Neuro d dx


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Neuro d dx

  1. 1. Neuro DDx EC Persistent embyronic ICA to vertebrobasilar connections: trigeminal (#1), hypoglossal, otic, proatlantic artery Intraaxial hemorrhage: HTN (#1), tumor, trauma, AVM, aneurysm, coagulopathy, amyloid angiopathy, emboli, hemorrhagic infarction, vasculitis, HTN encephalopathy (eclampsia, cyclosporine) Aneurysm: saccular – degenerative, trauma, mycotic, vasculopathies; fusiform – atherosclerotic; dissecting – trauma > vasculopathy > spontaneous SAH: aneurysm (#1), trauma, AVM, coagulopathy, extension of intraparenchymal bleed, idiopathic, spinal AVM Vascular malformations: AVM, capillary telangiectasia, cavernous malformation, venous anomaly, vein of Galen AVM or varix Stroke: atherosclerosis, cardiac emboli, arterial dissection, vasculopathy, IVDA, venous thrombosis, blood dyscrasias Venous sinus thrombosis: pregnancy, dehydration, infection, tumor, hypercoagulable state, trauma Primary brain injury: epidural hematoma, SDH, subdural hygroma, DAI, cortical contusion Secondary brain injury: cerebral herniation, diffuse cerebral edema, arterial dissection (spontaneous, trauma, HTN, vasculopathy, migraine, IVDA), CCF Extraaxial masses: hemisphere – meningioma, mets, lymphoma, arachnoid cyst, dermoid/epidermoid, hemorrhagic or infectious fluid collections, hemangiopericytoma; clivus/prepontine cistern – meningioma, mets, chordoma, chondrosarcoma; CPA mass – acoustic neuroma, meningioma, mets, epidermoid, petrous apex cholesterol granuloma, paraganglioma, aneurysm, arachnoid cyst Intraaxial masses: hemisphere – astrocytoma, GBM, oligodendroglioma, lymphoma, mets, PNET, ganglioglioma, DNET; sella – adenoma, craniopharyngioma, Rathke’s cyst, mets, abscess, sarcoid, EG stalk; brainstem – astrocytoma, GBM; pineal region – germinoma, teratoma, pineocytoma, pineoblastoma; cerebellum – astrocytoma, medulloblastoma, hemangioblastoma, mets, ependymoma, choroid plexus papilloma; temporal lobe in young patient – ganglioglioma, DNET, JPA, PXA Multiple lesions: tumor – mets, GBM, lymphoma; infection – abscess, fungus, cysticercosis, toxoplasmosis; vascular – embolic infarctions, multifocal hemorrhage, DAI, contusions, cavernous hemangiomas, vasculitis Corpus callosum lesions: tumors – GBM, lymphoma, lipoma, mets (rare); demyelinating – MS, ADEM, PML; infarct – always also involves cingulate gyrus; trauma - DAI Intrasellar masses: pituitary adenoma, apoplexy, craniopharyngioma, Rathke’s cyst, mets, aneurysm, abscess Suprasellar masses: SATCHMOE – sellar lesion extending superiorly, sarcoid, aneurysm, arachnoid cyst, teratoma, craniopharyngioma, hypothalamic glioma, mets, meningioma, optic nerve glioma, EG, epidermoid/dermoid; adults – macroadenoma (#1), meningioma, glioma, craniopharyngioma, aneurysm; children – craniopharyngioma (#1), glioma, germinoma, hypothalamic hamartoma, EG Posterior fossa tumors: adults – mets, hemangioblastoma, astrocytoma, choroid plexus papilloma, meningioma, epidermoid, dysplastic gangliocytoma; children -–JPA, medulloblastoma, brainstem glioma, ependymoma Brain tumor in infant: teratoma (#1), PNET, choroid plexus papilloma, astrocytoma Intraventricular tumors: adults – astrocytoma, subependymoma, meningioma, mets, cysticercosis; children – choroid plexus papilloma, ependymoma, medulloblastoma, teratoma, astrocytoma; lateral ventricle – PNET, choroid plexus papilloma, glioma, JPA, subependymoma, astrocytoma, mets, oligodendroglioma, meningioma, central neurocytoma; 3rd ventricle – astrocytoma, EG stalk, germinoma, extrinsic craniopharyngioma, colloid cyst, glioma, mets, pituitary or pineal mass, aneurysm, sarcoid; 4th ventricle – ependymoma, medulloblastoma, choroid plexus papilloma, mets, hemangioblastoma, subependymoma CPA mass: acoustic neuroma (#1), meningioma, epidermoid, arachnoid cyst, mets, ependymoma through Luschka, lipoma Cystic mass: tumor – cystic astrocytoma/GBM, hemangioblastoma, mets, necrotic pituitary adenoma, craniopharyngioma; benign – epidermoid/dermoid, arachnoid cyst, porencephalic cyst, colloid cyst, cavum variants, Rathke’s cyst, thrombosed aneurysm Diffuse infiltrative: lymphoma, gliomatosis cerebri, white matter disease Restricted diffusion: infarct, infection, possibly subacute hemorrhage Metastasis: intraaxial – lung, breast, colon, melanoma; extraaxial – breast, lymphoma, prostate, neuroblastoma; hemorrhagic – melanoma, renal, chorioCA, thyroid Tumors with CSF seeding: choroid plexus papilloma, ependymoma, PNET (medulloblastoma), piineoblastoma, germinoma, GBM Hyperdense lesion on CT: lymphoma, medulloblastoma/PNET, ependymoma, germinoma, GBM, hemorrhagic mets, mucinous mets, osteogenic tumor, hemorrhage, meningioma, colloid cyst, aneurysm
  2. 2. Calcified intraparenchymal lesions: oligodendroglioma, ependymoma, mucinous adenoCA, osteogenic sarcoma, toxoplasmosis, CMV, cysticercosis, TB, AVM, aneurysm, TS, Sturge-Weber, hematoma; sellar lesions – meningioma, craniopharyngioma, germ cell tumor, aneurysm T2 hypointense lesions: ferritin, hemosiderin, deoxyhemoglobin, intracellular methemoglobin, melanin, calcification, lymphoma, myeloma, neuroblastoma, fibrous tissue (meningioma), high protein concentration, flow void T1 hyperintense lesions: Gd, methemoglobin, melanin, certain states of calcium, fat (dermoid), high protein concentration (colloid cyst), slow flow Lesions with no enhancement: cysts, tumors with intact BBB (low-grade gliomas) Lesions with strong enhancement: meningioma, medulloblastoma/PNET, AVM, paraganglioma, aneurysm, HIV- associated lymphoma, GBM Ring enhancement: mets, abscess, GBM, infarct, contusion, AIDS, lymphoma, demyelinating, resolving hematoma, radiation Diffuse meningeal enhancement: meningitis, carcinomatosis (lymphoma, mets), post-op, SAH, intracranial hypotension, CSF leak Basilar meningeal enhancement: infection - TB (#1), fungal, pyogenic (more common on convexity), cysticercosis; tumor – lymphoma, leukemia, carcinomatosis; inflammatory – sarcoid, rheumatoid pachymeningitis, drugs, pantopaque, ruptured dermoid Ependymal enhancement: tumor – lymphoma, mets, CSF seeding (PNET, GBM); infection – spread of meningitis, CMV (rare); inflammatory ventriculitis – postshunt or after instrumentation, posthemorrhage T2 hypointense basal ganglia lesions: old age, any chronic degenerative disease (MS, Parkinson’s), childhood hypoxia T2 hyperintense basal ganglia lesions: tumor – lymphoma, NF; ischemia – hypoxic encephalopathy, venous infarction; neurodegenerative diseases (uncommon), Leigh’s dz; toxin – CO, CN, H2S poisoning, hypoglycemia, methanol; infection – Cryptococcus, parasites T1 hyperintense basal ganglia lesions: dystrophic calcifications (any cause), hepatic failure, NF, manganese Basal ganglia calcification: physiologic (#1), hypoparathyroid, HPT, TORCH, AIDS, TB, toxoplasmosis, cysticercosis (common), lead, CO, radiation, chemotherapy, Fahr’s disease, mitochondrial (common), ischemic- hypoxic injury White matter disease: demyelinating (MS, ADEM, CPM), dysmyelinating (leukodystrophies), tumor (lymphoma, mets) vasculopathies (small vessel ischemic dz, vasculitis, HTN, eclampsia, migraines, radiation, chemotherapy, cyclosporine, IVDA), inflammatory (Lyme, sarcoid, HIV, PML, CMV) Wallerian degeneration: infarction, trauma, demyelinating, radiation, neurodegenerative, tumor Neurodegenerative disorders: WM – demyelinating, dysmyelinating; GM – Alzheimer’s, Pick’s, multiinfarct dementia, Parkinson’s, lysosomal storage disorders, Wernicke’s, Creutzfeldt-Jakob, mesial temporal sclerosis; BG – Huntington’s, Wilson’s, Fahr’s, Leigh’s, ALS Cerebellar atrophy: oligopontocerebellar degeneration, alcohol, dilantin, hemosiderin deposition Noncommunicating hydrocephalus: Foramen of Monro obstruction – 3rd ventricle tumors, colloid cyst, oligodendroglioma, central neurocytoma, giant cell astrocytoma in TS, ependymoma, suprasellar tumors; aqueduct obstruction – congenital aqueductal stenosis, ventriculitis, IVH, tumor (mesencephalic, pineal, posterior 3rd ventricle region); 4th ventricle obstruction – DW malformation, IVH, infection, subependymoma, exophytic brainstem glioma, posterior fossa tumors Communicating hydrocephalus: meningitis (infectious, carcinomatous), SAH, surgery, venous thrombosis; NPH Cystic supratentorial congenital anomalies: holoprosencephaly, hydrancephaly, aqueductal stenosis, callosal dysgenesis, porencephaly, arachnoid cyst, cystic teratoma, epidermoid/dermoid, vein of Galen AVM Posterior fossa cystic abnormalities: DW malformation (vermian hypoplasia/aplasia and large posterior fossa), DW variant (normal size posterior fossa and vermian hypoplasia), megacisterna magna (normal vermis), retrocerebellar arachnoid cyst (must show mass effect), Chiari 4 (near complete absence of cerebellum), epidermoid/dermoid, cystic tumor, Joubert’s syndrome (superior vermian hypoplasia/aplasia), rhomboencephalosynapsis (vermian hypoplasia/aplasia + fusion) Absent septum pellucidum: holoprosencephaly, ACC, septooptic dysplasia, Chiari 2 Migration and sulcation anomalies: lissencephaly, schizencephaly, polymicrogyria, pachygyria, cortical heterotopia (focal, diffuse, subependymal), hemimegalencephaly Phakomatoses: NF, TS, VHL, Sturge-Weber Diffuse marrow involvement: mets, myeloma, lymphoma, leukemia, anemia, Paget’s, FD
  3. 3. Spine DDx Spinal cord compression: criteria – no CSF seen around cord, narrowed AP diameter of cord (<7mm), deformity of cord; causes – infection (TB, pyogenic), compression fracture (CA, trauma), spondylosis and disk disease (herniated nucleus, hypertrophy of ligaments, osteophyte, facet hypertrophy), primary bone disorders (Paget’s), epidural hematoma Intramedullary lesions: astrocytoma (#1), ependymoma (#2), hemangioblastoma, lymphoma, mets (rare), demyelinating disease/myelitis, syrinx, AVM, trauma (contusion), radiation, sarcoid, infection (rare), infarction Intradural extramedullary lesions: nerve sheath tumor (#1), meningioma, drop mets, lipoma, teratomatous lesion, arachnoid cyst, arachnoiditis/meningitis, AVM/AVF, ependymoma, sequestered disc fragment, lymphoma, sarcoid, pantopaque Extradural lesions: disc disease, mets, lymphoma, epidural abscess, epidural hematoma, lipomatosis (thoracic), synovial cyst, extramedullary hematopoiesis, Tarlov cyst, discitis/osteomyelitis, spondylolysis, RA Syrinx: primary – Chiari malformations, spinal dysraphism, DW, diastematomyelia; acquired – tumor (astrocytoma, ependymoma), trauma (spinal cord injury, vascular insult), inflammatory (arachnoiditis/meningitis, SAH) Head and Neck DDx External auditory canal: exostoses, malignant otitis externa, atresia Clivus mass: chordoma, chondrosarcoma, plasmacytoma, mets, lymphoma, FD, EG Petrous apex mass: cholesterol granuloma, mucocele, petrous apicitis, epidermoid, mets, myeloma, chondrosarcoma, meningioma, aneurysm Soft tissue mass in middle ear: cholesteatoma, cholesterol granuloma, glomus tympanicum tumor, aberrant ICA, high or dehiscent jugular bulb Intracanalicular IAC masses: exclusively intracanalicular – acoustic neuroma, facial neuroma, hemangioma, lipoma; not primarily intracanalicular – meningioma, epidermoid Hearing loss: conductive – otitis media, cholesteatoma, otosclerosis, trauma (longitudinal fracture); sensorineural – idiopathic hereditary, acoustic neuroma, trauma (transverse fracture) Pulsatile tinnitus: aberrant ICA, jugular bulb anomalies, glomus jugulare, glomus tympanicum, AVM, ICA aneurysm at petrous apex Jugular fossa mass: glomus jugulare (#1), NF (#2), schwannoma, chondrosarcoma, mets Orbital masses by etiology: tumors – hemangioma (adults: cavernous; children: capillary), lymphoma, mets (neuroblastoma, breast), lymphangioma, rhabdomyosarcoma, hemangiopericytoma, neurofibroma; inflammatory – pseudotumor, thyroid ophthalmopathy, cellulitis, abscess, Wegener’s; vascular – carotid-cavernous fistula, venous varix, thrombosis of superior ophthalmic vein; trauma – hematoma, FB, lens dislocation Extraconal disease: nasal disease – infection, neoplasm; orbital bone disease – subperiosteal abscess, osteomyelitis, FD, tumors, trauma; sinus disease – mucocele, invasive infections, neoplasm; lacrimal gland disease – adenitis, lymphoma, pseudotumor, tumor Intraconal disease: well-defined margins – hemangioma, schwannoma, orbital varix, meningioma; ill-defined margins – pseudotumor, infection, lymphoma, mets; muscle enlargement – pseudotumor, Graves’, myositis, carotid- cavernous fistula Vascular orbital lesions: tumor – hemangioma, lymphangioma, hemangioendothelioma, hemangiopericytoma, meningioma, hypervascular mets; vascular (with enlarged superior ophthalmic vein) – carotid cavernous fistula, cavernous thrombosis, orbital varix, ophthalmic artery aneurysm Optic neuritis: abnormal T2 signal and enhancement but not enlarged – MS, sarcoid, infection Optic neuropathy: abnormal T2 signal only – compression, ischemia, pharmacologic, toxins, trauma Optic nerve tumor: abnormal T2 signal and enhancement and nerve enlarged – glioma, meningioma Optic nerve sheath enlargement: tumor – optic nerve glioma, meningioma, meningeal carcinomatosis, mets, lymphoma, leukemia; inflammatory – optic neuritis, pseudotumor, sarcoid; increased intracranial pressure; trauma – hematoma Tramtrack enhancement of orbital nerve: optic nerve meningioma, optic neuritis, idiopathic, pseudotumor, sarcoid, lymphoma, leukemia, perioptic hemorrhage, mets, normal variant Ocular muscle enlargement: thyroid ophthalmopathy (#1, painless), pseudotumor (painful), infection from adjacent sinus, TB, sarcoid, carotid cavernous fistula, hemorrhage, tumor
  4. 4. Childhood orbital masses: retinoblastoma, rhabdomyosarcoma, optic nerve glioma, lymphoma, leukemia, hemangioma, lymphangioma, dermoid, neuroblastoma Adult orbital masses: hemangioma, schwannoma, melanoma, meningioma, lymphoma, pseudotumor, trauma Cystic orbital lesions: dermoid, epidermoid, teratoma, ABC, cholesterol granuloma, colobomatous cyst T1 hyperintense orbital masses: tumor – melanoma, retinoblastoma, choroidal mets, hemangioma; detachment – Coat’s disease, persistent hyperplastic primary vitreous, trauma; other – hemorrhage, phthisis bulbi Globe calcifications: tumor – retinoblastoma (95%), astrocytic hamartoma (TS, NF), choroidal osteoma; infection (chorioretinitis) – toxoplasmosis, herpes, CMV, rubella; other – phthisis bulbi (calcification in endstage disease, shrunken bulb), optic nerve drusen (most common cause of calcifications in adults, bilateral) Micropthalmia: persistent hyperplastic primary vitreous, retinopathy of prematurity, congenital rubella, phthisis bulbi Sudden onset proptosis: orbital varix, hemorrhage into cavernous hemangioma or lymphangioma, CCF, thrombosis of superior orbital vein Lacrimal gland enlargement: benign lymphoid hyperplasia, pseudotumor, sarcoid, Sjogren syndrome, pleomorphic adenoma, adenoid cystic CA, lymphoma, leukemia, dacryoadenitis Diffuse bone abnormality: FD, Paget’s, thalassemia, osteopetrosis, craniometaphyseal dysplasia, mets Radioopaque sinus: normal variant – hypoplasia, unilateral thick bone; sinusitis (acute: AFL; chronic: mucosal thickening, retention cysts) – allergic, aspergillosus, mucor, sarcoid, Wegener’s; solid masses – SCC, polyp, inverted papilloma, lymphoma, juvenile angiofibroma (most common tumor in children), mucocele (expansile, associated with CF in children), esthesioneuroblastoma, mets, osteoma, FD; postsurgical – Caldwell-Luc Mucosal space mass: SCC, lymphoma, rhabdomyosarcoma, melanoma, adenoids, juvenile angiofibroma, Thornwald’s cyst Parapharyngeal and carotid space masses: salivary gland tumors (80% benign), vagal schwannoma, cervical sympathetic plexus schwannoma, glomus vagale, nasopharyngeal CA, lymphadenopathy, abscess, cellulitis Prevertebral mass: mets, chordoma, osteomyelitis, abscess, hematoma Sublingual space mass: lymphangioma, ranula, hemangioma, lingual thyroid, inflammatory Simultaneous sublingual and submandibular space mass: diving ranula, lymphangioma, abscess Post-styloid parapharyngeal mass: salivary tissue, nerves, nodes, glomus tumor Prestyloid parapharyngeal mass: pleomorphic adenoma, Warthin’s, mucoepidermoid, adenoid cystic, branchial cleft cyst, neurogenic tumor, hemangioma, node Bilateral parotid low attenuation lesions: HIV lymphoepithelial cysts, Sjogren’s, Warthin’s tumor, infection Enlarged parotids: obesity, DM, alcohol, cirrhosis, malnutrition, drugs Sialoliths: sarcoid, Sjogren’s, HPT Cystic extrathyroid lesions: neck – branchial cleft cyst (lat to carotid), thyroglossal duct cyst (midline mass), ranula (retention cyst of sublingual glands), retention cysts of mucous glands (parotid), cystic hygroma (lymphangioma, most common < 2y/o); nasooropharnyx – Thornwald’s cyst, mucus retention cyst, necrotic SCC; larynx, paralaryngeal space – laryngocele, mucus retention cyst Cystic thyroid lesions: colloid cyst, cystic degeneration, cystic papillary tumor, cystic mets Bilateral thyroid masses: lymphoma, mets (RCC, lung), multiple primary tumors, MNG, thyroiditis, cysts Neck lymphadenopathy: enlarged Waldeyer’s ring – lymphoma, mononucleosis, HIV; skin lesions – KS, sarcoid, lymphoma, CA, cat-scratch, TB, Actinomycosis; enlarged nodular salivary glands – HIV, Sjogren, sarcoid, lymphoma, cat-scratch; calcified – thyroid CA, treated lymphoma, sarcoid, silicosis, TB Solid neck mass: SCC of larynx or nasooropharynx, lymphadenopathy, parotid tumor, neurofibroma, glomus tumor, dermoid, teratoma, infection, granulomatous inflammation, ectopic thyroid Vascular head and neck mass: glomus tumor – carotid body, vagale, jugulare, tympanicum; hemangioma; AVM; aneurysm (often ICA) – pseudoaneurysm, posttraumatic Vocal cord paralysis: tumor, post-op, iatrogenic, idiopathic AIDS: ENT complications in 50%; parotid – multiple intraparotid cystic masses (benign lymphoepithelial lesion), lymphadenopathy; sinonasal – sinusitis, KS; oral cavity – Candida, periodontal an gingival infections; pharynx/larynx – opportunistic infections, epiglottitis, lymphoma; temporal bone (rare) – otitis media, otitis externa Odontogenic: cysts, ameloblastoma, odontogenic carcinoma or sarcoma; nonodontogenic – osteosarcoma, chondrosarcoma, Ewing’s, myeloma