Neuroradiology Practice Questions

Q: Identify the following abnormality?

Schizencephaly. ***Schizencephaly*** - The image shows a **cleft-like defect** extending from the pial surface to the ventricle, lined by **gray matter**, which is characteristic of schizencephaly. - This typically results in communication between the **subarachnoid space** and the **ventricular system**. *Encephalocoele* - An encephalocoele is a **protrusion of brain tissue** and meninges through a defect in the skull, which is not depicted in this image. - It usually presents as a **sac-like bulge** on the head, often in the occipital or frontal regions. *Prosencephaly* - This term usually refers to the malformation spectrum associated with **holoprosencephaly**, characterized by a failure of the prosencephalon (forebrain) to properly divide. - Features include **fusion of the cerebral hemispheres**, a single ventricle, and facial anomalies, not a cortical cleft as seen here. *Lissencephaly* - Lissencephaly is characterized by a **lack of gyri and sulci** (smooth brain surface) or abnormally broad and flattened gyri, leading to a thickened cortex. - The image clearly displays presence of gyri and sulci, although with an additional unusual cleft, ruling out a primary diagnosis of lissencephaly.

Q: What is the most likely diagnosis in an imaging study showing a large posterior fossa?

Dandy-Walker malformation. ***Dandy-Walker malformation*** - Characterized by **hypoplasia of the cerebellar vermis** and cystic dilation of the fourth ventricle. - This leads to a **markedly enlarged posterior fossa**, often with upward displacement of the tentorium. *Arnold-Chiari malformation* - Involves **downward displacement of the cerebellar tonsils** through the foramen magnum. - This condition typically presents with a **small posterior fossa**, not an enlarged one. *Hydrocephalus* - Refers to an **accumulation of cerebrospinal fluid (CSF)** within the brain's ventricles. - While it can cause ventricular enlargement, it doesn't primarily involve an **enlarged posterior fossa** as a defining feature. *Platybasia* - A congenital anomaly where the **base of the skull is flattened**, leading to an upward angulation of the clivus. - This condition affects the skull base but does not directly cause a **large posterior fossa**; it can be associated with other congenital anomalies.

Q: The MRI image shows a smooth brain surface with absence of normal gyri and sulci. What is the diagnosis?

Lissencephaly. ***Lissencephaly*** - The image clearly displays a **smooth brain surface** with a notable **absence of normal gyri and sulci** (brain folds), characteristic of lissencephaly - This "smooth brain" appearance is pathognomonic for **lissencephaly**, a severe neuronal migration disorder resulting from abnormal neuronal migration during fetal development (typically 12-16 weeks gestation) - Associated with severe developmental delay, seizures, and intellectual disability - Caused by mutations in genes like LIS1, DCX, and TUBA1A *Incorrect: Schizencephaly* - Characterized by **clefts or splits** extending from the ventricles to the cortical surface, lined by gray matter - Would show a clear **CSF-filled cleft**, not a smooth brain surface *Incorrect: Polymicrogyria* - Features **excessive small gyri** with abnormal cortical layering - Brain surface appears bumpy or irregular, not smooth *Incorrect: Pachygyria* - Shows **broad, thick gyri** with shallow sulci - Still has visible gyri and sulci, unlike the completely smooth appearance of lissencephaly

Q: X-ray skull shows: (Recent NEET Pattern 2016-17)

Silver-beaten appearance. ***Silver-beaten appearance*** - The image shows a skull with multiple **gyral impressions** on the inner table, giving it a **bumpy**, 'silver-beaten' or 'copper-beaten' appearance. - This pattern is classically associated with **chronically increased intracranial pressure**, which causes the brain's convolutions to press against the skull. *Multiple myeloma* - Multiple myeloma typically presents with multiple, sharply demarcated **"punched-out" lytic lesions** in the skull, not diffuse gyral impressions. - These lesions often lack a sclerotic rim and are more discrete than the pattern seen here. *Histiocytosis-X* - Histiocytosis-X (now called Langerhans cell histiocytosis) can cause lytic skull lesions, often described as **"beveled edge"** or geographically distributed lesions. - While it can cause osteolytic bone destruction, it does not typically produce the widespread, uniform gyral impressions of a silver-beaten skull. *Letterer-Siwe disease* - Letterer-Siwe disease is an aggressive, disseminated form of **Langerhans cell histiocytosis** affecting infants. - While it can cause bone lesions, including in the skull, it typically manifests as generalized lytic lesions rather than the "silver-beaten" pattern indicative of chronic elevated intracranial pressure.

Q: What is shown in this skull X-ray?

Pepper pot skull. ***Pepper pot skull*** - The X-ray image displays a classic "pepper pot" appearance, characterized by diffuse **punctate lucencies** evenly distributed throughout the skull vault, resembling numerous small holes. - This finding is highly suggestive of **hyperparathyroidism**, where excessive parathyroid hormone leads to increased bone resorption, visible as demineralization and multiple small lytic lesions. *Artifacts* - **Artifacts** are extraneous marks or distortions on an image that do not represent true anatomical structures. - The observed pattern is a consistent, diffuse change in bone density, indicating a **pathological condition** rather than a technical error or imaging artifact. *Silver-beaten appearance* - A "silver-beaten" or **convolutional impression** refers to the undulating pattern on the inner table of the skull caused by increased **intracranial pressure** in children. - This appearance is characterized by broad, shallow indentations, which is distinct from the multiple small, sharply defined lucencies seen in pepper pot skull. *Hair-on-end appearance* - The **hair-on-end** or "crew-cut" appearance shows **perpendicular bony trabeculae** radiating outward from the skull vault, creating a spiculated pattern. - This finding is classically associated with **chronic hemolytic anemias** (thalassemia, sickle cell disease) due to marrow hyperplasia, not the diffuse lucencies seen here.

Q: What is the probable diagnosis for shown below the image?

Silver-beaten skull. **_Silver-beaten skull_** - The image displays a "beaten copper" or "silver-beaten" appearance of the skull, characterized by diffuse **lucencies and sclerotic changes** that resemble gyri and sulci impressions due to increased intracranial pressure. - This finding is often associated with conditions causing **chronic increased intracranial pressure** in children with open sutures. *Multiple myeloma* - Multiple myeloma typically presents with widespread, discrete, well-defined **lytic lesions** ("punched-out" lesions) in the skull, unlike the diffuse impression pattern seen here. - It is a plasma cell malignancy and usually affects older adults. *Histiocytosis-X* - Histiocytosis-X (now Langerhans cell histiocytosis) can cause lytic skull lesions, which are usually solitary or multiple, but often have a characteristic **beveled edge** or "hole within a hole" appearance, not the diffuse gyral impressions. - These lesions are typically more destructive and erosive. *Hydrocephalus* - While hydrocephalus causes increased intracranial pressure, leading to the "silver-beaten" appearance in children, hydrocephalus itself refers to the **accumulation of CSF**. - The "silver-beaten skull" is a radiological sign of chronic increased intracranial pressure, rather than the diagnosis of hydrocephalus itself, which is the underlying cause.

Q: Which is correct about the intracranial bleeding shown below?

Chronic subdural hematoma, hypodensity. ***Chronic subdural hematoma, hypodensity*** - The image displays a crescent-shaped collection of fluid with **hypodense characteristics** (darker than brain parenchyma) that crosses suture lines, which is typical for a subdural hematoma. - The **hypodensity indicates older, chronic blood** where the hemoglobin has degraded, differentiating it from acute (hyperdense) or subacute (isodense) collections. *Acute subdural hematoma, hypodensity* - An **acute subdural hematoma** would typically appear **hyperdense** (bright) on CT due to fresh blood. - The observed collection is clearly hypodense, ruling out an acute presentation. *Chronic epidural hematoma, hyperdensity* - An **epidural hematoma** is typically **lenticular (lens-shaped)** and does not cross suture lines, unlike the crescent shape seen here. - While chronic blood *can* be hypodense, an epidural hematoma by definition is outside the dura mater and would not present with this morphology. *Acute epidural hematoma, hyperdensity* - An **acute epidural hematoma** is characterized by a **lenticular (lens-shaped) hyperdense** collection of blood, which is distinctly different from the crescent-shaped, hypodense collection in the image. - Epidural hematomas occur between the dura mater and the skull, typically from arterial injury, and are bound by sutures.

Q: A 55-year-old diabetic patient develops sudden onset hemiparesis and facial asymmetry. NCCT scan shows:

Hyperdense MCA sign. ***Hyperdense MCA sign*** - The image exhibits a **bright (hyperdense) area** within the Sylvian fissure, indicated by the white arrow, representing a **thrombus occluding the middle cerebral artery (MCA)**. This is a direct sign of acute **ischemic stroke**. - Clinical presentation of sudden onset hemiparesis and facial asymmetry in a diabetic patient strongly suggests an **ischemic stroke**, and the hyperdense MCA sign on NCCT confirms a proximal vessel occlusion. *Cystic encephalomalacia* - This refers to the **end stage of an infarct**, where brain tissue is replaced by **CSF-filled cysts** and gliosis, appearing as hypodense areas. - This finding would indicate an **old stroke**, not an acute event causing sudden neurological deficits. *Subarachnoid hemorrhage* - This condition involves **blood in the subarachnoid space**, appearing as hyperdensity within the **sulci and basal cisterns**. - While it features hyperdensity, the location in the image (within the Sylvian fissure, consistent with MCA) and the patient's symptoms are not typical for isolated subarachnoid hemorrhage. *Lobar hemorrhage* - A lobar hemorrhage is an **intraparenchymal bleed** within a lobe of the brain, appearing as a **focal, well-defined hyperdense lesion within the brain parenchyma**. - The hyperdensity in the image is linear and located within a vascular structure, consistent with an occluded vessel rather than a parenchymal bleed.

Q: What is the correct diagnosis based on the image shown below?

Dense MCA sign. ***Dense MCA sign*** - The image displays a hyperdense (bright) appearance of the **Middle Cerebral Artery (MCA)**, particularly noticeble in the Sylvian fissure on the left side (indicated by the shorter arrow). This is highly suggestive of a **thrombus within the MCA lumen**, one of the earliest signs of an acute ischemic stroke on non-contrast CT [1]. - This finding is a strong indicator of **large vessel occlusion** and is crucial for guiding acute stroke management, such as the administration of thrombolytics or mechanical thrombectomy [1]. *Lacunar stroke* - Lacunar strokes are typically **small, deep infarcts** caused by occlusion of small penetrating arteries, which are not directly visible as a hyperdense vessel sign on non-contrast CT [3]. - The image shows a larger-scale vascular finding, not a small, isolated infarct characteristic of a lacunar stroke [3]. *Subarachnoid hemorrhage* - Subarachnoid hemorrhage (SAH) appears as **high-density blood** filling the subarachnoid spaces, fissures, and sulci [2]. - While the image shows some hyperdensity, it is specifically confined to a major arterial structure (MCA), not diffuse within the subarachnoid space as seen in SAH. *Intraventricular hemorrhage* - Intraventricular hemorrhage (IVH) is characterized by **hyperdense blood within the ventricular system** of the brain [2]. - The image does not show blood within the ventricles; the hyperdensity is clearly located along the course of a major cerebral artery. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Central Nervous System, pp. 1266-1268. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Manifestations Of Central And Peripheral Nervous System Disease, pp. 706-707. [3] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Central Nervous System, pp. 1269-1270.

Question 1

Identify the following abnormality?

Accepted Answer

Schizencephaly

Answer

Encephalocoele

Answer

Prosencephaly

Answer

Lissencephaly

Question 2

What is the most likely diagnosis in an imaging study showing a large posterior fossa?

Accepted Answer

Dandy-Walker malformation

Answer

Hydrocephalus

Answer

Platybasia

Answer

Arnold-Chiari malformation

Question 3

The MRI image shows a smooth brain surface with absence of normal gyri and sulci. What is the diagnosis?

Accepted Answer

Lissencephaly

Answer

Polymicrogyria

Answer

Pachygyria

Answer

Schizencephaly

Question 4

X-ray skull shows: (Recent NEET Pattern 2016-17)

Accepted Answer

Silver-beaten appearance

Answer

Multiple myeloma

Answer

Histiocytosis-X

Answer

Letterer-Siwe disease

Question 5

What is shown in this skull X-ray?

Accepted Answer

Pepper pot skull

Answer

Artifacts

Answer

Silver-beaten appearance

Answer

Hair-on-end appearance

Question 6

What is the probable diagnosis for shown below the image?

Accepted Answer

Silver-beaten skull

Answer

Multiple myeloma

Answer

Histiocytosis-X

Answer

Hydrocephalus

Question 7

Which is correct about the intracranial bleeding shown below?

Accepted Answer

Chronic subdural hematoma, hypodensity

Answer

Acute subdural hematoma, hypodensity

Answer

Chronic epidural hematoma, hyperdensity

Answer

Acute epidural hematoma, hyperdensity

Question 8

A 55-year-old diabetic patient develops sudden onset hemiparesis and facial asymmetry. NCCT scan shows:

Accepted Answer

Hyperdense MCA sign

Answer

Cystic encephalomalacia

Answer

Subarachnoid hemorrhage

Answer

Lobar hemorrhage

Question 9

What is the correct diagnosis based on the image shown below?

Accepted Answer

Dense MCA sign

Answer

Lacunar stroke

Answer

Subarachnoid hemorrhage

Answer

Intraventricular hemorrhage

Question 10

Which of the following is correct about the image shown below?

Accepted Answer

$A=$ Extradural hemorrhage, $B=$ Subdural hemorrhage, $C=$ Contusion

Answer

$A=$ Subdural hemorrhage, $B=$ Extradural hemorrhage, $C=$ Contusion

Answer

$A=$ Contusion, $B=$ Subdural hemorrhage, $C=$ Extradural hemorrhage

Answer

$A=$ Extradural hemorrhage, $B=$ Subdural hemorrhage, $C=$ Subarachnoid hemorrhage

Neuroradiology — MCQs

Neuroradiology — MCQs

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