Board Review 2 – Case 19

Neuroradiology board review. This lecture is geared towards the ABR core exam for residents, but it would be useful for review for the ABR certifying exam or certificate of added qualification (CAQ) exam for neuroradiology.

More description and the answer (spoiler!) are seen below the video.

This case shows a trauma patient with disruption of the arch of C1 on a CT of the cervical spine. There are injuries to both the anterior and posterior arch.

After presentation, the patient developed posterior fossa symptoms such as nausea and vertigo

The diagnosis is: Jefferson fracture with vertebral artery injury

A number of fractures in the neck have eponyms, and the Jefferson fracture is when the arch of C1 is fractured. It commonly involves injury to both the anterior and posterior arch, although this isn’t a requirement.

After high energy trauma, it is common to have injury to arteries in the neck, so it is important to consider this if a patient develops new symptoms. This patient had a traumatic wall injury of the left vertebral artery which is demonstrated on a T1 weighted fat saturated image of the neck, which showed T1 hyperintense methemoglobin in the wall.

Traumatic arterial injury is often graded using the Denver grading scale, which is as follows:

• Grade I – < 25% narrowing
• Grade II – > 25% narrowing or dissection flap
• Grade III – pseudoaneurysm
• Grade IV – occlusion
• Grade V – transection/active extravasation

Injury can be evaluated with either CTA (more common) or MRA.

Board Review 2 – Case 16

Neuroradiology board review. This lecture is geared towards the ABR core exam for residents, but it would be useful for review for the ABR certifying exam or certificate of added qualification (CAQ) exam for neuroradiology.

More description and the answer (spoiler!) are seen below the video.

This case shows a mass within the spinal canal of the upper thoracic spine. For any spinal canal mass, your first step is to determine if it is:

• intramedullary (in the spinal cord)
• intradural extramedullary (inside the dura, but outside the spinal cord)
• extradural

This mass appears to be extramedullary but intradural. The main differential considerations are meningioma, nerve sheath tumor/schwannoma, or metastasis. This mass has a relatively benign appearance and enhances avidly and homogenously.

The diagnosis is: meningioma

Spinal meningiomas are extramedullary masses that share an imaging appearance with intracranial meningiomas. They are often homogenous and enhance avidly. They can have calcification. The treatment, if symptomatic, is surgical resection.

Board Review 2 – Case 15

Neuroradiology board review. This lecture is geared towards the ABR core exam for residents, but it would be useful for review for the ABR certifying exam or certificate of added qualification (CAQ) exam for neuroradiology.

More description and the answer (spoiler!) are seen below the video.

This case shows a trauma patient who had a significant fall and now has lower extremity symptoms. On the MRI, there are a few compression fractures that you can see, but in addition there is T1 hyperintense fluid in the dorsal epidural space. In the setting of trauma, this is likely to be an epidural hematoma.

The diagnosis is: fracture with spinal epidural hematoma

Epidural hematoma is a dreaded complication of spine trauma that can cause worsening cord injury. It requires close monitoring and possibly surgical drainage if this may improve the symptoms. Look for intraspinal fluid collections after trauma, as they can be hard to identify.

Board Review 2 – Case 13

Neuroradiology board review. This lecture is geared towards the ABR core exam for residents, but it would be useful for review for the ABR certifying exam or certificate of added qualification (CAQ) exam for neuroradiology.

More description and the answer (spoiler!) are seen below the video.

This case shows an aggressive lesion of the upper thoracic spine in a relatively young patient. It appears to be centered in the posterior elements of the upper thoracic spine. There is central osseous matrix formation as well as a surrounding soft tissue mass with adjacent bone destruction. This is causing significant narrowing of the spinal canal.

The diagnosis is: osteosarcoma

In this case, you know you are dealing with an aggressive mass because of the soft tissue component and bone destruction. The differential includes primary bone lesions, metastatic disease, and lymphoma, but because of the new bone formation (osteoid matrix), it suggests osteosarcoma.