Neuro Cases

Question 1

Where and What is the DDx for this lesion?

Answer 1

Pineal Germinoma

Paediatric Pt group.

CT Fx: Nonenhanced CT - slightly hyperattenuating mass with areas of Ca++. Contrast-enhanced - homogeneous / intense enhancement.

MRI Fx: Usu. ISO-intense to grey matter on T1 and T2. Shows homogenous / intense enhancement.

DDx:

Pineal Parenchymal tumours:

1. Pineocytoma
2. Pineoblastoma

Germ cell tumours:

1. Pineal germinoma (most common; ~ 50% of all tumours)
2. Pineal embryonal carcinoma
3. Pineal choriocarcinoma
4. Pineal yolk sac carcinoma
5. Pineal teratoma

• Astrocytoma of pineal gland
• Pineal metastasis
• Pineal cyst
• Meningioma near pineal region

T1+Gad sagittal demonstrating enhancing pineal germinoma

Question 2

This is the MRI from an Immunocompromised Pt. What is the DDX?

Answer 2

Progressive Multifocal Leukoencephalopathy (PML)

CT

• Asymmetric focal zones of low attenuation involving the peri-ventricular and sub-cortical white matter.

MRI

• Multifocal, asymmetric peri-ventricular and sub-cortical involvement.
• There is little or no mass effect.
• T1: Usually hypo-intense
• T2 : HYPER-intense
• T1 C+ (Gd) : typically NO enhancement, however if present it may be associated with improved survival

DDx:

Question 3

Intramedullary Multifocal Abnormal T2W Signal DDx

Answer 3

Acute Disseminated Encephalomyelitis (ADEM)

Etiology:

• Autoimmune process post predisposing infection (e.g. mumps, strep., Varicella) producing an inflammatory reaction

Key Fx:

• Multifocal white matter lesions with relatively little mass effect or vasogenic edema
• Flame-shaped lesions with slight cord swelling
• Anywhere in spinal cord white matter
• Variable enhancement, depending on stage of disease
• Brain almost always involved

Top Differential Diagnoses

• Multiple sclerosis
• Viral myelitis
• Idiopathic transverse myelitis
• Less likely: Extensive spinal cord neoplastic disease such as
  
  • Astrocytoma,
  • Ependymoma

Treatment

• Steroid treatment with intravenous methylprednisolone is treatment of choice,
• Immunoglobulin therapy
• Plasmapheresis in fulminant case