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147 Cards in this Set
- Front
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Differential Dx of Basal Ganglia Lesions?
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Infection
toxoplasmosis cryptococcus cjd toxic/metabolic epm wilson's disease leigh's disease Ischemia lenticulostriate infarct hypoxic/ischemic encephalopathy internal cerebral vein thrombosis neoplasm lymphom/leukemia |
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Differential dx for ring enhancing lesions
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Metastases-mult g-w jxn
Abscess-+dwi, thin c+ Glioma-likes cc and deep wm Infarct-usually gyriform c+, except cbl, and bg Contusion-t1 shortening and susceptibility Demyelinating disease-incomplete ring c+, little mass effect Radiation necrosis-no perfusion atypical infection-tb, neurocystercicosis, fungal toxoplasmosis versus lymphoma-immune status |
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Cerebellopontine angle mass
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Schwannoma
Meningioma Ependymoma Lymphoma Inflammatory d/o Metastases |
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Clival mass
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Chordoma
Chondrosarcoma Plasmacytoma Metatases Lymphoma NOF |
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Diffuse marrow signal abnormality
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Chronic anemia
infiltrative processes ie leukemia, lymphoma, and sarcoid bone dysplasias |
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Most common neoplasms of the orbit
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cavernous hemangioma
capillary hemangioma lymphangioma |
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high signal intensity along apex of pituitary stalk at floor of third ventricle
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tuber cinereum lipoma
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absence of normal posterior pituitary high signal
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lch
hemosiderosis ectopic pituitary |
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connective tissue disorders associated with dislocations and/or subluxation of the lens
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marfan's
ehrlos danlos homocystinuria-inferior |
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parotid lesions
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benign mixed tumor (pleomorphic adenoma)
warthins tumor (cystic/solid, parotid tail) mets mucoepidermoid carcinoma adenoid cystic carcinoma (cn 7 spread) |
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Enhancing mass at jugular foramen
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glomus jugulare
mets schwannoma nasopharyngeal carcinoma meningioma chondroid lesions or chordoma |
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Cyst in 3rd ventricle
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ependymal cyst
arachnoid cyst colloid cyst cystersicosis epidermoid cyst cystic neoplasm |
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Hyperdense T1 lesions
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cavernous malformation
hemorrhagic mets metastatic melanoma amyloid angiopathy-subcortical htn DAI-subcortical, hx of trauma |
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midline posterior fossa mass in kids
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pnet
ependymoma cerebellar astrocytoma oligodendroglioma |
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tram track enhancement of the nerve sheath
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meningioma
sarcoid lymphoma mets pseudotumor |
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pituitary mass lesions in pituitary stalk
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lch
germinoma infection(meningitis/tb) lymphoproliferative d/o occ sarcoidosis glioma lymphocytic adenohypophysitis |
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expansile mass of the petrous apex
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mucocele
cholesterol granuloma multiple myeloma mets esp renal/thyroid chondrosarcoma cn v schwannoma |
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enhancement of the optic nerve
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optic neuritis
sarcoid infection primary tumor ie glioma or meningioma mets devics disease |
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basilar invagination
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ra
fibrous dysplasia pagets renal osteodystrophy cd osteomalacia |
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platybasia
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achondroplasia
osteogenesis imperfect ro pagets cleidocranial dysplasia down's syndrome |
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painless proptosis
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thyroid opthalmopathy
cavernous malformation mucocele or polyposis |
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painful proptosis
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pseudotumor
abscess cellulitis lymphoproliferative lesions thyroid opthalmopathy sarcoidosis wegeners |
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diffuse dural enhancement
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mets
leukemia/lymphoma granulomatous disease -leukemia, sarcoid -wegeners -erdheim chester -lipid granulomelosis spontaneous intracranial hypotension idiopathic hypertrophic pachymeningitis |
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ill-defined low attenuation mass lesion on ct
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glioma
demyelinating disease encephalitis |
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neoplasms that arise from the lateral ventricle along foramen of monroe or septum pellucidum
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oligodendroglioma
central neurocytoma fibrillary astrocytoma pilocytic astrocytoma ependymoma hemangioma subenpendymal gc astrocytoma choroid plexus papillloma |
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pontine hyperintensity
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ischemia
infection brainstem glioma demyelination myelinolysis pml |
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basal ganglia ca++
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endocrine
metabolic congenital/developmental inflammatory toxic |
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pediatric bg ca++
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fahr's syndrome
hypo/hyperparathyroidism MELAS HIV |
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High density in subarachnoid space
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blood
cellular material ie carcinomatosis, infection, sarcoid iodinated contrast-ie in renal failure CSF hypotension-check for sd collxns and large dural sinuses anoxia-?dense venous stasis, see in leptomeninges as well, white cerebellar sign, bg indistinct |
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confluent white matter lesions in adult
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demeylinating disease
neoplasm PML microvascular ischemic disease autoimmune mediated vasculitis |
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confluent white matter lesions in a child
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adem
ms dysmeylinating disease (leukodystrophy) |
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pineal masses
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pineal cyst
germ cell tumor pineal cell tumor meningioma tectal plate glioma |
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sellar/suprasellar mass in child
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craniopharyngioma
germ cell tumor rathke cleft cyst optic nerve/hypothalamic glioma hypothalamic hamartoma |
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posterior fossa mass in an adult
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infarction
mets hemangioblastoma vascular malformation htn hemorrhage |
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posterior fossa cyst
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mega cisterna magna
arachnoid cyst dandy-walker malformation joubert syndrome |
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csf fluid lined cortical defect
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prior infarct
schizencephaly porencephalic cyst |
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enhancing intramedullary spinal mass
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ependymoma
astrocytoma hemangioblastoma mets demyelinating disease |
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intradural extramedullary spinal mass
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nerve sheath tumor
meningioma csf mets |
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diffuse temporal lobe mass
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herpes encephalitis
ischemia/infarction gliomatosis cerebri limbic encephalitis status epilepticus |
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increased T2 signal intensity in the basal ganglia/thalami in child
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ischemia
co poisoning wilson's disease mitochondrial disorder kernicterus osmotic demeylination |
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intraparenchymal hemorrhage
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htn infarct-basal ganglia, pons, cerebellum
vascular malformation hemorrhagic infarct-lobar, venous hemorrhagic neoplasm contusion cerebral amyloid disease-typically lobar |
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corpus callosum lesion
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gbm
lymphoma demeylinating disease dai marchiafava bignami disease |
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subependymal nodules
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ts
heterotopic gray matter torch mets |
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mass supratentorial csf collection in newborn
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massive hydrocephalus
hydrancephaly alobar prosencephaly agenesis of cc with midline interhemispheric cyst bilateral open-lip schizencephaly |
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intraventricular mass
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meningioma
choroid plexus tumor central neurocytoma-enhances ependymoma/subependymoma-subep doesn't enh colloid cyst subependymal gc astrocytoma |
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cerebellar atrophy
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alchohol abuse
anticonvulsant therapy paraneoplastic syndrome sporadic olivopontocerebellar atrophy etc |
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spinal cord signal abnormality
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demyelinating disease
cord contusion intramedullary neoplasm transverse myelitis cord ischemia |
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cortically based enhancing neoplasm
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oligodendroglioma
astrocytoma ganglioglioma dysembryoplastic neuroepithelial tumor desmoplastic infantile glioma |
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epidural spinal mass
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disk extrusion
epidural hematoma epidural abscess mets epidural lipomatosis synovial cyst |
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prominent periventricular/basal ganglia cystic lesions
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virchow-robin spaces
lacunar infarct infection cystic neoplasm neuroglial cyst |
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Approach to CNS infections
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extra-axial
ring enhancing temporal lobe basal ganglia white matter imaging characteristics clinical history, immune status, age, chronicity of symptoms, geographic region |
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ddx subdural epyema
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effusion-nml dwi, no c+
chronic sdh - susceptibility on MR hygroma-trauma history |
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ddx bright sas on flair
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tumor
meningitis (pus) sah (blood) slow flow-ie pial collateral with carotid stenosis oxygen therapy |
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ddx basilar C+
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tb
fungal sarcoidosis |
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acute bacterial or viral leptomeningitis
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c+ over cerebrum
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chronic fungal or tb
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c+ basilar cisterns
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pachymeningeal enhancement
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idiopathic hypertrophic cranial pachymeningitis
intracranial hypotension dural metastasis infection sarcoidosis |
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leptomeningeal enhancement follows sulci and basilar cisterns
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meningitis
leptomeningeal tumor sarcoid |
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Stages of neurocysticercosis
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vesicular-larva in a clear cyst (cyst with dot), no edema
colloidal vesicular-scolex degen, edema, c+, t2 hyperintense with dark rim granular nodular-cyst wall thickens, decreased inflam nodular calcified-lesion mineralizes, no edema |
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ddx temporal lobe lesions
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mca infarct
low grade glioma gliomatosis |
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ddx white matter abn
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chronic small vessel disease
radiation/chemo transependymal csf ms/adem hiv encephalopathy cmv pml |
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subdural hematoma
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stops at midline
crosses sutures don't see dura crescent shaped countrecoup 4 bad signs heterogenous increased mass effect convex SAH |
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epidural hematoma
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heterogeneity-ie low density means active bleeding, ie swirl sign
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enhancing traumatic hematoma
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clues-bilateral, orbitofrontal, hemosiderin ring, other injuries, can enhance
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coup-contrecoup injury
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coup site-fracture, edh
contrecoup-sah, sdh, brain injury |
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DAI
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grade 1-lobar white matter
grade 2-splenium of corpus callosum grade 3-triad lobar wm corpus callosum dorsolateral brainstem |
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venous htn + hemorrhagic CVA
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can mimic DAI
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important skull fractures
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overlies a dural venous sinus-hem infarct
overlies the MMA-epidural hematoma overlies eloquent cortex depressed>table width open/compound- ie get infected tranverses ICA canal-pseudoaneurysm, dissection temporal bone fracture |
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carotid cavernous fistula
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proptosis
enlarged EOM convex cavernous sinus enlarged superior opthalmic vein retrobulbar fat stranding can get hemorrhagic venous infarcts |
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traumatic CCF
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high flow shunt with direct connect between ica and cavernous sinus
chemosis, proptosis, bruit, cranial nerve pasly, decreased vision, ha tx-manual cratoid jugular compression; transarterial endovascular embolization (balloon>coils>NBCA) |
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early nct signs of stroke
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losss of gray-white matter differentiation
cortical (insular) ribbons sign basal ganglia effacement hypodensity dense artery sign |
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look up stroke changes per hours
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?
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vascular territories
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aca-supplies cingular and superior frontal gyrus
mca deep-lenticulostriate from m1 segment which supply basal ganglia superifical-frontal, parietal, temporal lobe and insula pca-thalamus, mesial temporal lobe, occipital lobe in calcarine region, doesn't extend about ventricles basilar-posterior fossa, bilateral cerebellar hemispheres, pca territories anterior choroid artery-amygdala, hippocampus, internal capsule up to the ventricles, suspect when face, arm, leg all affected |
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carotid dissection
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proximal
progression of aortic dissxn common carotid artery ica extension uncommon false lumen asx or symptomatic distal mid to distal ica carotid bulb spared no false lumen subintimal hematoma symptomatic |
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hemorrhagic venous infarcts vascular territories
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patchy areas of hemmorhage surrounded by edema
superior sagittal sinus and cortical vein-parietal lobe staight sinus, internal cerebral veins-bilateral thalamus transverse sinus + vein of labbe-temporal lobe cavernous sinus |
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simplified histologic subtypes of brain tumors
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primary tumor of brain-glioma
primar tumor of brain coverings-meningioma primary neuronal tumors-neurocytoma primary tumors of primitive cells (medullo, PNET) secondary tumors (mets) |
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look for tumor related complications
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hydrocephalus
hemorrhage herniation |
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cyst with noduel and minimal surrounding edema lesions
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pilocytic astorcytoma
ganglioglioma pxa hemangioblastoma |
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imaging of tumors
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glioblastoma multiforme
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most common primary glioma
who grade IV older supratentorial white matter irregularly enhancing mass with central necrosis and edema poor px highly vascular and infiltrative |
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fibrillary astrocytoma
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low grade vs anaplastic
better px than gbm usually younger for low grade eventually degenerate who grade 2-no enhancement who grade 3-some enhancement |
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juvenile pilocystic astrocytoma
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who grade 1
peds or young adults excellen px dep on location well circum with cyst and min edema |
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pleomorphic xanthoastrocytoma
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rare, distinc astrocytoma subtype, who grade 1
indolent, benign tumor children, young adults superficial cortical location temporal lobe most comon cyst with mural nodules, minimal edema good px |
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oligodendrogliomas
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low grade and anaplastic
younger patients better px than astrocytoma 1p 19q deletion fronta lobe most common cortical involvement common, expanding cortex, var enhancement ca++ common can appear aggressive |
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intracranial tumors with ca++
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ddx
oligodendroglioma ependymoma craniopharyngioma choroid plexus tumor meningioma |
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ependymoma
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third most common ped brain tumo
60% infratentorial (4th vent) when supratentorial, extraventricular location common ca++ common anaplastic variant has poor px |
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meningioma
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most common extraaxial tumor
middle aged women excellent px except anaplastic variant can be multiple (meningiomata, neurofibromatosis) can be intraventricular (trigone, most common) or intraosseous ddx dural based mets hemangiopericytoma solitary fibrous tumor chondrosarcoma |
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hemangiopericytoma
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rare hypervascular extra-axial tumor
arises from outer layer of meninges, ie pericytes of zimmerman can occur anywhere in body tend to be more aggressive than meningioma usually no dural tail |
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primary cerebral lymphoma
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usually nonhodkin, b cell
usually adults multiple enhancing masses in deep gray or white matter and periventricular location maybe centrally necrotic in immune compromised patients tends to involve same place as glioma tend to have fairly low t2 signal int and mildly reduced diffusion |
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brain tumors with low t2 signal
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cellular tumors and high nuclear to cytoplasmic ration
ddx lymphoma pnet, medullobllastoma meningioma mucinous adeno met |
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intraventricular mass with attacment to septum
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central neurocytoma-enhances, vascular
subependymoma-doesn't enhance |
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pediatric brain tumors
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medulloblastoma-tends to met early on
juvenile pilocytic astrocytoma choroid plexus papilloma craniopharyngioma pleomorphic xanthoastrocytoma |
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csf dissemination
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pnet
medulloblastoma pineoblastoma ependymoma choroid plexus ca |
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choroid plexus papilloma vs carcinoma
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usually in young children
lateral ventricle in children, fourth ventricle in adults avid enhancement and ca++ common hydrocephalus |
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diffusion positive mass lesions
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ddx
epidermoid mucinous adeno ca met abscess cellular tumors ( ie lymphoma, pnet, meningioma) |
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epidural empyema (or abscess)
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extension from sinus
bony erosion valveless bridging veins lentiform shape frontal sinus most common complications dural sinus thrombosis osteomyelitis meningitis |
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subdural empyema
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high mortality
10% brain abscess, sinus thrombosis young kids-meningitis adults-paranasal sinuses bright dwi location convexity 50% parafalcine 20% ddx effusion-nml dwi, no c+ chronic sdh-suscept on mr hygroma-trauma hx |
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complications of meningoencephalitis
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infarct
hydrocephalus subdural empyema dural sinus thrombosis |
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leptomeningitis
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ct
insensitive, pre-LP mri flair and gad-sas abn dwi-infarct and subdural emphyema |
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factors favoring abscess over neoplasm
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asymmetric collagen dep->thinner rim c+ toward ventricle->propensity for iv rupture
daughter cysts light bulb bright diffusion thin smooth c+ rim t2 hyperintense center with dark rim (free radicals) |
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caseating brain tuberculoma
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dark t2 signal, abn chest xray
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ADEM
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multifocal BG and WM
10-14 days after infection/vacc maybe tumefactive minimal mass effect punctate, ring, and incomplete enhancing |
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invasive aspergillosis of the brain
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enhancement
immunocompromised-min immunocompetent-ring c+ angioinvasion by hyphae hemorrhage, septic infarcts, aneurysms dark t2 hemorrhage minimal mass effect direct from sinuses or hematogenous ie lungs dwi variable |
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hsv encephalitis
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mesial temporal lobe->limbic system
insula, inferior frontal, cingulate, spares bg bilateral, asymmetric patchy c+ early, and gyriform c+ later dwi+ |
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progressive multifocal leukoencephalopathy
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subacute demyelinating
jc virus asymmetric subcortical U, deep wm dark t1 signal location parieto-occipital bg, brainstem, cerebellum |
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cmv
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ventriculoencephalitis
cd4<50 chorioretinitis in 25% aids mri-thin pvwm t2 and subependymal c+ |
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cryptococcus
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meningitis
5-10% aids gelatinous pseudocysts dilated vr spaces nonenhancing bg and thalami |
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ica dissection
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neck pain, embolic events, horners, cn12 palsy
t1-fs spontaneous or posttraumatic ica (spont)-above bifurcation ica (traumatic)-distal cervical and skullbase vert c1/c2 irreg in sites unusual for athero string sign aneurysmal dilatation occlusion intimal flap |
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nontraumatic intraparenchymal hemorrhage
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underlying lesion
tumor-solic c+ avm-cta cavernoma-look for dva aneurysm-cta amyloid angiopathy-spares bg dural venous sinus-subcort. wm hypertension-bg, pons, cbl coagulopathy |
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multiple brain ca++
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cavernomas
neurocysticercosis prior infection ie toxo |
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multiple foci of susceptibility in the brain
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amyloid angiopathy
htn cavernomas shear injury |
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cavernomas
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discrete collection of endothelial lined sinusoids "caverns"
no intervening brain recurrent intralesional hemr. vascular hamartoma 0.25-1%/year hem risk 75 sporadic 10-30% familial angiographically occult assoc DVA mr hemosidern ring "black halo" popcorn t2 hyperintensity t1 hyper and hypo locules minimal or no c+ ct >50% calc dva no mass effect |
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capillary telangiectasia
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brainstem
assoc with radiation no t2 signal usually, unless big brush c++ dark GRE don't touch |
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spetzler-martin grading
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size of avm nidus (compact or diffuse)
<3cm-1pt 3-6cm-2pts >6cm-3pts eloquence of adj brain eloquent-1 point pattern of venous drainage superficial-0 deep-1 tx surgical resection gamma knife <3cm embolization |
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classic avm
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98% solitary or sporadic
2% multiple and syndromic (hht) 1-4% bleeding risk per year increased bleeding risk with feeding artery 15%, nidus aneurysm 50% venous stenosis deep location or drainage smaller nidus ct 25-30% ca++ iso/hyperdense vessels mri bag of worms no mass effect t2 gliosis |
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ICA and ECA anatomy
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look up ct, mr, angiogram
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pcomm aneurysm/sah
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cta to find aneurysm
look for 2nd and 3rd aneurysms 3rd nerve palsy complications hydrocephalus vasospasm |
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intracranial aneurysm risk factors
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smoking, cocaine, >50, f
family hx fibromuscular dysplasia anatomic variants (ie trigeminal artery) type IV ehlers-danlos nf1 adpckd |
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perstistent trigeminal artery
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fetal connection of cavernous carotid to upper 1/3 basilar artery
ddx fetal pca-supraclinoid ica above sella |
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dural sinus thrombosis
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ct-hyperdense and expanded sinus, empty delta sign post c+
mr-loss of normal flow void flair pitfall-acute dst dark tof mrv pitfall-t1 shortening pattern of venous ischemia sss-parasagittal tranverse-temporal lobe deep-bithalamic |
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venous infarcts
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subcortical white matter
hemorrhage doesn't follow arterial dist +/- reduced diffusion maybe mass like and mimic neoplasm |
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moya moya
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idiopathic progressive arteriopathy of childhood
occ of supraclinoid IC and prox cow moya moya like-sickle cell, NF, radiation, atherosclerosis, drugs angio-puff of smoke, cloudlike lenticulostriate collaterals ct/mr-bg and leptomeningeal c+ due to collateral slow flow peds-ischemia adults-hemorrhage |
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indirect CCF
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low flow
meningeal branches dAVF spontaneous, can be observed |
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direct CCF
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high flow
tramua, aneurysm rupture direct usually needs more direct tx |
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elevated ICP
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primary (idiopathic)
idiopathci intracranial hypertension aka pseudotumor cerebri secondary intracranial mass diffuse cerebral edema dural sinus thrombosis nl csf pressure-80-150 mmh20 |
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idiopathic intracranial htn
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mostly women, 3rd decade
obese, recent weight gain maybe med induced papilledema->optic neuroopathy headaches, transient visual obscurations, diplopia, pulsatile tinnitus empty sella narrowed mid transverse sinuses slitlike ventricles |
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infarcts in young patients
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cardiac-ie congenital hd, valve dz, la myxoma
prothrombotic d/o-ie ss, protein s or c, or antithrombin deficiencies, factor 5 leidin, lupus anticoagulant, polycythemia, platelete disorders, leukemia, chemotherapy related inherited- vascular-neurocutaneous synd, cadasil metabolic-melas, homocystinuria acquired vascular d/o dissection, NAT, moya moya, systemic or cns angiitis, migraines ocp, street drugs |
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MELAS
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mitochondrial myopathy
encephalopathy lactic acidosis stroke like episodes 2nd dec headache, psychosis, acute stroke like cortical lesions that cross usual vascular territories most often parietal and occipital dwi variable strokes, seizures mrs-inc lactate in csf and in "normal" brain |
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PRES
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acute encephalopathy
ct bilateral white matter hypodensity mr bilat predom white matter hyperintensity post fossa, parietal, occipital, and posterior frontal and temporal lobes neg dwi indicates that this is vasogenic edema assoc conditions htn eclampsia/pre-eclampsia acute gn hus ttp cvd seizures drug toxicity tacrolimus fk506 cyclosporine erythrpoietin cisplatin |
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myelination pattern
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caudal to cephalad
dorsal to ventral t1 changes before t2 t1 mature by 8 mo t2 mature by 2 y |
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agenesis of corpus callosum
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medial sulci radiate to high riding 3rd ventricle
everted cingulate gyri dilatation of the lateral ventricles, without true hydrocephalus |
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hypogenesis of the corpus callosum
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corpus develops from front to back
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midline lipomas
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dont touch
interhemispheric quadrigeminal plate/supracellar cistern suprasellar/interpeduncular cistern cerebellopontine angle sylvian cistern signal suppresses with fat sat |
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hypothalamic hamartoma
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insointense to gray matter, nonenhancing
present with precocious puberty, gelastic seizures |
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complete lissencephaly
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agyria, assoc with chromosomal anomalies
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incomplete lissencephaly
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pachygyria
chromosome anomalies |
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band heterotopia
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band of neurons located in white matter, follows gray matter signal intensity on all sequences and separated from cortex by myelinated white matter
sons can get classical lissencephaly |
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polymicrogyria
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disorganization or absence of layers of cortex
look like thickened cortex, but has multiple small gyri perisylvian/sylvian regions on sagittal images which are abnormally deep seizures +/- focal deficits/developmental delay genetic or acquired (in utero ischemia, infection) |
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periventricular nodular heterotopia
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isointense to cortex, nonenhancing
smooth, line ventricle if ovoid, long axis is parallel to ventricle may project into lumen of lateral ventricle |
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schizencephaly
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communication b/w sa space and ventricle
lined by dyplastic gray matter, polymicrogyria open lip when walls of cleft are separated versus closely opposed bilateral congenital or acquired often septum pellucidum absent unilateral or bilateral worse outcome when bilateral, open lip |
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alobar holoprosencephaly
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monoventricle
nonseparation of forebrain |
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semilobar holoprosencephaly
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lack of separation of forebrain
callosal hypogenesis only condition where posterior callosum maybe formed without anterior callosum |
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chiari 1 malformation
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low position of cerebellar tonsils (5mm below foramen magnum)
pointed morphology r/o other causes of tonsillar descent-intracranial hypotension, mass, increased intracranial pressure look for associated syrinx |
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chiari 2 malformation
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small posterior fossa
myelomeningocele hydrocephalus after closure of MMC tectal beaking interdigitation of gyri callosal hypo/agenesis cortical malformations |
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dandy walker malformation
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large posterior fossa
hypogenesis/agenesis of the vermis cystic dilatation of the 4th ventricle continuum with mega cisterna magna (normal vermis) dwm hydrocephalus callosal hypo/agenesis occiptal encephaloceles cortical malformations syrinx |
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pediatric sellar/suprasellar masses
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glioma
craniopharyngioma germ cell tumor histiocytosis hypothalamic hamartoma of tuber cinereum pit adenoma rathke cleft cyst |
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orbital masses in children
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abscess
pseudotumor benign tumors dermoid, epidermoid, teratoma, neurofibroma malignant tumors rhabdomyosarcoma, retinoblastoma, optic glioma, lymphoma/leukemia, histiocytosis, mets vascular malformation fibrous dysplasia graves disease |
