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WWWTP #20 Answer…

August 7, 2014


This patient presented to the ED with a headache.



This patient has an “Empty delta sign” in the superior sagittal  sinus (blue arrow).  This is indicative of dural venous sinus thrombosis.  There is a clot (dark) among normal blood in the sinus (light).  Remember to look at your sinuses for this rare occurrence.

Image Contributor:  Adriel Watts, MD

Author:  Russell Jones, MD

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WWWTP #20 (What’s Wrong With This Picture?)…

August 4, 2014


This patient presented to the ED with a headache.  What’s Wrong With This Picture?


Image Contributor:  Adriel Watts, MD

Author:  Russell Jones, MD

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CT Hemorrhagic stroke

October 30, 2013


Young patient presented with altered mental status, concern for drug use per EMS.  The patient had some response to naloxone but didn’t return to normal orientation.  On exam there was a subtle left gaze preference with a blood pressure of 280/160 mmHg.  The patient’s head CT non-contrast:


This head CT shows a large hemorrhagic stroke with 8mm of midline shift.  It also showed left uncal herniation on other cuts. 

This is an unfortunate complication to stimulant drug use, most commonly implicated are cocaine and methamphetamines.  One of the many reasons not to do drugs!

Author:  Russell Jones, MD

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Is the shunt series a dinosaur?

September 10, 2013


When a patient with a ventricular shunt presents to the ED, many times we will obtain a “shunt series.”  What is a “shunt series?”  Here is an example:
Shunt 1Shunt Series 2 Shunt series 3

The top image shows a lateral cranial view demonstrating the intracranial portion of the shunt (#1), the shunt reservoir and valve (#2), and a portion of the extracranial portion of the shunt catheter coursing down the lateral portion of the head.  The second image is an AP cranial radiograph.  This is another view of the shunt with the advantage of better imaging of the lateral extracranial catheter coursing down the neck and upper chest.  The third image is an AP abdomen which shows the rest of the catheter’s course into the abdomen.

How are these used?  Shunt series are used to look for kinks and breaks in the course of the catheter, most often the extracranial portion.

There is controversy whether we should use our time, expense, as well as the radiation to obtain shunt series.  Their yield is very low and CT imaging of the head or nuclear medicine shuntograms are much better at detecting shunt failure.  One series of 263 patients showed that less than 1% of shunt revisions were based on the findings on the shunt series (1).  Another study in 2011 demonstrated a lack of statistical significance in shunt series and surgical revision.  CT and nuclear medicine imaging, on the other hand, showed statistical correlation with shunt revision (2).

Kinda begs the question:  should we be obtaining shunt series at all?


1.  Griffey RT, Ledbetter S, Korasani R.  Yield and utility of radiographic “shunt series” in the evaluation of ventricle-peritoneal shunt malfunction in adult emergency patients. Emerg Radiol 2007; 13 (6): 307-11.

2.  Lehnert BE, et al.  Detection of ventricular shunt malfunction in the ED:  relative utility of radiography, CT, and nuclear imaging.  Emerg Radiol 2011; 18 (4): 299-305.

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Answer to headache/seizure…

July 16, 2013


A couple days ago I presented a middle-aged man with headache and seizure.  What type of imaging is this and what is your differential:

Cystic brain lesion CTT2 MRI cystic lesion

The top image is a non-contrast CT of the head.  The second image is an axial T2-weighted MRI of the head

Both images demonstrate a multi-cystic lesion in the left parietal area.  The MRI demonstrates significant surrounding edema.  A course differential for an intraparenchymal cystic brain lesion includes:

  • Parasitic infection (neurocysticercosis, hyatid cyst from Echinococcus granulosus)
  • Abscess
  • Tuberculosis
  • Neoplasm (craniopharyngioma, glioblastoma, metastases, and more…)
  • Enlarged periventricular spaces (Virchow-Robin spaces)
  • Benign cyst (e.g. neuroglial cyst)

I found a good article in Radiology that covers all types of brain cysts:

Osborn AG, Preece MT.  Intracranial Cysts:  Radiologic-Pathologic Correlation and Imaging Approach.  Radiology 239 (3); 2006.

Unfortunately I don’t have an answer to what this patient had, they are currently awaiting brain biopsy for further evaluation. 

Author:  Russell Jones, MD

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Middle-aged man with headache and seizure…

July 12, 2013


Middle-aged man presents with headache and seizure:

Cystic brain lesion CT

T2 MRI cystic lesion

What type of imaging modalities are demonstrated above and what is your differential?

Answer to follow

Author:  Russell Jones, MD

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New Stroke Tutorial – Evolution from acute to chronic infarction…

May 15, 2013

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Its important for medical students and EM providers to know the radiologic progression and timing of acute ischemic stroke. I came across this blog post from today. Great video review of Acute Ischemic Stroke temporal changes on CT!


New Stroke Tutorial – Evolution from acute to chronic infarction on CT and MRI. VIEW VIDEO:

via our Facebook page

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Brain Tumor…

April 25, 2013


Here is an MRI head on a patient with a headache and newly diagnosed brain mass:

MRI brain tumor

This is a T2 weighted MRI.  T2 weighting is particularly good at showing edema.  Simple fluid enhances and appears bright on the image.  Above you can see the tumor arising near the peripheral parietal area with a good amount of surrounding bright fluid consistent with edema.  Note that the edema shows up similar to the patient’s normal CSF in the ventricles. 

If you add contrast to the study (gadolinium) and T1 weight the image this is what you’ll see:

Brain Tumor 2

In T1 weighted imaging simple fluid is darker but in this case the tumor outlines very well with gadolinium.  This imaging is particularly good at picking up smaller tumors without large amounts of surrounding edema.  In this case several other smaller lesions were easily identified with T1 gadolinium imaging including one seen in the midbrain:

Midbrain 1

These turned out to be a metastatic lesions likely from the lung.  Metastases are the most common clinically important brain malignancies found outside of the pediatric population (the exact incidence of non-clinically apparent. 

Author:  Russell Jones, MD

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Rare cause of intracranial hemorrhage…

March 25, 2013

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This gentleman presented to the ED with headache that began several days prior.  He has a history of disseminated coccidioidomycosis:

IVH Coccidio 1

Disseminated Coccidioidomycosis  (DC) is rarely associated with intracerebral hemorrhage.  Not something we will see everyday!

Here is a brief discussion from the American Journal of Neuroradiology about two cases of fatal intracerebral hemorrhage from DC:

Coccidiomycosis ICH

Some highlights:

    • Coccidioides immitus resides in the topsoil of the Southwestern United States.  There are 60-80,000 new cases of coccidioidomycosis every year with disseminated disease occuring in less than 1% of the population.
    • Vasculitis may occur and usually causes ischemic CNS events but can lead to hemorrhage as well
    • Two case reports are discussed.  A 74-year-old male on chemotherapy for Waldenstrom’s macroglobinemia who had blood culture positive Coccidioidomycosis and developed signs of aphasia, confusion.  He ended up having a CT showing large parenchymal and subarachnoid hemorrhage  with a distal left middle cerebral artery aneurysm.  Second case was a 33-year-old male with a history of coccidioidal meningitis diagnosed a year earlier.  He came in with worsening headache and MR showed enlarging prepontine lesion with subtle enhancement.  He died suddenly and on autopsy had subarachnoid hemorrhage.  Numerus necrotic spherules of Coccidioides immitis were found in perivascular spaces and his basilar artery had full-thickness granulomatous changes with necrosis through the vascular wall.

Author:  Russell Jones, M.D.


1.  Erly WK, Labadie E, Williams PL, Lee DM, Carmody RF, Seeger JF.  Disseminated Coccidioidomycocsis Complicated by Vasculitis:  A Cause of Fatal Subarachnoid Hemorrhage in Two Cases.  Am J Neuroradiol 20: 1605-1608, October 1999.

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