Glomus Jugulare-MRI

"Contrast-enhanced MRI demonstrates enhancing soft-tissue masses at characteristic locations; these findings are important for diagnosis. Nonenhanced MRI can demonstrate glomus tumors, but the demonstration of a strongly enhancing mass is typical in the diagnosis of a glomus tumor. Contrast-enhanced imaging can show intense tumor enhancement, which again, is a key finding in the diagnosis. In addition, a salt-and-pepper fine vascular pattern can be seen in the tumors; this finding is suggestive of intrinsic tumor neovascularity and is particularly well demonstrated on T2-weighted images. Direct coronal imaging can show tumoral relationships to adjacent structures such as the brainstem and skull base, and deep cervical soft-tissue structures extraordinarily well depicted."

Case by Dr MGK Murthy, Dr Sumer Sethi of Teleradiology Providers

An Impromptu Trip to Calbayog

I took the weekend vacation to make an impromptu trip to Calbayog City, Samar. I will be a godfather, and it's a good opportunity to strengthen an old friendship. It will also be a good time to renew my connection to the rural atmosphere. Having lived in the smoke and dusty environs of Manila all my life, I felt that a regular journey to the countrysides can be a sort of release from the stress and tension of metro living.

But as it happened, while on the journey, my mind still wandered on so many unfinished works in my part-time job. It's about the work commissioned to me to build an online Encyclopedia of Komiks. Although the work is fun and I have all the necessary materials for it, the nagging sense that I had to finish the groundwork before the year is out is not very easy to think, especially as I'm doing the work alone, and no assistants to help me or editors to correct my writing. Building an encyclopedia in a few months time is no easy task, I should say. Anyway, more on that later. .

Well, the trip to Calbayog helped me regenerate my energies. I come back refreshed--breathed fresh air, ate fresh seafoods and vegetables. I was also able to meet a few old friends, renew acquaintances.

Best of all, I was able to reshoot my beloved photos of Samar. My Nikon D40x helped me a lot to do this. The smallest dslr today, it felt like just a compact digicam in my hand. I felt that the burden of carrying an slr is becoming a thing of the past, as more and more smaller yet more powerful cameras come out in the market regularly.

I made the trip to Calbayog amidst the path of Typhoon Hanna. It was not the first trip that I had running against a typhoon. In 2002, while on a sea voyage to Corregidor, our ship (a navy ship), happened to cross the path of a typhoon. It was a frightening experience (I was on the ship getting free ride to Corregidor). A passenger ship on the way to Manila sank, killing several passengers and our ship had to help retrieve the dead and survivors. We were not able to set foot to Corregidor and spent the whole day and night searching for bodies.

Typhoon Hanna delayed our trip for several hours. By the time I got to Calbayog, however, the weather had improved. I heard from the radio that Hanna was already in its path to Taiwan.

Anyway, here are the photos of my weekend trip to Calbayog. I hope you'll enjoy and at the same time forgive the low-quality composed pictures. Just think that through these pictures you have travelled with me to that far corner in the Philippines.



I had taken the seat at the back..because the front seats are already occupied by the early birds.




Good thing though, as there are no curious co-passengers to see me photographing the road we were treading.



Stranded passengers waiting for the go-signal to enter the ship for the voyage across the San Bernardino Strait, between Matnog, Sorsogon and Allen, Samar. The sky had cleared down a bit.



The rain didn't do too much disturbance to the sea. Shot while re-entering the bus in Allen, Samar.



This is Calbayog Taxi. Yes, they are like little jeepneys, or big trycicles. One ride anywhere in the villages is 10 pesos per person.



The main road of Calbayog.



Sea Rock Hotel along the Maharlika Hi-Way in Calbayog City. Behind the hotel is the Bagacay Beach. I chose to stay here for the two-day visit.



Another seaside hotel in Calbayog is "Seaside Drive Inn" . It also has cable TV, hot shower, and nice queen size bed.


The road to the city.




The old plaza of Calbayog, with Rizal monument.



A regular visitor to my blog requested that I shoot an interior of the Calbayog Cathedral (I think it was Gina Togonon of Canada). I abide to her request. Here it is, Gina.




Calbayog City Rural Market



A Stingray. Being sold for 500 pesos. I only bought 1 kilo had it abobo-cooked by my Mother-in-Law. It tasted like a shark.


RURAL SCENERIES



A piglet, for sale for 2,000 pesos. I wanted to buy the poor animal, but I live in Manila and can't take him home.


Early morning neighborhood chat is a favorite hobby(?) among many village people.



I bought a jug of Tuba for my lasenggero friends in Cubao. I myself don't drink too often. It was a long time already since I last tasted liquor. Maybe 2 hours ago.


You will not entirely miss Manila at all in Calbayog. Calbayog also has a Starback coffee shop. And look at the crew, they can readily pose for you for photo-ops.




Going back to Manila at Sunset time.

To be continued...:)

Diffuse intrinsic pontine glioma

Additional clinical information: The patient has neurofibromatosis type 1


Findings

Initial CT shows a new central dorsal pontine focus of FLAIR hyperintensity, demonstrating enhancement. One year later, there has been significant increase in the size of a heterogeneously enhancing expansile pontine mass lesion, with extension into the midbrain and along the cerebellar peduncles into the right cerebellar hemisphere.

Differential Diagnosis:
- Pontine Glioma
- Neurofibromatosis Type 1 associated hamartoma or foci of signal intensity
- Brainstem encephalitis
- Acute disseminated encephalomyelitis (ADEM)
- Tuberculoma
- Histiocytosis
- Pontine myelinolysis
- Infarct
- Lymphoma


Diagnosis: Diffuse intrinsic pontine glioma


Key points

Brainstem gliomas
- Represents 12% to 15% of all pediatric brain tumors
- Several types, including diffuse pontine glioma, tectal glioma, focal tegmental mesencephalic
- Histology is usually anaplastic astrocytoma or glioblastoma multiforme
- Does not metastasize outside of the central nervous system


NF1
- Association with tectal and diffuse pontine glioma
- Clinical Presentation:
Presents with headache, ataxia, cranial nerve palsies, hemiparesis
Age of presentation is in children and young adults
No sex predilection
Results in respiratory insufficiency
Treated with chemotherapy and radiation
Poor prognosis in children, with 10 to 30% 5 year survival


Imaging characteristics for diffuse pontine glioma

CT
- Isodense or hypodense, with indistinct margins
- Rare calcification or hemorrhage
- Only 10% will have hydrocephalus
- Variable enhancement

MRI
- Low signal on T1
- High signal on T2
- High signal on FLAIR
- Variable enhancement
- Demonstrates expansion of pons, obstruction of fourth ventricle

Spinal meningioma

Findings

Sagittal T1 and T2 sequences demonstrate an intradural extramedullary lesion in the midthoracic region which is soft tissue signal on T1 (Figure 1) and soft tissue signal on T2 (Figure 2). Sagittal T2 images demonstrate CSF capping above and below the lesion, which suggests an intradural extramedullary location.
Post contrast images demonstrate homogeneous enhancement of the lesion (Figure 3). A “dural tail” demonstrating the characteristic broad based dural attachment on post gad images is shown.
Incidentally, multiple hemangiomas are demonstrated on sagittal T2 images (Figure 2).


Diagnosis: Spinal meningioma


When evaluating lesions of the spinal cord, it is important to first determine in which space the lesion is located. Lesions may be intramedullary, intradural extramedullary, or extradural.

Meningiomas are the second most common tumor in the intradural extramedullary compartment (nerve sheath tumors most common). Meningiomas account for around 25% all spinal tumors and usually occur in the thoracic spine (80%). 15% of spinal meningiomas occur within the cervical spine. Occasionally, they may be purely extradural, or bridge both the intradural and extradural compartments.

Spinal meningiomas are usually located lateral or dorsolateral in the spinal canal. Since they are thought to arise from arachnoid cluster cells, their location is at the entry zone of nerve roots or the junction of dentate ligaments and dura mater. The spinal cord is usually compressed and displaced away from the lesion.

MR usually demonstrates an intradural extramedullary location. The lesions are usually isointense to the spinal cord on T1 and T2 or alternatively hypointense on T1 and hyperintense on T2. Immediate, homogeneous contrast enhancement is characteristic. Calcification may be seen. Most spinal meningiomas demonstrate broad-based dural attachment, and may show a “dural tail,” as in this case. The subarachnoid space above and below the lesion is widened, described as CSF “capping” of the lesion from below and above. This finding is important in confirming an intradural extramedullary location.

The mainstay of treatment is surgical resection, depending on the extent of the lesion. When complete resection is not possible, post-operative radiotherapy may be performed. Monitoring of symptoms is important following treatment.


Differential diagnosis for each spinal compartment

Achondroplasia

Findings

Frontal bossing is noted in the calvarium. There is mild narrowing of the foramen magnum. The ventricles and sulci are prominent. There is no mass effect or midline shift. There is no abnormal extra-axial fluid collection. No areas of abnormal attenuation are noted.

Differential diagnosis for frontal bossing and small foramen magnum:
- Achondroplasia
- Thanatophoric dysplasia
- Achondrogenesis
- Camptomelic dysplasia
- Pseudoachondroplasia
- Metatrophic dysplasia
- Hypochondroplasia


Diagnosis: Achondroplasia (skull findings)


Key points

Achondroplasia is a short-stature skeletal dysplasia caused by mutation of fibroblast growth factor receptor-3 gene
Usually not recognized until children > 2 years old
Calvaria enlarged with frontal bossing, megalencephaly
Skull base small with narrow foramen magnum
Narrow jugular foramina may cause hydrocephalus via venous hypertension
Thoraco-lumbar gibbus or kyphosis in infancy
Cervicomedullary decompression surgery in 17%
Short petrous carotid canals
Mastoids under pneumatized
Mid-face hypoplasia, dental crowding
Urgent to treat cranio-cervical junction stenosis to prevent sudden death
Normal lifespan and intelligence

I'm Back

I'm back from my trip to Calbayog. It was a happy journey back to the place I love, and indeed, I should say that I miss Samar and its Waray people. By regularly visiting Samar, I always feel knowing more and getting more familiar with it.
Actually, it was an impromptu trip, a spur of the moment, since I didn't plan at all to go to Samar. But a close friend in Calbayog invited me (at the 11th hour) to become a godfather to his son, and since this is the first time that I can actually become part of such an important occasion, I readily said yes.

The trip from Manila to Calbayog was generally pleasant, although we had to tread the road carefully due to the heavy rains caused by Typhoon Hanna.

There was a time that we even had to stop our bus because the rains had become so heavy our driver could barely see the road ahead. And so, the trip had to be delayed for several hours.
When we arrived in the Terminal in Matnog, Sorsogon, we had to wait several hours more to get a go signal from the Coast Guard that the sea is safe for a voyage. Thankfully by mid-afternoon of Saturday, the coast was clear and we started our voyage.

While on board, some of my co-passengers got soaked due to the sudden heavy rainfall amidst sea. The captain had to slow down the ship to almost cruising level speed. From afar, I can see dark heavy clouds in the horizon where we were heading. It certainly looked like we were heading for an impending disaster. Fortunately, the rain soon stopped and we had resumed normal speed...

And so, back in Samar I had been. I will post more in my next blog entry later today. Meantime, I have to take some moments to rest :)

Mastoiditis with cerebellar abscesses

Additional clinical history: Patient also had ear pain and some drainage from his left ear.


Findings

There are 2 ring-enhancing lesions within the left cerebellum measuring. There is increased signal of the lesions on the DWI images (low values on ADC maps). There is surrounding edema with mass-effect on the pons and brainstem as well as narrowing of the fourth ventricle. There is also thick enhancement of the meninges adjacent to the mastoid bone. There is expansion and enhancement of the mastoid air cells on the left. Other images showed narrowing of the left sigmoid sinus without thrombosis. There is no hydrocephalus.


Diagnosis: Mastoiditis with cerebellar abscesses


Key points

Most brain abscesses are caused by pyogenic bacteria
Most commonly, infectious agents gain access to the CNS by spread from a contiguous focus of infection, such as otitis media, mastoiditis, infection of the paranasal sinuses, or dental infection.
Ring enhancement represents most active area of infection
Diffusion-weighted MR may be useful in differentiating abscess from necrotic tumor. Abscess typically shows as bright areas on DWI with corresponding dark regions of "restricted diffusion" on ADC maps. That is, ADC values should be low in areas that are bright on DWI if the cause is restricted diffusion rather than the phenomenon of T2 shine-through. Necrotic tumors usually have higher ADC values (and corresponding dark areas on DWI).