Janica Walden Michael Solle Neuroradiology Case 1 History

Janica Walden, Michael Solle, Neuroradiology

Case 1: History 1 -2008: 26 male with ventriculomegaly & symptoms concerning for hydrocephalus with papilledema & headaches.

Case 1: Head CT

Case 1: MRI (FLAIR)

Case 1: MRI (CISS)

Case 1: Surgery Multiple cysts were visualized & removed from lateral & 3 rd ventricles.

Case 1: Pathology Light Microscope: Sections showed fragments of degenerating wall of a cysticercal cyst. Wall shows a small amount of calcification. Diagnosis: Cysticercosis

Neurocystircercosis Cysticercosis is the most common parasitic infection in immunocompetent patients: incidence is not increased in patients with AIDS, Cysticercosis is generally acquired by ingesting fruits or vegetables contaminated with eggs (Taenia solium, . ingesting larvae (undercooked pork) results in intestinal teniasis. Most common cause of acquired seizures. Gray-white junction- hematogenous spread (? ) Intraventricular lesions (20 -50%). Subarachnoid space lesions (racemose typecluster of grapes) (less than 10%).

Neurocystircercosis Vesicular stage: cyst-like lesion w/mural nodule (larva with full bladder & scolex, generally no contrast enhancement). Colloidal stage: cyst dies & produces inflammatory reaction (incomplete ring-enhancing lesion w/edema). Occasionally, multiple lesions are in the colloidal stage & produce an encephalitis-like picture. Granular stage: dead organism produces classic ring-enhancing lesion. Nodular stage: final stage in which lesion calcifies.

Case 2: History: 27 male with HIV, lumbar puncture was done… & india ink stained positive for cryptococcus.

Case 2: Intial study

Case 2: 1 st Follow up study

-Operation A single burr hole was made. Dura was opened & underlying pia was cauterized. Following this, using stereotaxy, a biopsy needle was advanced. Once the target was achieved, mild aspiration yielded gross purulence. Multiple specimens were obtained.

Case 2: op nd 2 Follow up study, post Patient non-compliant with medications.

Case 2: 3 rd Follow up study Improved compliance.

Case 2: 4 th Follow up study, further improvement

IRIS (immune reconstitution syndrome) HIV pts initiated on retroviral therapy. Restored immune system now reacting/overreacting (? ) to intact pathogens and/or residual antigens. Paradoxical worsening of a known condition, or appearance of a new condition following initiation of therapy.

IRIS Most commonly involved include CMV, mycobacterium, varicella zoster, herpes, PCP, & cryptococcus. Clinical presentation involves recurrence of symptoms related to a latent TB infection, or cryptococcal meningitis.

References: www. aidsrestherapy. com/content/4/1/9 http: //en. wikipedia. org/wiki/Immune_rec onstitution_inflammatory_syndrome

Case 3

Case 3

Case 3

Operation & pathology: Right frontal sinus mass pedunculated off of the posterior table of frontal sinus, which was noted to be dehiscent. Most consistent with an encephalocele. Fragments of central-nervous-system tissue, consistent with encephalocele/heterotopia.

Case 4: History 3 year old girl with presented with left leg weakness & limp x 3 weeks. Fell 3 weeks prior & had been limping ever since. 2 days prior to presentation she began not using her left hand.

Arterial spin label cerebral blood flow map.

Case 4: Pathology Sections show a proliferation of neoplastic astrocytes. Moderate nuclear atypia & mitotic figures. No necrosis, histologic findings consistent with anaplastic astrocytoma. Neoplastic cells diffusely stained for GFAP. Many nuclei of neoplastic cells stained positive for p 53. A Ki-67 immunostain reveals a labeling index of 12% in area sampled.

Case 5 74 year old male with diabetes & hypertension presented with weakness/extreme fatigue, weight loss & CN V & VI palsies.

CT

Findings Enhancing soft tissue mass at left petrous apex & left posterolateral wall of the left cavernous sinus. Measures 1. 8 cm x 1. 2 cm. Extends along cavernous sinus, erodes through sphenoid sinus wall. Extends along cisternal portion of V & into brainstem. Narrowing of adjacent left petrous internal carotid artery.

Pathology Acutely inflamed necrotic debris with fungal hyphae and giant cells present.