma in a 39-year-old man

Dr Ahmed Esawy

unenhanced and enhanced T1 craniopharyngioma

large intrasellar and suprasellar mass with cystic and enhancing components as well

as calcifications

DD : dermiod

Dr Ahmed Esawy

craniopharyngioma

Dr Ahmed Esawy

Metachronous hypothalamic and pineal gland germinomas in a 3-year-old girl

T1+C

Dr Ahmed Esawy

Girl, 11-year-old with

diabetes insipidus:

suprasellar germinoma

with cysts

Dr Ahmed Esawy

Boy, 14-year-old,

diabetes insipidus since

6 months: intra and

suprasellar germinoma

with heterogeneous solid

mass.

Dr Ahmed Esawy Boy, 11-year-old, oculomotor palsy: suprasellar malignant

germinoma with heterogeneous enhancement

Dr Ahmed Esawy

Girl, 9-year-old,

headaches and visual disturbances: Synchronous lesions in pineal and suprasellar

regions

germinoma

Dr Ahmed Esawy

The mass enhances after gadolinium.

Continue with next images

T2

Dr Ahmed Esawy

MRI OF Hypothalamic hamartoma

T1: isointense to cerebral cortex

T1 C+ (Gd): no contrast enhancement

T2

iso- to hyperintense to cerebral cortex

the higher the proportion of glial cells, the higher the T2 signal

MR spectroscopy

reduced NAA/Cr

increased myoinositol

increased Cho/Cr compared to the amygdala has also been reported

Dr Ahmed Esawy

Parahypothalamic hamartoma of the tuber cinereum in a 7-year-old boy

T1+NO C

Dr Ahmed Esawy

Hypothalamic hamartoma

T2

Dr Ahmed Esawy

Hypothalamic hamartoma

T1+C

Dr Ahmed Esawy

T2

T1 FLAIR

T1+C Hypothalamic hamartoma

Dr Ahmed Esawy

hamartomas on are enhanced sagittal T1-weighted MR images.

Here you can see the non-enhancing hamartoma attached to the tuber cinereum

between the pituitary stalk and mamillary body. There really is no differential diagnosis

Dr Ahmed Esawy

Parahypothalamic osteolipoma of the tuber cinereum in a 43-year-old woman

T1+NO C

FAT SUPRESSED T2

Dr Ahmed Esawy

Girl, 8-year-old, headaches and left visual impairement: suprasellar and pre

pontine epidermoid cyst

Dr Ahmed Esawy

Hypothalamic dermoid cyst in a 30-year-old man

FAT SUPRESSED T1 T1+NO C

Dr Ahmed Esawy

RCC in a 50-year-old woman

T1+NO C T2

Dr Ahmed Esawy

Girl, 1-year-old, MRI performed for psychomotor development delay: incidental

Rathke’s cleft cyst

Dr Ahmed Esawy

T1, T2 and T1-weighted images after gadolinium demonstrate another Rathke's cleft

cyst located in the pituitary gland

Dr Ahmed Esawy

• Suprasellar colloid cyst in a 44-year-old

T1+NO C

Dr Ahmed Esawy

a Boy, one-year-old, mildline defect with frontonasal encephalocele,

suprasellar arachnoid cyst, hypophysis hypoplasia

Dr Ahmed Esawy

Boy, 11-year-old, MRI for advanced puberty: incidental lipoma demonstrated, with

spontaneous T1 hypersignal posterior to the pituitary stalk

Dr Ahmed Esawy

Magnetic resonance images of the

hypothalamus

obtained (a) Axial spin-echo T2-weighted

(b) sagittal T2_Trufisp (c) coronal spin-

echo T2 images

all show well-defined lesions (arrowheads)

with heterogenous signal intensity. Areas of

haemorrhage are seen within the lesion

(mulberry appearance) that are surrounded

by a hypointense hemosiderin rim, which is

in keeping with the diagnosis of

cavernoma.

Cavernoma of the Hypothalamus

Dr Ahmed Esawy

Cavernoma of the Hypothalamus

A sagittal spin-echo T1-weighted magnetic resonance image obtained revealing the

hypothalamus and suprasellar cistern showing the cavernoma (arrowheads) causing

a mass effect and displacing the optic chiasm anteriorly and superiorly (white arrow).

Dr Ahmed Esawy

Hypothalamic-chiasmatic glioma in a 4-year-old boy

T1+NO C T2

Dr Ahmed Esawy

Hypothalamic and Chiasm Glioma

Dr Ahmed Esawy

Optic hypothalamic

astrocytoma 16 year child

Dr Ahmed Esawy

Pediatric Chiasmatic/ Hypothalamic

Gliomas

MRI –T1: Low -intensity with marked

gadolinium enhancement – T2:

Hyperintense mass

Dr Ahmed Esawy

MRI –T1: Low -intensity with marked

gadolinium enhancement enhancement –

T2: Hyperintense mass

Pediatric Chiasmatic Hypothalamic

Gliomas

Dr Ahmed Esawy

Hypothalamic ganglioglioma in a 20-year-old man

T1+NO C T1+ C T2

Dr Ahmed Esawy

T1+C T2 T1+ NO C FLAIR

Hypothalamic LIPOMA

Dr Ahmed Esawy

Choristoma in a 55-year-old man

T1+NO C T1+ C

Dr Ahmed Esawy

Hypothalamic hemangioblastoma in a 54-year-old woman

T1+NO C T1+C

Dr Ahmed Esawy

Hypothalamic cavernoma in a 9-year old boy

T1+NO C T2

Dr Ahmed Esawy Hypothalamic cavernoma in a 9-year old boy

T1+ C

Dr Ahmed Esawy

Metastatic carcinoma to the hypothalamic-pituitary axis in a 46-year-old woman with breast cancer

T1

T1+C T1+ C

Dr Ahmed Esawy

Hypothalamic encephalitis in a 35-year-old man with DI

T2

Dr Ahmed Esawy LCH in an 8-year-old boy with DI

T1+C

Dr Ahmed Esawy

Boy, 4-year-old, diabetes insipidus: Langerhans cell hystiocytosis

with enlarged pituitary stalk, occipital osteolysis

Dr Ahmed Esawy

MRI reveals normal and abnormal hypothalamic-pituitary regions. In two healthy

controls, a hot signal in the pituitary lobe that is clearly separated from the dorsum

sella can be observed (A,B: T1-weighted).

A patient with LCH shows a thickened stalk and the loss of the hot spot in the

posterior lobe (C: T1-weighted).

Dr Ahmed Esawy

Gadolinium-enhanced MRIs show a hypothalamic mass in two patients with LCH (A,

B), each of which was histopathologically confirmed to be LCH by biopsy

Dr Ahmed Esawy

MRI of patients with neurodegenerative disease after treatment for multifocal LCH

show high signals at the basal ganglia (A: Flair, TR=9000) and the cerebellar dentate

nuclear area (B: Flair, TR=9000).

Dr Ahmed Esawy

Neurosarcoidosis in a 32-year-old woman with DI

T1+NO C T1+ C

Dr Ahmed Esawy

Tl-weighted sagittal (a) after Gd-DTPA demonstrates a uniformly hyperintense lesion

with suprasellar (1) and hypothalamic components (2). (b) Tl-weighted coronal image

after Gd-DTPA demonstrates the cystic suprasellar portion to show marginal

enhancement (arrows); pituitary stalk (arrowheads). Note the relationship

of the lesion to the optic chiasm and the pituitary g1and

Sarcoidosis of the hypothalamus and pituitary stalk

Dr Ahmed Esawy

same patient before

Tl-weighted coranal, unenhanced

image, more posterior, shows the

granulomatous tissue in the

hypothalamus to be of spontaneously

high signal intensity.

Sarcoidosis of the hypothalamus

and pituitary stalk

Dr Ahmed Esawy

same patient before after 4 month Sagittal T1-weighted image demonstrates a

decrease in size of the hyperintense hypothalamic component, while the

presumed cystic suprasellar portion is unchanged

Dr Ahmed Esawy

same patient before after 6 month Sagittal (a) and coronal (b) image after Gd-DTPA

showa lterations in signal intensity and size in both parts of the lesion; the presumed

cystic component being more extensive.

Dr Ahmed Esawy Hemorrhagic pituitary adenoma with a fluid-fluid level in a 42-year-old woman

T1+ C

Dr Ahmed Esawy

EPP in an 8-year-old boy with growth retardation.

T1+NO C

Dr Ahmed Esawy

Dr Ahmed Esawy

pituitary macroadenomas are adenomas over 10mm in size

Dr Ahmed Esawy

pituitary macroadenomas are adenomas over 10mm in size

Dr Ahmed Esawy

pituitary macroadenomas

classic 'snowman' configuration caused by constriction by the diaphragma sellae.

Notice the blood-fluid level, indicating hemorrhage.

Dr Ahmed Esawy

pituitary macroadenomas

Dr Ahmed Esawy

Dr Ahmed Esawy

Dr Ahmed Esawy

T1-weighted image of a thrombosed aneurysm with high signal intensity on the

unenhanced scan

Dr Ahmed Esawy

partially thrombosed aneurysm in the suprasellar cistern.

The patent lumen is black on these T1-weighted images.

It is surrounded by clot of different ages arranged in layers reaching from the lumen

to the wall. It resembles an onion cut in half

Dr Ahmed Esawy

Dr Ahmed Esawy

Meningiomas are almost always solid lesions, sometimes with a cyst on the edge

Dr Ahmed Esawy

the spread of the lesion along the meninges. The epicentre of the lesion is above

the sella

the main differential diagnosis of

the enhancing mass would include

meningioma, pituitary adenoma and

an aneurysm

Dr Ahmed Esawy

Differential Diagnosis for Lesions

Involving the Hypothalamus

• Some hypothalamic lesions show remarkable

consistency in location, such as hamartoma and osteolipoma (in the tuber cinereum) .

• A thickened contrast-enhanced infundibulum is the most typical manifestation of germ cell tumors, lymphocytic hypophysitis, sarcoidosis,and LCH

• However, idiopathic, isolated infundibular stalk thickening can be seen in cases of central DI without evidence of infiltrative processes

Dr Ahmed Esawy

• Lesions of near isointensity relative to the brain include

germinomas,some hamartomas, and suprasellar

meningioma

• This signature MR spectroscopic finding associated

with hypothalamic hamartomas allows differentiation of

these neoplasms from other entities, such as

hypothalamic gliomas and metastatic deposits

Dr Ahmed Esawy

CNS lesions associated with central

precocious puberty

Hypothalamic hamartoma

Craniopharyngioma

Ependymoma

Optic fibromas

Optic glioma

Subarachniod cysts

Hydrocephalus

Cerberal vascular accidents

encephalitis

Dr Ahmed Esawy

Hypothalamic-pituitary gonadal axis

Arcuate nucleus regulate sexual

development Localized found between the

mamillary bodies And infundibulum

Dr Ahmed Esawy

Dr Ahmed Esawy

Dr Ahmed Esawy

Dr Ahmed Esawy

Dr Ahmed Esawy

T1 +C

9 Y old boy ,neurofibromatosis 1 and CPP

Dr Ahmed Esawy

T1 +C

4 Y old boy with CPP

Dr Ahmed Esawy

7y girl

Arachniod cyst with obstructive

hydrocephalus

Dr Ahmed Esawy

7y girl

Hypothalamic pilocystic

astrocytoma

TI+C