2/ With CSF leaks, everyone knows about brain sagging. But this can happen w/other pathologies, ie Chiari 1. Other findings can be seen on brain MRI in CSF leaks. But what are these findings? Are some findings more suggestive than others? Do more findings = ⬆️suspicion?
3/Dobrocky et al. looked at 9 quantitative & 7 qualitative signs seen on brain MRI in CSF leaks to see which are most important. Depending on type & # of findings, they developed a score to indicate what level of suspicion you should have for a leak. pubmed.ncbi.nlm.nih.gov/30776059/
4/Not surprisingly, they found the best sign for CSF leaks is classic pachymeningeal enhancement. While not always seen, it was seen in > 4 out of 5 leak patients, & almost never in others,unless they had recent LP. Therefore, this sign is worth 2 points on the scoring system
5/Classically, subdural collections are also associated, but these are seen less commonly than pachymeningeal enhancement (~about half of leaks), and other patients may have subdurals for other reasons (ie trauma) and therefore, this is only afforded one point.
6/A newer finding assoc w/leaks is rounding of the transverse sinus. Dural sinuses enlarge to compensate for loss of intracranial CSF in leak pts, & in doing so, their margins go from concave to convex. This was seen in 2/3rds of leak pts & never in others, so it is given 2 pts
7/Another overlooked finding in leak pts is⬇️in the suprasellar cistern around the chiasm. As the hindbrain sinks, eventually the chiasm sinks w/it & the cistern below it is attenuated. If the suprasellar cistern below the chiasm measures less than 4mm, this is worth 2 points.
8/Decrease in the pre-pontine cistern (<5mm) was not commonly seen, but was more than 4x more common in leak patients and was reproducible among readers of the scans, and so it was given 1 point.
9/Similarly, a decrease in the ponto-mammillary distance (<6.5mm between the mammillary bodies and top of the pons on the sagittal images) was also not commonly seen, but 3x more common in leak patients and therefore worth 1 point.
10/Other findings, such as the ponto-mesencephalic angle, attenuation of the quadrigeminal plate cistern, enlargement of the intercavernous sinus, and pituitary contour were not reproducible among readers of the scans and therefore not included in the score.
11/Here is the summary of the points awarded to each finding. The scoring system is classified as follows:
12/ So next time you are looking at a brain MRI for intracranial hypotension, you can feel confident in classifying your suspicion of a CSF leak. Say to them like they say in Billions--you are not uncertain 😉
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If you don’t know the time of stroke onset, are you able to deduce it from imaging?
Here’s a thread to help you date a stroke on MRI!
2/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.
3/Initially (less than 4-6 hrs), the only finding is restriction (brightness) on diffusion imaging (DWI).
You can remember this bc in the first few months, a baby does nothing but be swaddled or restricted. So early/newly born stroke is like a baby, only restricted
1/”I LOVE spinal cord syndromes!” is a phrase that has NEVER, EVER been said by anyone.
Do you become paralyzed when you see cord signal abnormality?
Never fear—here is a thread on all the incomplete spinal cord syndromes to get you moving again!
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
1/Do you get a Broca’s aphasia trying remember the location of Broca's area?
Does trying to remember inferior frontal gyrus anatomy leave you speechless?
Don't be at a loss for words when it comes to Broca's area
Here’s a 🧵to help you remember the anatomy of this key region!
2/Anatomy of the inferior frontal gyrus (IFG) is best seen on the sagittal images, where it looks like the McDonald’s arches.
So, to find this area 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, if you prefer. This 3 is helpful bc the inferior frontal gyrus has 3 parts—called pars
1/Need help reading spine imaging? I’ve got your back!
It’s as easy as ABC!
A thread about an easy mnemonic you can use on every single spine study you see to increase your speed & make sure you never miss a thing!
2/A is for alignment
Look for: (1) Unstable injuries
(2) Malalignment that causes early degenerative change. Abnormal motion causes spinal elements to abnormally move against each other, like grinding teeth wears down teeth—this wears down the spine
3/B is for bones.
On CT, the most important thing to look for w/bones is fractures. You may see focal bony lesions, but you may not
On MR, it is the opposite—you can see marrow lesions easily but you may or may not see edema associated w/fractures if the fracture is subtle