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Case ID: 14425

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DiagnosisPilomyxoid Astrocytoma (PMA), WHO Grade 2
History4 y.o. boy presents with recent onset of seizures.
Findings4 cm ring enhancing lesion in the left frontal lobe Moderate amount of perilesional edema
Differential DxPilocytic astrocytoma Ependymoma Abscess
Discussion ... (continues ...)
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ContributorSteven J Goldstein :: University of Kentucky - Author Info
ReviewerJames G. Smirniotopoulos, M.D. :: Uniformed Services University - Editor Info
Case Accepted: 2014-06-23 11:30:42-04 :: Revised: 2014-06-23 07:29:38.736184-04 :: Submitted: 2014-06-20 12:40:24.235651-04
Case ID: 14424

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DiagnosisAnaplastic ganglioglioma (WHO Grade III)
HistoryAn otherwise healthy 14-year old boy presents with 1-month history of complex partial seizures.
FindingsConventional multiplanar MR Imaging demonstrates a cortically-based mass lesion in the anteromedial portion of the left temporal lobe. The lesion is hyperintense on T2-weighted and FLAIR sequences, possibly containing a small cystic space in the medial portion. On T1-weighted sequence the lesion is slightly hypointense compared to gray matter signal intensity. There is no edema or mass effect in the surrounding brain parenchyma. Following contrast administration, the mass enhances strongly and homogeneously, except from the small cystic region in the medial aspect of the mass. The imaging findings are more compatible with a low-Grade intra-axial neoplasm
Differential Dxganglioglioma low-Grade diffuse astrocytoma oligodendroglioma DNET
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ContributorIoannis Vasiliou Papageorgiou :: No Academic Affiliation - Author Info
ReviewerJames G. Smirniotopoulos, M.D. :: Uniformed Services University - Editor Info
Case Accepted: 2014-06-23 11:30:42-04 :: Revised: 2014-06-23 07:29:38.736184-04 :: Submitted: 2014-06-20 12:40:24.235651-04
Case ID: 14418

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DiagnosisChondrosarcoma, moderate Grade
History60 y.o. woman presents with neck pain and lower extremity weakness.
FindingsEnhancing mass eroding the posterior elements at T1 and extending into the spinal canal producing severe cord compression.
Differential DxMetastatic disease Abscess Mesenchymal/bone tumor (sarcoma)
Discussion ... (continues ...)
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ContributorSteven J Goldstein :: University of Kentucky - Author Info
ReviewerJames G. Smirniotopoulos, M.D. :: Uniformed Services University - Editor Info
Case Accepted: 2014-06-23 11:30:42-04 :: Revised: 2014-06-23 07:29:38.736184-04 :: Submitted: 2014-06-20 12:40:24.235651-04
Case ID: 14396

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DiagnosisPilomyxoid Astrocytoma (PMA) WHO Grade 2
History13 y.o. girl developed headaches three weeks prior to admission. She was treated at that time with medication for migraine headache. One day before presentation she developed ataxia, nausea, and vomiting.
FindingsCT: There is hydrocephalus of both lateral and the third ventricle. There is a vermian mass overlying the fourth ventricle location. This lesion is "cystic" (fluid-like) with some punctuate calcification seen on CT. On the MR, there is some peripheral contrast enhancement of the mass.
Differential DxPilocytic Astrocytoma (WHO Gr 1) Hemangioblastoma (WHO Gr 1) Pilomyxoid Astrocytoma (WHO Gr 2) Medulloblastoma (WHO Gr 4)
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ContributorSteven J Goldstein :: University of Kentucky - Author Info
ReviewerJames G. Smirniotopoulos, M.D. :: Uniformed Services University - Editor Info
Case Accepted: 2014-06-23 11:30:42-04 :: Revised: 2014-06-23 07:29:38.736184-04 :: Submitted: 2014-06-20 12:40:24.235651-04
Case ID: 14388

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DiagnosisLow Grade (WHO Gr2) diffuse astrocytoma
HistoryA 38 y.o. woman presents with a 5-month history of seizures and gradual onset of behavioral changes.
FindingsMultiplanar MR Imaging demonstrates the presence of a T1 hypointense and T2 , FLAIR hyperintense mass lesion in the medial part of the right frontal lobe. The mass does not enhance after gadolinium administration and exhibits no diffusion restriction. The lesion causes mass effect on the corpus callosum, the lateral ventricles and the left frontal lobe. Almost two months following surgical resection of the right frontal mass, postoperative postcontrast T1 weighted images demonstrate no overt findings of residual or recurrent tumor.
Differential Dxcircumscribed astrocytoma (WHO Gr 1) diffuse astrocytoma, low Grade (WHO Gr 2) diffuse astrocytoma, anaplastic(WHO Gr 3) diffuse astrocytoma, glioblastoma (WHO Gr 4) oligodendroglioma (WHO Gr 2, 3) oligo-astrocytoma (WHO Gr 2,3 ganglioglioma (WHO Gr 2) cerebritis ischemic infarct changes from seizures or status epilepticus
Discussion ... (continues ...)
User Group
ContributorIoannis Vasiliou Papageorgiou :: No Academic Affiliation - Author Info
ReviewerJames G. Smirniotopoulos, M.D. :: Uniformed Services University - Editor Info
Case Accepted: 2014-06-23 11:30:42-04 :: Revised: 2014-06-23 07:29:38.736184-04 :: Submitted: 2014-06-20 12:40:24.235651-04
Case ID: 14377

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DiagnosisEpendymoma WHO Grade 2
History19 y.o. woman, who was seen in the ER at least 6 times over a one month period for severe headaches. On this, the seventh visit, would you get a scan?
FindingsComplex Fourth intraventricular mass with both cystic and solid components. This mass extends laterally into the foramen of Luschka. There is peri-lesional edema in the cerebellum. There is enhancement of the central and peripheral aspects of the mass. The lesion is causing obstructive hydrocephalus, enlarging all of the ventricles.
Differential DxAstrocytoma Choroid Plexus Papilloma Ependymoma Subependymoma Medulloblastoma (PNET)
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User Groupn
ContributorSteven J Goldstein :: University of Kentucky - Author Info
ReviewerJames G. Smirniotopoulos, M.D. :: Uniformed Services University - Editor Info
Case Accepted: 2014-06-23 11:30:42-04 :: Revised: 2014-06-23 07:29:38.736184-04 :: Submitted: 2014-06-20 12:40:24.235651-04
Case ID: 14350

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DiagnosisEpendymoma WHO Grade 2
History16 year old girl with one month of headaches. She had an outside CT scan and this MRI done for further evaluation.
FindingsComplex mass with both cystic and solid components. Mass appears to arise in the 4th ventricle and extends out the left foramen of Luschka. Solid portion of mass enhances after contrast administration.
Differential DxMedulloblastoma Choroid Plexus papilloma Ependymoma
Discussion ... (continues ...)
User Group
ContributorSteven J Goldstein :: University of Kentucky - Author Info
ReviewerJames G. Smirniotopoulos, M.D. :: Uniformed Services University - Editor Info
Case Accepted: 2014-06-23 11:30:42-04 :: Revised: 2014-06-23 07:29:38.736184-04 :: Submitted: 2014-06-20 12:40:24.235651-04
Case ID: 14301

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DiagnosisLeft Common Carotid Occlusion, High Grade stenosis right ICA
History58 year old woman who presents with multiple TIAs over the prior 6 months.
FindingsHigh Grade stenosis right ICA Occlusion left Common Carotid artery with reconstitution of the left Internal Carotid Artery via facial and thyroidal artery collaterals
Differential DxNone
Discussion ... (continues ...)
User Group
ContributorSteven J Goldstein :: University of Kentucky - Author Info
ReviewerJames G. Smirniotopoulos, M.D. :: Uniformed Services University - Editor Info
Case Accepted: 2014-06-23 11:30:42-04 :: Revised: 2014-06-23 07:29:38.736184-04 :: Submitted: 2014-06-20 12:40:24.235651-04
Case ID: 14283

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DiagnosisChondrosarcoma, moderate Grade
History44 year old man, with a recent onset of a change in his voice and trouble swallowing solid food.
FindingsExpansile destructive mass appearing to arise from the right cricoid cartilage. The mass has lower attenuation than muscle, destroys the cartilage, and is hypermetabolic on the PET.
Differential DxSquamous cell carcinoma Enchondroma Chondrosarcoma
Discussion ... (continues ...)
User Group
ContributorSteven J Goldstein :: University of Kentucky - Author Info
ReviewerJames G. Smirniotopoulos, M.D. :: Uniformed Services University - Editor Info
Case Accepted: 2014-06-23 11:30:42-04 :: Revised: 2014-06-23 07:29:38.736184-04 :: Submitted: 2014-06-20 12:40:24.235651-04
Case ID: 14250

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DiagnosisGlioblastoma Multiforme (Diffuse astrocytoma Grade 4)
History51 y.o. man with severe headache for four days
Findings• Large central, heterogeneous mass involving the bifrontal lobes with surrounding edema.   • The lesion itself demonstrates multiple apparent cystic regions some with fluid levels with diffuse heterogeneous enhancement.   • Portions of the anterior cerebral artery course through portions of this lesion. • Glioblastoma is the diagnosis of exclusion, although an aggressive oligodendroglioma or hemorrhagic metastasis are not entirely excluded
Differential Dx• Diffuse Astrocytoma High Grade (Gr 4 - glioblastoma) • Oligodendroglioma • Oligoastrocytoma • Primary CNS Lymphoma
Discussion ... (continues ...)
User Group
ContributorJames G. Smirniotopoulos, M.D. :: Uniformed Services University - Author Info
ReviewerJames G. Smirniotopoulos, M.D. :: Uniformed Services University - Editor Info
Case Accepted: 2014-06-23 11:30:42-04 :: Revised: 2014-06-23 07:29:38.736184-04 :: Submitted: 2014-06-20 12:40:24.235651-04
Case ID: 14144

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DiagnosisCerebellopontine angle meningioma WHO Grade II
History58 year old woman with a three day history of headaches, ataxia and hallucinations.,
FindingsCalcified mass in the CPA (cerebello-pontine-angle) cistern - extending from the right tentorial leaf into the sinodural angle with a moderate amount of intraaxial edema.
Differential Dx• Metastatic disease • Primary temporal bone tumor (Yolk Sac Tumor) • Glomus tumor • Meningioma • Hemangiopericytoma
Discussion ... (continues ...)
User Group
ContributorSteven J Goldstein :: University of Kentucky - Author Info
ReviewerJames G. Smirniotopoulos, M.D. :: Uniformed Services University - Editor Info
Case Accepted: 2014-06-23 11:30:42-04 :: Revised: 2014-06-23 07:29:38.736184-04 :: Submitted: 2014-06-20 12:40:24.235651-04
Case ID: 14127

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DiagnosisEpendymal neoplasms, Ependymoma WHO Grade II
History18 year old girl with headaches, nausea and vomiting for one month. She has been seen multiple times in the ER (7 visits) with no diagnosis nor significant relief. A CT scan of brain obtained on last visit ...
FindingsComplex enhancing mass within the 4th ventricle. Mass contains cystic elements. The mass obstructs the 4th ventricle outflow resulting in non-communicating hydrocephalus.
Differential Dx• Medulloblastoma • Ependymoma • Choroid Plexus papilloma • Pilocytic astrocytoma
Discussion ... (continues ...)
User Group
ContributorSteven J Goldstein :: University of Kentucky - Author Info
ReviewerJames G. Smirniotopoulos, M.D. :: Uniformed Services University - Editor Info
Case Accepted: 2014-06-23 11:30:42-04 :: Revised: 2014-06-23 07:29:38.736184-04 :: Submitted: 2014-06-20 12:40:24.235651-04
Case ID: 14088

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DiagnosisIntraventricular Hemorrhage (Grade IV IVH right, Grade III IVH left) with hydrocephalus
HistoryBorn at 27 weeks gestation. Co-morbidities include respiratory distress syndrome and apnea of prematurity.
FindingsImage 1: 1/27/12: Day 19 of Life Hemorrhage is seen within the right lateral ventricle and subsequent dilatation. The echogenciity surrounding the right lateral ventricle may either indicate periventricular hemorrhage or changes of early periventricular encephalomalacia. The left lateral ventricle appears normal in size with no hemorrhage within the ventricle seen in this image. (EVD in situ but not visualized on this image) Image 2: 2/6/12: Day 29 of Life Post EVD removal. Grade IV hemorrhage of the right lateral ventricle is seen, supported by intraventricular and periventricular haemorrhage with dilatation of the right lateral ventricle. The increased echogenicity of the right frontal and parietal lobes surrounding the right lateral ventricle is indicative of evolving encephalomalacia. There is also hemorrhage and dilatation of the left lateral ventricle but no evidence of periventricular extension indicating Grade III IVH. Image 3: MRI Brain: Axial SE T1: Day 16 of life There is marked dilatation of both the lateral and third ventricles. In the right lateral ventricle a large hematoma is seen. The sulci are reduced which is consistent with the patient's prematurity and hydrocephalus. Image 4: MRI Brain: Axial T2 GRE: Day 16 of life Again there is marked dilatation of the lateral ventricles and loss of sulci. Hematoma is seen in the right lateral ventricle. Image 5: MRI Brain: Coronal T1 Flair: Day 16 of Life Sagittal view again demonstrates dilatation of both lateral ventricles and third ventricle. Hematoma is seen in the right lateral ventricle.
Differential DxIt is important to distinguish the extent and grading of IVH for prognosis and follow up of likely complications which may evolve. These include periventricular leukomalacia or encephalomalacia(PVL or PVE), periventricular hemorrhagic infarction (PVI), and post hemorrhagic hydrocephalus.
Discussion ... (continues ...)
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ContributorChelsea S. Guymer :: Childrens Hospital of Dayton, OH - Author Info
ReviewerDawn E Light :: Childrens Hospital of Dayton, OH - Editor Info
Case Accepted: 2014-06-23 11:30:42-04 :: Revised: 2014-06-23 07:29:38.736184-04 :: Submitted: 2014-06-20 12:40:24.235651-04
Case ID: 14086

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DiagnosisAnaplastic astrocytoma, Grade III, Grade 3
History26 y.o. woman presented to ER with unremitting headache for 12 days
Findings• Infiltrative mass right frontal and temporal lobe. • Little to no enhancement following contast • No calcium within the mass on CT
Differential Dx• Astrocytoma • PNET • Metastatic tumor
Discussion ... (continues ...)
User Group
ContributorSteven J Goldstein :: University of Kentucky - Author Info
ReviewerJames G. Smirniotopoulos, M.D. :: Uniformed Services University - Editor Info
Case Accepted: 2014-06-23 11:30:42-04 :: Revised: 2014-06-23 07:29:38.736184-04 :: Submitted: 2014-06-20 12:40:24.235651-04
Case ID: 14063

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DiagnosisGlioblastoma multiforme (WHO Grade 4 astrocytoma)
History38 year old woman presents with headache and disorientation
Findings• Large heterogeneous mass in the right parietal lobe with extension across the splenium of the corpus callosum. • Mass enhances and has central regions of necrosis as well as perilesional edema.
Differential Dx• Metastatic disease • Tumefactive MS • Ependymoma • Astrocytoma (glioblastoma)
Discussion ... (continues ...)
User Group
ContributorSteven J Goldstein :: University of Kentucky - Author Info
ReviewerJames G. Smirniotopoulos, M.D. :: Uniformed Services University - Editor Info
Case Accepted: 2014-06-23 11:30:42-04 :: Revised: 2014-06-23 07:29:38.736184-04 :: Submitted: 2014-06-20 12:40:24.235651-04
Case ID: 13988

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DiagnosisEpendymoma. Grade II
History57 year old man with back and right leg pain for 2 months.
Findings• a 1.5 cm mass lying behind cauda equina at L1-2. • Mass enhances following contrast administration. • No associated bone changes nor neuroforaminal enlargement.
Differential Dx• Ependymoma (myxopapillary) • Herniated disc • Metastatic disease • Schwannoma • Meningioma • Paraganglioma
Discussion ... (continues ...)
User Group
ContributorSteven J Goldstein :: University of Kentucky - Author Info
ReviewerJames G. Smirniotopoulos, M.D. :: Uniformed Services University - Editor Info
Case Accepted: 2014-06-23 11:30:42-04 :: Revised: 2014-06-23 07:29:38.736184-04 :: Submitted: 2014-06-20 12:40:24.235651-04
Case ID: 13956

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DiagnosisOligodendroglioma, WHO Grade 2
History38 year old man who had 5 episodes of left hand and leg numbness lasting, from 3 minutes to 1 hour, over the course of 1 day.
Findings• 2.5 cm right parietal lobe mass with very little enhancement following contrast administration. • Mass has high signal changes on T2 and flair sequences.
Differential Dx• Astrocytoma • Metastatic tumor • Abscess
Discussion ... (continues ...)
User Group
ContributorSteven J Goldstein :: University of Kentucky - Author Info
ReviewerJames G. Smirniotopoulos, M.D. :: Uniformed Services University - Editor Info
Case Accepted: 2014-06-23 11:30:42-04 :: Revised: 2014-06-23 07:29:38.736184-04 :: Submitted: 2014-06-20 12:40:24.235651-04
Case ID: 13900

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DiagnosisAstrocytoma, low-Grade
History9 year old girl presents with a single episode of inattention and a staring spell.
Findings• Single 1.2 cm lesion (signal change) right parietal lobe. • Relatively homogeneous enhancement. • No surrounding edema.
Differential Dx• Astrocytoma • DIG (Dysplastic Infantile Ganglioglioma • DNET (Dysembryplastic Neuroepithelial tumor) • Ganglioglioma • Ependymoma
Discussion ... (continues ...)
User Group
ContributorSteven J Goldstein :: University of Kentucky - Author Info
ReviewerJames G. Smirniotopoulos, M.D. :: Uniformed Services University - Editor Info
Case Accepted: 2014-06-23 11:30:42-04 :: Revised: 2014-06-23 07:29:38.736184-04 :: Submitted: 2014-06-20 12:40:24.235651-04
Case ID: 13887

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DiagnosisSplenic Laceration, Grade V
History33 year old male presents after his car collided with the rear end of another vehicle at 100mph. Patient was ejected from his vehicle and landed 20 feet from the accident site. Denies use of anticoagulants.
FindingsCT abdomen and pelvis with contrast showed a shattered spleen with multiple lacerations and fractures extending through the full thickness of the spleen. There was a moderate amount of perisplenic hemorrhage and evidence of active contrast extravasation.
Differential DxSplenic subcasular hematoma Splenic infarction Splenic vein laceration with hematoma
Discussion ... (continues ...)
User Group
ContributorKelly Potts :: University of Kentucky - Author Info
ReviewerSteven J Goldstein :: University of Kentucky - Editor Info
Case Accepted: 2014-06-23 11:30:42-04 :: Revised: 2014-06-23 07:29:38.736184-04 :: Submitted: 2014-06-20 12:40:24.235651-04
Case ID: 13829

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DiagnosisAstrocytoma, low-Grade
History16 year old girl who was noted by her mother to have a first time seizure while sleeping. Patient admitted to smoking a "joint' prior to going to bed.
Findings• Calcified mass in left temporal lobe on CT scan. • No significant mass effect nor perilesional edema. • Minimal enhancement of mass on MRI.
Differential Dx• Astrocytoma • Oligodendroglioma • AVM • DNET
Discussion ... (continues ...)
User Group
ContributorSteven J Goldstein :: University of Kentucky - Author Info
ReviewerJames G. Smirniotopoulos, M.D. :: Uniformed Services University - Editor Info
Case Accepted: 2014-06-23 11:30:42-04 :: Revised: 2014-06-23 07:29:38.736184-04 :: Submitted: 2014-06-20 12:40:24.235651-04
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