0:00

Dr. Laser,

0:01

we're back with our 29-year-old with Von Hippel-Lindau.

0:04

He originally had a T1-FLAIR.

0:05

The sections were 5 mm or less,

0:08

but not as thin as we see here,

0:10

1 mm in the middle.

0:11

And at that time, it looked like a solid nodule.

0:14

Now, they had already resected it, and it had recurred.

0:17

And now two years later,

0:18

it is morphing on this recurrence and behaving a little

0:21

bit differently, which I find strange.

0:23

I understand that's not strange.

0:25

No, it's actually very common when

0:27

once the lesion has been resected,

0:28

it can come back as a cystic lesion when before it was

0:31

solid or it can come back from a solid lesion to a cystic lesion,

0:34

or it can come back from a solid lesion to a

0:37

solid lesion with a cyst inside.

0:38

Very bizarre.

0:39

Now, I know these lesions bleed readily.

0:42

They're very friable.

0:43

And when you look at them at surgery,

0:46

they're like cherry red nodules,

0:48

you can actually see the vascularity inside them.

0:50

But what makes them potentially brighter than CSF,

0:54

or the nodules a little bit bright.

0:57

Is it blood that does that?

0:58

It can be blood.

0:59

It can be methemoglobin from

1:05

from prior hemorrhage within the tumor

1:08

or you could have a lipid component,

1:10

which also could be intrinsically hyperintense

1:12

on a T1-weighted sequence.

1:13

Now, this one has an atypical appearance on recurrence

1:16

and that it is a solid nodule.

1:19

You kind of see...

1:20

I'll trace right over it right there.

1:23

And there's this dark spot in the middle

1:25

and that is not calcification.

1:28

That is not flow void either because if it was flow void,

1:30

it wouldn't be bright over here on the T2-weighted image.

1:34

So this is an actual solid lesion with right in the middle,

1:39

or slightly to the viewer's left,

1:40

a cystic component inside the mass.

1:44

So that configuration,

1:46

solid with a cyst inside, 12%.

1:49

Let's just quickly review before we leave this particular case,

1:52

the different appearances of Von Hippel-Lindau.

1:54

We've got a pure cyst,

1:56

8% of the time.

1:57

We've got a cyst with a mural nodule,

2:00

35% of the time.

2:01

That's the classic.

2:02

We'll show you a more classic appearance in a little bit,

2:05

with some flow voids in the mural nodule,

2:07

which helps you differentiate from pilocytic astrocytoma.

2:10

Then you've got the weird one where you've got a cyst

2:14

and then kind of a funny solid component to it.

2:17

That's 6%.

2:18

Perhaps that's tied for the least common.

2:20

And then you've got a cyst with a nodule.

2:24

And then inside the nodule is a cystic component.

2:27

That's 6% also.

2:29

Then you've got a solid lesion

2:31

and if you color that in,

2:34

and there's a part of that lesion that is a cyst,

2:38

just like in this case that we have here.

2:40

And that's seen about 12% of the time.

2:43

And then you've got a completely solid lesion all the way through.

2:47

That's the second most common type seen,

2:49

33% of the time.

2:50

Although those are usually smaller,

2:52

and you usually see those along the edge or

2:54

surface of the spine or the cerebellum.

2:57

Pomeranz and Laser out.

2:59

Out.

2:59

Out.