NERRS Sep 2013 Neuroradiology Case Unknowns

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NERRS Sep 2013 Neuroradiology Case Unknowns

  1. 1. Rafeeque A. Bhadelia, MD Associate Professor of Radiology Harvard Medical School Clinical Director, Neuroradiology Beth Israel Deaconess Medical Center HARVARD MEDICAL SCHOOL Unknown Cases
  2. 2. Alexander Lin, PhD Instructor in Radiology Harvard Medical School Clinical Spectroscopist Center for Clinical Spectroscopy Brigham and Women’s Hospital
  3. 3. HARVARD MEDICAL SCHOOL MR Spectroscopy in a Patient with Suspected Brain Tumor
  4. 4. Clinical Information
  5. 5.  37-year-old right-handed man with history of Asperger's syndrome and hypertension  Seven days prior to hospital admission, he began to notice right sided numbness and twitching and bitemporal headaches  Patient gave history of travelling to Botswana  Neurological examination was unremarkable  Laboratory examinations of blood and CSF were unremarkable
  6. 6. Subcortical hyperdense masses in the left fronto-parietal lobes with surrounding hypodensities extending to basal ganglia
  7. 7. FLAIR: Well defined hyperintense lesions in the left fronto-parietal lobes with hyperintensities in left basal ganglia, splenium of corpus callosum and left cerebellum
  8. 8. T1-weighted Post-gadolinium images show homogenously enhancing well defined lesions in left fronto-parietal lobes and enhancement in left cerebellum
  9. 9. ADC Diffusion ASL Diffusion trace and ADC images show slow (restricted) diffusion in the well defined enhancing left fronto-parietal lesions ASL show mild to moderate increased perfusion in left fronto-parietal lesions
  10. 10. Dynamic Susceptibility Contrast (DSC) Perfusion images show minimally increased rCBV and rCBF in left fronto-parietal lesions rCBF rCBV
  11. 11. Differential Diagnosis  Glioblastoma Multiforme  Metastasis  Lymphoma  Tumefactive Multiple Sclerosis  Subacute Infarcts
  12. 12. Creatine 2D- CSI (PROBE: TE=144, Section=10mm, NEX=1 NAA Choline
  13. 13. ROI 4ROI 2 ROI 3
  14. 14. ROI 5 ROI 7 ROI 9ROI 8 ROI 14 ROI 15 ROI 12 ROI 13
  15. 15. NAA Choline Creatine
  16. 16. ROI 1 ROI 2 ROI 3 ROI 4 ROI 7 ROI 8 ROI 9
  17. 17. ROI 15 ROI 14 ROI 16 ROI 17 ROI 18 ROI 19 ROI 20 ROI 21 ROI 27 ROI 26 ROI 25 ROI 24
  18. 18. Asim Mian, MD Assistant Professor of Radiology Boston University School of Medicine Neuroradiologist Boston Medical Center
  19. 19. Clinical Information
  20. 20.  59-year-old male with the history of a slow growing bony tumor of his right calvarium  The mass has grown over several years  No similar masses elsewhere  No associated neurological symptoms or pain  Medical consultation for cosmetic reasons
  21. 21. Computed Tomography
  22. 22. Magnetic Resonance Imaging
  23. 23. Post-gadolinium MPRAGE images for surgical planning
  24. 24. Post-gadolinium MPRAGE images for surgical planning
  25. 25. Cerebral Angiography
  26. 26. Right Internal Carotid Artery Injection
  27. 27. Left External Carotid Artery Injection
  28. 28. Right External Carotid Artery Injection
  29. 29. Deepak Takhtani, MD Associate Professor of Radiology University of Massachusetts Medical School Director Neuroradiology Section University of Massachusetts Medical Center
  30. 30. Clinical Information
  31. 31.  65-year-old female, with a past medical history significant for obesity, hypertension, and multiple sclerosis  A routine follow-up MRI for multiple sclerosis at an outside facility revealed a new dumbbell- shaped mass in the frontal area on the left  Patient referred for biopsy with differential diagnosis of plasmacytoma, lymphoma, or dural based metastasis
  32. 32. 2013 2012
  33. 33. MRI 2012
  34. 34. T1-weighted post-gadolinium
  35. 35. T1-weighted post-gadolinium
  36. 36. MRI 2013
  37. 37. T2-weighted FLAIR
  38. 38. T1-weighted post-gadolinium
  39. 39. MRI 2013 Pre-operative Study
  40. 40. Pre-operative MRI T1-weighted post-gadolinium
  41. 41. Based on MR features, surgery was cancelled and a diagnostic Ultrasound was performed
  42. 42. Transverse forehead Resting Transverse Forehead Valsalva
  43. 43. Color Doppler in resting Color Doppler during Valsalva maneuver
  44. 44. Follow up MRI 2013
  45. 45. T2-weighted
  46. 46. Pre and post-gadolinium T1-weighted
  47. 47. Post-gadolinium MPRAGE
  48. 48. Pamela W. Schaffer, MD Associate Professor of Radiology Harvard Medical School Associate Director of Neuroradiology Clinical Director MRI Massachusetts General Hospital
  49. 49. Clinical Information
  50. 50.  25-year old right handed man with complaints of cranial defect left side of his head for three years  For the past 6 months he has had headaches in the area of indentation, decreased hearing and occasional visual problems  No history of fever, weight loss, systemic illness or trauma
  51. 51. Computed Tomography
  52. 52. Magnetic Resonance Imaging
  53. 53. T2-weighted Images FLAIR
  54. 54. Post-gadolinium T1-weighted Axial Images
  55. 55. Post-gadolinium MPRAGE Sagittal and Coronal
  56. 56. Post-gadolinium MPRAGE Axial for Surgical Planning
  57. 57. Thank You HARVARD MEDICAL SCHOOL

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