Neuroradiology Practice Questions

Q: A 30-year-old female patient involved in a road traffic accident had nausea and vomiting. She was brought unconscious to the emergency room. The NCCT brain reveals the following findings. What is the most likely diagnosis? ![img-49.jpeg](img-49.jpeg)

a. Extradural hemorrhage. ***Extradural hemorrhage*** - The NCCT image displays a classic **biconvex** or **lens-shaped** hyperdense collection of blood, which is the hallmark radiological feature of an extradural (epidural) hemorrhage. - This type of hemorrhage is most commonly caused by trauma leading to a skull fracture that tears the **middle meningeal artery**, and the hematoma is confined by suture lines where the dura is tightly attached to the skull. *Subdural hemorrhage* - A subdural hemorrhage typically appears as a **crescent-shaped** collection of blood on a CT scan, as it spreads along the contour of the cerebral hemisphere. - It is usually caused by the tearing of **bridging veins** and, unlike an extradural hemorrhage, it can cross suture lines but is limited by dural reflections. *Intra-parenchymal hemorrhage* - This refers to bleeding **within the brain tissue** itself, which would appear as a hyperdense lesion located inside the brain parenchyma, often with surrounding edema. - While it can be caused by trauma (contusion), it is frequently associated with non-traumatic causes like **hypertension** or **amyloid angiopathy**. *Subarachnoid hemorrhage* - A subarachnoid hemorrhage is characterized by blood in the **subarachnoid space**, appearing as hyperdensity within the cerebral **sulci**, **fissures**, and **basal cisterns** on a CT scan. - It is commonly caused by the rupture of a **berry aneurysm** or trauma, but its appearance is distinctly different from the localized, lens-shaped collection seen in the image.

Q: A child presents with seizures. Contrast-enhanced CT reveals a cystic lesion with a dot sign. What is the most likely diagnosis?

Neurocysticercosis. **Neurocysticercosis (Correct Answer)** - This is the most common parasitic infection of the central nervous system, caused by the larval stage of the pork tapeworm, *Taenia solium* - The contrast-enhanced CT shows a cystic lesion with an eccentric hyperdense focus, which is the **pathognomonic "hole-with-dot" sign**, representing the scolex within the cyst - This imaging finding is highly specific for neurocysticercosis and is commonly seen in endemic areas *Tuberculoma (Incorrect)* - Tuberculomas typically present as single or multiple ring-enhancing lesions, often with a central nidus of calcification, known as the **"target sign"** - They are usually associated with significant vasogenic edema and are more common in patients with a history of tuberculosis or immunosuppression - The "dot sign" is not characteristic of tuberculomas *Brain abscess (Incorrect)* - A brain abscess appears as a well-defined, smooth, ring-enhancing lesion with a central area of necrosis and is typically surrounded by marked vasogenic edema - Clinically, patients often present with fever, headache, and focal neurological deficits - The pathognomonic scolex ("dot sign") is absent in brain abscesses *Cerebral metastasis (Incorrect)* - Metastases typically appear as multiple solid or ring-enhancing lesions located at the gray-white matter junction, often with edema out of proportion to the lesion size - While they can be cystic, the "hole-with-dot" sign is not a feature - Cerebral metastases are less common in children compared to adults with a known primary malignancy

Q: Eye of the tiger appearance on MRI is associated with:

Pantothenate kinase-associated degeneration. ***Pantothenate kinase-associated degeneration*** - The "eye of the tiger" sign is pathognomonic for **Pantothenate kinase-associated neurodegeneration (PKAN)**, a form of Neurodegeneration with Brain Iron Accumulation (NBIA). - It appears as a central area of high signal intensity (oedema/gliosis) surrounded by a rim of low signal intensity (iron deposition) in the **globus pallidus** on T2-weighted MRI. ***Wilson disease*** - Characterized by **copper deposition** in the liver, brain (e.g., basal ganglia, thalamus), and cornea (**Kayser-Fleischer rings**). - MRI findings typically show increased T2 signal intensity in the putamen, midbrain, and basal ganglia, but do not produce the classic "eye of the tiger" sign. ***Krabbe disease*** - This is a lysosomal storage disease (leukodystrophy) caused by a deficiency of the enzyme **galactocerebrosidase**. - MRI typically shows extensive white matter abnormalities and atrophy, but it is not associated with the **globus pallidus** changes seen in the "eye of the tiger" sign. ***Huntington chorea*** - A progressive brain disorder characterized by prominent atrophy of the **caudate nucleus** and putamen (striatum). - MRI primarily demonstrates severe **caudate atrophy** and is not associated with the characteristic PKAN finding in the globus pallidus.

Q: A 30-year-old male patient presents to OPD with complaints of recurrent headache and nausea, MRI of brain shown below. What is the diagnosis?

Meningioma. ***Meningioma*** - The MRI displays a classic **extra-axial mass** (meaning outside the brain parenchyma) arising from the convexity dura. - Key imaging features supporting this diagnosis are the **well-circumscribed, lobulated shape** and the **intense, homogenous enhancement** post-contrast. *Glioma* - Gliomas, such as **Glioblastoma Multiforme (GBM)**, are **intra-axial tumors** (arising within the brain tissue) and typically have irregular, infiltrating margins. - High-grade gliomas commonly show **ring enhancement** with central necrosis, which is not characteristic of the lesion depicted. *Ependymoma* - Ependymomas are typically found within the **ventricular system** (especially the fourth ventricle in adults, or lateral ventricles in children) or the spinal cord. - They are **intra-axial** tumors (ventricular location being the defining feature) and rarely present as extra-axial convexity lesions. *Pilocytic astrocytoma* - This tumor is predominantly seen in children and adolescents, often located in the **cerebellum** or along the optic pathways, usually presenting as an **intra-axial** tumor. - Radiologically, it typically appears as a large **cyst with an enhancing mural nodule**, which differs significantly from the solid, extra-axial lesion shown.

Q: Which of the following is the investigation of choice for spinal TB?

MRI. ***MRI*** - **Magnetic Resonance Imaging (MRI)** is the investigation of choice, as it provides excellent visualization of soft tissues, including the **spinal cord**, nerve roots, and early features like **bone marrow edema** and **paraspinal abscesses**. - It can clearly define the extent of the disease, including disc involvement, **epidural space compression**, and neural compromise, which is crucial for surgical planning. *Ultrasound* - **Ultrasound** is primarily used for assessing soft tissue masses and guiding aspirations but has limited ability to image deep structures like the **vertebral column** and spinal canal. - It cannot adequately assess the extent of **bone destruction**, vertebral body involvement, or **intradural pathology** associated with spinal TB. *CT scan* - **CT scan** is superior to conventional radiography for demonstrating **lytic bone destruction**, calcification, and fine bony detail associated with TB. - However, it is less effective than MRI in visualizing **soft tissue involvement**, **early marrow changes**, or the degree of **cord compression**. *CBNAAT* - **CBNAAT (Cartridge-Based Nucleic Acid Amplification Test)** is a **microbiological test** used for the rapid diagnosis of TB and detection of rifampicin resistance. - It requires a **tissue or fluid sample** (e.g., from aspiration or biopsy) and is used for **pathological confirmation**, not as the primary radiological investigation of choice.

Q: The following X-ray shows:

Right sided pansinusitis. ***Right sided pansinusitis*** - The image shows **opacification and mucosal thickening** in the **right maxillary, frontal, and ethmoid sinuses**, which is consistent with **pansinusitis**. - The sinuses on the left appear relatively clear compared to the complete opacification seen on the right side. *Fracture of mandible* - There is **no clear evidence of discontinuity or displacement** of the mandibular bone on the provided X-ray. - Mandibular fractures typically present as a **break in the cortical outlining** of the mandible, which is not visible here. *Orbital floor blowout* - An orbital floor blowout fracture would typically show **herniation of orbital contents** into the maxillary sinus, often accompanied by **air-fluid levels** or a **"teardrop" sign**, neither of which is clearly discernible. - While there is some soft tissue density in the right maxillary sinus, it's more representative of generalized inflammation rather than specific orbital contents. *Normal study* - The distinct **opacification of multiple sinuses** on the right side indicates an abnormality and is inconsistent with a normal study. - A normal sinus X-ray would show **clear, air-filled sinuses** with thin mucosal linings.

Q: The images show the presence of:

A= Ventriculo-peritoneal shunt, B= Ventriculo-atrial shunt. ***A= Ventriculoperitoneal shunt, B= Ventriculo-atrial shunt*** - Image A shows a catheter extending from the cerebral ventricle and terminating in the **peritoneal cavity** (abdomen), characteristic of a **ventriculoperitoneal shunt**. - Image B depicts a catheter extending from the ventricle to the **right atrium** of the heart, indicating a **ventriculo-atrial shunt**. *A= Ventriculo-atrial shunt, B= Ventriculo-peritoneal shunt* - This option incorrectly reverses the identification of the shunts shown in the images. - The catheter termination points are mismatched; image A terminates in the abdomen (VP shunt), not the heart (VA shunt). *A= Denver shunt, B= Leveen shunt* - **Denver shunts** and **Leveen shunts** are **peritoneovenous shunts** used for refractory **ascites**, not hydrocephalus. - These shunts drain ascitic fluid from the peritoneal cavity to systemic circulation, completely different from ventricular shunts for CSF drainage. *B= Leveen shunt, A= Denver shunt* - This option also misidentifies the shunts as peritoneovenous shunts used for **ascites management**. - Both Denver and Leveen shunts are unrelated to **hydrocephalus treatment** and ventricular CSF drainage systems.

Q: A child with intellectual disability and glaucoma was subjected to NCCT. CT scan findings are?

Tram track calcification. ***Tram track calcification*** - The combination of **intellectual disability**, **glaucoma**, and the characteristic **tram track calcifications** on NCCT are classic features of **Sturge-Weber syndrome**. - **Tram track calcifications** refer to the curvilinear calcifications seen in the cerebral cortex, paralleling the gyral contours, which are visible on the image. *Lissencephaly* - **Lissencephaly** is characterized by a **smooth brain surface** due to absent or decreased gyri and sulci. - This condition does not typically present with glaucoma or tram track calcifications. *Agyria* - **Agyria** is an extreme form of lissencephaly, meaning literally "without gyri." - It describes a completely smooth cerebral surface and is not associated with the calcifications or glaucoma seen in this presentation. *West syndrome* - **West syndrome** is an age-dependent epileptic encephalopathy characterized by **infantile spasms**, **developmental arrest**, and a **hypsarrhythmia** pattern on EEG. - While it can be associated with intellectual disability, it does not typically involve glaucoma or tram track calcifications.

Q: The image shows presence of:

Encephalocele. ***Correct: Encephalocele*** The image clearly shows an **extrusion of brain tissue and meninges through a defect in the skull**, particularly in the occipital region, which is characteristic of an encephalocele. The arrow points directly to this **sac-like protrusion of brain material** extending beyond the normal skull contour. This represents a neural tube defect where the cranial bones failed to close completely during development, allowing brain tissue to herniate through the defect. *Incorrect: Holoprosencephaly* Holoprosencephaly is characterized by a **failure of the prosencephalon to cleave into two cerebral hemispheres**, resulting in a single ventricular cavity and associated facial anomalies. This is an **internal structural abnormality** affecting brain division and differentiation, not an external protrusion. The image does not show incomplete hemispheric separation or midline fusion defects. *Incorrect: Anencephaly* Anencephaly is a severe neural tube defect characterized by **absence of a major portion of the brain, skull, and scalp**. In anencephaly, the cranial vault is largely absent with exposed, rudimentary brain tissue. The image shows a **substantially intact cranial cavity with normal brain tissue** and an external sac, which is completely different from the massive tissue absence seen in anencephaly. *Incorrect: Dandy-Walker syndrome* Dandy-Walker syndrome involves a **malformation of the cerebellum and posterior fossa**, specifically characterized by cystic dilation of the fourth ventricle, hypoplasia or agenesis of the cerebellar vermis, and an enlarged posterior fossa. This is an **internal posterior fossa anomaly** without external herniation of brain tissue through a skull defect. The imaging finding shown is external to the skull, not an internal cerebellar/fourth ventricle malformation.

Q: Keyhole sign on fetal ultrasound is seen in:

Dandy-Walker syndrome. ***Dandy-Walker syndrome*** - The ultrasound image shows **enlargement of the posterior fossa** with a **large cyst occupying the space normally taken by the cerebellum**, and a **keyhole sign** (arrow pointing to a defect where the cerebellar vermis should be). This is characteristic of Dandy-Walker syndrome. - Absence or **hypoplasia of the cerebellar vermis** is a hallmark feature, leading to communication of the fourth ventricle with a posterior fossa cyst. *Arnold-Chiari malformation* - Characterized by **herniation of cerebellar tonsils** through the foramen magnum and often associated with myelomeningocele. - Key ultrasound findings include a **lemon sign** (flattened frontal bones) and **banana sign** (anteriorly curved cerebellum), which are not depicted here. *Spina bifida* - This is a **neural tube defect** involving incomplete closure of the spinal column. - While it can be associated with Arnold-Chiari malformation, the primary features of spina bifida (e.g., a **sacral defect** with a mass) are not shown in these images. *Aqueductal stenosis* - Results in **dilation of the lateral and third ventricles** due to obstruction of cerebrospinal fluid flow in the aqueduct of Sylvius. - It primarily affects the supratentorial ventricular system and does not typically involve the **posterior fossa cyst** and **vermic hypoplasia** seen in the image.

Question 1

A 30-year-old female patient involved in a road traffic accident had nausea and vomiting. She was brought unconscious to the emergency room. The NCCT brain reveals the following findings. What is the most likely diagnosis? ![img-49.jpeg](img-49.jpeg)

Accepted Answer

a. Extradural hemorrhage

Answer

b. Subdural hemorrhage

Answer

c. Intra-parenchymal hemorrhage

Answer

d. Subarachnoid hemorrhage

Question 2

A child presents with seizures. Contrast-enhanced CT reveals a cystic lesion with a dot sign. What is the most likely diagnosis?

Accepted Answer

Neurocysticercosis

Answer

Tuberculoma

Answer

Brain abscess

Answer

Cerebral metastasis

Question 3

Eye of the tiger appearance on MRI is associated with:

Accepted Answer

Pantothenate kinase-associated degeneration

Answer

Wilson disease

Answer

Krabbe disease

Answer

Huntington chorea

Question 4

A 30-year-old male patient presents to OPD with complaints of recurrent headache and nausea, MRI of brain shown below. What is the diagnosis?

Accepted Answer

Meningioma

Answer

Glioma

Answer

Pilocytic astrocytoma

Answer

Ependymoma

Question 5

Which of the following is the investigation of choice for spinal TB?

Accepted Answer

MRI

Answer

Ultrasound

Answer

CT scan

Answer

CBNAAT

Question 6

The following X-ray shows:

Accepted Answer

Right sided pansinusitis

Answer

Fracture of mandible

Answer

Orbital floor blowout

Answer

Normal study

Question 7

The images show the presence of:

Accepted Answer

A= Ventriculo-peritoneal shunt, B= Ventriculo-atrial shunt

Answer

A= Denver shunt, B= Leveen shunt

Answer

B= Leveen shunt, A= Denver shunt

Answer

A= Ventriculo-atrial shunt, B= Ventriculo-peritoneal shunt

Question 8

A child with intellectual disability and glaucoma was subjected to NCCT. CT scan findings are?

Accepted Answer

Tram track calcification

Answer

Lissencephaly

Answer

Agyria

Answer

West syndrome

Question 9

The image shows presence of:

Accepted Answer

Encephalocele

Answer

Holoprosencephaly

Answer

Anencephaly

Answer

Dandy-Walker syndrome

Question 10

Keyhole sign on fetal ultrasound is seen in:

Accepted Answer

Dandy-Walker syndrome

Answer

Arnold-Chiari malformation

Answer

Spina bifida

Answer

Aqueductal stenosis

Neuroradiology — MCQs

Neuroradiology — MCQs

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