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Daniel Gewolb, MD

@daniel_gewolb

Jun 8, 2023 • 9 tweets • 6 min read • Read on X

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@The_ASSR

What is the most likely diagnosis in this 30 y/o w/ history of discitis/osteomyelitis presenting w/ fevers, chills, and neck pain? 🧠
#ent #Neurosurgery #Neurology #medtwitter #MedEd @The_ASSR #NeuroTwitter

Answer: Longus Colli Calcific Tendinitis

▶️Etiology: inflammatory reaction in response to deposition of calcium hydroxyapatite crystals (just like in the rotator cuff)

▶️This case is a bit tricky as the history is somewhat misleading (though it often is in radiology)

Imaging:

▶️Sagittal STIR shows marked retropharyngeal/prevertebral edema (yellow arrow) and focal hypointensity from the hydroxyapatite crystals (green arrow)

▶️Axial T2 again shows the marked edema

▶️T2* is key in this case showing the markedly hypointense amorphous calcs at the longus colli tendons

▶️Pre and post con T1 shows the edema w/ reactive enhancement (yellow arrows) and the focal hypointense calcs (green arrows)

General imaging features:
▶️Amorphous calcifications at C1-C2 junction near the insertion of the longus colli muscles is pathognomonic

▶️ Be careful not to mix up calcification at the C1-C2 junction w/ the more common COARSE calcs in DJD!

Imaging cont:

▶️Calcs on MR can be trickier, look for MARKED FOCAL HYPOINTENSITY on T2*/GRE at the C1-C2 JUNCTION

▶️Expect prevertebral and/or retropharyngeal edema

▶️Reactive soft tissue enhancement on T1C+

DDX:
Must differentiate from infection (as calcific tendinitis is treated with time and NSAIDs)

▶️For infection, expect a more spherical or convex retropharyngeal collection, more enhancement, and presence of head and neck infection

▶️Calcifications at the C1-C2 junction are pathognomonic for calcific longus colli tendonitis 🧠

Companion cases:
▶️Radiograph showing prevertebral swelling and amorphous calcs on C1-C2 junction
▶️Appearance on CT in a different patient showing the amorphous calcs and edema

Companion case 3 (DJD fake out!!):

▶️CT shows COARSE calcifications at C1-C2 junction with mild pharyngeal edema (from prior radiation in this case)

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Daniel Gewolb, MD

@daniel_gewolb

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

⭐️ 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

Daniel Gewolb, MD

@daniel_gewolb

Jul 4

⭐️ What is the most likely diagnosis in this pregnant patient presenting with seizures? 🧠

#Neurology #medicine #radres #futureradres #Neurosurgery #MRI #FOAMed

⭐️ 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

Daniel Gewolb, MD

@daniel_gewolb

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 glucose

⭐️ 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

Daniel Gewolb, MD

@daniel_gewolb

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 @TheASNR

⭐️ 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

Daniel Gewolb, MD

@daniel_gewolb

Apr 26

⭐️ What is the most likely diagnosis in this 45 y/o M found down with history of polysubstance abuse?

#Neurology #Medicine #radres #Neurosurgery #futureradres #radres #FOAMed #MRI @AlbanyMedRadRes @TheASNR

⭐️ Answer: Opioid-associated amnestic syndrome

🔷Toxicology was + for fentanyl and no other parts of the brain were affected on MRI

🔷Pathophys: Unclear, possibly neuronal hyper metabolism and/or ischemic component

🔷Clinical: New-onset amnesia for >24 hours

🔷Imaging:
▶️Diffuse, symmetric diffusion restriction in the hippocampi

▶️Usually mild T2/FLAIR signal in same areas

Read 7 tweets

Daniel Gewolb, MD

@daniel_gewolb

Mar 19

⭐️ 30 y/o presents w/ R sided weakness & fall. Pt had a recent admission ~4 months ago for headache, AMS, seizure & diplopia. Clinically stable until now.

🔷LP 4 months ago: protein >600
🔷Comparison in 🧵

What is your diagnosis?

#medicine #MedEd #radres #futureradres #Neurology #Neurosurgery #FOAMed @TheASNR

🔷Comparison from ~4 months ago 👇

⭐️ Hint: TB work up negative and CT chest, abdomen and pelvis also negative. The spine was imaged 👇

Read 7 tweets

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