Combining diffusion and perfusion differentiates tumor from bevacizumab-related imaging abnormality (bria)

J Neurooncol. 2014 Dec;120(3):539-46. doi: 10.1007/s11060-014-1583-2. Epub 2014 Aug 19.


A subset of patients with high-grade glioma and brain metastases who are treated with bevacizumab develop regions of marked and persistent restricted diffusion that do not reflect recurrent tumor. Here, we quantify the degree of restricted diffusion and the relative cerebral blood volume (rCBV) within these regions of bevacizumab-related imaging abnormality (BRIA) in order to facilitate differentiation of these lesions from recurrent tumor. Six patients with high-grade glioma and two patients with brain metastases who developed regions of restricted diffusion after initiation of bevacizumab were included. Six pre-treatment GBM controls were also included. Restriction spectrum imaging (RSI) was used to create diffusion maps which were co-registered with rCBV maps. Within regions of restricted diffusion, mean RSI values and mean rCBV values were calculated for patients with BRIA and for the GBM controls. These values were also calculated for normal-appearing white matter (NAWM). RSI values in regions of restricted diffusion were higher for both BRIA and tumor when compared to NAWM; furthermore RSI values in BRIA were slightly higher than in tumor. Conversely, rCBV values were very low in BRIA-lower than both tumor and NAWM. However, there was only a trend for rCBV values to be higher in tumor than in NAWM. When evaluating areas of restricted diffusion in patients with high-grade glioma or brain metastases treated with bevacizumab, RSI is better able to detect the presence of pathology whereas rCBV is better able to differentiate BRIA from tumor. Thus, combining these tools may help to differentiate necrotic tissue related to bevacizumab treatment from recurrent tumor.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Aged
  • Angiogenesis Inhibitors / adverse effects*
  • Angiogenesis Inhibitors / therapeutic use
  • Antibodies, Monoclonal, Humanized / adverse effects*
  • Antibodies, Monoclonal, Humanized / therapeutic use
  • Bevacizumab
  • Blood Volume
  • Brain / drug effects
  • Brain / pathology
  • Brain / physiopathology
  • Brain / radiation effects
  • Brain Neoplasms / drug therapy
  • Brain Neoplasms / pathology*
  • Brain Neoplasms / physiopathology
  • Brain Neoplasms / radiotherapy
  • Cerebrovascular Circulation
  • Diffusion
  • Diffusion Magnetic Resonance Imaging / methods*
  • Female
  • Glioma / drug therapy
  • Glioma / pathology*
  • Glioma / physiopathology
  • Glioma / radiotherapy
  • Humans
  • Male
  • Middle Aged
  • Neoplasm Grading
  • Perfusion Imaging / methods*
  • White Matter / drug effects
  • White Matter / pathology
  • White Matter / physiopathology
  • White Matter / radiation effects


  • Angiogenesis Inhibitors
  • Antibodies, Monoclonal, Humanized
  • Bevacizumab