Neuro-imaging for the Ophthalmologist · Neuro-imaging for the Ophthalmologist Karl C. Golnik, MD,...
Transcript of Neuro-imaging for the Ophthalmologist · Neuro-imaging for the Ophthalmologist Karl C. Golnik, MD,...
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Neuro-imaging for the
Ophthalmologist
Karl C. Golnik, MD, MEd
University of Cincinnati &
The Cincinnati Eye Institute
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“Neuro-ophthalmology is that
subspecialty where the diagnosis
is made upon reinterpretation of
allegedly normal scans.”
William F. Hoyt MD
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1. Describe what type of neuro-imaging to
order.
2. List pit-falls in imaging interpretation.
3. Recognize MRI and CT findings of
common neuro-ophthalmology problems.
Objectives
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I. CT vs. MRI
II. Pitfalls
III. Common Neuro-
ophthalmology Conditions
Outline
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A. Brainstem lesion
B. Bitemporal hemianopsia
C. Thyroid eye disease
D. Acute stroke
MRI is preferable to CT in all of the following
except?
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• Patient factors: metal, claustrophobia
• MRI better for brain/skull base
• CT equivalent in orbit, better for bone
• MRA vs. CTA
CT vs. MRI
Golnik K. MRI vs CT. in Curbside Consultation in Oculoplastic
Surgery. Eds: Kersten RC, McCulley T. Slack, 2010.
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• MRI head – diplopia, bilateral optic neuropathy,
retrochiasmal VF defect, any suspected intracranial
pathology
• MRI Orbit – unilateral optic neuropathy
• CT head – cerebral bleed, hydrocephalus
• CT orbit – Graves, orbital process
• CTA vs MRA – depends on your institution
CT vs. MRI
Golnik K. MRI vs CT. in Curbside Consultation in Oculoplastic
Surgery. Eds: Kersten RC, McCulley T. Slack, 2010.
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I. CT vs. MRI
II. Pitfalls
1. Wrong study
2. No contrast
3. No fat suppression
4. No instructions
5. No persistence
Outline
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60-yo-man awoke today with blurred
vision, imbalance.
PMH: DM, HTN
Exam
VF: R homonymous hemianopsia
1. Wrong Study
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CT: normal MRI: multiple strokes
Stroke may not show on CT within first 24 hours.
MRI better than CT except in orbit or bone.
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What is your access to Neuroimaging?
A. MRI same day if needed
B. MRI within 1 week
C. MRI within 1 month
D. CT only
E. neither available
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70 yo wf c/o ptosis 1 day
after discharge for DVT.
MRI “normal”
PMH: melanoma
Exam: 5 prism diopter
RHT in downgaze, 3mm
proptosis + ptosis
1. Wrong Study
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MRI brain MRI orbit
Give good instructions & order the correct test of
the correct anatomy.
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40-yo-WF c/o gradual loss of vision OS.
PMH: none
Exam
VA: 20/20, 20/60
Color: 0/10 OS
P: 2+ L-RAPD
2. No Contrast
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Non-contrast MRI Gadolinium MRI
If optic neuropathy is present, always order
Orbit MRI with gadolinium.
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30-yo-WF c/o gradual loss of vision OS.
PMH: none
Exam
VA: 20/20, 20/80
Color: 0/10 OS
P: 3+ L-RAPD
3. No Fat Suppression
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MRI no gad MRI + gad
MRI + gad +
fat suppression
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59-yo-WM c/o double vision x 6 weeks.
PMH: htn
Exam
R 5th,6th,7th
n palsies
4. No Instructions
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MRI + gadolinium
“L pontine lacunar
infarct”
Give detailed instructions
No Secrets!
R metatstatic lesion
(lung ca)
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23-yo-WF c/o diplopia in left gaze
PMH: hyperthyroidism
Exam
mild lid retraction OD,
ET in L gaze
4. No Instructions
MRI “normal”
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4. No Instructions
EOMS routinely misread or overlooked.
Check yourself or call radiologist
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24-yo-WM c/o visual loss OD x 3 months.
PMH: Ewings sarcoma femur
Exam
R optic neuropathy
MRI x 2 “normal, no mass”
5. No Persistence
Dx: Optic Neuritis
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VA: 10/3/02 20/40
11/6/02 20/80
1/12/03 CF
Optic Neuritis?
no gad or fat
suppression
+ gad & fat
suppression
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1. Get the correct study
2. Give contrast
3. Get fat suppression
4. Give specific instructions
5. Be persistent
Top 5 Pitfalls - Solutions
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The MR image below is
A. T2
B. T1
C. T1 with fat suppression
D. T1 with contrast & fat
suppression
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T1, T2, Fat Suppression & Gadolinium
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Ct vs mri bone
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I. CT vs. MRI
II. Pitfalls
III. Common Neuro-
ophthalmology Conditions
1. Inflammatory
2. Tumors
3. Vascular
4. Miscellaneous
Outline
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Graves Orbitopathy
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CNS Sarcoid
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Optic Neuritis & Plaques
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I. CT vs. MRI
II. Pitfalls
III. Common Neuro-
ophthalmology Conditions
1. Inflammatory
2. Tumors
3. Vascular
4. Miscellaneous
Outline
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This patient probably has?
A. Double vision
B. Bitemporal field defect
C. Headache
D. Nystagmus
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I. CT vs. MRI
II. Pitfalls
III. Common Neuro-
ophthalmology Conditions
1. Inflammatory
2. Tumors
3. Vascular
4. Miscellaneous
Outline
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A. Double vision
B. Bitemporal field
defect
C. Headache
D. Nystagmus
This patient
probably has?
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Diffusion Weighted Image (DWI)
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I. CT vs. MRI
II. Pitfalls
III. Common Neuro-
ophthalmology Conditions
1. Inflammatory
2. Tumors
3. Vascular
4. Miscellaneous
Outline
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Miscellaneous
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Miscellaneous
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Miscellaneous
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Miscellaneous
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Thank-you for your attention.