Disclosures

When and Where We Make a Difference

Critical Imaging Diagnoses:

No financial disclosures nor conflict of interest to report

I’m from the Government …
James G. Smirniotopoulos, M.D. Radiology and Radiological Sciences Uniformed Services University Bethesda, MD

… and I here to help!

Learning Objectives Develop a “checklist” checklist” for imaging to improve your ability to identify significant findings Recognize imaging findings that will acutely change patient management

MR and CT Imaging Checklists
Anatomic Locations
– Sagittal Images
Sup. Sag. Sinus Corpus Callosum Sella Region Clivus

Morphologic Features
– Mass Effect
Yes, proportional Less than expected No mass effect

– Axial Images
Skull, Epi/Sub Epi/Sub Dural SAS Cortical Gray Matter White Matter Deep Gray Matter Ventricles

– Abnormal WM Signal
Vasogenic Edema Demyelination Infiltrating neoplasm

– Enhancing Ring Lesion
Necrotic Neoplasm Reactive (e.g. abscess) Fluid or Inflammatory

MR and CT Imaging Checklists
Anatomic Locations
– Sagittal Images
Sup. Sag. Sinus Corpus Callosum Sella Region Clivus

Superior Sagittal Sinus Thrombosis

– Axial Images
Skull, Epi/Sub Epi/Sub Dural SAS Cortical Gray Matter White Matter Deep Gray Matter Ventricles
Venous Infarct: Deeper, white matter, may spare parts of cortex

Sup. Sag. Sinus Thrombosis
Dehydration Paraneoplastic Syndromes w/hypercoag Spinal Anesthesia PostPost-partum

MR and CT Imaging Checklists
Anatomic Locations
– Sagittal Images
Sup. Sag. Sinus Corpus Callosum Sella Region Clivus

– Axial Images
Skull, Epi/Sub Epi/Sub Dural SAS Cortical Gray Matter White Matter Deep Gray Matter Ventricles

Gliomatosis Cerebri

Diffuse Astrocytoma of Corpus Callosum:

“Butterfly Glioma” Glioma”

Gliomatosis cerebri: 2 or more lobes infiltrated by a diffuse astrocytoma Courtesy of R.D. Zimmerman, NY

Diffuse Astrocytoma of Corpus Callosum:

“Butterfly Glioma” Glioma”

Corpus Callosum Lesions

Glioblastoma: Central Necrosis

CNS Lymphoma: Hyperdense

Lymphoma: hyperdense PCNSL FLAIR T2W Low water content … restricted diffusion Low water content … hyperattenuation T1W Gd+ CNS Lymphoma Micro Pathology DENSELY CELLULAR Perivascular infiltration Increased RETICULIN fibers HIGH N/C (nuclear/cytoplasm) Small Round Blue Cell Tumor High attenuation/low signal intensity Small * Round * BlueBlue-Cell Tumor Perivascular Infiltrate Rimphoma RIM PHOMA .

Sinus Corpus Callosum Sella Region Clivus Mass Lesion Presentation Bitemporal Hemianopsia – Axial Images Skull. Epi/Sub Epi/Sub Dural SAS Cortical Gray Matter White Matter Deep Gray Matter Ventricles Bitemporal Hemianopsia Pituitary Adenoma Met Hemoglobin in Sella Region Macroadenoma Adult Patient Microadenoma – < 10 mm – entirely within gland – Endocrine Sx. Sag. Prolactinoma Ⓕ Acromegaly Gigantism Cushing Disease Pituitary MACROMACRO-Adenoma Macroadenoma – – – > 10 mm balloon sella Visual Sx if >6 mm above sella bitemporal hemianopsia .MR and CT Imaging Checklists Anatomic Locations – Sagittal Images Sup. Sag. Sx. Epi/Sub Epi/Sub Dural SAS Cortical Gray Matter White Matter Deep Gray Matter Ventricles MR and CT Imaging Checklists Anatomic Locations – Sagittal Images Sup. Sinus Corpus Callosum Sella Region Clivus Agenesis of the Corpus Callosum – Axial Images Skull.

Sag. Sinus Corpus Callosum Sella Region Clivus Bilateral Abducens (CNN6) Palsy – Axial Images Skull. Sag. Epi/Sub Epi/Sub Dural SAS Cortical Gray Matter White Matter Deep Gray Matter Ventricles – One stone to the head killed him Pituitary Apoplexy Hemorrhage into a macroadenoma Craniopharyngioma – Bright T1W MR and CT Imaging Checklists Anatomic Locations – Sagittal Images Sup.Pituitary Apoplexy Met Hemoglobin in Sella Region Macroadenoma Pituitary Apoplexy David and Goliath Did Goliath have Gigantism and/or Acromegaly? He was a “Giant” He was an Angry Giant from HA and ICP Did he have a Macroadenoma? – David was able to sneak up to him bitemporal hemianopsia “Tunnel Vision” MR and CT Imaging Checklists Anatomic Locations – Sagittal Images Sup. Epi/Sub Epi/Sub Dural SAS Cortical Gray Matter White Matter Deep Gray Matter Ventricles . Sinus Corpus Callosum Sella Region Clivus – Axial Images Skull.

Epi/Sub Epi/Sub Dural SAS Cortical Gray Matter White Matter Deep Gray Matter Ventricles ☺ Smile of the Quadrigeminal Cistern . Sinus Corpus Callosum Sella Region Clivus Depressed Skull Fx – Axial Images Skull. can be managed with observation – Axial Images Skull. Sag. Sag. Sinus Corpus Callosum Sella Region Clivus Small EDH.Chordoma Bulky Clival Mass Chordoma Midline Bone Destruction MR and CT Imaging Checklists Anatomic Locations – Sagittal Images Sup. Epi/Sub Epi/Sub Dural SAS Cortical Gray Matter White Matter Deep Gray Matter Ventricles MR and CT Imaging Checklists Anatomic Locations – Sagittal Images Sup. no herniation.

Sinus Corpus Callosum Sella Region Clivus History 42 y. ICA Aneurysm ICA Aneurysm . with Lethargy – Axial Images Skull. Epi/Sub Epi/Sub Dural SAS Cortical Gray Matter White Matter Deep Gray Matter Ventricles No papilledema Kernig Sign + Brudzinski Sign + Kernig sign: Pain elicited by straightening the knee with the hip/thigh flexed.o. Brudzinski sign: Pain and/or rigidity with simultaneous neck and knee/hip flexion.o. woman with acute onset of: – “the worst headache of my life” life” Headache. Sinus Corpus Callosum Sella Region Clivus Child Abuse? 2 y. Epi/Sub Epi/Sub Dural SAS Cortical Gray Matter White Matter Deep Gray Matter Ventricles MR and CT Imaging Checklists Anatomic Locations – Sagittal Images Sup. y.o. Sag.MR and CT Imaging Checklists Anatomic Locations – Sagittal Images Sup. Kernig & Brudzinski+ – Axial Images Skull. Sag.

Pneumococcal Meningitis Fever.Zuckerguss Serpentine . Sinus Corpus Callosum Sella Region Clivus Subarachnoid Space Enhancement Leptomeningeal Enhancement . Sag. MD. Kernig +.Cortical Gyral Carcinomatous Meningitis Meningitis Encephalitis MR and CT Imaging Checklists Anatomic Locations – Sagittal Images Sup. MGH CSF Spread . Roig.MR and CT Imaging Checklists Anatomic Locations – Sagittal Images Sup.o. Epi/Sub Epi/Sub Dural SAS Cortical Gray Matter White Matter Deep Gray Matter Ventricles . Sinus Corpus Callosum Sella Region Clivus HSV Encephalitis Hx: 23 y. w/confusion – Axial Images Skull. Epi/Sub Epi/Sub Dural SAS Cortical Gray Matter White Matter Deep Gray Matter Ventricles Bacterial glycopeptides cause Breakdown in the BBB and contrast leaks into CSF in the SAS Zulmarie Roig. Brudzinski + – Axial Images Skull. Sag. MD and Gil Gonzalez.

branch Function of Time – IV TPA up to 3 hrs – IA up to 6 hrs – Desmoteplase up to 9 hrs . left sided weakness – Axial Images Skull. Sinus Corpus Callosum Sella Region Clivus CVA: Progression Over 3 Days Day 1 Day 3 No Sulci Hx: 53 y.MR and CT Imaging Checklists Anatomic Locations – Sagittal Images Sup.o. Sag. Epi/Sub Epi/Sub Dural SAS Cortical Gray Matter White Matter Deep Gray Matter Ventricles Low attenuation “Insular Ribbon” Sign Cerebral Infarction MCA Cerebral Infarction MCA 2 hrs of Sx 4 hrs of Sx 2 hrs of Sx 4 hrs of Sx DWI ADC DWI ADC Chronic Infarct Hemorrhagic Transformation Reperfusion Injury – Restoration of Systemic pressure into dead brain Anterior Cerebral Artery Function of Ischemic Volume – Entire MCA vs.

HT had TAH/BSO – Axial Images Skull. Epi/Sub Epi/Sub Dural SAS Cortical Gray Matter White Matter Deep Gray Matter Ventricles DWI Dysembryoplastic Neuroepithelial Tumor (DNET) Another Cortical Wedge Lesion MR and CT Imaging Checklists Anatomic Locations – Sagittal Images Sup.PCA Infarct MR and CT Imaging Checklists Anatomic Locations – Sagittal Images Sup. Sag. Ischemic gray-matter. w/ Seizures – Axial Images Skull. Sinus Corpus Callosum Sella Region Clivus Hx: 13 y. Sinus Corpus Callosum Sella Region Clivus 65 y. Epi/Sub Epi/Sub Dural SAS Cortical Gray Matter White Matter Deep Gray Matter Ventricles Proton Density T1W Anoxia During Surgery Anoxia During Surgery Diffuse patchy abnormal loss of normal attenuation in cortical gray-matter. Sag.o. cortical (ACA & MCA) and basal ganglia (caudate). NOTE: Relative sparing of the PCA (occipital lobes and thalami) .o.

o. Epi/Sub Epi/Sub Dural SAS Cortical Gray Matter White Matter Deep Gray Matter Ventricles . MGAFMC Findings Intraaxial Diffuse Bilateral abnormalities – Low attenuation in Cortical Gray Matter – Low attenuation in basal ganglia Lab: Serum Na+ 121 Psychogenic polydipsia Water Intoxication Overhydration – Athletes drinking too much water Iatrogenic – D5W w/o salts “Edema” Edema” – What Kind? Interstitial Cytotoxic Hydrostatic Treatment – Fluid restriction – Ringer’ Ringer’s Lactate or Hypertonic Saline 1. Sinus Corpus Callosum Sella Region Clivus Multiple Sclerosis Small Ovoid Lesions perpendicular to lateral ventricle Woman w/confusing symptoms – Axial Images Skull. Sag.D. Epi/Sub Epi/Sub Dural SAS Cortical Gray Matter White Matter Deep Gray Matter Ventricles Courtesy Aimee Hawley. M. Sinus Corpus Callosum Sella Region Clivus 34 yo comatose woman. woman w/Coma – Axial Images Skull.MR and CT Imaging Checklists Anatomic Locations – Sagittal Images Sup.8% saline (not 4%NS and NOT D5W) MR and CT Imaging Checklists Anatomic Locations – Sagittal Images Sup. 34 y. psychiatric pt. Sag.

MR and CT Imaging Checklists Anatomic Locations – Sagittal Images Sup. Sinus Corpus Callosum Sella Region Clivus 71 yo man with HIV/AIDS – Axial Images Skull. Sinus Corpus Callosum Sella Region Clivus Acute Pure Motor Hemiplegia 14 yo girl with congenital HIV – Axial Images Skull. smooth. high fever. and two weeks of watery diarrhea Toxoplasmosis Left thalamic mass –low attenuation with hyperdense rim. Sinus Corpus Callosum Sella Region Clivus MR and CT Imaging Checklists Anatomic Locations – Sagittal Images Sup. Epi/Sub Epi/Sub Dural SAS Cortical Gray Matter White Matter Deep Gray Matter Ventricles TOXOPLASMOSIS 14 yo AA girl with congenital HIV and CD4 count of 50 presents with mental status change. Sag. surrounding vasogenic edema. Sag. Sag. hypointense T2 rim (collagen capsule). calcification . Epi/Sub Epi/Sub Dural SAS Cortical Gray Matter White Matter Deep Gray Matter Ventricles – Axial Images Skull. round rim enhancement. restricted diffusion Typical deep gray matter paracentral abscesses with rim enhancement and surrounding edema Toxoplasmosis: Calcification after Treatment MR and CT Imaging Checklists Anatomic Locations – Sagittal Images Sup. Epi/Sub Epi/Sub Dural SAS Cortical Gray Matter White Matter Deep Gray Matter Ventricles Lesions shrinks. vasogenic edema resolves.

Sinus Corpus Callosum Sella Region Clivus Bruns Syndrome – Positional HA Chronic HA – Acutely Worse – Axial Images Skull. Epi/Sub Epi/Sub Dural SAS Cortical Gray Matter White Matter Deep Gray Matter Ventricles Hydrocephalus: Vents > Sulci . Epi/Sub Epi/Sub Dural SAS Cortical Gray Matter White Matter Deep Gray Matter Ventricles Medial Lenticular – Globus Pallidus Toxic and Metabolic Intrinsic – Diabetic Ketoacidosis – Hypoglycemic Coma CO Poisoning: Selective for Globus Pallidus Extrinsic Toxic Exposure – CO – Methanol. Sinus Corpus Callosum Sella Region Clivus Coma at home after Ice Storm – Axial Images Skull.1° CNS Lymphoma 71 yo AA man with a history of HIV/AIDS presented with gait instability Low SI mass lesions in the right MCP. Ethylene Glycol – Solvent Leukoencephalopathy MR and CT Imaging Checklists Anatomic Locations – Sagittal Images Sup. and left thalamus with surrounding vasogenic edema The T1weighted post gadolinium images show predominantly ring enhancement with areas of central necrosis MR and CT Imaging Checklists Anatomic Locations – Sagittal Images Sup. Sag. Sag. left insula.

Sinus Corpus Callosum Sella Region Clivus 3rd Ventricle Cysticercosis Positional Headaches – Axial Images Skull. Sinus Corpus Callosum Sella Region Clivus MR and CT Imaging Checklists Anatomic Locations – Sagittal Images Sup. Epi/Sub Epi/Sub Dural SAS Cortical Gray Matter White Matter Deep Gray Matter Ventricles MR and CT Imaging Checklists Anatomic Locations – Sagittal Images Sup. Epi/Sub Epi/Sub Dural SAS Cortical Gray Matter White Matter Deep Gray Matter Ventricles Intraventricular Meningioma McCain .MR and CT Imaging Checklists Anatomic Locations – Sagittal Images Sup.Palin . Sag. Sinus Corpus Callosum Sella Region Clivus – Axial Images Skull. Sag. Epi/Sub Epi/Sub Dural SAS Cortical Gray Matter White Matter Deep Gray Matter Ventricles – Axial Images Skull. Sag.Smirniotopoulos John … How did we Lose? .

g. Epi/Sub Epi/Sub Dural SAS Cortical Gray Matter White Matter Deep Gray Matter Ventricles – Abnormal WM Signal Vasogenic Edema Demyelination Infiltrating neoplasm – Abnormal WM Signal Vasogenic Edema Demyelination Infiltrating neoplasm – Ring Lesion Necrotic Neoplasm Reactive (e.g. proportional Less than expected No mass effect – Axial Images Skull. proportional Less than expected No mass effect f – Abnormal WM Signal Vasogenic Edema Demyelination Infiltrating neoplasm – Ring Lesion Necrotic Neoplasm Reactive (e. abscess) Fluid or Inflammatory MR and CT Imaging Checklists Obtunded w/blown pupil Brain Herniation Syndromes Morphologic Features – Mass Effect Yes. abscess) Fluid or Inflammatory – Ring Lesion Necrotic Neoplasm Reactive (e. proportional Less than expected No mass effect Morphologic Features – Mass Effect Yes.g. Sinus Corpus Callosum Sella Region Clivus MR and CT Imaging Checklists Morphologic Features – Mass Effect Yes. abscess) Fluid or Inflammatory t t Brain Herniation Syndromes Pupillary Reaction f C t U M t Blown Pupil: T T CNN3 (Oculomotor) nerve ipsilateral to the mass lesion.MR and CT Imaging Checklists Anatomic Locations – Sagittal Images Sup. Note CNN4 . Sag.

proportional Less than expected No mass effect – Abnormal WM Signal Vasogenic Edema Demyelination Infiltrating neoplasm – Ring Lesion “Blown Pupil” Necrotic Neoplasm Reactive (e. proportional Less than expected No mass effect Morphologic Features – Mass Effect Yes.g.Pupil .g. proportional Less than expected No mass effect – Abnormal WM Signal Vasogenic Edema Demyelination Infiltrating neoplasm – Abnormal WM Signal Vasogenic Edema Demyelination Infiltrating neoplasm – Ring Lesion Necrotic Neoplasm Reactive (e. abscess) Fluid or Inflammatory – Ring Lesion Necrotic Neoplasm Reactive (e.g. abscess) Fluid or Inflammatory Two Pts: Compare Mass Effect Long-standing Headache (yrs) New onset Seizures AVM – No Mass Effect GBM – Has Mass Effect . HA.Intrinsic Ocular Muscle MR and CT Imaging Checklists Morphologic Features – Mass Effect Yes. Hemiplegia MR and CT Imaging Checklists Long-standing Headache (yrs) Morphologic Features – Mass Effect Yes. abscess) Fluid or Inflammatory MR and CT Imaging Checklists BP 180/135.

abscess) Fluid or Inflammatory Vasogenic Edema A type of interstitial edema produced by abnormally increased capillary permiability Spreads from site of abnormal vessels at ~7~7-10 mm/week May reach a steadysteady-state – can’ can’t estimate age of lesion from extent of edema Spreads along association tracts > corticocorticospinal tracts >>> commissures FingerFinger-like pseudopods of watery white matter Meningioma with extensive Edema MR and CT Imaging Checklists Morphologic Features – Mass Effect Yes.g. proportional Less than expected No mass effect Glioblastoma Multiforme – Abnormal WM Signal Vasogenic Edema Demyelination Infiltrating neoplasm – Ring Lesion Necrotic Neoplasm Reactive (e. abscess) Fluid or Inflammatory Neoplastic cells extend into the edema … and beyond. proportional Less than expected No mass effect – Abnormal WM Signal Vasogenic Edema Demyelination Infiltrating neoplasm – Ring Lesion Necrotic Neoplasm Reactive (e.g. into the “normal” WM T1-gad T2 .MR and CT Imaging Checklists Morphologic Features – Mass Effect Yes.

proportional More than expected No mass effect – Abnormal WM Signal Vasogenic Edema Demyelination Infiltrating neoplasm – Ring Lesion Necrotic Neoplasm Reactive (e. proportional Less than expected No mass effect – Abnormal WM Signal Vasogenic Edema Demyelination Infiltrating neoplasm – Ring Lesion Necrotic Neoplasm Reactive (e. abscess) Fluid or Inflammatory . proportional Less than expected No mass effect – Abnormal WM Signal Vasogenic Edema Demyelination Infiltrating neoplasm – Ring Lesion Necrotic Neoplasm Reactive (e. HIV+ Lesion w/o Mass Effect .g.g. abscess) Fluid or Inflammatory Courtesy Doug Phillips.MR and CT Imaging Checklists Seizure and Obtundation Hemorrhage into a PrePre-existing mass Acute hemiplegia and confusion in a 68 year old man Morphologic Features – Mass Effect Yes. UVA GBM MR and CT Imaging Checklists Variable and Confusing Sx Morphologic Features – Mass Effect Yes. abscess) Fluid or Inflammatory NOTE: Vasogenic Edema Courtesy Doug Phillips.PML Morphologic Features – Mass Effect Yes.g. UVA MR and CT Imaging Checklists Severe HA.

affects the corpus callosum Courtesy Jacqueline Bello. HIV+ Morphologic Features – Mass Effect Yes. died from PML in 1971 Lysis of Oligodendrocytes Demyelination Geographic and Peripheral – Little or No Mass Effect – Little or No Enhancement Poor Survival of 22-6 months reported Improved survival w/ HAART . abscess) Fluid or Inflammatory .D.up to 33-4 years MR and CT Imaging Checklists Severe HA.g. Progressive Multifocal Leukoencephalopathy WM Disease . Hodgkins. No Mass. Looks like vasogenic edema … but.JC Papova/Polyoma Virus – Initials of first patient cultured (1) John Cunningham Tx for Hodgkins. M. proportional Less than expected No mass effect – Abnormal WM Signal Vasogenic Edema Demyelination Infiltrating neoplasm – Ring Lesion Necrotic Neoplasm Reactive (e.D. No Enhancement Courtesy Jacqueline Bello. no mass Looks like vasogenic edema Courtesy Jacqueline Bello. M. no enhancement ! Courtesy Jacqueline Bello.D.T2W – Geographic hyperintensity FLAIR Geographic hyperintensity. M. T1 w/Gd – No enhancement PML Looks like vasogenic edema … but.D. M.

proportional Less than expected No mass effect – Abnormal WM Signal Vasogenic Edema Demyelination Infiltrating neoplasm – Ring Lesion Necrotic Neoplasm Reactive (e.PML MR and CT Imaging Checklists Morphologic Features – Mass Effect Yes. T2 T1-gad Infiltrates through White Matter Tracts Gliomatosis Cerebri CHO Cr NAA ? { . This is NOT edema secondary to a lesion.g. This is the tumor itself infiltrating through the white-matter. Vasogenic edema often spares the internal capsule. abscess) Fluid or Inflammatory WHO Gr 2 Astrocytoma (“gliomatosis cerebri” cerebri”) (“edema edema” ” w/o contrast enhancement) Gliomatosis Cerebri: Cerebri: Diffuse Astrocytoma – 2 lobes NOTE: Although this looks like “vasogenic edema” – there is no enhancement.

HA.g. Recent Dental work Morphologic Features – Mass Effect Yes. abscess) Fluid or Inflammatory – Ring Lesion Necrotic Neoplasm Reactive (e. abscess) Fluid or Inflammatory MR and CT Imaging Checklists Fever. abscess) Fluid or Inflammatory Mag. proportional Less than expected No mass effect Abscess – Abnormal WM Signal Vasogenic Edema Demyelination Infiltrating neoplasm – Ring Lesion Necrotic Neoplasm Reactive (e.g. proportional Less than expected No mass effect – Abnormal WM Signal Vasogenic Edema Demyelination Infiltrating neoplasm – Abnormal WM Signal Vasogenic Edema Demyelination Infiltrating neoplasm – Ring Lesion Necrotic Neoplasm Reactive (e.g. it can’t be “vasogenic” edema? Why does it look like like interstitial vasogenic edema? Microcystic change Neovascularity w/BBB causes contrast Enhancement and “vasogenic” edema Gr 4 Astrocytoma Gr 2 Astrocytoma MR and CT Imaging Checklists Morphologic Features – Mass Effect Yes.T1W Gd+ Gd+ in Two Astrocytomas Without Contrast Enhancement. susceptibility from atomic oxygen in macrophages . proportional Less than expected No mass effect MR and CT Imaging Checklists Morphologic Features – Mass Effect Yes.

med. pp. – Ring Lesion Necrotic Neoplasm Reactive (e.Toxo MR and CT Imaging Checklists Morphologic Features Fluid Secreting Pilocytic Astrocytoma Neoplasm + thin rim of enhancing Nodule – Mass Effect Yes. 878-885 GBM Abscess . and it is not influenced by the etiological agents responsible for its causation.g. reson.UNC DWI: Necrosis vs. proportional Less than expected No mass effect gliosis – Abnormal WM Signal Vasogenic Edema Demyelination Infiltrating neoplasm 5 min .” Magn. PUS Ring Lesion Differences GBM Abscess “We conclude that viable cell density is the main biological parameter responsible for restricted diffusion in brain abscess. vol. 2005.Abscess Brain Abscess AA Peaks Inverted AA Peaks DWI Viscous Pus and Coagulation Necrosis Short TE MRS Long TE MRS MRS Courtesy of Mauricio Castillo . no4. 54. abscess) Fluid or Inflammatory “Cyst” .

Fluid Secreting Tumor: Pilocytic Astrocytoma Fluid Secreting Tumor: Pilocytic Astrocytoma NOTE: Fluid has protein – not identical to CSF signal nor attenuation Fluid Secreting Tumor: Ganglioglioma Enhancement w/o Vasogenic Edema “open ring sign” sign” Absent vasogenic edema … signal abnormality ends at edge of enhancement Open (Incomplete) Ring Sign Demyelinating Disease FluidFluid-secreting “Cystic” Cystic” Neoplasms Inflammatory Breakdown of the blood-brain-barrier from Enhancement w/o Vasogenic Edema a Demyelinating Lesion Masdeau JC. Leslie D. Masdeu JC. Moreira J. Neurology 2000. Visintainer P: Openring imaging sign: highly specific for atypical brain demyelination. J. “incomplete ring” ring” Absent vasogenic edema … signal abnormality ends at edge of enhancement & incomplete ring . 6(2):104-107. Quinto C. Olivera C. Visintainer P. A new imaging sign in demyelinating disease. Cavaliere R. 54(7):1427-1433. Tenner M. Trasi S. Grundman M: The open ring.Neuroimaging 1996.

with Lethargy – Axial Images Skull. Sag. Sinus Corpus Callosum Sella Region Clivus Morphologic Features – Mass Effect Yes. Sinus Corpus Callosum Sella Region Clivus MR and CT Imaging Checklists Anatomic Locations – Sagittal Images Sup.g. Sag.o.31 yo ♀.Multiple Sclerosis “open ring sign” sign” Enhance for 3-8 weeks Summary Perivenular Absent vasogenic edema … signal abnormality ends at inflammation edge of enhancement & incomplete ring MR and CT Imaging Checklists Anatomic Locations – Sagittal Images Sup. Epi/Sub Epi/Sub Dural SAS Cortical Gray Matter White Matter Deep Gray Matter Ventricles DWI ADC Medial Lenticular – Globus Pallidus . Epi/Sub Epi/Sub Dural SAS Cortical Gray Matter White Matter Deep Gray Matter Ventricles – Abnormal WM Signal Vasogenic Edema Demyelination Infiltrating neoplasm – Axial Images Skull. Sag. proportional Less than expected No mass effect 2 y. abscess) Fluid or Inflammatory Cerebral Infarction MCA MR and CT Imaging Checklists Anatomic Locations – Sagittal Images Sup. Sinus Corpus Callosum Sella Region Clivus Coma at home after Ice Storm 2 hrs of Sx 4 hrs of Sx – Axial Images Skull. Epi/Sub Epi/Sub Dural SAS Cortical Gray Matter White Matter Deep Gray Matter Ventricles – Enhancing Ring Lesion Necrotic Neoplasm Reactive (e.

usuhs. UVA Mahalo ! Dank u wel ! Merci Beaucoup Muchas Gracias Go Raibh Maith Agat Danke Schön ! . it can’t be “vasogenic” edema … it must be tumor infiltration Two Pts: Compare Mass Effect Long-standing Headache (yrs) New onset Seizures Neovascularity w/BBB causes contrast Enhancement and “vasogenic” edema Gr 4 Astrocytoma Gr 2 Astrocytoma AVM – No Mass Effect GBM – Has Mass Effect Hemorrhage into a PrePre-existing mass Acute hemiplegia and confusion in a 68 year old man Thank You! Muito Obrigado Visit us on the web: ありがとうございます。感謝いたします。 rad.edu EUXAPIΣTΩ ! NOTE: Vasogenic Edema Courtesy Doug Phillips.T1W Gd+ Gd+ in Two Astrocytomas Without Contrast Enhancement.

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