Neuroradiology Practice Questions

Q: What condition is characterized by a "tram track" appearance on a CT scan of the head?

Sturge-Weber syndrome. **Explanation:** **Sturge-Weber Syndrome (SWS)**, also known as encephalotrigeminal angiomatosis, is the correct answer. The "tram track" appearance on a non-contrast CT scan refers to **gyriform cortical calcifications**. These occur due to chronic ischemia caused by an underlying leptomeningeal angioma (usually on the same side as a facial Port-wine stain). This leads to calcium deposition in the second and third layers of the cerebral cortex, tracing the outlines of the sulci and gyri, resembling parallel railroad tracks. **Analysis of Incorrect Options:** * **Von Hippel-Lindau (VHL):** Characterized by retinal and CNS **hemangioblastomas** (typically in the cerebellum or spine), renal cell carcinoma, and pheochromocytoma. It does not feature gyriform calcification. * **Tuberous Sclerosis (TS):** Features **subependymal nodules** (which can calcify) and cortical tubers. While calcification is common, it presents as discrete nodules or "candle guttering" along the ventricles, not a "tram track" pattern. * **Neurofibromatosis (NF):** NF1 is associated with optic gliomas, Lisch nodules, and sphenoid wing dysplasia. NF2 is associated with bilateral vestibular schwannomas. Neither typically presents with intracranial tram-track calcifications. **High-Yield Clinical Pearls for NEET-PG:** * **Triad of SWS:** Facial capillary malformation (Port-wine stain in the $V_1/V_2$ distribution), leptomeningeal angioma, and glaucoma. * **Imaging Gold Standard:** **Contrast-enhanced MRI** is the most sensitive modality to detect the leptomeningeal enhancement (pial angioma) early in life, before calcifications develop. * **Skull X-ray:** Can also demonstrate the "tram track" sign in older children. * **Associated finding:** Enlargement and enhancement of the ipsilateral choroid plexus.

Q: Wine glass appearance on T2W-MRI Brain is seen with which condition?

Amyotrophic Lateral Sclerosis. **Explanation:** **Amyotrophic Lateral Sclerosis (ALS)** is a progressive neurodegenerative disease involving both upper and lower motor neurons. The characteristic **"Wine Glass Appearance"** on T2-weighted or FLAIR MRI sequences is a classic radiological sign of ALS. 1. **Why ALS is correct:** In ALS, there is degeneration and gliosis of the **Corticospinal Tracts (CST)**. On coronal MRI sections, this appears as symmetrical hyperintensities extending from the internal capsule, through the cerebral peduncles, and down into the pons. The shape formed by these diverging hyperintense tracts resembles the stem and bowl of a wine glass. 2. **Why the other options are incorrect:** * **Metachromatic Leukodystrophy:** Characterized by a **"Tigroid pattern"** or "Leopard skin appearance" due to spared perivascular myelin islands within areas of demyelination. * **Canavan Disease:** Presents with diffuse, symmetric white matter involvement and is uniquely associated with a **marked elevation of N-acetylaspartate (NAA)** on MR Spectroscopy. * **Creutzfeldt-Jakob Disease (CJD):** Typically shows the **"Hockey stick sign"** (hyperintensity in the pulvinar and dorsomedial thalamus) or "Pulvinar sign." **High-Yield Clinical Pearls for NEET-PG:** * **Motor Neuron Disease (MND):** ALS is the most common form. It characteristically **spares** the extraocular muscles and anal sphincter. * **Motor Cusp Sign:** Another MRI finding in ALS where there is hypointensity of the precentral gyrus (motor cortex) on T2/FLAIR due to iron deposition. * **Riluzole:** A glutamate antagonist used to slow progression; it is a frequently tested pharmacological fact.

Q: All of the following are MRI features of Mesial temporal sclerosis, except:

None of the above. **Mesial Temporal Sclerosis (MTS)**, also known as Hippocampal Sclerosis, is the most common cause of drug-resistant focal epilepsy. It involves neuronal loss and gliosis within the hippocampus and adjacent structures. ### **Explanation of the Correct Answer** The correct answer is **D (None of the above)** because all three listed options (A, B, and C) are recognized MRI features of MTS. In the context of an "except" question, if all statements are true, "None of the above" is the logical choice. ### **Analysis of Options** * **Atrophy of Hippocampus (Option B):** This is the **most sensitive and specific** finding. MRI shows a decrease in hippocampal volume and an associated **increase in T2/FLAIR signal intensity** (due to gliosis). * **Atrophy of Fornix (Option A):** The fornix is the major efferent pathway of the hippocampus. Chronic hippocampal atrophy leads to Wallerian degeneration of the ipsilateral fornix and mammillary bodies. * **Blurring of Grey-White Matter Junction (Option C):** This occurs in the anterior temporal lobe. It is a secondary sign reflecting underlying cortical dysplasia or metabolic changes associated with chronic seizures. ### **High-Yield Clinical Pearls for NEET-PG** * **Gold Standard Imaging:** MRI is the modality of choice. The best sequences are **Coronal T2 and FLAIR** (perpendicular to the long axis of the hippocampus). * **Secondary Signs:** 1. Dilatation of the temporal horn of the lateral ventricle (ex-vacuo). 2. Loss of hippocampal internal architecture (loss of "digitations"). 3. Atrophy of the mammillary bodies. * **Clinical Presentation:** Typically presents as **Complex Partial Seizures** (Temporal Lobe Epilepsy), often preceded by a history of febrile seizures in childhood.

Q: Trouser leg appearance in myelography is typically seen in which type of spinal cord tumor?

Intramedullary tumor. **Explanation:** The **"Trouser leg appearance"** (also known as the "Capping" or "Inverted V" sign) is a classic myelographic finding characteristic of **Intramedullary tumors**. **1. Why Intramedullary tumor is correct:** Intramedullary tumors (e.g., Ependymoma, Astrocytoma) originate within the spinal cord parenchyma. As the tumor grows, it causes **fusiform enlargement** of the spinal cord. On a myelogram, the contrast column is displaced peripherally and thinned as it passes the expanded cord. When the contrast meets the poles of the enlarged cord, it splits into two narrow streams, resembling the legs of a pair of trousers. **2. Why other options are incorrect:** * **Extradural tumors (e.g., Metastases):** These arise outside the dural sac. They cause a "ragged" or "brush-like" appearance due to complete or partial block, displacing the entire dural sac away from the bone. * **Intradural extramedullary tumors (e.g., Meningioma, Schwannoma):** These arise outside the cord but inside the dura. They typically produce a **"Meniscus sign"** or "Cup-shaped" defect, displacing the spinal cord to the opposite side rather than expanding it. **Clinical Pearls for NEET-PG:** * **Most common intramedullary tumor in adults:** Ependymoma (often associated with NF-2). * **Most common intramedullary tumor in children:** Astrocytoma. * **MRI** is now the gold standard for spinal cord imaging, but myelographic signs remain high-yield for exams. * **Summary of Myelography Signs:** * *Intramedullary:* Trouser leg appearance / Fusiform cord widening. * *Intradural Extramedullary:* Meniscus sign / Diamond sign. * *Extradural:* Curtain sign / Feathered edge.

Q: Diffuse axonal injury is best detected by which imaging modality?

MRI. **Explanation:** **Diffuse Axonal Injury (DAI)** is a form of traumatic brain injury caused by high-velocity acceleration-deceleration or rotational forces, leading to the shearing of axons at the interface of tissues with different densities (typically the gray-white matter junction). **Why MRI is the Correct Answer:** MRI is the gold standard and most sensitive modality for detecting DAI. While conventional MRI sequences (T1/T2) are superior to CT, specialized sequences are even more effective: * **Susceptibility-Weighted Imaging (SWI)** and **Gradient Echo (GRE):** These are the most sensitive for detecting "hemorrhagic" DAI (petechial hemorrhages) due to the paramagnetic effect of hemosiderin. * **Diffusion-Weighted Imaging (DWI):** Highly sensitive for detecting "non-hemorrhagic" DAI by identifying areas of cytotoxic edema. **Why Other Options are Incorrect:** * **CT Scan (NCCT/CECT):** CT is often the first-line investigation in trauma to rule out life-threatening bleeds (EDH/SDH), but it is notoriously insensitive for DAI. In over 50–80% of DAI cases, the CT scan appears completely **normal** despite the patient being in a deep coma (Clinico-radiological dissociation). * **Transcranial Doppler:** This is used to measure cerebral blood flow velocity (e.g., in vasospasm post-SAH) and has no role in the structural diagnosis of axonal shearing. **High-Yield Clinical Pearls for NEET-PG:** * **Most common sites for DAI:** Gray-white matter junction (most common) > Corpus Callosum (Splenium) > Brainstem (Dorsolateral aspect). * **Clinical Hallmark:** A patient with a low GCS score (coma) whose CT scan is disproportionately normal. * **Grading:** Grade I (Gray-white junction), Grade II (Corpus callosum), Grade III (Brainstem). * **Prognosis:** DAI is one of the most common causes of persistent vegetative state following head trauma.

Q: What is the diagnosis for a 10-year-old child presented with vision problems, given the CT scan below?

Craniopharyngioma. ***Craniopharyngioma*** - Most common **suprasellar tumor** in children, typically presenting with **visual field defects** due to **optic chiasm compression**. - Classic CT features include **calcifications** (90% in children) and **cystic-solid mixed appearance** in the suprasellar region. *Pituitary macroadenoma* - Extremely rare in **pediatric patients** and typically presents with **endocrine dysfunction** rather than isolated vision problems. - CT shows **homogeneous enhancement** without the characteristic **calcifications** seen in craniopharyngiomas. *Germinoma* - More commonly affects the **pineal region** rather than suprasellar area, causing **Parinaud syndrome** and **hydrocephalus**. - CT typically shows **homogeneous hyperdense mass** without calcifications and responds dramatically to **radiation therapy**. *Lipoma* - Appears as **hypodense lesion** with **fat attenuation** (-50 to -100 HU) on CT, distinctly different from craniopharyngioma. - Usually **asymptomatic** and rarely causes **mass effect** or visual disturbances in children.

Q: What is the imaging study of choice for the paranasal sinuses?

CT Scan. **Explanation:** **1. Why CT Scan is the Correct Answer:** Non-Contrast Computed Tomography (NCCT) is the **gold standard** and imaging study of choice for the paranasal sinuses (PNS). The primary reason is its superior ability to provide high-resolution visualization of the complex bony anatomy and the **ostiomeatal complex (OMC)**. It accurately depicts mucosal thickening, fluid levels, and bony erosions, which is essential for diagnosing chronic sinusitis and planning Functional Endoscopic Sinus Surgery (FESS). **2. Analysis of Incorrect Options:** * **USG (A):** Ultrasound has no role in routine PNS imaging due to the air-filled nature of the sinuses, which reflects sound waves, preventing visualization of deeper structures. * **X-ray PNS (C):** While historically used (e.g., Waters' view for maxillary sinuses), X-rays are now considered obsolete for definitive diagnosis due to significant bony overlap and low sensitivity for early mucosal changes. * **FDG PET scan (D):** This is a functional imaging modality used primarily for staging and detecting metastasis in malignancies. It is not used for routine anatomical evaluation of the sinuses. **3. High-Yield Clinical Pearls for NEET-PG:** * **Standard View:** The **Coronal plane** is the most important for CT PNS as it best demonstrates the ostiomeatal complex. * **MRI vs. CT:** While CT is best for bone, **MRI** is the investigation of choice for suspected **fungal sinusitis** (shows signal void on T2) or when evaluating the intracranial/intraorbital extension of a tumor. * **Waters' View:** Also known as the Occipitomental view; it is the best X-ray view for the Maxillary sinus. * **Caldwell View:** Best X-ray view for the Frontal and Ethmoid sinuses.

Q: What does a angiogram of the basilar artery bifurcation show?

Aneurysm. **Explanation:** The **basilar artery bifurcation** (the point where the basilar artery divides into the two posterior cerebral arteries) is one of the most common sites for the formation of **saccular (berry) aneurysms** in the posterior circulation. **1. Why Aneurysm is correct:** Angiography is the gold standard for visualizing vascular lumen abnormalities. At arterial bifurcations, hemodynamic stress and structural weakness in the tunica media lead to the formation of aneurysms. A "top of the basilar" aneurysm is a classic radiological finding. When an angiogram is performed in this region, it is most frequently indicated to evaluate the size, neck, and morphology of such an aneurysm for surgical clipping or endovascular coiling. **2. Why other options are incorrect:** * **Brain Tumor:** While tumors can be vascular, they are primarily diagnosed via MRI or CT. Angiography might show "tumor blush" or vessel displacement, but it is not the primary diagnostic tool for a tumor at a bifurcation. * **Arteriovenous Malformation (AVM):** AVMs appear as a "bag of worms" (nidus) with early venous drainage. While they can occur anywhere, the specific mention of the *bifurcation* point is a classic descriptor for aneurysmal pathology. * **Atherosclerotic Block:** While atherosclerosis can affect the basilar artery, it usually presents as diffuse narrowing or irregular stenosis along the length of the vessel rather than a focal finding specifically at the bifurcation. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site for Berry Aneurysm:** Junction of the Anterior Communicating Artery (ACom) and Anterior Cerebral Artery (ACA). * **Most common posterior circulation site:** Basilar artery apex (bifurcation). * **Clinical Presentation:** Rupture leads to **Subarachnoid Hemorrhage (SAH)**, characterized by a "thunderclap headache." * **Gold Standard Investigation:** Digital Subtraction Angiography (DSA).

Q: Which of the following is characteristic of Lhermitte-Duclos disease?

Thickened cerebellar folia. **Lhermitte-Duclos Disease (LDD)**, also known as **Dysplastic Cerebellar Gangliocytoma**, is a rare, slow-growing WHO Grade I tumor characterized by the replacement of normal cerebellar internal granular cells with hypertrophied ganglion cells. ### **Explanation of Options** * **A. Thickened cerebellar folia (Correct):** The hallmark of LDD is the focal expansion of the cerebellar cortex. On MRI, this appears as a "striated" or **"tiger-striped" pattern** due to the thickening of cerebellar folia with alternating layers of high and low signal intensity on T2-weighted images. This occurs because the tumor causes a disorganized hypertrophy of the cerebellar layers rather than a destructive mass effect. * **B. Atrophic cerebellar folia:** This is the opposite of what occurs in LDD. Atrophy is seen in chronic alcohol abuse, phenytoin toxicity, or paraneoplastic syndromes, where the folia shrink and the sulci widen. * **C. Vermian hypoplasia:** This is a feature of **Dandy-Walker Malformation** or Joubert Syndrome, involving a developmental failure of the cerebellum, not a neoplastic/dysplastic thickening. * **D. Septum pellucidum agenesis:** This is characteristic of **Septo-optic Dysplasia** (De Morsier syndrome), not cerebellar pathology. ### **High-Yield Clinical Pearls for NEET-PG** * **Association:** LDD is considered a pathognomonic feature of **Cowden Syndrome** (PTEN Hamartoma Tumor Syndrome). If you see LDD, screen the patient for breast, thyroid (follicular), and endometrial cancers. * **Imaging Gold Standard:** MRI is the modality of choice. Look for the **"Tiger-striped appearance"** in the posterior fossa. * **Contrast Enhancement:** Typically, there is **no enhancement** (or very minimal) on post-gadolinium sequences. * **Genetics:** Mutations in the **PTEN gene** on chromosome 10.

Q: Which of the following techniques is best for differentiating recurrence of a brain tumor from radiation therapy-induced necrosis?

PET scan. **Explanation:** Differentiating **tumor recurrence** from **radiation necrosis** is a common clinical challenge because both entities can present with similar symptoms and appear as enhancing lesions on conventional imaging. **Why PET Scan is the Correct Answer:** The differentiation relies on **metabolic activity**. * **Tumor Recurrence:** Malignant cells are hypermetabolic and show high uptake of radiopharmaceuticals like **18F-FDG** (Fluorodeoxyglucose) or amino acid tracers (e.g., 11C-Methionine). * **Radiation Necrosis:** This represents dead tissue and inflammatory changes, which are hypometabolic and show **low or absent uptake**. Therefore, PET imaging (specifically FDG-PET or Amino Acid PET) is the gold standard for functional differentiation. **Why Other Options are Incorrect:** * **MRI and Contrast-enhanced MRI (A & B):** While MRI is the modality of choice for initial diagnosis, it lacks specificity here. Both recurrence and necrosis cause a breakdown of the blood-brain barrier, leading to **contrast enhancement** and perilesional edema. Standard MRI cannot reliably distinguish between the two. (Note: Advanced MRI techniques like MR Spectroscopy or Perfusion MRI are better, but PET remains the classic exam answer). * **CT Scan (D):** CT has poor soft-tissue resolution for the brain and cannot assess the metabolic status of the tissue. **Clinical Pearls for NEET-PG:** * **MR Spectroscopy (MRS):** Look for a **Choline peak** (marker of cell membrane turnover). High Choline = Recurrence; Low Choline/High Lactate = Necrosis. * **MR Perfusion:** High **rCBV** (relative Cerebral Blood Volume) suggests recurrence (neovascularization), while low rCBV suggests necrosis. * **Hot vs. Cold:** On PET, a "Hot" lesion (increased uptake) indicates tumor, while a "Cold" lesion indicates necrosis.

Question 1

What condition is characterized by a "tram track" appearance on a CT scan of the head?

Accepted Answer

Sturge-Weber syndrome

Answer

Von Hippel-Lindau syndrome

Answer

Tuberous sclerosis

Answer

Neurofibromatosis

Question 2

Wine glass appearance on T2W-MRI Brain is seen with which condition?

Accepted Answer

Amyotrophic Lateral Sclerosis

Answer

Metachromatic Leukodystrophy

Answer

Canavan Disease

Answer

Creutzfeldt Jakob Disease

Question 3

All of the following are MRI features of Mesial temporal sclerosis, except:

Accepted Answer

None of the above

Answer

Atrophy of fornix

Answer

Atrophy of hippocampus

Answer

Blurring of Grey white matter junction of ipsilateral temporal lobe

Question 4

Trouser leg appearance in myelography is typically seen in which type of spinal cord tumor?

Accepted Answer

Intramedullary tumor

Answer

Extradural tumor

Answer

Intradural extramedullary tumor

Answer

All the above

Question 5

Diffuse axonal injury is best detected by which imaging modality?

Accepted Answer

MRI

Answer

Non-contrast CT scan

Answer

Contrast-enhanced CT scan

Answer

Transcranial Doppler

Question 6

What is the diagnosis for a 10-year-old child presented with vision problems, given the CT scan below?

Accepted Answer

Craniopharyngioma

Answer

Pituitary macroadenoma

Answer

Germinoma

Answer

Lipoma

Question 7

What is the imaging study of choice for the paranasal sinuses?

Accepted Answer

CT Scan

Answer

USG

Answer

X-ray PNS

Answer

FDG PET scan

Question 8

What does a angiogram of the basilar artery bifurcation show?

Accepted Answer

Aneurysm

Answer

Brain Tumor

Answer

Arteriovenous malformation

Answer

Atherosclerotic block

Question 9

Which of the following is characteristic of Lhermitte-Duclos disease?

Accepted Answer

Thickened cerebellar folia

Answer

Atrophic cerebellar folia

Answer

Vermian hypoplasia

Answer

Septum pellucidum agenesis

Question 10

Which of the following techniques is best for differentiating recurrence of a brain tumor from radiation therapy-induced necrosis?

Accepted Answer

PET scan

Answer

MRI

Answer

Contrast-enhanced MRI

Answer

CT scan

Neuroradiology — MCQs

Neuroradiology — MCQs

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