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?
⭐️ 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)
▶️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
🔷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 glucose
🔷 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
🔷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!!! 🍾
⭐️ 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