Daniel Gewolb, MD Profile picture
Mar 16, 2023 10 tweets 6 min read Read on X
Preoperative approach to sellar region masses, what the surgeon needs to know (at least what I think they need to know)

Additional reporting tips from surgeons are welcomed and encouraged! #Neurosurgery @TheASNR #radres #MedEd #MedTwitter #futureradres #endocrine #Neurology
1️⃣Where is the mass located?

Is it sellar based? suprasellar (S)? clival? Planum sphenoidale (PS)? Tuberculum sellae (arrow)?

▶️Location can change operative approach including but not limited to subfrontal vs transsphenoidal
2️⃣Where is the normal pituitary gland?

▶️this can be tough when the mass is large but the normal tissue often enhances more avidly than tumor so look for a strip of relatively avid enhancement along the periphery of the mass. Surgeons do not want to remove normal pit tissue
3️⃣Where is the tumor in relation to the stalk?

Transection of the pit stalk can lead to endocrine dysfunction
4️⃣Does the mass invade the cavernous sinus?

I have seen some variation for evaluating cavernous sinus invasion

I use encasement of greater than 2/3 of the cavernous carotid as invasion and if it crosses the midcarotid line I use that as more suggestive/indeterminate
5️⃣Is there hemorrhage/evidence of apoplexy?

High signal on T1 and fluid-fluid levels on T2 suggest hemorrhage which should be correlated for apoplexy. SWI is often not helpful due to surrounding bone/air susceptibility and lack of associated hemosiderin deposition
6️⃣Where is the optic chiasm? Is it compressed?

Avoiding injury to the optic chiasm and debulking tumor/decompressing the chiasm is of course, preferred
7️⃣Where is the intersinus septum of the sphenoid? Are there cavernous carotid variants? Where is the anterior clinoid in relation to the carotid? Is the carotid canal covered? Are there sphenoid sinus variants?

Sinus setum: yellow➡️
Carotid canal: green➡️
Onodi cell: red➡️
Learning points to report:
1️⃣Mass location
2️⃣Where is the normal pit tissue
3️⃣Stalk location
4️⃣Cavernous sinus invasion
5️⃣Any hemorrhage/apoplexy
6️⃣Optic chiasm compression
7️⃣Sphenoid sinus and carotid variant anatomy 🧠
Bonus: A patent sphenopalatine artery improves the odds of a healthy nasosetal flap used to cover the surgical defect and prevent postop CSF leak. 🧠

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More from @daniel_gewolb

Sep 7
⭐️ Tips for distinguishing treatment change from tumor progression from my own experience and the literature ☢️

**Sorry for the long and very complicated post!**

#Neurosurgery #Neurology #radres #futureradres @TheASNR @UMiamiHealth #MRI @Radiopaedia #ENT #Medicine @PennRadiologyImage
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🔷For glioblastoma we need to rely on many clinical and imaging features to distinguish (no one feature is specific enough to diagnose so we need to take the whole clinical and radiographic picture into account)
🔷Important features to consider:
▶️Recency of treatment
💡 Radiation necrosis is usually seen from 2 to 32 months after therapy, with 85% of cases occurring within 2 years. A new or worsening abnormality starting 3 years after completion of radiation therapy is very unlikely to be due to pure radiation necrosis. In the first 2–3 years, both tumor and radiation necrosis can occur

▶️Clinical symptoms (although both tumor progression and radiation necrosis can be symptomatic, we want to be careful calling tumor progression in a patient who is clinically doing well as this is devastating news for the patient and there are only limited options for therapy)
Read 13 tweets
Aug 1
⭐️What is the most likely diagnosis in this patient presenting with a lump on the head?

More images in 🧵

#MedEd #medicine #neurology #neurosurgery #ENT #radres #peds @Radiopaedia #futureradres @AlbanyMedRadRes Image
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⭐️ Answer: Intradiploic epidermoid cyst

▶️CT shows a circumscribed low density skull mass with smooth scalloped margin suggesting a benign lesion

▶️Density/signal intensity is near CSF with the exception of FLAIR which shows incomplete suppression (dirty signal not black like CSF)Image
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Read 6 tweets
Jul 19
🔷What is the most likely diagnosis and clinical syndrome in this patient with left ear pain, cranial nerve 6 palsy, and retro-orbital pain? 🧠 🤔

#Neurology #ent #neurosurgery #radres #NeuroTwitter #futureradres #MRI #Medicine @ASHNRSociety @RSNA #Ophthalmology Image
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⭐️ Answer: petrous apicitis complicated by brainstem abscess

🔷Petrous apicitis can display the clinical triad of Gradenigo’s syndrome

1️⃣Otorrhea
2️⃣Cranial nerve 6 palsy
3️⃣Pain in distribution of trigeminal nerve
▶️Petrous apicitis usually occurs as a complication of otomastoiditis when the infection spreads to the skull base.

▶️The petrous apex is in close proximity to Dorello’s canal (where cranial nerve 6 runs through) and Meckel’s cave (where the trigeminal ganglion is located)
Read 6 tweets
Jul 4
⭐️ What is the most likely diagnosis in this pregnant patient presenting with seizures? 🧠

#Neurology #medicine #radres #futureradres #Neurosurgery #MRI #FOAMed Image
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⭐️ Answer: Cortical vein thrombosis (CVT)

▶️CVT causes retrograde venous pressure leading to focal vasogenic edema

▶️Increased back pressure is characterized by dilated veins and petechial hemorrhage which can progress to large hematomas and ischemic neurological damage
🔷Two types of edema can develop:
1️⃣Vasogenic (from venous back pressure)
2️⃣Cytotoxic (ischemia)

🔷Risk factors:
💡 Up to 20% are idiopathic
1️⃣Trauma
2️⃣Tumor/malignancy (compression/invasion from meningioma)
3️⃣Infection
4️⃣Hormonal (pregnancy)
5️⃣Dehydration
Read 7 tweets
Jun 22
🔷What is the most likely diagnosis in this 70 y/o F who lives with feral cats presenting w/ vomiting, diarrhea, leukocytosis, fever for 3 days and progressive decline in level of consciousness?

🔷CSF: initially normal, repeat a few days later ⬆️ WBC (lymphocyte predominant), ⬆️ Protein, normal glucoseImage
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⭐️ Answer: Viral encephalitis (Specifically Rabies)

🔷 South Central Asia and Southeast Asia appear to have the greatest number of cases

🔷Dogs are the most common reservoir 🐶 (bats in developed countries🦇)
🔷CLINICAL:

▶️Incubation period typically 3 weeks to 2 months (range 5 days to 6 months)
▶️Prodromal symptoms: fever, malaise, anxiety,
and itching at the inoculation site

💡Once in the body, the virus begins retrograde flow to extend to the dorsal root ganglion, which may correlate with neuropathic pain

▶️CNS manifestations: Mental status changes of excessive agitation and depression with hydrophobia and aerophobia
Read 5 tweets
Jun 19
🔷35 y/o F w/ history of Li Fraumeni syndrome presents w/ intermittent left sided weakness and pain. The feeling is of heaviness, difficulty w/ grip, dropping objects and frequent falls. Episodes last for weeks to months. What is your diagnosis? 🧠

🎉Congrats to all the rad fellow matches today!!! 🍾

#Neurology #MRI #MedEd #medicine #neurosurgery #radres #futureradres #FOAMed @TheASNRImage
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⭐️ Answer: Tumefactive demyelination (MS in this case)

🔷Imaging in this case is specific enough to diagnosis with confidence but we need extra caution in patients with genetic predisposition to malignancy

💡 In cases where imaging or clinical picture are atypical or discordant for demyelination (especially if there is a genetic disorder), it is best to refer to neurology for proper work up, possible trial of steroids and short imaging follow up
🚩 Be suspicious against MS if your patient has:
1️⃣Systemic symptoms (fever, weight loss, joint or skin symptoms, etc.)
2️⃣Seizures, hearing loss, meningitis signs, movement disorder, aphasia
3️⃣”Family history”
4️⃣Age (<20 or >50)
5️⃣Lesions are symmetric
6️⃣Hemorrhage or dense on CT
7️⃣Diffusion restriction other than leading edge
8️⃣Strokes
9️⃣Cysts
🔟Cortical infiltration
Read 6 tweets

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