 When the next case I'm going to start this out with a little bit of an audience challenge, and here's the challenge Here's the lesion and the question for the audience and for dr. Pomeranz and I is What is this thing? It's a big thing and what I'm going to tell you is That there is enough information on this single view to arrive at a definitive Tissue diagnosis really definitive definitive tissue diagnosis. I better hurry up and that's right look hard Some of you guys will have it already. I'm going to see if dr. Pomeranz is going to let us have any fun with him, but I kind of doubt that he rarely does So but in five minutes for those of you who don't know the answer you're going to have it well, we're going to show cases like this at the course and we've got a Solid but also a cystic component lesion in the cerebellum of an adult that happens to be a 35 year old Which is a typical age for this lesion the most prime the most common primary Tumor of the cerebellum in the adult is hemangioblastoma So that would be at the top of your list, but I noticed you left me off right here Yes, I was hoping you wouldn't see that and I did see it because you left it there hanging for me like a hanging Chad, and it's a small Sub-peel hypervascular nodule so this patient has a spinal and a cerebellar hemangioblastoma There it is again on the axial t1c plus and there it is again on the axial t2-weighted image with a little flow void Within it, which is one of the characteristics of hemangioblastoma along with the enhancing hypervascular nodule and the cystic component So you have to at least consider the diagnosis of von Hippel Lindau syndrome and in fact favorite with multiple hemangioblastomas the first thing I would do on my checklist and we'll go over this at the Course is I'd look at the orbits to see if there is the retinal angioma or the retinal Hemangioblastoma which may present not as an enhancing nodule but rather as a hemorrhagic detachment And then I start thinking about some of the other Important criteria the so-called big six for von Hippel Lindau syndrome, which is associated with chromosome 3 the rule of 3s Von Hippel Lindau chromosome 3 and what are the six cardinal lesions? We've got cerebellar hemangioblastoma or Cerebellar and spinal then we've got retinal lesions then after that we've got cysts cysts of the pancreas Epidermis liver lung and kidney And we get into pheochromocytoma and or renal cell Carcinoma and von Hippel Lindau is divided up as to whether they have one or the other you've got Epidermal cyst adenomas and finally endo lymphatic cyst abnormalities So what's been your experience with these lesions because I know they they can really bleed like stank and being a neurosurgeon I'll bet you've been in the soup with these lesions Actually, it's a really great case The first thing is as far as the endo lymphatic sac So that's the other thing to look at when on a brain study good point Look at looking at the eyes make sure there's not a retinal one and make sure there's not an endo lymphatic sac That would tie up tie it up for you, but it's actually a great case. Okay? Classic Enhancing mural nodule in a cyst so you get in the cyst you got this big thing there. It's color-coded. Okay? The same color is Play-Doh with the red and the yellow mixed You have to get around it because it's highly vascular if you get into it You're in the in for a bad day a lot of times they'll shell out and these people can do great But like missing this spinal one that could come back to haunt you which you which you Unfortunately didn't do sure you you said color-coded though MR is in black and white You mean when you're looking at you look in surgery. Yeah, these are sort of clay like and That they're once you see it you're not you'll never forget it, but it's a great case these people do great I've had actually great experience with it So the problem is missing it not recognizing it and missing some of these associated lesions is where you really get into trouble Once the diagnosis made this patient. It's going to do well Von Heppel Lindau syndrome beautiful example Let's move on to another case shall we?