RITE Images 2008 Flashcards
Patient presents with precocious puberty
Brain Tumor - Hamartoma in tuber cinereum
NOT a colloid cyst
Spinal vascular malformation
Numerous intra-&extramedullary flow voids (indicating fast flow) w/ a nidus in the cord @ C5-C6 & large posterior draining vein
Dural AVF?
What type of tumor?
1st line chemotherapeutic agent?
Pseudopalisading necrosis & infiltrating high-grade glioma w/ microvascular proliferation
Treat with temozolamide
Nocardia – GMS +, FITE (+)
Aspergillus – GMS +, FITE -, septated & 45 degree angle branching
What is the imaging abnormality?
What genetic disease process
Where is the genetic abnormality?
Developmental/Neurogenetic D/o
Autosomal recessive hereditary spastic paraplegia with thin corpus callosum (ARHSP-TCC)
Patient has spastic paraparesis , MR, & thin CC
SPG11 locus on chromosome 15 endocing spatascin
Thin corpus callosum
Medulloblastoma
Contrast enhanced MRI showing multiple nodular lesions & drop mets
Can also be seen in CAGE
Choroid plexus tumors
Anaplastic gliomas
Germinomas
Ependymomas
Arachnoid cyst
Extraaxial cyst w/ CSF like signal intensity on both pulse sequences
What is it?
- Meningioma
- Intramedullary lesion
- lipoma
Meningioma
Intradural extramedullary – widened SAS & compressed spinal cord
- NOT intramedullary lesions*
- Ependymoma, astrocytoma, hemangioblastoma*
- NOT lipoma - hyperintense on T1*
Cavernous malformation
Stroke
Acute hemorrhage
Bright ring on T1 that doesn’t enhance w/ GAD & dark on T2 (A) -> intracellular methemoglobin
ring is bright on both pulse sequences = extracellular methemoglobin
Deoxyhemoglobin – core of hemorrhage being gray on both T1 & T2
Edema – bright signal surrounding acute hemorrhage
Brain tumor
Cystic astrocytoma
- NOT*
- Hemangioblastoma – would be in posterior fossa*
- Abscess – would homogenously enhance & cause more hemiparesis*
Critical Care/Trauma
Methemoglobin
Bright on T2 & T1
Central neurocytoma
synaptophysin + ->neurons affected; occurs near ventricles; mean age 29 years, males / females equally affected
Cord compression @ C1
Abnormal signal @ C1 that has mixed signal characteristcis on both T1 & T2; distortion of anterior cord, penciling of odointoid, & dislocation between anterior arch of C1
What is D?
Straight sinus
Stroke
Infarction @ different stages of organization
Multiple lesions affecting both cortex & white matter
Recent (light dark) & old (deep dark)
ACA
Pediatrics –
Megalencephalic leukodystrophy with subcortical cysts
Large heads during infancy
leukodystrophies
alexander
Canavan
megalencephalic leukodystrophy with subcortical cysts
menke – X linked; large head due to SD bleeding or effusions
glutaric aciduria – large head enlarged SAS or subdural effusions
Lennox gastaut
multiple seizure types
MR
interictal EEG showing spike & wave
What is it?
- CO poisoning
- HD
- PD
- Wilson’s disease
- Gliomatosis cerebri
Wilsons
high intensity in bilateral
putamen
thalami
- Not carbon monoxide à GP only*
- Not huntington b/c normal caudate & no brain atrophy*
- Not PD b/c putamen & thalami would be normal*
- Gliomatosis cerebri – infiltrating astrocytoma of white matter*
Neurosarcoidosis
Enhancing nodular patchy diffuse, gray matter abnormalities,
- Toxo affects both gray & white matter*
- Cerebrotendinous xanthomatosis – white matter disease*
Cerebello pontine olivary atrophy
Loss of belly of pons
Cerebellar atrophy
RRMS
Dawson’s fingers
T1 + GAD – old + enhancing lesions indicating breakdown of BBB & active disease
With old & recent lesions -> relapsing remitting MS
NOT CADASIL or adrenoleukodystrophy
Rasmussen disease
Progressive focal esizures that increase in duration & severity
Chagnes in white matter with hyperintensity à then atrophy
Focal & multifocal epileptiform discharges & slowing
Homonymous hemianopsia
- NOT alexia without agraphia b/c splenium of CC not involved*
- NOT alexia with agraphia, R / L disorientation, pure agraphia b/c parietal lobe not involved*
Tuberous sclerosis
Triad – MR, epilepsy, & facial angiofibromas (adenoma sebaceum)
Cortical hamartomas (cause seizures) , SEGAs (unlikely to cause seizures)
Chromosome 9q34 (hamartin) & 16q 13 (tuberin)
G/W
Misplaced shunt
tip of shunt in interhemispheric fissure & NOT in 3rd ventricle
Large ventricles, widened sylvian fissures, compressed sulci in convexity -> communicating hydrocephalus
If shunt was working -> patient’s symptoms would have improved and not worsened.
PML – JC virus – causes multifocal demyelination; giant oligos
Primary infection at kidney -> to CNS via infected mononuclear cells – affects astrocytes
Viral latency & reactivation during immunosuppression
70-90% are asymptomatic
Klippel-Feil syndrome
Incomplete segmentation of cervical spine
Hypoplastic to absent intervertebral discs & hypoplastic adjacent vertebral bodies at multiple levels
Congenital d/o AD or AR
SDH
Methemoglobin clot in subdural space
Bright on T1
not epidural hematoma – b/c it does not cross suture lines
Not subdural hygroma or empyema b/
En plaque meningioma is hypointense on T1
GBM
Schizencephaly w/ septo-optic dysplasia
NOT porencephaly b/c cyst would be lined with white matter
Schizencephaly cyst is lined with heterotopic gray matter
Central pontine myelinolysis or osmotic demyelination syndrome
Midline triangular lesion
Often assoc w/ extrapontine myelinolysis that is clinically asymptomatic
SC, DRG, SNC & PN are hardly affected in CPM
Perched & nonarticulating facet
Subluxation of C5 anterior to C6 w/ widening of interspace between C5 & C5 posterior spinous process indicative of a severe ligamentous disruption.
Paramedian view - C5 facet perched on C6 fact & is not articulating
Bilateral solitary nonarticulating facets or naked facet sign = spinal instability
SDH from traumatic rupture of bridging veins
- NOT diffuse axonal injury from rotational accelerations of head*
- Contusion would show petechial hemorrhage @ area of trauma*
Pituitary apoplexy – pituitary infarction w/ rapid swelling & pressure exertion on neighboring structures; pituitary adenoma w/ necrosis (low intensity area)
Anatomic variant of both anterior cerebral arteries originating from L ICA
R PCA originates from anterior circulation (fetal origin)
No aneurysm or stenoses
Tumor
Epilepsy question
Pre & post gad
NOT cystic
Clivus chordoma
Embryonic notochord remnants
Extrapontine lesion
Rabies / negri bodies – round or oval eosinophilic inclusion in cytoplasm of neurons esp in purkinje cells & hippocampal pyramidal cells
Flu lik sx, pain or paresthesias at bite site
Normal aging
Lipofuscin in cytoplasm of neuron
What is this?
What is the boxed finding?
Pleomorphic xanthoastrocytoma or ganglioglioma – these present with with seizures
pleomorphic glial neoplasm with hypercellularity & lymphcytic infiltrates
Boxed is eosinophilic granular body
Wernicke’s – hemorrhagic necrosis & atrophy of mammilary bodies
Triad of confusion, ataxia, nystagmus
Can be seen in after obesity surgery 4-12 weeks post op esp in young women with vomiting
Ependymoma – myxopapillary variant
Rounded lesion that enhances
Not met, schistosomiasis, herniated disc, neurofibromata
Germinal matrix hemorrhage – located in walls of lateral ventricles
I – hemorrhage localzied to germinal matrix only
II – ruptured into ventricle w/o ventricular dilatation
III – ruptured into ventricle WITH ventricular dilatation
IV – ruptured into ventricular system & cerebral parenchyma
Ventriculitis
Enhancement of ependyma
NOT choroid plexus papilloma w/ CSF spread, ependymoma, transependymal flow of CSF, TS w/ candle guttering
Vein of Galen aneurysm
Congenital anomaly
Anoxic encephalopathy
Near complete absence of cortical to white matter delineation indicating diffuse edema as a result of a severe generalized neuro insult
Hypothalamus / pituitary
Benign pituitary adenoma apoplexy – necrotic devitalized tumor
Apoplectic hemorrhage or necrosis w/in the tumor
Subpial corpora amylacea
Acute RMCA stroke
No cortical or subcortical lesion on FLAIR à r/o abscess, chronic infarction, hemorrhage
A – Flair
B DWI
C Infarct
Saccular aneurysm on LACA anterior to genu of CC
NOT pericallosal aneurysm
Acute myelitis
Fusiform cord enlargment on T2 over several spinal levels
Spinal cord enlargement
Intramedullary increased T2
Variable enhancement over several spinal levels
Neurofibroma
Not meningioma, met (would involve vertebrae) , ependymoma extruded disc
Pick disease
Tauopathy – rounded intracytoplasmic inclusions showing immunoreactivity with tau immunostains
AD
Decreased metabolism in parietal & temporal lobes & retrosplenial region
- LBD – occipital hypometabolism*
- CBD – one hemispheric association cortex hypometabolism*
- Semantic dementia – L temporal tip*
Epidural hematoma
Colloid cyst
Tethered cord
Downward extension of conus to sacral region; no cauda equina
Conus adheres to posterior aspect of SC w/in the sacrum
Progressive neuro deterioration due to traction on the conus medullaris
Medulloblastoma
“small blue cell tumor” w/ hypercellularity & cells w/ rounded hyperchromatic nuclei & little cytoplasm
Intracranial hypotension 2ndary to persistent CSF leak in prominent abnormal meningeal nehnacement
Not acute pyogenic meningitis or tuberculous meningitis (basilar)
How old is this hemorrhage?
20 days old
Methemoglobin – bright on T 1 & T2 occur after 4 days
Hemosiderin – gray on T1 & dark on T2 occurs during 2nd or 3rd weeks.
CADASIL = mutation in Notch 3 gene
EM shows granular osmophilic material (GOM) in skin
Occlusion
Normal flow void of left carotid replaced by hyperintense signal -> occlusion
R cavernous sinus has normal appearing flow void
NOT
Mesial temporal sclerosis, pituitary tumor, suprasellar mass, optic nerve glioma
Hypsarrhythmia – seen in patients with infantile spasms
High voltage, irregular slow waves w/ multiple sharp & spike d/cs
Colloid cyst of 3rd ventricle
Migration anomaly
Lesion representing heterotopic gray matter
Cavum septum pellucidum
Cerebellar cystic hemangioblastoma
Healed toxoplasmosis
Multiple calcified lesins in brain parenchyma bilaterally and cerebellum primarily at G/W jxn
AIDS
HIV encephalopathy – generalized atrophy & diffuse confluent low density of white matter
NOT sarcoid à no calcification
|NOT Sturge Weber syndrome –
NOT calcification due to hyperPTH – b/c calcification in BG, dentate nuclei of cerebellum, & periventircular white matter
NOT TS - calcifications are subependymal
Lymphoma
T1 – variable enhancement
T2 – hypointense
Mold themselves w/ structures such as globe & orbital wall
MS – give IFN B to reduce # of future episodes of demyelination
NOT methylpred, clopidogrel, tetracycline, cyclophosphamide
Wallerian degeneration of cortical spinal tract, hyperintense track
on R brainstem
Precocious puberty, peculiar laughing seizures (gelastic seizures)
Hypothalamic hamartoma
Childhood tumor at floor of 3rd ventricle
Pedunculated -> precocious puberty
Can be endocrinologically active w/ acromegaly
Polyarteritis nodosa
Acute vasculitis of epineurial artery; transmural arterial inflammation by polymorphonuclear neutrophils & fibrinoid necrosis
Hx of fever, weight loss, myalgias, malaise w/ HTN, & polyneuropathy -> PAN
30% of patients with PAN have circulating antibodies to HBV
Carotid body tumor
Mass lesion in R CA
Lesion has contrast enhancement = marked vascularization
Duchenne muscular dystrophy
Decrease or absence of dystrophin staining
AD
Atrophy of medial structures – hippocampus
NOT FTD, CBD, PKD
Basilar meningitis (can be seen in TB)
Contrast enhancement along leptomeninges esp overlying cerebellar folia up to vermis bilaterally
- NOT*
- Intracranial hypotension – generalized thickening w/ enhancement of pachymeninges*
Hypertension causing lacunar infarcts
lenticulostriate arteries
Fahr disease or idiopathic calcification of the basal ganglia / cerbellum
See it on CT in BG & cerebellum
Calcification is hypointense on T2
If no metabolic derangement can be found (hyper pth, amyloid, wilson) - think of this when you see B calcifications in BG/cerbellum
NOT Leigh’s b/c necrosed BG esp putamen à low density on CT, & hyperintense T2
Loss of flow signal in prox L MCA
High grade prox MCA stenosis
Cherry red color & hemorrhagic necrosis of GP -> Carbon monoxide poisoning
- Not Leigh’s -> B thalamus involved*
- Pantothenate kinase associated neuro degen ->accumulate iron in GP*
Susac syndrome
triad
- retinal branch occlusion
- hearing impairment
- MRI like MS (midline of CC)
hyperintense scattered subcortical T2
leptomeningeal enhancement
focal lesions in thalamus, BG
Glioma
Intraaxial pontine lesion that enhances
- NOT arachnoid cyst – b/c lesion is surrounded by brain parenchyma*
- NOT porencephalic cyst b/c it doesn’t communicate with ventricular or SAS*
Acute disseminated encephalomyelitis
Affects children & young adults -> abrupt HA & fever 2-12 days after infection & resolves w/in 1 week; after vaccinations historically
Luxol fast blue PAS stains for myelin – see demyelinating lesions
Perivenular inflammatory & myelin loss -> ADEM
Hyperdense sign on LMCA – acute thrombosis (arrow)
L sulcal effacement, hypodense l BG, frontal, anterior parietal, & superior temporal lobes
Metastatic lung CA or thyroid
Thyroid transcritpion factor 1 reactive
Pyogenic abscess / or tumor
Cerebral abscess
Vasogenic edema in white matter of L parietal lobe
GAD enhanced shows focal corticomedullar noduleof enhancement that is the site of the lesion and cause of vasogenic edema
MS plaques
Thoracic sensory level relates to plaques in thoracic cord
CJD
Decreased diffusion of caudate & antrior portion of lenticular nuclei
Superficial siderosis
Deafness & cerebellar ataxia; hemosidern deposits in subpial layers of brain & SC -> chronic slow or repeated bleeding into SAS
MRI shows hemosiderin deposition along upper cerebellar folia w/ adjacent cerebellar atrophy!!!
Dandy Walker malformation
Missing inferior vermis, 4th ventricle enlarged connects w/ cisterna magna, posterior fossa enlarged
Porencephalic cyst
Covered by arachnoid & extends from SAS to ventricular system
Cerebral sinus thrombosis
A – CT – hemorrhage in R posterior frontal region & cerebral edema w/in R frontal cortical region
B – MRI FLAIR – “
C – MRV – flow void from superior sagittal sinus & R transverse sinus & trace of flow signal from R sigmoid along w/ decreased flow signal in R parasagittal cortical veins
