NEURORADIOLOGY

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crapeanglr
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14085
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NEURORADIOLOGY
Updated:
2010-04-13 12:10:52
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neuro imaging neuroradiology radiology head neck brain orbit
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Neuroradiology differentials and pearls for the oral radiology boards
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  1. DDx: Rim enhancing mass(es) with surrounding vasogenic edema
    "MAGIC"

    • Metastases(es) - Shaggy inner wall, DWI - usually
    • Abscess(es) - smooth rim enhancing inner wall, DWI+, fever
    • -Bacterial
    • -Toxoplasmosis
    • Glioma - usually aggressive if vasogenic edema is present, DWI - usually
    • Infarcts - DWI +, no fever
    • Contusions - trauma
  2. Subdural collection with enhancement of the rim
    • Subdural empyema
    • -correlate with patient's clinical status to exclude hematoma
  3. Edema in the temporal lobes or involvement of inferior frontal lobe and opposite insula
    HSV 1 infection
  4. bilateral insular and temporal lobe involvement
    Think HHV 6
  5. DDx: Leptomeningeal enhancement
    • Meningitis
    • Tumor
    • Sarcoidosis
  6. DDx: Basilar Leptomeningeal Enhancement
    • TB
    • Sarcoid
    • Metastases
    • Lymphoma
  7. Imaging findings of different types of meningitis
    • Aseptic (viral): few imaging findings, early dilation of temporal horns
    • Bacterial: mild enhancement, obliteration of CSF spaces
    • Fungal/TB: thick exudates often at base of brain
  8. Acute vs Chronic meningitis means what type of infections?
    • acute (viral, bacterial)
    • chronic (fungal, TB)
  9. Diffuse cystic lesions in the brain without edema
    Cysticercosis

    • •Agent: Taenia solium (pork tapeworm)
    • •Hematogenous spread
    • •Involves: parenchyma, ventricles, CSF
    • •Early: Mild inflammatory response (unenhancing)
    • •Late: larval death, profound inflammatory response cyst, mural nodule
  10. Progressive atrophy of the brain and diffuse white matter abnormalities
    HIV encephalitis
  11. Progressive atrophy of the brain and focal white matter abnormalities
    Progressive Multifocal Leukoencephalopathy
  12. Meningeal enhancement including lat vents, gelatinous pseudocysts in VR spaces (T2 hyperintense)
    Cryptococcal infection in AIDS
  13. Ovoid-finger like WM lesions arranged perpendicular to the lateral ventricles, usually symmetric
    Multiple sclerosis

    "Dawson's fingers"
  14. Locations other than periventricular WM to find MS
    • spinal cord
    • middle cerebellar penduncle
  15. Area of low density on CT and low signal on T1 MR with a rim of enhancement only on one side of the lesion
    Tumefactive MS
  16. Assymetric WM lesions shortly after viral infection or vaccination
    ADEM (acute disseminated encephalomyelitis)
  17. Posterior WM demyelination with thin rim of enhancement indicated rim of demyel.
    Adrenoleukodystrophy
  18. Subcortical T2 hyperintense lesions on WM with vent enlargement
    Krabbe DZ
  19. Tigroid appearance with extensive involvement of entire WM, with prominent cerebellar involvement
    Metachromatic Leukodystrophy
  20. Large head–Generalized white matter abnormality–Elevated N-acetyl aspartate (NAA) on MR spectroscopy
    Canavan's DZ
  21. DDx: Vascular causes of WM dz
    • Vasculitis (e.g., Systemic Lupus Erythematosus) - young female typically not periventricular
    • Lacunar Infarctions - older patients, HTN, dementia
    • Vascular Malformations
  22. Hyperintense T2 signal in pons, rapid sodium correction causes
    Central pontine myelinolysis
  23. Older patient with diffuse, symmetric WM hyperintensity on T1
    Methotrexate
  24. Corpus callosal and WM abnormality with history of trauma
    Diffuse axonal injury
  25. DDx: Intramedullary spinal lesions
    • •Syrinx
    • •Spinal cord tumors
    • –Glioma/Astrocytoma
    • –Pilocytic astrocytoma
    • –Ependymoma
    • –Hemangioblastoma
    • –Metastases
    • •Trauma
    • •Demyelinating disease
    • •Granulomatous disease (SARCOID)
    • •Myelitis (inflammatory, vasculitis)
    • •Dural Venous Fistula
  26. DDx: cyst in the spinal cord without enhancment or nodular component
    Chiari I with a central cord syrinx
  27. DDx: cyst within the spinal cord with solid enhancing component
    "HEMP MET"

    • hemangioblastoma - smaller nodular component
    • ependymoma - more focal, curvilinear nodular enhancement
    • myxopappillary ependymoma - larger, usually at level of filum terminale can extend to cervical cord
    • pilocyticastrocytoma - larger enhancing nodular component
    • met
  28. DDx: Focal signal abn in spinal cord with circumscribed enhancement
    • Metastasis
    • Ependymoma
    • Hemangioblastoma(without associated cyst)
    • Cavernoma(without prior hemorrhage)
    • Demyelinatingdisease
    • Sarcoid
  29. DDx: Focal signal abn with ring enhancement in spinal cord
    • Metastasis
    • Ependymoma (typically more solidly enhancing)
    • Demyelinating disease(typically more diffusely enhancing)
    • Sarcoid
    • Lymphoma
  30. DDx: Focal signal abn with diffuse fuzzy enhancement in spinal cord
    • Metastasis
    • Demyelinating DZ
    • Sarcoid
    • Lymphoma
    • Glioma, Astrocytoma
  31. DDx: Diffuse signal abn in the spinal cord with multiple focal and ill-defined areas of enhancement
    • Metastases
    • Demyelinating dz
    • Sarcoid
    • Lymphoma
    • ADEM
    • Lupus vasculitis
    • Glioma, Astrocytoma
  32. DDx: Diffuse signal abn in the spinal cord without contrast enhancement
    • Demyelinating Dz
    • Sarcoid
    • Lymphoma
    • ADEM
    • Lupus vaculitis
    • Glioma, Astrocytoma
    • Spinal cord infarct
  33. Flow voids on T2WI on surface of cord and punctate enhancement
    Spinal dural AVF
  34. Intradural extramedullary spinal lesions
    • •Tumors
    • –Myxopapillary ependymoma
    • –Neurofibroma
    • –Schwannoma - ring enhancing
    • –Meningioma - avid enhance, may Ca2+
    • –Metastases - multiple
    • –Dermoid/Epidermoid
    • •Vascular lesions
    • •Arachnoid cyst
    • •Lipomas
    • Disc herniation - ring enhancment, doesn't enlarge neural foramen
  35. DDx: Multiple rounded contrast enhancing lesions through out the subarachnoid space.
    Drop mets vs neurofibromas
  36. Lesions which have drop mets in or around the cord
    • Germinoma
    • Pinealblastoma
    • Pilocyticastrocytoma
    • Ependymoma
  37. DDx: Heterogenous mass in cord; high on T1 and T2; no enhancment
    • Complex lipoma
    • Melanoma
    • Dermoid
    • Cavernoma
  38. Common mets to spine
    • –Breast
    • –Prostate
    • –Lung
    • –kidney
  39. osteoblastic mets
    • –Prostate
    • –Breast
    • –Carcinoid
    • –Ovarian
    • –TCC
    • –lymphoma
  40. Decreased density in the spine
    • 1. Osteoporosis (central lucency)
    • 2. Paget’s (thickened cortex)
    • 3. Osteomalacia
    • 4. Multiple myeloma (punched out, striations)
  41. Increased density in the spine (ivory verteberal body)
    • 1. Paget’s
    • 2. Lymphoma
    • 3. Infection
    • 4. Metastasis
    • 5. hemangioma (striated)
  42. Posterior vertebral body scalloping
    • 1. Congenital
    • •OI
    • •Mucopolysaccharidoses
    • •Achondroplasia
    • 2. Dural ectasia
    • •Neurofibromatosis
    • •Ehlers-Danlos
    • •Marfan’s
    • 3. Increased central canal pressure
    • •Syrinx
    • •Spinal canal tumors
  43. DDx: Brain mass, general
    • •Hemorrhage
    • •Infection / Inflammation
    • •Vascular: Infarction, Vascular Malformation
    • •Trauma
    • •Tumor: Primary, Metastasis, Lymphoma, Reaction to treatment
    • •Demyelination
    • •Congenital
  44. DDx: Supratentorial Mass
    • •Gliomas: Astrocytoma, Anaplastic Astrocytoma, Glioblastoma (GBM), Oligodendroglioma-Ca2+
    • •Lymphoma
    • •Metastasis
    • •Meningioma
    • •Seizure lesions: Ganglioglioma, Pleomorphic Xanthroastrocytoma
    • •Other: Epidermoid, Arachnoid cyst
  45. DDx: Infratentorial Mass
    • •Medulloblastoma
    • •Ependymoma
    • •Brainstem Glioma
    • •Cerebellar Glioma
    • •Hemangioblastoma
    • •Metastasis
  46. DDx: Parasellar brain lesions
    • "CRAMP"
    • Craniopharyngioma
    • Rathke’s Cleft Cyst
    • Aneurysm
    • Meningioma
    • Pituitary Adenoma

    • OTHERS:
    • •Ectopic Pituitary
    • •Germinoma
    • •Optic Nerve Glioma
    • •Hypothalamic Glioma
    • •Metastasis
    • •Hamartoma of the Tuber Cinereum
    • •Others: Dermoid, Arachnoid Cyst
  47. DDx: Pineal region tumors
    • •Germ Cell: Germinoma, Teratoma, Embrynal, Choriocarcinoma, Yolk Sac
    • •Pineal Cell: Pineocytoma, Pineoblastoma
    • •Others neoplasms: Metastasis, Astrocytoma, Ependymoma, Meningioma, Lymphoma
    • •Others: Pineal Cyst, Lipoma, Arachnoid Cyst, Dermoid, AVM
  48. DDx: Intraventricular tumors
    • •Central Neurocytoma
    • •Choroid Plexus Papilloma
    • •Colloid Cyst
    • •Giant Cell Astrocytoma
    • •Ependymoma
    • •Meningioma/ Metastases
    • •Subependymoma
  49. DDx: Cerebellopontine angle lesions
    • •Acoustic Schwannoma
    • •Meningioma
    • •Epidermoid
    • •Arachnoid Cyst
    • •Others: Metastasis, Other Schwannomas, Aneurysm
  50. DDx: Skull base lesions
    • •Chondrosarcoma
    • •Chordoma
    • •Nasopharyngeal Carcinoma
    • •Metastasis
    • •Others: Glomus Tumor, Schwannoma, Myeloma, Lymphoma
  51. DDx: Potential abnormalities on angio of the aorta/great vessels on angio
    • trauma, dissection, vasculitides
    • Atherosclerotic disease proximal great vessels
    • subclavian steal
    • Takayasu’s arteritis
  52. DDx: Vascular related conditions seen on angio of the neck
    • •Stenosis
    • -atherosclerosis
    • -fibromuscular disease
    • -dissection
    • •Tumors
    • -Carotid body tumor - embolize preop
    • •Trauma
  53. DDx: Reasons for doing selective ECA angio
    • "NEAT"
    • Neoplasms - glomus jugulare, angiofibroma, meningioma
    • Epistaxis
    • Arteriovenous malformations
    • Trauma - indirect CCF (carotid-cavernous fistula)
  54. If shown coronal/frontal view of an ECA injection, they are trying to show you what?
    IMAX - probably for epistaxis
  55. Two intracranial views on angio
    • •Internal carotid artery injection
    • •Vertebral artery injection
  56. DDx: ICA conditions seen on angio
    • Trauma
    • -CCF (direct)
    • Aneurysms
    • Vessel stenosis/occlusions
    • -atherosclerosis
    • -vasculitis
    • -vasospasm
    • -embolic
    • Arteriovenous malformations
    • Tumors
  57. DDx: Infants angio of head neck
    • •Occlusions
    • •moya moya
    • •Vein Of Galen malformations
  58. How to sort out severe hydrocephalus from hydranenchepahly?
    Thin rim of cortex should still be seen in hydrocephauls, sometimes best seen on MR
  59. Small unilateral cerebral hemisphere
    Dyke-Davidoff-Mason syndrome
  60. "Undivided front of the brain"
    Holoprosencephaly
  61. DDx: Cystic disorders of the posterior fossa
    • •Dandy-Walker Complex
    • -Malformation - upturned torcula, enlarged PF
    • -Variant
    • •Mega Cisterna Magna - normal PF size, but cystic
    • •Arachnoid Cyst - mass effect cyst in PF, but no real upturned torcula, hydrocephalus
  62. guitar pick 4th ventricle
    rhombencephalosynapsis

    • fusion of the cerebellar hemishperes
    • usually get hydrocephalus
  63. which territory ischemic stroke can be treated with surgical resection?
    • PICA territory
    • cerebellar hemisphere can be resected
    • o/w can cause hydro and is life threatening
  64. DDx: Common ocular lesions
    • •Tumors
    • -metastasis
    • -melanoma
    • -retinoblastoma (child, Ca2+)
    • •Retinal detachment
    • •Infection
    • •Inflammatory
    • •Trauma
  65. Shrunken possibly calcified globe that doesn't function
    Pthisis bulbi
  66. Punctate Ca2+, posterior globe
    drusen
  67. DDx: Leukocoria
    • •Retinoblastoma - doesn't have to be Ca2+, also look at pineal gland to assess for trilateral lesion
    • •Primary Hyperplastic Vitreous
    • •Coat’s Disease - small b/l globes with increased density
    • •Retinopathy of Prematurity - linear calc posterior globe, small globes
  68. DDx: Extraocular muscle lesions
    • •Grave’s disease - IMSLO progression usually, can be unilateral, fat clean
    • •Pseudotumor - usual MT involvement, fat dirty
    • •Lymphoma
    • •Metastasis
    • •Granulomatousdisease
    • •Infection
    • •Carotid cavernous fistula
  69. Most important features in differentiating graves from pseudotumor?
    • Clean or dirty intraconal fat
    • Painful or not

    • Pseudotumor - painful, dirty fat
    • Graves - non-painful, clean fat
  70. DDx: Optic nerve enlargement
    • •Optic-nerve glioma - NF1
    • •Optic-nerve meningioma - tram track Ca2+
    • •Optic neuritis - enhancement
    • •Increased intracranial pressure
    • •Pseudotumor
    • •Graves’ disease
    • •Lymphoma, leukemia, meningeal carcinomatosis
  71. DDx: Well defined intraconal mass not involving the optic nerve
    • –cavernous hemangioma
    • –neurofibroma (CN III-V)
    • –pseudotumor
    • –venous varix
  72. DDx: Ill defined Intraconal Mass not Involving Optic Nerve
    • –Lymphoma
    • –Metastasis
    • –Pseudotumor
    • –Infection
    • –Lymphangioma, venous varix, capillary hemangioma
  73. DDx: Extraconal mass in an adult
    • •Adjacent structure
    • –Infection, inflammatory, or tumor
    • –Lacrimal Gland
    • •Lymphoma
    • •Metastasis
    • •Pseudotumor
    • •Granulomatous Disease
  74. DDx: Extraconal mass in a child
    "CaLL RN"

    • Capillary Hemangioma
    • Langerhans Cell Histiocytosis (LCH or EG)
    • Lymphangioma
    • Rhabdomyosarcoma
    • Neuroblastoma
  75. DDx: Lacrimal gland enlargement
    "ELDer GraM"

    • •Epithelial tumors
    • –Benign Adenomas (50%)
    • –Carcinomas (50%)
    • •Lymphoid lesions
    • –Lymphoma
    • –Benign Hyperplasia
    • –Pseudotumor
    • –Sjogren’s
    • •Dermoid
    • •GranulomatousDiseases
    • –Wegener’s
    • –Sarcoid
    • •Metastasis

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