Board Review 1 – Case 13

Posted on May 28, 2018December 18, 2018 by Brent Weinberg, MD

Board Review 1 – 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 a hyperdense mass in the left posterior nasal passages. There is expansion of the left sphenopalatine foramen. In a relatively young patient, there is really only one diagnostic consideration.

The diagnosis is: Juvenile nasal angiofibroma (JNA)

Juvenile nasal angiofibromas are masses that arise in the sphenopalatine foramen in young boys. They are extremely vascular lesions and are typically treated by embolization of branches of the external carotid artery which supply the mass prior to resection.

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Board Review 1 – Case 12

Posted on May 28, 2018December 18, 2018 by Brent Weinberg, MD

Board Review 1 – Case 12

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

In this case, there are curvilinear calcifications which follow the cortex in the right cerebral hemisphere on CT. On MRI, there is atrophy of the right cerebral hemisphere with abnormal veins coursing through the deep white matter of the right cerebral hemisphere. On contrast enhanced images, there is avid enhancement of the right hemisphere leptomeninges.

The diagnosis is: Sturge-Weber syndrome

Sturge-Weber syndrome is a variant in which normal cortical vessels fail to form, and the hemisphere is drained by abnormal mesenchymal veins which course through the cerebral hemisphere. Classic imaging findings include cortical calcifications of one hemisphere.

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Board Review 1 – Case 11

Posted on May 28, 2018December 18, 2018 by Brent Weinberg, MD

Board Review 1 – Case 11

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

This case shows a hyperdense structure in the third ventricle near the foramen of Monro on CT of the head. There is mild associated hydrocephalus. Findings on MRI confirm the presence of a mass which is well demarcated and hyperintense on T1 and T2 weighted imaging with minimal enhancement.

The diagnosis is: Colloid cyst

A colloid cyst is a well demarcated, benign mass in the third ventricle near the foramen of Monro. These masses make patients susceptible to rapid onset hydrocephalus which can be fatal, which necessitates their resection.

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Board Review 1 – Case 10

Posted on May 20, 2018December 11, 2018 by Brent Weinberg, MD

Board Review 1 – Case 10

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

This case shows bilateral areas of reduced diffusion in the medial thalami, concerning for infarcts. When the bilateral thalami are involved by infarcts, the differential includes artery of Percheron infarct, basilar tip occlusion, and venous infarct.

The diagnosis is: artery of Percheron infarct

The artery of Percheron is a variant in which the thalamic perforators from the PCA are supplied from a trunk from one P1. When this trunk is occluded, bilateral thalamic infarcts can occur.

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Board Review 1 – Case 9

Posted on May 20, 2018December 11, 2018 by Brent Weinberg, MD

Board Review 1 – Case 9

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

This case shows multiple areas of intracranial edema with post-contrast enhancement in a patient with HIV. The key to the diagnosis in this case is the appearance on diffusion weighted imaging (bright) and ADC, consistent with centrally reduced diffusion.

The diagnosis is: intracranial abscess

Intracranial abscesses are parenchymal collections of pus within the brain. Their key feature is peripheral enhancement with centrally reduced diffusion. They are more common in immune suppressed patients.

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Board Review 1 – Case 8

Posted on May 20, 2018December 11, 2018 by Brent Weinberg, MD

Board Review 1 – Case 8

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

This case shows a right sided hyperdense extraaxial collection on a CT. This collection crosses sutures and has a crescent shape, suggesting a subdural location.

The diagnosis is: subdural hematoma

Subdural hematomas are extraaxial collections of blood which can be spontaneous or seen after trauma. Most commonly they are caused by bridging subdural veins. They have a high mortality and can sometimes require evacuation.

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Board Review 1 – Case 7

Posted on May 20, 2018January 15, 2019 by Brent Weinberg, MD

Board Review 1 – Case 7

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

This case is a patient presenting to the ER with headache. The CT demonstrates scattered areas of edema, warranting further evaluation with an MRI.

The MRI shows parenchymal nodular areas of enhancement with surrounding edema. There is also coating of the surfaces of the brain with abnormal enhancement, known as leptomeningeal enhancement. When this is nodular, it is highly concerning for metastatic disease.

The diagnosis is: metastatic disease

Nodular leptomeningeal enhancement on MRI is concerning for several serious pathologies. The differential includes meningitis, both with bacterial and unusual (TB and fungal) pathogens, inflammatory pathologies such as sarcoidosis, and carcinomatosis (as in this case).

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Board Review 1 – Case 6

Posted on May 19, 2018January 15, 2019 by Brent Weinberg, MD

Board Review 1 – Case 6

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

This case is a young postpartum patient with seizure and somnolence. The MRI shows FLAIR hyperintense white matter abnormalities in a predominantly posterior distribution. There is likely a small amount of subarachnoid hemorrhage.

The diagnosis is: posterior reversible encephalopathy syndrome, or PRES.

PRES has several names, including acute hypertensive encephalopathy, although this is also misleading because there are several causes, including hypertension and many medications. It is a primary disorder of vasoregulation, with edema occurring in subcortical white matter.

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Board Review 1 – Neurodegenerative review

Posted on May 19, 2018June 3, 2018 by Brent Weinberg, MD

Board Review 1 – Neurodegenerative review

Neuroradiology board review – neurodegenerative review

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Board Review 1 – Case 5

Posted on April 24, 2018December 11, 2018 by Brent Weinberg, MD

Board Review 1 – Case 5

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

This case has a patient with Parkinsonian symptoms and shows a nuclear medicine scan of the basal ganglia. This scan is an I131-ioflupane scan, or DaTscan. In this, the normal distribution is in both the caudate and putamen (like a comma). In parkinsonian syndromes, the putamen loses its normal signal and the image becomes more like a period.

The diagnosis is: parkinson’s disease

DaTscan can be useful in differentiating true parkinsonian syndromes (including MSA and PSP) from vascular or drug-induced parkisonism, among other causes. However, it cannot differentiate between PD, MSA, and PSP.

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