Daniel Gewolb, MD Profile picture
Chief Neuroradiology Fellow @PennRadiology l Former Chief resident @AlbanyMedRadRes l SGU ’18 l Daily Educational Cases #RadRes #Neurorad #RadEd
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Nov 19 16 tweets 6 min read
Intracranial HYPOtension, imaging findings and diagnostic approach

Imaging and learning points in 🧵 🧠

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


▶️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
Aug 28 8 tweets 3 min read
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
Aug 17 7 tweets 3 min read
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


Jul 26 8 tweets 4 min read
Distinguishing between pathologic & compression fractures can be difficult

Here are some tips to help in 🧵

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

Some findings more suggestive of pathologic fracture:

1️⃣Other spinal mets Image
Jul 18 5 tweets 2 min read
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
Jul 7 4 tweets 2 min read
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

▶️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 🧠

Jul 1 5 tweets 2 min read
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
▶️Less commonly, peripheral

💡 Hypertensive angiopathy can result in both hemorrhage or ischemia
Jun 10 14 tweets 10 min read
Differential Diagnosis for cortically based masses


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

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

Temporal lobe is most common
Jun 9 4 tweets 4 min read
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 ImageImageImageImage ▶️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
Jun 8 9 tweets 6 min read
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 ImageImageImageImage 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)
Jun 7 7 tweets 4 min read
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 ImageImageImageImage 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
May 27 14 tweets 7 min read
Tips & tricks of DWI to help narrow the differential

Hypercellular tumor
Epidermoid cyst
Toxic/metabolic disorders
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

Cytotoxic edema due to trapped intracellular fluid leads to restriction

Look for wedge shaped restriction in a vascular territory Image
May 25 7 tweets 4 min read
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)
May 23 10 tweets 6 min read
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?
May 22 4 tweets 3 min read
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
May 21 6 tweets 5 min read
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 🧠
May 21 9 tweets 5 min read
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
May 19 9 tweets 5 min read
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
Mar 27 8 tweets 3 min read
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?
Mar 27 4 tweets 5 min read
Case of a radiation induced pseudoaneurysm in this patient with headache and AMS 🧠

Imaging in thread #Neurosurgery #Neurology #neurotwitter #radres #MedEd #MedTwitter @TheASNR ImageImageImageImage ▶️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) ImageImage
Mar 21 7 tweets 3 min read
What is the most likely diagnosis in this 25 y/o M with headache? 🧠

Answer later tonight #radres #Neurology #Neurosurgery #MedEd #MedTwitter #NeuroTwitter @RSNA ImageImageImageImage Most likely diagnosis?