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NERRS Sep 2013 Neuroradiology Case Answers
1. Unknown Cases
Rafeeque A. Bhadelia, MD
Associate Professor of Radiology
Harvard Medical School
Clinical Director, Neuroradiology
Beth Israel Deaconess Medical Center
HARVARD
MEDICAL
SCHOOL
2. Alexander Lin, PhD
Instructor in Radiology
Harvard Medical School
Clinical Spectroscopist
Center for Clinical Spectroscopy
Brigham and Women’s Hospital
4.
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
5. Subcortical hyperdense masses in the left fronto-parietal lobes
with surrounding hypodensities extending to basal ganglia
6. FLAIR: Well defined hyperintense lesions in the left fronto-parietal lobes with
hyperintensities in left basal ganglia, splenium of corpus callosum and left cerebellum
7. T1-weighted Post-gadolinium images show homogenously enhancing well defined
lesions in left fronto-parietal lobes and enhancement in left cerebellum
8. 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
20. Primary CNS Lymphoma (PCNLS)
PCNLS accounts for 1-5 % of brain tumors
PCNSL may have characteristic imaging
appearance due to hypercellularity and high
nuclear/cytoplasmic ratio
PCNLNS has predilection for the periventricular
and superficial regions and presents as multiple
masses predominantly in supra-tentorial regions
21.
CT
Hyperdense lesions ( 70%). Hemorrhage is uncommon
MRI
FLAIR/T2-hyperintense homogenously enhancing
masses in high grade lesions. Enhancement may be
minimal or absent in low grade lesions
Lesions may show slow(restricted diffusion) in high
grade lesions (more than in glioma or metastasis) due to
hypercellularity
MR perfusion shows minimally increased (much less
than glioma), normal or decreased rCBV
22.
Scintigraphy
Thallium201 scan can show increased uptake
PET with FDG show very high uptake which may
help differentiation from glioma and metastasis
MR Spectroscopy
Large Choline peak
High choline/creatine ratio
Lactate peak may be seen
23.
MRS Pitfalls
GBM: 2HG would have been definitive
Metastasis: Lack of high Cho at the lesion
periphery
Lymphoma: Short echo would show higher lipid
and lactate
Tumefactive Multiple Sclerosis: Difficult to
differentiate with MRS
Subacute Infarcts: Much higher lactate would have
been present
24. Asim Mian, MD
Assistant Professor of Radiology
Boston University School of Medicine
Neuroradiologist
Boston Medical Center
26.
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
40. Primary Intraosseous
Meningioma
Rare subtype of extra-dural meningioma arising
from the skull (convexity of skull base)
Most patients are >50-years with no sex
predilection
Presents as firm painless scalp mass with intact
skin and may be detected incidentally
<1% of all meningiomas
Osteoblastic 80%
Osteolytic 20%
41.
Plain Radiographs and CT
Focal area of hyperostosis in osteoblastic variety
with expansion of calvarium
MRI
Hypointense lesion on T1 and T2-weighted images
(or hyperintense on T2WI)
May show intrinsic enhancement
Enhancement of the underlying dura due to invasion
or dural irritation
No “dural tail”
43. Differential Diagnosis
Fibrous Dysplasia
Osteoma
No intrinsic enhancement or dural enhancement or tumor
blush
Osteosarcoma
Younger patient (stops growing after puberty). Ground glass
appearance. No dural enhancement or tumor blush
Irregular contour and soft-tissue mass. Heterogeneous signal
and enhancement
Paget’s Disease
Heterogeneous signal, no intrinsic or dural enhancement
44. Deepak Takhtani, MD
Associate Professor of Radiology
University of Massachusetts Medical School
Director
Neuroradiology Section
University of Massachusetts Medical Center
46.
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 dumbbellshaped mass in the frontal area on the left
Patient referred for biopsy with differential
diagnosis of plasmacytoma, lymphoma, or dural
based metastasis
67. Sinus Pericranii
A sub-periosteal blood-filled sac that communicates
with the intracranial veins through an emissary vein
Associated with Developmental Venous Anomaly
(DVA)
Mostly congenital but can be acquired
Usually located in frontal region
Represents 4% of palpable scalp masses
Can be seen at any age but mostly young adults
Increases in size in supine position or with Valsalva
maneuver. May completely disappear in supine position
68.
CT
Slightly hyperdense sub-periosteal lesion which
enhances similar to other intra-cranial veins with
associated bony defect of emissary vein
MRI
Isointense on T1 and hyperintense on T2weighted images with intense enhancement
(puddling of contrast) in scalp lesion as well as of
the extra-axial venous component
69.
70.
Angiography
Arterial and capillary phases are normal with
accumulation of contrast adjacent to the
transcalvarial defect
Ultrasound
The scalp lesion changes size with upright position
and Valsalva maneuver
Color Doppler shows change in flow direction with
Valsalva
71. Differential Diagnosis
Neonates and children
Cephalocele, meningocele
Dermoid cyst
Hemangioma
Metastasis (neuroblastoma)
Adults
Sebaceous cyst
Intracranial extra-axial mass (meningioma,
lymphoma)
72. Pamela W. Schaffer, MD
Associate Professor of Radiology
Harvard Medical School
Associate Director of Neuroradiology Clinical
Director MRI
Massachusetts General Hospital
74.
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
88. Gorham Disease
Patients younger than 40-years in age
No sexual or familial predilection
Patient presents with progressive defect (depression) of
skull
Although medical and radiation therapy is attempted in
the past, surgical removal followed by artificial bone
replacement remains the treatment of choice
89. Pathology
Intra-osseous proliferation of hemangiomatous
or lymphangiomatous tissue resulting in
progressive osteolysis of the affected bone
Two stages of are described:
First stage: Vascular proliferation in connective
tissue consistent with hemangiomatosis
Second stage: Fibrous tissue replaces the absorbed
bone without regeneration of bone matrix
90. Imaging
CT
Well defined skull defect with benign characteristics
Thinning and disappearance of central portion and
absence of new bone formation
MRI
Low signal central portion on T1 and T2-weighted
images indicating fibrosis
Enhancement at the margins suggestive of
hemangiomatous active component of the disease
91.
Tc-99 bone imaging (not performed in this
case) shows absence of uptake in the central
portion with increased uptake at the margins
Lo et al AJNR 2004 25: 415-418