 So there'll be 15 euro questions and let's start with the first one here on your screen MRI finding depicted on this image Maybe seen with all except So the question is all except So I saw most of you chose option a but later on you saw that word all except So extra pontine my lino lysis flavivirus and kifillitis verni case of billsons So this is something very easy. We all revise it often t2 basal ganglia symmetric hyper intensity and their differences so 37% have said see and then again. There is a divide. So let's see what the answer is It's see so it can be seen with this extra pontine my lino lysis This and Wilson's but this kind of appearance of t2 a hyper intensity in basal ganglia is not common with verni case So this is a list of differential of t2 hyper intensity in basal ganglia is chemia hypoxic ischemic Entiphylopathy venous infarction. We already saw auto immune and kifillitis CJD extra pontine my lino lysis toxins like carbon monoxide cyanide neurotoxicity Almost any kind of viral and kifillitis can lead to this picture and even lymphoma can cause it But what do we see in verni case? We see it as t2 flare hyper intensities without which are symmetrical But they are in the areas of mammillary body, which we saw today in the anatomy talk dorsomedial thalamide Pectal plate periequeductal green matter around the third ventricle. So now this is the second question on your screen and You can see the images sagittal t2 post contrast even and action And these are your options on the screen What is your possible diagnosis patient who is a 47 year old male and has complaints of acute onset upper limb tingling and numbness Right, so we have received a lot of responses and let's see What it is so it is 42% of you feel it is hemangioblastoma and 13% as thinking of B 16 for tuber colomas also So what is this it's a 47 year old? male gentleman and the diagnosis for this case is hemangioblastoma So what we saw here was a lesion which is Relatively hypo intense on t2 weighted images and a lot of perilesional edema and it's a nodular enhancement which we are seeing That what we are not identifying is that there is no obvious large cystic component No obvious hemorrhagic area and anything which will be there in this spinal cord will always cause a lot of edema or Disproportionate edema because of the fact that spinal cord is a small area is a constricted space So spinal Hemangioblastomas are the third most common Intramedulary spinal neoplasm representing 2 to 6 percent of all intramedulary tumors So they should be thought as a differential whenever fits into and their age group is 40 to 50 years of age Mostly you see like discrete nodules Sometime there will be syringes or cysts associated with them and the most common location is the thoracic cord Great now. This is another differential question on your screen and the options are also there so we can start the poll MRI findings depicted on this image can be seen with all except so there is a finding these are diffusion and axial flare images and you have to identify What all can cause it but the answer has to be the one which cannot cause this particular finding So we have received the responses but lot of confusion in there So but 29% think that it is the option D, which is methanol toxicity So let's see what this entity is and what is the answer the answer to this question is methanol toxicity And this is called as the cytotoxic lesion of the corpus callosum also called as the transient sprenial hyper intensity And we have a lot of causes for this like seizures can also that's good just a post-tictal thing So it is most of the time confused with infarct restricted diffusion may make you think that it's a small infarct But the location and player hyper intensity and clinical correlation makes it easier So it can be post epilepsy or post seizure Metabolic disturbances like electrolyte imbalance infections CNS malignancies Drugs and toxins can also lead to this even subarachnoid hemorrhage sometime can cause this to happen But methanol toxicity will not cause this finding commonly here that time we see bilateral basal ganglia changes So now let's move to the next question and this is the question with options on your screen There are sagittal T2 and T1 weighted images and you have to identify what this condition is So 36% of you who think that this is metastasis and then 37% Have diagnosed it as cumulus So this was cumulus So this is an entity where we have the osteonecrosis of the bone and you have delayed vertebral body collapse due to Ischemia and non-union of the anterior vertebral bodies with which fractures after major trauma These are not metastasis Where you can see that even the posterior margins are not convex. There is wedging of these vertebrae They are not homogenously hyper intense on T1 weighted images and on T2 you can also see this positive fluid sign Which is seen with osteoporotic fractures. So these are all osteoporotic fractures or traumatic fractures And they have developed into bone infarcts or osteonecrosis Next question is on your screen and with four options So we can start the poll at the same time 57 year old gentleman with progressive bilateral facial nerve palsy and all of them are the possible diagnosis except so we have the result and the Maximum 47% votes are to the option number D Which is scleroderma and that is the correct answer So what we are seeing here on this image is that there are multiple cranial nerves which are involved and they are Thickened and they are enhancing so we are dealing with a situation where we have multiple cranial nerve Involvement thickening enhancement and the differential to this is Metastasis neurofibromatosis type 2 lymphoma is an important one leukemia multiple sclerosis CIDP Limes is not very common in India Neurosarquoid and metachromatic So commonly seen our lymphoma and Neurosarquoid and Maybe with metastasis and also with para neoplastic syndromes, but scleroderma will not cause any CNS symptoms So that was the answer Next question on your screen. This is a young male patient 29 year old and He has complaints of headache and vomiting and these are the images on your screen and see the images and I'll take The slide to the option one. Also, this one is the slide with options this Colorful image which you are seeing is the perfusion ASF Non-contrast perfusion which we can perform and assess the areas of hyper perfusion within this region This is post contrast T1 pre contrast T1 So most of you have identified it correctly as her typical Central Neurosytoma. So this is our typical Central Neurosytoma and because of the location because of the morphology You can identify it correctly. So these are WHO grade 2 neuro epithelial intraventricular tumors with fairly characteristic imaging features and they usually have heterogeneous appearance and heterogeneous post contrast enhancement Calcification is common and can be typically puncted MR spectroscopy where we saw a tall Colleen peak also is a characteristic feature Another set of images on your screen next question. So here you see a post contrast actual T1 diffusion and coronal T2 You see a lesion which is homogenously enhancing restricted Diffusion and T2 hypo intensity. This is the same patient Where we have obtained a single voxel spectroscopy. So this is how this patient's spectroscopy look like and these are your four options All are true for this pathology except Lipid peak is seen due to active presence of macrophages containing a strong rate of moving lipid CT hypodense enhancing supratentorial mass Colleen peak may be seen Restricted diffusion is a characteristic. So again, I'll show you the image This is the finding and these are the options. So we have the answers with us and 34% of you feel that this is answer number C 32% are towards answer option number B So what is it? Colleen peak may be seen and CT hypodense enhancing supratentorial mass So first of all, we should diagnose what this situation is This is primary CNS lymphoma a lesion which is homogenously enhancing lesion which is showing the restricted diffusion and is showing a Tall Colleen peak. So this is your creatinine at 3.02 So this peak is your Colleen at 3.22 and you can see that The Colleen peak is above the creatinine peak which should not be there So this is the reversal of your hunter's angle. So you definitely see elevated Colleen So what are all these features suggestive of these are suggestive of hypercellularity? So you have something which is hypercellular densely packed cells are there and that fits into lymphoma So anything which will be densely cellular and which will be a kind of densely packed cells will be present Then that has to look hyper dense on CT not hypodense. Therefore, this option is correct This option is the answer of the question. So you will see everything except a CT hypodense lesion. So that was the question In primary CNS lymphomas, you can have a typical hypodense T1 lesions Which are showing restricted diffusion and MR spectroscopy will show you Colleen peak and along with the Colleen peak because of these Macrophages, you will also have a lipid lactate doublet peak. So that is a twin peak sign which is seen with lymphoma So this is the next question on your screen. These are MRI images depicting acute and subsequent chronic changes in pediatric disease spectrum So the question is not asking you the diagnosis So these are three images of the same disease in acute phase and these are the two in the same disease spectrum different patient in Later phase chronic phase So in this particular disease The calvaryl size changes whatever the diagnosis is the calvaryl size changes. So you have to choose one option Where the size of the calvaryl does not change Similar to the change in this disease. So little tricky question, but you can attempt it easily So the responses wise the answer to the question You have given is C-glutinous acid urea type 1 which is the diagnosis in this situation So that was you are correct But the answer as per the question asked is D fetal rubella syndrome. So what is it? This is glutinous acid urea type 1. So you see that there is Area of restricted diffusion and T2 hyper intensity with edema in bilateral basal ganglia And later on you can see that the sylvan fishers are widened out and these areas are smaller in size And basal ganglia T2 hyper intense. So this is glutinous acid urea type 1 What happens to the calvaryl here? You get macrocephaly. So the size increases So everything which can increase this skull size or macrocephaly related pathologies are congenital hydrocephalus Hydrogencephaly neurofibromatosis type 1 Cubrosclerosis metabolic storage disorders Alexander's canavans Glutinous acid urea nunans, but rubella, which is a part of your taut spectrum Torch infestation need to microcephaly and not macrocephaly. So therefore that was the answer Now this is your next question the ninth question on your screen. You can choose your answers from the option box So most of you feel that it is the second option medulloblastoma and that is the correct answer The appearance is little odd So there was some confusion but this is medulloblastoma, which is the most common malignant brain tumor of the childhood And just to revise we have four types. That is your WNT Sonic hedgehog and group 3 and group 4. So the ones which are in midlines, they can be group 3 group 4 cerebellar hemisphere involvement is very likely with the sonic hedgehog variety and therefore that has Intermediate prognosis whereas the cerebellar peduncles when involved with the WNT subgroup that has the best prognosis Next question on your screen. So we can have the polling options So here is a young person who has developed progressive thoughts welling over the left frontal convexity and The person is immuno competent. So what is your diagnosis? Metastasis osteosarcoma aspergilloma or lymphoma So we have the answers and most of you feel it is aspergilloma 41% and then 27% feel it is osteosarcoma So we have a CT image also where you see that there is complete bone erosion So this is a case of aspergilloma Where retrospectively we saw that this mass lesion was completely more or less hypo intense on T2 weighted images and flare images and Also that there was complete cautious erosion on swan They were areas of blooming which could correspond to the fungal hyphae and fungal byproducts So aspergilloma can have various radiographic presentations and they may be associated Fungal ball or masses which can be slow-growing and they will cause cautious erosions like this They can also cause the involvement of the vessels vasculitis and cerebral infarction Next question on your screen. You have to identify the phenomena. So you have your polling options So most of you have identified this phenomena correctly. So this is cross cerebellar diastasis So this is something interesting We had this in last year's quiz also and you see this on ASL Non-contrast perfusion image. There is a phenomena where one part of your cerebral hemisphere is hypoperfused and Contralateral cerebellar hemisphere is hypoperfused. So this refers to depression in function, metabolism and perfusion affecting the cerebellar hemisphere occurring as a result of the contralateral focal supratentorial abnormality So this patient had status epilepticus episode and this is a post-tictal change So most likely the phenomena is due to interruption of the corticopontoserebellar white matter tract But this is the question on your screen. Identify the lesion. This are very commonly seen in the brain But in the cord sometime it's rare So your polling options are on your screen and you see sagittal T2 and sagittal T1 post contrast and axial post contrast So 50% of you think that these are intra medullary tuberculomas and that is the correct answer So still 50% had some doubt related to this particular thing So these are typical T2 hypo intense lesions which are peripherally enhancing and we see a lot of perillational d-mark Conglomerate lesions, spinal intra medullary tuberculomas are rare and most of the time secondary to the tubercular involvement elsewhere in the body So this patient also had multiple tuberculomas in the brain and also there were pulmonary involvement. So this is the next case fetal MRI and you can start And to this most of you have replied as a venous gallon and then see a C-dural sinus malformation So this is a fetal MRI with a large abnormal flow void, which is a vascular channel But the location is not venous gallon. So we have just seen the venous anatomy and revised it So we know that venous gallon malformation is somewhere here. So this is a dural sinus malformation Which has been partially thrombosed and they are known to resolve also So in fetal MRI if you pick it up or even on fetal ultrasound if you pick it up, if you follow them They will slowly reduce in size. So that is important to identify Sometime if they are thrombose on ultrasound people may think that these are posterior fossa masses So this is not venous gallon malformation Another question you have this phenomena of transynaptic degeneration Which track is involved in this particular phenomenon? So you have two sets of images and We are showing two abnormalities which are interrelated So we have our polling answers and we see that 43% of you feel it is dentator rubro olivary pathway and next 38% is cerebellum olivary pathway. So this is something related to the olivary pathway So this is hypertrophic olivary degeneration, which is happening because of this cavernoma and the pathway which is involved here is the Dentator rubro olivary pathway which is resulting in hypertrophy of the inferior olivary nucleus So the parts are red nucleus inferior olivary nucleus and the contralateral denti nucleus. This is something interesting Last question for this quiz Identify the pathology. So we can start with the polling options so we have already received over 100 responses and Most of you feel that it is Option number two sin telencephaly, which is the correct answer. So what is this sin telencephaly? so this is a Spectrum in the entity of holoprosencephaly and you will see middle inter hemispheric variant Which is a mild subtype of holoprosencephaly that is characterized by an abnormal midline connection Of the cerebral hemisphere between the posterior frontal and the parietal region So this is something with which is very similar to low bar holoprosencephaly But the inter hemispheric fissure is characteristically absent. The rest of the brain appears more or less Normal structurally and here you have appearance of a mono ventricle due to fusion. So this is sin telencephaly So, thank you everyone with this we come to an end of this short quiz