@AlbanyMedRadRes

@AlbanyMedRadRes

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/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/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/To be or not 2b?? That is the question!

Do you have questions about how to remember cervical lymph node anatomy & levels?

Here’s a #tweetorial to show you how--#Superbowl weekend edition!
#medtwitter #meded #neurorad #HNrad #FOAMed #FOAMrad #radres #radtwitter #ENT #radiology

2/Google cervical lymph node anatomy & you always get this anatomic picture w/the head flung back like a model posing.

But unless you live in LA, your patients don’t look like this & understanding anatomy from this image is difficult

3/First, you need to know how lymph node drainage works in the neck.

Nodes drain like rivers—smaller streams drain into larger rivers.

In the neck, there are outer circle nodes (peripheral) & inner circle nodes—both drain into the large river of the deep cervical nodes

Read 17 tweets

Lea Alhilali, MD

@teachplaygrub

1/If all you know is: To Zanzibar By Motor Car—then you don’t even know half of facial nerve anatomy—literally!

Here’s a #tweetorial on the facial nerve anatomy you don’t know!

#medtwitter #neurotwitter #neurorad #radres #meded #FOAMed #neurosurgery #neurology #radtwitter

2/On coronal MRI sequences, the brainstem in the region of the facial nerve looks like a bodybuilder.

But it looks like one of those body builders who concentrates only on upper body workouts, so they are huge up top (the pons) & but have chicken legs (the medulla)

3/Facial nerve comes out in this region from between the pons & medulla.

It looks like a weightlifting belt, coming out from the waist between the giant pons upper body & the medulla chicken legs

Read 15 tweets

Lea Alhilali, MD

@teachplaygrub

1/Time to FESS up! Do you understand functional endoscopic sinus surgery (FESS)?

If you read sinus CTs, you must know what they’re doing to make the helpful findings

Here’s a #tweetorial to help you!
#medtwitter #meded #FOAMed #FOAMrad #radres #neurorad #HNrad #radtwitter

2/The first step is to insert the endoscope into the nasal cavity.

The first two structures encountered are the nasal septum and the inferior turbinate.

3/So on every sinus CT you read, the first question is whether there is enough room to insert the scope. Will it go in smoothly or will it be a tight fit?

Read 19 tweets

Ladiologist Consult 🩻

@ladiologist

31yo F, brother sudden cardiac death at 34yo, father sudden cardiac death at 45yo

Should she be worried??

#radtwitter #medtwitter #cardiotwitter #whyCMR

Patient also had basal septal hypertrophy up to 21mm (left), associated with delayed enhancement (right)

Dad was thought to have died from MI. Brother had suspicion of ARVD on echo, died before CMR, no autopsy. Her CMR was requested to rule out ARVD.

Read 4 tweets

Ladiologist Consult 🩻

@ladiologist

21 month old male, cough, prolonged fever, normal chest X-ray, abnormal echo

#radtwitter #medtwitter #pedsrad #cardiotwitter

coronary artery aneurysms secondary to Kawasaki disease

Kawasaki disease: preschool age, fever, conjunctivitis, rash peeling on fingers/toes, red tongue

Read 3 tweets

Lea Alhilali, MD

@teachplaygrub

1/Is your ability to remember temporal lobe anatomy seem, well, temporary?

Here’s a #tweetorial to help you remember the structures of the temporal lobe!

#medtwitter #meded #neurotwitter #radtwitter #radres #neurorad #FOAMed #neurosurgery #medstudenttwitter #neurology

2/Temporal lobe can be divided centrally & peripherally. Centrally is the hippocampus. It’s a very old part of the brain & is relatively well preserved going all the way back to rats. Its main function is memory—getting both rats & us through mazes—including the maze of life

3/Peripherally is the neocortex. Although rats also have neocortex, theirs is much different structurally than humans.

So I like to think of neocortex as providing the newer (neo) functions of the temporal lobes seen in humans: speech, language, visual processing/social cues

Read 12 tweets

Lea Alhilali, MD

@teachplaygrub

1/Nothing strikes fear into the heart of a radiologist like the question,“Is it safe to do an MRI on this pt w/an implanted device?”

Never fear again! Here’s a #tweetorial on how to navigate implanted devices & #MRI
#medtwitter #meded #radtwitter #radres #neurotwitter #neurorad

2/MRI & CT are like nuclear & coal power, respectively. Everyone knows CT is worse for you & usually MRI is very safe & better for your body

But like nuclear power, when things go bad in MRI, they can go horribly wrong. Flying chairs into the magnet wrong. So, people are afraid

3/The trouble is from the magnetic attractive forces. There are 3 ways these attractions can wreak havoc. First is translation. Magnet literally pulls an object, like a chair, towards itself. This is the strongest attraction—like two lovers who literally can’t stay apart.

Read 22 tweets

Daniel Gewolb, MD

@daniel_gewolb

62 y/o M presents with signs of raised intracranial pressure. CT shows a hyper dense mass crossing the corpus callosum. On MR, the mass is hypointense on T2WI, restricting diffusion, and homogenously enhancing along the periventricular surface.
#radtwitter #radres #neurotwitter

The corpus callosum is composed of very dense white matter tracks. Only aggressive tumors or lesions that effect the white matter cross the midline through the CC.

Diff Diagnosis for CC masses

High grade astrocytoma/Glioblastoma
Primary CNS lymphoma
Tumefactive Demyelination

Dx: Primary CNS lymphoma

PCNSL has a highly variable imaging appearance. Classically, it presents as a hyperdense mass with restricted diffusion and relatively hypointensity on T2WI due to hypercellularity. The mass enhances homogeneously and may cross the CC. #Neurosurgery

Read 4 tweets

Daniel Gewolb, MD

@daniel_gewolb

45F presents with painless progressive left eye vision loss. MR shows homogenous enhancement encasing the left optic nerve with an associated lesion at the entrance of the optic canal (yellow arrow)
#radres #futureradres #NeuroRad #MedTwitter @AlbanyMedRadRes

Differential Diagnosis:

Optic Neuritis
Optic nerve sheath meningioma
Optic nerve glioma
Orbital sarcoidosis
Orbital lymphoma
Orbital pseudotumor

#Ophthalmology #radtwitter

Diagnosis: Optic nerve sheath meningioma

Remember the optic nerve is an extension of the CNS and therefore, is surrounded by meninges and arachnoid cap cells from which meningiomas arise. Look for the “tram-track” sign of enhancement surrounding the optic nerve
#Ophthalmology

Read 4 tweets

Daniel Gewolb, MD

@daniel_gewolb

@TheASNR

23 yr old with headache. MR shows a “bubbly” mass in the right lateral ventricle near the foramen of Monro. The mass abuts the septum pellucidum and displays mild contrast enhancement.

#neurotwitter #radtwitter #RadEd #MedTwitter #radres @TheASNR @ESNRad @ASHNRSociety

Differential diagnosis:
Subependymoma
Choroid plexus neoplasm
Central neurocytoma
Intraventricular meningioma
Mets

Answer: confirmed central neurocytoma

Classically, look for the “bubbly” mass abutting/attached to the septum pellucidum near the foramen of monro with enhancement.

#futureradres

Read 3 tweets

Daniel Gewolb, MD

@daniel_gewolb

@TheASNR

Child presents with weakness. MR shows enhancement of the pial surface of the conus and ventral cauda equina nerve roots.

#radtwitter #MedTwitter #radres #futureradres #Pediatrics #Neurology @TheASNR @The_ASPNR @AlbanyMedRadRes

Differential diagnosis:

Leptomeningeal carcinomatosis
Lymphoma
Arachnoiditis (all causes)
Guillain-barre
Neurosarcoidosis

Diagnosis: Guillain-Barré syndrome

These are the typical imaging features for GBS. Contrast is absolutely necessary.

There was no history to suggest systemic sarcoidosis, malignancy, or recent procedure (risk factor for spinal meningitis/arachnoiditis)

Read 3 tweets

Daniel Gewolb, MD

@daniel_gewolb

@ACRRFS

Patient presents with altered mental status. Unenhanced CT shows discrete hypodense foci in the bilateral paramedian thalami
#radres #futureradres #radtwitter @ACRRFS @RSNA

Differential diagnosis includes:
Top of the basilar artery syndrome
Artery of Percheron infarct
Bilateral internal cerebral vein thrombosis

Answer: Artery of Percheron infarct

The artery of Percheron is a rare anatomic variant where a single artery supplies both medial thalami, typically arising from the P1 segment of the PCA.

Read 4 tweets

Dra. Cecilia Ferrario

@draceciferrario

80 yo ♀️ with chronic cough.
What would you do with this "ugly" lung lesion? 🧵👇🏻

#radres #radtwitter #radiology #chestrad

❓❓❓

If you asked for a mediastinal window 👏👏👏
*️⃣Lipoid pneumonia*️⃣
Lung disease caused by fat accumulation that produces chonic inflammation
Two types:Endogenous and exogenous
Exogenous lipoid pneumonia is caused by aspiration of fatty or oil substances (laxatives in this case)

Read 3 tweets

Lea Alhilali, MD

@teachplaygrub

1/My hardest #tweetorial yet! Are you up for the challenge?

How stroke perfusion imaging works!

Ever wonder why it’s Tmax & not Tmin? Do you not question & let RAPID read the perfusion for you? Not anymore!
#stroke #neurotwitter #neurorad #meded #FOAMed #radtwitter #medtwitter

2/Perfusion imaging is based on one principle: When you inject CT or MR intravenous contrast, the contrast flows w/blood & so contrast can be a surrogate marker for blood. This is key, b/c we can track contrast—it changes CT density or MR signal so we can see where it goes

3/So if we can track how contrast gets to the tissue (by changes in CT density or MR signal), then we can approximate how BLOOD is getting to the tissue. And how much blood is getting to the tissue is what perfusion imaging is all about.

Read 18 tweets

Daniel Gewolb, MD

@daniel_gewolb

55 yr old with stuffy nose. CT demonstrates a destructive mass centered in the olfactory recess with extension through the cribriform plate. MR shows avid enhancement of the invasive mass.
#radres #NeuroRad #radtwitter #MedTwitter

Differential:
Sinonasal carcinoma (SCC, SNUC, adenocarcinoma)
Esthesioneuroblastoma
Lymphoma
Mets

Answer: confirmed Esthesioneuroblastoma

Esthesioneuroblastoma presents as a destructive mass with intracranial extension and waist centered at the cribriform plate. Peritumoral cysts at the tumor-brain interface are classic though were not seen in this case.

Read 3 tweets

Lea Alhilali, MD

@teachplaygrub

1/”I LOVE spinal cord syndromes!” is a phrase that has NEVER, EVER been said by anyone.
Never fear—here is a #tweetorial on all the incomplete #spinalcord syndromes!
#medtwitter #neurotwitter #neurology #neurosurgery #neurorad #radres #meded #FOAMed #FOAMrad #radtwitter #spine

2/Spinal cord anatomy can be complex. On imaging, we can see the ant & post nerve roots. We can also see the gray & white matter. Hidden w/in the white matter, however, are numerous efferent & afferent tracts—enough to make your head spin.

3/Lucky for you, for the incomplete cord syndromes, all you need to know is gray matter & 3 main tracts. Anterolaterally, spinothalamic tract (pain & temp). Posteriorly, dorsal columns (vibration, proprioception, & light touch), & next to it, corticospinal tracts—providing motor

Read 20 tweets

Lea Alhilali, MD

@teachplaygrub

1/Asking “How old are you” can be dicey—both in real life & on MRI! Do you know how to tell the age of blood on MRI?

Here’s a #tweetorial on how to date blood on MRI
#medtwitter #neurorad #radtwitter #RSNA2022 #RSNA22 #radres #neurosurgery #neurology #meded #neurotwitter #FOAMed

2/If you ask someone how to date blood on MRI, they’ll spit out a crazy mnemonic about babies that tells you what signal blood should be on T1 & T2 imaging by age

But mnemonics are crutch—they help you memorize, but not understand. If you understand, you don’t need to memorize

3/If you look at the mnemonic, you will notice one thing—the T1 signal is all you need to tell if blood is acute, subacute or chronic

T2 signal will tell if it is early or late in each of those time periods—but that type of detail isn’t needed in real life. So let’s look at T1

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