neuroradiology board review andrew conger, md 10/2/2012
TRANSCRIPT
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Neuroradiology Board Review
Andrew Conger, MD10/2/2012
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Question
1. Which of the following is a risk factor for clinically evident neurologic complications in the first 24 hours after cerebral angiography?– I. Age over 70 years– II. Duration over 90 minutes– III. History of TIA or CVA– VI. History of systemic hypertensionA. I, II, IIIB. I, IIIC. II, VID. IVE. Al of the above
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Answer
E. All of the above ( I, II, III, IV)
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Neurologic complications of cerebral angiography: prospective analysis of 2,899 procedures and review of the literature.
• Willinsky RA, Taylor SM, TerBrugge K, Farb RI, Tomlinson G, Montanera W.• Radiology May 2003• Lit review:
– Transient and reversible deficits 0.4-2.3% mean 1.3% – Permanent deficit 0.1-0.5% mean 0.3%– Overall neurologic complication rate 1.6%
• Results of this study:– Transient and reversible deficits 0.8%– Permanent deficit 0.5%– Overall neurologic complication rate 1.3%
• Risk factors– Increased age (>55, >65, >70)– History of TIA/CVA – High grade arterial stenosis (>50%, >70%)– History of hypertension– SAH/ICH (urgent/emergent angio)– Long duration of procedure (>10min, >90min)– High volume of contrast
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Question
2. The most common non-neurologic complication of cerebral angiography via a femoral approach is
A. AnginaB. Allergic reactionC. HematomaD. MIE. Pseudoaneurysm
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Answer
C. Hematoma
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Complications of cerebral angiography: a prospective analysis of 2,924 consecutive procedures.
• Dawkins AA, Evans AL, Wattam J, Romanowski CA, Connolly DJ, Hodgson TJ, Coley SC.
• Neuroradiology 2007• Hematoma 0.4%• Arterial dissection 0.44%• Allergic reaction 1/2924• Neurologic complications 0.34% (none permanent)
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Complications of modern diagnostic cerebral angiography in an academic medical center.
• J Vascular Interventional Radiology, 2009• 3636 angios, complication data prospectively collected• CVA 1/3636• Dissections 0.14%• Puncture site complications 0.14%
– 1 retroperitoneal hemorrhage– 1 femoral abscess– 2 CFA occlusions with LE ischemia– 1 pseudoaneurysm
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Question
3. Branches of the meningohypophysial trunk include the I. Tentorial arteryII. Inferior hypophysial arteryIII. Dorsal meningeal arteryIV. Superior hypophysial artery
A. I, II, IIIB. I, IIIC. II, IVD. IVE. all of the above
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Answer
A. I, II, III
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Meningohypophyseal trunk
• Meningohypophyseal trunk is largest and most proximal branch of cavernous ICA (C4), usually comes of posteriorly
• Three branches are: – inferior hypophyseal artery (D)– tentorial artery (of Bernasconi and Cassanari) (C)– dorsal meningeal artery (B) (lateral tentorial artery?)
• Highly variable• Can include a persistent trigeminal artery
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4. Which of the following is the most common of the persistent anastomoses?A. cervical intersegmental arteryB. proatlantal intersegmental arteryC. primitive hypoglossal arteryD. primitive otic arteryE. primitive trigeminal artery
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E. Persistent trigeminal artery
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5. Which of the following connects the petrous ICA to basilar artery?
A. cervical intersegmental arteryB. proatlantal intersegmental arteryC. primitive hypoglossal arteryD. primitive otic arteryE. primitive trigeminal artery
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D. Primitive otic artery
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6. Which of the following connects the proximal cavernous ICA to the basilar artery?A. cervical intersegmental arteryB. proatlantal intersegmental arteryC. primitive hypoglossal arteryD. primitive otic arteryE. primitive trigeminal artery
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E. Persistent trigeminal artery
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7. The precentral cerebellar vein usually drains into the:A. internal cerebral veinB. lateral mesencephalic veinC. posterior mesencephalic veinD. straight sinusE. vein of Galen
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E. Vein of GalenThe precentral cerebellar vein is a midline vessel
that courses medially over the brachium pontis, parallels the roof of the fourth ventricle, and curves upward behind the inferior colliculus and precentral lobule of the vermis to drain into the vein of Galen
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8. Anterior temporal lobe masses characteristically displace the A. anterior choroidal artery laterallyB. anterior choroidal artery mediallyC. anterior choroidal artery upwardD. posterior choroidal artery downwardE. posterior choroidal artery upward
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B. Anterior choroidal artery medially
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36 year old female presents with 2 weeks of HA and new onset seizures. Contrasted T1 MRI reveals the following. Pt started on AED and referred to you. What is the next most appropriate step in this patient’s management?
a. Stereotactic radiosurgery
b. Cerebral angiogramc. Evaluate gradient echo
MRI sequenced. Surgical resection
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C. Evaluate gradient echo MRI sequence
10-30% of venous angiomas have an associated cavernous malformation
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Venous angioma or developmental venous anomaly
• “Medusa-like” collection of dilated medullary veins near the angle of a cerebral ventricle seen best on contrasted T1 MRI
• Non-hereditary congenital anomaly, incidence may be as high as 2% of general population, usually solitary, multiple in blue rubber nevus syndrome
• Typically asymptomatic, may be associated with seizures, may cause HA when thrombosed
• Hemorrhage has been reported but very rare• Drain normal brain parenchyma. Surgery does not improve
symptoms, and can cause venous infarcts• 10-30% have an associated cavernous malformation
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Venous angioma
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Venous angioma--pathology
• Compensatory dilatation of venous channels secondary to hypoplasia of the regional venous circulation.
• Variably dilated venous structures separated by normal white matter. There is no microscopic evidence of recent or old bleeding.
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Venous angioma
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Cavernous malformation• Aka cavernoma, cavernous angioma, cavernous hemangioma, CCM• Typically sporadic, but familial forms exist (5%), associated with
chromosome 7 in some Mexican populations• Many are asymptomatic. Can present with seizures, HA, progressive
neurologic deficit, hemorrhage• 0.5% per year rate of hemorrhage for sporadic cases, 1% for familial• “Popcorn” appearance on GRE MRI sequence with hypointense
hemosiderin rim, sometimes contrast enhancing on T1 sequence• Appearance on CT, T1 MRI and T2 MRI depends on acuity of hemorrhage• Do not show up on angiogram• Histologically cavernous malformations are composed of a "mulberry-
like" cluster of dilated thin-walled capillaries, with surrounding hemosiderin, no feeding artery
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Cavernous malformation
• Classically described as a tightly packed array of ectatic vessels with variable hyalinization of the walls. Often surrounded by abundant old hemorrhage and reactive gliosis.
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Cavernous malformation
• Lack of arterial component as evidenced by this EVG stain helps to distinguish from AVM
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Cavernous malformation
• They usually lack intervening brain tissue between abnormal blood vessels, however, exceptions exist.
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Acute SAH is more difficult to diagnose on MRI than on CT because….
A. Extracellular methemoglobin is isointense on T1 and T2
B. Hemosiderin is isointense on T1 and T2C. Most radiologists are not familiar with the
appearance of acute SAH on MRID. The high oxygen tension in the SA space prevents
conversion of oxyhemoglobin to deoxyhemoglobinE. The low oxygen tension in the SA space prevents
the conversion of deoxyhemoglobin to oxyhemoglobin
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Answer
D. The high oxygen tension in the SA space prevents conversion of oxyhemoglobin to deoxyhemoglobin
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Evolution of hemorrhage on MRI
Hyperacute stage (4-6 hours after hemorrhage)
• Hemostatic plug is formed and RBCs become spherocytes, oxyhemoglobin present
• T1—isointense to parenchyma with mild edema around clot
• T2—hyperintense to parenchyma with mild edema
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Hyperacute hemorrhage
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Evolution of Hemorrhage on MRI
Acute stage (7-72 hours)
Clot retraction, RBCs degenerate into echinocytes, oxyhemoglobin converts to deoxyhemoglobin, significant edema
T1—isointense T2—hypointense
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Acute hemorrhage
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Evolution of Hemorrhage on MRI
Early subacute phase (4-7 days)
RBCs lose spicules and degenerate into tiny spherocytes, intracellular deoxyhemoglobin converts to methemoglobin (from periphery of clot to core), significant edema
T1—isointense with hyperintense ringT2—hypointense
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Early subacute hemorrage
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Evolution of Hemorrhage on MRI
Late subacute phase (1-4 weeks)RBC lysis occurs, extracellular methemoglobin, edema diminishes neovascular proliferation occurs and reactive inflammatory changes occur around hematoma, no BBB around clot
T1—hyperintenseT2—hyperintense
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Late subacute hemorrhage
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Evolution of hemorrhage on MRI
Early chronic stage (weeks to months)Cavity shrinks, inflammatory changes diminish, edema resolves, clot wall contains macrophages loaded with ferritin and hemosiderin
T1-hyperintense with iso to hypointense ringT2-hyperintense with hypointense ring
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Early chronic hemorrhage
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Evolution of hemorrhage on MRI
Late chronic stage (months to years)
Fibrotic scar containing macrophages with iron storage products
T1—hypointenseT2—hypointense
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Late chronic hemorrhage
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Evolution of Hemorrhage on MRIStage Iron product T1 T2Hyperacute oxyhemoglobin isointense hyperintense(4-6 hrs)
Acute deoxyhemoglobin isointensehypointense (7-72 hrs)
Early subacute intracellular methemoglobin isointense with hyper ring hypointense (4-7 days)
Late subacute extracellular methemoglobin hyperintense hyperintense (1-4 weeks)
Early chronic methemoglobin, ferritin/hemosiderin hyperintense with hyperintense(weeks to months) in macrophages iso to hypo ring with hypo ring
Late chronic ferritin/hemosiderin(months to years) in macrophages hypointense hypointense
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What is the approximate age of the hematoma depicted on this nonenhanced axial T1 MRI?
A. HyperacuteB. AcuteC. Early subacuteD. Late subacuteE. Chronic
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Answer
C. Early subacute
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• 29 year old male with family history of brain tumors presents with HA, coordination difficulty, and problems with walking. He has the following MRI. Also of note his H/H is 16/62. Which of the following abnormalities is NOT likely related to his diagnosis?– A. Renal mass seen on CT abdomen– B. Occasional surges in blood pressure– C. Lung AVMs– D. Retinal tumor
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C. Lung AVMs
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Von Hippel-Lindau disease• Autosomal dominant mutation of VHL tumor suppressor gene on
chromosome 3, inadequate regulation of VEGF, PDGF, TGFs• CNS Hemangioblastomas (60% of cases): cerebellum 65%, brainstem
20%, spinal cord 15%, • Retinal hemangioblastomas (50% of cases)• Renal cell carcinoma (30% of cases)• Pheochromocytomas (10% of cases) • Endolymphatic sac tumors• Epididymal cystadenoma• Erythropoeitin production can result in polycythemia vera• Diagnosis—multiple CNS hemangioblastomas or one CNS
hemangioblastoma + one visceral lesion + one first order relative with VHL disease.
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• 59 year old male presents with progressive visual loss. PMHx reveals kidney stones and multiple peptic ulcers. Labs show Ca=13. MRI below. Most likely diagnosis? A. meningioma, b. craniopharyngioma, c. MEN type 1 d. MEN type 2
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C. MEN type 1
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Multiple Endocrine Neoplasia type 1 (Wermer syndrome)
• Pituitary, pancreatic, parathyroid tumors• Typically pituitary adenomas (prolactinoma 30%, non-functional 26%,
GH secreting 13%, ACTH secreting 10%, FSH/LH secreting 9%, TSH secreting 1%)
• Pancreatic tumors:– Islet cell tumors (60% of MEN 1 pt) secretory
• Beta cell or insulinoma (40% of islet cell tumors) cause hypoglycemia• Non-beta cell (60%)
– Gastrinoma—increased gastric acid, ZE syndrome (refractory PUD diarrhea/steatorrhea)– Glucagonoma--hyperglycemia– VIPoma—severe secretory diarrhea, hypokalemia
• Parathyroid—diffuse hyperplasia, mulitple adenomas, solitary adenoma– Hyperparathyroidism: hypercalcemia, osteoporosis, nephrolithiasis, high blood
pressure
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MEN
• 2a (Sipple synd): medullary thyroid, pheochromocytoma, parathyroid
• 2b: medullary thyroid, pheochromocytoma, mucocutaneous neuromas
MEN 1= PPPMEN 2a=MPPMEN2b=MMP
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• 19 year old female presents with exophthalmos and the MRI below. There is a family history of brain tumors and “skin spots”. Which of the following chromosomes most likely contains the genetic defect?a. 7b. 22c. 17d. 3e. 11