⭐️ Tips for distinguishing treatment change from tumor progression from my own experience and the literature ☢️

**Sorry for the long and very complicated post!**

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🔷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)

⭐️What is the most likely diagnosis in this patient presenting with a lump on the head?

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🔷What is the most likely diagnosis and clinical syndrome in this patient with left ear pain, cranial nerve 6 palsy, and retro-orbital pain? 🧠 🤔

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⭐️ 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

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

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⭐️ 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

🔷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🦇)

🔷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? 🧠

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⭐️ 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

⭐️ 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

⭐️ 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?

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🔷Comparison from ~4 months ago 👇

⭐️ Venous variants and abnormalities are the most common causes of pulsatile tinnitus

Differential and learning points in 🧵

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🔷Ddx for venous causes of PT:

Idiopathic intracranial hypertension
Sigmoid plate dehiscence +/- diverticulum
Transverse sinus stenosis (w/ or w/o IIH)
Jugular bulb abnormalities
Dilated emissary veins
Extracranial IJ compression
Prominent occipital sinus
Occipital sinus stenosis

Back from Belize! 🇧🇿

🔷What is the most likely diagnosis in this 25 y/o F w/ a band-like scalp lesion and local alopecia?

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Answer: Linear Scleroderma aka Scleroderma en coup de sabre

🔷Linear scleroderma is a focal form of scleroderma resulting in atrophy and alopecia of the frontal or frontoparietal scalp

🔷Atrophy involves the subjacent skull +/- underlying brain parenchyma (as seen in this case)

⭐️ What is the most likely diagnosis in this asymptomatic patient? What would your recommendation be if any?

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Answer: Benign-appearing notochordal lesion (formally ecchordosis physaliphora, EP)

💡 If no remote priors for comparison, recommend 6 month follow up which can be extended if unchanged at that time

⭐️What is the most likely diagnosis in this 40 y/o M presenting w/ 10 days of L neck/throat/ear pain, worsened by neck palpation and head turning?

🔷PMH: None
🔷ESR/CRP: Mildly ⬆️

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⭐️ Answer: Transient Perivascular Inflammation of the Carotid Artery (Carotidynia or Fay syndrome)

What is the most likely diagnosis in this 30 y/o M presenting with seizures, fever & headache?

🔷CSF x2:
Worsening neutrophilic pleocytosis despite Abx
Negative infectious studies
No malignancy on cyto/flow
OCBs +

🔷CT CAP: normal
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Additional image 👇
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⭐️ Classic case: 45 y/o Female presents w/ intermittent R pulsatile tinnitus for 1-2 years, what’s the most likely diagnosis?

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Answer: Glomus Tympanicum Paraganglioma

🔷PATHOLOGY: Benign tumor arising from glomus bodies along the inferior tympanic nerve (Jacobson nerve)

60 y/o F presents w/ several months of confusion, word finding difficulty & gait dysfunction

🔷What is your best guess and differential?

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🔷More images 👇

55 y/o F w/ no significant PMH presents with headache and bump on the head. What’s the most likely diagnosis? 🤔 🧠

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What is the most likely diagnosis in this 55 y/o F presenting w/ 2 years of progressive gait instability, mild dysarthria, bilateral dysmetria, & mild left bradykinesia? 🧠

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Answer: Multiple System Atrophy Cerebellar Type (MSA-C)

🔷MSA is an adult onset sporadic neurodegenerative disease presenting w/ motor and autonomic symptoms

Difficult case, let’s run this together. 70 y/o M w/ Hx of HTN presents with acute confusion, dysarthria and facial droop

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🔷First thing we notice is hemorrhage in the left basal ganglia

🔷Classically, hemorrhage in the basal ganglia in an adult with hypertension we think of hypertensive hemorrhage but the morphology does not match here

What is the finding in this 55 y/o asymptomatic patient? Any associations? 🤔

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Answer: Hypothalamic adhesion

🔷This finding is incidental in most patients though the neuroradiologist should look for subtle midline and other associated abnormalities particularly in children

🔷Reported associations:
Gray matter heterotopia
Midline anomalies

What is the most likely diagnosis in this 20 y/o M presenting w/ seizure, weakness, AKI & hypertension?

CT in 🧵

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CT 👇

Patient here for follow up imaging of a high grade glioma. Based on the imaging, what therapy are they likely receiving? 🤔 🧠

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Answer: Bevacizumab (Avastin)-induced coagulative necrosis

🔷Patients on Bevacizumab can develop well-defined areas of difffusion restriction within the treatment bed usually w/ PROFOUNDLY LOW ADC values

🔷The diffusion restriction corresponds to atypical gelatinous necrosis