Lea Alhilali, MD Profile picture
Mar 15, 2023 8 tweets 5 min read Read on X
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 Image
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. Image
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 Image
4/Next are Santa’s angry raised eyebrows. These are the sphenoparietal sinuses.

I remember these are the eyebrows bc I call them “seen”-oparietal sinuses & you see w/your eyes.

These have this “eyebrow” shape bc they are following the curve of the greater sphenoid wing Image
5/Sphenoparietal sinuses meet in the middle at the cavernous sinus—like your eyebrows meet in the middle at your nose.

I remember the cavernous sinus & intracavernous sinuses are Santa’s nose bc you dig in a cavern. And where do all kids like to go digging? Their nose! 🤢 Image
6/Right below Santa’s nose is his mustache & this is the basilar plexus, right below the cavernous sinus.

You can remember this bc mustaches are made of a base & handlebars—and the BASE of Santa’s mustache is the BASilar plexus Image
7/Extending from Santa’s mustache is his beard. These are the petrosal sinuses (inferior & superior), important in many neurosurgical approaches.

You can remember that the PETROsal sinuses make up sides of the beard bc you use PETROleum to smooth the sides of your beard Image
8/Finally, Santa’s mouth is the marginal sinus. I remember this bc the word marginal sounds like “Aaaargh”—the sound pirates make from their mouth. I call it the Maaaargh—inal sinus

So hopefully this thread has given you some ELF-confidence when it comes to skullbase anatomy! Image

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More from @teachplaygrub

Mar 21
1/Don't fall for the siren song of calling all bright round objects at foramen of Monro colloid cysts.

Like a true siren song, this may be a TRAP!

If you hear the call of colloid—read this first!

Here's a thread about lesions here that can trap you--& how you can avoid them! Image
2/Here are 3 lesions, all round and bright and in the region of the foramen of Monro.

Can you tell from the images which is a colloid cyst and which may be something else?

Choose which one or ones you think are a colloid cyst! Image
3/In this case it was A!

B was a tortuous basilar

C was a cavernoma of the chiasm/hypothalamus that had bled and projected into the third ventricle. Image
Read 12 tweets
Mar 16
1/Remembering spinal fracture classifications is back breaking work!

A thread to review the scoring system for thoracic & lumbar fractures—“TLICS” to the cool kids! Image
2/TLICS scores a fx on (1) morphology & (2) posterior ligamentous complex injury

Let's start w/morphology

TLICS scores severity like the steps to make & eat a pizza:

Mild compression (kneading), strong compression (rolling), rotation (tossing), & distraction (tearing in) Image
3/At the most mild, w/only mild axial loading, you get the simplest fx, a compression fx—like a simple long bone fx--worth 1 pt.

This is like when you just start to kneading the dough. There's pressure, but not as much as with a rolling pin! Image
Read 13 tweets
Mar 14
1/The 90s called & wants its carotid imaging back!

It’s been 30 years--why are you still just quoting NASCET?

Do you feel vulnerable when it comes to identifying plaque vulnerability?

Here’s a thread to help you identify high risk plaques with carotid plaque imaging Image
2/Everyone knows the NASCET criteria:

If the patient is symptomatic & the greatest stenosis from the plaque is >70% of the diameter of normal distal lumen, patient will likely benefit from carotid endarterectomy.

But that doesn’t mean the remaining patients are just fine! Image
3/Yes, carotid plaques resulting in high grade stenosis are high risk.

But assuming that stenosis is the only mechanism by which a carotid plaque is high risk is like assuming that the only way to kill someone is by strangulation. Image
Read 25 tweets
Mar 12
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 left behind

25% of infarcts are posterior circulation

Do you know pc-ASPECTS?!

Here’s how to remember pc-ASPECTS! Image
2/Many know anterior circulation ASPECTS.

It uses a 10-point scoring system to semi-quantitation the amount of the MCA territory infarcted on non-contrast head CT

If you need a review: here’s my thread on ASPECTS: Image
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 ptsImage
Read 12 tweets
Mar 10
1/I always say you can tell a bad read on a spine MR if it doesn’t talk about lateral recesses.

What will I think when I see your read? Do you rate lateral recess stenosis?

Here’s a thread on lateral recess anatomy & a grading system for lateral recess stenosis Image
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 Image
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, and this leads into the service road which takes the car to the roads that it needs to get to its destination Image
Read 21 tweets
Mar 3
1/Does PTERYGOPALATINE FOSSA anatomy feel as confusing as its spelling?

Does it seem to have as many openings as letters in its name?

Are you pterrified of the pterygopalatine fossa (PPF)?

Let this thread on PPF anatomy help you out. Image
2/The PPF is a crossroads between the skullbase & the extracranial head and neck

There are 4 main regions that meet here:

(1) Skullbase itself posteriorly, (2) nasal cavity medially, (3) infratemporal fossa laterally, and (4) orbit anteriorly. Image
3/At its most basic, you can think of the PPF as a room with 4 doors opening to each of these regions: one posteriorly to the skullbase, one medially to the nasal cavity, one laterally to the infratemporal fossa, and one anteriorly to the orbit Image
Read 18 tweets

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