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 & 3rd ventricles.

Case 1: Pathology Light Microscope: Diagnosis: Cysticercosis 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 type- cluster of grapes) (less than 10%).

Neurocystircercosis Vesicular stage: Colloidal stage: Granular 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: 1st 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: 2nd Follow up study, post op Patient non-compliant with medications.

Case 2: 3rd Follow up study Improved compliance.

Case 2: 4th Follow up study, further improvement

IRIS (immune reconstitution syndrome) HIV pts initiated on retroviral therapy. Restored immune system now reacting/over-reacting (?) 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_reconstitution_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 p53. 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.