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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