M.T. Makada, MD

Case History: A 24-year-old female presented with complaint of pain during chewing with locking of jaw, more on left side, and clicking sound while opening the mouth for two months.

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Case History: 24-year-old female with pain while chewing and locking of jaw.

Jaw Pain While Chewing

Case History: 24-year-old male presented with complaints of right shoulder pain associated with slowly increasing swelling for five years.No complaint of blackening or redness over right shoulder and no complaint of tingling, numbness, or paresthesia.

Case History: 24-year-old male with complaints of shoulder pain, slowly increasing swelling for five years.

Shoulder Pain, Swelling

 A 75-year-old male with complaints of occasional headache for last two years. Laboratory examination, ophthalmic examination and family history were unremarkable. Neurophysician sent patient for routine brain MRI.

 T2WI axial and sagittal images show a small 12x8 mm well-defined, well-circumscribed heterogenous signal intensity lesion to adjacent grey matter with tiny focal area of CSF intensity in left lateral ventricle along inter ventricular septum in the region of foramen of monro (arrow).

 FLAIR axial and coronal images show a small well-defined, well-circumscribed hyperintense signal intensity lesion to adjacent grey matter in left lateral ventricle along inter ventricular septum in the region of foramen of monro (arrow).

 T1W axial image shows isointense signal intensity lesion to adjacent grey matter with focal cystic area in left lateral ventricle along inter ventricular septum in the region of foramen of monro.

 Diffusion weighted axial image shows no restricted diffusion within the lesion (arrow).

 T1 weighted FAT SAT axial imges show minimal to mild enhancement on post contrst study within lesion.

On MRI, a small 12x8 mm well-defined, well-circumscribed lesion was noted in the left lateral ventricle along inter ventricular septum in the region of foramen of monro. It showed heterogenous signal with adjacent grey matter on T2WI (Figure 1) with a tiny focal cystic area, which followed CSF signal, hyperintense signal on FLAIR weighted images (Figure 2) and isointense to white matter on T1WI (Figure 3) and did not show restricted diffusion on diffusion weighted images (Figure 4). No susceptibility artifact was noted. On post contrast study, the lesion showed minimal to mild enhancement (Figure 5). No evidence of obstructive hydrocephalus was seen.

: Subependymoma are uncommon, benign (WHO grade I) tumors, which are slow growing and non-invasive. Subependymoma tend to present in middle-aged to older individuals. There is a slight male predilection (M: F 2.3:1). Typically, patients are asymptomatic and small lesions are discovered incidentally. In some cases, especially when the tumors are larger, presentation is with symptoms of raised intracranial pressure due to obstructive hydrocephalus.


CT shows isodense intraventricular mass compared to adjacent brain, which does not usually enhance. Surrounding vasogenic edema is usually absent. MRI-T1 iso shows hypointense to white matter, T2-heterogenous to adjacent white and grey matter, with susceptibility related signal drop out due to calcifications occasionally seen no adjacent parenchymal edema. On post contrast-T1 fat sat images there is usually no enhancement, although at times may demonstrate mild enhancement


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Case History: 75-year-old male with complaint of occasional headaches for last two years.

Subependymoma of Lateral Ventricle

 A 75-year-old male presented with complaint of mucus discharge from an external opening on skin at anterior aspect of mid part of neck on left side. No history of trauma or surgery and unremarkable family history. Upon examination, there was an external opening on skin at anterior aspect of mid part of neck on the left side. Naked eye examination of the oropharynx did not reveal any visible opening at posterior to tonsillar pillar.

The patient was subjected to radiologic investigations. A fistulogram was performed but did not reveal internal opening. Further, on contrast CT, observed an elongated fusiform-shaped approximately 8-10 cm long, well-defined, smoothly marginated thin-walled, peripherally rim enhancing cystic lesion extending from the anterior surface of the mid part of the neck on the left side up to lateral wall of hypopharynx at the hypoid bone level. It had an external opening on the anterior surface of the mid part of the neck on the left side (Figure 1A). It lies anterior to carotid vessels and lateral to thyrohyoid membrane and antero-medial to sternocleidomastoid muscle (Figure 1B). Cranially, it terminated in the lateral wall of left pyriform fossa at hyoid level. It did not open into posterior to tonsillar pillar, so it ruled out second branchial fistula (Figure 2–4). On the basis of these radiological findings, final diagnosis was made of complete fistula of third branchial cleft. The patient was operated on and complete excision of the cord-like fistulous tract was done, which followed up to the lateral wall of left pyriform fossa. The excised tract measured 9 cm in length. It was found to lie over the carotid sheath and was not going up to tonsillar pillar or in between the internal and external carotid arteries, so it ruled out second branchial cleft fistula which is most common in literature (Figure 5).

 Contrast CT axial images at thyroid gland level (A) show external opening of cystic lesion in anterior surface of the mid part of the neck on the left side (small arrow). In B, at thyroid cartilage level, the cystic lesion (large arrow) lies anterior to carotid vessels and lateral to thyrohyoid membrane and antero-medial to sternocleidomastoid muscle.

 Contrast CT axial images of upper neck at hyoid bone level show a well-defined smoothly marginated peripherally rim enhancing cystic lesion (large arrow in A) opens in to lateral wall of left pyriform fossa (B, small arrow). It does not open into posterior to tonsillar pillar, so it ruled out possibility of second branchial cleft fistula.

 Contrast CT sagittal images of the neck show an elongated fusiform-shaped long well-defined smoothly marginated peripherally rim enhancing cystic lesion extending from anterior surface of the middle part of the neck (long arrow in A) and opens in to lateral wall of left pyriform fossa (small arrow in B).

 Contrast CT coronal images of the neck show an elongated fusiform shaped long well-defined smoothly marginated peripherally rim enhancing cystic lesion extending from anterior surface of the middle part of the neck and opens in to lateral wall of left pyriform fossa.

 Postoperative specimen. Complete excision of cord-like tract was performed, which followed up to the lateral wall of left pyriform fossa. The excised tract measured 9 cm in length. It was found to lie over the carotid sheath and was not going up to the tonsillar pillar or in between the internal and external carotid arteries, so it ruled out second branchial cleft fistula which is most common in literature.

: Complete fistula of third branchial cleft

 Third branchial cleft cysts are rare. A third branchial fistula extends from the same skin location as a second branchial fistula; however, a third branchial fistula pierces the thyrohyoid membrane to enter the larynx, terminating on the lateral aspect of the pyriform sinus. Third branchial cleft cysts occur anywhere along that course, but they are characteristically located deep to the sternocleidomastoid muscle. The external opening occurs about two-thirds of the way down the SCM anteriorly, similar to second branchial cleft cysts. The tract ascends along the carotid sheath posteriorly to the internal carotid artery, under the glossopharyngeal nerve, and over the vagus nerve and hypoglossal nerve to open into the pyriform sinus. Second branchial cleft anomalies are most common. The majority of these have an external opening in the neck along the anterior border of sternocleidomastoid at the junction of the upper two-thirds with the lower one-third and the internal opening extends up to the posterior pillar of the tonsil. In our case, the fistulous tract had external opening in the mid part of the neck along the sternocleidomastoid muscle and terminated in the lateral wall of pyriform fossa.

 CT - rounded, sharply circumscribed, fluid density centrally, thin wall. Ultrasound - sharply demarcated, posterior acoustic enhancement, imperceptible walls. MRI-T1 - variable signal dependant on protein content, high protein content; high signal, low protein content: low signal, T2 - usually high signal, T1 C+ (Gd) - no enhancement in uncomplicated lesions.

 Paramedian thyroglossal duct cyst, cystic lymph nodes, necrotic nodal metastases, esp. SCC and papillary thyroid cancer, tuberculous adenitis.


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Case History: 75-year-old male presents with complaint of mucus discharge from external opening on skin at anterior aspect of mid part of neck on the left side.

Complete Fistula of Third Branchial Cleft

 A 45-year-old female presented with complaint of occasional headache for last three years. Family and past history were unremarkable. Neurological and systemic examinations were normal. Blood analysis was within normal limits and EEG did not show abnormal discharges.

. T2W axial (A) and sagittal (B) MRI image show well defined intermediate to high signal intensity lesion in quadrigeminal cistern on right side (large white arrow) abutting inferior coliculus. The lesion does not cause mass effect or obstruct hydrocephalous and normal corpus callosum (small white arrow) in sagittal image.

. T1W axial MRI image shows high signal intensity lesion in quadrigeminal cistern on right side (arrow) which follow fat signal.

. FLAIR coronal MRI images show high signal intensity lesion in quadrigeminal cistern (arrow).

. Diffusion weighted MRI image shows no restricted diffusion within lesion (arrow).

. T1W fat sat pre-contrast (A) axial MRI image shows hypointense signal, suggests suppression of fat signal of the lesion (arrow) and T1W fat sat post-contrast (B) axial image shows no enhancement within the lesion (arrow).

Patient was referred for MRI brain by neurophysician.MRI was performed using 1.5 Tesla Siemens Magnetom Essenga spin echo T2 weighted (T2WI), T1WI, fluid attenuation inversion recovery (FLAIR), diffusion weighted (DWI), pre-contrast T1W fat sat and post-contrast T1W fat sat with slice thickness 5 mm. On MRI, there was a lesion in quadrigeminal plate cistern on the right side which showed intermediate to high signal on T2WI (Figure 1), high signal onT1WI (Figure 2), FLAIR (Figure 3), no restriction on diffusion weighted imaging (Figure 4), low signal on pre-contrast T1 fat sat (Figure 5) and showed no enhancement on post-contrast T1W fat sat (Figure 6). Sagittal MR revealed a normal corpus callosum (Figure 7). The diagnosis lipoma in quadrigeminal plate cistern on right side was made. The patient was managed conservatively and the patient's headaches subsided with conservative management.

 Lipoma in quadrigeminal plate cistern on right side

 Intracranial lipomas (ICLs) are rare intracranial lesions. They represent a group of congenital malformations of the brain parenchyma, are located more frequently in the pericallosal cistern and associated with other parenchymal or brain vascular malformations in up to half of cases. Intracranial lipomas are slow growing benign congenital lesions accounting for 0.1-0.5 percent of all primary brain tumors and are usually detected as incidental findings.

 Intracranial lipomas are histologically benign lesions that are congenital hamartomatous malformations derived from the embryologic meninx primitiva. ICLs are usually an isolated finding, but, uncommonly, may be associated with other intracranial malformations such as callosal dysgenesis with pericallosal lipomas. Lipomas of the quadrigeminal plate are usually asymptomatic,

 but may cause significant symptoms of mass effect in about 20 percent of patients.

 Pressure on the ventricular system can result in consequent neurologic deficits, obstructive hydrocephalus or raised intracranial pressure.

 Radiological characteristics of quadrigeminal cistern lipoma is always definitive on imaging, hence histopathological confirmation is almost never required.

 On CT scan, the lipoma is characterized by attenuation values of fat density (-50 to -100 Hounsfield units) and absence of post-contrast enhancement.

 On MRI, the lipoma has short T1 and T2 and therefore, a hyperintense signal is present on T1-weighted images and a relatively low to moderate intensity signal on T2-weighted images. The differential diagnoses of lipomas in the quadrigeminal cistern include: arachnoid cysts, tectal plate cyst, tectal masses (gliomas), supracerebellar abscess, dermoid and epidermoid cysts, ruptured P4 segment aneurysm of the posterior cerebral artery and, rarely, pineal region mass.

 The lipoma can be differentiated with other negative attenuation value lesions (epidermoid or dermoid tumors) that two tumors will demonstrate heterogeneous attenuation values.8 Intracranial lipomas rarely become symptomatic and surgery is seldom required. The usual neurological symptoms are intracranial hypertension and hydrocephalus, which can be treated by shunt procedure.

 Incidental and asymptomatic lipoma of the quadrigeminal region do not require surgical intervention,

 as our patient also presented with headaches but it appeared to be unrelated to the lipoma, as no compressive, obstructive or evidence of raised intracranial pressure were seen, hence the patient was managed conservatively.


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Case History: 45-year-old female with complaint of occasional headache for three years, had normal neurological and systemic exams.

Quadrigeminal Plate Cistern Lipoma 

 A 15- month-old male patient brought by his parents with complains of one episode of focal seizure involving right side of body, developmental delay and disproportional increase in size of head (left>right). Birth history was normal: full term, vaginal delivery and unremarkable. His laboratory investigations were within normal limits.

. T2W axial images showed disproportionate enlargement of left cerebral hemisphere with shallow sulci and enlarged gyri as compared to right side. There was enlarged lateral ventricle with colpocephaly with contralateral displacement of posterior falx and occipital lobe (arrow).

. T1W axial images showed disproportionate enlargement of left cerebral hemisphere with shallow sulci and enlarged gyri as compared to right side. There was enlarged lateral ventricle with colpocephaly with contralateral displacement of posterior falx and occipital lobe (arrow).

. FLAIR axial images showed disproportionate enlargement of left cerebral hemisphere with shallow sulci and enlarged gyri as compared to right side. There was enlarged lateral ventricle with colpocephaly with contralateral displacement of posterior falx and occipital lobe.

. Gradient echo (GRE) and diffusion weighted (DWI) axial images showed similar findings as mentioned previously on T2W, T1W and FLAIR images, and no evidence of abnormal signal intensity of calcification or hemorrhage in GRE and abnormal restricted diffusion in DWI.

. T2W sagittal images showed normally developed corpus callosum and brain stem.

MRI of the brain was performed using T2W, T1W, FLAIR sequences in 1.5 Tesla Siemens Magnetom Essenza.

On T2W, T1W and FLAIR weighted images: Disproportionate enlargement of left cerebral hemisphere with shallow sulci and enlarged gyri as compared to right side. There was enlarged lateral ventricle with colpocephaly with contralateral displacement of posterior falx and occipital lobe. However, there was no evidence of abnormal calcification or associated developmental venous anomalies.

: Hemimegalencephaly is a rare congenital disorder of cortical malformation with hamartomatous overgrowth on all or a part of a cerebral hemisphere. This results from either increased proliferation or decreased apoptosis (or both) of developing neurons. The majority (90 percent) of patients is presented with focal and generalized infantile spasms and developmental delay, hemiparesis and hemianopia are usually also evident.

Hemimegalencephaly is divided into three forms:

1. Isolated form
2. Syndromic form: associated with a variety of syndromes typically including hemicorporal hypertrophy of the ipsilateral part of the body. Such associated syndromes include:

• Epidermal nevus syndrome
• Klippel-Trenaunay syndrome
• McCune-Albright syndrome
• Proteus syndrome
• Unilateral hypomelanosis of Ito
• Neurofibromatosis type 1 (NF1): rare
• Tuberous sclerosis: rare

3. Total hemimegalencephaly: hemihypertrophy also involves the brainstem and cerebellum
All modalities able to image the brain (ultrasound, CT and MRI) will be able to more or less identify the key features, although MRI will give the best imaging. Typical MRI features of the affected hemisphere include:

1. Increased lateral ventricle size, sometimes may be small
2. Shallow sulci enlarged gyri
3. Enlarged/thickened calvaria 4. Contralateral displacement of the posterior falx
5. White matter calcification
6. Associated with developmental venous anomalies (DVAs)
7. The cortex of the involved hemisphere may be normal, but often demonstrates polymicrogyria/ lissencephaly/agyria /pachygyria and grey matter heterotopia

Differential diagnoses include:
• Enlarged hemisphere
• Gliomatosis cerebri
• Small hemisphere, making the normal hemisphere appear large
• Rasmussen encephalitis
• Dyke-Davidoff-Masson syndrome
• Sturge-Weber syndrome
• Other neuronal migration anomalies without overgrowth
• Polymicrogyria/ lissencephaly/agyria/pachygyria


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Case History: 15-month-old with focal seizure, developmental delay, disproportionate increase in size of head.