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Movement Disorders On Disclaimer I have no conflicts of interest to disclose Dr. Stijn Roels AZ Nikolaas Belgium Contents 1/ Embryology - Embryology Neural tube closes around 28th day postconception - Ventricular system It will form several vesicles (prosencephalic / mesencephalic / rhombencephalic) - Cerebral CSF spaces Forebrain vesicle will form both lateral and - Spinal CSF spaces 3rd ventricle Midbrain vesicle will form cerebral aqueduct - Anatomical variants Hindbrain vesicle will form 4th ventricle Embryology Embryology Image by OpenStax - https://cnx.org/contents/[email protected]:fEI3C8Ot@10/Preface, CC BY 4.0, https://commons.wikimedia.org/w/index.php?curid=30147939 Image by University of New-South-Wales in Sydney 1/ Embryology Embryology Foramina y Monro (usually described as 2 seperate foramina/sometimes as 1 Y-shaped structure) y Magendie (midline aperture 4th ventricle) y Luschka (bilateral aperture 4th ventricle) During 2nd gestational month midline meningeal mesenchyme forms invagination in ventricular system to form tela choroidea Case courtesy of Dr Matt Skalski, Radiopaedia.org, rID: 37808 Image by University of New-South-Wales in Sydney Embryology 2/ Ventricular system For those interested in more detailed information on embryonal development: Terminology Excellent site from University of New-South-Wales in Sydney (Australia) Lateral ventricles https://embryology.med.unsw.edu.au/embryology/index.php/Neural_System_Development# Neural_Movies 3 horns (anterior/occipital/temporal Excellent high resolution annotated MRI movies of embryonal development sometimes anterior = frontal occipital = posterior Atria (confluence of horns) Choroidal fissure where plexus attaches Lateral ventricles 2/ Ventricular system Foramina of Monro connect lateral to 3rd ventricle Image courtesy of Dr Matt Skalski, Radiopaedia.org, rID: 37808 3rd ventricle several recesses connection to lateral and 4th ventricle Cerebral aqueduct 3rd ventricle 3rd ventricle CaseCase courtesycou of Dr Matt Skalski, Radiopaedia.org, rID: 37808 CaseCase courtesycou of Dr Matt Skalski, Radiopaedia.org, rID: 37808 Mammillary bodies Tuber cinereum 3rd ventricle 3rd ventricle CaseCase courtesycou of Dr Matt Skalski, Radiopaedia.org, rID: 37808 CaseCase courtesycou of Dr Matt Skalski, Radiopaedia.org, rID: 37808 Supra-optic recess Infundibular recess 3rd ventricle 3rd ventricle CaseCase courtesycou of Dr Matt Skalski, Radiopaedia.org, rID: 37808 CaseCase courtesycou of Dr Matt Skalski, Radiopaedia.org, rID: 37808 Lamina terminalis Anterior commissure 3rd ventricle 3rd ventricle CaseCase courtesycou of Dr Matt Skalski, Radiopaedia.org, rID: 37808 CaseCase courtesycou of Dr Matt Skalski, Radiopaedia.org, rID: 37808 Interthalamic Suprapineal adhesion recessus 3rd ventricle 3rd ventricle CaseCase courtesycou of Dr Matt Skalski, Radiopaedia.org, rID: 37808 CaseCase courtesycou of Dr Matt Skalski, Radiopaedia.org, rID: 37808 Pineal recessus Aqueduct 2/ Ventricular system 4th ventricle 4th ventricle Rhomboid shaped Lateral recesses become Luschka foramina Foramen of Magendie Obex Case courtesy of Dr Matt Skalski, Radiopaedia.org, rID: 37808 3/ Cerebral CSF spaces Cisterns Essentially subarachnoid spaces y Traversed by pial-covered septa, vascular structures and cranial nerves Focal dilations of the CSF spaces are called cisterns y Suprasellar (red) y Interpeduncular (yellow), quadrigeminal & paired ambient (blue) = perimesencephalic cistern y Prepontine (green) & cerebellopontine angle (purple) y premedullary (orange) & cerebellomedullary (blue) y cisterna magna Image by F. Barkhof et al (eds) in Clinical Neuroradiology (copyright by Springer Nature Switzerland AG 2019) Cisterns Cisterns Image by F. Barkhof et al (eds) in Clinical Neuroradiology (copyright by Springer Nature Switzerland AG 2019) Image by F. Barkhof et al (eds) in Clinical Neuroradiology (copyright by Springer Nature Switzerland AG 2019) Cisterns Structures inside CSF Choroid plexus y Highly vascularised y Ependymal lining around connective tissue y Secrete CSF and maintain BBB y Focal thickening in atria = glomera Image by F. Barkhof et al (eds) in Clinical Neuroradiology (copyright by Springer Nature Switzerland AG 2019) Choroid plexus Structures inside CSF Arachnoid (Pacchonian) Granulations y Focal projections of arachnoid membrane into dural venous system y Usually adjacent to junction between sinus or superficial draining vein y Larger granulations can be seen to protrude into the inner table of skull or as filling defect in sinus Case courtesy of Dr Matt Skalski, Radiopaedia.org, rID: 37808 Arachnoid (Pacchonian) Arachnoid (Pacchonian) Granulations Granulations By Mysid - Made by Mysid Inkscape, based on plate 769 from Gray&#039;s Anatomy (1918, public domain)., Public Domain, https://commons.wikimedia.org/w/index.php?curid=10493338 4/ Spinal CSF spaces Subarachnoid space in continuity with premedullary cistern and cisterna magna Obex at the beginning of the spinal cord to form central canal which ends at conus medullaris Terminal ventricle sometimes observed (<5y) Lumbar cistern (biggest cistern in human) ends around S2 5/ Anatomical variants Lateral ventricle asymmetry Lateral ventricle asymmetry Usually similar in size Cavum septi pellucidi (et vergae) Cavum veli interpositi y In 5-10% of patients a definite asymmetry is Megacisterna magna (Blake pouch cyst?) seen Benign enlargement of subarachnoid space in infancy (BESS) Arachnoid cyst Ventricular cyst If not severe or no underlying causes or Ependymitis granularis complications observed no further Xanthogranuloma investigation required Spinal meningeal cysts Intra- or extradural arachnoid cyst Tarlov cyst Sacral meningocele Cavum septi pellucidi (et vergae) Septa pellucida forms around 3rd month of gestation and fuses close to birth If no fusion occurs there appears a CSF space: cavum septi pellucidi When extends posteriorly: cavum vergae (very rarely isolated) Cavum veli interpositi Double fold of pia-arachnoid meninges extending from fornices to roof of 3rd ventricle y Contains posterior choroidal arteries and internal cerebral veins Cavum veli interpositi cyst Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 35909 Megacisterna magna - Blake’s pouch cyst Enlargement of subarachnoid space without cyst formation If cyst with a wall then this becomes a Blake’s pouch cyst Benign enlargement of subarachnoid space in infancy (BESS or BESSI) Usually observed around frontal lobes Males more affected than females Children may present with macrocephaly or frontal bossing Usually disappears by age of 2 Differential with subdural collection (cortical vein sign) No definitive cut-off values Arachnoid cyst Can occur anywhere Wide range of sizes Almost always incidental finding Ventricular cyst Can occur anywhere Wide range of sizes Almost always incidental finding &DVHFRXUWHV\RI'U0HKPHW<D÷WX5DGLRSDHGLDRUJU,' Case courtesy of Royal Melbourne Hospital, Radiopaedia.org, rID: 13744 Ependymitis granularis Sounds more worrying then it is Symmetrical triangular region of flair/T2 hyperintens signal at anterior and lateral sides of frontal horns of the lateral ventricles (usually < 1cm) No signal change on T1-weighted images Choroid plexus xanthogranuloma Usually in older patients Myxoid cysts (build up of desquamated cells from plexus) y Usually at site of glomera y Usually < 1 cm y On MRI they can show diffusion restriction y Can show a rim of calcification (“string of pearls”) Spinal meningeal cyst Classification by Nabor et el. y type I: extradural meningeal cyst without neural tissue ż type Ia: extradural spinal arachnoid cyst ż type Ib: sacral meningocele y type II: extradural meningeal cyst containing neural tissue (Tarlov cyst) y type III: intradural spinal arachnoid cyst Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 21791 Spinal meningeal cyst type Ia & type III extra- or intradural arachnoid cyst May occur at any age No gender prediliction Variable size Most frequent at thoracic level (80%) Mostly asymptomatic Sometimes connection with subarachnoid space can be seen Large differential for type III cysts (cord herniation, (epi)dermoid cyst, infectious) Spinal meningeal cyst type Ib Spinal meningeal cyst type II sacral meningocele Tarlov cyst Rare congential lesion Also called perineural cysts cyst within sacral thecal sac y CSF dilatations of the nerve root sheath = extradural sacral cyst true meningocele Found in up to 5% of the population Usually associated with spinal dysraphism More frequent in women Discussion about cysts being symptomatic Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 6284 Conclusion Important to know normal anatomy so you can recognize pathology A lot of anatomical variants which should not be mistaken for pathology Always look at clinical findings to make notice of pathological variant (does it fit?).
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