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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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More from @daniel_gewolb

Daniel Gewolb, MD

@daniel_gewolb

Nov 27

🔷What is the most likely diagnosis in this 70 y/o who presents w/ sudden onset severe low back pain radiating to the lower extremities? 🦃

#radres #futureradres #Neurology #neurosurgery #MRI #FOAMed #Medicine @TheASNR @Radiopaedia

⭐️ Answer: Spontaneous spinal epidural hematoma (no clear risk factor in this case)

🔷CLINICAL: Abrupt onset of severe neck or back pain that can radiate into the extremities and commonly is followed by symptoms ranging from nerve root agitation to full neurologic impairment

🔷RISK FACTORS:
▶️Idiopathic (40-60%)
▶️Anticoagulant use
▶️AVM, AVF or other vascular malformation
▶️Underlying coagulopathy
▶️Tumor
▶️Pregnancy

❓ Possible explanation for cases without known risk factors: 🧠 🩸The internal epidural plexus that drains the abdomen and thorax is a low pressure, valveless system that may rupture when the pressure is increased from valsalva maneuvers ❓

Read 6 tweets

Daniel Gewolb, MD

@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 @PennRadiology

🔷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

Daniel Gewolb, MD

@daniel_gewolb

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

More images 👇

⭐️ 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)

Read 6 tweets

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

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