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Daniel Gewolb, MD Profile picture
@daniel_gewolb
May 25 • 7 tweets • 4 min read Twitter logo Read on Twitter
Child with a history of dental caries presents with a firm mass at the angle of the mandible. What is the most likely diagnosis? 🤔 🧠

#neurotwitter #ent #peds #Neurology #neurosurgery @ASHNRSociety @The_ASPNR #MedTwitter ImageImageImageImage
Answer: Sclerosing osteomyelitis of Garré

▶️Biopsy showed a reactive and reparative osseous process and bone culture grew oral flora (though cultures are usually negative)
▶️SOG is thought to be due to a low grade infection possibly 2/2 dental disease. However, there should be no signs of acute infection (suppuration, bony sequestration or draining tracts)
▶️SOG is considered a variant of chronic non-suppurative osteomyelitis and is more common in male children

▶️CRMO and SAPHO may be related to or the same diseases and are indistinguishable to my knowledge (would love input from those more experienced here)
Imaging:

▶️Unilateral (usually) mandibular involvement

▶️Dense CORTICAL thickening

▶️Onion skin PERIOSTEAL reaction (aka periostitis Ossificans)

▶️Narrowed medullary cavity
▶️Fibrous dysplasia is the main ddx which has the ground glass matrix but EXPANDS the medullary cavity and THINS the cortex with NO periosteal reaction. FD is also more common in the maxilla than the mandible
▶️Biopsy often necessary to exclude malignant processes such as osteosarcoma

Ddx for sclerotic dental lesions:

Odontoma
Cementoosseous dysplasia
Fibrous dysplasia
Sclerosing osteomyelitis of Garré
Sarcoma (ewings, osteo, chondro)
Mets
Cementoblastoma
Padgets
Lymphoma ImageImageImage

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More from @daniel_gewolb

Daniel Gewolb, MD Profile picture
May 27
Tips & tricks of DWI to help narrow the differential

Ddx:
Stroke
Abscess
Hypercellular tumor
Hematoma
Epidermoid cyst
Encephalitis
Seizure
Demyelination
Toxic/metabolic disorders
CJD
Other stuff I’m forgetting
#Neurology #neurosurgery #radres #MedTwitter #MedEd @TheASNR ImageImageImageImage
Anything that traps fluid can restrict diffusion! Here are some tricks I use to narrow the ddx

1️⃣STROKE
Cytotoxic edema due to trapped intracellular fluid leads to restriction

Look for wedge shaped restriction in a vascular territory Image
2️⃣ABSCESS
Trapped purulent material leads to LIGHT BULB BRIGHT restriction

DWI is excellent for differentiating tumor from pyogenic abscess as the abscess will have CENTRAL restriction

Abscess should also have vasogenic EDEMA, ENHANCEMENT, and possible dual rim sign (T2 & SWI) ImageImage
Read 14 tweets
Daniel Gewolb, MD Profile picture
May 23
Interesting case in this patient with acute right-sided weakness

#neurorad #neurotwitter #meded #Neurosurgery #Neurology @TheASNR @RSNA #medtwitter ImageImageImageImage
Can you determine the diagnosis off the CT?
▶️Initial non-con CT shows a 3cm hyperdense lobulated extra-axial mass in the expected region of the left MCA bifurcation, consistent with a giant aneurysm. There are associated peripheral calcifications

▶️ What is the cause of the surrounding hypodensity?
Read 10 tweets
Daniel Gewolb, MD Profile picture
May 22
Case of emphysematous epiglottitis in an adult

Epiglottitis is an emergency as it can potentially cause airway compromise especially in children who have smaller airways #neurotwitter #ent #peds #Neurosurgery #MedTwitter #MedEd @ASHNRSociety ImageImage
▶️In children the diagnosis can be confirmed with upright plain film. CT requires placing the patient supine which may exacerbate inspiratory strider

▶️In adults, the diagnosis may not be suspected clinically so patients may end up with a CT scan as in this case
▶️Bacterial infection typically 2/2 H. Influenza in unvaccinated children

▶️In adults, possible pathogens include Strep, Staph, and H. influ
Read 4 tweets
Daniel Gewolb, MD Profile picture
May 21
Case of diffuse CSF seeding of tumor in this patient w/ WHO grade 4 diffuse hemispheric glioma

#NeuroTwitter #neurosurgery #Neurology #peds #futureradres @The_ASPNR #MedEd ImageImageImageImage
▶️Prospectively this mass was thought to be an embryonal tumor w/ multilayered rosettes given the marked diffusion restriction, hemorrhage, and lack of surrounding edema 🧠
Imaging:

▶️T2 shows a heterogenous slightly hyperintense mass w/ areas of hypointensity

▶️No surrounding edema/infiltrating tumor is seen on T2/FLAIR

▶️Fluid-fluid level is seen suggestive of hemorrhage (arrow) Image
Read 6 tweets
Daniel Gewolb, MD Profile picture
May 21
Learning case in this 40 y/o F with history of whole brain radiation as a child for brain tumor treatment
#NeuroRad #neurosurgery #Neurology @TheASNR #NeuroTwitter #meded #radres ImageImageImageImage
Brain radiation is a risk factor for the development of meningiomas …this patient subsequently developed multiple meningiomas including this large frontal meningioma Image
The mass was treated and immediate post op CT shows expected post op change with the resection cavity, some hemorrhage, and pneumocephalus Image
Read 9 tweets
Daniel Gewolb, MD Profile picture
May 19
Interesting case of complicated acute bacterial rhinosinusitis in this child with no PMH presenting w/ HA, fever & L sided weakness

#NeuroTwitter #ent #radres #neurosurgery @TheASNR @ASHNRSociety @PhilipRChapman1 #radres #futureradres ImageImageImageImage
CT shows opacification of the frontal and anterior ethmoid sinuses without evidence of cortical dehiscence

💡 In peds, infection can spread through vascular channels w/o destroying the bone ImageImage
MR shows abnormal signal filling the sinuses with associated restricted diffusion 2/2 purulent material

Post contrast we see areas of relative hypoenhancement in comparison to the normal mucosa on the contralateral side ImageImageImage
Read 9 tweets

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