Neurospot17.06.2016

THORSANG CHAYOVAN R3/AJ. NUTTHA SANGHAN

Quiz 1: Mount Fuji• Bilateral subdural hypertensive

pneumocephalus• Compression of the frontal lobes• Neurosurgical emergency• Differentiation between hypertensive

VS non-hypertensive • Hypertensive pneumocephalus afters

• Subdural hematomas drainage• Skull base, paranasal sinuses and

posterior fossa surgeries • Head trauma

Quiz 2: Dense artery• Early sign of acute middle cerebral

artery infarction• An increase in density of MCA

proximal segments secondary to thrombosis• DDx • Parietal calcification• Focal subarachnoid hemorrhage

Quiz 3: Caput medusae• Developmental venous anomaly• A network of dilated, abnormal medullary

veins with radial distribution, converging into a dominant, transparenchymal vein• May drain into a cortical vein, dural sinuses

or into the deep venous system • Most frequent intracranial vascular

abnormalities• Associated with cavernomas• May lead to intracranial hemorrhage,

thrombosis and venous infarction

Quiz 4: Popcorn ball • Cavernoma (Cavernous Malformation)• Benign vascular hamartoma• Composed of packed immature blood vessels

with microhemorrhage• Hyperdense on noncontrast CT; 50% Calcification • Lobulated appearance; no mass effect • Low signal T2w (HS) • High signal T1w (Met-Hb) • No to faint enhancement on post contrast• DDx: AVM--incomplete hemosiderin rim, flow

voids on T2w

Quiz 5: Eye-of-the-tiger

• T2w-Low-signal globus palladi surrounds a central, small hyperintense area• Hallervorden-Spatz (HS) syndrome • Neurodegeneration with brain iron

accumulation (NBIA) • Pantothenate kinase II (PANC2)-associated

neurodegeneration• Excessive iron accumulation • Central high signal: gliosis, increased water

content, and neuronal loss with disintegration, vacuolization, and cavitation of the neurophil

Hallervorden-Spatz (HS) syndrome • Neurodegenerative disorder associated with extrapyramidal

dysfunction and dementia• Triad of iron deposition, axonal spheroids, and gliosis in the globus

pallidi• MRI: differentiating HS syndrome from infantile axonal dystrophy—no

iron deposition • DDx other extrapyramidal Parkinsonian disorders • Cortical-basal ganglionic degeneration• Steele-Richardson-Olszewski syndrome• Early-onset levodopa-responsive Parkinsonism

Quiz 6: Dawson's fingers• Multiple sclerosis• White matter inflammatory changes

around the perimedullary veins• Ovoid lesions; longest axis perpendicular

to corpus callosum • Demyelinating plaques

• Juxtacortical white matter• Periventricular white matter• Corpus callosum• Callosal-septal interface

• High signal intensity on sequences with long repetition time

• Hyposignal intensity on T1w

Multiple sclerosis• Perivascular lymphocyte infiltration• McDonald criteria 2016

Dissemination in space Dissemination in time

CorticL/Juxtacortical (involves U-fiber)

New T2w/Gd-enhancing lesion

Periventricular (Dawson’s finger) Multistage

Infratentorial

Spinal cord

Optic nerve

Wernicke encephalitis • Congestion and petechial hemorrhage

• Subependymal regions • Mammillary bodies

CADASIL: Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy

• Recurrent lacunar and subcortical white matter strokes in multiple vascular territories• Young and middle age patients

without known vascular risk factors• Diffuse; anterior temporal lobe

(86%) and external capsule (93%) • Microhemorrhages• Cerebral atrophy

Marchiafava-Bignami disease• Chronic alcoholism• Corpus callosum necrosis and

demyelination• Atrophy and necrosis• T1w hypointense, T2w

hyperintense linear/punctate regions

Quiz 7: Salt and pepper • Paraganglioma• Salt = tumor matrix • T2w hyperintense (slow intratumor

flow and hemorrhage) • Vivid enhancement (rapid wash-in and

wash-out)

• Pepper = small vessels within these masses• Flow-voids on T1w and T2w

Paraganglioma• Near nerves and vessels• Neuroectodermal origin• Head and neck; 4 most common sites

• Glomus valgale tumor• Carotid body tumor• Glomus jugulare tumor• Glomus jugulotympanicum tumor

• Hypervascular tumor• Homogeneously enhancing when small• Heterogeneously enhancing when large• Flow voids

• Erode skull base, hourglass shape

Quiz 8: Eccentric target • CNS toxoplasmosis• A ring enhancing abscess

associated with an enhancing mural nodule • Highly specific but low sensitivity

(found in 30% of cases)• Believed to represent internal

folds and invaginations of the abscess walls

CNS Toxoplastomosis• Propensity for the basal ganglia, corticomedullary

junction, white matter, and periventricular regions• Calcification in congenital

• Uncommon calcification in acquired

• Mass effect• Thin, smooth, or poorly defined rim of enhancement

• Solid eccentric nodular enhancement/no enhancement

• T1w: hypointense/peripheral hyperintensity >> not lymphoma

• T2w: high/mixed signal intensity • DWI: peripheral hyperintensity (hemorrhage in walls)

Quiz 9: Molar tooth • Altered mesencephalon on axial

sections • Thickened and more horizontally

oriented superior cerebellar peduncles extending perpendicularly from brainstem• Joubert syndrome

Quiz 10: Hot cross bun

• Multiple systems atrophy type C• Cruciform pontine hyperintensity • Selective loss of neurons of

transverse pontocerebellar fibers• Neurodegenerative disorder with

basal ganglia and olivopontocerebellar complex involvement

Quiz 11: Figure eight• Lissencephaly• Defective neuronal migration

between 8th-14th gestational weeks• Figure eight configuration • Colpocephaly, flat gyri,

thickened cortex and cortico/subcortical atrophy• Miller-Dieker syndrome

Quiz 12: Bilateral CP angle masses• AMEN• A: acoustic schwannoma• M: meningioma• E: ependymoma• N: neuroepithelial cyst

(arachnoid/epidemoid)

Quiz 13: Martini glass

• Persistent hyperplastic primary vitreous (PHPV) • Congenital embryonic remnants of

hyaline vessels in Cloquet’s canal• Fibrovascular tissue • Attached lens to optic nerve head• Connecting laterally to abnormally

elongated ciliary process

• Retinal detachment 30%

Quiz 14: Tram-track• A central linear

hypodensity/hypointensity delimitated by affected optic nerve sheath• Useful in differentiation

from optic nerve gliomas

Quiz 15: face of the giant panda• Wilson's disease--genetic disorder of

the copper metabolism• Hepatocellular degeneration • Accumulation in liver and brain• T2w hyperintensity-- pontine

tegmentum• T2w hypointensity• Periaqueductal gray matter• Partial red nuclei • Lateral aspect of the substantia nigra

pars reticulata • Upper colliculus

Panda sign of sarcoidosis• Gallium-67 citrate scan finding• Bilateral involvement of parotid

and lacrimal glands • Superimposed on the normal

uptake in nasopharyngeal mucosa

Osmotic demyelination syndrome• Pons• Basal ganglia• Thalami• Cerebral peduncles• Subcortical white

matter• Cerebellum• Cervicomedullary

junction

Quiz 16: Empty orbit sign

• Neurofibromatosis type 1 • Orbit on skull film or CT• Lack of the innominate line due

to dysplasia of the greater wing of the sphenoid, shortening of the lateral wall of the orbit and flattening of the orbital angle

Quiz 17: TS• Bourneville-Pringle syndrome• Calcified subependymal nodules

(hamartomas)• Subependymal giant cell

astrocytomas• Foramen of Monroe (Most)

• Cortical/subcortical tubers• Thickened cortex, enlarged gyri

• White matter radial migration lines• Cyst-like white matter lesions

Quiz 18: Sturge-Weber• Encephalotrigeminal angiomatosis• Congenital low-flow vascular malformation• Port-wine stain on face in trigeminal

distribution• Leptimeningeal angioma primarily parieto-

occipital distribution• Seizure, severe metal retardation• Intracranial gyral calcification

• Tram track distribution• Occipital location

• Ipsilateral enlargement and enhancement of choroid plexus

Quiz 19: Spoke wheel• Typical angiographic appearance

found in meningioma• Multiple small arteries radially

distributed from a dominant feeding artery • Extra-axial, slow-growing, well-

vascularized lesions with a benign behavior • Dural tail and hyperostosis of the

adjacent bone

Quiz 20: Stripe/tigroid

• Linear hypointensities radiating from ventricular margins within hyperintense white matter• No enhancement• A specific pattern of demyelination sparing perivascular white matter • Dark spots/linear areas against a bright affected white matter >> leopard skin

• Metachromatic leukodystrophy (MLD)

References• http://www.scielo.br/scielo.php?pid=S01

00-39842011000200013&script=sci_arttext&tlng=en

• http://www.scielo.br/scielo.php?pid=S0100-39842011000200014&script=sci_arttext&tlng=en

• http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2765171/

• pdf.posterng.netkey.at/download/index.php?module=get_pdf

• Diagnostic neuroradiology; Anne G. Osborn

• Diagnostic imaging: brain

• Diagnostic imaging: head and neck• Head and neck imaging; Peter M. Som• http://pubs.rsna.org/doi/full/10.1148/ra

diographics.19.6.g99no251605• http://pubs.rsna.org/doi/full/10.1148/ra

diol.2393050459• http://pubs.rsna.org/doi/full/10.1148/rg.

294085205• http://www.ajnr.org/content/16/8/1653.

full.pdf• http://www.slideshare.net/fernferretie/t

he-orbit• http://radiopaedia.org/articles/hot-cross-

bun-sign• http://radiopaedia.org/articles/panda-sig

n-of-sarcoidosis• http://radiologykey.com/toxic-and-metab

olic-brain-disease• http://www.ncbi.nlm.nih.gov/pmc/article

s/PMC4365670/pdf/BJBMS-1-1.pdf• http://saraswatastar.weebly.com/radiolo

gical-signs.html• https://www.urmc.rochester.edu/

medialibraries/urmcmedia/imaging/education/educational-resources/documents/paragangliomas_000.pdf