Neuroradiology Practice Questions

Q: Which peak on MR spectroscopy is seen in tuberculoma?

Lipid lactate. **Explanation:** In Magnetic Resonance Spectroscopy (MRS), the presence of a **Lipid-Lactate peak** is a hallmark finding for **CNS Tuberculosis (Tuberculoma)**. 1. **Why Lipid-Lactate is correct:** Tuberculomas are characterized by solid caseous necrosis. The cell walls of *Mycobacterium tuberculosis* are exceptionally rich in lipids (mycolic acids). During the necrotic process, these lipids are released, resulting in a prominent **lipid peak** (at 0.9 and 1.3 ppm). Additionally, the anaerobic metabolism within the granuloma leads to the accumulation of **lactate** (at 1.33 ppm), which typically appears as a doublet. 2. **Why other options are incorrect:** * **N-acetyl aspartate (NAA):** This is a marker of neuronal integrity. It is **decreased** in almost all pathological lesions (tumors, infections, infarcts) because of the displacement or destruction of healthy neurons. * **Creatine:** This represents energy metabolism. It is usually stable or decreased in lesions; it is not a specific marker for infection. * **Choline:** This is a marker of cell membrane turnover. While it may be mildly elevated in inflammatory processes, a significantly high Choline peak is more characteristic of **malignant tumors** (like high-grade gliomas) rather than tuberculomas. **High-Yield Clinical Pearls for NEET-PG:** * **Tuberculoma vs. Neurocysticercosis (NCC):** On MRS, Tuberculomas show a high lipid peak, whereas NCC typically shows peaks of succinate, acetate, and amino acids (like leucine). * **The "Target Sign":** On MRI, a central calcification or enhancement surrounded by a hypointense rim is classic for tuberculoma. * **MRS Peaks Summary:** * **NAA (2.0 ppm):** Neuronal marker. * **Choline (3.2 ppm):** Membrane turnover (Tumors). * **Creatine (3.0 ppm):** Energy stores. * **Lipid/Lactate (1.3 ppm):** Necrosis/Infection.

Q: Deep white matter lesions with bilateral deep bright thalamic appearance are suggestive of which disease?

Krabbe's disease. **Explanation:** **Krabbe’s Disease (Globoid Cell Leukodystrophy)** is a lysosomal storage disorder caused by a deficiency of the enzyme **galactocerebrosidase (GALC)**. This leads to the accumulation of psychosine, which is toxic to oligodendrocytes. * **Imaging Hallmark:** On CT/MRI, Krabbe’s disease characteristically presents with **hyperdensities/T2-hyperintensities** in the **thalami**, caudate nuclei, and posterior limb of the internal capsule. The "deep bright thalamic appearance" combined with white matter involvement is a classic radiologic sign for this condition. **Analysis of Incorrect Options:** * **Alexander Disease:** Characterized by **frontal lobe predominance** of white matter lesions and the presence of Rosenthal fibers. It often presents with macrocephaly. * **Canavan’s Disease:** Notable for diffuse white matter involvement and **macrocephaly**. The hallmark metabolic marker is elevated **N-acetylaspartic acid (NAA)** on MR spectroscopy. * **Metachromatic Leukodystrophy (MLD):** The most common leukodystrophy (Arylsulfatase A deficiency). It typically shows a **"tigroid" or "leopard skin" pattern** of demyelination, sparing the subcortical U-fibers, but does not typically show the bright thalamic sign. **High-Yield Pearls for NEET-PG:** * **Krabbe’s:** Look for "Globoid cells" on biopsy and optic atrophy clinically. * **Thalamic Hyperdensity (CT):** Krabbe’s disease is the classic pediatric association. * **Macrocephaly + Leukodystrophy:** Think Alexander disease or Canavan’s disease. * **Adrenoleukodystrophy:** Predominantly involves the **posterior (occipital)** white matter.

Q: In children, increased intracranial pressure is manifested by which of the following?

Sutural diastasis. **Explanation:** In children, the skull is a dynamic structure where the cranial bones are not yet fused, being held together by fibrous joints called sutures. When intracranial pressure (ICP) increases, the expanding brain or cerebrospinal fluid exerts outward pressure. In pediatric patients (typically up to age 10–12), this results in **Sutural Diastasis**—the widening of the cranial sutures (usually >2mm). This is the most sensitive and earliest radiological sign of increased ICP in children, as the skull expands to accommodate the pressure. **Analysis of Options:** * **Sutural Diastasis (Correct):** As explained, the unfused sutures in children act as a "pressure release valve," making this the hallmark sign. * **Rarification of the dorsum sellae (Incorrect):** While this is a classic sign of chronic increased ICP, it is primarily seen in **adults** or older children whose sutures have already fused. In these cases, the pressure is transmitted to the bony sella turcica, leading to erosion. * **Lytic lesions (Incorrect):** Lytic lesions represent focal bone destruction (e.g., Multiple Myeloma, Metastasis, or Langerhans Cell Histiocytosis) and are not a physiological response to generalized intracranial pressure. **High-Yield Clinical Pearls for NEET-PG:** * **Copper Beaten Skull (Silver Beaten):** Gyral impressions on the inner table of the skull due to chronic increased ICP. While suggestive, it can be a normal finding in growing children (ages 4–10). * **Macewen’s Sign:** A "cracked pot" sound heard on percussion of the skull, clinically correlating with sutural diastasis. * **Adult Signs of Increased ICP:** Erosion of the dorsum sellae, thinning of the floor of the sella, and enlargement of the internal auditory canal (if associated with specific tumors).

Q: An extra-axial enhancing lesion is seen on MRI. What is the most likely diagnosis?

Meningioma. **Explanation:** The diagnosis of an extra-axial lesion is based on specific imaging features: displacement of the subarachnoid space, widening of the bony margins, and the "CSF cleft sign." **1. Why Meningioma is correct:** Meningiomas are the most common **extra-axial** intracranial tumors. On MRI, they typically appear as well-circumscribed, dural-based masses that are isointense to gray matter on T1 and T2 sequences. Crucially, they show **intense, homogenous enhancement** after gadolinium administration and often exhibit a **"Dural Tail Sign"** (thickening of the adjacent dura), which is a classic NEET-PG high-yield finding. **2. Why the other options are incorrect:** * **Ependymoma:** These are typically **intra-axial** (specifically intraventricular) tumors. In children, they commonly arise from the floor of the 4th ventricle and may extend through the foramina of Luschka and Magendie ("plastic ependymoma"). * **Arachnoid Cyst:** While extra-axial, these are CSF-filled sacs. They follow CSF signal intensity on all sequences (dark on T1, bright on T2) and **do not enhance** with contrast. * **Lipoma:** These are composed of fat. They appear hyperintense (bright) on T1 and show a characteristic **drop in signal on fat-suppression sequences**. They do not show typical solid enhancement. **High-Yield Clinical Pearls for NEET-PG:** * **Meningioma Association:** Often associated with **NF-2** (especially if bilateral or multiple). * **Histology:** Look for **Psammoma bodies** (concentric calcifications) and whorled patterns. * **Imaging Sign:** The **"Sunburst" or "Spoke-wheel" appearance** on angiography due to supply from the middle meningeal artery. * **Location:** Most common at the parasagittal/falcine region.

Q: What is the investigation of choice for cystic lesions in the brain?

CT Scan. **Explanation:** The investigation of choice for identifying and characterizing **cystic lesions in the brain** is a **CT Scan**. **Why CT Scan is the Correct Choice:** In the context of neuroimaging, a CT scan is highly sensitive at detecting fluid-filled spaces (cysts) because fluid has a characteristic low attenuation (0–20 Hounsfield Units). CT is particularly superior for identifying **calcification** within the cyst wall or internal components (e.g., the scolex in Neurocysticercosis), which is a critical diagnostic feature. Furthermore, contrast-enhanced CT (CECT) effectively demonstrates ring enhancement, helping differentiate between simple cysts, abscesses, and cystic tumors. **Analysis of Incorrect Options:** * **Ultrasound (A):** Limited by the adult skull; it is only useful in neonates through the open anterior fontanelle. * **Angiography (B):** This is an invasive procedure used to visualize vascular structures (aneurysms, AVMs) and does not provide detail on the internal morphology of cystic lesions. * **MRI Scan (D):** While MRI offers superior soft-tissue contrast and is excellent for evaluating the brain parenchyma, CT remains the preferred initial "investigation of choice" for cystic lesions due to its ability to detect calcification and its widespread availability in emergency settings. **High-Yield Clinical Pearls for NEET-PG:** * **Neurocysticercosis (NCC):** The most common cause of seizures worldwide; CT shows the "hole-with-a-dot" appearance (scolex). * **Hydatid Cyst:** Appears as a large, unilocular cyst with a "water lily sign" or "double-line sign" on imaging. * **Arachnoid Cysts:** Follow CSF density on all sequences and do not show contrast enhancement. * **Gold Standard for Calcification:** Always choose **CT** over MRI for any lesion where calcification is a diagnostic hallmark.

Q: Subependymal calcified nodules are seen in which of the following conditions?

Tuberous sclerosis. **Explanation:** **Tuberous Sclerosis Complex (TSC)** is the correct answer. It is a neurocutaneous syndrome (phakomatosis) characterized by the classic **Vogt’s triad** of seizures, intellectual disability, and adenoma sebaceum. The hallmark neuroimaging findings include: 1. **Subependymal Nodules (SENs):** These are small hamartomas located along the walls of the lateral ventricles. They frequently undergo **calcification** (best seen on CT) and have a "candle-guttering" appearance. 2. **Subependymal Giant Cell Astrocytoma (SEGA):** A benign tumor typically located near the Foramen of Monro. 3. **Cortical Tubers:** Areas of cortical dysplasia. **Why the other options are incorrect:** * **Sturge-Weber Syndrome:** Characterized by **"tram-track" cortical calcifications** (gyriform) and leptomeningeal angiomatosis, usually in the occipital/parietal regions, not subependymal nodules. * **Neurofibromatosis Type 2 (NF2):** Associated with the **MISME** mnemonic (Multiple Inherited Schwannomas, Meningiomas, and Ependymomas). Bilateral vestibular schwannomas are the pathognomonic feature. * **Von Hippel-Lindau (VHL):** Characterized by **hemangioblastomas** of the cerebellum and retina, along with renal cell carcinoma and pheochromocytoma. **High-Yield Clinical Pearls for NEET-PG:** * **Ash-leaf spots** (hypopigmented macules) are the earliest cutaneous sign of TSC. * **Shagreen patches** (connective tissue nevi) are commonly found on the lower back. * **Cardiac Rhabdomyomas** are the most common fetal/neonatal cardiac tumors associated with TSC (often regress spontaneously). * **Renal Angiomyolipomas (AMLs)** are the most common renal manifestation.

Q: CT findings in Epidural Hematoma (EDH) are typically described as?

Hyperdense lesion. **Explanation:** **1. Why "Hyperdense lesion" is correct:** In the acute phase, an Epidural Hematoma (EDH) consists of fresh, clotted blood. On a Non-Contrast Computed Tomography (NCCT) scan, acute blood has high attenuation (typically 60–80 Hounsfield Units) due to the high concentration of hemoglobin. Therefore, it appears as a **hyperdense (bright white)** area. This is the primary radiological description of the density of the lesion. **2. Why the other options are incorrect:** * **Crescent-shaped collection:** This describes a **Subdural Hematoma (SDH)**. SDHs are not restricted by dural attachments and spread along the brain surface, following its contour. * **Concavo-convex collection:** This is a geometric misnomer in this context. An EDH is classically described as **Biconvex or Lentiform (lens-shaped)**. It is convex on both sides because the blood is under high pressure (usually arterial) and is limited by the cranial sutures where the dura is firmly attached to the skull. * **None of the above:** Incorrect, as hyperdensity is a hallmark feature of acute intracranial hemorrhage. **3. Clinical Pearls for NEET-PG:** * **Source of Bleed:** Most commonly the **Middle Meningeal Artery** (associated with temporal bone fractures at the Pterion). * **Clinical Presentation:** Classically associated with a **"Lucid Interval"** (initial loss of consciousness followed by a period of recovery before rapid deterioration). * **Anatomical Boundary:** EDH **does not cross cranial sutures** (because the dura is attached there) but **can cross the midline** (dural reflections like the falx). * **Swirl Sign:** The presence of hypodense areas within the hyperdense clot indicates active, hyperacute bleeding (unclotted blood).

Q: A 35-year-old female presented with a history of multiple transient ischemic attacks. What is the most likely diagnosis suggested by the given carotid angiogram?

Fibromuscular dysplasia. ***Fibromuscular dysplasia*** - Classic **"string of beads"** appearance on angiography in a **young female** with TIAs is pathognomonic for fibromuscular dysplasia. - This **non-atherosclerotic** vascular disease commonly affects the **renal** and **carotid arteries** in women aged 20-60 years. *Atherosclerosis* - Typically presents as **smooth, eccentric plaques** rather than the characteristic beaded appearance. - More common in **older patients** with traditional cardiovascular risk factors like smoking, diabetes, and hypertension. *Thrombosis* - Would appear as an **abrupt cutoff** or **filling defect** within the vessel lumen on angiography. - Usually associated with **acute onset** symptoms rather than recurrent transient episodes. *Carotid dissection* - Angiographic findings include **tapering stenosis** with a characteristic **flame-shaped** narrowing or **double lumen** sign. - Often presents with **sudden severe headache** or neck pain along with neurological symptoms.

Question 1

Which peak on MR spectroscopy is seen in tuberculoma?

Accepted Answer

Lipid lactate

Answer

N-acetyl aspartate

Answer

Creatinine

Answer

Choline

Question 2

Deep white matter lesions with bilateral deep bright thalamic appearance are suggestive of which disease?

Accepted Answer

Krabbe's disease

Answer

Alexander disease

Answer

Canavan's disease

Answer

Metachromatic leukodystrophy

Question 3

A 7-year-old patient presents with headache, paralysis of upward gaze, loss of light perception and accommodation, nystagmus, and failure of convergence. CT scan showed a homogenous hyperdense lesion above the sella and in the posterior part of the third ventricle. MRI showed that the lesions were homogenous and isointense on T1-weighted imaging, and isointense on T2-weighted imaging with intense contrast enhancement. What is the most likely diagnosis?

Accepted Answer

Germinoma

Answer

Teratoma

Answer

Dermoid

Answer

Choroid plexus carcinoma

Question 4

In children, increased intracranial pressure is manifested by which of the following?

Accepted Answer

Sutural diastasis

Answer

Lytic lesions in the skull wall

Answer

Rarification of the dorsum of the sella

Answer

None of the above

Question 5

An extra-axial enhancing lesion is seen on MRI. What is the most likely diagnosis?

Accepted Answer

Meningioma

Answer

Ependymoma

Answer

Arachnoid cyst

Answer

Lipoma

Question 6

What is the investigation of choice for cystic lesions in the brain?

Accepted Answer

CT Scan

Answer

Ultrasound

Answer

Angiography

Answer

MRI scan

Question 7

Subependymal calcified nodules are seen in which of the following conditions?

Accepted Answer

Tuberous sclerosis

Answer

Sturge Weber syndrome

Answer

Neurofibromatosis type 2

Answer

Von Hippel Lindau syndrome

Question 8

CT findings in Epidural Hematoma (EDH) are typically described as?

Accepted Answer

Hyperdense lesion

Answer

Crescent-shaped collection

Answer

Concavo-convex collection

Answer

None of the above

Question 9

Upstream and downstream hydrocephalus is seen in which of the following conditions?

Accepted Answer

Choroid plexus papilloma

Answer

Ependymoma

Answer

Pineal germinoma

Answer

Meningioma

Question 10

A 35-year-old female presented with a history of multiple transient ischemic attacks. What is the most likely diagnosis suggested by the given carotid angiogram?

Accepted Answer

Fibromuscular dysplasia

Answer

Atherosclerosis

Answer

Thrombosis

Answer

Carotid dissection

Neuroradiology — MCQs

Neuroradiology — MCQs

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