Hey, welcome back everybody. So I think for the next 15 minutes or so, we can help with questions that you guys have. I think what I would suggest is if you have some leftover questions from any of the talks this morning, you know, throw them in that chat function real quick and our moderator can throw those out at us. And as a way to kind of get some things started, I can show a couple quick cases and see if they stimulate some more questions. All right. So while you guys are typing up questions, here's an example of a case. 40-year-old who presents with a headache. They have a past medical history significant for cerebral aneurysms. Their exam is pretty unremarkable. We have a neuroradiologist with this. So let's let him teach us a little bit about the imaging that I have here. Okay. So, you know, the first thing you always want to understand is, you know, what you're looking at. So this is obviously a coronal T1 weighted. I assume it looks like a post-contrast image and you have a supercellar mass. You would put measurements on it that's in the midline that's extending and I can see abutting the undersurface of the optic chiasm. So, you know, traditionally, exactly. Thank you. And I assume it's enhancing. As you guys know, from my prior lecture, I would want to look at a pre and post and make sure that, you know, it's not bright on T1 and bright on post to determine if it's enhancing. A lot of times, diagnoses in neuroradiology are made based on location. Supercellar tumors and other supercellular pathology definitely fall into that category. And like SACHMO is the acronym for the various things. So, you know, I don't, the one thing you want to be careful of in this area is making sure, because you can have one of the, one of the diagnoses is an aneurysm. This is pretty midline. It's hard to tell from this image. I would be surprised if it's an aneurysm, but there is some hypotenuation in there. That's what you want to make sure it's not. Most likely, the other thing to notice is that a pituitary adenoma, which is technically the most common, should be kind of a dumbbell shape, like a snowman, because it starts in the cella and then extends supercellar. And it should be indistinguishable from the gland itself. And in this case, it really looks like there's something kind of discreet on top of the cella pushing down. So statistically, this is most likely to be a pituitary adenoma, but the limited imaging I have here makes me suspicious that this is not an adenoma, that this might be something else. Could be a craniopharyngioma, could be an aneurysm, could be, you know, some other tumor. So my plan would be, look at all these sequences. Yeah, Dr. Hayman stole my thunder there. So sorry. I would definitely go through the SACHMO mnemonic. So think about skull base inflammatory processes like sarcoid, A for aneurysm is important thought. There are some tumors like teratomas that sometimes you could see in this area that are rare, maybe in a really young person. We mentioned craniopharyngioma. CT would be very helpful for that type of lesion to look for things like calcifications on imaging. Those craniopharyngiomas are going to be mostly super cellar, very cystic, irregular looking. Could be something like an optic glioma, but this looks very distinct from the optic pathways up there. M, metastatic lesion. I think I've seen one metastatic lesion in this area in my career, but those would be much more irregular. They would look more aggressive. If they were next to the cella tursica, the bone might look more eroded versus that symmetrically expanded cella that we would see for a pituitary adenoma. Yeah. Any thoughts from the audience? Any questions or thoughts from the audience about the plan? Laura, are you seeing any questions there for us? I don't see questions directed at the plan just yet. I see others that we can probably touch base on after this case study. Yeah. So my plan, if I consider all that differential, which I think is important, we don't want to put blinders on and just assume that this is an adenoma and then rush them off to surgery to decompress that optic chiasm. So my plan would be to investigate all those things. I would do the pituitary panel, check out the function of their pituitary. I would think about, if I saw other images that kind of brought up the idea of metastatic lesion, I would do a met workup. And then of course, with this family history, we would want to do an NGO. In this case, this did turn out to be an aneurysm. So it's a good thing that we didn't rush in through their nose and poke it with a scalpel before we figured that out. All right, let's stop with that. Let's go to some of those questions, Laura. Thank you for that. Yes, I want to just put in CT NGO as a question mark. As far as visual field testing and workup for pituitary tumors, one of the audience members just wanted to know if that's obviously essential in treatment and diagnosis. Yes, so my strategy for that is I would prefer to have formal visual field testing with the nice Goldman parametric testing that the ophthalmologist can do before any sort of treatment because that can help me counsel the patient and then it can help me monitor their outcome afterwards. So if there's time, there's no urgency to it, I would get that outpatient ophthalmology formal evaluation before treatment if you can. Very good, thank you. I have a question for both of you regarding screening. You know, this family history of cerebral aneurysms kind of, you know, reminded me of the earlier part in your lecture about neurofibromatosis too and the likelihood that they have, you know, acoustic neuromas and meningiomas. And we sometimes get referrals from outside primary care doctor wanting to screen, you know, how common or what are your recommendations on screening for patients with NF2, patients who have had family members with a GBM, you know, you see so many, you know, concerned about their, you know, brain obviously with the family history, even if there isn't a, you know, genetic component to some of these lesions as you mentioned, but what are your thoughts on some of the screening questions that we have from patients? Yeah, it's a difficult question. In my experience for pretty much all those examples that you threw out, insurance will not cover screening. It's been my biggest limitation. For the examples that you threw out, so if I have a patient who has a strong family history of aneurysms, I will counsel them about that and I will encourage something like a CTA. And usually that's not a problem getting that, but that's only if they have a really strong family history. Familial cerebral aneurysms are very uncommon. I don't know the exact number, maybe five percent. Most of those are sporadic. If they come in with a new diagnosis of NF1 or NF2, of course I will, I'll image their entire neuroaxis to make sure that we understand the extent of their disease, but usually do not encourage familial screening for that and certainly not for GBM, malignant gliomas or pituitaries or meningiomas. I, in my experience, those hereditary syndromes that I just briefly mentioned in my talks, are so rare that we really, I rarely ever see them. I think I've seen in the past five years, maybe one patient who had a syndrome and it was obvious because he had about four different tumor types, so we knew there was some sort of genetic mutation and after a bit more thought, we figured out he had the syndrome. Yeah, so that's my thoughts about some of that familial screening. I'll piggyback on that and say I have to deal with this issue, though not to the same extent as a provider, but we, you know, if people are asking about screening and I'm pigeonholing a little bit, but you may be dealing with a patient that has an underlying level of anxiety or hypo, you know, is a little bit hypo, a little bit of a hypochondriac and I think, I mean, I see this on the imaging side. I think that sometimes we create patients or problems for patients where none existed before, right? And this is the idea of incidental findings. So they have a history of GBM or something like that and you do a screening and you get a radiologist that is to the right on the receiver operator curve, right? And it's going to call everything and be like, oh, they have low lying tonsils and they've got a partially empty cell and there's some, you know, white matter ditzels. And, you know, you may have a report that's like borderline Chiari. Maybe they have idiopathic intracranial hypertension, you know, mild ischemic small vessel disease or something like that. And somebody else would have looked at it and just been like, you know, this is all just kind of like, like I'm an undercaller myself. I usually don't give diagnoses. I try not to give patients problems because again, on my side, like sometimes I'll see stuff and I'm like, what are we doing? And we're repeating like an MRI every year for like a subcentimeter pineal cyst, you know, or a chlorine plexus sanfo granulome or something like that, because it was said in the report and the patient's worried about it. And, you know, as a provider, then you're stuck with it. You just can't convince them otherwise not to, you know, not to worry about it or or follow it or something like that. So, you know, it becomes one of those issues where it was said to me this way by one of my mentors, don't ask questions you don't know the answer to pal. Like if there's not a real clinical concern, you can create problems and clinical concerns for patients, you know, where where they otherwise wouldn't have one. So just something to think about. 100% agree. Patients coming in with their reports. And, you know, certainly, you know, even as you mentioned, a small pineal region, you know, says that, you know, things like that, you know, they'll have a headache and want to have their imaging sooner than their, you know, two or three year follow up. So it does lend to overuse. One quick question in the context of trauma from our audience, you know, if in a traumatic contusion, you know, what kind of things can you look for to predict progression of a contusion or, you know, perhaps, you know, warrants a little bit more monitoring of a patient with a contusion? For me, that's categorical. Like, in other words, if a patient has any intracranial hemorrhage, my experience is, and I don't make the decision, they're going to get follow up, like any subdural that's acute, any hemorrhagic parenchymal contusion. So I don't think about it in terms of like, does something predict enlargement or not, like they're going to get follow up. The only thing I would comment on is you can tell sometimes if the patient has a coagulopathy, right? Like if there's a fluid fluid level or something like that, or if you had the time to go into the chart, or sometimes it'll be provided for you clinically, then you might want to get a shorter term follow up. And I don't know if Dr. Adamson has a differing opinion. But like, if they come in with a first diagnosis of blood in the brain, they're almost certainly going to get, you know, at least a six hour follow up if it's if it's an acute trauma. Absolutely agree. And always consider, you know, mechanism and velocity and things like that. This is very good. I'll wait and see if we have some other questions here. In the setting of trauma, it is standard in neurosurgery. If you see an abnormality at any type of acute problem from the trauma, whether it's a little tiny traumatic subarachnoid hemorrhage, or a tiny subdural, or contusion, we would always recommend to repeat the CT because that's going to be quick, easy, sensitive, to make sure those things are stable. And our general rule of thumb is to do it six hours. And that number comes from our literature at looking at traumatic acute epidural hematomas. That's typically an epidural, an arterial bleed, and arterial bleeds are a bit more problematic. And we want to make sure we catch that. So there's a good bit of literature that says if an epidural hematoma is going to expand, it's going to happen within six hours. And it's probably not going to expand after six hours. So that's where that number comes from. And we kind of apply it across the board to all traumatic things. A lot of contusions will transform. They will hemorrhage a little bit. So that's one reason we always recommend follow-up imaging if we see just a contusion. We really want to prove anything that's acute from trauma is stable. You had mentioned the pineal cyst. You just kind of threw that out there. And just interestingly, that is probably the most common lesion where I see radiologists specifically telling us in their reports. I don't know the organization. The American National Radiology Association says there is no need to monitor a simple pineal cyst. Less than one centimeter, I think. I see that very often. And I like that, actually, because I agree. I've never seen a simple pineal cyst progress in large. So that's interesting, something I've noticed over the past few years, which I think is helpful. Again, it depends on who your basis is. If you have neuroradiologists reading your reports, you're going to get that. But if you have generalists reading your reports, and they're just covering their base, and they don't know, then it's much more like, we see this. I see outside hospital reports. I'm just like, oh my goodness. Why are you making an issue out of this? I want to go back and say one thing I think is really important about trauma, though. And again, I tell trainees this, but it's super important for providers, too. Don't ever forget that trauma can be secondary. There may have been an underlying problem that resulted in the trauma that you need to diagnose. I had a case recently where a patient came in. They had a headache. I think they had tripped or something. It was a young patient. They had some subarachnoid, convexity subarachnoid hemorrhage. And it wasn't the faculty, but the neurosurgery resident had looked at it and been like, yeah, it's trace subarachnoid hemorrhage. No problem. We're going to discharge him. And I said, wait a second. I was like, you agree that the hemorrhage is there, right? And he said, yeah, it's there. I said, well, it shouldn't be there. Why is it there? This could be a sentinel hemorrhage from an unruptured aneurysm. Maybe that's the problem. And that turned out to be the case. I could actually see the aneurysm on the CT hand anyways, because it was big. But I reached out to our neurosurgery chair. And I was like, I think. And he was like, oh, yeah, we need to evaluate this. And it turned out to be an aneurysm. So just don't forget that just because somebody presents this trauma, that's not necessarily what their primary problem was. Wow. Excellent point. Excellent point. Another question is, do you see utility in using dual energy CT scans to discern between hemorrhage and contrast staining? It's so funny that you say that, because we just got like a really new fancy Philips spectral CT. And it can do that. But the problem is it's in the ED. And the post angiogram CTs are always done on the inpatient side, on the inpatient CT. So we never use it for that. But yes, it's supposed to be able to do that. But to be honest with you, my personal experience with it, even though we have one, is that we never use it for that. And generally, the other thing you can do is just follow it. Contrast staining clears like within 24 hours, or at least will improve. And true subarachnoid hemorrhage will hang around. Wow. Yeah, that's good. Again, short-term follow-up is usually the answer. You don't want to image unnecessarily. But it can do that, yes. A dual energy should be able to. And that's what's written. That's one of the indications for them. They're not super common, though. Absolutely. CTs, I mean. Thank you. As far as Dr. Adamson, when we talk about following benign lesions, pituitary adenomas, meningiomas, if they're stable, you had a slide earlier about your recommendations. And if there's a residual post-surgery that you follow, do you do continue year to year? And then after five years, if it's stable, I mean, do you continue to follow them, I guess, lifelong? Well, we don't actually have any national standard guidelines that answer that question. But just in my practice and my colleagues' practice, again, most folks would monitor that situation for at least five years. And then if you haven't seen any changes after five years, most would tell patients there's probably no need to continue monitoring it. I have noticed sometimes various insurances will stop to cover imaging if it's been stable in benign situations after five years. I talk to my patients, and I try to get a sense also for my patients what's most comfortable for them. And sometimes we'll compromise. And I'll say, well, why don't we repeat it in two years and see how things look and go from there. But I do believe in those situations, if nothing has changed after five years, then you're probably safe to stop monitoring. And remember, we're typically dealing with patients who probably are about 60 years of age. So even if they have a small residual adenoma or meningioma, and if it grows a little bit in six, seven, eight years, it's probably still never going to be clinically significant. Thank you so much for doing this Q&A. Y'all were both very popular. We need to wrap up. I'm sorry, Laura. Let me just throw in real quick because I also talked about gliomas. So when you're dealing with benign gliomas, that question is a little bit different. There are some gliomas that can transform into higher-grade malignant gliomas. So monitoring low-grade, benign types of glioma is a little bit more important to monitor that lifelong. Thank you so much. We have enjoyed having both of you take part in the Q&A. And we hope all the other, if you haven't stopped to take a quick break, we will be back at the bottom of the hour. Thank you so much. Thanks, everyone.

cerebral aneurysm

differential diagnoses

familial risk factors

dual-energy CT scans

preventive diagnostics

patient management