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Hippocampal Contouring: A Contouring Atlas for RTOG 0933Vinai Gondi, M.D.1Wolfgang A. Tome, Ph.D. 1Howard A. Rowley, M.D.2Minesh P. Mehta, M.D. 3Departments of 1Human Oncology and 2Neuroradiology, University of Wisconsin Comprehensive Cancer Center3Department of Radiation Oncology, Northwestern University Feinberg School of Medicine1MRI-CT FusionMRI: Three-dimensional spoiled gradient (3D-SPGR) axial MRI scan of the head with standard axial and coronal FLAIR, axial T2-weighted and gadolinium contrast-enhanced T1-weighted sequence acquisitions . 1.25mm slice thickness is preferred to contour the hippocampus accurately. Slice thickness of 1.5mm or less is permitted. Obtain in supine position; immobilization devices used for CT simulation and daily radiation treatments not necessary.CT Simulation: Non-contrast treatment-planning CT scan of the entire head region. 1.25-1.5mm slice thickness is preferred for accurate hippocampal sparing planning. Slice thickness of 2.5mm or less is permitted. Immobilize patient in supine position using an immobilization device such as an Aquaplast mask over the head. Treat patients in the immobilization device.MRI-CT Fusion: Fuse the 3D-SPGR MRI and the treatment-planning CT.2General Principles Please note that we are not contouring the entire hippocampus, but focusing mostly on the subgranular zone (SGZ) Contour the hippocampus on T1-weighted MRI axial sequences. Given the preponderance of gray matter in the hippocampus, focus contouring on the T1-hypointense signal medial to the temporal horn.3MR Images courtesy of: Holmes CJ, Hoge R, Collins L, et al. Enhancement of MR Images Using Registration for Signal Averaging Journal of Computer Assisted Tomography 22, 324-333 (1998)Red: HippocampusBegin contouring at the most caudal (inferior) extent of the crescentic-shaped floor of the temporal horn of the lateral ventricle and contour the hypointense grey matter located medial to the CSF hypointensity, not the white, bright white matter.4Temporal HornRed: HippocampusMR Images courtesy of: Holmes CJ, Hoge R, Collins L, et al. Enhancement of MR Images Using Registration for Signal Averaging Journal of Computer Assisted Tomography 22, 324-333 (1998)Fimbriae5Continue contouring in a cephalad (superior) direction, medial to the temporal horn of the lateral ventricle and contour the hypointense grey matter, not the white, bright white matter.Red: HippocampusMR Images courtesy of: Holmes CJ, Hoge R, Collins L, et al. Enhancement of MR Images Using Registration for Signal Averaging Journal of Computer Assisted Tomography 22, 324-333 (1998)6Continue contouring in a cephalad (superior) direction. Avoid contouring the fimbriae, the T1-hyperintense structures located superomedial to the hippocampus.FimbriaRed: HippocampusMR Images courtesy of: Holmes CJ, Hoge R, Collins L, et al. Enhancement of MR Images Using Registration for Signal Averaging Journal of Computer Assisted Tomography 22, 324-333 (1998)7Continue contouring in a cephalad (superior) direction, medial to the temporal horn of the lateral ventricle and contour the hypointense grey matter, not the white, bright white matter. Note that the contours are progressively moving in a supero-posterior direction, keeping in line with the curved banana shaped structure of the hippocampus. Avoid the fimbriae and also avoid the grey matter (amygdala and uncus) located anterior to the tip of the temporal horn of the ventricles.Red: HippocampusMR Images courtesy of: Holmes CJ, Hoge R, Collins L, et al. Enhancement of MR Images Using Registration for Signal Averaging Journal of Computer Assisted Tomography 22, 324-333 (1998)8As contouring proceeds postero-cranially, the anterior boundary of the hippocampus is defined by the anterior edge of the temporal horn, to distinguish the hippocampus from the T1-hypointense gray matter of the amygdala, lying anterior and superior to the hippocampus. The medial boundary of the hippocampus is defined by the “boomerang-shaped” uncusAmygdala UncusRed: HippocampusMR Images courtesy of: Holmes CJ, Hoge R, Collins L, et al. Enhancement of MR Images Using Registration for Signal Averaging Journal of Computer Assisted Tomography 22, 324-333 (1998)9Uncal RecessUncal RecessContinue contouring in a cephalad (superior) direction, medial to the temporal horn of the lateral ventricle and contour only the hypointense grey matter, not the white, bright white matter. Continue to avoid the fimbriae and also avoid the grey matter (amygdala and uncus) located anterior to the tip of the temporal horn of the ventricles.Red: HippocampusMR Images courtesy of: Holmes CJ, Hoge R, Collins L, et al. Enhancement of MR Images Using Registration for Signal Averaging Journal of Computer Assisted Tomography 22, 324-333 (1998)The emergence of the uncal recess of the temporal horn defines the anterior boundary of the hippocampus. This may not be seen on all axial image sets due to its limited size. The medial boundary of the hippocampus becomes defined by the medial edge of the uncal recess.10Medial edge of Uncal RecessUncal recessRed: HippocampusMR Images courtesy of: Holmes CJ, Hoge R, Collins L, et al. Enhancement of MR Images Using Registration for Signal Averaging Journal of Computer Assisted Tomography 22, 324-333 (1998)11Continue contouring in a cephalad (superior) direction, medial to the temporal horn of the lateral ventricle and contour only the hypointense grey matter, not the white, bright white matter. Continue to avoid the fimbriae and also avoid the grey matter (amygdala and uncus) located anterior to the tip of the temporal horn of the ventricles.Red: HippocampusMR Images courtesy of: Holmes CJ, Hoge R, Collins L, et al. Enhancement of MR Images Using Registration for Signal Averaging Journal of Computer Assisted Tomography 22, 324-333 (1998)Postero-cranially, the medial boundary of the hippocampus is defined by the lateral edge of the quadrageminal cistern which is the CSF containing space lateral to the pons.12Quadrageminal cisternRed: HippocampusMR Images courtesy of: Holmes CJ, Hoge R, Collins L, et al. Enhancement of MR Images Using Registration for Signal Averaging Journal of Computer Assisted Tomography 22, 324-333 (1998)13Continue contouring in a cephalad (superior) direction; note that at this level, the temporal horn of the lateral ventricle may no longer be visible on every slice, but the quadrigeminal cistern serves as a medial reference landmark. Contour only the hypointense grey matter, not the bright white matter.Quadrageminal cisternRed: HippocampusMR Images courtesy of: Holmes CJ, Hoge R, Collins L, et al. Enhancement of MR Images Using Registration for Signal Averaging Journal of Computer Assisted Tomography 22, 324-333 (1998)The hippocampus remains medial to the temporal horn of the lateral ventricle throughout its extent, and so on slices where you can visualize it, use it as a consistent reference. The quadrigeminal cistern remains a good medial landmark.14Temporal horn of the lateral ventricleQuadrageminal cisternRed: HippocampusMR Images courtesy of: Holmes CJ, Hoge R, Collins L, et al. Enhancement of MR Images Using Registration for Signal Averaging Journal of Computer Assisted Tomography 22, 324-333 (1998)15Quadrageminal cisternThe hippocampus remains medial to the temporal horn of the lateral ventricle throughout its extent, and so on slices where you can visualize it, use it as a consistent reference. The quadrigeminal cistern remains a good medial landmark.Temporal horn of the lateral ventricleRed: HippocampusMR Images courtesy of: Holmes CJ, Hoge R, Collins L, et al. Enhancement of MR Images Using Registration for Signal Averaging Journal of Computer Assisted Tomography 22, 324-333 (1998)16The hippocampal tail remains posterior to the thalamus as it curves medially toward the splenium of the corpus callosum. Note that it is still medially located relative to the lateral ventricle. Also note that the thalamus, basal ganglia and internal capsule now become visible.ThalamusQuadrageminal cisternCaudatePutamenRed: HippocampusMR Images courtesy of: Holmes CJ, Hoge R, Collins L, et al. Enhancement of MR Images Using Registration for Signal Averaging Journal of Computer Assisted Tomography 22, 324-333 (1998)17Internal CapsuleThe hippocampal tail remains posterior to the thalamus as it curves medially toward the splenium of the corpus callosum. Note that it is still medially located relative to the lateral ventricle. Also note that the thalamus, basal ganglia and internal capsule now become visible.Red: HippocampusMR Images courtesy of: Holmes CJ, Hoge R, Collins L, et al. Enhancement of MR Images Using Registration for Signal Averaging Journal of Computer Assisted Tomography 22, 324-333 (1998)18The postero-cranial extent of the hippocampal tail is located just antero-medially to the atrium of the lateral ventricle.Atrium of the lateral ventricleHippocampal tailRed: HippocampusMR Images courtesy of: Holmes CJ, Hoge R, Collins L, et al. Enhancement of MR Images Using Registration for Signal Averaging Journal of Computer Assisted Tomography 22, 324-333 (1998)19The postero-cranial extent of the hippocampal tail is located just antero-medially to the atrium of the lateral ventricle.Atrium of the lateral ventricleHippocampal tailRed: HippocampusMR Images courtesy of: Holmes CJ, Hoge R, Collins L, et al. Enhancement of MR Images Using Registration for Signal Averaging Journal of Computer Assisted Tomography 22, 324-333 (1998)Even in its cephalad (superior) extent, the hippocampal tail remains lateral to the lateral edge of the quadrageminal cistern.20Quadrageminal cisternRed: HippocampusMR Images courtesy of: Holmes CJ, Hoge R, Collins L, et al. Enhancement of MR Images Using Registration for Signal Averaging Journal of Computer Assisted Tomography 22, 324-333 (1998)21Even in its cephalad (superior) extent, the hippocampal tail remains lateral to the lateral edge of the quadrageminal cistern.Quadrageminal cisternRed: HippocampusMR Images courtesy of: Holmes CJ, Hoge R, Collins L, et al. Enhancement of MR Images Using Registration for Signal Averaging Journal of Computer Assisted Tomography 22, 324-333 (1998)Terminate hippocampal contours at the point where the T1-hypointense structure no longer borders the atrium of the lateral ventricle. At this point, the crux of the fornix emerges anteriorly and the splenium of the corpus callosum can be visualized posteriorly.22SpleniumRed: HippocampusMR Images courtesy of: Holmes CJ, Hoge R, Collins L, et al. Enhancement of MR Images Using Registration for Signal Averaging Journal of Computer Assisted Tomography 22, 324-333 (1998)23The grey signal from the hippocampus is no longer visible. Do not contour any further.MR Images courtesy of: Holmes CJ, Hoge R, Collins L, et al. Enhancement of MR Images Using Registration for Signal Averaging Journal of Computer Assisted Tomography 22, 324-333 (1998)Generate the hippocampal avoidance zone using a 5mm volumetric expansion on the hippocampus. 24Red: HippocampusGreen: Hippocampal Avoidance ZoneRed: HippocampusGreen: Hippocampal Avoidance ZoneMR Images courtesy of: Holmes CJ, Hoge R, Collins L, et al. Enhancement of MR Images Using Registration for Signal Averaging Journal of Computer Assisted Tomography 22, 324-333 (1998)25Hippocampal 1) Tail 2) Body3) HeadGenerate the hippocampal avoidance zone using a 5mm volumetric expansion on the hippocampus. MR Images courtesy of: Holmes CJ, Hoge R, Collins L, et al. Enhancement of MR Images Using Registration for Signal Averaging Journal of Computer Assisted Tomography 22, 324-333 (1998)26Hippocampal 1) Tail 2) Body3) HeadRed: HippocampusGreen: Hippocampal Avoidance ZoneHippocampal 1) Tail 2) Body3) HeadThe hippocampus has three anatomic subdivisions: the head, body, and tail; note that the head is inferior or caudad, the body is superoposterior and the tail is most cephalad (superior) and posterior, and an overall “banana” shape emerges on sagittal images, located in the plane of the lateral ventricle.MR Images courtesy of: Holmes CJ, Hoge R, Collins L, et al. Enhancement of MR Images Using Registration for Signal Averaging Journal of Computer Assisted Tomography 22, 324-333 (1998)27Hippocampal 1) Tail 2) Body3) HeadRed: HippocampusGreen: Hippocampal Avoidance ZoneThe hippocampus has three anatomic subdivisions: the head, body, and tail; note that the head is inferior or caudad, the body is superoposterior and the tail is most cephalad (superior) and posterior, and an overall “banana” shape emerges on sagittal images, located in the plane of the lateral ventricle.MR Images courtesy of: Holmes CJ, Hoge R, Collins L, et al. Enhancement of MR Images Using Registration for Signal Averaging Journal of Computer Assisted Tomography 22, 324-333 (1998)On sagittal sections, confirm delineation of the hippocampus separate from neighboring structures, such as the amygdala.28Hippocampal 1) Tail 2) Body3) HeadRed: HippocampusGreen: Hippocampal Avoidance ZoneAmygdalaMR Images courtesy of: Holmes CJ, Hoge R, Collins L, et al. Enhancement of MR Images Using Registration for Signal Averaging Journal of Computer Assisted Tomography 22, 324-333 (1998)29Hippocampal 1) Tail 2) Body3) HeadRed: HippocampusGreen: Hippocampal Avoidance ZoneOn sagittal sections, confirm delineation of the hippocampus separate from neighboring structures, such as the amygdala.AmygdalaMR Images courtesy of: Holmes CJ, Hoge R, Collins L, et al. Enhancement of MR Images Using Registration for Signal Averaging Journal of Computer Assisted Tomography 22, 324-333 (1998)30Hippocampal 1) Tail 2) Body3) HeadRed: HippocampusGreen: Hippocampal Avoidance ZoneOn coronal sections, confirm delineation of the hippocampus separate from neighboring structures, such as the parahippocampal gyrus, which has different signal intensity.Parahippocampal GyrusMR Images courtesy of: Holmes CJ, Hoge R, Collins L, et al. Enhancement of MR Images Using Registration for Signal Averaging Journal of Computer Assisted Tomography 22, 324-333 (1998)31Hippocampal 1) Tail 2) Body3) HeadRed: HippocampusGreen: Hippocampal Avoidance ZoneOn coronal sections, confirm delineation of the hippocampus separate from neighboring structures, such as the parahippocampal gyrus, which has different signal intensity.Parahippocampal GyrusMR Images courtesy of: Holmes CJ, Hoge R, Collins L, et al. Enhancement of MR Images Using Registration for Signal Averaging Journal of Computer Assisted Tomography 22, 324-333 (1998)On sagittal and coronal sections, confirm separation between the hippocampal tail and the crus of the fornix. Note the location of the hippocampii medial to the ventricles on the coronal images.32Hippocampal 1) Tail 2) Body3) HeadRed: HippocampusGreen: Hippocampal Avoidance ZoneCrus of the fornixCrus of the fornixMR Images courtesy of: Holmes CJ, Hoge R, Collins L, et al. Enhancement of MR Images Using Registration for Signal Averaging Journal of Computer Assisted Tomography 22, 324-333 (1998)33Hippocampal 1) Tail 2) Body3) HeadRed: HippocampusGreen: Hippocampal Avoidance ZoneOn sagittal and coronal sections, confirm separation between the hippocampal tail and the crus of the fornix. Note the location of the hippocampii medial to the ventricles on the coronal images.
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