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Neuroradiology

 

Training Goals & Learning Objectives

GENERAL GOALS

Residents may rotate through the Division of Neuroradiology during each of their four years of training. The timing and structure of neuroradiology rotations will vary between training programs and therefore it is not possible to provide program-specific goals for each level of training. It is expected that residents will progressively develop their abilities to perform and interpret imaging studies of the central nervous system. Residents will be taught the practical clinical skills necessary to interpret neuroradiologic studies, including plain radiographs, CT scans, MRI and ultrasound exams of 1) brain and skull; 2) spinal cord and vertebral column; and 3) head and neck. They will be instructed in the performance and interpretation of invasive procedures including cerebral angiography, myelography/spinal canal puncture, and image-guided biopsies of the spine and skull base.

The residents will receive instruction in the science that underlies clinical neuroradiology, in particular neuroanatomy and neuropathology. They will learn the physical principles of CT, MR, plain radiography, and digital angiography. They will learn the relative value of each modality, enabling them to choose the appropriate study and the appropriate protocol for each patient.

It is expected that residents will participate in the performance of the full range of examinations done by the division. They will obtain consents and perform intravenous injections of contrast. The residents will learn the indications and contraindications for contrast administration and to recognize and treat adverse reactions. Residents will protocol and monitor CT and MR exams after they have demonstrated a sufficient level of knowledge and experience to perform these tasks. Residents will aid in the performance of invasive procedures including angiograms, myelograms, spinal taps and other minimally invasive procedures such as image-guided vertebral and skull base biopsies. They will learn to explain these procedures to patients and their families, obtain pre-procedure consent and write pre- and post-procedure orders. They will learn techniques of arterial puncture, catheter choice and manipulation, and contrast dosage. They will learn to recognize and treat complications of these invasive procedures.

The residents will learn to dictate concise and appropriate radiographic reports and to serve as consultants to referring physicians.

KNOWLEDGE BASED OBJECTIVES

I) Anatomy:

    A. Intracranial

Early rotations: Become familiar with the appearance of major intracranial structures as visualized on axial CT and MR scans. Be able to identify all major structures and components of the brain, ventricles and subarachnoid (cisterns) space.

Middle rotations: Develop more detailed knowledge of intracranial anatomy as displayed on multi-planar images.

Late rotations: Be able to identify subdivisions and fine anatomic details of the brain, the ventricles, subarachnoid space, vascular structures, sella turcica, and cranial nerves.

    B. Head and Neck 

Early rotations: Learn the anatomy of the calvarium, skull base and soft tissues of the neck as displayed on plain radiographs.

Middle rotations: Become familiar with the complex anatomy of the orbit, petrous bone, skull base and soft tissues of the neck as displayed on CT and MR in multiple planes.

Late rotations: Be able to identify all key structures and have knowledge of established anatomic classification systems for each area.

    C. Spine

Early rotations: Become familiar with the normal appearance of the spine on plain radiographs and axial CT scans. Be able to assess spinal alignment and be able to identify all osseous components of the spinal canal by completion of first rotation.

Middle rotations: Learn to identify normal osseous structures, intervertebral discs, support ligaments and the contents of the thecal sac (spinal cord and nerve roots) on CT, MR, and myelography.

Late rotations: Be able to identify all normal structures on multi-planar images.

    D. Vascular

Early rotations: Learn to identify the large vessels of the cervical and intracranial regions (carotid, vertebral and basilar arteries, jugular veins and dural venous sinuses) as they appear on routine CT and MR studies of the head and neck.

Middle rotations: Learn to identify these same structures and their key branches on catheter, MR angiography and sonography (extra-cranial vessels).

Late rotations: Be able to identify all important extra- and intra-cranial arteries (secondary and tertiary branches of the carotid and basilar arteries) and veins (cortical and deep cerebral veins) on all imaging modalities. 

II) Pathology and Pathophysiology:

Learn the basic pathology and pathophysiology of diseases of the brain, spine, and head and neck.

Early rotations: Become familiar with the common traumatic, ischemic and inflammatory conditions of the brain, skull base, neck and spine.

Middle rotations: Learn the pathophysiology of rapidly evolving processes, in particular cerebral infarction and inflammation.

Late rotations: Learn the pathologic and histologic features that allow for characterization of neoplastic lesions and learn the accepted classification system (WHO) of tumors.

III) Imaging Technology:

    A. CT

    Early rotations: Become familiar with imaging parameters, including window and level settings, slice thickness, inter-slice gap, and helical imaging parameters, and image reconstruction algorithms (e.g., soft tissue and bone). Learn the typical CT density of commonly occurring processes such as edema, air, calcium, blood and fat.

    Middle rotations: Learn the appropriate imaging protocols used for assessment of the full range of lesions encountered in Neuroradiology.

    Late rotations: Learn the principles and utility of multi-planar reconstruction and CT angiography.

    B. MR

Early rotations: Learn the basic physical principles of MR. Be able to identify commonly used pulse sequences and become familiar with standard MR protocols. Learn the intensity of normal tissues on routine pulse sequences.

Middle rotations: Learn the clinical utility of each routine pulse sequence. Learn how to combine pulse sequences to produce effective and efficient imaging protocols for common disease processes. Learn the intensity encountered in hemorrhage, fat and calcium.

Late rotations: Learn to protocol complex clinical cases. Become familiar with more advanced imaging techniques such as MR angiography, fat suppression, diffusion/perfusion, activation studies, and MR spectroscopy.

IV)     Image interpretation:

    A. Intracranial

Early rotations: Develop skills in the interpretation of plain films of the skull. Learn to interpret CT scans with a particular emphasis on studies performed on individuals presenting with acute or emergent clinical abnormalities (infarction, spontaneous intracranial hemorrhage, aneurysmal subarachnoid hemorrhage, traumatic brain injury, infection, hydrocephalus, and brain herniation).

Middle rotations: Learn the CT and MR findings of hyperacute infarction (including findings on diffusion weighted MRI). Learn to identify and characterize focal lesions and diffuse processes and be able to provide a short differential diagnosis for the potential causes of these processes.

Late rotations: Develop the ability to use imaging findings to differentiate different types of focal intracranial lesions (neoplastic, inflammatory, vascular) based on anatomic location (e.g., intra- vs. extra-axial), contour, intensity and enhancement pattern. Learn to identify and differentiate diffuse intracranial abnormalities (e.g., hydrocephalus and atrophy). Lean to recognize treatment-related findings (e.g., post-surgical and post-radiation). Become familiar with the utility of new MR sequences (diffusion/perfusion, functional MR and MR spectroscopy).

    B. Head and Neck

Early rotations: Learn to identify common acute emergent lesions. Become familiar with the plain film and CT appearance of (a) traumatic (fractures and soft tissue injuries) of the orbit, skull base, face and petrous bones and (b) inflammatory (sinusitis, orbital cellulitis, otitis, mastoiditis, cervical adenitis and abscess) lesions. Learn to identify airway compromise and obstruction.

Middle rotations: Expand knowledge of the appearance of traumatic lesions on CT. Be able to characterize fractures based on clinical classification systems (e.g., Le Fort fractures). Learn to identify neoplastic masses arising in the orbit, skull base, petrous bone and soft tissues of the neck. Be able to use standard anatomic classification schemes to accurately describe the location of mass lesions.

 Late rotations: Learn the differential diagnosis of mass lesions. Understand and be able to identify patterns of disease spread within and between areas of the head and neck (e.g., perineural and nodal spread). Learn to recognize treatment- related findings (e.g., post-surgical and post-radiation). Learn to identify pathologic processes on multi-planar MR studies.

    C. Spine

Early rotations: Learn the appearance of traumatic lesions on plain radiographs with an emphasis on findings of spinal instability. Become familiar with the CT and MRI findings of degenerative disease.

Middle rotations: Learn the CT, MRI and myelographic findings of spinal cord compression. Become familiar with findings on all three modalities that allow for accurate spatial localization of spinal lesions (extra-dural, intra-dural, extra-medullary, and intra-medullary). Be able to identify and differentiate discogenic and arthritic degenerative diseases. Learn to identify and characterize traumatic lesions (e.g., stable vs. unstable, mechanism of injury) using routine and reformatted CT scans.

Late rotations: Learn the imaging findings that allow for the differentiation of inflammatory and neoplastic lesions. Learn the imaging features of intraspinal processes, including syringomyelia, arachnoiditis and spinal dysraphism. Learn to recognize post-surgical and other treatment-related findings.

    D. Vascular

    Early rotations: Learn to recognize the angiographic features of extra- and intracranial atherosclerosis utilizing catheter angiography, MRA and sonography.

    Middle rotations: Learn the indications, limitations, risks and benefits for each technique used for visualization of vascular anatomy and pathology. Learn the angiographic appearance of aneurysms, vascular malformations, occlusive diseases and neoplasms.

    Late rotations: Learn the indications, risks and benefits for neurointerventional procedures including embolization, angioplasty and stenting.

    E. Pediatrics

Early rotations: Learn to recognize the normal appearance of the brain (e.g., myelination), spine (e.g., ossification) and head and neck (e.g., sinus development) encountered in the newborn, infant, and child. Be able to identify the features of hydrocephalus on CT and MR.

Middle rotations: Learn to recognize congenital lesions and malformations. Be able to detect disorders of the perinatal period on sonography, CT, and MR.

Late rotations: Be able to identify and differentiate acquired lesions (traumatic, ischemic, inflammatory and neoplastic) of the newborn, infant, child, and adolescent.

TECHNICAL AND NON-INTERPRETIVE OBJECTIVES

1) Patient care

Early rotations: Learn to obtain informed consent, by explaining the risks and benefits of contrast-enhanced CT/MR to the patient. Learn appropriate techniques for injection of contrast (including use of power injectors). Learn to recognize and treat contrast reactions.

Middle rotations: Learn to obtain informed consent for invasive procedures including angiography, spinal punctures/myelography and image-guided biopsies. Be able to explain the risks, benefits and complications of these procedures to patients and their families.

Late rotations: Learn to write pre- and post-procedure orders. Be able to evaluate the clinical status of patients prior to, during and after the procedure. Learn to recognize complications of these procedures and to initiate appropriate treatment.

2) Catheter angiography

Early rotations: Observe the performance of diagnostic angiograms of the cervical and cranial vessels.

Middle rotations: Learn the basic techniques of arterial puncture and catheter manipulation. Assist senior residents, fellows, and attendings in the performance of angiograms.

Late rotations: Learn to safely position catheters within extra-cranial vessels. Learn the appropriate dose of contrast material for angiography of each vessel. Learn the angiographic protocols for the evaluation of a variety of disease processes (e.g., aneurysmal subarachnoid hemorrhage). Be able to perform diagnostic angiography under the supervision of an attending radiologist.

3) Image-guided biopsies and spinal canal

Early rotations: Learn to perform fluoroscopically guided punctures of the lumbar spinal canal for the purpose of myelography, spinal fluid collection, and intrathecal injection of medications.

Middle rotations: Assist senior residents, fellows, and attendings in the performance of image-guided biopsies. Be able to perform myelography under the supervision of an attending radiologist.

Late rotations: Be able to perform image-guided biopsies of the spine and skull base under the supervision of an attending radiologist.

Decision making/Value judgment skills

Early rotations: Learn the appropriate format for dictation of reports of neuroradiologic imaging studies. Provide consultations for house staff and referring physicians on imaging studies after reviewing the exam with an attending radiologist.

Middle rotations: Protocol and monitor CT studies. Be able to modify imaging protocols based on identification of unexpected or novel findings. Provide provisional interpretations and consultations of plain radiographs, CT scans and MR scans performed in the Emergency Department. Learn the clinical and imaging indications for acute stroke intervention including intra-arterial thrombolysis.

Late rotations: Direct the choice of imaging modality and protocol neuroradiologic studies. Act as a consultant to junior radiology residents. Learn to identify those cases that require the additional expertise in assessment of imaging studies.

NEURORADIOLOGY CORE CURRICULUM

    I.  Intracranial

        A. CNS Infections

            1. Imaging strategies

            2. Pyogenic infections

                Meningitis
                Cerebritis
                Abscess
                Subdural and epidural empyema (abscess)

            3.  Encephalitis

                Herpes (HSV I & II)
                Sporadic and epidemic
                Chronic – subacute sclerosis panencephalitis (SSPE)
                Prior disease – (Creutzfeldt Jakob)

            4.  Granulomatous infections

                Meningeal (basal) – hydrocephalus
                Parenchymal – granuloma and abscess
                Vasculitis – infarction
                Etiology – TB, sarcoid, fungi

            5.  Infections in the immunocompromised host

                Toxoplasmosis
                HIV
                PML
                CMV
                Lymphoma
                Cryptococcal infection

        B. White Matter Disease

            1. Multiple sclerosis

            2. Acute disseminated encephalomyelitis (ADEM)

            3. Small vessel ischemic disease, hypertension, vascular disease

            4. Radiation/chemotherapy changes

            5. Trauma (axonal injuries)

            6. White matter changes in the elderly

            7. Osmotic myelinolysis (central pontine myelinolysis)

            8. Dysmyelinating disorders

                Adrenoleukodystrophy
                Krabbe's
                Metachromatic leukodystrophy (MLD)
                Alexander
                Canavan's

        C.     Trauma

            1. Imaging strategies CT/MR/skull films

            2. Mechanisms

            3. Primary vs. secondary

            4. Focal lesions

                Cortical contusions
                Diffuse axonal injury (DAI) -- shearing
                Subarachnoid hemorrhage (SAH)
                Subdural hemorrhage (SDH)
                Epidural hemorrhage (EDH)
                Parenchymal hemorrhage with differentials

            5. Ages of hemorrhage by CT/MR

            6. Intraventricular hemorrhage

            7. Diffuse cerebral swelling and edema

            8. Herniation syndromes

            9. Skull fractures, types, complications

            10. Vascular injuries—dissection, pseudoaneurysm, penetrating injuries,lacerations, complications

            11. Non-accidental trauma

        D. Neoplasms and other masses

            1. Tumor classification by histology

                Glial
                Astrocytoma
                Glioblastoma multiforme (GBM)
                Oligodendroglioma
                Ependymoma
                Subependymoma
                Pleomorphic xanthoastrocytoma (PXA)
                Neuro-glial
                Central neurocytoma
                Ganglioma/ganglioneuroma
                Primitive neuroectodermal tumor (PNET)
                Dysembryoplastic neuroectodermal tumor (DNET)
                Lymphoma
                Primary or secondary
                Metastases
                Meningioma
                Choroid plexus tumors
                Other mesenchymal tumors

            2.     Tumor evaluation by location

                Intra-axial vs. extra-axial
                Infra-tentorial masses – pediatric
                Medulloblastoma
                Ependymoma
                Brainstem glioma
                Cerebellar juvenile pilocytic astrocytoma (JPA)
                Infra-tentorial masses – adult
                Hemangioblastoma
                Metastasis
                Sellar/parasellar
                Pituitary adenoma
                Craniopharyngioma
                Rathke's cleft cyst
                Meningioma
                Arachnoid cyst
                Hypothalamic glioma
                Hamartoma
                Germinoma
                Chordoma
                Lymphoma
                Pituitary hypoplasia with ectopic posterior pituitary gland
                Pituitary hemorrhage (apoplexy)
                Pituitary abscess
                Pineal region
                Germ cell tumors (germinoma)
                Pineocytoma and pineoblastoma
                Pineal cyst
                Meningioma
                Glioma
                Cerebellopontine angle tumor
                Vestibular Schwannoma
                Meningioma
                Epidermoid
                Arachnoid cyst
                Metastases
                Schwannomas of other cranial nerves (V-X)
                Aneurysm (AICA)
                Intraventricular tumors
                Choroid plexus papilloma and carcinoma
                Colloid cyst
                Giant cell astrocytoma
                Subependymoma
                Central neurocytoma
                Meningioma
                Glioma
                Metastases
                AVM
                Cysticercosis
                Skull base
                Chordoma
                Chondrosarcoma
                Nasopharyngeal carcinoma
                Myeloma, lymphoma and leukemia
                Metastases
                Schwannoma (lower cranial nerves)
                Glomus tumors
                Meningiomas
                Fibrous dysplasia

        E. Cerebrovascular disease

            1.   Infarction

                Strategies for imaging
                CT—signs of hyperacute infarction
                MR—value of diffusion weighted images (DWI)
                Etiology
                Occlusions, large/small vessel
                Embolic
                Watershed (hypoperfusion)
                Hypoxia/anoxia
                Dissection
                Fibromuscular dysplasia (FMD)
                Vasculitis
                Venous thrombosis
                Vasospasm
                Migraine
                Hemorrhagic vs. bland
                Appearance over time CT/MR, MRA, CTA, angiography

            2.   Spontaneous hemorrhage

                Aneurysm
                AVM
                Tumor
                Hematologic causes
                Drugs
                Infarct
                Congophylic (amyloid) angiopathy
                Hypertension
                Imaging of hemorrhage over time CT/MR
                Serial changes on MR

            3.   Aneurysms

                Types, locations, associated conditions
                Incidence by location and of multiple aneurysms
                Complication: rupture, mass effect, hydrocephalus, spasm
                Imaging, MRI, MRA, CT, catheter angiography and CT angiography

            4.  Cerebrovascular malformations

                Capillary telangiectasia
                Cavernous angioma (CA)
                Developmental venous anomaly (DVA)
                Arteriovenous malformations (AVM)
                Classification based on size of components
                Vein of Galen malformation

            5.   Angiography

                Film screen, DSA, catheters, injection rates, projections, filming sequences, complications
                Normal anatomy and variants
                Common carotid artery (CCA)
                External carotid artery (ECA) and branches
                Internal carotid artery (ICA)
                Cavernous branches
                Persistent fetal connections
                Circle of Willis
                ACA, MCA, PCA branches
                Vertebro-basilar (VB) arteries
                ECA, ICA, VB collaterals and anastomoses
                Pathologic processes
                Stenosis and occlusion (ASCVD, FMD, Takayasu, emboli)
                Neoplasms
                Fistulas
                AVM
                CA
                DVA (association with CA)
                Aneurysms (berry, atherosclerotic and traumatic)
                Trauma (AV fistulas, transections, dissections)
                Dissection (spontaneous)
                Arteritis
                Spasm
                Venous thrombosis (venous sinuses, cortical veins, deep veins)
                Infants/children
                Occlusions
                Arteritis (Moya, Moya)

        F.    Congenital CNS lesions

            1.    Embryology of brain development

            2.    Disorders of organogenesis

                Ancephaly
                Cephaloceles
                Chiari malformations (I-IV)
                Corpus callosum anomalies: dysgenesis, lipomas
                Hydranencephaly
                Porencephaly

            3.   Disorders of neuronal migration and sulcation

                Lissencephaly
                Cortical dysgenesis: agyria-pachygyria, polymicrogyria
                Heterotopia
                Schizencephaly
                Unilateral megalencephaly

            4.  Disorders of diverticulation and cleavage

                Holoprosencephaly (alobar, semilobar, lobar)
                Septo-optic dysplasia
                Absent septum pellucidum

            5.  Posterior fossa cystic disorders  

                Dandy-Walker complex
                Mega cisterna magna
                Arachnoid cyst
                Disorders of histogenesis (phakomatoses)
                Neurofibromatosis type I and type II
                Tuberous sclerosis
                Sturge-Weber-Dimitri syndrome
                Von Hippel-Lindau
                Ataxia-telangiectasia; Louis-Bar syndrome
                Rendu-Osler-Weber syndrome
                Basal cell nevus syndrome

    II.  Head and Neck Radiology

        A. Paranasal sinuses

            1. Anatomy of paranasal sinuses

            2. Congenital disease

                Dermal sinus tract
                Encephalocele
                Choanal atresia
                Dacrocystocele   

            3. Inflammation/infection

                Acute sinusitis
                Chronic sinusitis (allergic, fungal, granulomatous)
                Polyposis
                Mucocele

            4. Benign sinus tumors

                Osteoma
                Antrochoanal polyp
                Juvenile angiofibroma
                Inverted papilloma      

            5. Malignant sinus tumors

                Squamous cell carcinoma
                Esthesioneuroblastoma
                Lymphoma
                Metastases
                Lethal midline granuloma

        B.   Oral cavity, oropharynx, hypopharynx

            1. Anatomy, contents

            2. Masses

                Squamous cell carcinoma
                Dermoid/epidermoid
                Lingual thyroid
                Ranula
                Hemangioma

            3.     Infection

                Cellulitis, abscess (Ludwig's angina)

        C.     Parapharyngeal space

            1.  Location, contents, anatomy and importance in relation to other spaces

            2.  Pharyngeal mucosal space (anatomy, contents)

                Infection (tonsillar abscess, adenitis)
                Pleomorphic adenoma (minor salivary glands)
                Squamous cell CA
                Non-Hodgkin's lymphoma
                Thornwaldt cyst

            3. Masticator space (anatomy, contents)

                Tumors (mesenchymal)
                Infection

            4. Parotid space (anatomy, contents)

                1st brachial cleft cyst
                Infection
                Lymphoepithelial lesions
                Sjogren's
                Pleomorphic adenoma
                Warthin's tumors
                Mucoepidermoid carcinoma
                Adenoid cystic carcinoma
                Metastases
                Lymphoma

            5. Carotid space (anatomy, contents)

                Paragangliomas (glomus tumors)
                Schwannoma
                Neurofibroma
                Nodal metastases

            6. Retropharyngeal space (anatomy, contents)

                Neoplastic and reactive lymph nodes
                Infection ("Danger space")

        D. Perineural spread

        A. Larynx

            1.  Squamous cell carcinomas

                Staging
                Supraglottic, glottic, subglottic
                Treatment effects (surgery and radiation)
                Airway obstruction

            2.  Trauma (laryngeal fractures) 

        B. Thyroid

            1.  Masses

                Multinodular goiter
                Adenoma
                Cyst
                Carcinoma

        C. Cystic neck masses

            1. Second brachial cleft cyst
            2. Thyroglossal duct cyst
            3. Cystic hygroma
            4. Laryngocele, internal, external
            5. Abscess
            6. Ranula
            7. Dermoid/epidermoid

            D. Lymphadenopathy

            1. Graded by level and/or anatomic space
            2. Size criteria for pathologic nodes
            3. Etiology

                Lymphoma
                Metastases (aerodigestive carcinoma)
                Cat scratch fever
                Atypical mycobacterium
                Mononucleosis
                Castleman's disease

        E. Temporal bones

            1. Imaging techniques (Multi-planar CT/MR)
            2. Anatomy/embryology
            3. Trauma

                Transverse and longitudinal fractures
                CSF leaks, brain herniation

            4. Tumors

                Schwannoma
                Vestibular (8th) (common)
                Facial (7th) and trigeminal (5th)
                Meningioma
                Lipoma
                Dermoid/epidermoid
                Metastases

            5. Pulsatile tinnitus

                Glomus tympanicum
                High riding/dehiscent jugular vein
                Ectopic carotid
                AVM, AV fistula
                Atherosclerotic disease
                Dissection
                FMD

            6. Inflammatory disease

                Otitis media
                Mastoiditis
                Cholesteatoma (acquired or congenital)
                Malignant external otitis
                Cholesterol granuloma
                Hemorrhage or inflammation cochlea, vestibule (labyrinthitis) 

            7. Congenital anomalies

                External ear atresia/hypoplasia (ossicular anomalies)
                Enlarged vestibular/cochlea aqueducts
                Cochlear/vestibular aplasias-hypoplasias
                Internal auditory canal anomalies

        F. Orbits

            1. Imaging techniques

            2. Anatomy/embryology

                Lesion localization based on relationship to muscle cone

            3.      Lacrimal gland tumors

                Epithelial
                Pleomorphic adenomas
                Carcinomas
                Lymphoma
                Dermoid
                Metastases

            4.      Extra-conal masses

                Orbital wall or sinus neoplasms with extension
                Subperiosteal abscess/orbital cellulitis from
                sinusitis/osteomyelitis
                Metastases
                Lymphoma/leukemia/myeloma
                Lymphangioma/hemangioma
                Rhabdomyosarcoma
                Histiocytosis
                Pseudotumor and granulomatous disease

            5. Extra-ocular muscles (conal)

                Graves' disease
                Orbital myositis (pseudotumor)
                Granulomatous disease
                Lymphoma/leukemia
                Metastases
                Carotid cavernous fistula

            6. Intra-conal lesions

                Related to optic nerve
                Glioma
                Meningioma
                Optic nerve
                Increased intracranial pressure
                Pseudotumor
                Graves' disease
                Meningeal carcinomatosis
                Leukemia
                Separate from optic nerve (well-defined)
                Cavernous angioma, capillary angioma
                Varix
                Neurofibroma/Schwannoma
                Meningioma
                Pseudotumor
                Lymphoma
                Separate from optic nerve (ill-defined – infiltrative)
                Infection
                Metastases
                Pseudotumor

            7. Intra-ocular

                Adult
                Melanoma
                Metastases
                Drusen
                Child
                Retinoblastoma
                Retrolental fibroplasia
                Coat's disease
                Primary hypertrophic persistent vitreous (PHPV)
                Any age
                Metastases
                Retinal detachment
                Infection and inflammation (endophthalmitis), AIDS
                Phthsis bulbi

            8.      Trauma

                Fractures of the orbital wall
                Extra-ocular muscle entrapment
                Orbital emphysema
                Intra-orbital hematoma
                Penetrating soft tissue injuries
                Laceration of the optic nerve or muscles
                Ocular – ruptured globe, intra-ocular hemorrhage, dislocated lens
                Foreign body

    III.  Spinal Imaging

        A. Anatomy and Biomechanics

            1. Vertebral bodies
            2. Facet joints and transverse processes
            3. Lamina and spinous processes
            4. Support ligaments
            5. Specific characteristics of cervical, thoracic, and lumbar segments
            6. Cranio-vertebral and lumbo-sacral junctions
            7. Normal stability and motion

        B. Imaging Modalities

             1. Role and relative merit of noninvasive imaging studies

                Plain radiography, CT, MR, nuclear medicine, PET imaging

            2.  Role of invasive procedure

                Myelography (including CT) angiography, biopsies, facet injections, nerve root blocks, discography

        C. Trauma

             1. Mechanism of injury

                Flexion
                Extension
                Axial loading
                Compression
                Distraction
                Rotation

            2.  Stable fractures and ligamentous injuries

                Compression fracture
                Isolated anterior column
                Isolated posterior column
                Unilateral locked facet
                Hyperextension, teardrop
                Clay Shoveler's (spinous process C7)

            3. Unstable injuries (involvement of the middle column and ligaments)

                Hyperflexion teardrop
                Facet joint disruption and dislocation (bilateral locked facets)
                Hyperflexion ligamentous injury without fracture
                Odontoid fracture
                Distration fracture (Hangman's) (C2/C3)
                Chance
                Burst

            4. Traumatic disc herniation
            
            5. Extrinsic cord compression
            
            6. Cord contusion

            7. Intra-spinal hemorrhage

                Epidural hematoma (EDH)
                Subdural hematoma (SDH)
                SAH subarachnoid hemorrhage (SAH)
                Cord hematoma (hematomyelia)

            8. Post-traumatic abnormalities

                Instability with spondylolithesis
                Syringomyelia
                Arachnoiditis
                Pseudomeningocele and root avulsion

        D. Degenerative disease

            1. Epidemiology
            2. Disc degeneration
            3. End plate degeneration
            4. Disc herniation

                Distribution
                Imaging findings

            5. Spinal stenosis

                Distribution
                Imaging findings

            6. Postoperative changes

                Epidural scar
                Arachnoiditis
                Recurrent herniation or stenosis

        E.      Inflammatory and demyelinating disease

            1. Discitis/osteomyelitis

                Acute (spontaneous and postoperative)
                Epidural and paravertebral abscess
                Chronic low grade discitis

            2. Vertebral body tuberculosis (Potts Disease)

            3. Meningitis (arachnoiditis)

                TB, sarcoid, CMV, AIDS

            4. Spinal cord lesions

                Abscess, granuloma
                Transverse myelitis
                Multiple sclerosis
                ADEM

        F. Neoplastic disease

            1. Osseous

                Primary tumors – benign
                Hemangioma
                Osteoid osteoma/osteoblastoma
                Chondroid tumors
                Giant cells
                Aneurysmal bone cyst (ABC)
                Chordoma
                Primary tumors –malignant
                Osteoid
                Chondroid
                Metastases
                Lymphoma
                Myeloma
                Leukemia

            2. Extradural

                Neurofibroma
                Lymphoma
                Metastases

            3. Intradural extramedullary

                Meningioma
                Schwannoma
                Neurofibroma
                Dermoid
                Lipoma
                Epidermoid
                Epidermal inclusion cyst
                Metastases (carcinomatous meningitis)
                Lymphoma

            4. Intramedullary

                Ependymoma
                Astrocytoma
                Hemangioblastoma
                Metastases
                Lymphoma

        G. Cystic lesions

            1. Extradural

                    Meningocele
                    Pseudo-meningocele (postoperative and post-traumatic)
                    Root sleeve cysts (Tarlov) and terminal meningocele

                2. Intradural extramedullary

                    Arachnoid cyst
                    Post-inflammatory and post-hemorrhagic arachnoiditis

                3. Intramedullary

                    Syringomyelia/hydromyelia
                    Chiari malformation, post-traumatic, post-infectious, neoplastic

            H. Vascular lesions

                1. Dural venous fistula
                2. AVM
                3. Cavernous angioma
                4. Spinal cord infarct

            I. Developmental spine disease

                1. Normal embryologic development of spine
                2. Open dysraphisms
                3. Myelomeningocele
                4. Lipomyelomeningocele (tethered cord)
                5. Myelocele
                6. Diastemometamyelia
                7. Occult spinal dysraphisms
                8. Tight filum, thick filum
                9.  Intradural lipoma
                10. Dorsal dermal sinus