0:00

So this was probably the hardest one. Okay. And so I couldn't make 'em,

0:04

couldn't make it easy for everyone. He had to throw a couple of hard cases in.

0:08

But I think that what I, in the discussion that I gave, I, I,

0:11

I remember looking at this case and I,

0:13

and I think the patient came in with vision loss or something,

0:16

or headaches or something like that.

0:18

And I think what it does help me do is really refine my search pattern.

0:24

So when I'm looking at re a regular brain, Mr. Um, you know, like most men,

0:29

I think I have attention deficit disorder. My,

0:31

my brain kind of goes from one thing to another thing.

0:34

So what I do is when I look at something, I,

0:36

I have to be very structured in my reports.

0:39

And so in the sense that I try to keep my reports as consistent as possible.

0:43

And anytime I look at any study,

0:45

whether it's a brain M r I or even a skull-based m R I or a neck m r i and they

0:50

actually have a sagal images,

0:51

the first thing where I go to is I look at the sagal images and I go through the

0:55

midline structures.

0:56

So the first structure I look at is I look at the corpus Callum,

0:59

then I look at the optic chiasm, then I look at the, the, uh, pituitary gland,

1:04

then I look at the pineal region.

1:06

Then I look at the tip of the cerebellum to make sure that there's no, uh,

1:10

chiari malformation. So in this particular case, if you do your search pattern,

1:16

then the abnormality becomes obvious.

1:19

And that is the diffusely thickened optic chiasm.

1:22

So this optic chiasm is way too thick. Um,

1:25

and when you look at your next brain MRIs,

1:27

you'll be able to really appreciate how thick that chiasm is.

1:31

And then when we looked at the other sequences here,

1:35

and when you look at the flare sequence, and I'll narrow it down a little bit,

1:38

then what you start to notice is that if you look at the post, the, uh,

1:42

post chias asthmatic segment of the optic chiasm, you can see it's bright.

1:46

And now you start seeing these areas of increased signal involved in the medial

1:50

portion of the right cerebellar p dunkle.

1:53

And then when you look a bit a little bit lower,

1:55

you can see this abnormal signal here involving the right lateral aspect of the

1:58

pons.

1:59

So when you put this diffuse enlargement of the optic

2:04

nerve and you sort of combine it with all of these lesions that you end up

2:08

seeing these areas of high T two signal, here's one involving the right half,

2:12

the splenium of the corpus callosum,

2:14

then you can come up with a diagnosis of of neurofibromatosis type one.

2:19

So this turned out to be a very, uh, unusual rare case of NF type one.

2:24

But you can make the diagnosis based on the enlarge of the optic chiasm and then

2:28

also on the, uh,

2:31

high areas of flare and T two signal,

2:34

which have pathologically been able,

2:36

have been pathologically shown to represent hematomas.

2:40

So this is the case I showed earlier about the optic neuritis,

2:44

and this is more of the classic case that you would expect to see in optic nerve

2:48

glioma. So this is somewhat similar to what we saw before.

2:51

See that diffusely thickened optic chiasm here, see how thick that is.

2:55

And on the coronal T two weighted images, here's diffuse

2:58

Enlargement of the optic nerve and look what it's doing to the optic sheath.

3:01

It's, uh, diffusely enlarged.

3:04

This is a coronal T two weighted images demonstrating increased enlargement of

3:08

the pre-K asthmatic segment of the optic nerve.

3:11

Here's a T one weighted image with contrast demonstrating diffuse enhancement.

3:15

This is that enlargement on T two and then on the SAG T one weighted images,

3:20

excuse me. And sometimes this is defined.

3:23

This is referred to as a sausage SA shaped appearance of the optic nerve.

3:27

That's indicative of an optic nerve glioma.