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71 Cards in this Set

  • Front
  • Back
1. Typical symptoms
2. Imaging appearance
3. Distinction from infectious meningitis?
1. cranial nerve palsies, chronic meningitis, hypothalamic-pituitary dysfunction
2. nodular leptomeningeal infiltration, hypophysitis, centered around skull base, cerebellum, sellar/parasellar region
3. More nodular – though both may have diffuse basilar cistern enhancement
Basal meningitis a/w lacunar infarcts – think?
Tuberculous meningitis
Intracranial Extension of Sphenoid Sinus Infection
1. Agents
2. Route
3. Sequelae
1. Mucor, Aspergillosus, Bacterial
2. Through thin sphenoid sinus wall, epidural abscess
3. Cavernous sinus thrombosis, cranial nerve palsy, carotid artery occlusion, infarcts
Tolosa-Hunt Syndrome
1. What is it?
2. symptoms
3. Complications
1. Pseudotumor from orbital apex to cavernous sinus
2. Painful ophthalmoplegia, visual deficits
3. avernous sinus thrombosis, carotid arteritis
Temporal Lobe “Edema” – DDx
1. HSV Encephalitis
2. Viral Meningitis
3. Acute/subacute infarct
4. Gliomatosis/Infiltrative Astroctyoma
5. Limbic Encephalitis
6. Cysticercosis
7. SLE
8. PML
9. Transverse Sinus Thrombosis
10. Primary angiitis of CNS
Confluent Zones of White Matter Abnormality – DDx
1. PML
2. HIV Encephalitis
3. Radiation Change
4. Chemotherapy toxicity
5. Territorial Infarct
6. Aging/chronic microangiopathic change
7. Leukodystrophy
9. Vasculitis
10. Venous Hypertension
11. Encephalitis
12. PRES
13. Unilateral Megalencephaly
14. Band heterotopia
Multifocal Pathcy Lesions Involving White Matter – DDx
2. PML
3. Microangiopathic Disease
4. Sjogren’s syndrome
5. SLE
6. Hypertensive encephalopathy
7. Primary CNS angiitis
8. Dural Venous Thrombosis
9. Tuberous Sclerosis
Multiple Punctate Lesions in White Matter
1. Microangiopathic Disease
2. VR spaces
4. Mets
5. Lyme Disease
6. Sarcoidosis
7. Border Zone infarcts
8. Small artery infarcts
9. Vasculitis
10. Diffuse Axonal Injury
Symmetric Lesions within Deep Nuclei - DDx
1. Age-related calcifications
2. Liver/Renal Disease
3. Fahr’s Disease
4. CO poisoning/ other toxicity
5. Mets
6. MS
7. Vasculitis
8. Bithalamic astroctyoma
9. SLE
10. Leigh Disease
11. Maple Syrup Urine Disease
12. Adrenoleukodystrophy
13. Old Hypoxic/Ischemic Injury
14. Hallervorden-Spatz Disease
15. Hepatocerebral degeneration
16. Amyotrophic Lateral Sclerosis
17. Extrapontine Myelinolysis
18. Parkinson Disease
19. Deep Venous Thrombosis
20. Basilar artery ischemia/Thalamoperforator/Percheron
21. Viral Encephalitis
22. Anoxia
23. NF spots
Leptomeningeal Enhancement – DDx
1. Chemical meningitis
2. Bacterial/mycobacterial/viral meningitis
3. Sarcoidosis
4. Meningeal Carcinomatosis
5. CSF tumor seeding
6. Moya-Moya
7. Leukemia
8. Sturge-Weber syndrome
9. Acute infarct
Thickened Dural Enhancement – DDx
1. CSF Hypotension
2. Dural metastasis
3. Post-operative change
4. Idiopathic pachymeningitis
5. Meningioma
6. Subdural empyema
7. Sarcoidosis
8. Systemic Lymphoma
Ventricular Enlargement – DDx
1. Obstructive hydrocephalus – mass
2. Aqueductal stenosis
3. NPH
4. Decreased resorption s/p hemorrhage, infection, tumor
5. CSF overproduction due to CPP
6. Ventricular trapping due to herniation/shift
7. Ex Vacuo dilatation – infarct
8. Ex Vacuo dilatation – PVL
9. Colpocephaly due to CC dysgenesis
10. Huntington’s disease
11. Hydranencephaly
12. Holoprosencephaly
13. Porencephaly
14. Septo-Optic Dysplasia
Intracranial Pneumocephalus – DDx
1. Post-surgical – hypophysectomy, sinus surgery
2. Trauma/fracture
3. Sinus Osteoma
4. Neoplasm invading sinus (Pituitary adenoma, epidermoid, paranasal sinus malignancy)
5. Mucocele
6. Sinus/mastoid infection (gas forming organism)
Complications of Intracranial Pneumocephalus – DDX
1. Tension
2. CSF rhinorrhea
3. Meningitis, epidural or brain abscess
4. Extracranial pneumocephalus (collection in subaponeurotic space
Cerebral Atrophy – Types and DDx
1. Diffuse
2. Focal
3. Reversible Process simulating atrophy
Diffuse Cerebral Atrophy – DDX
1. Trauma
2. RTX
3. Drugs – dilantin, steroids, MTX, marijuana, hard drugs, chemotx
4. Demyelinating disease – MS, encephalitis
5. Degenerative Disease – Alz, Picks, Jakob-Creutzfeld
6. Cerebrovascdular disease – SVID, multiple infarcts
7. Advancing age, anorexia, renal failure
Focal Brain Atrophy – DDX
1. Vascular
2. chemical
3. metabolic
4. traumatic
5. idiopathic (Dyke-Davidoff-Mason syndrome)
Reversible Process Simulating Atrophy (in younger people) – DDx
1. Anorexia Nervosa
2. alcoholism
3. catabolic steroid tx
4. pediatric malignancy
Cerebellar Atrophy – DDx
1. Generalized atrophy (cerebral + cerebellar)
2. Cerebellar atrophy without cerebral atrophy
a. Olivopontocerebellar degeneration/Marie ataxia/Friedreich ataxia – young adult onset ataxia
b. Ataxia-telangiectasia
c. Ethanol toxicity – predominantly vermis/midline
d. Phenytoin-toxicity – predominantly cerebellar hemispheres
e. Idiopathic degen 2º carcinoma (paraneoplastic) – usually oat cell carcinoma of lung
f. RTX
g. Focal cerebellar atrophy – infarction, traumatic injuery
What malignancy most common to cause cerebellar degeneration (paraneoplastic)?
1. Oat cell Ca of lung (small cell)
Ventriculomegaly – 3 categories DDx
1. Macrocephaly
2. Microcephaly
3. Normocephaly
Ventriculomegaly with Macrocephaly – DDx
(Increased IVP)
1. CSF flow obstruction
a. Communicating hydrocephalus
b. Non-communicating hydrocephalus
2. Overproduction of CSF
3. Neoplasm
Ventriculomegaly with Microcephaly – DDx
(Normal IVP)
1. Primary failure of brain growth
a. Dysgenesis
i. Holoprosencephaly
ii. Aneuploid syndromes (trisomies)
iii. Migrational (<6 layers)
b. Environment – alcohol, drugs, toxins
c. Infection – TORCH
2. Loss of brain mantle
d. Infection: Torch
e. Vascular accident:
i. Hydranencephaly
ii. Schizencephaly
iii. Porencephaly
f. Hemorrhage
i. Porencephaly
ii. Leukomalacia
Colpocephaly – DDx
1. Callosal dysgenesis/agenesis
2. Arnold-chiari Malformation
3. Holoprosencephaly
Midline Cystic Structures - DDx
1. Cavum septi pellucidi – anterosuperior to anterior ipllar of fornix
2. Cavum vergae – posterior to columns of fornix
3. Cavum Veli Interpositi – extension of quad plate cistern above third ventricle
4. Colloid cyst
5. arachnoid cyst
Posterior Fossa Cystic Malformation - DDx
1. Dandy-Walker Variant
2. Arachnoid Cyst
3. Megacisterna Magna
4. Epidermoid
Diffusely swollen Hemispheres – DDx
1. Metabolic
a. Metabolic encephalopathy – uremia, reye syndrome, ketoacidosis
b. Anoxia: cardiopulmonary arrest, near drowning, smoke inhalation, ARDS
2. Neurovascular
c. Hypertensive encephalopathy
d. Superior sagittal sinus thrombosis
e. Head trauma
f. Pseudotumor cerebri
3. Inflammation
g. Herpes encephalitis, CMV, toxoplasmosis
Edema of Brain – three types and scenarios – DDX
1. Vasogenic edema – inflammation, neoplasm, mets, hemorrhage, infarction
2. Cytotoxic edema – ischemic, anoxia
3. Interstitial Edema – increase in IVP with transependymal flow of CSF à increase in periventricular interstitial spaces à blurring of GM/WM, compressed slitlike lateral ventricles, compression of sulci/cisterns i.e. diffuse cerebral edema)
Cholesterol-Containing CNS Lesions – DDX
1. Epidermoid Inclusion Cyst
2. Cholesterol Granuloma
3. Aquired epidermoid of middle ear
4. Congenital cholesteatoma of middle ear
5. Craniopharyngioma
Periventricular Hypodensity – DDx
1. Encephalomalacia
2. Porencephaly
3. Resolving hematoma
4. Cystic Tumor
Suprasellar Low-density Lesion with Hydrocephalus – DDx
1. Cyst
a. Arachnoid cyst
b. Ependymal cyst of 3rd ventricle
c. Parasitic cyst of 3rd venticle (cysticercosis)
d. Dilated 3rd ventricle (aqueductal stenosis)
2. Cystic Mass
e. Epidermoid
f. Hypothalamic pilocystic astrocytoma
g. Cystic craniopharyngioma
Mesencephalic Low-density Lesion
1. Normal – decussation of superior cerebellar peduncles at level of inferior colliculi
2. Syringobulbia – Arnold-chiari, trauma, synringomyelia exension
3. Brainstem infarction
4. Central pontine myelinolysis
5. Brainstem glioma
6. Mets
7. Graunoma in TB/Sarcoid
Intracranial Hemorrhage
1. Infarction – hemorrhagic
2. Trauma
3. Hypertension
4. AVM
5. Coagulopathy
6. Aneurysm
7. Neoplasm
8. Sinus thrombosis
Increased Density of Falx
1. SAH
2. Interhemispheric Subdural hemorrhage
3. Diffuse cerebral edema (relative)
4. Dural calcifications (CRF hypercalcemia, basal cell nevus syndrome, hyperPTH)
5. Normal falx (can be normal dense in peds)
Dense Cerebral Mass – DDX
1. Tumor
a. Meningioma
b. Lymphoma
c. Hemorrhagic or calcified/mucinous met
d. Medulloblastoma
2. Vessel
e. Aneurysm
f. Hematoma
g. AVM
Dense Lesion Near Foramen of Monro
1. Intraventricular Lesion
a. Colloid cyst
b. CPP/granuloma
c. Meningioma
d. AVM of septal, thalamostriate, internal cerebral veins
2. Periventricular Mass
e. Lymphoma
f. TS tuber/SEGA
g. Met (mucinous adenoca, hemorrhagic met)
h. GBM of septum pellucidum
3. Masses projecting superiorly from base of skull
i. Pituitary adenoma
j. Craniopharyngioma
k. Aneurysm
l. Doliectatic basilar artery
Intracranial Calcifications
1. Physiologic
2. Infection – TORCH, healed abscess, hydatic cyst, tuberculoma, cysticercosis
3. Neoplasm –
4. Endocrine – HyperPTH, hypervitaminosis D, hypoPTH, pseudohypoPTH, CO poisoning, lead poisoning
5. Embryologic – Neurocutaneous syndromes (TS, Struge-Weber, NF), Fahr dz, Cockayne syndrome, Basac cell nevus syndrome
6. Arteriovenous – AVM, aneurysm, hemangioma, subdural hematoma
7. Leftover Ls – lipoma, lipoid proteinosis, lissencephaly
CMV vs Toxo calcifications -
1. CMV – CircuMVentricular
2. Toxo - inTraparenchymal
Neoplasms with Calcification
Ca+ Come
1. Craniopharyngioma
2. Astrocytoma, aneurysm
3. CPP
4. Oligodendroglioma
5. Meningioma, medulloblastoma
6. Ependymoma
Parasellar mesial-temporal/hippocampal calcification – bilaterally symmetric, bean-shaped, think ___ ?
Lipoid proteinosis
Physiologic Intracranial Calcification
1. Pineal calcification (pineal calc <6yo or >10mm suggests pineal neoplasm (teratoma/pineoloma)
2. Habenula
3. Choroid plexus
4. Dura, falx, tentorium
5. Petroclinoid ligament – b/w tip of dorsum sella and apex of petrous bone
6. Interclinoid Ligament
7. ateriosclerosis of ICA
8. Basal ganglia
Periventricular Calcification – Peds
1. Congenital Infection: CMV, toxo
2. TS
Gyral Enhancement
1. Meningeal Tumor
a. meningeal carcinomaotosis from systemic tumor (breast, SCLCA, malignant melanoma, lymphoma, leukemia
b. Primary CNS tumor seeding – GBM, Ependymoma, JPA, Pineoblastoma, medulloblastoma
2. Meningitis – pyogenic, Tb, fungal, cysticercosis, sarcoidosis
3. Sequela of SAH – fibroblastic proliferation
4. Subacute Infarct
Gyral Enhancement – DDx
1. Cerebritis
2. AVM (bleed)
3. Lymphoma
4. Meningitis
5. Infarct
6. Carcinomatosis
7. Encephalitis
Enhancing Ventricular Margins – DDx
1. Subependymal spread of Metastatic Tumor
a. Bronchogenic Ca (esp SCLCA)
b. Melanoma
c. Breast Ca
2. Subependymal seeding of CNS primary
d. Glioma
e. Ependymoma
3. Ependymal seeding of CNS primary
f. Medulloblastoma
g. Germinoma
4. Lymphoma
5. Inflammatory Ventriculitis
Ring-enhancing Lesion of Brain
1. Neoplasm
a. Primary – high grade glioma, meningioma, lymphoma, leukemia, pituitary macroadenoma, acoustic neuroma, craniopharyngioma
b. Mets
c. Sarcoma
2. Infection
d. Abscess: pyogenic, fungal, parasitic
e. Empyema (epidural, subdural, intraventricular)
3. Hemorrhagic-ischemic
f. Resolving infarction
g. Aging hematoma
h. Operative bed following resection
i. Thrombosed aneurysm
4. Demyelinating Disorder
j. Radiation necrosis
k. Necrotizing leukoencephalopathy after MTX
Ring-Enhancing Lesion Crossing Corpus Callosum
1. Glioma
2. Astroctyoma
3. Lymphoma
4. GAL
1. Glioma
2. Astroctyoma
3. Lymphoma
Dense and Enhancing Lesions – DDx
1. Aneurysm
2. Meningioma
3. Lymphoma
4. Medulloblastoma
5. Mets
Multifocal enhancing Lesions
1. Multiple infarcts
2. Mets
3. Lymphoma
4. Multifocal GBM
6. Septic emboli
7. AVMs
Innumerable Small Enhancing Cerebral Nodules
1. Mets
2. Primary CNS lymphoma
3. Disseminated infection
a. Cysticercosis
b. Histoplasmosis
c. Tb
4. Inflammation
d. Sarcoidosis
e. MS
5. Subacute Multifocal Infarction
f. Hypoperfusion, mulitiple emboli, cerebral vasculaitis (SLE), meningitis, cortical vein thrombosis
Periventricular T2-bright Lesion – Young Pt
1. MS
2. Migraine
3. Vasculitic-disorder (SLE, Behcets, SCD)
4. ADEM (post-viral leukoencephalopathy)
5. VR space
6. Leukodystrophy – symmetric diffuse confluent involvement
7. Ependymitis granularis
Periventricular T2-bright Lesions – Elderly
1. Etate Crible (sieve-like)/gliosis
2. Lacunar infarcts
What is the triad of a CNS vasculitis disorder
1. Cortical infarcts
2. deep WM lesions
3. hemorrhage
Periventricular T2-bright Lesions in PTs with AIDS
1. Toxoplasmosis
2. HIV encephalitis – dirty white matter (well defined patchy)
3. Lymphoma
4. PML
Periventricular T2-bright Lesions in Pts with Trauma
1. DAI
2. Diffuse necrotizing leukoencephalopathy (intrathecal MTX + whole brain RTX
Acute Bilateral BG Lesions – Peds
1. Vascular compromise
a. Hemolytic-uremic syndrome (microthrombosis of BD, thalami, hippocampi, cortex)
b. Encephalitis (viral)
2. Nutrient Compromise
c. Hypoxia: respiratory arrest, near drowning, strangling, barbituate intoxication
d. Hypoglycemia – hemorrhage rare
e. Osmotic myelinolysis
3. Acute poisoning
f. CO – globus pallidus
g. Hydrogen Sulfide
h. Cyanide
i. Methanol
Chronic Bilateral BG Lesions – Peds
1. Inborn errors of Metabolism
a. Leigh Disease (SANEM – subacute necrotizing encephalomyelopathy), get lactic acidosis, putamenal involvement)
b. Wilson Disease – hepatolenticular degeneration – lenticular nucleus=
c. Mitochondrial encephalomyelopathies
i. Lactic academia 2º to abnormal mitochondria, RRF on bx
d. Maple syrup urine disease (leu, iso val, inability to catabolize branched-chain amino acids)
2. Degenerative Disease
e. Huntington’s disease
f. Dystrophic calcifications
3. Dysmyelinating disease (BG are part WM)
g. Canavan Disease
h. Metachromatic Leukodystrophy
4. NF – NF spots
Low-attenuation Lesion in BG
1. Poisoning: CO, Barbiturates, hydrogen sulfide, cyanide, methanol
2. Hypoxemia
3. Hypoglycemia
4. Hypertension (lacunar infarcts)
5. Wilson idsease
BG Calcification
1. Physiologic with aging
2. Endocrine
a. HypoPTH, pseudohypoPTH,
b. Hypoerparathyroidism
c. Hypothyroidism
3. Metabolic
d. Leigh disease
e. Mitochondrial cytopathy
f. Fahr disease – familial cerebrovascular ferrocalcinosis
4. Congenital/Developmental
g. Familial idiopathic symmetric BG calcification, Hastings-James syndrome, Cockayne syndrome, Lipoid proteinosis (hyalinosis cutis), NF, TS, Oculocraniosomatic disease, Methemoglobinopathy, Down Syndrome
5. Inflammation
h. Toxoplasmosis, congenital rubella, CMV
i. Measles, chicken pox
j. Pertussis, coxsackie B virus
k. Cystercircosis
l. SLE
6. Trauma
n. Childhood leukemia following MTX Tx
o. RTX
p. Birth anoxia, hypoxia
q. Cardiovascular event
7. Toxic
r. CO poisoning
s. Lead intoxication
t. Nephrotic syndrome
Basal Ganglia Calcifications
1. Birth Anoxia
2. Idiopathic (most common), Infarct
3. RTx
4. Toxoplasmosis, CMV
5. hypoparathyroidism/pseudoHPT
Linear echogenic foci in thalamus and BG
1. in utero infection
b. Syphilis
c. HIV
2. Chromosomal abnormality
e. Trisomy 13
3. Others (anoxic injury)
f. Perinatal asphyxia, RDS, cyanotic congenital heart disease, necrotizing enterocolitis
g. Fetal Alcohol syndrome
h. Nonimmune hydrops
Classification of CNS anomalies
1. Dorsal Induction Anomalies
2. Ventral Induction Anomalies
3. Neuronal Proliferation & Histogenesis
4. Neuronal Migration anomaly
5. Destructive Lesions
1. Defects of Neural Tube Closure: Chiari malformation, encephalocele, anencephaly, spinal dysraphism, hydromyelia
2. holoprosencephaly, SOD, Dandy-Walker malformation , agenesis of septum pellucidum
3. NF, TS, primary hydranencephaly, neoplasia, vascular malformation
4. Due to infection, ischemia, metabolic disorders: schizencephaly, agyria, pachygyria, gray matter heterotopia, dysgenesis of corpus callosum, lissencephaly, polymicrogyria, unilateral megalencephaly
5. Hydranencephaly, porencephaly, hypoxia, toxicoses, inflammaty disease (TORCH)
Absence of septum pellucidum
1. Septo-optic dysplasia
2. Holoprosencephaly
3. callosal agenesis
4. schizencephaly
5. severe chronic hydrocephalus
6. destructive porencephaly
1. NF
2. TS
3. Sturge-Weber
4. VHL
5. Ataxia-telangiectasia
Demyelinating Disease (normal myelin destroyed by disease)
1. MS
2. Alzheimer Disease
3. Parkinson disease
4. CJD
5. Menkes disease (sexlinked recessive disorder of copper metabolism)
6. PML
7. Disseminated Necrotizing Leukoencephalopathy
8. Globoid Cell Leukodystrophy
9. Spongiform degeneration
Dysmyelinating Disease
1. Macrocephalic
a. Alexander disease (frontal first)
b. Canavan Disease (white matter diffusely affected)
2. Hyperdense thalami, caudate, corona radiata – Krabbe disease
3. family hx (x-linked recessive)
c. XLA
d. Pelizaeus-Merzbacher disease
4. Others
e. Metachromatic LD – most common hereditary leukodystrophy
f. Binswanger disease
g. Multi-infarct dementia
h. Pick disease
i. Huntington disease
j. Wilson Disease
k. Reye Syndrome
l. Mineralizing microangopathy
m. Diffuse sclerosis
Hypertensive Sequelae
1. Hypertensive encephalopathy
2. Hypertensive hemorrhage
3. Lacunar infarcts
Causes of Immunocompromise
2. Malignancy
3. Cancer Therapy
4. Transplant/Inflammatory disease Immunosuppressive treatment
5. Collagen Vascular Disease
AIDS-related pathologies
1. Lymphoma
2. thrombocytopenia
3. plasmacytoma
4. Kaposi’s Sarcoma
5. PML
Prolactin Elevation
1. Normal = __
2. Causes
1. up to 25 ng/ml
2. Interference with hypothalamic-pituitary axis
a. Hypothalamic tumor
b. Parasellar tumor
c. Pituitary adenoma
d. Sarcoidosis
e. Histiocytosis
f. Traumatic infundibular transection
3. Pharmacologic agents
g. Alpha-methyldopa, reserpine, phenothiazine, tricyclics, ocp’s
4. Hypothyroidism (TRH also stimulates prolactin)
5. Renal Failure
6. Cirrhosis
7. Stress/recent surgery
8. Breast examination
9. Pregnancy
10. Lactation
1. Hydrocephalus (ventricles >> sulci)
a. Ballooned and tight frontal horns –
b. Dilated temporal horns
c. - Dilated 3rd (hourglass shape) with flow void on MR
d. - decreased mammillopontine measurement (expanded 3rd pushes mammillary bodies post./inf.
e. Dilated 4th ventricle
f. Periventricular abnormal signal/density

2. Atrophy (sulci and ventricles dilate proportionately)
g. - Large cortical sulci
h. - Less 3rd ventricular dilatation (with parallel sides NOT hourglass shape)
i. - Increased with age
COMMENT: Normal pressure hydrocephalus evaluated by nuclear cisternogram.  No migration of activity over convexities/persistent intraventricular activity ... 50% aided by shunt ("shunt responsive NPH")