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Q9.1. Diagnosis Please

9.1a. 9.1b. 9.1c. 9.1d. Diffusion weighted image (DWI). FLAIR Image. T1-wtd image. Post-contrast Axial T1-wtd image. Diffusion weighted image (DWI). 9.1e. 9.1f. 47 year-old left handed gentleman with one day history of somnolence, left facial droop and slurred speech.

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Q9.1. Diagnosis Please

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  1. 9.1a 9.1b 9.1c 9.1d Diffusion weighted image (DWI) FLAIR Image T1-wtd image Post-contrast Axial T1-wtd image Diffusion weighted image (DWI) 9.1e 9.1f 47 year-old left handed gentleman with one day history of somnolence, left facial droop and slurred speech. Q9.1. Diagnosis Please MRA Circle of Willis Post-contrast coronal T1 wtd image

  2. Q9.2. Diagnosis Please 9.2a 9.2b 9.2c 9.2d (DWI)image Post-contrast Axial T1-wtd image FLAIR Image T1-wtd image 51 year-old patient multiple myeloma presented with acute onset of right side weakness leading to MRI of the brain 3 days later. 51 year-old patient multiple myeloma presented with acute onset of right side weakness leading to MRI of the brain 3 days later. 51 year-old patient with multiple myeloma presented with acute onset of right sided weakness leading to MRI of the brain 3 days later.

  3. Q9.3. Diagnosis Please 9.3a 9.3b 9.3c 9.3d Diffusion weighted image (DWI) FLAIR Image T1-wtd image Post-contrast Axial T1-wtd image 9.3e 9.3f 72 year-old left handed white man with history of chest pain, 5 days prior to MRI, which subsided. Patient went to a gas station and could not read the credit card and signs in the gas station and was unable to read the magazines in the doctor’s office. Neurological examination revealed alexia without agraphia. MR Angiography Neck Post-contrast coronal T1 wtd image

  4. Q9.4. Diagnosis Please June 29, 2004 July 30, 2004 9.4a 9.4b 9.4c 9.4a. Non-contrast CT Brain 9.4b. Non-contrast CT Brain 9.4c. Non-contrast CT Brain Patient is status post recent right temporal craniectomy for extensive right middle fossa skull-based meningioma, with follow-up post-operative CT images.

  5. Q9.5. Diagnosis Please 9.5a 9.5b 9.5c 9.5d Diffusion weighted image (DWI) FLAIR Image T1-wtd image Post-contrast Axial T1-wtd image 9.5e 58 year-old male with history of renal cell carcinoma presented with 3 weeks history of dressing apraxia consisting of difficulty in performing routine tasks such as getting dressed, tying his shoes, difficulty with recall and inferior quadrantopsia with no focal motor deficits. Symptoms slowly improved. Differential diagnosis: Stroke versus metastasis. Post-contrast sagittal T1 wtd image

  6. Q9.6. Diagnosis Please DW Image FLAIR Image T1-wtd image Post-contrast Axial T1-wtd image July 31, 2003 9.6a 9.6b 9.6c 9.6d 9.6e 9.6f 9.6g 9.6h DW Image FLAIR Image T1-wtd image Post-contrast Axial T1-wtd image December 31, 2003 73 year-old male with stage IV non-small cell carcinoma presented with 2 weeks history of sudden onset of speech difficulty with difficulty in word finding, symptoms gradually improved. Clinical diagnosis: Stroke versus metastasis.

  7. 9.1a 9.1b 9.1c 9.1d 9.1e 9.1f Diagnosis: Acute one day old infarction involving the right middle cerebral artery (MCA) territory. Diffusion weighted image (DWI) Acute infarction is seen as an area of increased signal intensity on DWI (arrow in A), FLAIR image (arrow in B), with no evidence of hemorrhage on T1-wtd image (C) and no enhancement on post contrast images (D). Intravascular enhancement also an indication of acute stroke is shown on coronal T1 weighted image (arrow in F). MR angiography of circle of Willis demonstrates small caliber of right Sylvian branches of MCA (arrows in E) when compared to the normal side.

  8. 9.2a 9.2b 9.2c 9.2d DWI Post-contrast Axial T1-wtd image FLAIR Image T1-wtd image Diagnosis: Small acute 3 day old infarction involving the left insular cortex, the territory of left MCA, best noted on diffusion weighted image (arrow in A) and with enhancement (arrow in D).

  9. 9.3e 9.3f 9.3a 9.3b 9.3c 9.3d Diagnosis: Acute infarction (5 day old) involving the left posterior cerebral artery (PCA) territory. Diagnosis: Acute infarction (5 day old) involving the left posterior cerebral artery (PCA) territory. The area of infarction is seen as an area of increased signal intensity on DWI (arrow in A) and FLAIR image (arrow in B) involving the left posterior temporal-occipital lobe. Mild enhancement seen on post contrast images (arrow in D and F). Figure E represents screening 2D time of flight MR angiogram of the neck vessels revealing no obvious occlusion of major vessels in the neck.

  10. June 29, 2004 July 30, 2004 9.4a. Non-contrast CT Brain 9.4b. Non-contrast CT Brain 9.4c. Non-contrast CT Brain Non-contrast CT brain on 8 days post-operatively demonstrated a focal area of low attenuation within the right frontal lobe cortex (arrow in A) and adjacent white matter representing acute infarct. Scan done a month later (B & C) demonstrated a massive acute/subacute infarct involving the right MCA territory (white arrows in B & C) and ACA (anterior cerebral artery) territory (yellow arrow in C) with mass effect and subfalcine herniation to the left (fig. B).

  11. Q9.5. Diagnosis Please 9.5a 9.5b 9.5c 9.5d Diffusion weighted image (DWI) FLAIR Image T1-wtd image Post-contrast Axial T1-wtd image Diagnosis: Subacute infarct 3 weeks old involving the right middle cerebral (MCA) artery territory. 9.5e Abnormal T2 wtd hyperintensity involving the right posterior temporal-parietal-occipital lobe with gyral thickening best noted on FLAIR image (arrows in B). Subacute blood outlining the cortex is best seen on pre-contrast T1-wtd image (arrows in C). There is no definite contrast enhancement obscured by bright signal intensity of blood. The right MCA territory infarct is also shown on sagittal post contrast T1-wtd image (arrows in E). Diffusion weighted image reveals bright signal intensity (arrows in A) involving the cortex from restricted diffusion, an important sequence in the diagnosis of acute stroke. Post-contrast sagittal T1 wtd image

  12. Q9.6. Diagnosis Please July 31, 2003 9.6a 9.6b 9.6c 9.6d Diagnosis: Non-hemorrhagic subacute enhancing infarct (2 weeks old) involving the left basal ganglia region. Subacute infarct is seen as an area of increased signal intensity on FLAIR image (arrow in B) and bright signal intensity on DWI (arrow in A). Enhancement of the infarct is shown on post contrast image (arrow in D). A repeat MRI scan done 5 months later showed resolution of infarct and no evidence of bright signal intensity on diffusion weighted image E. 5 months old infarct. 9.6e 9.6f 9.6g 9.6h December 31, 2003

  13. Imaging Findings of Stroke: Acute Stroke (up to 7 days) • MR imaging of the brain is far more sensitive than CT imaging to recognize acute infarction. • Diffusion wtd. pulse sequence (DW imaging) is the most sensitive MR sequence to demonstrate stroke. This sequence is sensitive to restricted diffusion within the cell from stroke-induced cytotoxic edema and the region of acute stroke is seen as an area of bright signal on DWI (Figs. 1a, 2a). Cytotoxic edema can occur immediately after the initial insult thus DWI images can reveal, the area of acute infarct immediately after the insult. • Intravascular contrast enhancement, another sign of early stroke (Figure 1f). • Sulcal effacement, gyral edema (Fig. 5b), loss of gray-white matter interface can occur within 12 hours of stroke. • Parenchymal contrast enhancement (Fig. 6d), mass effect (Fig. 4b) and hemorrhage can occur within 1-7 days of insult. 1a 2a 5b 6d Subacute infarct: (1 week to 8 weeks) • Contrast enhancement slowly decreases in time but can persist for 8 weeks, with decreasing mass effect and abnormal signal intensity: Old Infarct: 4b • Focal area of encephalomalacia • Porencephalic dilatation of adjacent ventricle. • Residual old blood products may be present. 6e

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