@The_ASPNR

@The_ASPNR

Lea Alhilali, MD

@teachplaygrub

1/Understanding cervical radiculopathy is a pain in the neck! But knowing the distributions can help your search
A #tweetorial to help you remember cervical radicular pain distributions

#medtwitter #radres #FOAMed #FOAMrad #neurorad #Meded #meded #spine #Neurosurgery

2/First, a rule of thumb—or rather a rule of elbow! You have 10 fingers. If you divide that in half, you get 5.

If you divide your arm in half, that's at the elbow, you'll also get 5--C5 that is! C5 radiates to the elbow. So if it radiates below this, it's > C5 & above is < C5

3/So let’s start with C2. C2 predominantly radiates along the dorsal aspect of the scalp, as it supplies the greater occipital nerve. I remember this bc the number 2 has a swan like neck that mimics the contour of the back of the head and its distribution

Read 9 tweets

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

Daniel Gewolb, MD

@daniel_gewolb

@TheASNR

Tips & tricks of DWI to help narrow the differential

Ddx:
Stroke
Abscess
Hypercellular tumor
Hematoma
Epidermoid cyst
Encephalitis
Seizure
Demyelination
Toxic/metabolic disorders
CJD
Other stuff I’m forgetting
#Neurology #neurosurgery #radres #MedTwitter #MedEd @TheASNR

Anything that traps fluid can restrict diffusion! Here are some tricks I use to narrow the ddx

1️⃣STROKE
Cytotoxic edema due to trapped intracellular fluid leads to restriction

Look for wedge shaped restriction in a vascular territory

2️⃣ABSCESS
Trapped purulent material leads to LIGHT BULB BRIGHT restriction

DWI is excellent for differentiating tumor from pyogenic abscess as the abscess will have CENTRAL restriction

Abscess should also have vasogenic EDEMA, ENHANCEMENT, and possible dual rim sign (T2 & SWI)

Read 14 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

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

Daniel Gewolb, MD

@daniel_gewolb

@TheASNR

Interesting case of complicated acute bacterial rhinosinusitis in this child with no PMH presenting w/ HA, fever & L sided weakness

#NeuroTwitter #ent #radres #neurosurgery @TheASNR @ASHNRSociety @PhilipRChapman1 #radres #futureradres

CT shows opacification of the frontal and anterior ethmoid sinuses without evidence of cortical dehiscence

💡 In peds, infection can spread through vascular channels w/o destroying the bone

MR shows abnormal signal filling the sinuses with associated restricted diffusion 2/2 purulent material

Post contrast we see areas of relative hypoenhancement in comparison to the normal mucosa on the contralateral side

Read 9 tweets

Lea Alhilali, MD

@teachplaygrub

1/Do you want a BASIC approach to skullBASE lesions?

My FINAL tweetorial on skullbase lesions—posterior skullbase & overall approach!

This #tweetorial will teach you to diagnose skullbase lesions by answering only TWO simple questions!

#medtwitter #meded #neurosurgery #radres

2/Remember, you can think of pathology at the skullbase like bad things that can happen while running. Bad things can get you from below—like falling into a pothole. They can come from within—like a sudden heart attack, or bad things can strike from above, like a lightning bolt

3/Same thing w/the skullbase—bad things can come from below, within, or above. Lesions from below are potholes tripping you up. Lesions from w/in the skullbase are like heart attacks strikning from inside. Lesions from above are the lightning, hitting the skullbase from above

Read 14 tweets

SIR RFS

@SIRRFS

@ElekAlperen

Check out this starter kit on Adrenal Vein Sampling created by MSC Reserves, Alperen Elek (@ElekAlperen), Lulu Zhang, MD, and Tina Chatterje ( @tinachatterje3)! #iRad #meded #radiology #interventionalradiology #radres #iradres

PA symptoms can range from fatigue to joint pain. Keep an eye out for these signs and consider PA as a potential cause.

Discover the fascinating anatomy of the adrenal glands - small but powerful glands located above the kidneys that play a crucial role in regulating hormones and the body's response to stress.

Read 8 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

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

Nirmal Pandey MD DM Neurologist

@nirmalregency

Learning through mistakes.
(1/11) 38F. 90kg. No PMH. Fever x 3-4D ☞ body pains.
D6: frequent seizures. Multiple ASMs.
D7: CT head + CSF WNL.
D11: MR brain WNL (not shown).
D13: Repeat CSF WNL.
D16: Repeat MR Brain👇 faint b/l medial temporal hyperintensities.
Acyclovir ✅

(2/11) D19: shifted here.
Seizures ++, mostly over face w/ partial preserved consciousness.
Intubated. 4 ASMs ☞ Ketamine bolus ☞ infusion.
D19: IVIG + IV MPS also started.
Repeat CSF: routine normal. CSF BioFire -ve, including HSV. Acyclovir stopped.

(3/11) CSF autoimmune encephalitis panel -ve👇Serum paraneoplastic antibody panel -ve 👇

Read 16 tweets

Ana Villanueva

@AnaVillanuevaCa

80 yo M. Known cardiovascular disease and anemia. Acute abdominal pain and vomit.

Diagnosis? Only ONE answer is correct 😉

#radres #futureradres #FOAMrad #FOAMed #GITwitter #Endoscopy #GIpath

1. Ischemic colitis
2. IBD
3. Tumor
4. None of the above

Correct answer: None of the above. Why?

This is a case of ischemic colitis AND colon cancer⬇️

Were you able to pick up both? Can you see the difference?

Learning points
🌟Satisfaction of search bias (CAREFUL!)

🌟There is a known ASSOCIATION between is ischemic colitis and tumor. Different patterns can be seen.

Old but useful paper to check out if you would like to learn more 🤓

Read 3 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

Daniel Gewolb, MD

@daniel_gewolb

@TheASNR

Case of a radiation induced pseudoaneurysm in this patient with headache and AMS 🧠

Imaging in thread #Neurosurgery #Neurology #neurotwitter #radres #MedEd #MedTwitter @TheASNR

▶️Initial head CT shows subarachnoid hemorrhage centered in the right cerebellopontine angle cistern

▶️CTA confirms an aneurysm of the right anterior inferior cerebellar artery (AICA)

▶️MR displays and ice cream shaped enhancing mass extending through the right internal auditory canal into the cerebellopontine angle cistern, consistent with a vestibular schwannoma #icecream

▶️Careful search into the history confirms the schwannoma was treated with radiation

Read 4 tweets

Daniel Gewolb, MD

@daniel_gewolb

@RSNA

What is the most likely diagnosis in this 25 y/o M with headache? 🧠

Answer later tonight #radres #Neurology #Neurosurgery #MedEd #MedTwitter #NeuroTwitter @RSNA

Most likely diagnosis?

Answer: confirmed germinoma, all these masses are on the differential for a pineal region mass …perhaps the most helpful clue is the age and gender rather than the imaging 🧠

Read 7 tweets

Daniel Gewolb, MD

@daniel_gewolb

@TheASNR

Glioblastoma is the most common variety of astrocytoma

The presence of necrosis is the characteristic feature of glioblastoma

Imaging details in thread #Neurosurgery #neurotwitter #radres #MedTwitter #Neurology @TheASNR

Some correlates for high grade astrocytoma include necrosis, marked mass effect, restricted diffusion (often patchy, eccentric or nodular in glioblastoma), elevated CBV, enhancement, and older age

The presence of ependymal spread is another poor prognostic sign (shown below)

Important learning point: when dealing with glioblastoma, the neoplasm extent is not defined by the area of enhancement but rather by the entire area of T2/FLAIR abnormality. Microscopic infiltrating tumor clearly extends beyond the areas of enhancement. 🧠

Read 5 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.

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