RITE Images 2008 Flashcards by Denis E

Patient presents with precocious puberty

Brain Tumor - Hamartoma in tuber cinereum

NOT a colloid cyst

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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?

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What type of tumor?
1st line chemotherapeutic agent?

Pseudopalisading necrosis & infiltrating high-grade glioma w/ microvascular proliferation

Treat with temozolamide

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Nocardia – GMS +, FITE (+)

Aspergillus – GMS +, FITE -, septated & 45 degree angle branching

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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

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Medulloblastoma

Contrast enhanced MRI showing multiple nodular lesions & drop mets

Can also be seen in CAGE

Choroid plexus tumors

Anaplastic gliomas

Germinomas

Ependymomas

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Arachnoid cyst

Extraaxial cyst w/ CSF like signal intensity on both pulse sequences

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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*

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Cavernous malformation

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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

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Brain tumor

Cystic astrocytoma

NOT*
Hemangioblastoma – would be in posterior fossa*
Abscess – would homogenously enhance & cause more hemiparesis*

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Critical Care/Trauma

Methemoglobin

Bright on T2 & T1

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Central neurocytoma

synaptophysin + ->neurons affected; occurs near ventricles; mean age 29 years, males / females equally affected

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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

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What is D?

Straight sinus

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Stroke

Infarction @ different stages of organization

Multiple lesions affecting both cortex & white matter

Recent (light dark) & old (deep dark)

ACA

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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

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Lennox gastaut

multiple seizure types

interictal EEG showing spike & wave

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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*

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Neurosarcoidosis

Enhancing nodular patchy diffuse, gray matter abnormalities,

Toxo affects both gray & white matter*
Cerebrotendinous xanthomatosis – white matter disease*

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Cerebello pontine olivary atrophy

Loss of belly of pons

Cerebellar atrophy

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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

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Rasmussen disease

Progressive focal esizures that increase in duration & severity

Chagnes in white matter with hyperintensity à then atrophy

Focal & multifocal epileptiform discharges & slowing

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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*

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**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 1. retinal branch occlusion 2. hearing impairment 3. 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