Category Archives: Aunt Mickeys

Aunt Mickey (They Look the Same until You Undress Them). Posterior Fossa Tumor or Something Else?

51-year-old male with no significant past medical history presented with 3+ months H/O intermittent dizziness, intermittent headaches, difficulty going down stairs and 3+ days H/O tingling and numbness on the right side of face, right hand and foot. MRI revealed increased T2 signal and swelling of the entire pons including the middle cerebellar peduncles with effacement/obliteration of the prepontine and CP angle cisterns. Center of the lesion was heterogeneously T2 hypointense and showed heterogeneous contrast enhancement, small focus of diffusion restriction, focal area of increased CBV and high choline to creatine ratio (2.18) & a tall lactate peak on MR … Continue reading >>

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Aunt Mickey (They Look the Same until You Undress Them). Calvarial Metastases or Something Else?

A 59 year-old woman presented with an approximate one-year history of worsening sensory disturbances and pain in the right side of her scalp and face.  Her past medical history was otherwise unremarkable.  Part of her initial work-up involved imaging of the head, which revealed multiple lytic lesions of varying sizes throughout the skull.    An unenhanced CT was done (Figure 1), and several circumscribed lytic lesions of varying sizes were seen throughout the calvarium.  There was no periosteal reaction or sclerosis surrounding the lesions.  There were no intracranial lesions. The patient was referred to a neurosurgeon for biopsy because no underlying … Continue reading >>

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Aunt Mickey (They Look the Same until You Undress Them). Cavernous Sinus Tumor or Something Else?

A young male presented with progressive right sided cranial nerve palsies was diagnosed as having a cavernous sinus syndrome.  CT was done (Fig. 1) and showed a mass in the right cavernous sinus extending to the sphenoid sinus.  Note that the mass contained some flecks of calcium and remodeled adjacent bones.  At this point in time, the differential diagnosis included mainly a solid tumor (schwannoma, neurofibroma, meningioma, metastases [less like due to age and absence of primary tumor), lymphoma, and hemangioma).  MR imaging with contrast was obtained and a coronal T1 image (Fig. 2) demonstrated that the mass enhanced homogeneously … Continue reading >>

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Aunt Mickey (They Look the Same until You Undress Them). Meningioma or Something Else?

73 year old lady presented with six weeks history of odd behavior, increasing apathy, expressive aphasia, and mild headache. An MRI including diffusion and perfusion imaging was obtained. MRI revealed a T1 hypointense (to cortex) and slightly T2 hyperintense (to cortex) extra-axial mass in the left frontal region. There were multiple central T2 hyperintense areas. On post contrast T1 weighted sequence, there was intense enhancement of the mass except the central T2 hyperintense areas.There were prominent diffusion restriction and high rCBV in most parts of the tumor in diffusion and perfusion imaging respectively.

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Aunt Mickey (They Look the Same until You Undress Them). Meningioma or Something Else?

51 year old lady presented with headache and gait disturbances. An MRI including perfusion imaging was obtained. MRI revealed an extra-axial, dural based mass of the posterior fossa which was isointense to gray matter on T1 weighted sequence and hyperintense to gray matter on T2 weighted sequence. There was no diffusion restriction. On T2 weighted sequence, there was wedge shaped area of perilesional T2 hyperintensity extending transversely and superiorly to involve vermis. With contrast, the lesion showed intense homogenous enhancement. On perfusion study, there was considerable increase in rCBV. Preoperatively it was diagnosed as meningioma and the patient was scheduled … Continue reading >>

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Aunt Mickey (They Look the Same until You Undress Them). Carotid-Cavernous Fistula or Something Else?

A middle age woman presented with left progressive proptosis.  A contrast enhanced CT was done and showed enlargement of the left superior ophthalmic vein on the axial plane (see below).  A coronal image confirmed this abnormality and demonstrated that the extraocular muscles and retro-orbital fat had a normal appearance.

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Physical examination showed no chemosis, vision loss or cranial nerve palsies.  Because of this the patient was brought back for repeat contrast enhanced CT of the orbits with Valsalva maneuver.  This study showed mild additional enlargement of the already prominent left superior ophthalmic vein and also of the right sided one … Continue reading >>

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Aunt Mickey (They Look the Same until You Undress Them). Lhermitte-Duclos or Something Else?

A young man presented with ataxia.  Brain contrast enhanced MRI was done including DWI and perfusion.  T2WI showed a mixed intensity lesion in the inferior right cerebellar hemisphere which contained some “dark stripes”.  DWI ADC map show restricted diffusion centrally.  After contrast the lesion enhanced in a striped fashion and perfusion showed low rCBV (see below).  Llermitte-Duclos disease was considered in the differential diagnosis.

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Further questioning of patient disclosed that the symptoms had had a sudden onset 7 days earlier.  The diagnosis of subacute infarction of the right posterior inferior cerebellar artery territory was considered as the most likely cause … Continue reading >>

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Aunt Mickey (They Look the Same until You Undress Them). Meningioma or Something Else?

A young African American woman presented with progressive left vision loss.  Brain MRI with contrast and perfusion studies were obtained.  The studies showed a dural-based lesion involving the lateral aspect of the left cavernous sinus which extended superiorly and crossed the planum sphenoidale to insinuate itself around the contralateral anterior clinoid process. The lesion was isointense to gray matter on T1WI, dark on T2WI, showed homogeneous gadolinium enhancement and increased rCBV on the perfusion images (see below).  The provisional diagnosis of meningioma was made and the patient scheduled for surgical decompression of left optic canal.

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Before surgery, a chest radiograph … Continue reading >>

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Aunt Mickey (They Look the Same until You Undress Them). Myxopapillary Ependymoma or Something Else?

This young male presented with chronic but progressive low back pain and lower extremity weakness.  MR imaging of the lumbar spine with contrast showed a lesion, intradural/extramedullary, extending from T12 to L4.  The lesion “expanded” the spinal canal and produced significant remodeling (scalloping) of the posterior vertebral bodies.  The mass had mostly low T1 signal pre contrast, mostly high T2 signal and enhanced after gadolinium.  Is it a large myxopapillary ependymoma?

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Analysis of axial images showed that the mass involved the spinal canal but extended out into the paraspinal regions, including the right psoas muscle, via several neural foramina.  The … Continue reading >>

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Aunt Mickey (They Look the Same until You Undress Them). Subarachnoid Hemorrhage or Something Else?

A young female presented to an outside hospital with headache of one day duration. An MR brain study was done and interpreted as showing acute subarachnoid hemorrhage in the right temporal/occipital region.  The patient was transferred to our hospital for treatment and before performing a lumbar puncture a head CT was done.  The CT was interpreted as normal.  CSF was obtained and was also normal.

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Analysis of images showed an artifact involving the right lower side of the skull seen only on the DWI, ADC and a T2* sequence.  This magnetic susceptibility artifact was found out to have been due … Continue reading >>

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