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39 Cards in this Set
- Front
- Back
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Mass in atria of lateral ventricle
DDx (adult vs. peds)? |
Adult:
Menigioma Glial tumor (astrocytoma or ependymoma) Met Vascular lesion (hemangioma) CPP or CPC (most often in 4th ventricle in adults) Peds CPP or CPC JPA PNET |
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Suprasellar mass
DDx (adults vs. peds)? |
Adults:
Common Pituitary Macroadenoma Meningioma Saccular Aneurysm Craniopharyngioma Pilocytic Astrocytoma less common Dilated Third Ventricle Arachnoid Cyst Neurocysticercosis Rathke Cleft Cyst Neurosarcoid Langerhans Cell Histiocytosis Germinoma Dermoid Cyst Lipoma rare Lymphocytic Hypophysitis Tuber Cinereum Hamartoma Epidermoid Cyst Pituicytoma Diffuse Astrocytoma, Low Grade Pilomyxoid Astrocytoma Ectopic Neurohypophysis Metastasis Lymphoma, Metastatic Leukemia Cavernous Malformation Tuberculoma Pituitary Abscess Peds: Pilocytic astrocytoma Craniopharyngioma (Ca++, cystic, enhancement) Pituitary Hyperplasia (prepubescent male, menstruating female) Germinoma (DI) Tuber Cinereum Hamartoma Arachnoid Cyst EG (DI) Pituitary Stalk Anomalies (ectopia, duplication) Teratoma Lipoma Pituitary Macroadenoma Dermoid Cyst Leukemia Pilomyxoid Astrocytoma (large bulky, hemorrhage) Saccular Aneurysm Retinoblastoma (Trilateral) Lymphocytic Hypophysitis (DI) Lymphoma, Primary CNS Rathke Cleft Cyst (intracystic nodule) |
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Pineal Mass
DDx (adults vs. peds)- |
Adults:
common Pineal Cyst (may have rim enh) Germinoma (central "engulfed" Ca++) Pineocytoma less common Teratoma Pineoblastoma ("exploded" peripheral Ca++) rare Retinoblastoma (Trilateral) Germ Cell Neoplasms, Malignant NOS Diffuse Astrocytoma, Low Grade Peds: common Pineal Cyst less common Germinoma Teratoma rare Pineoblastoma Retinoblastoma Pineocytoma |
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Bright BG on T1W
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Physiologic Ca
NF-1 Hyperalimentation/Manganese Hepatic Dz/TIPS less common Hypoxic Ischemic Encephalopathy Carbon monoxide poisoning Wilson Dz ("face of the giant panda") Kernicterus (peds) Rare Hallervoden-Spatz ("eye of the tiger") Fahr dz (Ca++ w/i BG and dentate nucleii BL) Hypothyroidism Hypo/hyper/pseudo/pseudopseudohypoparathyroidism Encephalitis (rabies, japanese) Congenital HIV) |
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Bright BG on T2W
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HIE
Hypotensive stroke CO poisoning PRES Drug abuse Ostmotic demyelination NF1 Encephalitis ADEM Vasculitis - SLE - HUS gliomatosus cerebri CJD Mitochondrial defect - Leigh - MELAS |
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BG Ca++
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Senile
Hypo/Hyperparathyroidism Prenatal Infection (CMV, HIV) Fahr dz (dentate nucleii too) |
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Hallervorden Spatz
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Hallervorden-Spatz Syndrome
Preferred terms: Pantothenate kinase-associated neurodegeneration (PKAN) or NBIA-1 Progressive neurodegenerative disorder with brain iron accumulation "Eye of the tiger": Symmetric GP T2 hyperintensity surrounded by hypointensity May see T1 hyperintensity in T2 hypointense areas (iron accumulation) |
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Diffuse pachymeningeal enhancement
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Postoperative (may last years)
Infectious pachymeningitis Mets Intracranial Hypotension (positional HA, sagging midbrain, low-lying tonsils) Lymphoma Sarcoid Subdural hematoma Granulomatous dz (TB, Wegners, Sarcoid) Idiopathic hypertrophic pachymeningitis Intracranial pseudotumor Extramedullary hematopoeisis |
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NF1
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Cafe au lait spots
Plexiform neurofibroma neurofibromas (->neurofibrosarcoma 5%) Lisch nodules (iris hamartoma) Optic gliomas Low grade brainstem gliomas (pilocytic astrocytomas) Osseus dysplasia (greater wing sphenoid) Lateral thoracic meningocele Dural ectasia Pseudarthrosis Wilm's tumor Leukemia/lymphoma Pheochromocytoma Medullary throid CA Melanoma |
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Scoliosis
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Idiopathic
Congenital - Chiari 2 - Hydromyelia - Segmentation anomaly - Diastematomyelia - Tethered cord - Lipoma - Meningocele |
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Diastematomyelia
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Cord split into 2 hemicords (85% T9-S1)
+/- fibrous or osseus central canal spur +/- syringohydromyelia Assoc. w/: - segmentation and fusion anomalies (SFA) - Intersegmental laminar fusion (60%); virtually pathognomonic for diastematomyelia - Spinal dysraphism (myelocele/myelomeningocele 15-25%, hemimyelocele 15-20%) - Tethered spinal cord (75%); thickened filum terminale (40-90%) - Syringohydromyelia (50%) one or both hemicords, usually above diastematomyelia - Congenital scoliosis (79%) - 15-20% of Chiari 2 malformations - Spinal lipoma (26%) - Dermoid cyst (13%) |
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Syringomyelia
(What is it and DDx?) |
Cystic spinal cord cavity not contiguous with central cord canal (lined by gliotic parenchyma separate from central canal)
AKA: - syringohydromyelia (features of both hydromyelia and syrindomyelia) - syrinx Expanded spinal cord with dilated, beaded, or sacculated cystic cavity Normal or canal enlarged canal, vertebral scalloping (severe, longstanding syrinx) DDx: - Ventriculus terminalis (Asymptomatic (normal) dilatation of terminal cord central canal only) - Cystic spinal cord tumor - Myelomalacia - Hydromyelia Etiology: Primary: - Hydrocephalus - Chiari 1 or 2 malformation (increased incidence w/ basilar invagination) - myelomeningocele or other spinal dysraphism - tethered cord - congenital scoliosis - spinal cord injury Secondary: Trauma Intramedullary neoplasm (ependymoma. astrocytoma) Inflammation (arachnoiditis, SAH) Infarct P/W: - Cloak-like pain and temperature sensory loss with preservation of position sense, proprioception, light touch - Distal upper extremity weakness, gait instability Tx: Address underlying cause (decompress canal, correct osseus abnormalities, lyse adhesions) |
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Hydromyelia
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Cystic central canal dilatation (lined by ependymal cells)
"hydrocephalus of the cord" |
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Ventriculus Terminalis
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Asymptomatic (normal) dilatation of terminal cord central canal only
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Cystic spinal cord tumor
(Intradural intramedullary) |
DDx:
Astrocytoma - can be longer - can be holocord - often eccentric, infiltrative - indistinct margins - hemorrhage uncommon - tumor cysts and syrinx less common - most common primary cord neoplasm in children Ependymoma - cervical > thoracic > conus - 30% of ependymomas are spinal - well circumscribed - symmetric expansion of cord - tumoral cysts; rostral or caudal cysts - syrinx in 50-90% - "cap" sign: hemosiderin at cranial or caudal margin 20-64% of cord ependymomas - a/w NF2 - most common primary cord neoplasm in adults Demyelating Dz (MS or ADEM) - often multifocal - 90% have brain lesions - lesions more often peripheral, posterolateral - ill-defined - faint nodular or patchy enhancement Hemangioblastoma - cyst with enhancing highly vascular nodule - flow voids may be present - extensive surrounding edema - thoracic > cervical - older patients - 1/3 with von Hippel-Lindau disease Metastatic Dz Cord infarct - sudden onset of symptoms - posterior columns typically spared in anterior spinal infarct Idiopathic transverse myelitis - centrally located - 3-4 vertebral segments in length - thoracic > cervical - variable enhancement - diagnosis of exclusion |
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NF2
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Schwannomas
- commonly CN VIII > CN V Meningiomas (intracranial or spinal) Ependymomas (intracranial or spinal) Calcifications along the choroid or cerebellar cortex AD inheritance - chromosome 22 |
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Parotid mass (bilateral)
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Warthins tumor
- cystic, solid or mixed - 20% bilateral Sjogrens Sarcoid RA HIV - benign lymphoepithelial lesions Lymphoma/Leukemia Metastatic dz - SCC - melanoma Oncocytoma |
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Parotid mass (unilateral)
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Benign mixed tumor (AKA pleomorphic adenoma)
- solid or cystic - high T2 Warthins - solid, cystic or mixed - high T2 - smoking related - 20% bilateral Metastatic dz - melanoma - SCC skin Salivary gland malignancy - can arise in benign mixed tumor - irregular, infiltrating margins - perineural spread (esp. adenoid cystic) - mucoepidermoid CA, adenoid cystic CA, primary SCC, adeno CA, ductal CA, acinic CA Lipoma Schwannoma Plexiform neurofibroma (NF1) Oncocytoma Low-flow VM (venous or lymphatic) 1st branchial cleft cyst Infantile hemangioma - peds Rhabdomyosarcoma - peds |
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Intraconal mass
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Cavernous hemangioma
- MC intraconal mass in adults - Well-circumscribed ovoid enhancing mass - peripheral nodular enhancement that fills in Optic glioma - a/w NF1 - fusiform enlargement of CN2 - "kinking/buckling" of CN2 Meningioma - avid enhancement - "tram-track" encasement of CN2 - Ca++ Idiopathic pseudotumor - simultaneous involvement of lacrimal, sclera, extraocular muscles Intraorbital hematoma Metastatic dz Cavernous sinus thrombosis - enlarged SOV Venous Varix Lymphoma - NHL - extraconal > intraconal Lymphatic malformation Sarcoid - may also involve lacrimal gland or extraocular muscles Coloboma - defect in globe at optic nerve insertion with outpouching of vitreous - fluid density Schwannoma/MNST Orbital Erdheim-Chester Dz - non-Langerhans histiocytosis with orbital xanthogranulomatous deposits in ~ 30% of cases - infiltrative extra- ± intraconal masses; often bilateral |
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Leukodystrophies
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Inherited disorders characterized by defects in the ability to produce or maintain myelin
Krabbe disease (globoid cell leukodystrophy [GLD]) - increased density on CT in basal ganglia - early cerebellar involvement - increased diffusion and ↑ ADC - lysosomal enzyme galactosylceramidase I → accumulation of psychosine and cerebroside Alexander disease - enhancement of the ventricular lining, periventricular rim, and frontal WM - Megalencephaly with ↑ signal in frontal WM, thalami, brainstem structures on T2WI - increased diffusion - glial fibrillary acidic protein (GFAP) → excess Rosenthal fibers in white matter Canavan disease - ↑ NAA on MRS, one of the only conditions where this is found - Megalencephaly - restricted diffusion and ↓ ADC - ↑ signal in occipital WM early, progressing to entire brain Metachromatic leukodystrophy (MLD) - early sparing of the subcortical U-fibers and perivascular WM - ↑ signal in hemispheric WM on T2WI ("tigroid" appearance of striping due to perivascular sparing) - restricted diffusion and ↓ ADC - lysosomal enzyme arylsulfatase-A (ARSA) → accumulation of sulfatide Adrenoleukodystrophy (ALD) - X-linked - early involvement of the parietal periventricular WM - Enhancement of zone of active inflammation - increased diffusion and ↑ ADC - peroxisomal enzyme acyl-CoA synthetase → accumulation of long-chain fatty acids Vanishing white matter disease - AKA childhood ataxia with cerebral hypomyelination (CACH) - ↑ WM signal on T2WI, ↓ on T1WI - eukaryotic initiation factor 2B → episodic WM cavitation after febrile infections or minor head trauma |
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Ocular lesion in a child
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Rb
- MC ocular tumor of childhood - MC cause of leukocoria - 75% unilateral, 25% bilateral - trilateral or quadrilateral - coarse Ca++ - mild hi T1W, low T2W, enh PHPV - persistant hyperplastic primary vitreous - 2nd MC cause of leukocoria - enhancing retrolental soft tissue "martini glass shape" - small hyperdense globe - a/w retinal detachment Congenital cataract - opacified lens - majority sporadic, 20% familial Retinopathy of prematurity - due to exposure to supplemental O2 - hyperdense globes +/- retrolental soft tissue - us. BL Coat's disease - retinal telangiectasis and exudative retinal detachment - 80-90% unilateral - CT: small hyperdense globe - No Ca++ - MR: retinal detachment with T1 and T2 hyperintense exudate Toxocariasis - eosinophilic granuloma caused by infection of larval nematode Toxocara cani - diffuse hyperdensity in vitreous ± discrete mass - no calcification Coloboma Ocular astrocytoma - retinal astrocytic hamartoma is ocular manifestation of tuberous sclerosis complex - Enhancing exophytic juxtapapillary or epipapillary retinal mass - Mass may be multifocal ± bilateral Norrie disease - X-linked recessive syndrome of retinal malformation, deafness, and mental retardation - bilateral hyperdense vitreous, small anterior chamber - small lens without calcification - may have associated retrolental mass, retinal detachment, microphthalmia, optic nerve atrophy Walker-Warburg - hydrocephaly, agyria, retinal detachment ± encephalocele - bilateral retinal detachment - vitreous ± subretinal hemorrhage - associated hydrocephalus, agyria/dysgenesis of cerebral and cerebellar gray and white matter |
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Microphthalmos in a child
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- isolated
- associated with: - craniofacial anomalies - coloboma - persistent hyperplastic primary vitreous - retinopathy of prematurity - Norrie disease |
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Ocular mass in an adult
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Ocular/retinal hemorrhage
Retinal detachment Idiopathic orbital inflammatory disease - Ocular lesions: ↑ enhancement + irregular or nodular scleral thickening Ocular melanoma Endophthalmitis - Acute: Thickening and enhancement of uveal-scleral layers - Phthisis bulbi (small shrunken globe ± hyperdense vitreous, enhancing vitreous and scleral or vitreal calcification) Staphyloma - Acquired buckling of scleral wall in posterior pole of globe - myopia Choroidal hemangioma - congential vascular hamartoma - typically presents in middle-aged/elderly - isolated or part of Sturge-Weber syndrome Choroidal osteoma - benign ossifying tumor of choroid - young women (20-30 years) - 75% unilateral - well-defined lenticular calcification in choroidal-retinal layer of posterior pole of globe - T1 hyperintense, T2 hypointense; marked enhancement Mets |
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Ocular calcifications
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Drusen
Rb Phthisis bulbi Retinal banding Choroidal osteoma |
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Hyperintense CSF on FLAIR
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subarachnoid hemorrhage
meningitis meningeal carcinomatosis venous sinus thrombosis primary meningeal melanosis status eplepticus stroke supplemental oxygen renal insufficiency w/ prior gadolinium |
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Nasal Mass
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Sinonasal polyposis
Sinonasal polyp - young adult Allergic fungal sinusitis - peripheral low density/central high density Juvenile angiofibroma - centered on sphenopalatine fossa - T2 hyperintense with salt and pepper appearance due to flow voids Rhinolith Inverted papilloma - older adult 40-70 - polypoid mass centered at middle meatus/maxillary antrum/nasal cavity - remodels bone Sinonasal osteoma Sinonasal pleomorphic adenoma (benign mixed tumor) Sinonasal NST Lymphoma Melanoma Mandible-Maxilla giant cell granuloma - "eggshell" periphery with central matrix calcifications |
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High density in subarachnoid
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Hemorrhage
Contrast dye (myelography) Protein (meningitis/melanosis/empyema) |
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Absence of normal high T1W intensity of posterior pituitary
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Pituitary hypoplasia
Ectopic pituitary EG Hemosiderosis Traumatic transection |
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Progressive opthalmoplegia
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Myaesthenia gravis
Ocular pharyngeal dystrophy Chronic progressive external ophthalmoplegia Kearns-Sayre - mitochondrial myopathy + cardiac conduction abnormalities + elevated CSF pressure SANDO |
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Leigh disease
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Neurodegenerative disease
Mitochondrial disorder ↑T2W, hypointense T1W, bilateral symmetric increased signal in caudates, BG, thalami, globus palidi, PAD, cerebellar nuclei MRS - ↑ choline, ↓ NAA - Lactate peak often present; may be large |
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What substances are bright on T1W?
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Fat
Methemoglobin (hemorrhage) Ca++ (some forms) Mn++ Cholestrol crystals Gadolinium Melanin |
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Spontaneous, non-traumatic intraparenchymal hematoma
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Hypertension
Hemorrhagic transformation of infarct Cavernous angioma Amyloid angiopathy Mycotic aneurysm AVM vasculitis drugs (meth, coke) |
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Spine: extradural lesions
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Disc herniation
Osteophyte Synovial cyst Hematoma Abscess Met Local extension from bone neoplasm Lipomatosis |
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CNS neoplasm with subarachnoid seeding and drop mets
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GBM
CPP/CPCA Medulloblastoma Ependymoma Germinoma |
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Vertebral body masses
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Malignant:
Mets Myeloma Chordoma (benign but aggressive) Lymphoma Benign: Hemangioma ABC Osteoblastoma EG GCT |
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Vertebra plana
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Trauma
Osteoporosis Mets MM EG Lymphoma/Leukemia GCT Osteomyelitis Hemangioma AVN (Kummel's disease) |
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Basilar invagination
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Paget's
Osteomalacia FD Rickets Achondroplasia OI CCD Hyperparathyroid Hurlers |
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Carotid space lesion
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Carotid body paraganglioma (aka glomus caroticum, chemodectoma)
- splays ext and int carotid - hypervascular, flow voids, "salt and pepper" - may be a/w MEN or VHL Schwannoma Neurofibroma Glomus vagale - higher in neck Carotid artery aneurysm Lymphoma Jugulodigastric node/Met |
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Masticator space mass
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Odontogenic abscess
Spread of SSCA Spread of Parotid mass Lymphoma Osseous Neoplasm: EG Ameloblastoma - benign but locally agressive tumor originating from odontoid epithelium - expansile lytic mass - "soap bubble" appearance - cyst with enhancing nodule and walls Met |
