Classification of Modic endplate changes in degenerative spine disease

Degenerative vertebral endplate and subchondral bone marrow changes were first noted on MR imaging by de Roos et al in 1987.A formal classification was subsequently provided by Modic et al in 1988, based on a study of 474 patients, most of whom had chronic low back pain (LBP). These authors described 2 types of endplate and marrow changes:


Type 1 changes were hypointense on T1-weighted imaging (T1WI) and hyperintense on T2-weighted imaging (T2WI) and were shown to represent bone marrow edema and inflammation.

Type 2 changes were hyperintense on T1WI and isointense or slightly hyperintense on T2WI and were associated with conversion of normal red hemopoietic bone marrow into yellow fatty marrow as a result of marrow ischemia.

Type 3 changes were subsequently described as hypointense on both T1WI and T2WI and were thought to represent subchondral bone sclerosis.

Mixed-type 1/2 and 2/3 Modic changes have also been reported, suggesting that these changes can convert from one type to another and that they all present different stages of the same pathologic process.

Modic Change
Type 1 :T1 Low T2 High
Type 2 : T1 High T2 High
Type 3 : T1 Low T2 Low

Salt and Pepper Sign

This sign is seen on MRI images in paragangliomas such as glomus tumors .

The sign is indicative of the hypervascularity of the mass. The 'pepper' represents multiple areas of signal void of vessels and the 'salt' represents the hyperintense foci due to slow-flow vessels or hemorrhages in these hypervascular tumors. The sign is seen in tumors that are more than 1 cm in diameter. The sign is not specific for paragangliomas and has been reported in other hypervascular lesions such as metastatic hypernephroma and metastatic thyroid carcinoma. Four common locations of paragangliomas in the head and neck are the carotid body, the jugular foramen, along the path of the vagus nerve, and the middle ear. Paragangliomas can be multiple and bilateral, especially in familial cases, and hence evaluation of the entire neck and of both sides is needed.

This term is used also for:

Sjogren syndrome
The parotid gland in Sjogren's syndrome has also been described as having a salt and pepper appearance, due to a combination of punctate regions of calcification (pepper) and fatty replacement (salt)

Vertebral haemangiomas
A less common usage for the term is for vertebral haemangiomas which have a courser black and white dotted appearance especially on axial T2 and T1 images (salt = fat, pepper = coarsened trabeculae).

MRI noise artefact
A related use of the term is to describe the noise sometimes seen in MRI images.

When you think about it, you can probably find folk who have used the term for all sorts of lesions... any lesion that has a fine granular imaging texture will do the trick.

Erdheim-Chester Disease

T1 mdc, T2, T1 Meningioma????? strange signal on T2 image!!!
It isn't a Meningioma, it's Erdheim-Chester Disease.
Rare condition thought to be a histiocytosis of the non-Langerhans cell type, with widespread manifestations. It is a systemic lipogranulomatous disorder with infiltration by foamy, lipid-laden histiocytes and giant cells, with or without fibrosis. Musculoskeletal involvement is relatively characteristic.
Dural accumulations, may mimic meningiomas, although the signal characteristics are somewhat different, as the accumulations in ECD are low on T2.

In the intracranial district it can involve also hypothalamus, pituitary infundibulum: presenting with diabetes insipidus, and retro-orbital tissue.

neuradiological sign: Dural Tail

Dural tail sign
This sign represents thickening and enhancement of the dura mater in continuity with a mass, which on MR images, gives the appearance of a tail arising from the mass. The dural tail is thought to represent reactive change; however, it may also be due to tumor invasion.Three criteria need to be met for a 'positive' dural tail sign: the tail should be seen on two successive images through the tumor, it should taper away from the tumor, and it must enhance more than the tumor. This sign has been traditionally considered as highly specific for meningioma. However, it is seen only in 60% of meningiomas and has also been reported in nonmeningiomatous lesions such as chloromas, primary CNS lymphomas, sarcoidosis, schwannomas, metastases, and syphilitic gummata.

Little Red Cap in the wood of neuroradiological signs

While walking in the woods, to bring a piece of cake and a
bottle of wine to her beloved grandmother, Little Red Cap
is abruptly confronted with a blizzard of unknown to her
neuroradiological signs.
Would you be willing to help the sweet little girl by
recognizing these signs and by coupling the neuroimages with
the corresponding inspiring objects, plants, animals, monsters,
and cartoons (Fig. 1)?

For a help looks for them into the next posts

clinical case: Pneumocephalus

A healthy 54-year-old woman presented with progressive abnormal acoustic sensations, aphasia, and visual-field disturbances. She reported no head trauma or recent infection, such as otitis media. An initial cranial radiograph revealed air in the left temporal region without evidence of a fracture (Panel A, arrow). A computed tomographic scan of the head showed a large amount of air in the left temporal lobe; the involved area was approximately 4 cm by 3 cm by 5 cm (Panel B, arrow).

Pneumocephalus is the presence of air or gas within the cranial cavity. It is usually associated with disruption of the skull: after head and facial trauma, tumors of the skull base, after neurosurgery or otorhinolaryngology, and rarely, spontaneously. Pneumocephalus can occur in scuba diving, but is very rare in this context.
If there is a valve mechanism which allows air to enter the skull but prevents it from escaping, a tension pneumocephalus can occur (similar to what can happen in a tension pneumothorax.
CT scans of patients with a tension pneumocephalus typically show air that compresses the frontal lobes of the brain, which results in a tented appearance of the brain in the skull known as the Mount Fuji sign.The name is derived from the resemblance of the brain to Mount Fuji in Japan, a volcano known for its symmetrical cone. In typical cases, there is a symmetrical depression near the midline (such as the crater of a volcano), due to intact bridging veins.
Its occurrence seems to be limited to tension pneumocephalus (not occurring in pneumocephalus without tension. The sign was first described by a team of Japanese neurosurgeons.

http://content.nejm.org/cgi/content/full/358/12/e13/F1

Clinical case

History : 30 years old man with new seizure

T2 and FLAIR images demostrate left frontal lobe cortical signal abnormality with subcortical cystic areas, this lesion has hypointense T1 signal and doesn't shows post contrast enanchement.

Diagnosis: Dysembryoplastic neuroepithelial tumour (DNET)

Dysembryoplastic neuroepithelial tumour (or DNET) is a benign (WHO Grade I) slow growing tumour arisig from either cortical (vast majority) or deep grey matter. They are thought to arise from secondary germinal layers and are frequently (upto 80% of cases) associated with co-existent cortical dysplasia, and is characteristically the cause of intractable partial seizures (see temporal lobe epilepsy).
They demonstrates essentially no growth over time, although very gradual increase in size has been described. As expected prognosis is excellent and even though these lesions are often incompletely resected, tumour progression is uncommon. Additionally even in cases of incomplete ressection, seizure frequently cease.
Location
The temporal lobe is the most common location, but all parts of the CNS containing grey matter are potential locations.
-temporal lobe: over 60% of cases
-frontal lobe: 30% of cases
-caudate nucleus
-cerebellum: presentation is then more commonly with ataxia rather than seizures
-pons

Radiographic Features
CT
if cortical may scallop the inner table of of the skull vault (44 - 60%)
calcification in 20 - 40% (more common histologically)
low density
no enhancement
MRI
high T2WI signal with high signal 'bubbly appearance'
FLAIR mixed signal intensity with bright rim sign.
low on T1WI
haemosiderin staining uncommon on Gradient Echo as bleeding into DNETs only occasionally occurs, although as calcification is not infrequent
no enhancement
no restriction on DWI
non-specific MRS although lactate may be present

Differential diagnosis
The differential diagnosis will depend on the location of the tumour.
Mesial temporal lobe
see also temporal lobe tumours
tumours (in order of decreasing frequency)
ganglioglioma
DNET
pilocytic astrocytoma
diffuse astrocytoma
oligodendroglioma
pleomorphic xanthoastrocytoma
cysts
neuroepithelial cyst
choriod fissure cyst
other
herpes simplex encephalitis: usually some bilateral changes, and different presentation
limbic encephalitis: usually some bilateral changes, and different presentation
mesial temporal sclerosis
Cortical
low grade astrocytoma
ganglioglioma
pleomorphic xanthoastrocytoma
oligoastrocytoma/oligodendroglioma
taylor dysplasia