1. Janica Walden, Michael Solle, Neuroradiology

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

3. Case 1: Head CT

4. Case 1: MRI (FLAIR)

5. Case 1: MRI (CISS)

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

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

8. 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%).

9. 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.

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

11. Case 2: Intial study

12. Case 2: 1 st Follow up study

13. -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.

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

15. Case 2: 3 rd Follow up study  Improved compliance.

16. Case 2: 4 th Follow up study, further improvement

17. 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.

18. 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.

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

20. Case 3

23. 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.

24. 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.

26. Arterial spin label cerebral blood flow map.

27. 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.

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

30. CT

31. 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.

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