Brain masses, lesions, and other on imaging

Question 1

large solitary tumor within cerebral hemisphere with irregular enhancing margins and central necrotic core

Answer 1

glioblastoma multiforme tends to spread across the corpus callosum

Question 2

multiple lesions at the junction of gray and white matter with surrounding edema

Answer 2

non seminomatous germ cell tumors

Rarely metastasize to brain but when they do they show up as mentioned

Question 3

what is seen on imaging with cerebral toxoplasmosis

Answer 3

ring enhancing lesions on neuroimaging. Rarely seen in immunocompetent pts Seen in HIV pts

Question 4

HIV pt with headache confusion and fever. Check for what?

Answer 4

cerebral toxoplasmosis

Question 5

CNS TB presents with

Answer 5

subacute febrile illness followed by meningismus, focal deficits, confusion, and seizure

Question 6

CNS TB on imaging

Answer 6

basilar meningeal enhancement hydrocephalus, tuberculomas (iso hyperdense encapsulated lesions with ring ehancement)

Question 7

Mexican immigrant presents with seizure. think about

Answer 7

neurocysticerocosis

Question 8

Multiple viable cysts 5-20 mm hypodense lesions in brain parenchyma

Answer 8

neurocysticerocosis

Question 9

Name the condition

Answer 9

glioblastoma multiforme.

from glial cells and it grows so fast there are no calcifications.

seizure or focal weakness, headache worse on coughing or lying down.

Question 10

34 y o woman with acute headache then generalized tonic clonic seizures. Felt fine until 6 hrs ago when she developed a 10/10 throbbing bilateral headache and blurry vision. She is mulitple HTN meds and never had a history of seizure.

Temp normal, BP 210/140 and HR 80 and neuroexam: awake and alert but oriented to person and place. See copper and silver wiring no papilledema on fundoscopic exam. CT shows loss of greay white matter differentiation in posterior occipital parietal lobes and this is the MRI. What does she have?

Answer 10

PRES - posterior reversible encephalopathy syndrome

AKA
reversible posterior leukoencephalopathy syndrome (RPLS)

Question 11

what causes PRES?

Answer 11

often seen with hypertensive crisis,

chemotherapy agents (cyclosporine)

eclampsia, preeclampsia,

allogenic bone marrow transplant

medical renal dx,

autoimmune dx,

sepsis and shock.

Question 12

what is posterior leukoencephalopathy syndrome?

Answer 12

PRES

also called hyperperfusion encephalopathy

brain capillary leak syndrome

Question 13

What is the pathophysiology behind PRES or brain capillary leak syndrome?

Answer 13

brain edema likely from diminished sympathetic innervation of the posterior circulation.

posterior regions of the brain are more susceptible to injury from high mean arterial pressures, which MAP increased in brain parenchyma and subseqent vasogenic edema

Question 14

which areas of the brain are most susceptible to PRES?

Answer 14

parietal and occipital lobes, then the frontal lobes and inferior temporal occipital junction and cerebellum

rare case reports of brainstem and cervical cords.

Question 15

Treatment of PRES:

Answer 15

lowering BP - no more than 25% in first 6 hrs

stop any precipitating drugs

antiepileptic therapy for seizures

most pts are experience reversal in symptoms within 2 weeks.

Must also need to get imaging. MRI imaging to rule out stroke or ICP

Question 16

what is this CT scan show?

Answer 16

subarachnoid hemorrhage and this is a medical emergency. need to get aniogram to do coiling or embolization

Can be seen with fibromuscular dysplasia or twisting of arteries (see spontaneous coronary artery dissection or renal FMD)

25% mortality rate in 1st 24 hrs of presentation to hospital due to rebleeding.

Question 17

what is on this CT scan of the head?

Answer 17

subarachnoid hemorrhage.

look for acute blood products or white contrast in the cisterns on neuroimaging.

Question 18

Herpes simplex virus encephalitis you see:

Answer 18

high signal flaire abnormality with enhancement in bilateral or unilateral temporal lobes

see fever, headache, change in mental status and seizures.

Question 19

what is seen in idiopathic intracranial hypertension

Answer 19

young obese women with recurrent postural headaches (worse in supine position) and visual obscurations, papilledema, and rarely visual loss

no changes on brain MRI.

Question 20

what does this image show?

Pt had MVA, new onset headache which radiates to left side of neck. Also has global aphasia, right homonymous hemianopsia, left pupillary miosis and partial ptosis and left gaze preference

Reduced sensation on right side of face and body and right sided hemiparesis and extensor response at the right big toe on plantar cutnaeous stimulation.

Answer 20

Has traumatic left internal carotid artery dissection causing ipsilateral MCA stroke and ipsilateral horners syndrome. carotid dissection can present as transient vision loss, ischemic stroke or embolic stroke

Because the post ganglionic sympathic fibers run on outside surface of ICA to supply the head, ICA dissection can damage fibers and lead to partial ipsilateral Horner’s (partial ptosis, miosis without anhidrosis).

See MRA/CTA with a ICA with t_apered, flame-shaped apperance rather than blunt stumped appearance_ of vascular occlusion.

Question 21

how are cervical neck artery dissections treated?

Answer 21

many are treated with aspirin and not anticoagulation

Question 22

If there’s any concern for brain herniation what to do next?

Answer 22

IV dexamethasone to prevent brain herniation. Dexamethasone is preferred because lacks mineralcorticoid effects.

may see Cushing’s triad: high BP and irregular respirations and bradycardia - sign of ICP

Question 23

what to do for ICP?

Answer 23

while waiting for definitive treatment options, some other thing should be

ELEVATION of hehad of bed to 30 degrees,

artificial respiratory alkalosis with lower ICPs

also need emergent intubation-even if there’s no respiratory compromise

give glucocorticoids

needs CT head to confirm herniation to look for a cause (stroke, tumor, hemorrhage)

Question 24

second most frequent cause of thunderclap headache is:

Answer 24

reversible cerebral vasoconstriction syndrome - recurrent thunderclap headache. See multifocal constriction of intracranial vessels normalizing within 3 months of onset.

Triggered: exertion, valsalva maneuver, emotion, and bathing

Presentation: focal deficits, encephalopathy and seizures

Need to get a MRA/CTA and CSF analysis to rule out stroke and infection.

Brain MRI may show areas of white matter edema in occipital or parietal lobe compatible with posterior reversible encephalopathy syndrome. see a_reas of ischemia and hemorrhage in parenchyma and sub dural or subarachnoid hemorrhage_

Question 25

Treatmemt of reversible cerebral vasoconstriction syndrome

Answer 25

Management: resolution of predisposing factors, avoidance of physical exertion and treat BP (no more than 25% in first 6 hrs)

STOP medication (generally immunosuppressive driving BP elevation)

can use verapamil and nimodipine

no steroids

repeat MRI and CTA is needed in 12 weeks to make sure that vasospasm improves and then can taper medication.

Question 26

what is reversible posterior leukoencephalopathy syndrome RPLS also known as

Answer 26

PRES - posterior reversible encephalopathy syndrome

• see moderate to severe headache, seizure, AMS and visual disturbances.

Can have hemianopsia, visual neglect, visual hallucinations, cortical blindness

see extreme hypertension that develops rapidly.

Question 27

what medications can cause reversible posterior leukoencephalopathy syndrome?

Answer 27

cyclosporine (most common) but others include:

bevcizumab,

sorafenib,

platinum based chemotherapy,

tacrolimus

methotrexate

gemcitabine.

Question 28

posterior circulatory stroke syndromes

Answer 28

CN involvement can help with localization based on the origin within the brainstem:

midbrain: CN3-4

pons: CN 5-8

medulla oblongata: CN9-12