Board Review 2 – Case 18

Posted on July 4, 2019 by Brent Weinberg, MD

Board Review 2 – Case 18

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 patient with cerebellar tonsils which extend below the foramen magnum. They have a “peglike” or triangular configuration, and extend well below the foramen magnum. The differential for this finding includes Chiari malformation, cerebellar tonsillar ectopia, idiopathic intracranial hypertension (IIH), and spontaneous intracranial hypotension (SIH).

The diagnosis is: Chiari malformation

Chiari malformation is a congenital abnormality in which the cerebellar tonsils extend below the foramen magnum and the posterior fossa is small. Patients can have chronic headaches. CSF flow studies of the foramen magnum can be useful to determine if patients are likely to benefit from surgical decompression with suboccipital craniectomy.

When combined with other abnormalities, there are specific diagnoses, which are:

Chiari II – cerebellar tonsillar abnormality + lumbar meningocele/myelomeningocele
Chiari III – cerebellar tonsillar abnormality + occipital meningocele

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Board Review 2 – Case 17

Posted on July 4, 2019 by Brent Weinberg, MD

Board Review 2 – Case 17

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

This case shows a CT with hyperdensity ventral to the pons and midbrain consistent with hemorrhage. Further imaging, including MRI and CT angiogram, were normal

The diagnosis is: benign perimesencephalic hemorrhage

This is a relatively benign form of subarachnoid hemorrhage of unknown etiology. The blood products are seen ventral to the pons, and are more common in younger patients. No vascular abnormality or tumor is found, and it is thought to be a result of disrupted veins, although the real cause is unknown. Outcomes are better compared to aneurysmal or traumatic subarachnoid hemorrhage.

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Board Review 2 – Case 16

Posted on February 10, 2019February 10, 2019 by Brent Weinberg, MD

Board Review 2 – Case 16

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.

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Board Review 2 – Case 15

Posted on January 24, 2019January 15, 2019 by Brent Weinberg, MD

Board Review 2 – Case 15

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.

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Board Review 2 – Case 14

Posted on January 21, 2019January 15, 2019 by Brent Weinberg, MD

Board Review 2 – Case 14

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

This case shows a patient with a new neurologic deficit and a relatively normal noncontrast head CT. Perfusion, on the other hand, shows an area of decreased CBV, increased MTT, and increased Tmax in the posterior aspect of the left middle cerebral artery (MCA) distribution. There is an associated vessel occlusion on CT angiogram.

The diagnosis is: cerebral ischemia (stroke)

This patient has an area of ischemia in the left MCA territory. Because the CBV is relatively maintained, this tissue is mostly considered penumbra. When there is a significant decrease in volume and flow, it is considered core infarct that is not likely to recover.

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Board Review 2 – Case 13

Posted on January 17, 2019January 15, 2019 by Brent Weinberg, MD

Board Review 2 – Case 13

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.

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Board Review 2 – Case 12

Posted on January 14, 2019 by Brent Weinberg, MD

Board Review 2 – Case 12

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

This case shows multiple images throughout the body, with initial emphasis on the lumbar spine, where there is destruction of a lumbar vertebral body and surrounding abscess and inflammatory changes of the adjacent disc. There is relative sparing of the lumbar discs.

There is also disease elsewhere in the body, including an osseous lesion in a left-sided rib, ground glass and tree-in-bud nodules in the lungs, and nodular enhancing lesions in the brain. This makes you think about some sort of systemic process.

The diagnosis is: spinal tuberculosis

Spinal tuberculosis is a serious disease which can cause a discitis-osteomyelitis. The classic teaching, although it may not be true, is that the disease will spare the intervertebral discs. Other things to consider in the differential are metastatic disease and other infections.

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Board Review 2 – Case 11

Posted on January 10, 2019January 10, 2019 by Brent Weinberg, MD

Board Review 2 – Case 11

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

This case shows MRI imaging from a relatively normal study of the lumbar spine. However, upon closer inspection, it is clear that there is a heterogenous mass in the right kidney.

The diagnosis is: renal cell carcinoma

Masses in the kidney can be a missed source of pain, and it is important to look for incidental findings. Plus, your board exam will not necessarily tell you which topic you are dealing with. Radiologists are most commonly sued because of failure to diagnose, so be careful.

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Board Review 2 – Case 10

Posted on December 2, 2018 by Brent Weinberg, MD

Board Review 2 – Case 10

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

This case shows a relatively homogeneous mass of the cervical spine replacing several vertebral bodies. There is involvement of the adjacent soft tissues, epidural space, and posterior elements.

The differential diagnosis for this mass is lymphoma, myeloma, and metastatic disease. Given young age of the patient, myeloma and metastatic disease are less likely, although possible.

The diagnosis is: lymphoma.

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Board Review 2 – Case 9

Posted on December 2, 2018December 2, 2018 by Brent Weinberg, MD

Board Review 2 – Case 9

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

This case shows narrowing of the thecal sac in the lower lumbar spine due to a cystic lesion that is in the dorsal epidural space just to the left of the midline. There is minimal surrounding abnormal enhancement.

The diagnosis is: synovial cyst

Synovial cysts, along with bursal cysts from the spinous processes, are cystic lesions which can cause canal narrowing. These can be treated with minimally invasive rupture versus surgical resection.

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