Neuroradiology Practice Questions

Q: All are features of raised intracranial tension in adults except?

Sutural diastasis. **Explanation:** The correct answer is **Sutural diastasis (Option D)**. The fundamental concept here is the difference between the pediatric and adult skull. In **adults**, the cranial sutures are fused (synostosed). Therefore, when intracranial pressure (ICP) rises, the sutures cannot separate. In contrast, **sutural diastasis** (separation of sutures >2mm) is a hallmark sign of raised ICP in **infants and children** (usually up to age 10-12) because their sutures are still patent. **Analysis of Incorrect Options:** * **Erosion of Dorsum Sella (Option A) & Posterior Clinoid Process (Option B):** These are the **earliest and most common** radiologic signs of chronic raised ICP in adults. The pressure from the distended third ventricle (pulsatile CSF) transmits directly onto the sella turcica, leading to rarefaction and erosion of the cortical bone, starting with the posterior clinoid processes and the dorsum sella. * **Inner Table Convolutions (Option C):** Also known as **"Copper Beaten Skull"** or "Fingerprinting," these represent prominent gyral impressions on the inner table of the skull due to chronic pressure from the underlying brain. While it can be a normal variant in children, in adults, it is a classic sign of long-standing raised ICP (e.g., craniosynostosis or obstructive hydrocephalus). **High-Yield Clinical Pearls for NEET-PG:** * **Earliest sign of raised ICP on X-ray:** Erosion of the lamina dura of the polyspastic dorsum sella. * **Sutural Diastasis:** Most commonly involves the **coronal suture** in children. * **J-shaped Sella:** Associated with optic chiasm gliomas, mucopolysaccharidosis (Hurler syndrome), and achondroplasia. * **Empty Sella Syndrome:** Herniation of the subarachnoid space into the sella, often associated with Idiopathic Intracranial Hypertension (Pseudotumor cerebri).

Q: Which of the following is a cystic supratentorial tumor?

Craniopharyngioma. **Explanation:** The correct answer is **Craniopharyngioma**. **1. Why Craniopharyngioma is correct:** Craniopharyngiomas are benign (WHO Grade I) tumors derived from the remnants of **Rathke’s pouch**. They are characteristically **supratentorial** (specifically suprasellar) in location. Radiologically, they are known for their heterogeneous appearance, often described by the "90% rule": 90% are cystic, 90% show calcification (especially in the adamantinomatous type), and 90% enhance. The presence of "motor oil" fluid within the cysts is a classic pathological finding. **2. Why the other options are incorrect:** * **Medulloblastoma:** This is a highly malignant (WHO Grade IV) tumor that occurs in the **infratentorial** compartment (posterior fossa). It typically arises from the roof of the 4th ventricle and is solid, not primarily cystic. * **Ependymoma:** While ependymomas can occur supratentorially, they are most commonly found in the **infratentorial** compartment (floor of the 4th ventricle) in children. They often present as solid masses with "plastic" growth (extending through the foramina of Luschka and Magendie). **Clinical Pearls for NEET-PG:** * **Bimodal Age Distribution:** Craniopharyngiomas peak at 5–14 years and 50–75 years. * **Adamantinomatous vs. Papillary:** Adamantinomatous (children) is cystic/calcified; Papillary (adults) is usually solid/mixed and lacks calcification. * **Clinical Triad:** Visual field defects (bitemporal hemianopia), endocrine dysfunction (growth retardation, DI), and increased intracranial pressure. * **Imaging Hallmark:** Suprasellar calcification on CT is the most suggestive feature in a pediatric patient.

Q: In subarachnoid hemorrhage, where is blood most commonly collected in the skull?

Basal cistern. **Explanation:** **Subarachnoid Hemorrhage (SAH)** refers to the presence of blood within the subarachnoid space—the area between the arachnoid mater and the pia mater. This space normally contains cerebrospinal fluid (CSF) and major cerebral blood vessels. **Why Basal Cisterns are the correct answer:** The most common cause of non-traumatic SAH is the rupture of a **saccular (berry) aneurysm**. These aneurysms typically occur at the bifurcations of the arteries forming the **Circle of Willis**, which is anatomically located within the **basal cisterns** (large expansions of the subarachnoid space at the base of the brain). Consequently, when an aneurysm ruptures, blood immediately accumulates in these cisterns (e.g., suprasellar, interpeduncular, and sylvian cisterns). On a non-contrast CT (NCCT), this appears as hyperdense (white) signals replacing the normally dark CSF. **Analysis of Incorrect Options:** * **Around falx cerebri:** While blood can track into the longitudinal fissure, isolated blood here is more characteristic of a subdural hematoma (SDH) or traumatic SAH, rather than the classic presentation of a ruptured aneurysm. * **Near cerebellum:** Blood in the posterior fossa cisterns occurs but is less common as a primary site unless the aneurysm is on the vertebral or basilar arteries. * **Tentorium:** Blood along the tentorium is a classic sign of a subdural hematoma (SDH) tracking along the dural folds. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Investigation:** Non-contrast CT (NCCT) Head is the initial investigation of choice (95-98% sensitive in the first 24 hours). * **Lumbar Puncture:** If CT is negative but clinical suspicion is high, look for **xanthochromia** (yellowish CSF due to bilirubin). * **Classic Sign:** "Star-shaped" hyperdensity in the basal cisterns on CT. * **Most common site for Berry Aneurysm:** Junction of the Anterior Communicating Artery (A-com) and Anterior Cerebral Artery.

Q: A female patient with breast cancer presents with altered sensorium. What does the following MRI suggest?

Limbic encephalitis. ***Limbic encephalitis*** - **Paraneoplastic limbic encephalitis** is a well-known complication of breast cancer, often associated with antibodies like **anti-Hu**, **anti-Ri**, or **anti-amphiphysin**. - Classic MRI findings show **bilateral medial temporal T2/FLAIR hyperintensity** involving the **hippocampus** and **amygdala**, consistent with the clinical presentation of altered sensorium. *Herpes simplex encephalitis* - Typically shows **asymmetric temporal lobe involvement** with hemorrhagic changes and **mass effect**, unlike the bilateral symmetric pattern seen in limbic encephalitis. - Associated with **fever**, **focal seizures**, and **CSF pleocytosis** with positive HSV PCR, not typically linked to malignancy. *Gliomatosis cerebri* - Characterized by **diffuse infiltrative growth** involving multiple lobes and white matter tracts without forming a discrete mass. - Shows **extensive T2/FLAIR hyperintensity** throughout multiple brain regions, not limited to the limbic structures as seen here. *Metastasis* - Brain metastases from breast cancer typically present as **discrete enhancing lesions** with surrounding **vasogenic edema** and **mass effect**. - Usually appear as **well-circumscribed lesions** at the **gray-white matter junction**, not the bilateral limbic pattern characteristic of this case.

Q: In idiopathic basal ganglia calcification, which structure is most often calcified?

Globus pallidus. **Explanation:** **Idiopathic Basal Ganglia Calcification (IBGC)**, also known as **Fahr’s Disease**, is a rare neurodegenerative disorder characterized by abnormal calcium deposition in the brain parenchyma. **1. Why Globus Pallidus is Correct:** The **globus pallidus** is the most common and typically the earliest site of calcification in this condition. It is highly sensitive to metabolic disturbances and mineral deposition. On CT scans, these calcifications appear as symmetric, high-attenuation areas. While the disease is called "basal ganglia" calcification, the deposition specifically begins or is most prominent in the globus pallidus before involving other structures. **2. Analysis of Incorrect Options:** * **Caudate Nucleus & Putamen:** While these structures (which together form the **Striatum**) are frequently involved as the disease progresses, they are rarely the primary or most heavily calcified site compared to the globus pallidus. * **Striatum:** This is a collective term for the caudate and putamen. While involved in advanced stages, it is not the "most often" or earliest site involved. **3. NEET-PG High-Yield Pearls:** * **Imaging Modality of Choice:** **Non-contrast CT (NCCT) Head** is the gold standard for detecting calcification (appears hyperdense/white). * **Symmetry:** A key feature of Fahr’s is that calcifications are typically **bilateral and symmetric**. * **Other Sites:** Calcification can also be seen in the thalamus, dentate nucleus of the cerebellum, and subcortical white matter. * **Differential Diagnosis:** Always rule out secondary causes of basal ganglia calcification, most notably **Hypoparathyroidism** and **Pseudohypoparathyroidism**, which present with similar radiological findings. * **Clinical Presentation:** Patients may present with movement disorders (parkinsonism, chorea), cognitive decline, or psychiatric symptoms.

Q: Basal ganglia calcification is seen in all of the following conditions except:

Acromegaly. **Explanation:** Basal ganglia calcification (BGC) is a common radiological finding caused by the deposition of calcium and other minerals in the basal ganglia, particularly the globus pallidus. **1. Why Acromegaly is the Correct Answer:** Acromegaly is caused by an excess of Growth Hormone (GH) and is associated with bony overgrowth, soft tissue hypertrophy, and visceromegaly. While it affects mineral metabolism (hypercalciuria), it is **not** typically associated with intracranial or basal ganglia calcification. Therefore, it is the "except" option. **2. Analysis of Incorrect Options:** * **Hypoparathyroidism (Option A):** This is the **most common** pathological cause of BGC. Low levels of Parathyroid Hormone (PTH) lead to hyperphosphatemia. The high calcium-phosphate product results in the deposition of calcium in the small vessels of the basal ganglia. * **Hyperparathyroidism (Option C):** Both primary and secondary hyperparathyroidism can lead to metastatic calcification in the brain due to deranged calcium-phosphate homeostasis. * **Hypothyroidism (Option B):** Though less common than parathyroid disorders, hypothyroidism is a recognized metabolic cause of BGC, often associated with altered calcium metabolism or as part of multi-systemic syndromes. **3. NEET-PG High-Yield Pearls:** * **Fahr’s Disease:** A rare, genetic, progressive neurological disorder characterized by idiopathic, symmetrical basal ganglia calcification. * **Physiological Calcification:** Often seen in elderly patients (usually >40 years), typically involving only the globus pallidus and appearing faint/symmetrical. * **Other Causes:** TORCH infections (especially CMV and Toxoplasmosis), Carbon Monoxide poisoning, Lead poisoning, and post-radiotherapy. * **Imaging Modality of Choice:** **CT scan** is significantly more sensitive than MRI for detecting and characterizing intracranial calcification.

Q: What is the investigation of choice for SCIWORA?

MRI. **Explanation:** **SCIWORA** stands for **Spinal Cord Injury Without Radiographic Abnormality**. It is a clinical-radiological syndrome where a patient exhibits signs of post-traumatic myelopathy (spinal cord injury) despite having normal conventional imaging. **Why MRI is the Correct Answer:** The hallmark of SCIWORA is that the injury involves the **soft tissues**—specifically the spinal cord, ligaments, or intervertebral discs—rather than the bony architecture. **MRI** is the investigation of choice because it has superior soft-tissue contrast resolution. It can detect intramedullary pathology such as cord edema, hemorrhage, or contusion, as well as ligamentous disruptions that are invisible on X-rays or CT scans. **Why Other Options are Incorrect:** * **X-ray & CT (Options A & B):** By definition, SCIWORA implies that these modalities are **normal**. They are excellent for identifying fractures, dislocations, or bony instability, but they cannot visualize the internal parenchyma of the spinal cord. If a fracture is seen on CT, the diagnosis is no longer SCIWORA. * **All of the above (Option D):** While X-ray and CT are often the *initial* screening tools in trauma, they are not the definitive investigation for diagnosing the cord injury itself in this specific syndrome. **High-Yield Clinical Pearls for NEET-PG:** * **Demographics:** Most common in the **pediatric population** (especially <8 years) due to increased spinal column elasticity and ligamentous laxity compared to the cord. * **Most Common Site:** Cervical spine. * **Prognostic Indicator:** On MRI, the presence of **cord hemorrhage** signifies a worse prognosis compared to simple edema. * **Management:** Rigid immobilization and avoidance of high-risk activities for several weeks, even if the initial MRI is negative but clinical symptoms persist.

Q: Which of the following is NOT a radiological feature of meningioma?

Decalcification of the inner table. ### Explanation **Meningiomas** are the most common benign intracranial tumors, arising from the arachnoid cap cells. Their radiological features are primarily driven by their slow growth and high vascularity derived from the meningeal vessels. **Why "Decalcification of the inner table" is the correct answer:** Meningiomas typically cause **hyperostosis** (thickening and increased density) of the overlying bone, rather than decalcification or erosion. This reactive bone formation occurs due to tumor invasion of the haversian canals or as a response to chronic irritation. Therefore, decalcification (thinning/destruction) of the inner table is not a characteristic feature. **Analysis of Incorrect Options:** * **A. Lamellar calcification:** Meningiomas frequently contain **Psammoma bodies**, which are microscopic, laminated (lamellar) calcifications. On CT, roughly 20–25% of meningiomas show visible calcification. * **B. Enlarged foramen spinosum:** Meningiomas are highly vascular and often receive their blood supply from the **middle meningeal artery**. Chronic increased blood flow through this artery leads to the compensatory enlargement of the foramen spinosum. * **C. Increased meningeal vascular markings:** Due to the recruitment of dural vessels (external carotid artery branches), X-rays often show prominent, tortuous vascular grooves on the inner table of the skull leading toward the tumor site. **NEET-PG High-Yield Pearls:** * **Gold Standard Imaging:** Contrast-enhanced MRI (shows the characteristic **"Dural Tail Sign"**). * **Angiography:** Shows a **"Sunburst"** or **"Mother-in-law"** appearance (tumor flushes early and stays late). * **Histology:** Look for **Psammoma bodies** and **whorled patterns** of cells. * **Location:** Most common at the parasagittal region/convexities.

Q: What is true about the MRI/CT appearance of a lateral meningocele?

Widened neural foramen. **Explanation:** A **Lateral Meningocele** is a protrusion of the arachnoid and dura mater through an enlarged intervertebral foramen. It is most commonly associated with **Neurofibromatosis Type 1 (NF-1)**. **1. Why "Widened neural foramen" is correct:** The hallmark of a lateral meningocele is the herniation of the thecal sac through the neural foramen. Over time, the CSF pressure within the meningocele causes **pressure erosion** of the surrounding bone. This leads to the characteristic imaging finding of a **widened neural foramen**, often accompanied by scalloping of the posterior vertebral bodies and thinning of the pedicles. **2. Analysis of Incorrect Options:** * **A. Solid dural masses:** This is incorrect because a meningocele is a **cystic** lesion. On MRI, it follows CSF signal intensity (hypointense on T1, hyperintense on T2) and does not show internal solid enhancement. * **B. Usually outside the spinal canal:** While the "sac" protrudes outward, the condition is defined by its communication with the spinal subarachnoid space. It is an extension of the spinal canal contents, not a separate entity outside it. * **D. Generally, there is no spinal cord compression and deformity:** This is incorrect. Large meningoceles can cause significant **mass effect**, leading to spinal cord compression, displacement, and progressive kyphoscoliosis. **High-Yield Facts for NEET-PG:** * **Association:** Strongly associated with **NF-1** (found in ~70-85% of cases). * **Location:** Most common in the **thoracic spine** (apex of the convex side of a scoliosis curve). * **Differential Diagnosis:** Must be distinguished from a **Schwannoma** (which is solid and enhances) and a **Paravertebral Abscess**. * **Imaging Gold Standard:** **MRI** is the investigation of choice to demonstrate the communication with the subarachnoid space.

Question 1

All are features of raised intracranial tension in adults except?

Accepted Answer

Sutural diastasis

Answer

Erosion of dorsum sella

Answer

Erosion of posterior clinoid process

Answer

Inner table convolutions

Question 2

Which of the following is a cystic supratentorial tumor?

Accepted Answer

Craniopharyngioma

Answer

Ependymoma

Answer

Medulloblastoma

Answer

None of the above

Question 3

In subarachnoid hemorrhage, where is blood most commonly collected in the skull?

Accepted Answer

Basal cistern

Answer

Around falx cerebri

Answer

Near cerebellum

Answer

Tentorium

Question 4

A 28-year-old man presented with headache. A CT head shows a low attenuation mass in the left temporoparietal region which has a similar density to CSF and shows no enhancement following contrast administration. Diffusion-weighted MRI shows high signal. Which of the following is the most probable diagnosis?

Accepted Answer

Epidermoid cyst

Answer

Migraine

Answer

Arachnoid cyst

Answer

Multiple sclerosis

Question 5

A female patient with breast cancer presents with altered sensorium. What does the following MRI suggest?

Accepted Answer

Limbic encephalitis

Answer

Herpes simplex encephalitis

Answer

Gliomatosis cerebri

Answer

Metastasis

Question 6

In idiopathic basal ganglia calcification, which structure is most often calcified?

Accepted Answer

Globus pallidus

Answer

Caudate nucleus

Answer

Putamen

Answer

Striatum

Question 7

Basal ganglia calcification is seen in all of the following conditions except:

Accepted Answer

Acromegaly

Answer

Hypoparathyroidism

Answer

Hypothyroidism

Answer

Hyperparathyroidism

Question 8

What is the investigation of choice for SCIWORA?

Accepted Answer

MRI

Answer

CT

Answer

X-ray

Answer

All of the above

Question 9

Which of the following is NOT a radiological feature of meningioma?

Accepted Answer

Decalcification of the inner table

Answer

Lamellar calcification

Answer

Enlarged foramen spinosum

Answer

Increased meningeal vascular markings

Question 10

What is true about the MRI/CT appearance of a lateral meningocele?

Accepted Answer

Widened neural foramen

Answer

Solid dural masses

Answer

Usually outside the spinal canal

Answer

Generally, there is no spinal cord compression and deformity

Neuroradiology — MCQs

Neuroradiology — MCQs

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