Board Review 1 – Case 20

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

Board Review 1 – Case 20

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 CT of the orbits with proptosis and enlargement of the extraocular muscles. There is relative sparing of the myotendinous junction (where the muscles meet the globe).

The diagnosis is: Graves ophthalmopathy

Graves disease is one of the most common causes of bilateral opthalmopathy, although findings do not have to be symmetric. Findings often do not improve with treatment of Graves disease.

Youtube Playlist

Board Review 1 – Case 19

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

Board Review 1 – Case 19

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

The initial CT in this patient shows subtle hyperintensity in the pons which could easily be mistaken for artifact. However, MRI confirms a central and symmetric hyperintensity within the pons.

The diagnosis is: osmotic demyelination

Osmotic demyelination is a diagnosis characterized by central FLAIR hyperintensities in the pons, although abnormalities can occur anywhere in the brain. They are associated with abnormalities in serum osmolality, particularly sodium concentration. The primary differential consideration is infarct, although these are rarely bilaterally symmetric.

Youtube Playlist

Board Review 1 – Case 18

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

Board Review 1 – Case 18

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

This case starts with a CT of the thoracic spine which demonstrates a dumbell shaped mass in the left posterior mediastinum which extends into the left sided neural foramen. There is smooth remodeling of the adjacent bone, suggesting that this is a chronic finding. MRI shows a T2 hyperintense and avidly enhancing mass.

The diagnosis is: schwannoma

Schwannomas of the spine can be intradural or extradural masses. Their characteristic appearance is an avidly enhancing mass that extends through and remodels the neural foramina. Primary differential considerations include meningioma and neurofibroma.

Youtube Playlist

Board Review 1 – Case 17

Posted on May 28, 2018January 15, 2019 by Brent Weinberg, MD

Board Review 1 – Case 17

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

In this patient with trigeminal neuralgia, there is a mass in the left cerebellopontine angle which is causing mass effect on the pons and cerebellar peduncle. Its imaging appearance is close to that of CSF on all sequences except diffusion weighted imaging (DWI), on which it is bright.

Lesions of the cerebellopontine angle can be cystic or solid. Cystic appearing masses include arachnoid cysts and epidermoid.

The diagnosis is: epidermoid

Epidermoids of the cerebellopontine angle are inclusion cysts which contain secretions which are bright on DWI, distinguishing them from arachnoid cysts. They tend to have minimal if any enhancement.

Youtube Playlist

Board Review 1 – Case 16

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

Board Review 1 – Case 16

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

This case shows a solitary lesion with central T2 hyperintensity and surrounding siderosis (dark on T2). The area shows no real enhancement, although there is a linear branching structure adjacent to the lesion

The diagnosis is: cerebral cavernous malformation

Cerebral cavernous malformations are angiographically occult vascular malformations which consist of clusters of abnormal capillaries without a shunt. Their characteristic appearance is a rim of hemosiderin which may take on the appearance of a popped popcorn kernel. Developmental venous anomalies (DVAs), are often seen with isolated cavernous malformations.

Other times, patients may have multiple lesions which can be associated with familial syndromes.

Youtube Playlist

Board Review 1 – Case 15

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

Board Review 1 – Case 15

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

This case starts with a CT showing bilateral temporal bone fractures after a major trauma. There are a number of potential complications of temporal bone fractures, but on the left the ossicles are no longer in alignment.

The diagnosis is: ossicular dissociation from trauma

Fractures of the temporal bone can cause a number of complications, including meningitis, conductive hearing loss, and facial nerve injury. This shows dislocation of the malleus and incus on the left. Fractures should be classified by whether they involve the otic capsule or spare the otic capsule.

Youtube Playlist

Board Review 1 – Case 14

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

Board Review 1 – Case 14

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

This case starts with a CT showing a mass in the right ethmoid air cells. There is dehiscence of the adjacent cribriform plate. MRI with contrast shows a mass predominantly in the ethmoid air cells, although there is intracranial extension with abnormal dural enhancement.

The diagnosis is: esthesioneuroblastoma

Esthesioneuroblastomas are neuroblastomas of the olfactory nerves. Their classic description is a mixed sinus and intracranial mass which sometimes has an intracranial cyst. The main differential diagnostic consideration is a squamous cell carcinoma of the sinuses.

Youtube Playlist

Board Review 1 – Case 13

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

Board Review 1 – Case 13

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.

Youtube Playlist

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.

Youtube Playlist

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.

Youtube Playlist