Board Review 1 – Case 10

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

Board Review 1 – Case 10

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 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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Board Review 1 – Case 4

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

Board Review 1 – Case 4

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

In this case, there are bilateral basal ganglia and cortical FLAIR hyperintensities. Thalamic abnormalities involve the pulvinar nucleus and make an L-shaped abnormality known as the “hockey stick sign”.

The diagnosis is: creutzfeldt-jakob disease, or CJD.

CJD is a prion disease characterized by rapidly progressive dementia. The vast majority of cases are spontaneous, although some can be acquired through exposure to prions in meat.

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Board Review 1 – Case 3

Posted on April 22, 2018December 11, 2018 by Brent Weinberg, MD

Board Review 1 – Case 3

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

In this case, the patient has T2 hyperintensity in the pons. This abnormality takes on a cruciform shape which is known as a “hot crossed bun” appearance.

The diagnosis is: multisystem atrophy, or MSA

Multisystem atrophy is a degenerative disease which is similar to Parkinson’s disease. It does not respond well to typical Parkinson’s disease treatments. There are 3 main types of MSA.

MSA-P has Parkinsonian predominant symptoms.
MSA-C is predominated by cerebellar symptoms and ataxia
MSA-A (autonomic) is dominated by autonomic instability and was previously known as Shy-Drager syndrome

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Board Review 1 – Case 2

Posted on April 21, 2018December 10, 2018 by Brent Weinberg, MD

Board Review 1 – Case 2

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

In this case, the patient has focal midbrain atrophy. On sagittal images, this gives the midbrain the appearance of a hummingbird, with a concave upper margin to the midbrain. This is called the hummingbird sign. On axial images, the interpeduncular cistern is widened, giving the midbrain the appearance of “Mickey Mouse”

The diagnosis is: progressive supranuclear palsy, or PSP

PSP is a degenerative disease which is similar to Parkinson’s disease. Other key features include vertical gaze palsy and dementia. It does not respond well to typical Parkinson’s disease treatments.

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