Intracranial HYPOtension, imaging findings and diagnostic approach

Imaging and learning points in 🧵 🧠

#Neurology #neurosurgery #MedEd #radres #futureradres #neurorad @The_ASSR





Clinical:

▶️Headache that is worst when upright and improves with lying flat as it gets the sagging brain off the jagged skull base (at least that’s how I remember it)

💡May also present with chronic headaches or without headaches

What is the most likely diagnosis in this patient with sensorineural hearing loss and fullness of the neck? 🧠

#ENT #neurology #neurosurgery #radres #MedEd #MedTwitter @ASHNRSociety



Answer: Pendred syndrome

▶️Pendred syndrome is an inherited cause of deafness

▶️Modiolar deficiency and vestibular enlargement are invariably seen

▶️Enlarged vestibular aqueducts are often seen

What is the most likely diagnosis in this patient with a left base of tongue mass and a negative biopsy?

Couple more images in 🧵

#ent #Neurosurgery #Neurology #MedEd #futureradres #radres #NeuroTwitter @ASHNRSociety @Radiopaedia

Distinguishing between pathologic & compression fractures can be difficult

Here are some tips to help in 🧵

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Some findings more suggestive of pathologic fracture:

1️⃣Other spinal mets

What is the most likely diagnosis in this 25 y/o M who was found down? 🧠

#Neurology #neurotwitter #neurosurgery #MedEd #MedTwitter @TheASNR @RSNA #futureradres





Answer: Cerebellar, hippocampal, and basal nuclei transient edema with restricted diffusion (CHANTER) syndrome

▶️CHANTER syndrome is a distinct pattern of imaging manifestations representing a form of opioid induced neurotoxicity

Incomplete hippocampal inversion is an uncommon finding in patients without epilepsy

💡 The finding should heighten suspicion for a seizure disorder

#Neurology #peds #Neurosurgery #radres #neurotwitter #MedTwitter



Imaging:
▶️ROUNDED morphology with more vertical and medial orientation (yellow arrow)
▶️DEEP more VERTICALLY oriented COLLATERAL SULCUS (blue arrow)
▶️Blurred hippocampal structure
▶️NORMAL SIZE AND SIGNAL (different from MTS)
▶️Enlarged-appearing temporal horn 🧠

Hypertensive and cerebral amyloid angiopathy are 2 of the most common causes of intracranial micro-hemorrhage 🧠

💡Recognizing the pattern of micro bleeds can help determine etiology
#NeuroTwitter #radres #Neurology #Neurosurgery #MedEd #MedTwitter

💡 Typical hypertensive micro bleed pattern (best seen on SWI/T2*):
▶️Deep gray matter
▶️Brainstem
▶️Less commonly, peripheral

💡 Hypertensive angiopathy can result in both hemorrhage or ischemia

Differential Diagnosis for cortically based masses

P-DOG 🐶

1️⃣Pleomorphic Xanthoastrocytoma (PXA)
2️⃣Dysembryoplastic neuroepithelial tumor (DNET)
3️⃣Oligodendroglioma
4️⃣Ganglioglioma
#Neurology #neurosurgery #peds #radres #neurotwitter @The_ASPNR @TheASNR #MedTwitter 1️⃣PXA

Originate in the subpial astrocytes typically in children and young adults often with a seizure history

Temporal lobe is most common

Tuberculous Meningitis in this child w/ fevers and lethargy

💡 COMMUNICATING HYDROCEPHALUS with DEEP INFARCTION is highly suggestive of granulomatous meningitis
#neurology #MedTwitter #neurotwitter @TheASNR #MedEd #futureradres ▶️In children, primary TB infection is commonly associated w/ meningitis

▶️Exudative meningitis of the basal cisterns can obstruct the normal CSF flow resulting in hydrocephalus

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)

Interesting case, what is the most likely diagnosis in this 25 y/o F w/ 1 year history of migraine headaches, left hand numbness, and b/l retinal artery occlusions? 🧠 👁️
#Ophthalmology #neurology #neurosurgery #neurotwitter #MedEd @TheASNR #MedTwitter Answer: Susac syndrome 🧠

▶️Susac syndrome is a microangiopathy (likely autoimmune affecting the precapillary arterioles) with a strong female predilection, typically occurring in women age 20-40

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 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

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 Answer: Sclerosing osteomyelitis of Garré

▶️Biopsy showed a reactive and reparative osseous process and bone culture grew oral flora (though cultures are usually negative)

Interesting case in this patient with acute right-sided weakness

#neurorad #neurotwitter #meded #Neurosurgery #Neurology @TheASNR @RSNA #medtwitter Can you determine the diagnosis off the CT?

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 ▶️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

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 ▶️Prospectively this mass was thought to be an embryonal tumor w/ multilayered rosettes given the marked diffusion restriction, hemorrhage, and lack of surrounding edema 🧠

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 Brain radiation is a risk factor for the development of meningiomas …this patient subsequently developed multiple meningiomas including this large frontal meningioma

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 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

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?

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)

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?