1. AQP4‑NMOSD optic neuritis (most likely)
2. MOGAD optic neuritis (usually more anterior, optic sheath oedema)
3. Multiple sclerosis optic neuritis (short segment, unilateral)
4. Granulomatous/infective optic neuritis (sarcoid, TB, syphilis)
Come back next week to see the answer. In the meantime, check our social networks to leave your guesses!
With left-sided dyspraxia
Well-defined cystic lesion in subcutaneous plane of lateral margins of orbit on left
Underlying bone and adjacent lacrimal gland are unremarkable
Orbital dermoid cyst
Orbital teratoma
Orbital dermolipoma
Orbital hemangioma
Orbital rhabdomyosarcoma
Orbital dermoid cyst – TRUE
Orbital teratoma – TRUE
Orbital dermolipoma – TRUE
Orbital hemangioma – TRUE
Orbital rhabdomyosarcoma – FALSE
They are thought to occur as a developmental anomaly in which embryonic ectoderm and mesoderm are trapped in the closing neural tube between the 5th and 6th weeks of gestation
These lesions are usually extraconal, non-enhancing masses with smooth margins, cystic, and/or solid components
They are typically heterogeneous with soft tissue, fluid, and fatty (sebum) components; occasionally calcifications may be present
They are most commonly located superotemporally, arising from the zygomaticofrontal suture, followed by superonasally, arising from the frontoethmoidal or frontolacrimal sutures
Ruptured dermoids may show adjacent inflammatory changes
Superficial lesions barely require cosmetic excision, while a deeper lesions may require more invasive methods involving micro-dissection and orbitotomy
Kudo K, Tsutsumi S, Suga Y et al. Orbital dermoid cyst with intratumoral inflammatory hemorrhage: case report. Neurol. Med. Chir. (Tokyo). 2008;48 (8): 359-62. Pubmed citation
Ahmed RA, Eltanamly RM. Orbital epidermoid cysts: a diagnosis to consider. J Ophthalmol. 08;2014: 508425. doi:10.1155/2014/508425 – Free text at pubmed – Pubmed citation
Chaudhry IA. Management of deep orbital dermoid cysts. Middle East Afr J Ophthalmol. 2008;15 (1): 43-5. doi:10.4103/0974-9233.53376 – Free text at pubmed – Pubmed citation
With left-sided dyspraxia
Duration uncertain
The case was initially interpreted as CSF seeding by a malignant choroid plexus tumor.
However, retrospective investigation of CTA showed another pathology.
This case demonstrates several small areas of cortical enhancement in the right hemisphere. These enhancing areas correspond to small regions of subacute cortical ischemia in the right MCA territory, caused by a ruptured carotid plaque with an intraluminal thrombus. The mass in the antrum of the left ventricle is an incidental intraventricular meningioma. Follow-up scans showed regression of the cortical enhancement and stable intraventricular meningioma on the left.
Teaching points:
Subacute ischemia may enhance and in some cases mimic tumors or CSF seeding.
Ruptured carotid plaque with intraluminal thrombus presents with finger-like filling defect of the internal carotid.
Choroid plexus carcinomas are rare in elderly patients with an intraventricular meningioma being way more common. Typical location, sharp tumor-brain interface, homogeneous enhancement and T2 hypointensity allow for a confident diagnosis of an intraventricular meningioma.
With worsening paresis of cranial nerves CN3-7
Axial T2 image on the left shows partial obliteration of the right Meckel’s cave and an ill-defined T2 hypointense lesion on the right temporal fossa.
Axial T2 image on the right shows atrophy of the right-sided masticatory muscles.
Post-contrast 3D T1 FSE fat-saturated images showing an enhancing lesion overlying the right temporal fossa, with perineural spread along CN7, the auriculotemporal nerve and continuing intracranially via the right foramen ovale (note the asymmetry in enhancement).
3D bSSFP images (CISS) before (left) and after (right) contrast administration. bSSFP images contain both T1 and T2 information, therefore showing enhancement after contrast administration.
While pre-contrast image doesn’t depict any obvious pathology, the post-contrast image on the right clearly highlights tumor deposits (red arrows) along the lateral aspect of the right cavernous sinus. The tumor has encased the cranial nerves, leading to the patient’s symptoms. For comparison, the normal anatomy of the cranial nerves is shown on the left (green arrows).
This case shows a histologically verified squamous cell carcinoma of the temporal fossa spreading along the CN7, auriculotemporal nerve, mandibular nerve and into the right cavernous sinus.
Teaching points:
Multiple CN palsies of CN3-6 should raise a suspicion of cavernous sinus pathology.
Auriculotemporal nerve is an important connection between the facial and mandibular nerves.
bSSFP sequences like CISS contain both T1 and T2 information and therefore show post-contrast enhancement which can be diagnostically useful in conjunction to their excellent spatial resolution.
25-year-old female patient:
– Presented with swollen right cervical lymph nodes
TB cervical lymphadenitis
Mild progression in size of multiple necrotic lymph nodes in bilateral supraclavicular, axillary regions, internal yugular (more prominent at right side).
What do you see in the following images?
Scalp haemangioma
Right parietal subcutaneous well-defined soft tissue oval lesion. It demonstrates low signal on T1W image, Intermediate signal on T2W image with prominent vascular flow voids, and avid enhancement on the post contrast image. No adjacent osseous or soft tissue abnormality. No intracranial extension.
Infantile hemangiomas are benign vascular tumours, most of these tumours arise in the craniofacial region. Most of them are not present at birth but they increase in size during the first year of life, with a subsequent progressive involution during early childhood.
Differential diagnosis includes: epidermoid cyst, lymphatic malformation, and sinus pericranii.
What do you see in the following images?
Nasolabial cyst
Right nasolabial lesion with remodeling of the maxillary alveolus bone. On MRI it shows high signal intensity on both T1- and T2-weighted images with no signal suppression on the T2 FLAIR with Fat saturation sequence.
Differential Diagnosis:
Nasolabial cyst with hemorrhage
Epidermal inclusion cyst
Dermoid cyst
Dentigerous cyst
Ossification of the membranous labyrinth, high-density bone deposition involving all the cochlear turns.
This usually occurs as a complication of suppurative labyrinthitis, either due to otomastoiditis or meningitis. Other causes include trauma, autoimmune diseases, and surgery.
24-year-old male:
– Feels a lump in the upper lateral corner of right eye.
– MRI was made.
Preseptal lesion right supero-lateral corner, lateral to lacrimal gland.
T2 and T1 hyperintense, low signal after fat suppression.
No enhancement (right upper picture).
Slight remodeling of bone.
No invasive growth no post-septal component.
Diagnosis: dermoid cyst, also fits with age and location of lesion.
Dehiscent left jugular bulb
Absence of the sigmoid plate that normally separates the jugular bulb from the middle ear cavity with a resultant bulging of the jugular bulb into the middle ear cavity
