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Long Island Radiological Society Interesting Case Panel Prepared by Steven Lev, MD Director of Neuroradiology, NUMC Tuesday, November 12, 2013 Nassau University Medical Center East Meadow, NY Case 1 41 yo hispanic male with 3 month history of headaches and visual disturbances. STOP Proceed to next slide for diagnosis Racemose Neurocysticercosis Multiseptated suprasellar cystic lesion in the sellar/suprasellar region. DDx: Craniopharyngioma, arachnoid cyst and epidermoid. Echinococcal parasitic cysts have also been identified in this location. Can you identify any additional cystic lesions? (Hint: look at the coronal view). •Neurocysticercosis is a parasitic disease caused by Taenia solium •Main cause of acquired epilepsy in developing countries. •Stages: Inflammatory reaction, gliosis and calcification of the nodule. •Cystic, racemose or mixed forms. • •Racemose form: Basilar cisterns, “cluster of grapes” appearance. •Hydrocephalus. Case 2 21 yo male with history of seizures STOP Proceed to next slides for diagnosis Band Heterotopia Finding: There are bilateral bands of grey matter within the white matter, between the epenyma and the cortex. Abnormal migration of gray matter during brain development. No enhancement with contrast Glucose uptake on PET is similar to normal cortex. Developmental delay and intractable seizures in a child. Companion Case: Nodular Heterotopia Subependymal type shows nodules, isointense and non-enhancing to gray matter, along lateral ventricle DDx: TS, however these calcify and do not follow gray matter Associated with many other congenital abnormalites, such as chiari and other migrational disorders Case 3 65yo female with hearing loss and dizziness STOP Proceed to next slide for diagnosis Superficial Siderosis Findings: Axial MR T2W (left) and T2 FLAIR images (middle, right) show subtle dark outlines around the brainstem and in the medial cerebellar hemispheres consistent with hemosiderin deposition secondary to chronic recurrent hemorrhages. Key Facts: •Source of bleeding often not evident •Hemosiderin deposition in the subpial layers of brain and spine •Adult onset slowly progrssive gait ataxia •Sensineural hearing impairment •Surgical treatment depends on identification of a bleeding source Kumar N. Neuroimaging in Superficial Siderosis: An In-Depth Look, AJNR 2010 31: 5-14 Case 4 31 yo male with 5 mo history of progressive numbness and tingling in left hand STOP Proceed to next slide for diagnosis Schwanomma with Central Necrosis Findings: Sagittal T1W, T2W and T1W post gadolinium show a welldefined intrathecal extramedullary mass, compressing the cord anteriorly, extending from the C2-C3 through the C4-C5 levels. It has a characteristic meniscus sign. Key Facts: •Focal proliferation of Schwann cells •Intradural extramedullary •Differential includes meningioma, drop mets •Peripheral contract enhancement should suggest the diagnosis Reference: Friedman DP, Tartaglino LM, Flanders AE. Intradural schwannomas of the spine: MR findings with emphasis on contrastenhancement characteristics. AJR 1992 Jun; 158 (6) : 1347-50 Case 5 61 yo male with multiple right sided cranial nerve palsies Case courtesy of Michael Lev, MD Massachusetts Eye and Ear Hospital STOP Proceed to next slide for diagnosis Giant Petrous Apex Aneurysm • Pulsatile tinnitus, sensorineural hearing loss. • May be congenital or acquired. • Possible wall calcifications and thrombosis • Enhancement of mass in petrous ICA. • MR: Complex signal on T1WI and T2WI due to flow void and thrombus. • Treatment: Endovascular Petrous carotid aneurysm can mimic a cholesterol cyst on CT. However this is a Do Not Touch Lesion !