Neuroradiology Practice Questions

Q: A 40-year-old patient complains of a headache. A CT head was taken, as shown below. What is the most accurate diagnosis?

Subarachnoid hemorrhage (SAH) - aneurysm. ***Subarachnoid hemorrhage (SAH) - aneurysm*** - The CT scan likely showed diffuse high attenuation (white areas) within the **subarachnoid spaces**, particularly in the basal cisterns and sulci, which is characteristic of SAH. - A common cause of non-traumatic SAH, especially in a 40-year-old presenting with a headache (often described as **"thunderclap" headache**), is a ruptured **cerebral aneurysm**. *Epidural hemorrhage* - An epidural hemorrhage typically appears as a **lenticular** or **biconvex** (lens-shaped) collection of blood, usually associated with an overlying skull fracture and often crossing the midline. - It occurs between the dura mater and the inner table of the skull, rarely extending into the subarachnoid space. *Subdural hemorrhage* - Subdural hemorrhages appear as **crescent-shaped** collections of blood, typically bridging the cerebral sulci and conforming to the brain's curvature. - They occur between the dura mater and arachnoid mater and are usually due to tearing of **bridging veins**, often following a head injury. *Intraparenchymal hemorrhage* - This involves bleeding directly into the **brain parenchyma** and appears as a focal area of high attenuation within the brain tissue itself. - While it can cause headache, its appearance on CT is distinct from bleeding in the subarachnoid spaces.

Q: A 40-year-old male presents with a history of headaches, fever, and new-onset seizures. An MRI of the brain is performed, revealing a ring-enhancing lesion with central restricted diffusion on diffusion-weighted imaging (DWI). What is the most likely diagnosis?

Brain abscess. ***Brain abscess*** - A **ring-enhancing lesion** with **central restricted diffusion** on DWI is highly characteristic of a brain abscess, due to the presence of pus containing densely packed inflammatory cells and bacteria with high viscosity. - The clinical presentation of **headaches, fever**, and **new-onset seizures** is consistent with an infectious process and increased intracranial pressure. - This combination of imaging and clinical features is pathognomonic for pyogenic brain abscess. *Glioblastoma multiforme* - While GBM can present with **ring-enhancing lesions** and seizures, it typically exhibits **facilitated diffusion** (high ADC values) on DWI due to necrotic tumor core, not restricted diffusion. - GBM is a highly infiltrative tumor with extensive **vasogenic edema**. - Fever is uncommon in GBM unless there is secondary infection. *Metastatic brain tumor* - Metastatic lesions can be **ring-enhancing** and cause seizures, but **restricted diffusion** is not typical unless there is acute hemorrhage or superimposed infection. - The presence of **fever** points away from uncomplicated metastasis. - Multiple lesions at the gray-white matter junction are more typical of metastases. *Toxoplasmosis* - Toxoplasmosis in **immunocompromised individuals** (HIV/AIDS with CD4 <100) causes **multiple ring-enhancing lesions** with predilection for basal ganglia. - Restricted diffusion is **not consistently seen** with toxoplasmosis, unlike pyogenic abscesses. - The specific DWI finding of central restricted diffusion makes brain abscess the most definitive diagnosis.

Q: An 80-year-old male with a history of frequent falls presents with progressive headache, confusion, and mild hemiparesis over the past few weeks. A CT scan of the head is performed, and the image provided shows a crescent-shaped, hypodense collection over the left cerebral hemisphere with a slight midline shift. What is the most likely diagnosis?

Chronic subdural hematoma. ***Chronic subdural hematoma*** - The presented CT scan shows a **crescent-shaped, hypodense collection** over the left cerebral hemisphere, which is characteristic of a chronic subdural hematoma. **Hypodensity** indicates older, liquefied blood. - The patient's age (**80-year-old** with **frequent falls**), and the **progressive symptoms** (headache, confusion, mild hemiparesis over weeks) are highly consistent with a chronic rather than acute presentation. *Acute subdural hematoma* - An acute subdural hematoma would typically present as a **hyperdense** (bright) crescent-shaped collection on CT due to fresh blood. - Symptoms would usually be more acute and severe, developing over hours to days, which does not match the "past few weeks" progression. *Epidural hematoma* - An epidural hematoma is typically **lens-shaped (biconvex)**, not crescent-shaped, and usually results from a traumatic arterial bleed. - While it can cause midline shift, its characteristic shape and often acute presentation (often with a lucid interval) differentiate it from the described scenario. *Intracerebral hemorrhage* - An intracerebral hemorrhage occurs within the brain parenchyma, appearing as a **hyperdense mass within the brain tissue** on CT, not as a collection over the cerebral hemisphere. - The symptoms would depend on the location but would not typically involve a crescent-shaped collection outside the brain parenchyma.

Q: Bleeding as shown in the image is due to which of the following vessels?

Bridging veins. ***Bridging veins*** - The image depicts a **subdural hemorrhage (subdural hematoma)**, a collection of blood between the dura mater and the arachnoid mater, typically appearing as a **crescent-shaped** hyperdensity that conforms to the brain surface. - This type of hemorrhage is caused by the tearing of **bridging veins** that traverse the subdural space, connecting the cerebral cortex to the dural venous sinuses. - Tearing of these veins occurs due to rapid acceleration-deceleration forces causing the brain to move relative to the dura, stretching and rupturing the veins. This is common in **head trauma**, especially in the elderly (due to brain atrophy increasing vein vulnerability) or infants. *Lenticulostriate artery* - Rupture of the lenticulostriate arteries (perforating branches of the middle cerebral artery) typically leads to **intraparenchymal hemorrhage**, specifically in the basal ganglia or internal capsule. - This type of bleeding is confined within the brain parenchyma, rather than collecting in the subdural space as seen in the image. - Associated with hypertensive hemorrhage. *Vertebral artery* - The vertebral arteries supply the posterior circulation of the brain, and their rupture can lead to **subarachnoid hemorrhage** (if a posterior circulation aneurysm ruptures) or **intraparenchymal bleeding** in the brainstem or cerebellum. - Bleeding from the vertebral artery is not associated with the subdural collection pattern shown in the image. *Middle meningeal artery* - The middle meningeal artery runs in the epidural space, and its rupture (often due to temporal bone fracture) causes an **epidural hematoma**. - An epidural hematoma is characterized by a **biconvex (lentiform) shape** on imaging and is situated between the dura mater and the skull, which is distinct from the **crescent-shaped** subdural collection shown. - Does not cross suture lines, unlike subdural hematomas which can extend over multiple lobes.

Q: A cerebral angiogram shows stenosis of the terminal internal carotid arteries with an abnormal network of collateral vessels. Which finding is most characteristic of moyamoya syndrome?

Lenticulostriate collaterals. ***Lenticulostriate collaterals*** - Moyamoya syndrome is characterized by **stenosis or occlusion of the supraclinoid internal carotid arteries** and the development of an abnormal network of collateral vessels, particularly the **lenticulostriate arteries**, to compensate for decreased blood flow. - These collaterals appear as a "puff of smoke" or **"moyamoya" vessels** on angiography, which are distinct from the "string of beads" typically seen in fibromuscular dysplasia. *Corkscrew vessels* - **Corkscrew vessels** are not typically associated with Moyamoya syndrome but are more characteristic of other conditions like **vasculitis** or **atherosclerosis** in some contexts. - This term usually describes tortuous and dilated vessels, which differ from the specific collateral development in Moyamoya. *Serpentine collaterals* - While Moyamoya involves collateral formation, the term **"serpentine collaterals"** is a general description for tortuous vessels and not specific to the unique pathology or anatomical location of collaterals in Moyamoya. - The distinctive feature of Moyamoya is the involvement and hypertrophy of small, deep collaterals such as the lenticulostriate arteries. *Spider vessels* - **Spider vessels** (telangiectasias or spider angiomas) are cutaneous findings associated with conditions like **hepatic cirrhosis** or hereditary hemorrhagic telangiectasia, not a cerebral angiographic sign of Moyamoya syndrome. - This term refers to superficial vascular lesions composed of a central arteriole surrounded by radiating capillaries.

Q: An MRI brain shows 'molar tooth sign' in the posterior fossa. This radiological finding is pathognomonic for which condition?

Joubert syndrome. ***Molar tooth sign - Joubert syndrome*** - The **molar tooth sign** on MRI, characterized by elongated superior cerebellar peduncles and an abnormally deep interpeduncular fossa, is the **pathognomonic diagnostic feature** for **Joubert syndrome**. - It signifies cerebellar vermis hypoplasia/aplasia and abnormal brainstem configuration, leading to the clinical manifestations of **ataxia**, **oculomotor apraxia**, **hyperpnea/apnea episodes**, and **developmental delay** seen in Joubert syndrome. - Additional MRI features include **bat wing configuration of the 4th ventricle** and **thick, horizontal superior cerebellar peduncles**. *Lemon sign - Chiari II malformation* - The **lemon sign** refers to the bitemporal indentation of the fetal skull on ultrasound, often associated with **spina bifida** and **Chiari II malformation**. - It indicates cranial deformity due to reduced intracranial pressure from open neural tube defects, not related to Joubert syndrome. *Banana sign - Chiari II malformation* - The **banana sign** describes the characteristic curved shape of the cerebellum on fetal ultrasound when the posterior fossa is effaced due to **Chiari II malformation**. - This flattening and anterior displacement of the cerebellum is associated particularly with **myelomeningocele**, and is not a feature of Joubert syndrome. *Baseball cap sign - Holoprosencephaly* - The **baseball cap sign** is a neuroimaging finding seen in **holoprosencephaly**, particularly the semi-lobar or lobar forms, where the **frontal horns of the lateral ventricles appear fused or closely apposed**. - This finding indicates severe forebrain malformation and midline fusion defects, not characteristic of Joubert syndrome.

Q: A brain MRI shows 'hot cross bun' sign in pons. Which additional finding would best support the diagnosis of multiple system atrophy?

Putaminal rim sign. ***Putaminal rim sign*** - The **putaminal rim sign** (T2 hypointensity along the lateral margin of the putamen with hyperintense signal within the putamen) is a characteristic and relatively specific finding for **multiple system atrophy (MSA)** on MRI. - Combined with the **'hot cross bun' sign** (pontine atrophy and cruciform high signal intensity on T2-weighted images), these findings are highly suggestive of MSA, reflecting the degeneration of pontocerebellar fibers and substantia nigra-striatal pathways. *Midbrain 'hummingbird' sign* - The **midbrain 'hummingbird' sign** (atrophy of the midbrain tegmentum with relative preservation of the pons) is a classic imaging feature of **progressive supranuclear palsy (PSP)**, not MSA. - This sign indicates selective atrophy in PSP affecting the midbrain, leading to a characteristic appearance on sagittal MRI. *Morning glory sign* - The **morning glory sign** refers to a congenital anomaly of the optic disc, where the optic nerve head is enlarged, excavated, and surrounded by a peripapillary glial ring. - This finding is a developmental ocular defect and is not associated with neurodegenerative conditions like multiple system atrophy. *Empty delta sign* - The **empty delta sign** is an imaging finding seen on contrast-enhanced CT or MRI of the brain, indicative of **cerebral venous sinus thrombosis**, specifically in the superior sagittal sinus. - It represents the lack of contrast within the thrombosed sinus, surrounded by enhancing dura, and is unrelated to MSA.

Q: An MRI brain shows 'pencil shavings' appearance in the corpus callosum. Which additional finding would best support the diagnosis of multiple sclerosis?

Dawson's fingers. ***Dawson's fingers*** - **Dawson's fingers** are ovoid lesions oriented perpendicular to the callososeptal interface, commonly visualized on MRI, and are highly characteristic of multiple sclerosis. - The "pencil shavings" appearance in the corpus callosum refers to specific lesions that, combined with Dawson's fingers, strongly indicate **demyelination** consistent with MS. *Empty delta sign* - The **empty delta sign** is a neuroimaging finding associated with **venous sinus thrombosis**, particularly in the superior sagittal sinus. - This sign indicates a thrombus filling the sinus, which is distinct from the demyelinating lesions seen in multiple sclerosis. *Hot cross bun sign* - The **hot cross bun sign** is typically observed in **multisystem atrophy (MSA)**, specifically the cerebellar type (MSA-C), on MRI. - It reflects degeneration of the pontine and cerebellar tracts, and is not a feature of multiple sclerosis. *Morning glory sign* - The **morning glory sign** is a congenital anomaly of the optic disc, characterized by an enlarged, funnel-shaped disc with a central glial tuft. - This is a developmental malformation and has no association with multiple sclerosis or its acquired demyelinating lesions.

Q: What is the investigation of choice for diagnosing subarachnoid hemorrhage (SAH)?

CT scan. ***CT scan*** - A **non-contrast CT scan of the head** is the immediate investigation of choice for diagnosing SAH due to its high sensitivity for detecting fresh blood. - It can quickly identify the presence of **blood in the subarachnoid space**, especially within the first 6-12 hours after symptom onset. *Radionuclide scan* - This imaging technique uses **radioactive tracers** to evaluate organ function or blood flow. - It is **not used for acute diagnosis** of SAH, as it does not directly visualize blood in the CNS. *X-ray skull* - An **X-ray of the skull** primarily visualizes bone structures and can detect fractures or other bony abnormalities. - It is **ineffective at detecting blood** in the subarachnoid space and is not used for SAH diagnosis. *MRI* - While MRI can detect SAH, especially in subacute or chronic phases, it is **less sensitive than CT for acute SAH** due to longer acquisition times and motion artifacts. - It is often considered if CT is negative and clinical suspicion remains high, but **not as the initial investigation of choice** in an acute setting.

Q: A man presents to the emergency department with a head injury following a vehicular accident. What is the investigation of choice?

NCCT. ***NCCT*** - **Non-contrast Computed Tomography (NCCT)** of the head is the **investigation of choice** for acute head trauma due to its rapid acquisition, wide availability, and excellent sensitivity for detecting acute hemorrhage, fractures, and mass effects. - It rapidly identifies life-threatening conditions such as **epidural, subdural, and intracerebral hemorrhages**, which require immediate intervention. *MRI* - **MRI** is superior for detecting subtle brain tissue injuries, diffuse axonal injury, and non-hemorrhagic lesions but is generally **not the first-line investigation** in acute trauma due to longer scan times, limited availability in the emergency setting, and inability to detect acute hemorrhage as clearly as CT. - Its use is typically reserved for follow-up studies or when CT findings are inconclusive or specific soft tissue detail is required. *CECT* - **Contrast-enhanced CT (CECT)** of the head is reserved for specific indications like evaluating vascular lesions (e.g., aneurysms, arteriovenous malformations) or tumors, which are generally **not the primary concern** in the initial assessment of acute head trauma. - Administering contrast agents can delay imaging, may pose risks to patients with renal impairment or allergies, and does not significantly improve the detection of acute traumatic hemorrhage compared to NCCT. *X-ray* - **X-rays** of the skull are useful for detecting **skull fractures**, but they provide **limited information** regarding intracranial injuries or soft tissue damage, which are critical in head trauma. - They have largely been superseded by CT scans, which offer a more comprehensive view of both bony structures and intracranial contents.

Question 1

A 40-year-old patient complains of a headache. A CT head was taken, as shown below. What is the most accurate diagnosis?

Accepted Answer

Subarachnoid hemorrhage (SAH) - aneurysm

Answer

Epidural hemorrhage

Answer

Subdural hemorrhage

Answer

Intraparenchymal hemorrhage

Question 2

A 40-year-old male presents with a history of headaches, fever, and new-onset seizures. An MRI of the brain is performed, revealing a ring-enhancing lesion with central restricted diffusion on diffusion-weighted imaging (DWI). What is the most likely diagnosis?

Accepted Answer

Brain abscess

Answer

Glioblastoma multiforme

Answer

Metastatic brain tumor

Answer

Toxoplasmosis

Question 3

An 80-year-old male with a history of frequent falls presents with progressive headache, confusion, and mild hemiparesis over the past few weeks. A CT scan of the head is performed, and the image provided shows a crescent-shaped, hypodense collection over the left cerebral hemisphere with a slight midline shift. What is the most likely diagnosis?

Accepted Answer

Chronic subdural hematoma

Answer

Acute subdural hematoma

Answer

Epidural hematoma

Answer

Intracerebral hemorrhage

Question 4

Bleeding as shown in the image is due to which of the following vessels?

Accepted Answer

Bridging veins

Answer

Lenticulostriate artery

Answer

Vertebral artery

Answer

Middle meningeal artery

Question 5

A cerebral angiogram shows stenosis of the terminal internal carotid arteries with an abnormal network of collateral vessels. Which finding is most characteristic of moyamoya syndrome?

Accepted Answer

Lenticulostriate collaterals

Answer

Corkscrew vessels

Answer

Serpentine collaterals

Answer

Spider vessels

Question 6

An MRI brain shows 'molar tooth sign' in the posterior fossa. This radiological finding is pathognomonic for which condition?

Accepted Answer

Joubert syndrome

Answer

Chiari II malformation

Answer

Myelomeningocele

Answer

Holoprosencephaly

Question 7

A brain MRI shows 'hot cross bun' sign in pons. Which additional finding would best support the diagnosis of multiple system atrophy?

Accepted Answer

Putaminal rim sign

Answer

Midbrain 'hummingbird' sign

Answer

Morning glory sign

Answer

Empty delta sign

Question 8

An MRI brain shows 'pencil shavings' appearance in the corpus callosum. Which additional finding would best support the diagnosis of multiple sclerosis?

Accepted Answer

Dawson's fingers

Answer

Empty delta sign

Answer

Hot cross bun sign

Answer

Morning glory sign

Question 9

What is the investigation of choice for diagnosing subarachnoid hemorrhage (SAH)?

Accepted Answer

CT scan

Answer

Radionuclide scan

Answer

X-ray skull

Answer

MRI

Question 10

A man presents to the emergency department with a head injury following a vehicular accident. What is the investigation of choice?

Accepted Answer

NCCT

Answer

MRI

Answer

CECT

Answer

X-ray

Neuroradiology — MCQs

Neuroradiology — MCQs

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