@TheASNR

@TheASNR

Lea Alhilali, MD

@teachplaygrub

1/ “Say Aaaaaaah!” I was explaining to my resident how I remember tongue anatomy on imaging & he said, “You have to put it on Twitter!”

So here's a #tweetorial about how to remember tongue anatomy on imaging.

#medtwitter #radres #medstudent #FOAMed #FOAMrad #neurorad #meded

2/ When you look on the coronal plane at the tongue, the first thing you notice are two column like structures that look like a pair of jeans—genioglossus—or as I like to say “jean-ee-o-glossus.” Genioglossus is latin for jeans of the tongue, right? 

3/Right below the jeans are what look like a pair of clown shoes—the geniohyoid. So you see a pair of legs going right into a pair of shoes.

Read 7 tweets

Lea Alhilali, MD

@teachplaygrub

1/Time is brain! So you don’t have time to struggle w/that stroke alert head CT.
Here’s a #tweetorial to help you with the CT findings in acute stroke.

#medtwitter #FOAMed #FOAMrad #ESOC #medstudent #neurorad #radres #meded #radtwitter #stroke #neurology #neurotwitter

2/CT in acute stroke has 2 main purposes—(1) exclude intracranial hemorrhage (a contraindication to thrombolysis) & (2) exclude other pathologies mimicking acute stroke. However, that doesn’t mean you can’t see other findings that can help you diagnosis a stroke.

3/Infarct appearance depends on timing. In first 12 hrs, the most common imaging finding is…a normal head CT. However, in some, you see a hyperdense artery or basal ganglia obscuration. Later in the acute period, you see loss of gray white differentiation & sulcal effacement

Read 13 tweets

Daniel Gewolb, MD

@daniel_gewolb

Interesting case in this patient with acute right-sided weakness

#neurorad #neurotwitter #meded #Neurosurgery #Neurology @TheASNR @RSNA #medtwitter

Can you determine the diagnosis off the CT?

▶️Initial non-con CT shows a 3cm hyperdense lobulated extra-axial mass in the expected region of the left MCA bifurcation, consistent with a giant aneurysm. There are associated peripheral calcifications

▶️ What is the cause of the surrounding hypodensity?

Read 10 tweets

Lea Alhilali, MD

@teachplaygrub

1/”Tell me where it hurts.” How back pain radiates can tell you where the lesion is—if you know where to look!

A #tweetorial about how to remember lumbar radicular pain distributions.

#medstudenttwitter #medtwitter #radres #FOAMed #FOAMrad #neurorad #tweetorial #Meded

2/Let’s start with L1. L1 radiates to the groin. I remember that b/c the number 1 is, well, um…phallic. So the phallic number 1 radiates to the groin.

3/Let’s skip to L3 for a second. I remember L3 is to the knee—easy, it rhymes!

Read 8 tweets

Daniel Gewolb, MD

@daniel_gewolb

@TheASNR

Learning case in this 40 y/o F with history of whole brain radiation as a child for brain tumor treatment
#NeuroRad #neurosurgery #Neurology @TheASNR #NeuroTwitter #meded #radres

Brain radiation is a risk factor for the development of meningiomas …this patient subsequently developed multiple meningiomas including this large frontal meningioma

The mass was treated and immediate post op CT shows expected post op change with the resection cavity, some hemorrhage, and pneumocephalus

Read 9 tweets

Nirmal Pandey MD DM Neurologist

@nirmalregency

We were consulted for a 2nd opinion.
30F. D1. Deep dog bite L cheek while tending fields. Multiple others bitten. Dog was killed the same day by villagers. #NeuroTwitter #MedTwitter #IDtwitter #NeuroRad #Neurology

D2. Visited PHC.
Prescribed PVRV (Abhayrab) D2, D5, D8, D13. NO RIG given.

D16. Fever, uncontrolled vomiting.
D20: admitted. Rx as sepsis.
D22 discharged. No hydro/aerophobia.
D23. Drowsy/unresponsive/taking orally food/water. Readmitted.
NB: Aerophobia is seen in ~50%, Hydrophobia in 10-15%

Read 11 tweets

Lea Alhilali, MD

@teachplaygrub

1/Do radiologists sound like they are speaking a different language when they talk about MRI? T1 shortening what? T2 prolongation who?

Here’s a translation w/a #tweetorial introduction to MRI.

#medtwitter #FOAMed #FOAMrad #medstudent #neurorad #radres #ASNR23 #neurosurgery

2/When it comes to bread and butter neuroimaging—MRI is definitely the butter. Butter makes everything taste better and packs a lot of calories. MRI can add so much information to a case

3/In fact, if CT is a looking glass into the brain—MRI is a microscope. It can tell us so much more about the brain and pathology that affects the brain.

So let’s talk about the basic sequences that make up an MRI and what they can show us.

Read 22 tweets

Lea Alhilali, MD

@teachplaygrub

1/Don’t let all your effort be in VEIN!

Developmental venous anomalies (DVAs) are often thought incidental but ignore them at your own risk!

A #tweetorial about how to know when DVAs are the most important finding

#meded #medtwitter #neurorad #neurotwitter #radtwitter #radres

2/DVAs aren’t hard to recognize on imaging—they have a typical “caput medusae” appearance.

Dilated medullary veins look like snakes all converging into the medusa head of a large draining vein.

3/DVAs are incredibly common—1 in 50 may have one

Although >90% are asymptomatic, that would still results in a relatively large number of patients w/symptoms

Also, w/increasing knowledge of DVA physiology, we may find they’re responsible for more symptoms than we realize

Read 21 tweets

The American Society of Neuroradiology

@TheASNR

ASNR COTW #143

Hx: Altered mental status with oral pain.

NO SPOILERS!!! Give hints in the form of GIF or answer attached poll.

Answer in 24 hrs

#Neuro #Neurorad #Erad #radres #FOAMed #FOAMrad #medtwitter #ASNRCOTW

What disease process is associated with oral ulcers and enhancing hyperintense T2 signal lesions in the brain and spinal cord?

The answer is: Neuro-Behçet’s disease!
See you next week!

Read 3 tweets

Lea Alhilali, MD

@teachplaygrub

1/Is trying to understand peripheral nerve injury getting on your last nerve? Is the brachial plexus breaking you?

Here’s a #tweetorial to help you understand, recognize & remember the classification of peripheral nerve injuries
#medtwitter #meded #FOAMed #neurorad #neurotwitter

2/Normally the peripheral nerve is protected by surrounding myelin & connective tissue.

Think of the nerve like a hot dog. It is wrapped nice & cozy: first, by toppings right up against the hot dog (myelin) & then a bun holding it all in (connective tissue)

3/Although nerve injury can be compressive or stretch or even from radiation, it is easiest to think of it like a punch to the face. Imaging that sort of injury hits the nerve, like a fist to your face

Read 19 tweets

The American Society of Neuroradiology

@TheASNR

ASNR COTW #142

Hx: 62 y/o male initially found unresponsive on the street presents with bradycardia and anterograde amnesia.

NO SPOILERS!!! Give hints in the form of GIF or answer attached poll.

Answer in 24 hrs

#Neuro #Neurorad #radres #FOAMed #FOAMrad #medtwitter #ASNRCOTW

What is the most likely diagnosis given the history and MRI findings in the referenced images?

The answer is: Opioid-associated amnestic syndrome!
See you next week!

Read 3 tweets

Lea Alhilali, MD

@teachplaygrub

1/Time is brain! But what time is it?

If you don’t know the time of stroke onset, are you able to deduce it from imaging?

Here’s a #tweetorial to help you date a #stroke on MR!
#medtwitter #meded #neurotwitter #neurology #neurorad #radres #radtwitter #radiology #FOAMed #FOAMrad

2/In up to 25% of acute stroke patients, the time of last known well is well, not known. Then it’s important to use the stroke’s MR imaging features to help date its timing. Is it hyperacute? Acute? Subacute? Or are the “stroke” symptoms from a seizure from their chronic infarct?

3/Strokes evolve, or grow old, the same way people evolve or grow old. The appearance of stroke on imaging mirrors the life stages of a person—you just have to change days for a stroke into years for a person. So 15 day old stroke has features of a 15 year old person, etc.

Read 22 tweets

Lea Alhilali, MD

@teachplaygrub

1/Feeling unarmed when it comes to evaluating cervical radiculopathy & foraminal narrowing on MR?

Here’s a #tweetorial that’ll take that weight off your shoulder & show you how to rate cervical foraminal stenosis!
#medtwitter #meded #FOAMed #radtwitter #neurorad #spine #radres

2/First, the anatomy. Nerve rootlets arise from the anterior & posterior horns, merging to form anterior (motor) & dorsal (sensory) nerves roots in the thecal sac.

These come together & the dorsal root has its dorsal root ganglion before the spinal nerve extends extravertebral

3/Think of it like a road system but carrying information/impulses instead of cars. Small roads (rootlets) merging to make larger roads (roots), before these finally merge together onto the big highway, which is the dorsal root ganglion and spinal nerve

Read 22 tweets

Lea Alhilali, MD

@teachplaygrub

1/Does the work up for dizziness make your head spin?

Wondering what you should look for on an MRI for dizziness?

Here’s a #tweetorial on what you can (and can’t) see on MRI in #dizziness

#medtwitter #meded #neurotwitter #neurorad #radres #HNrad #neurotwitter #stroke #FOAMed

2/The etiology for dizziness depends both on how you define dizziness (i.e., vertigo, imbalance) & where you see the patient

For imaging, subtle distinctions in symptoms usually aren’t provided & many common diagnoses are without imaging findings (BPPV, vestibular migraine)

3/The most important finding on imaging for dizziness is a stroke from vertebrobasilar insufficiency (VBI)

It's a relatively uncommon etiology of dizziness, but its prevalence increases in emergent/acute dizziness populations

Missed VBI can have profound consequences/morbidity.

Read 24 tweets

Lea Alhilali, MD

@teachplaygrub

1/I call the skullbase “homebase” bc you can’t make an anatomy homerun without it!

Most know the arteries of the skullbase, but few know the veins. Do you?

Here’s a🧵to help you remember #skullbase venous #anatomy!
#medtwitter #meded #neurorad #radtwitter #neurosurgery #radres

2/When I look at the skullbase veins, I see an angry Santa yelling at me. His eyebrows are raised, his mouth is open, & he has a mustache w/a big beard hanging down.

Each I look at the skullbase, I look for this Santa—bc each part of him is an important venous structure.

3/So let’s start w/Santa’s eyes. The eyes are actually not a venous structure, but an important landmark—foramen ovale, where the V3 trigeminal nerve exit.

I remember ovale is Santa's eyes bc eyes are OVAL, so his eyes are OVALE

Read 8 tweets

Lea Alhilali, MD

@teachplaygrub

1/To call it or not to call it? That is the question!

Do you feel a bit wacky & wobbly when it comes to calling normal pressure hydrocephalus on imaging?

Here’s a #tweetorial about imaging NPH!

#medtwitter #meded #neurotwitter #neurorad #radres #dementia #neurosurgery #FOAMed

2/First, you must understand the pathophysiology of “idiopathic” or iNPH. It was first described in 1965—but, of the original six in the 1965 cohort, 4 were found to have underlying causes for hydrocephalus.

This begs the question—when do you stop looking & call it idiopathic?

3/Thus, some don’t believe true idiopathic NPH exists. After all, it’s a syndrome defined essentially only by response to a treatment w/o ever a placebo-controlled trial.

However, most believe iNPH does exist--but its underlying etiology is controversial. Several theories exist

Read 19 tweets

Lea Alhilali, MD

@teachplaygrub

1/I always say you can tell a bad read on a spine MR if it doesn’t talk about the lateral recess

What will I think when I see your read? What do you say about lateral recesses?

Here’s a #tweetorial on lateral recess #anatomy & grading stenosis
#medtwitter #neurorad #spine

2/First anatomy.

Thecal sac is like a highway, carrying the nerve roots down the lumbar spine.

Lateral recess is part of the lateral lumbar canal, which is essentially the exit for spinal nerve roots to get off the thecal sac highway & head out into the rest of the body

3/Exits have 3 main parts.

First is the deceleration lane, where the car slows down as it starts the process of exiting.

Then there is the off ramp itself.

The off ramp leads into the service road, which takes the car to the roads that it needs to get to its destination

Read 21 tweets

Lea Alhilali, MD

@teachplaygrub

1/Does trying to remember inferior frontal gyrus anatomy leave you speechless?

Do you get a Broca’s aphasia trying to name the parts?

Here’s a #tweetorial to help you remember the #anatomy of this important region

#medtwitter #meded #neurotwitter #neurorad #radtwitter #radres

2/Anatomy of the inferior frontal gyrus (IFG) is best seen on the sagittal images, where it looks like the McDonald’s arches.

To find the IFG on MR, I open the sagittal images & scroll until I see the arches. When it comes to this method of finding the IFG, "i’m lovin it."

3/Inferior frontal gyrus also looks like a sideways 3 on sagittal images, if you prefer.

This 3 is helpful bc the inferior frontal gyrus has 3 parts—or "pars"

Read 13 tweets

Lea Alhilali, MD

@teachplaygrub

1/Having trouble remembering how to differentiate dementias on imaging?

Here’s a #tweetorial to show you how to remember the imaging findings in dementia & never forget!

#medtwitter #meded #neurorad #radres #dementia #alzheimers #neurotwitter #neurology #FOAMed #FOAMrad #PET

2/The most common functional imaging used in dementia is FDG PET. And the most common dementia is Alzheimer’s disease (AD).

On PET, AD demonstrates a typical Nike swoosh pattern—with decreased metabolism in the parietal & temporal regions

3/The swoosh rapidly tapers anteriorly—& so does hypometabolism in AD in the temporal lobe. It usually spares the anterior temporal poles.

So in AD look for a rapidly tapering Nike swoosh, w/hypometabolism in the parietal/temporal regions—sparing the anterior temporal pole

Read 16 tweets

Lea Alhilali, MD

@teachplaygrub

1/Your baby’s all grown up! Cerebellum may mean “little cerebrum” but its jobs are anything but little

Do you know cerebellar anatomy beyond vermis & hemispheres?

Here’s a #tweetorial about the functional #anatomy of the cerebellum!
#medtwitter #neurotwitter #neurorad #meded

2/Cerebellum means “little cerebrum” or “little brain” bc it looks like a mini brain--a mini me to the cerebrum one might say.

However, it does not play a mini role. In fact, despite being significantly smaller than the cerebrum, it contains as many neurons as the cerebrum

3/When most people think of cerebellar function, they think of balance. And the first thing that comes to mind with cerebellar dysfunction is imbalance & dizziness.

However, the cerebellum is involved in much more, including cognitive functions

Read 17 tweets

Lea Alhilali, MD

@teachplaygrub

1/Do you know all the aspects of, well, ASPECTS?

Many know the anterior circulation #stroke scoring system—but posterior circulation (pc) ASPECTS is often unknown

Here’s a #tweetorial to help you remember pc-ASPECTS
#medtwitter #neurotwitter #meded #neurorad #neurology #FOAMed

https://twitter.com/teachplaygrub/status/1587472264764657664

2/Many know anterior circulation ASPECTS. It uses a 10 point scoring system to semi-quantitate the amount of the MCA territory infarcted on non-contrast head CT.

If you need a review: here’s my tweetorial on ASPECTS:

https://twitter.com/teachplaygrub/status/1587472264764657664

3/But it’s only useful for the anterior circulation. Posterior circulation accounts for ~25% of infarcts. Even w/recanalization, many of these pts do poorly bc of the extent of already infarcted tissue. So there’s a need to quantitate the amount of infarcted tissue in these pts

Read 12 tweets

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