NEURO

Epidural Hematoma
• Often result from skull fracture that disrupts middle meningeal
artery
– Skull fractures seen in 85-95%
• Most are temporal or temporoparietal
• Venous epidural hematomas less common
– Tend to occur at vertex, posterior fossa, or anterior aspect of middle
cranial fossa
• Findings
– Well-defined, high-attenuation lenticular or biconvex extra-axial
collection
– Usually will not cross cranial sutures
 Meningioma
• MC extra-axial tumor
• MC locations: parasagittal dura, convexities, CPA cistern, olfactory groove,
planum sphenoidale, cavernous sinus, intraventricular (trigone of lateral
ventricle)
• NCCT: 60% hyperdense, 20% Ca+
• MR: iso to slightly hypo T1, iso to hyper T2
• Angio: “mother-in-law” sign
• Can have cystic, osteoblastic, chondromatous, fatty degeneration
• Enhance avidly
• Edema variable, somewhat related to size
• 72% have dural tail
• May encase arteries
• Multiple meningiomas in NF2
• MC tumor post radiation
• Signs of extra-axial mass
– Buckle gray-white jxn, expand ipsilateral CSF space,
may have bony reaction/hyperostosis
• DDx extra-axial mass in adult: meningioma,
dural mets, skull mets, lymphoma, epidermoid,
arachnoid cyst, schwannoma, neurofibroma
CPA Cistern
Olfactory Groove
Sphenoid Ridge, Optic Nerve Sheath
Intraventricular
Foramen Magnum
Angiography
• Hemangiopericytoma
– Resemble meningiomas, but have narrower dural
attachment, are lobulated instead of hemispheric, are
heterogeneous, destroy bone instead of causing
hyperostosis, do not calcify, and have larger internal
vessels on MR
Hemangiopericytoma
 Suprasellar Aneurysm
• ALWAYS include aneurysm in sellar DDx
• If seen on CT, ask for contrast or MR
• MR: flow void or layers of thrombus, pulsation
artifact (phase encoding)
• Also shown: CPA cistern (PICA, AICA,
vertebral), PComm, basilar tip, MCA trifurcation
aneurysms
CPA Cistern Aneurysm
PComm Aneurysm
Basilar Tip Aneurysm
MCA Trifurcation
PICA
Mycotic Aneurysm
 Cerebral Venous Sinus Thrombosis

• Risk factors: dehydration, hypercoagulable state,

pregnancy, sepsis, meningitis, tumor invasion
• Consider venous infarct for the following
– Young patient
– Not corresponding to a vascular territory
– Hemorrhage
– Rounded
– Sparing cortex
– Bilateral parasagittal
Cerebral Venous Sinus Thrombosis
Cerebral Venous Sinus Thrombosis
Mastoiditis w/Sinus Thrombosis
 Pineal Mass (Germinoma)
• Posterior aspect of 3rd ventricle on axial images, top of
midbrain colliculi on sagittal
• Germinoma
– NCCT: hyperdense
– MR: intermediate T1, slightly hypo T2
– Often see Ca+ pineal adjacent to it
• Pineocytoma and pineoblastoma
– NCCT: hyperdense
– MR: intermediate T2
– Both enhance avidly
– May explode the pineal Ca+, displacing it peripherally
• Pineal cysts
– NCCT: slightly hyperdense to CSF
– May appear to have rim enhancement, probably normal
enhancing pineal tissue around it
• Other pineal lesions: teratoma (contains fat),
choriocarcinoma, embryonal cell CA
• Look for hydrocephalus (often seen w/pineal lesions
obstructing posterior 3rd ventricle or aqueduct of Sylvius)
• Parinaud: paralysis of upward gaze
• Should never see pineal Ca+ before 7 y
Pineocytoma
Pineal Cyst
 Acute MCA Infarct
• CT
– Hyperdense MCA
– Insular ribbon
• MR
– T2 edema begins at 8 h
– Prior to this, may see abnormal arterial enhancement in area of
infarct due to vessels with slow flow
– May also show absence of flow voids on unenhanced spin echo
MR
 Ring-Enhancing Lesions
(Lung CA Metastases)
• DDx ring-enhancing lesion (“MAGICL DR”)
– Mets
– Abscess (multiple favors hematogenous spread, also include
fungal and parasitic)
– Glioma
– Infarct
– Contusion
– Lymphoma
– Demyelinating
– Resolving hematoma
• Ask about immune status
– If compromised, discuss toxoplasmosis vs. lymphoma
– Favor toxo: multiple, BG location, eccentric nodule
– Favor lymphoma: periventricular location, callosal
involvement, hyperdensity on NCCT, iso/hypointensity on T2,
subependymal spread, ventricular encasement
– PET or SPECT thallium are better than MR
• Lymphoma is hot on PET and thallium, but toxo is not
– Another way to distinguish is by trial of antitoxo meds (f/u
imaging in 14 d), or if needed, biopsy
• Discriminators
– DWI restriction: infarct, pyogenic abscess, cellular
tumors (lymphoma, PNET), some demyelinating
lesions
– MR perfusion
• Elevated rCBV: mets (nonelevated peritumoral rCBV),
glioma (elevated peritumoral rCBV)
– MR spectroscopy
• High Cho: mets, glioma
• Decreased metabolites: infarct (elevated rCBV in
penumbra), abscess, demyelinating, radiation necrosis
• Lactate: ischemia, inflammation, infection
• Other amino acids, acetate, succinate: abscess
Radiation Necrosis
Radiation Necrosis
Abscess
Toxoplasmosis
Toxoplasmosis
Tuberculoma
Aspergillosis

• Findings related to
angioinvasion
– Hemorrhage,
infarcts,
aneurysms
Subacute Lenticulostriate Infarct
Contusion
 Multiple Sclerosis
• CT: hypodense
• MR: iso to low T1 and high T2, best seen on FLAIR
• 2-20% have isolated spine MS plaques
• Brain lesions may be punctate or large and confluent
• Corpus callosum has very high sensitivity and specificity
• Dawson fingers: ovoid periventricular lesions
• Tumefactive MS: mass with enhancement
• Acute MS may enhance (nodular or ring pattern) for 2-8 w
• Optic neuritis: high signal in optic nerve on T2 w/enhancement and
enlargement of nerve
• Spine MS: intramedullary lesion, get brain MR
• DDx: Lyme disease, ADEM, vasculitis
• Devic disease (neuromyelitis optica): optic neuritis
(often bilateral) + acute transverse myelitis
– Spinal lesions (compared to MS) tend to be large: > 3
vertebral segments, across full cord thickness on axial
• Marburg: acute, fulminant variant
– Large confluent white matter lesions w/edema, possible
enhancement
• Balo concentric sclerosis: rare variant
– Irregular, concentric zones of increased signal on T2
MR
Dawson Fingers
Tumefactive MS
Optic Neuritis
Spine MS
• MC spinal cord “inflammatory” disorder
• Isolated spinal cord disease in < 20%
• 2/3 of lesions occur in cervical region
• Findings
– High T2/STIR lesions
– Usually no significant change in cord diameter
(occasionally, subtle cord expansion in acute phase,
mild atrophy in chronic phase)
– Enhancement correlates with acute lesion activity
– Plaques tend to be peripheral (white matter)
– Typically shorter than two vertebral segments in
length and involve less than half the cross-sectional
area of the cord
• If suspected MS, get MR brain
Balo Concentric Sclerosis
 DDx: Acute Disseminated
Encephalomyelitis (ADEM)
DDx: Vasculitis (SLE)
Vasculitis
 Glomus Tumor (Jugulare)
• Jugulare
– Destruction of jugular foramen
• Tympanicum
– May have pulsatile tinnitus
– Typical location is adjacent to cochlear promontory
• Carotid body tumor
– At bifurcation of common carotid artery
• Vagale
– Usually displaces carotid anteriorly in parapharyngeal space
• DDx: schwannoma, meningioma, mets
• MR enhancement pattern of glomus tumors is specific
– Intense enhancement in first 60 s, dip in the enhancement at 20-40 s
– Salt & pepper
– Remember not to give iodinated contrast to pt w/known glomus w/o alpha
adrenergic blockade, may get hypertensive crisis
Glomus Tympanicum
Glomus Tympanicum
Carotid Body Tumor
Glomus Vagale
 Hemangioblastoma
• Usually posterior fossa intra-axial cyst w/enhancing mural nodule,
off midline, in an adult
• Spinal hemangioblastoma
– Enlarged cord w/cystic and some solid, round, enhancing nodules
(intramedullary in 60%, extra in 40%) and prominent flow voids around
cord
• Lesions may be multiple and usually have edema
• May cause hypertension b/c they secrete erythropoietin
• 25-40% associated w/VHL
– Capillary hemangioblastomas of the CNS and retina
– Cysts, renal clear cell carcinoma
– Pheochromocytoma
– Pancreatic cysts, islet cell tumors
– Endolymphatic sac tumors
– Epididymal cysts, cystadenomas
Spinal Hemangioblastoma
Endolymphatic Sac Tumor
 Melanoma Metastases
• NCCT: hemorrhagic/hyperdense lesions
• MR: high T1 and iso to low T2
• DDx: hemorrhagic mets (breast, lung, renal,
thyroid, chorioCA, retinoblastoma, melanoma),
hemorrhagic GBM/primary, multiple cavernous
angiomas, angioinvasive infections (aspergillosis,
zygomycosis)
• Ask if pt has a known primary/skin lesion
RCC Metastasis
Zygomycosis
 Mucocele
• CT: isodense smooth mass, epicenter in sinus, expands
and thins sinus wall
• MR: usually high T1 and T2, but can be low T2 if high
protein
• Peripheral enhancement is very important in
distinguishing from a tumor
• “FEMS”: frontal > ethmoid > maxillary > sphenoid
• Diplopia or proptosis from orbital compression
(extraconal lesion)
• Often h/o sinusitis, allergy, trauma
 Ependymoma
• Soft or “plastic” tumor: squeezes out through 4th
ventricle foramina into cisterns
• 2/3 infratentorial, 4th ventricle
• 1/3 supratentorial, majority periventricular WM
(intraparenchymal)
• Ca+ common (50%); +/- cysts, hemorrhage
• MR: iso to hypo T1, iso to hyper T2
• Enhances heterogeneously
• DDx: medulloblastoma/PNET
• Tumors w/CSF dissemination
– Medulloblastoma/PNET
– Pineoblastoma
– Ependymoma
– Choroid plexus CA
DDx: Medulloblastoma/PNET
Supratentorial Ependymoma
 Callosal Agenesis
• CT/MR findings
– Missing part/all of CC, starts from splenium
– High riding 3rd ventricle
– Widely spaced parallel lateral ventricles
– Enlarged Probst bundles (WM track) b/w frontal horns
– Steer horn-shaped (and pointed) frontal horns
– Interhemispheric fissure extends to 3rd ventricle
– Colpocephaly
– Absent/inverted cingulate gyrus
• Assoc w/agyria, pachygyria, Dandy-Walker,
heterotopias, septo-optic dysplasia, Chiari
Callosal Dysgenesis w/Lipoma
Callosal Dysgenesis w/Lipoma
Hypogenesis
 Spinal Epidural Abscess
• Findings of spondylodiskitis with adjacent enhancing
epidural phlegmon +/- peripherally enhancing fluid
collection
• Posterior epidural space (80%), anterior (20%),
circumferential (caudal to S2)
• Lower thoracic and lumbar > cervical and upper thoracic
• T1WI: iso to hypointense to cord
• T2WI: hyperintense
• Enhancing phlegmon on T1 C+
• Peripherally enhancing necrotic abscess on T1 C+
• S aureus MC, TB next MC
Diskitis/Osteomyelitis
 Isodense Subdural Hematoma
• Look for sulcal effacement, buckling of
grey/white jxn, midline shift, mass effect
• Causes of isodense subdural: subacute timing
(b/w acute and chronic), DIC, tear of dura
(mixture of blood and CSF), anemia
Acute on Chronic SDH
 Pituitary Macroadenoma
• Pituitary adenoma
– Micro (< 10 mm)
• 75% present w/hormonal symptoms (others w/bitemporal hemianopsia,
headache, cranial nerve abnormality)
• MR: low T1, variable T2, easier to see postcontrast (hypoenhancing),
mild downsloping of sphenoid sinus roof, upward convexity of
diaphragma sella, deviation of stalk
– Macro (> 10 mm)
• Propensity for hemorrhage and infarction
• Can get apoplexy
• Snowman appearance from sellar adenoma growing through
diaphragma sella
Pituitary Microadenoma
Pituitary Apoplexy
• DDx sellar/suprasellar lesion
– Aneurysm
– Pituitary adenoma
– Craniopharyngioma: Ca+, partially cystic, solid/nodular
enhancement
– Meningioma
– Pilocytic astrocytoma
– Others: arachnoid cyst, Rathke cleft cyst, sarcoid, EG,
germinoma, dermoid/epidermoid cyst, lymphocytic
hypophysitis, tuber cinereum hamartoma, mets, tuberculoma
Craniopharyngioma
Craniopharyngioma
Dermoid
Sarcoid
Tuber Cinereum Hamartoma
TB/Fungal Meningitis
Chordoid Glioma

• Characteristic location
(hypothalamus, anterior
third ventricle)
• Ovoid shape
• CT: hyperdense
• Uniform intense contrast
enhancement
 Optic Nerve Glioma
• Type of pilocytic astrocytoma
• 2/3 of primary optic nerve tumors
• Mean age 8 y
• 30-40% associated w/NF 1, often bilateral
• CT: enlarged optic nerve and canal, fusiform or nodular
• Variable enhancement, Ca+ rare
• MR: iso T1, iso to high T2, except in NF, often is low in center on
T2 w/high signal at periphery, called arachnoidal gliomatosis
• KEY: glioma has epicenter on optic nerve and cannot be
distinguished from the nerve
• Pt age is very helpful (peds)
Bilateral Optic Nerve Gliomas (NF 1)
 Optic Nerve Sheath Meningioma
• Enhancing mass surrounding intraorbital optic nerve w/Ca+
• “Tram-tracking”: tumor enhancement or calcification on either
side of optic nerve
• “Perioptic cysts”: ↑ CSF w/in nerve sheath surrounding distal
optic nerve between tumor and globe
• CT: hyperdense
• MR: iso T1, variable T2
• DDx nerve sheath enhancement: sarcoid, mets, lymphoma,
pseudotumor
 Choroid Plexus Papilloma
• Majority occur in pts < 5 y
• 50% in atrium of lateral ventricle, left > right
• 40% in 4th ventricle (posterior medullary velum) & foramina
of Luschka
• Hydrocephalus usually due to overproduction of CSF by the
tumor
• CT: hyperdense, frondlike, 25% have Ca+
• MR: low T1, mixed T2, heterogeneous from hemorrhage,
Ca+, and flow voids
• Enhance dramatically
Choroid Plexus Papilloma
• Choroid plexus carcinoma
– Child < 5 y w/enhancing intraventricular mass, ependymal invasion
– Ca+ 20-25%
– Heterogeneous enhancement +/- CSF seeding
– Enhanced MR of entire neuraxis prior to surgery
– May be difficult to differentiate from papilloma
• DDx intraventricular mass: choroid plexus tumors (peds),
meningioma, mets, ependymoma, subependymoma (frequently
multiple, most do not enhance), astrocytoma, central neurocytoma
(oligodendroglioma), colloid cyst, subependymal giant cell
astrocytoma (foramen of Monro)
DDx: Choroid Plexus Carcinoma
DDx: Central Neurocytoma
DDx: Subependymoma
 Herpes Encephalitis
• HSV 1
• MR: high T2 in medial temporal lobe(s) and inferior frontal
lobe(s), with enlargement, restricted diffusion
– Involves limbic system: temporal lobes, insula, subfrontal area, cingulate
gyri
– Basal ganglia usually spared
• CT: often normal early
• May have hemorrhage
• Enhancement variable, may be patchy, gyriform, meningeal
• Often bilateral but asymmetric
• Tx: acyclovir
 Heterotopic Gray Matter
• GM located in wrong place due to arrest of
neuronal migration
• Seizures and developmental delay
• CT: difficult to see, same density as GM
• MR: isointense to GM on all sequences
• No Ca+, no enhancement
• Subependymal (MC), subcortical, and band
heterotopias
 CSF, Vessels w/in
Subcortical Heterotopia
 Manganese Toxicity
• Attributed to ↑ manganese (Mn) levels
• Also seen with TPN  high serum Mn levels
• Bilateral symmetric globus pallidus ↑ T1
– Common in pts w/chronic liver disease
• DDx high T1 signal BG: physiologic Ca+, NF 1 (GP),
hepatic encephalopathy, TPN, HIE, CO poisoning (GP),
kernicterus (GP), Wilson disease (GP), endocrine
(hypothyroid, any parathyroid), Fahr disease
• DDx high T2 signal BG
– Infection: encephalitis (viral MC), Creutzfeldt-Jakob, cryptococcosis,
toxoplasmosis
– Toxic/metabolic: Leigh, Wilson, MELAS, MERRF, osmotic demyelination
syndrome, CO poisoning
– Ischemia: HIE, lenticulostriate infarct
– Neoplasm: lymphoma, gliomatosis cerebri, mets, primary
– NF 1 (myelin vacuolization)
– ADEM
– Vasculitis: SLE, HUS, infection (bacterial/TB meningitis)
– Drug abuse: amphetamines (stroke, vasculitis)
– Huntington (caudate, putamen)
– Hallervorden-Spatz
Creutzfeldt-Jakob Disease
Cryptococcosis
 Cryptococcosis
(Gelatinous Pseudocysts)
Leigh Disease
Osmotic Demyelination Syndrome
 Hallervorden-Spatz Disease
(Pantothenate Kinase-associated
Neurodegeneration)
 Tuberculous Meningitis
• DDx leptomeningeal enhancement: infection (bacterial,
viral, fungal), tumor, sarcoid
• Infection
– Classic is TB with basilar meningitis
– Basal cisterns are most affected
– Epicenter at interpeduncular cistern, w/spread to prepontine,
sylvian, superior cerebellar cistern
– May get hydrocephalus
– Fungal disease causes same findings, less often bacteria
(Listeria)
• Sarcoid
– Looks like TB
– Get CXR and ACE level
• Neoplasm
– Primary CNS, mets from lung, breast, leukemia,
lymphoma
• DDx pachymeningeal enhancement: postoperative,
ventriculostomy catheters, intracranial
hypotension, meningioma, mets (breast, prostate),
secondary CNS lymphoma, granulomatous disease
Neurosarcoid
Neurosarcoid
Leptomeningeal Metastases
Pachymeningeal Enhancement
(Intracranial Hypotension)
Pachymeningeal vs. Leptomeningeal
Gyral Enhancement

• DDx
– Vascular: reperfusion of
ischemic brain, migraine,
PRES, seizures
– Inflammatory: meningitis,
encephalitis
 Nodular Cortical and
Subcortical Enhancement

• DDx
– Hematogenous
dissemination of
metastatic neoplasms and
clot emboli
Open Ring Enhancement

• DDx
– Multiple sclerosis (without
mass effect)
– Tumefactive
demyelination (with mass
effect)
– Fluid-secreting neoplasms
(with mass effect and
occasionally with
surrounding vasogenic
edema)
Periventricular Enhancement

• DDx
– Primary CNS lymphoma
– Primary glial tumors
– Infectious ependymitis
 Parotid Benign Mixed Tumor
• AKA pleomorphic adenoma
• DDx parotid lesions: benign tumor, malignant tumor,
lymphoepithelial, inflammatory
• Benign tumors
– 80% of parotid masses
– Most are pleomorphic adenomas
• Well-defined, smooth +/- capsule
• CT: similar in density to muscle
• MR: hypo T1, bright T2
• 20% malignant degeneration (CA ex pleomorphic adenoma)
– Warthin
• Next MC benign tumor
• 20% multicentric, unilateral or bilateral
• Cystic component in 30%
• Favors parotid tail
• Elderly men
• MR: heterogeneous, hypo T1, variable T2
• NM: hot on Tc-99m pertechnetate
– Less common: oncocytoma (looks like BMT),
hemangioma (peds, very bright T2, intense enhancement
+/- phleboliths), neurofibroma, schwannoma (CN 5 or 7),
lipoma
Warthin Tumor
Warthin Tumor
• Malignant tumors
– Frequently cause facial nerve paralysis clinically
– MR: generally dark on T2, but variable
– Mucoepidermoid CA is MC malignant parotid tumor
– Cannot rely on border or shape to distinguish malignant from
benign in parotid
– Always include in parotid tumor DDx
– Others: adenoid cystic CA, squamous cell CA, adenocarcinoma,
undifferentiated, basal cell and squamous cell CA from skin or
EAC, acinic cell (rare)
• Generally need biopsy for any parotid tumor
Mucoepidermoid Carcinoma
Lymphoma
• Inflammatory/infectious
– Look for stranding in adjacent fat
– Etiologies: sialolith, viral (esp mumps), bacterial, autoimmune (Sjogren),
sarcoid
• Lymphoepithelial cysts
– AIDS
– Usually multiple bilateral
– In younger pt, think of this instead of Warthin, which usually involves
older group
– CT/MR: cystic parts follow CSF density/intensity
• DDx multiple bilateral parotid lesions: lymphoepithelial cysts,
Warthin, Sjogren, sarcoid, mets, acinic CA
Calculus-Induced Parotitis
Sjogren Syndrome
Benign Lymphoepithelial Lesions of HIV
 Dermoid, Orbit
• DDx lacrimal gland lesion
– Benign mixed tumor
– Lymphoma
– Idiopathic orbital inflammatory disease (pseudotumor)
– Adenoid cystic CA
– Sarcoidosis
– Sjogren
– Dermoid and epidermoid, orbit
• Can tell dermoid by fat/fluid level, o/w cannot
really distinguish lesions
• If bone destruction, favor malignant
Sarcoid
 Tuberous Sclerosis
• Seizures, mental retardation, facial angiofibroma (adenoma sebaceum)
• Associated findings
– Renal: angiomyolipoma and cysts 40-80%
– Cardiac: rhabdomyomas 50-65%; majority involute
– Lung: lymphangioleiomyomatosis/fibrosis
– Solid organs: adenomas, leiomyomas
– Skin: ash-leaf spots (majority) including scalp/hair; facial angiofibromas;
shagreen patches 20-35% post pubertal
– Extremities: subungual fibromas 15-20%; cystic bone lesions; undulating
periosteal new bone formation; bone islands
– Ocular: giant drusen (astrocytic hamartoma) (50%)
– Dental pitting of permanent teeth in most adults with TS
• CNS
– Periventricular subependymal nodules, cortical and subcortical
tubers, WM lesions, and subependymal giant cell astrocytomas
– 80% of subependymal tubers are Ca+, 50% of parenchymal
tubers Ca+
– MR
• Subependymal nodules (30-80%), cortical tubers (12%), SGCA enhance
• Tubers low T1, high T2
• If Ca+, low signal
– CT: only SGCA enhance
– SGCA
• Hallmarks are growth and enhancement
• Often causes obstructive hydrocephalus b/c located at/near foramen of
Monro
 Esthesioneuroblastoma
• Arises from the olfactory nerve
• Causes nasal obstruction, epistaxis, decreased sense of
smell
• Often Ca+
• MR: intermediate to low T2, tend to cross cribriform
plate into anterior cranial fossa
• DDx: squamous cell CA (not Ca+), lymphoma, SNUC,
inverted papilloma, adenoCA, chondrosarcoma of nasal
septum, mets
 Cerebellar Infarct,
Vertebral Artery Dissection

• Cerebellar infarction
– Usually occurs in older males
– HA, vertigo, dysarthria, N/V, nystagmus, dysmetria, gait
disturbance
– Check 4th ventricle for symmetry to find subtle mass effect,
and check temporal horns for hydrocephalus
– Can cause upward or downward transtentorial herniation
– Look at vertebral and basilar arteries on MR
• Carotid/vertebral dissection
– 10-25% of infarcts in young, middle-aged pts
– Etiology: spontaneous, HTN, major trauma, trivial
trauma (chiropractic = classic), iatrogenic
– Must ask for MRA or angio
– MR: high T1 from intramural hemorrhage, irregular
or narrow lumen
– Angio: string sign (segmental tapering), sometimes 2
lumens, aneurysmal dilatation, vascular occlusion,
intimal flap, retention/poor washout from dissection
Vertebral Artery Dissection
Carotid Artery Dissection
Carotid Artery Dissection
 Vestibular Schwannoma
• DDx cerebellopontine angle lesion
– Vestibular schwannoma (80%): expands IAC, may
have associated arachnoid cyst (10%)
– Meningioma (11%): dural tail
– Ependymoma (4%): mass in 4th ventricle
– Neuroepithelial cyst (5%)
• Epidermoid (bright DWI), arachnoid cyst (mirrors CSF)
– Aneurysm (PICA, vertebral, basilar): must exclude
 Ependymoma
• If see cystic intramedullary cord lesion, give
contrast to differentiate syrinx from cystic tumor
or syrinx secondary to tumor
• DDx tumor w/secondary syrinx: astrocytoma,
ependymoma, hemangioblastoma
Myxopapillary Ependymoma
• Ependymoma
– Circumscribed, enhancing cord mass with hemorrhage
– Central canal widening: 20%
– Polar (rostral or caudal) or intratumoral cysts: 50-90%
– Focal hypointensity: hemosiderin
– Intense, well-delineated homogeneous enhancement:
50%
– Fusiform cord enlargement
• Astrocytoma
– Usually large, involving full diameter of cord
– Enhances
– Often infiltrating and unresectable
– Cannot reliably distinguish from ependymoma
Astrocytoma
• Hemangioblastoma
– Tends to involve C- and T-spine
– Most have cystic and solid components
– Solid components enhance, may have hemorrhage
– May cause multiple nodules, which can be eccentric,
mimicking an extramedullary tumor
– Flow voids in tumor or prominent posterior draining
veins
– 1/3 have VHL
Hemangioblastoma
 Disk Herniation
• Localized (< 50% of disk circumference) displacement of disk material beyond
confines of disk space
• Protrusion
– Herniated disk with broad-base at parent disk
• Greatest dimension of disk herniation in any plane ≤ distance between edges of the base in same
plane
• Extrusion
– Herniated disk with narrow or no base at parent disk
• Greatest dimension of disk herniation in any plane > distance between edges of the base in same
plane
• Sequestered: free fragment
– Extruded disk without continuity to parent disk
• Migrated
– Disk material displaced away from site of herniation
– Regardless of continuity
• Intravertebral herniation: Schmorl node
Free Fragment
 Trigeminal Schwannoma
• Can be based in middle cranial fossa, Gasserian
ganglion, or posterior fossa
• MR: iso T1, hyper T2, with avid enhancement
• May erode petrous apex (DDx: cholesterol granuloma,
epidermoid, mets, meningioma, chordoma,
chondrosarcoma)
• May enlarge foramen ovale, rotundum, and SOF
• Atrophy of muscles of mastication
Trigeminal Schwannoma
• Meningioma
– Follows lateral margin of the cavernous sinus
– May extend posterior along tentorium in “dove’s tail”
appearance
– Tend to encase ICA rather than displace it, opposite of a
schwannoma
• DDx cavernous sinus/parasellar lesion: aneurysm,
meningioma, trigeminal schwannoma, pituitary
adenoma extending lateral, perineural spread from
mets or H&N lesion, chondrosarcoma from sellar
bone
Parasellar Meningioma
 Thyroid Orbitopathy
• Usually bilateral
• CT: enlarged extraocular muscles (“I’M SLow”),
spares musculotendinous insertions
• Optic nerve compression by enlarged muscles
• Increased orbital fat and proptosis
• Lacrimal glands may be involved
• Orbital pseudotumor
– Usually unilateral
– Involves muscular insertions
– Often involves orbital fat
– Can present as muscle thickening, mass, or stranding
in the fat
– Assoc w/other autoimmune disease: Wegener, PAN,
retroperitoneal fibrosis, sclerosing cholangitis, Reidel
thyroiditis, mediastinal fibrosis
– MR: low T2
– DDx: lymphoma, sarcoid, Wegener
Orbital Pseudotumor
Orbital Lymphoma
 Pilocytic Astrocytoma
• Mostly in peds
• Usually cyst with enhancing mural nodule, off midline
– Occasionally solid, then similar to medulloblastoma,
ependymoma
• May cause hydrocephalus
• DDx tumor w/cyst and mural nodule appearance: JPA
(anywhere), pleomorphic xanthoastrocytoma and
ganglioglioma (temporal lobe), hemangioblastoma
(posterior fossa)
DDx: Ganglioglioma
 Brainstem Glioma
• Majority astrocytomas, usually WHO grade II
• Pontine MC
• Findings: expansile enlargement of brainstem, ventral
pons extends beyond anterior margin of basilar artery,
exophytic growth into cisterns (20%)
• Cranial nerve palsies, pyramidal tract signs, ataxia
• Prognosis guarded (10-30% 5-year survival)
• Tx: chemotherapy and radiation therapy
• DDx brain stem mass lesion
– Brainstem glioma
– Tuberculoma (MC worldwide)
– Lymphoma
– Rhombic encephalitis (Listeria)
– Demyelinating disorders (ADEM, multiple sclerosis)
– Infarction
– Resolving hematoma
– Vascular malformation
 Tethered Cord, Lipoma
• In infant, normal conus should be above L2-3
• Tethered cord: conus ends below L2 inferior
endplate; tethered by thickened filum +/-
fibrolipoma, terminal lipoma
• US: nerve roots do not float freely, filum may be
short and thick (> 2 mm)
• +/- Occult spinal dysraphism such as
lipomyelomeningocele
 Carotid-Cavernous Fistula
• Direct CCF: high-flow, single hole fistula between ICA
and cavernous sinus
– Etiology: trauma (MC), ruptured aneurysm, iatrogenic,
spontaneous (Ehlers-Danlos, Marfan)
• Indirect CCF: dural AVF of cavernous sinus, typically
supplied by numerous ECA +/- cavernous ICA branches
– Etiology: mostly idiopathic
• Pulsatile exophthalmos, orbital bruit, glaucoma
• Enlarged extraocular muscles, proptosis
– DDx: pseudotumor, Graves, CCF
• Dilated superior ophthalmic vein
– DDx: CCF, cavernous sinus thrombosis, venous varix, Graves,
normal variant
• May cause bowing of cavernous sinus outward and extra
flow voids
• Angio: can show communication and may show filling of
superior +/- inferior ophthalmic veins, petrosal sinus to IJ,
and cortical veins
• Tx: detachable balloons, coils
Carotid-Cavernous Fistula
 Vein of Galen Malformation
• Malformation actually involves median
prosencephalic vein
• MC extracardiac cause of high-output CHF in
newborn period
• Classification
– Choroidal (neonatal): multiple feeders from
pericallosal, choroidal, and thalamoperforating arteries
– Mural (infant): few feeders from uni- or bilateral
collicular or posterior choroidal arteries
• US: anechoic lesion posterior to 3rd ventricle
w/flow on Doppler, usually w/hydrocephalus
• NCCT: mildly hyperdense lesion posterior to 3 rd
ventricle in region of quadrigeminal plate cistern
• MR: better evaluation than CT
• Angio: inject as little contrast as needed b/c of
CHF risk
 Synovial Cyst
• Round, sharply-marginated mass immediately
adjacent to a degenerated facet (with fluid in
facet), lateral to thecal sac
• CT: fluid density w/soft tissue rim which may be
Ca+ or have rim enhancement
• MR: fluid or blood intensity, variable
• KEY is recognizing location at facet
 Aberrant Internal Carotid Artery
• ICA deviated posterolaterally into middle ear
• Normal bony partition b/w ICA and middle ear is
missing
• Pulsatile tinnitus
• Look for dehiscence along posterolateral carotid
canal and soft tissue extending onto or near cochlear
promontory
• DDx: glomus tympanicum (on single coronal image,
o/w Aunt Minnie  get axial)
 Hemangioma w/Epidural Extension

• Typical hemangioma
– XR: striated with thick trabeculae and lucent vascular channels
– CT: corduroy, polka dot pattern
– MR: usually bright T1/T2
• Usually asymptomatic, but can lead to compression fx or
extend as extradural mass and compress cord/nerves
• DDx: mets/myeloma, lymphoma, plasmacytoma, Paget,
infection
 Multiple Myeloma:
Focal, Variegated, Diffuse Patterns
Plasmacytoma (“Mini Brain”)
 Epidermoid Cyst
• DDx cystic CPA lesion: arachnoid cyst,
epidermoid cyst
• Difference is on DWI and FLAIR
– Epidermoid slightly higher than CSF on FLAIR,
shows diffusion restriction
– Arachnoid cyst follows CSF signal, no restriction
– Both should not enhance
 Epidermoid Cyst
(Quadrigeminal Plate Cistern)
 Colloid Cyst
• Occur in anterosuperior 3rd ventricle near foramen of
Monro
• Often cause hydrocephalus
• HA worse with tilting head forward
• CT: usually dense
• MR: high T1 (proteinaceous), variable
• Rim enhancement in 40%
• DDx: aneurysm (get MR, check for flow voids,
pulsation)
 Facial Schwannoma
• CT: tubular mass following course of CN 7 w/smooth
enlargement of bony FN canal
• T1 C+ MR: homogeneously enhancing
• Appearance dictated by specific location along CN 7
– Geniculate ganglion: ovoid smooth enlargement of geniculate fossa w/thin
bony walls
– Tympanic segment: pedunculated mass emanates from tympanic segment
into middle ear cavity
– Mastoid segment: either tubular with sharp margins or globular with
irregular margins depending on whether FNS breaks into surrounding
mastoid air cells
 Arteriovenous Malformation
• Large feeding artery (1 or more) and enlarged early
draining veins, plus a cluster of tangled vessels
• Tend to bleed
• NCCT: tangled vessels hyperdense, serpentine or
punctate, +/- curvilinear or speckled Ca+
• MR: curvilinear flow voids and dilated feeding arteries
• MRA: helps map the supply
• Angio: enlarged feeding artery, nidus, and enlarged
veins with early filling
 Spinal AVM
• Type I: dural arteriovenous fistula (DAVF)
• Type II: intramedullary glomus type AVM (similar to brain
AVM)
• Type III: juvenile-type AVM (large complex intramedullary,
extramedullary AVMs)
• Type IV: intradural extra/perimedullary AVF
• Findings
– Type I: flow voids with cord hyperintensity
– Type II: intramedullary nidus (may extend to dorsal subpial surface)
– Type III: nidus may have extramedullary and extraspinal extension
– Type IV: pial fistula (venous varices displace, distort cord)
Type I
Type II
Type III
Type IV
 Periventricular Leukomalacia
• White matter insult, usually in premature
• Watershed infarcts in perforating arteries
• Findings
– Large atria of lateral ventricles
– High T2 signal extending right up to ventricle
– Decreased WM
– Irregular atrial shape
– Cystic cavitation in a periventricular location, mostly at
trigone of lateral ventricles
Cystic PVL
 Progressive Multifocal
Leukoencephalopathy
• Demyelinating disease caused by papovavirus
• AIDS pts
• Large multifocal subcortical WM lesions without mass
effect, enhancement
– Supratentorial subcortical WM MC
– Posterior fossa & thalamus less common
• DDx: HIV encephalitis (atrophy and confluent
symmetric, periventricular/diffuse WM disease), CMV
• Fatal
DDx: HIV Encephalitis
DDx: CMV Ependymitis
 Hypotensive/Hypoxic
Cerebral Infarction
• Cortically-based wedge-shaped abnormality at border-
zone between vascular territories
• Deep white matter (WM) watershed with “rosary” or
“string of pearls/beads” appearance
• Pseudolaminar necrosis = curvilinear gyriform
cortically-based abnormality
• Diffuse supratentorial abnormality following severe
global asphyxia (“white cerebellar” or “reversal sign”)
Diffuse Cerebral Edema
 Pachygyria
• = Incomplete lissencephaly
• Short, broad, thick gyri caused by abnormal
sulcation and gyration
• Malformation due to abnormal neuronal
migration
 Polymicrogyria

• Findings: irregular
cortical-white matter
interface and shallow
or absent overlying
sulci
• Can be seen w/CMV
(periventricular Ca+)
 Spondylolysis
• Spondylolysis
– Break in pars interarticularis of lamina
– Oblique XR: break in neck of Scotty dog
• Spondylolisthesis
– Grade 1: superior vertebral body subluxed by one-fourth of a vertebral
body
– Grade 2: subluxation by half a vertebral body
– Grade 3: subluxation by three-fourths of a vertebral body
– Grade 4: subluxation by whole width of a vertebral body
– Can cause foraminal stenosis and impinge on nerve roots in central canal
– Tx: surgery for slip of 50% or more, unremitting pain, neuro deficits
 Acute Hypertensive Encephalopathy,
PRES
• Patchy cortical/subcortical PCA territory lesions in a pt
w/severe acute/subacute HTN
• Parieto-occipital hyperintense cortical lesions in 95%
• DWI: usually normal
• T1 C+: variable patchy enhancement
• Etiology (related to HTN): pre-eclampsia/eclampsia,
uremia, drug toxicity, severe infection
• Favorable outcome with prompt recognition, treatment
of HTN
• Eclampsia findings
– Hyperintense lesions on T2-weighted, FLAIR, or
PD sequences affecting white matter and adjacent
gray matter of occipital/parietal lobes
– Deep white matter structures, basal ganglia, and white
matter of frontal or temporal lobes and brainstem can
also be affected
Eclampsia
Eclampsia
 Squamous Cell Carcinoma
• DDx aggressive sinus lesion w/bone destruction
– Squamous cell CA (MC): low T2, heterogeneous, solid enhancement
– Aggressive fungal disease (aspergillosis, mucormycosis)
– Minor salivary gland tumors: adenoid cystic CA (perineural spread),
mucoepidermoid CA
– Inverted papilloma
– Lymphoma
– Sarcoma
– Bone mets, myeloma
– Esthesioneuroblastoma
– Melanoma
Inverted Papilloma
Inverted Papilloma
 Squamous Cell Carcinoma
• Tongue
– Enhancing, invasive mass of mucosal surface of oral
tongue
– Staging oropharyngeal SCC
• T1: < 2 cm, T2: 2-4 cm, T3: > 4 cm, T4: invasion of
adjacent structures such as bone or soft tissues of neck
• Check for spread to contralateral tongue, mandibular
invasion, nodal involvement
• Lingual tonsil/tongue base
– Lingual tonsil: Waldeyer ring component posterior to
circumvallate papilla, extending inferiorly to vallecula
– CECT: when small, mucosal asymmetry (tumor surrounded by
enhancing lymphoid tissue)
– MR: iso to slightly high T2 in tongue, floor of mouth
– Enhances
– 75% have cervical lymphadenopathy at presentation
– DDx: lymphoma, minor salivary gland tumor (nodes rare)
– Tumor volume more important than T-stage for therapy
– Tx
• Surgery or XRT alone (small)
– When unilateral, partial glossectomy may be performed
• Combination XRT & chemotherapy (large)
Cervical Lymph Nodes
 Retropharyngeal Abscess
• Posterior displacement of prevertebral muscles identifies
retropharyngeal location
• Retropharyngeal space is potential space posterior to
superficial mucosal space and pharyngeal constrictors and
anterior to prevertebral space
– Conduit for spread of tumor or infection from pharynx into
mediastinum
• DDx retropharyngeal space lesion: nodal malignancy
(lymphoma, SCC), infection/abscess (TB, tonsillitis, dental
disease, endocarditis, trauma)
• Differentiate abscess vs. cellulitis w/contrast
 Orbital Cellulitis
• Orbital septum acts as a barrier to infection
– Most infections preseptal, involving lid and conjunctiva
• Postseptal can lead to spread to globe, optic nerve, caverous sinus
(+/- thrombosis), meninges, epidural or cerebral abscess
• Suspect if see stranding in intraconal fat
• Most from Staph or Strep from adjacent sinusitis, especially
maxillary
– Other causes: postsurgical, derm infection, trauma
• Painful ophthalmoplegia, proptosis, chemosis, decreasing visual
acuity
 Acute Otomastoiditis, Complicated

• Most cases of mastoiditis occur in assoc w/middle ear

infections, which may be due to malfunction or obstruction
of Eustachian tube
• Most related to Pneumococcus and H influenzae
• Complications: venous sinus thrombosis (mostly sigmoid)
leading to venous infarction, petrous apicitis, meningitis,
epidural/cerebral abscess
• CT: opacification of air cells +/- erosion of bone
• MR: best for assessing meningeal, venous sinus, epidural,
and parenchymal involvement
 Empty Sella
• Sella turcica partially filled with CSF
– Rarely completely “empty”
– Pituitary gland seen as thin, flattened rim of tissue along sellar floor
• Primary: idiopathic, normal variant, no history of trauma, surgery,
radiation
• Secondary: surgery, radiation, bromocriptine therapy, residua of
Sheehan syndrome (postpartum pituitary necrosis)
• Usually asymptomatic, b/c almost all have a small remnant of
pituitary tissue
• If stalk is deviated, DDx: arachnoid cyst, epidermoid, Rathke, pars
intermedia cyst
 Tuber Cinereum Hamartoma
• Rare congenital malformation of normal neuronal tissue
• Benign
• Boys w/gelastic seizures, precocious puberty,
developmental delay, hyperactivity
• Well-circumscribed round or oval mass centered at tuber
cinereum (base of infundibulum)
• No Ca+ or hemorrhage
• Same signal as brain on CT/MR
• NO enhancement
 Fibrous Dysplasia, Skull Base
• DDx: Paget, blastic mets, GCT, ossifying fibroma
• Monostotic, polyostotic
• McCune-Albright syndrome: polyostotic w/precocious
puberty, café-au-lait spots
• Cherubism: involving mandible and maxilla
• Mazabraud: polyostotic w/soft tissue myxomas
• MR: variable T1 and T2 w/enhancement
• CT: characteristic ground-glass (get CT)
Fibrous Dysplasia
Fibrous Dysplasia
 Corpus Callosum Lesion (GBM)
• DDx enhancing corpus callosum lesion: GBM,
lymphoma, multiple sclerosis
 Schizencephaly
• Abnormal GM lined cleft from surface of brain (pia) to
ventricle (ependyma)
• Usually seizures and mental retardation
• DDx: porencephalic cyst (lined by WM, not GM)
• Closed lip = apposed walls, often a dimple in the ventricle
where cleft inserts
• Open lip = wide separation of walls
• 80% have absent septum pellucidum
• Also assoc w/GM heterotopias, pachygyria
• Bilateral in 35-50%
 TORCH (CMV)
• CMV
– Maternal CMV infection  fetus in 30-50%
– Hepatosplenomegaly, jaundice, psychomotor retardation,
chorioretinitis, deafness
– 1st trimester  migrational anomalies: agyria, polymicrogyria,
delayed myelination, cerebellar hypoplasia
– Later infection  periventricular Ca+, delayed myelination
– Usually NO BG or cortical Ca+ as in toxoplasmosis
– Can see dilated ventricles due to atrophy
• Toxoplasmosis
– Protozoan parasite w/cats as terminal hosts
– Hydrocephalus, chorioretinitis, intracranial Ca+
– Random and multifocal Ca+, commonly involve BG
• Herpes type 2
– Similar pattern to adults w/type 1
– Temporal and parietal lobes as well as BG, brainstem,
cerebellum
Toxoplasmosis
Herpes Simplex
• Rubella
– Uncommon due to immunization
– Meningitis, microcephaly, vasculopathy leading to
Ca+ around vessels
– Cataracts and cardiomyopathies
• Others: HIV (diffuse Ca+ similar to toxo), human
parvovirus B19
Rubella
HIV
 Arachnoid Cyst
• DDx retrocerebellar cyst
– Dandy-Walker malformation/variant (large posterior
fossa, vermian dysgenesis)
– Arachnoid cyst (mass effect)
– Mega cisterna magna (no mass effect)
DDx: Dandy-Walker Malformation
• Arachnoid cyst
– Congenital or result of infection, trauma
– Collection of CSF in layers of pia-arachnoid
– Displaces and compresses cerebellum, while mega
cisterna magna has no mass effect
– DOES NOT communicate with 4th ventricle or cause
hydro, unlike DW malformation
– MR: follows CSF on all sequences
– DDx: porencephalic cyst, epidermoid, low grade
cystic astrocytoma, chronic SDH, dilated ventricle
Arachnoid Cyst
• Porencephalic cyst
– Within brain parenchyma rather than displacing it,
and connects w/ventricle
• Cystic astrocytoma
– Enhancement: peripheral or mural nodule
• Epidermoid
– Diffusion restriction, slightly different from CSF on
FLAIR
 Ranula
• Cystic lesion due to obstruction of sublingual gland duct from
infection, trauma, or calculi
• Simple = above mylohyoid muscle
• Plunging = through the muscle
• Wall usually enhances
• Pointed edge along anterior extent in sublingual space
• Rupture can cause encapsulated mucus-containing infection in
deep tissues of neck
• DDx: dermoid, lymphatic malformation
• Tx: intraoral (simple) vs. cervical (plunging) surgical approach
 Neurocysticercosis
• Brain second MC organ involved after skeletal
muscle
• Taenia solium = pork tapeworm
• More common in Southwest US, Latin
Americans
• Seizures (90%)
• Intraventricular, subarachnoid (basal cisterns),
parenchymal forms
• Parenchymal: cystic lesion, may contain small isointense
mural nodule (scolex), marked edema when larva dies,
eventual Ca+, +/- rim or nodular enhancement
– DDx: mets, septic emboli, abscess
• Intraventricular: harder to see, similar signal to CSF, +/-
enhancement, rupture leads to ventriculitis
• Subarachnoid (racemose): meningeal/basal cisterns, may
appear as grapelike clusters, no mural nodule or Ca+
• Tx: praziquantel and albendazole
Parenchymal
Parenchymal (Calcified)
Subarachnoid (Racemose)
Intraventricular
 Chiari 1
• Findings: tonsillar herniation w/syrinx
• Downward displacement of cerebellar tonsils through
foramen magnum (3-5 mm below line joining basion to
opisthion) w/nl positon of 4th ventricle
• 75-80% assoc w/syringohydromyelia, usually cervical
• Decreased sensation, numbness, weakness, HA
• Assoc w/Klippel-Feil, platybasia, atlanto-occipital
assimilation, basilar invagination
 Flexion Teardrop Fracture
• Due to severe flexion injury, usually at C5, less common
at C4 or C6
• Triangular fragment anteroinferior aspect VB
• Fx of posterior elements common
• Kyphotic angulation
• Disruption of intervertebral disk, PLL, posterior
ligaments produces spinal instability
• Assoc w/quadriplegia and other cord injury
• Facets are often diastatic
 Kummell Disease
• Delayed, post-traumatic collapse of vertebral body
• Findings
– Gas in collapsed vertebral body (intravertebral vacuum
cleft) is diagnostic
– Loss of height, sclerosis of vertebral body
• Felt to be secondary to osteonecrosis
• Presence of vacuum cleft excludes infection or
neoplasm
• Benign vs. malignant compression fx
– Malignancy tends to involve pedicles, whereas benign
does not
– Look for other levels of involvement, b/c if you see
noncompressed vertebral bodies at other levels which also
have abnormal signal, then you can assume malignant
– Cortical destruction is a feature of malignancy
– Malignant fxs tend to show abnormal T1 signal involving
> 80% of the VB, benign has less
– Soft tissue mass and cord compression are not helpful
distinguishing features
 Spinal Meningitis
• DDx thickened, enhancing cauda equina
– Tumor: leptomeningeal carcinomatosis (breast, lung, melanoma),
drop mets from brain neoplasm, leukemia/lymphoma
– Infection: TB/meningitis, CMV polyradiculopathy (AIDS)
– Sarcoidosis
– Guillain-Barre
– Arachnoiditis
– NF 1
– Hereditary motor and sensory neuropathy (type I: Charcot-Marie-
Tooth; type III: Dejerine-Sottas)
Dejerine-Sottas Disease
 Moyamoya Disease
• Occlusive disease of large intracranial arteries seen predominantly in children
• Stenosis of terminal portion of ICA and proximal ACA and MCA
• Angio: net-like “puff of smoke” appearance due to prominent collaterals
• Collaterals: leptomeningeal from cerebral arteries, parenchymal via BG,
transdural mostly from ECA via middle meningeal and ophthalmic
• Usually in Japanese pts
• Progressive course
• TIA and stroke in peds, parenchymal or SA hemorrhage in adults
• Similar pattern seen in sickle cell, XRT, NF, atheromatous disease
• MR: lack of distal ICA flow voids, multiple flow voids in BG from collateral
vessels
• Watershed infarcts, ischemia, atrophy, dilated ventricles may be seen
• Tx: ECA to ICA diversion, such as superficial temporal to MCA
Moyamoya Disease
Moyamoya Disease
Moyamoya Disease
 Ankylosing Spondylitis
• Fused and osteoporotic spine of AS is vulnerable to
injury from minor trauma
• Pseudarthroses form easily, MC at C/T or T/L jxn
• Fx usually extends through syndesmophyte and disk
space
• Widening of anterior disk space
• Fx then extends through posterior elements
• Similar predisposition to fx and pseudarthrosis in DISH
Pseudarthrosis
 DISH + OPLL

• Diffuse idiopathic skeletal hyperostosis, ossification

of posterior longitudinal ligament
• Profound ossification of spinal soft tissues (annulus
fibrosis, ALL, PLL)
• Resembles DJD, except no disk space narrowing and
no sclerosis
• MC middle-aged and elderly, M > F
• MC in thoracic spine, although cervical spine
frequently involved
• DDx
– Retinoid arthropathy (pts using retinoic acid for skin
diseases): skeletal hyperostoses of cervical spine MC
– Fluorosis: bulky paraspinous ligament calcification,
diffusely osteopenic or sclerotic bones in a patchy or
“chalky” pattern, dental abnormalities such as mottled
tooth enamel
 Neurogenic (Charcot) Arthropathy

• Hallmarks of neurogenic arthropathy (5 D’s)

– Destruction
– Dislocation
– Disorganization
– Density (increased)
– Debris or heterotopic new bone
• Neuropathic shoulder assoc w/syrinx
• Charcot foot assoc w/DM
Neurogenic (Charcot) Arthropathy
 Failed Back Surgery Syndrome
• Continued low back pain +/- radicular pain after lumber surgery
(15%)
• Stenosis: “trefoil” appearance of lumbar spinal canal on axial
imaging
• Instability: deformity increases with motion & increases over time
• Recurrent herniation: NONENHANCING well-defined mass
arising out of intervertebral disk
• Fibrosis: infiltration of epidural/perineural fat by ENHANCING
soft tissue density (intensity)
• Arachnoiditis: clumping, adhesion of cauda equina nerve roots
Failed Back: Fibrosis
Failed Back: Arachnoiditis
 Juvenile Nasopharyngeal Angiofibroma

• Benign but aggressive hypervascular mass arising

from sphenopalatine foramen on lateral nasal
cavity wall
• Extends laterally into pterygopalatine fossa in 90%
• Angio
– Enlarged ECA branches supply tumor, dense capillary
blush and delayed wash out
– Distal branches of internal maxillary artery invariably
involved
JNA
Unilateral Locked Facet
 Neurofibromatosis Type 2
• Case findings
– Bilateral vestibular schwannomas
– Prepontine meningioma
• Chromosome 22
• MISME: multiple inherited schwannomas,
meningiomas, and ependymomas
 Schwannoma
• Neoplasm of nerve sheath in peripheral nervous system
• 70-75% intradural extramedullary, 15% extradural
• MC intradural extramedullary mass
• DDx: neurofibroma, meningioma, myxopapillary ependymoma
• Findings
– Well-circumscribed, “dumbbell” shaped, enhancing spinal mass
– Enlarged intervertebral foramen
– Thinned pedicle
– CT: isodense to cord, nerve roots
– MR: iso/hypo T1, hyper T2, “target sign” (high signal rim, low intensity
center)
– Intense enhancement
 Acquired Cholesteatoma
• Originate from stratified squamous epithelium of
tympanic membrane
• Findings: soft tissue mass within middle ear cavity,
typically with associated bony erosion, displacement of
ossicles
• Superior portion of TM (pars flaccida) retracts easily and
is MC site
– Prussak space: superior recess of TM, located medial to pars
flaccida b/w scutum and neck of malleus
• DDx: otitis media
 Hypertensive Hemorrhage
• Putamen (35-50%), subcortical white matter
(30%), cerebellum (15%), thalamus (10-15%),
pons (5-10%)
• Small hemorrhages may resolve with few deficits
• Poor prognosis: bleeds in posterior fossa, those
with large amount of mass effect, those that
extend into ventricular system
 Spine Metastases (Lung)
• Findings: low T1, variable T2, intervertebral
disks spared (distinguish from inflammatory
processes)
Osteoid Osteoma
Osteoblastoma
Aneurysmal Bone Cyst
 Cavernous Malformation
• Thin-walled sinusoidal vessels (neither arteries nor veins)
• May present w/seizures or small parenchymal hemorrhages
• CT
– High density regions on noncontrast CT
– May have associated calcifications and enhance
• MR
– Copious amounts of hemosiderin surrounding various circumscribed
regions of hemorrhage (methemoglobin)
– Complete rim of hemosiderin (as opposed to tumors)
• Angiography: usually occult
Cavernous Malformation
w/Hemorrhage
 Lymphoma
• CT: hyperdense on NCCT
• MR: low T2, diffusion restriction, uniform/ring enhancement
• May have bihemispheric involvement via corpus callosum
• May have dural involvement
• Immunocompetent: solitary homogeneously enhancing mass
• HIV: supratentorial parenchymal (55%), variable enhancement,
multiple (50%), periventricular lesions w/ependymal seeding
Lymphoma
 Chordoma, Clivus
• Arises from remnants of primitive notochord
• Histology: physaliphorous cells
• More common in men (2:1)
• Destructive midline mass centered in clivus
– Predilection for spheno-occipital synchondrosis
• May be found anywhere along craniospinal axis
– 35% clivus
– 50% sacrum (DDx: GCT, mets, myeloma, lymphoma,
plasmacytoma, Ewing sarcoma)
– 15% vertebral bodies, C > T/L (DDx: CPPD deposits, synovial
pannus, TB)
Chordoma, Spine
Chordoma, Spine
Chordoma, Sacrum
DDx: Giant Cell Tumor
 Developmental Venous Anomaly

• AKA venous angioma

• Congenitally anomalous veins that drain normal
brain
• Vast majority asymptomatic and do not bleed
• Occasionally assoc w/cavernous angioma
• Angio
– Persistence of normally filling aberrant veins
– Usually occur in the periventricular region
• MR
– Enhancing stellate venous complex (caput medusae,
umbrella shape) that extends to ventricular or cortical
surface
• Tx: nonsurgical; sacrifice of pathway can produce
venous infarction of brain tissue being drained
Developmental Venous Anomaly
 Allergic Fungal Sinusitis
• Findings: multiple sinus opacification &
expansion on NCCT with hyperdense material
• DDx hyperdense secretions
– Inspissated secretions
– Fungal sinusitis
– Hemorrhage
– Calcification
 Lytic Skull Lesion
• DDx
– Mets/myeloma
– Epidermoid/dermoid
– EG
– Leptomeningeal cyst
– Postoperative
– Paget disease (osteoporosis circumscripta)
– Hemangioma
Multiple Myeloma
 Basilar Invagination
• DDx (“PF ROACH”)
– Paget disease
– Fibrous dysplasia
– Rickets/osteomalacia
– OI
– Achondroplasia
– Cleidocranial dysplasia
– Hyperparathyroidism
 Craniocervical Junction Craniometry

• C1-2 interspinous space: ≤ 10 mm

• Atlanto-dental interval: adults < 3 mm, children < 5 mm in flexion
• Pseudosubluxation
– Physiologic anterior displacement at C2-3 and C3-4 to age 8
– Anterior displacement of C2 on C3 up to 4 mm
• Wackenheim line: posterior odontoid tip should lie immediately inferior
• Welcher basal angle (evaluate platybasia)
– Angle b/w lines drawn along plane of sphenoid bone and posterior clivus
– Normal < 140°, average 132°
• Chamberlain (McGregor) line: odontoid tip ≥ 5 mm (7 mm) above line abnormal
• Clivus canal angle
– Junction of Wackenheim line and posterior vertebral body line
– 180° extension, 150° flexion, < 150° abnormal
• McRae line: normal 35 mm diameter
 Subdural Empyema
(Frontal Sinusitis)
• Causes: hematogenous dissemination,
osteomyelitis of calvarium, otitis
media/mastoiditis, paranasal sinusitis,
postcraniotomy, posttraumatic, purulent bacterial
meningitis
• Fever, vomiting, meningismus, seizures,
hemiparesis
• Venous thrombosis or brain abscess develops in >
10%
• CT
– Isodense to low density extra-axial collection
• MR
– Isointensity on T1 and high signal on T2/FLAIR
– Diffusion restriction (distinguish from sterile
effusion)
– Rim/gyriform enhancement may be observed
• Tx: antibiotics, craniotomy and drainage
 Plexiform Neurofibroma in NF 1
• NF 1 diagnostic criteria (2 or more of the following)
– Six or more cafe-au-lait spots 1.5 cm or larger in post-pubertal,
0.5 cm or larger in pre-pubertal
– Axillary or groin freckling
– Two or more neurofibromas of any type
– One or more plexiform neurofibroma
– Optic glioma
– Two or more Lisch nodules (benign melanotic iris hamartomas)
– Distinctive bony lesion: dysplasia of sphenoid bone, dysplasia or
thinning of long bone cortex
– First degree relative with NF 1
Optic Glioma
Optic Gliomas + Bright T2 Foci
Sphenoid Wing Hypoplasia +
Plexiform Neurofibroma
 Dural Ectasia +
Anterior Sacral Meningocele
• DDx posterior vertebral body scalloping
– Congenital: OI, mucopolysaccharidoses,
achondroplasia
– Dural ectasia: neurofibromatosis, Ehlers-Danlos,
Marfan
– Increased central canal pressure: syrinx, spinal canal
tumor
 Holoprosencephaly (Semilobar)
• Alobar: complete absence of midline forebrain division 
monoventricle and fused cerebral hemispheres
• Semilobar: incomplete forebrain division  partial separation of
cerebral hemispheres, typically posteriorly
• Lobar: complete ventricular separation with focal areas of
incomplete cortical division or anterior falcine hypoplasia
• Distinctive midline facial malformations occur in most cases
– From most severe to least: cyclopia + proboscis, hypotelorism + proboscis,
hypotelorism + single nostril, hypotelorism + midline clefting, milder facial
dysmorphic features
• Developmental delay, variable seizures, pituitary dysfunction,
hydrocephalus, feeding difficulties
Alobar
Alobar
 Dehiscent High Jugular Bulb
• Dehiscent: lacks a complete cortical covering
• High or high riding: extends into middle ear,
above level of floor of IAC or tympanic annulus
• Visible at otoscopy as a smooth, convex, bluish
mass in middle ear
• May present with pulsatile tinnitus
 Central Pontine Myelinolysis
(Osmotic Demyelination Syndrome)
• MC seen w/electrolyte abnormalities
(hyponatremia) that are rapidly corrected
• MC in children and alcoholics w/malnutrition
• MR: high T2 in central pons with sparing of
descending corticospinal tracts
• Extrapontine sites of involvement: white matter
of cerebellum, thalamus, globus pallidus,
putamen, lateral geniculate body
 Fibromuscular Dysplasia
• Nonatheromatous fibrous and muscular thickening alternating
w/dilatation of arterial wall
• Findings: “string of beads”, unifocal or multifocal tubular
stenosis, lesions confined to only a portion of arterial wall
• Although all layers of artery may be involved, media is MC
affected
• Assoc w/intracranial aneurysms, arterial dissection
• MC CNS vessel affected is ICA, approximately 2 cm or more
from bifurcation (in 90%)
• Multiple vessel involvement common (bilateral carotid in 60%)
• Predominantly affects women (80%), mean age 50 y
• DDx
– Atherosclerotic disease: usually asymmetric and has a
propensity for the bifurcation
– Vascular spasm secondary to the catheter: identified
at the tip of the catheter, dilatation of the vessel is not
seen
– Standing waves: do not usually have the constrictive
picture characteristic of FMD
 Septo-Optic Dysplasia
• Mildest form of holoprosencephaly
• Hypoplasia of optic nerves with complete or partial
absence of septum pellucidum
• Findings: absence of septum pellucidum, characteristic
squared-off appearance of frontal horns, variable
hypoplasia of optic nerves
• Endocrine abnormalities common
• Migration anomalies (schizencephaly in 50%) and
periventricular cysts are also seen
 Amyloid Angiopathy
• Frequently lobar in nature
– Rare in cerebellum, white matter, basal ganglia, brain stem
• Not assoc w/systemic amyloidosis
• Assoc w/dementia
• Affects elderly individuals
• MR: diffuse punctate regions of hypointensity on GRE
• Propensity for recurrent hemorrhage or multiple
simultaneous hemorrhages
• DDx
– Hypertension
– Multiple cavernous malformations including those
secondary to radiation therapy
– Previous traumatic brain injury
 Mondini Malformation
• Incomplete development of the 2.5 turns of the
cochlea
• Basal turn relatively well formed
• Middle and apical turns may balloon into a cyst
 Michel Aplasia
• Total absence of inner ear structures
• Assoc w/other skull base deformities (platybasia),
abnl course of CN VII, and jugular vein
anomalies
• Stapes does not develop
• Oval window absent
 Chiari 2
• Supratentorial brain
– Nearly all present with hydrocephalus
– Most show partial or complete callosal agenesis
– Falx cerebri often fenestrated, resulting in herniation of
individual gyri across midline
– Massa intermedia is enlarged
– Beaked tectum
– Posterior cingulate gyrus often dysplastic
– Associated with lacunar skull
• Resolves spontaneously by age 6 m
• Posterior Fossa
– Diminutive posterior fossa
– Cerebellum squeezed up against tentorium, down
through foramen magnum (tonsillar herniation), and
forward around brainstem
– Fourth ventricle squeezed into a small vertical slit
– Pons and medulla are also squeezed inferiorly, and
with fixed attachments of the upper cervical spinal
cord, cervicomedullary kink often develops
• Spine
– Most present with myelomeningocele
 Sturge-Weber Syndrome
• AKA encephalotrigeminal angiomatosis
• Angiomatous lesions of skin and meninges
– Port-wine nevus in ophthalmic division of CN V
– Pial angiomatosis
• Failure of normal regression of embryonal blood vessels
– Result in chronic ischemia of gray matter, leading to gyral atrophy and
underlying gliosis, gyral Ca+
– Alteration of normal superficial cortical venous drainage  enlargement of
deep and subependymal veins
• Gadolinium enhancement can reveal full extent of pial angiomatosis
• Ipsilateral choroid plexus hypertrophy
 Pelizaeus-Merzbacher Disease
• Rare X-linked leukodystrophy
• MR: arrest of myelin development, usually in
neonatal period with diffuse high T2 white matter
that extends peripherally to involve subcortical U
fibers
• Abnormal eye movements, nystagmus,
extrapyramidal hyperkinesias, spasticity, slow
psychomotor development
Pelizaeus-Merzbacher Disease
 Oligodendroglioma
• Classic appearance is adult with heterogeneous
calcified mass within the periphery of a frontal
lobe with calvarial erosion and relative absence
of edema
• DDx tumors w/calcification: oligodendroglioma,
ependymoma, craniopharyngioma, choroid
plexus tumor, meningioma
Oligodendroglioma
 Dental Abscess
• Masticator space
– Contents
• Muscle of mastication (masticator, temporalis,
medial/lateral pterygoids)
• Mandible (bones, teeth)
• CN V3 (inferior alveolar nerve)
– Pathology: odontogenic abscess, osteomyelitis, direct
spread of SCC, lymphoma, minor salivary tumor,
sarcoma of muscle or bone
Rhabdomyosarcoma
• Superficial mucosal space
– Contents
• Mucosa
• Lymphoid tissue (adenoids, lingual tonsils)
• Minor salivary glands
– Pathology: nasopharyngeal CA, SCC, lymphoma,
minor salivary gland tumors, juvenile angiofibroma,
rhabdomyosarcoma
Nasopharyngeal Carcinoma
• Parapharyngeal space
– Contents
• Fat
• CN V3
• Internal maxillary, ascending pharyngeal artery
– Pathology: minor salivary gland tumor, lipoma,
cellulitis/abscess, schwannoma
• Carotid space
– Contents
• CN IX-XII
• Sympathetic nerves
• Jugular chain nodes
• Carotid artery
• Jugular vein
– Pathology: schwannoma, neurofibroma,
paraganglionoma, metastatic adenopathy, lymphoma,
cellulitis/abscess, meningioma
Neurofibroma
Carotid Body Tumor
Vagal Schwannoma
• Parotid space
– Contents
• Parotid gland
• Intraparotid lymph nodes
• Facial nerve (VII)
• External carotid artery
• Retromandibular vein
– Pathology: salivary gland tumors (bright T2  benign,
low T2  more likely malignant), metastatic
adenopathy, lymphoma, parotid cysts
Pleomorphic Adenoma
Pleomorphic Adenoma
• Retropharyngeal space
– Contents
• Lymph nodes (lateral and medial retropharyngeal)
• Fat
– Pathology: infection, metastatic adenopathy,
lymphoma
Suppurative Lymph Node
(Rouviere)
• Prevertebral space
– Contents
• Cervical vertebrae
• Prevertebral muscles
• Paraspinal muscles
• Phrenic nerve
– Pathology: abscess/cellulitis, osseous metastases,
chordoma, osteomyelitis
Diskitis + Prevertebral Abscess
• Trans-spatial disease
– Lymphatic masses (lymphatic malformation)
– Neural masses (neurofibroma, schwannoma,
perineural spread of tumor)
– Vascular masses (hemangioma)
– Aggressive neoplasm or infection
Lymphatic Malformation
 Capillary Telangiectasia
• Asymptomatic
• Don’t touch lesion
 Acute Cerebellitis
• Acute onset of cerebellar dysfunction
• May be infectious (viral) or parainfectious
• Resolves spontaneously, weeks to months
• Findings: cerebellar edema, variable enhancement
• Tx: supportive care, tx of hydrocephalus, steroids
• DDx: demyelinating, vasculitis, toxic (cyanide),
metabolic, paraneoplastic (lung, breast), ischemia
 Diffuse Axonal Injury
• MC seen in high-speed motor accidents
• CT
– Small, petechial hemorrhages at gray-white junction
of cerebral hemispheres or corpus callosum
• MR
– Nonhemorrhagic: small foci of increased T2 within
white matter
– Petechial hemorrhage: variable signal according to
age of blood
• Characteristic locations
– Parasagittal frontal and periventricular temporal white
matter near gray-white junction (mildest injury)
– Lobar white matter, corpus callosum, especially
posterior body, splenium (more severe trauma)
– Dorsolateral midbrain and upper pons (most severe
trauma)
DAI
DDx: Fat Embolism
 Temporal Bone Fracture
• May present with deafness, facial nerve palsies,
vertigo, dizziness, or nystagmus
• Physical signs: hemotympanum, CSF otorrhea, and
ecchymosis over mastoid process (“Battle sign”)
• Findings such as opacification of mastoid air cells,
fluid in middle ear cavity, pneumocephalus, or
occasionally pneumolabyrinth, should raise the
suspicion
• Longitudinal fracture (70-90%)
– Parallels long axis of the petrous pyramid
– Results from blow to side of the head
– Complications: conductive hearing loss, dislocation or fx of
ossicles, CSF otorhinorrhea
• Transverse fracture
– Perpendicular to long axis of petrous bone
– Usually results from blow to occiput or frontal region
– Complications usually more severe: sensorineural hearing loss,
severe vertigo, nystagmus, perilymphatic fistula, facial palsy (30-
50%)
 DNET
• Dysembryoplastic neuroepithelial tumor
• Benign tumor arising within supratentorial cortex
• Almost always assoc w/partial complex seizures
• Findings
– May occasionally appear cystic
– Focal cortical lesion MC in temporal lobe that is hypodense on
T1 and hyperintense on T2
– Minimal, if any, edema or enhancement
• DDx: ganglioglioma, low grade astrocytoma, PXA
 Spinal Cord Infarction
• Spinal cord supplied by one anterior spinal artery, two
posterolateral spinal arteries, and perimedullary plexus
connecting them
• Anterior spinal artery formed superiorly from branches
from both vertebral arteries
– Also fed by several radicular arteries in cervical and thoracic
regions
– Main blood supply to lower spinal cord, approximately T8
through conus medullaris is derived from arteria radicularis
anterior magna or artery of Adamkiewicz
• Although venous infarction can occur, usually due to occlusion of
one of feeding arteries
• Artery of Adamkiewicz occlusion can result in infarction of lower
spinal cord, including conus medullaris
• Findings: central high T2 (gray matter; owl eyes appearance),
slight expansion of cord in acute stages, atrophy when chronic
• DDx: transverse myelitis, spinal cord neoplasm
• Causes: aortic surgery, trauma, complication from aortography,
polycythemia, disk herniation, hypertension, syphilis,
thrombophlebitis
 Lhermitte-Duclos Disease
• AKA dysplastic cerebellar gangliocytoma
• Mass-like lesion usually seen in the cerebellum as a diffusely
infiltrative process
• Unclear whether this lesion is a neoplasm, hamartoma, or
dysplasia
• WHO grade I
• Increased intracranial pressure and/or ataxia
• Half of pts also have Cowden disease
– Autosomal dominant phakomatosis assoc w/colonic polyps,
cutaneous tumors, meningioma, glioma, thyroid and breast
neoplasms
• CT
– Often normal
• MR
– Classic feature is a “striated” cerebellar mass on both
T1WI and T2WI with minimal surrounding vasogenic
edema and no enhancement
– Hyperintense on T2WI
 Diastematomyelia
• Spinal cord is “split” into two hemicords by a
sagittal bony or cartilaginous spur
• Each hemicord has a dorsal and ventral horn and
a central canal
• Most occur in the lower thoracic region and are
accompanied by vertebral segmentation
abnormalities
• Syrinx develops in 50%
 Adrenoleukodystrophy
• X-linked recessive (also autosomal recessive neonatal form)
• Peroxisomal enzyme deficiency: acyl-CoA synthetase
• Head size: normal
• Typical age of onset b/w 5 and 10 y
• Adrenal insufficiency, abnormal skin pigmentation
• Striking predilection for visual and auditory pathways
w/symmetric involvement of the periatrial white matter with
extension into splenium of the corpus callosum
• No gray matter involvement
 Thyroglossal Duct Cyst
• 90% of congenital neck lesions
• Usually found in children
• Remnant of the thyroglossal duct along pathway of descent of
thyroid gland
– May occur anywhere from foramen cecum (tongue base) to normal thyroid
location
• 65% infrahyoid, 15% hyoid, 20% suprahyoid
• 75% midline, 25% off midline
• May have higher density from protein
• May rim enhance
• Tx: surgery (Sistrunk procedure)
 Ruptured Dermoid
• Dermoids more typically occur in midline as
opposed to epidermoids, which are generally off
midline
• Male pts more commonly affected
• Findings
– Possibility of ruptured dermoid should be considered
when multiple scattered fat particles are seen (low
attenuation on CT, high T1 on MR)
• DDx: Pantopaque
Dermoid
15 months
later
 MELAS
• Mitochondrial myopathy, encephalopathy, lactic acidosis, and
stroke-like episodes
• Usually appear healthy at birth with normal early development
• Later delayed growth, episodic vomiting, seizures, recurrent cerebral
injuries resembling stroke
• Dysfunctional mitochondria
• MR
– Multiple cortical and subcortical infarct-like lesions that cross vascular
boundaries
– Varying degrees of generalized cerebral and cerebellar atrophy
– Parietal and occipital lobes and basal ganglia are frequently involved
– Follow-up may show resolution and subsequent reappearance of abnormal
areas
 Normal MR Spectroscopy

TE = 280 ms

TE = 35 ms
 Bilateral Thalamic Acute Infarcts

• DDx
– Infarction of artery of Percheron (single perforating
artery trunk that supplies paramedian thalamic
arteries)
– Deep venous thrombosis (internal cerebral veins)
 Multisystem Atrophy
• Hot cross bun sign
• Neurodegenerative disorder
• Involves, to varying degrees, basal ganglia
(MSA-p = striatonigral degeneration),
olivopontocerebellar complex (MSA-c =
olivopontocerebellar atrophy), and autonomic
system (Shy-Drager)
 Superficial Siderosis
• Result of chronic recurrent hemorrhages (bleeding from
cranial or spinal dural AVMs, tumors, postoperative
manipulation)
• Hearing loss, cerebellar dysfunction, pyramidal tract
signs, progressive mental deterioration
– Cranial nerves II, V, VII, and VIII are involved
• MR: marked hypointensity on T2WI, particularly with
gradient-echo images, around leptomeninges and on
cranial nerves
 Dermoid Cyst
• Usually manifest during 2nd and 3rd decades of life
• No gender predilection
• Only 7% occur in head and neck
– Lateral eyebrow MC location
– ~10% floor of mouth (second MC location)
• ~5% undergo malignant degeneration into squamous cell
carcinoma
• Tx: surgery (above mylohyoid  intraoral approach,
below mylohyoid  external neck approach)
• Findings
– Moderately thin-walled, unilocular masses, located in
submandibular or sublingual space
– CT
• Central cavity usually filled with homogeneous, hypoattenuating (0-18
HU) fluid
• May appear to be filled with “marbles,” due to coalescence of fat into
small nodules within the fluid matrix (virtually pathognomonic)
• Rim of these cysts often enhances
– MR
• Depicts relationship of cysts to mylohyoid muscle
• Variable T1, usually hyperintense on T2
• Clearly demarcated rim but frequently heterogeneous internal
appearance
 Lemierre Syndrome
• Septic jugular vein thrombophlebitis
• Uncommon life-threatening anaerobic sepsis that
occurs after oropharyngeal infections
– Initial tonsillitis and peritonsillar abscess due to
anaerobic gram-negative bacillus Fusobacterium
necrophorum
• Teenagers and young adults
– Has also been observed in infants and children
 Choroidal Melanoma
• MC primary intraocular tumor in adults
• Melanomas may occur in any of the three subdivisions of the
uvea: iris, ciliary body, and choroid
• White-to-black ratio, 15:1
• Most occur in those older than 50 y
• CT: hyperattenuating
• MR: high T1, low T2
• DDx: choroidal hemangioma (high T2), uveal mets (breast and
lung CA, bilateral in 1/3), lymphoma/leukemia
DDx: Choroidal Hemangioma
 Joubert Syndrome
• Autosomal recessive
• Abnormal eye movements w/nystagmus and
inability of smooth pursuit of a moving object,
episodes of hyperpnea and apnea, and delayed
generalized motor development
• Assoc w/retinal coloboma and retinal dystrophy
in approximately 50%
• Findings
– Partial or complete absence of the vermis
– Hypoplastic cerebellar peduncles, and fourth
ventricular deformity
– Combination of hypoplasia of cerebellar peduncles
(molar tooth sign) and severe hypoplasia of vermis
(bat-wing fourth ventricle) is highly suggestive
– Cerebellar hemispheres are usually normal
– Cerebrum usually not affected
Joubert Syndrome
 Retinal Detachment
• Separation of sensory retina from retinal pigment epithelium
• Characteristic V shape, w/apex at the optic disk on cross-sectional
images, extends to ora serrata
• In complete detachment, leaves of retina may be so closely
opposed that they are imperceptible, and entire vitreous cavity
may be ablated
• MR can distinguish serous, proteinaceous, and hemorrhagic
detachments
• Tx: scleral buckle, pneumatic retinopexy, laser therapy,
cryotherapy, vitrectomy
Choroidal Detachment
 Choroidal Detachment
• Fluid accumulation in suprachoroidal space (b/w choroid and
sclera)
• May occur after ocular surgery, trauma, or an inflammatory
choroidal process (uveitis)
• Spares region of optic disk, in posterior third of globe
– Anchoring effect of short posterior ciliary arteries, veins, and nerves
• Possible presence of underlying ocular mass (e.g., retinoblastoma
in children, uveal melanoma in adults) should be considered when
retinal or choroidal detachment is detected
 Fahr Disease
• DDx basal ganglia calcification
– Fahr
– Metabolic: hyper-/hypo-/pseudohypo-PTH
– Idiopathic
– Peds: TORCH (CMV, toxoplasmosis, HIV), HIE
 Amyotrophic Lateral Sclerosis
• MC form of motor neuron disease
• Progressive, neurodegenerative disorder
• Upper (hyperreflexia, spasticity) and lower
(fasciculation, atrophy) neuronal symptoms
– No autonomic, sensory, or cognitive involvement
• Male predilection, onset in middle and late adult
years
• MR
– High T2/PD involving corticospinal tracts
• Extends from corona radiata, through posterior limb of
internal capsule, into ventral brain stem, and finally into
anterolateral column of spinal cord
– Low T2 in motor cortex attributed to iron deposition
 Huntington Disease
• Progressive hereditary disorder that appears in the fourth
and fifth decades of life
• Movement disorder (typically choreoathetosis), dementia,
emotional disturbance
• Autosomal dominant w/complete penetrance
• Findings
– Diffuse cortical atrophy w/caudate nucleus and putamen most
severely affected
– Atrophy of caudate nucleus results in characteristic enlargement
of the frontal horns, which take on a heart-shape configuration