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Daniel Gewolb, MD

@daniel_gewolb

Mar 27 • 4 tweets • 5 min read • Twitter logo

@TheASNR

Case of a radiation induced pseudoaneurysm in this patient with headache and AMS 🧠

Imaging in thread #Neurosurgery #Neurology #neurotwitter #radres #MedEd #MedTwitter @TheASNR

▶️Initial head CT shows subarachnoid hemorrhage centered in the right cerebellopontine angle cistern

▶️CTA confirms an aneurysm of the right anterior inferior cerebellar artery (AICA)

▶️MR displays and ice cream shaped enhancing mass extending through the right internal auditory canal into the cerebellopontine angle cistern, consistent with a vestibular schwannoma #icecream

▶️Careful search into the history confirms the schwannoma was treated with radiation

Learning points:

💡 The Anterior inferior cerebellar artery (AICA) normally crosses the 8th cranial nerve at the CP angle cistern

💡When masses are treated with radiation, they can occasionally induced pseudoaneurysms of nearby vessels which are high risk for rupture

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More from @daniel_gewolb

Daniel Gewolb, MD

@daniel_gewolb

Mar 27

@The_ASPNR

What is the most likely diagnosis in this adolescent with seizure? 🧠

(Sorry I have no CT without)

#neurotwitter #peds #Neurosurgery #Neurology @The_ASPNR @TheASNR #MedTwitter

What is the most likely diagnosis?

Answer: Confirmed supratentorial ependymoma

Predicting tumors is incredibly challenging in the absence of specific features …some learning points on the case in 🧵

Read 8 tweets

Daniel Gewolb, MD

@daniel_gewolb

Mar 21

@RSNA

What is the most likely diagnosis in this 25 y/o M with headache? 🧠

Answer later tonight #radres #Neurology #Neurosurgery #MedEd #MedTwitter #NeuroTwitter @RSNA

Most likely diagnosis?

Answer: confirmed germinoma, all these masses are on the differential for a pineal region mass …perhaps the most helpful clue is the age and gender rather than the imaging 🧠

Read 7 tweets

Daniel Gewolb, MD

@daniel_gewolb

Mar 20

@TheASNR

Glioblastoma is the most common variety of astrocytoma

The presence of necrosis is the characteristic feature of glioblastoma

Imaging details in thread #Neurosurgery #neurotwitter #radres #MedTwitter #Neurology @TheASNR

Some correlates for high grade astrocytoma include necrosis, marked mass effect, restricted diffusion (often patchy, eccentric or nodular in glioblastoma), elevated CBV, enhancement, and older age

The presence of ependymal spread is another poor prognostic sign (shown below)

Important learning point: when dealing with glioblastoma, the neoplasm extent is not defined by the area of enhancement but rather by the entire area of T2/FLAIR abnormality. Microscopic infiltrating tumor clearly extends beyond the areas of enhancement. 🧠

Read 5 tweets

Daniel Gewolb, MD

@daniel_gewolb

Mar 16

@TheASNR

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

Read 10 tweets

Daniel Gewolb, MD

@daniel_gewolb

Mar 14

@TheASNR

Can you figure out the cause of hemorrhage in this case?

Imaging and case details in thread #Neurosurgery #radres #MedTwitter #Neurology @TheASNR #MedEd #neurotwitter

Initial MRI shows an expansile enhancing mass in the right parasagittal frontal lobe

The patient underwent craniotomy for tumor debulking. Post operative MRI and CT demonstrate hemorrhage in the right cerebellar hemisphere, far from the operative site. What’s the cause of the hemorrhage? 🤔 🧠

Read 5 tweets

Daniel Gewolb, MD

@daniel_gewolb

Mar 6

@TheASNR

What’s the most likely diagnosis in this 30 yr old presenting following an episode of shaking

More images in thread. Answer in a few hours 🧠 #radres #Neurosurgery #neurology #MedTwitter #neurotwitter @TheASNR

Read 6 tweets

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