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Undeleted > Neuro- iphone > Flashcards

Neuro- iphone Flashcards

1
Q

Ddx restricted diffusion

A 
Infarct
Abscess/empyema
Epidermoid cyst
DAI
Sz/status
Encephalitis
Densely cellular tumor (mening, sm blue cell)
PRES (rarely, = infarct)
CJD
MS
Osmotic demyelination
Hypoglycemia
Wernicke's
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1
Q

T1 bright (6 things)

A 
Fat
Proteinaceous fluid
Subacute hemorrhage (methemoglobin)
Melanin
Gd
Ca (rarely)
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2
Q

Causes of susceptibility artifact on GRE/SWI

A 
air
hemorrhage (methemoglobin, deoxyhemoglobin)
calcium
metal
(others?)
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3
Q

MR evolution of stroke:

Acute infarct vs.
Subacute infarct vs.
Old lacunar infarct vs.
Virchow-Robin

A

Acute:
Restrict diffusion +/- mild T2/FLAIR edema

Subacute:
ADC normalizes before DWI, typically by one week (then DWI nL by 2 wks?). Also, FLAIR increases as ADC normalizes. Look for e/o laminar necrosis with high T1 signal and hallmark gyriform enhancement @ 1-2 wks (also hyperdense & enhancing on CT). May also see petechial hemorrhage (high T1 methemoglobin).
-May see enh at 3 days-3 wks

Chronic lacune:
T2 & FLAIR bright, no diffusion abnormality

VR:
T2 bright only, normal FLAIR

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4
Q

Ddx of ischemic stroke in kids

A 
Congenital heart dz
Blood dyscrasias
Meningitis
Arterial dissection
Trauma
ECMO
Venous thrombosis
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5
Q

Ddx of ischemic stroke in young adult

A 
Cardiac emboli
Athero
Drug abuse
Arterial dissection
Coagulopathy
Vasculitis
Venous thrombosis
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6
Q

Ddx of ischemic stroke in elderly

A 
Athero
Cardiac emboli
Coagulopathy
Amyloid
Vasculitis
Venous thrombosis
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7
Q

Causes of non-traumatic ICH

A 
#1 overall- HTN
#1 in elderly- CAA
#1 in kids- vascular malformation

Other causes:

  • Hemorrhagic transformation of ischemic stroke, esp venous (look for underlying tumor)
  • Aneurysm
  • CA
  • Coagulopathy
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8
Q

Shape & Common sites of HTN hemorrhage

A

-Typically ovoid in shape

Basal ganglia
Thalami
Cerebellum
Pons
Sometimes in lobar WM (less specific)

-Look for assoc sign of chronic uncontrolled HTN (i.e. punctate GRE microbleeds/old hemorrhage in same dist, wm dz on FLAIR, lacunes)

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9
Q

Common sites of Cerebral amyloid angiopathy-related hemorrhage

A

Lobar
Cortical
Cortical-subcortical

-Look for assoc signs of CAA (multiple GRE microbleeds in peripheral cortical distribution/old bleeds, wm dz)

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10
Q

DAI on CT

A

Small petechial hemorrhages (or hypodensities) at SC GW jcn or CC

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11
Q

Vascular malformations: hemorrhagic vs. NON

A

Hemorrhagic:

  • AVM
  • Cavernoma

NON-hemh:

  • DVA
  • Capillary telangiectasia (pons)
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12
Q

Places to look for SAH

A
  • interpeduncular cistern
  • dependent portions of ventricle
  • sulci (by quadrant)
  • r/o hydrocephalus… if any enlargement of temporal horns, this is an emergency! Be careful, b/c easy to miss synmetric enlargement!
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13
Q

Common sites for aneurysm

A

Branch points:

  • Acomm
  • Pcomm
  • basilar tip
  • MCA trifurcation
  • PICA origin
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14
Q

Tumors more prevalent in women

A

Meningioma (4:1)
Neurofibroma
Pineocytoma
Pituitary tumor

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15
Q

Tumors more prevalent in men

A 
Pineal germinoma (10:1)
Pineal parenchymal tumor (4-7:1)
Medulloblastoma (3:1)
GBM (3:2)
Choroid pelxus papilloma (2:1)
CNS lymphoma
Hamartoma of the tuber cinereum
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16
Q

Hemorrhagic tumors

A

GBM most common
Mets #2 (RCC, thyroid, chorio, melanoma)
Oligodendroglioma (#2 primary)

2 primaries, 4 mets

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17
Q

Intra-axial lesions w marked edema (6)

A

(“MARGHL” mneumonic)

Mets
Abscess
Radiation necrosis
GBM
Hematoma (mild)
Lymphoma (?mild)
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18
Q

Ring-enhancing lesions

A 
MAGIC(L)-DR:
---------------------
M ets
A bscess
G BM
I nfarct (subacute)
C ontusion
L ymphoma (rarely, AIDS)
D emyelinating dz (incomplete rim)
R adiation necrosis ... OR ... Resolving hematoma
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19
Q

Distinguishing ring-enhancing lesions on MR:

  • Abscess
  • GBM
  • Mets
  • Demyelinating dz
  • Resolving hematoma
A

Abscess:

  • thin uniform enh (and low T2) rim, RESTRICT DIFFN, can be multiple w daughter cyst
  • bacterial if central DWI, fungal if peripheral nodular DWI
  • toxo if HIV+, peripheral, DWI neg, can be mult

GBM:
-nodular thick wall, HEMH, low DWI signal

Mets:
-thick walled, often multiple, h/o 1o CA, DWI neg, some can hemh

Demyelinating dz:
-incomplete rim, often multiple

Resolving hematoma:
-h/o trauma, T1/T2/GRE changes from blood products

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20
Q

Calcified GLIAL tumors

A

O ligodendroglioma (70-90%)
E pendymoma (44%)
A strocytoma (low-grade only, 10-20%)
[G BM rarely! Suggests degen of low-grade tumor]

Notes:

  • a calcified intracial tumor is most likely to be an astrocytoma since they are much more common, even though almost all oligodendrogliomas calcify
  • these are all glial tumors, other tumors also calcify
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21
Q

Other calcified tumors

A

Extra-axial:

  • Meningioma
  • Craniopharyngioma
  • Chordoma

Intra-axial:

  • Mets
  • Choroid plexus papilloma
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22
Q

Common intra-axial mets

A

lung (extra too)
breast (extra too)
melanoma (can be hemorrhagic)
colon

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23
Q

Common extra-axial mets

A

breast (also intra)
prostate
lung (also intra)
neuroblastoma

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24
Q

Common hemorrhagic mets

A

melanoma
RCC
thyroid
chorio

** CAREFUL on GRE, some mets can be GRE+ due to Ca (e.g. colon)!!

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25
Q

Congenital brain tumors (< 60 days old)

A

Teratoma #1 by far (1/3-1/2), most are supratentorial (2/3)

PNET (primitive neuroectodermal tumor):  curvilinear, sparse Ca
Astrocytoma
Choroid plexus papilloma
Ependymoma
Medulloepithelioma
Germinoma
Angioblastic meningioma
Ganglioglioma
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26
Q

Most common location for intracranial neoplasm in kids

A

Posterior fossa

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27
Q

Posterior fossa masses in children (in order of freq w typical location of each)

A

1: Medulloblastoma- vermis (think Midline), restricts diffusion

Brainstem glioma- us. astrocytoma

Choroid plexus papilloma- 4th ventricle

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28
Q

CPA masses

A

Consider these all as p-fossa masses!!

A coustic (or vestibular) Scwhannoma ** #1 most common (80%)
M eningioma
E pendymoma
N euroepithelial cyst (arachnoid or epidermoid)

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29
Q

Ddx cerebellar lesion in ADULTS

A

-Mets

…or…

  • Hemangioblastoma (= most common 1o):
  • predominantly cystic w small nodule
  • assoc w VHL

-also remember AMEN for p-fossa!

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30
Q

Intraventricular masses (top 3)

A 
#1-  Choroid plexus papilloma
#2-  Ependymoma
#3-  Subependymoma
central neurocytoma
SEGA (subependymal giant cell atrocytoma)
all other astrocytomas
meningioma
colloid cyst
choroid plexus CA
mets
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31
Q

Most common lateral ventrical mass @ foramen of Monro

A

SEGA
Pilocytic astrocytoma

Both w typical age 10-40 yo

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32
Q

Most common lateral ventrical mass @ body, according to age

A

0-10:
PNET (primitive neuroectodermal tumor)
Teratoma
Choroid plexus papilloma

10-40:
Ependymoma
Pilocytic astrocytoma
Central neurocytoma

> 40:
Subependymoma

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33
Q

Most common lateral ventrical mass @ trigone, according to age

A

0-10:
Choroid plexus papilloma

> 40:
Meningioma
Mets

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34
Q

Masses of anterosuperior 3rd ventricle

A 
Colloid cyst
Meningioma
Choroid plexus papilloma
Hamartoma
Glioma
Vascular lesion
Granulomatous dz
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35
Q

Pineal region masses

A

3 main groups:

      1. Germ cell tumors: ** ~60%
        • germinoma (young male)
        • teratoma
        • embryonal sinus tumor
        • choriocarcinoma
  1. Pineal parenchymal tumors: ~14%
    - pineocytoma (adults)
    - pineoblastoma (kids)
  2. Others:
    - pineal cyst
    - glioma
    - meningioma (tentorial)
    - Vein of Galen malformation
    - arachnoid cyst
    - lipoma
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36
Q

Suprasellar masses

A

S ella (pituitary) tumor
S arcoid

A neurysm
A rachnoid cyst

T eratoma
C raniopharyngioma

H ypothalamic gliomatoma
H amartoma of tuber cinereum
H istiocytosis

Meningioma
Mets
Optic nerve glioma

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37
Q

Craniopharyngioma vs Rathke’s cleft cyst

A

Both can be cystic

  • CP enhance (think CP = C+), can Ca+
  • Rathke’s have mural nodule, do NOT enhance
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38
Q

1o vs 2o CNS lymphoma

A

1o- periventricular, CC, homog enh, almost all B-cell

2o- us meningeal

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39
Q

Epidermoid vs. Dermoid:

  • freq
  • peak age
  • germ cells
  • location
  • imaging
A

Epi. Dermoid
Freq: epidermoids more common
Peak age: 40-50 vs 20-30
Germ cells: ectoderm vs ecto+meso
Location: off midline (CPA, parasellar, p-fossa) vs midline (pericerebellar, suprasellar)
Imaging: follows CSF & restr diffn vs fat

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40
Q

DDx for intradural intramedullary spine lesion

A
  • demyelinating dz (MS, transverse myelitis, NM optica aka Devic’s, adem?)
  • contusion
  • infarct
  • syringohydromyelia
Masses:
ependymoma (myxopapillary vs ?cellular)
astrocytoma
hemangioblastoma
lipoma/epidermoid/dermoid
AVM
Rarely mets
Rareel abscess
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41
Q

Ddx for intradural extramedullary spine mass

A 
meningioma
schwannoma/neurinoma
neurofibroma
hemangiopericytoma
lipoma/epidermoid/dermoid
arachnoid cyst/adhesion
drop/lepromeningeal mets
veins or AVM
pulsation artifact!!
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42
Q

DDx for extradural spine mass

A

Degen:

  • herniated disc
  • synovial cyst
  • osteophyte
  • rheumatoid pannis

Non-degen:

  • mets
  • abscess
  • hematoma
  • 1o tumor (expansion or invasion)
  • epidural lipomatosis
43
Q

Osteomyelitis vs Modic type I changes vs Tumor infilatration

A

-Sometimes cannot tell since all endplates are T1 dark, T2 bright!

  • compare to priors
  • look for 2o signs of infection with prevertebral ST edema/enhancement extending above and below level
  • if disc is dark on T2, can r/o discitis
  • tumors restrict diffusion, us single level, us ST & discs spared
44
Q

Clivus lesions

A

1 Mets

Chordoma (midline, min enh)
Plasmacytoma
Chondrosarcoma (more lateral)

Meningioma
Petrous apicitis (Gradenigo syndrome, CNopathies)
45
Q

Carotid space masses

A

Reactive LN
Met LN (us necrotic CCA)
Paraganglioma (carotid body ?if split ICA/ECA, or glomus vagale)
Schwannoma (thick nod rim enh, cystic centrally)
Neurofibroma
Lymphoma
Mets (rare)

46
Q

Lesions that cross corpus callosum

A 
GBM
CNS lymphoma (can infiltrate BG/brainstem too!)
MS
DAI
Gliomatosis
Splenium:
DAI
Viral infx
Sz meds?
ADEM
Marchidava-Bignami (EtOH)

PML
Adrenal Leukodystrophy
Lipoma(?)
AVM(?)

47
Q

Classes of WM diseases

A
  1. Primary demyelination
  2. Ischemic demyelination
  3. Infection-related demyelination
  4. Toxic and metabolic demyelination
  5. Dysmyelination (leukodystrophy)
48
Q

Diseases of Primary demyelination

A

MS (periventricular, juxtacortical, rarely cortical, spares BG [vs ADEM], incomplete ring enh highly specific)

49
Q

Diseases of Ischemic demyelination [and pattern]

A
  • chronic small vessel ischemic disease [scattered]
  • infarction (thromboembolic, lacunar, and deep WM)
  • vasculitis (incl lupus and sarcoid) [scattered]
  • drug-induced vasculopathy [convexities]
  • dissection
  • migranous ischemia
  • moyamoya [scattered]
  • anoxic
  • CADASIL [a-temporal, m-fronal, ext capsule]

?isch
-PRES (cortical & subcortical, posterior predominance, can progress to infarct and restrict diffn)

50
Q

Infection-related demyelination

A
  • PML [U-fibers, no mass effect or enh]
  • HIV [early diffuse hazy T2 wm changes]
  • ADEM [monophasic numerous WM/BG patches, all enh, may also involve cortex, brainstem/p-fossa/cord]
  • SSPE
  • Lyme
  • Neurosyphilis
51
Q

Diseases of toxic or metabolic demyelination

A
  • Osmotic demyelination (formerly central pontine, but can also affect thalami, BG, & WM)
  • Wernicke-Korsakoff (med thal, other areas)
  • Radiation injury [confluent, U-fibers]
  • Necrotizing leukoencephalopathy
  • Marchiava-Bignami disease (CC esp genu & splenium)
  • Delayed post-hypoxic leukoencephalopathy (confluent wm, restricted diffn, rapidly progressive)
52
Q

Diseases of dysmyelination

A
  • Metachromatic Leukodystrophy [diffuse, “tigeroid” appearance of wm, most common]
  • Adrenal Leukodystrophy [symmetric occ & splenium CC]
  • Leigh Disease [focal SC & deep GM, incr lactate peak]
  • Alexander Disease [frontal]
  • Canavan Disease [diffuse +/- cortical GM, marked NAA peak]i
53
Q

Alzheimer disease

A

parietotemporal atrophy (out of proportion to WM dz)

54
Q

Huntington disease

A

bilateral caudate & putamen atrophy w frontal horn enlargement

55
Q

Causes of bilateral BG/thalamic hypodensity or signal abnormality

A

?needs work

  • Hypoxic ischemic injury (also cortical GM)
  • CO (GP)
  • MeOH (putamen)
  • viral encephalitis
  • Wilson’s dz
  • mitochondrial d/o (e.g. Leigh)
  • C-J dz

Bithalamic:

  • venous infarct
  • CVA: artery of percheron
  • West Nile
  • Wernicke’s
56
Q

Causes of communicating hydrocephalus

A

NPH
SAH or IVH
Meningitis
Post-inflammatory scarring of arachnoid granulations

57
Q

Normal marrow:disc brightness on MR

A

T1: marrow > disc. Reverse suggests diffuse infiltration (e.g. leukemia).
T2: disc > marrow. Reverse suggests disc dessication.

58
Q

Causes of non-communicating hydrocephalus

A

Intraventricular tumor

Focal mass effect

59
Q

Orbital pathology

A

Muscles:
Graves ophthalmopathy
Pseudotumor cerebri (painful)
Lymphoma

Nerve:
Optic neuritis
Meningioma (peripheral enh)
Glioma (NF-1)

60
Q

Ddx U-fiber lesions

A 
PML
Radiation injury
PRES
MS (e.g. Marburg)
ADEM
Viral encephalitis

Others??

61
Q

Evaluation of temporal bones

A

.

62
Q

Ddx long segment cord abnL

A 
Transverse myelitis as a result of any of the following:
Idiopathic
ADEM
Sarcoid
CVD (Sjogren, Rheumatoid dz, Lupus)
MS
Vasculitis

Others not to miss:
XRT (look at verts for fatty prolif in portal)
Cord infarct
dAVF w cord changes

63
Q

Ddx sacral mass

A 
Chordoma (T2 bright areas also mildly enh, soap bubble "physaliferous" cells)
Chondrosarcoma
Plasmacytoma/MM
Met
Lymphoma
Osteosarcoma
Osteochondromatosis (rarely)

GCT
Brown tumor

Others?

64
Q

Making a CTA perfusion map

A
  1. Open Brilliance
  2. Select Perfusion Series, always with 240 images. If displayed in PACS, can choose “Open Selected Series”
  3. Check curves, adjust by clicking back arrow to step 1 if needed:
    - Adjust windows 1st in order to better identify vessels
    - Can clear prior curves by clicking “Ax” icon bottom right
    - Both must start near zero
    - Select ACA for artery
    - Select Superior Sag Sinus or Straight Sinus for vein (start ROI within parenchyma away from bone in order to have an accurate selection).
    - Arterial peak should be earlier and lower
    - Venous peak should be later and much taller
  4. Review perfusion maps, then review superimposed maps by selecting left hemisphere and right hemisphere icons individually (red core, green infarct)
  5. Send to PACS via drop-down menu next to floppy disk icon, select “Save Batch As”, name w your initials, click Ok, might take a few mins to show up.

-use vitrea 3D to ID vessel occlusions

  • MTT/TTP most sens, least sp… look here first for subtle abnL, ten see if real on CBV/CBF (CBF most spec)
  • decreased CBV = DWI correlate = infarct
  • Mismatch btw CBV and CBF = penimbra
  • If no change in CBV, but decreased CBF then hypoperfused but no infarct. Dont just go by automated red/green areas!
  • normal CBF roi (50-100), penumbra cbf (15-30), infarct < 15
65
Q

Core infarct vs. Penumbra

A
  • CBV: decreased in core infarct, normal/slightly high in penumbra
  • Both have increased MTT and decreased CBF

** if no CBV abnL, then all hypoperf w/o infarct!

66
Q

Recurrent tumor vs. rad necrosis

A

Recurrence will be hot on PET

67
Q

Ddx solitary focal cortical lesion

A

-Cortical dysplasia
-DNET (no/min enh)
-Neoplasm (oligo Ca, low-grade astro, paraganglioma, ganglioglioma +/- enh, others)
?

68
Q

Lepto v. Pachymeninges

A 
Lepto=  pia + arachnoid
Pachy=  dura
69
Q

Carotid-cav fistula

A

Dx:
Contrast in sinus on CTA
Signal in sinus on MRA-TOF

Types:
Direct (ICA)
Indirect (ECA collat)

Us p-traumatic, others?

Complications blindness from pressure on ON

70
Q

Tumefactive MS?

A

Marburg

Balo concentric sclerosis

71
Q

Types of heterotopia?

A

Band
Subependymal
Focal subcortical

72
Q

Intraventricular fat

A

Ruptured epidermoid if antidependent T1

Others?

73
Q

Ddx Gd-enhancing nerves (incl CN)

A 
Leptomeningeal mets
Lymphoma
Sarcoid
Viral neuritis
Demyelinating dz (Lyme, MS, Guillam-Barre, CIDP, etc)
Others?
74
Q

How to ID dominant hemisphere

A

Marginal ramus of Sulvian fissure is more horiz (v. ascending on non-dom side)

75
Q

ICA segments

A

C1- cervical

INTRACRANIAL:
Pre-cav:
C2- petrous (vert, horiz)
C3- lacerum

Cavernous:
C4- cav
(ant genu)
C5- clinoid

Supra-clinoid:
C6- ophto = 1st intradural!

Terminal:
C7- terminal

76
Q

MCA segments

A

M1- horiz
M2- insular
M3- opercular
M4- cortical branches

77
Q

ACA segments

A

A1- horiz/pre-comm
A2- vertical/post-comm
A3- distal/pericallosal

78
Q

PCA segments

A

P1- mesen/pre-comm
P2- ambient
P3- quadrigeminal
P4- calcarine

79
Q

Vert segments

A 
V1- extraosseous
V2- foraminal (C6-C3)
V3- extraspinal
(enters dura @ foramen magnum)
V4- intradural/intracranial

40% codominant
40% L
20% R

80
Q

All BG supplied by ___ lenticulostriates EXCEPT ___

A

-MCA (M1)

-caudate head supplied by ACA lenticulastriate branch called
recurrent artery of Huebner

81
Q

Blood supply of thalamus

A
  • multiple thalamoperforators from PCA & basilar tip

- Artery of Percheron = anatomic variant w single large perforator from P1 supplying bilat thalami & median midbrain

82
Q

Broca’s area

A

posterior aspect of inferior frontal gyrus, in pars operc?

83
Q

Wernicke’s area

A

posterior aspect of superior temporal gyrus, more spec?

84
Q

Venous drainage of brain:

  • Galen tributaries & path to jugular
  • anastamotic cortical veins
A
  • Vein of Galen (convergence of bilat ICVs, bilt basal veins of Rosenthal)
  • Galen + ISS join @ straight sinus
  • Straight + SSS + bilat transverse sinuses join at torcular heterophil
  • transverse to sigmoid to jugular

Anastamotic cortical veins

  • vein of Trolard joins SSS
  • vein of Labbe joins transverse
  • superficial MCV joins @ jcn of Trolard/Labbe
85
Q

Cavernous sinus

  • drainage
  • CN
A

Inf and sup petrosal?

86
Q

Blood supply of posterior limb of internal capsule

A

Anterior choroidal artery from ?ICA, just prox to circle of Willis

87
Q

ECA to ICA collaterals

A
  • Internal maxillary artery, ?mult others in skull base
  • Superficial temporal to ophthalmic
  • others?
88
Q

Ddx parotid mass

A
  1. Benign Mixed Tumor (aka pleomorphic adenoma)
  2. Warthin tumor
  3. Met (Necrotic w SCCA)
Others:
Salivary tumors
NHL
Schwannoma
1st BC cyst
89
Q

Septo-optic dysplasia

A

1- Absent septum pellucidum
2- Hypoplastic ON (T2 bright rim of CSF on coronal)
3- small pituitary

90
Q

Ddx dural thickening and enhancement

A
  1. En plaque meningioma
  2. Mets (esp prostate)
  3. Lymphoma
  4. Post-op

Sarcoid
TB
Intracranial HoTN (diffuse)
Pseudotumor

91
Q

Causes of mastoid effusion

A
  • Eustachian tube dysfcn (intubated)
  • Blood from T-bone fxr
  • Mastoiditis
  • NP mass
92
Q

Post-angio staining on CT

A

.

93
Q

Ddx mandible lesion

A

?
Osteonecrosis
Osteosarcoma
Fibrous dysplasia

94
Q

Ddx petrous apex mass

A

Chondrosarcoma

Signal chars

-

95
Q

Ddx bilat BG calcs

A

Aging
Farrs dz

Metabolic (any PTH dz)
TORCHES
HIV (= AIDS if in infant)
Cystercercosis
Chronic CO poisoning
96
Q

Arterial supply of precuneus (occipital lobe)

A

MCA! Not PCA

97
Q

Location of PCA thrombus if thalami spared

A

P3 or P4

If thalami involved, must be at P1/P2

98
Q

Ddx pulsatile tinnitus

A 
Glomus tymp
Dehisc jug
?ICA
?others
Glomus jug?
99
Q

Ddx calcific longus colli

A

Calcific tendinitis of longus colli

Focal ca w prevertebral ST swelling

Neck pain, mild fever, odynophagia, no white count

100
Q

Approach to FLAIR abnL

A

volume neg
vol neutral
volume positive

101
Q

Ddx sulcal FLAIR abnL

A

Meningitis
SAH
High flow 100% O2
Venous congestion

102
Q

Culprit aneurysm

A

Focal hemorrhage
Largest
Irreg
(in that order)

103
Q

Ddx medial temporal lobe FLAIR

A

HSV
Other viral: EEE?
Status epilepticus
Limbic encephalitis

104
Q

Ddx widespread white matter FLAIR hyperintensity

A
  • Delayed post-hypoxic leukoencephalopathy (luid interval)
  • Heroine inhalation
  • PRES
  • PML
  • HIV encephalopathy
  • Dysmyelination d/o (Metachromatic Leukodystrophy)
  • usual nonspec wm stuff…?
105
Q

Ddx thickened calvarium

A 
fibrous dysplasia (w 2o ABC)
Paget's
hemangioma
anemias
Dilantin
acromegaly
hyperostosis

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