Neuro-imaging for the Ophthalmologist. Karl C. Golnik, MD, MEd University of Cincinnati & The Cincinnati Eye Institute
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1 Neuro-imaging for the Ophthalmologist Karl C. Golnik, MD, MEd University of Cincinnati & The Cincinnati Eye Institute
2 Neuro-ophthalmology is that subspecialty where the diagnosis is made upon reinterpretation of allegedly normal scans. William F. Hoyt MD
3 Objectives 1. Describe what type of neuro-imaging to order. 2. List pit-falls in imaging interpretation. 3. Recognize MRI and CT findings of common neuro-ophthalmology problems.
4 I. CT vs. MRI II. Pitfalls Outline III. Common Neuroophthalmology Conditions
5 MRI is preferable to CT in all of the following except? A. Brainstem lesion B. Bitemporal hemianopsia C. Thyroid eye disease D. Acute stroke
6 CT vs. MRI Patient factors: metal, claustrophobia MRI better for brain/skull base CT equivalent in orbit, better for bone MRA vs. CTA Golnik K. MRI vs CT. in Curbside Consultation in Oculoplastic Surgery. Eds: Kersten RC, McCulley T. Slack, 2010.
7 CT vs. MRI MRI head diplopia, bilateral optic neuropathy, retrochiasmal VF defect, any suspected intracranial pathology MRI Orbit unilateral optic neuropathy CT head cerebral bleed, hydrocephalus CT orbit Graves, orbital process CTA vs MRA depends on your institution Golnik K. MRI vs CT. in Curbside Consultation in Oculoplastic Surgery. Eds: Kersten RC, McCulley T. Slack, 2010.
8 Outline I. CT vs. MRI II. Pitfalls 1. Wrong study 2. No contrast 3. No fat suppression 4. No instructions 5. No persistence
9 60-yo-man awoke today with blurred vision, imbalance. PMH: DM, HTN 1. Wrong Study Exam VF: R homonymous hemianopsia
10 CT: normal MRI: multiple strokes Stroke may not show on CT within first 24 hours. MRI better than CT except in orbit or bone.
11 What is your access to Neuroimaging? A. MRI same day if needed B. MRI within 1 week C. MRI within 1 month D. CT only E. neither available
12 70 yo wf c/o ptosis 1 day after discharge for DVT. MRI normal PMH: melanoma 1. Wrong Study Exam: 5 prism diopter RHT in downgaze, 3mm proptosis + ptosis
13 MRI brain MRI orbit Give good instructions & order the correct test of the correct anatomy.
14 2. No Contrast 40-yo-WF c/o gradual loss of vision OS. PMH: none Exam VA: 20/20, 20/60 Color: 0/10 OS P: 2+ L-RAPD
15 Non-contrast MRI Gadolinium MRI If optic neuropathy is present, always order Orbit MRI with gadolinium.
16 3. No Fat Suppression 30-yo-WF c/o gradual loss of vision OS. PMH: none Exam VA: 20/20, 20/80 Color: 0/10 OS P: 3+ L-RAPD
17 MRI no gad MRI + gad MRI + gad + fat suppression
18 59-yo-WM c/o double vision x 6 weeks. PMH: htn Exam R 5 th,6 th,7 th n palsies 4. No Instructions
19 MRI + gadolinium L pontine lacunar infarct R metatstatic lesion (lung ca) Give detailed instructions No Secrets!
20 4. No Instructions 23-yo-WF c/o diplopia in left gaze PMH: hyperthyroidism Exam mild lid retraction OD, ET in L gaze MRI normal
21 4. No Instructions EOMS routinely misread or overlooked. Check yourself or call radiologist
22 5. No Persistence 24-yo-WM c/o visual loss OD x 3 months. PMH: Ewings sarcoma femur Exam R optic neuropathy MRI x 2 normal, no mass Dx: Optic Neuritis
23 VA: 10/3/02 20/40 11/6/02 20/80 1/12/03 CF Optic Neuritis? no gad or fat suppression + gad & fat suppression
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25 Top 5 Pitfalls - Solutions 1. Get the correct study 2. Give contrast 3. Get fat suppression 4. Give specific instructions 5. Be persistent
26 The MR image below is A. T2 B. T1 C. T1 with fat suppression D. T1 with contrast & fat suppression
27 T1, T2, Fat Suppression & Gadolinium
28 Ct vs mri bone
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30 I. CT vs. MRI II. Pitfalls III. Common Neuroophthalmology Conditions 1. Inflammatory 2. Tumors 3. Vascular 4. Miscellaneous Outline
31 Graves Orbitopathy
32 CNS Sarcoid
33 Optic Neuritis & Plaques
34 I. CT vs. MRI II. Pitfalls III. Common Neuroophthalmology Conditions 1. Inflammatory 2. Tumors 3. Vascular 4. Miscellaneous Outline
35 This patient probably has? A. Double vision B. Bitemporal field defect C. Headache D. Nystagmus
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42 I. CT vs. MRI II. Pitfalls III. Common Neuroophthalmology Conditions 1. Inflammatory 2. Tumors 3. Vascular 4. Miscellaneous Outline
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46 This patient probably has? A. Double vision B. Bitemporal field defect C. Headache D. Nystagmus
47 Diffusion Weighted Image (DWI)
48 I. CT vs. MRI II. Pitfalls III. Common Neuroophthalmology Conditions 1. Inflammatory 2. Tumors 3. Vascular 4. Miscellaneous Outline
49 Miscellaneous
50 Miscellaneous
51 Miscellaneous
52 Miscellaneous
53 Thank-you for your attention.
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