Case Conference: Neuroradiology Case 1: 22yo F w/ HA and prior Seizures David E. Rex, MD, PhD Stanford University Hospital Department of Radiology Case 1: Tumor Most likely gangiloglioma, oligodendroglioma, or a dysembryoplastic neuroepithelial tumor. Less likely old trauma and seizure. Unlikely old infection with seizure. MRI may help, but biopsy likely for definitive dx. Case 2: 37yo M originally presented with 15mos of HA s. Case 2: Posterior Fossa Arachnoid Cyst Usually incidental and without symptoms. When large, the mass effect can cause herniation of brain and even infarcts. Can grow over time. A cystoperitoneal shunt was placed to divert the fluid to the abdomen. Case 3: 86yo F post fall from standing. 1
Case 3: Subdural Hematoma with Subarachnoid extension. Subdural hematoma in a parafalcine and tentorial distribution. Punctate focus of increased density in the interpeduncular fossa indicated subarachnoid extension / SAH. Case 4: 47yo F with a resolved right facial droop. without contrast with contrast Case 4: Subacute Infarct of the Caudate Head. with contrast The hypodensity indicates edema / infarct. Enhancement comes on after the acute event and resolves in the chronic state. Therefore the infarct is subacute. Encephalomalacia is also already present. Case 5: 78yo F w/ left sided weakness and left facial droop. Enhanced Case 5: 78yo F w/ left sided weakness and left facial droop. CTA Tmax CBF Case 5: Right ICA / MCA clot with right MCA territory acute stroke. Tmax CBF CBF mostly preserved, therefore tissue at risk of infarct, but still perfused, albeit slowly by collateral circulation. ACA territory is less affected due to the presence of the anterior communicating artery. Patient taken to cath lab for intervention to attempt clot removal. 2
(Acute onset expressive aphasia & right facial droop). (Acute onset expressive aphasia & right facial droop). MTT CBF CBV 3
4 th order MCA branch cutoff Case 6: Distal left MCA territory embolism. Early, especially small, infarcts can be invisible on CT. Small distal clots may not be noticed on CT Angiography. CT Perfusion is more sensitive and helps determine infarct vs. tissue at risk. Case 6: Distal left MCA territory embolism. Case 6: Distal left MCA territory embolism. Follow-up MRI 7 hours later confirms a tiny left insular cortex infarct. Perfusion abnormality resolved by this time indicating successful reperfusion of the brain tissue. 4
Case 7: 74yo M, may have presented with headache, seizure or left sided weakness. Case 7: Arteriovenous Malformation Abnormal connection of arteries directly to veins. Arterial pressures in venous circulation. May form arterial or venous aneurysms (a varix). Shunting of blood in high flow state. Can bleed or infarct. High density is either prior embolization or calcium from prior injury. Case 8: 93yo F post fall. Case 8: C1 burst fracture & Dens fracture. C1 anterior and posterior arch fractures. Dens fracture through the base and posteriorly displaced (type II). Prevertebral soft tissue swelling / hematoma. Case 9: 47yo M with right eye blurring, swelling, pain & chemosis. Case 9: Endophthalmitis with vitreal or retinal detachment. Infection of the globe (in this case with Klebsiella). Linear density within the vitreous humor indicated detachment. Involvement of the optic lens with an asymmetric irregular appearance. Thickened sclera. Enlarged lacrimal gland. No retrobulbar involvement. 5
Case 10: 54yo M with unrelated neurologic symptoms. Case 10: Multiple Aneurysms Left large carotid terminus saccular aneurysm. Right carotid terminus saccular aneurysm. Right supraclinoid ICA saccular aneurysm. Left basilar tip aneurysm originating between the SCA and PCA origins. Happy Scanning 6