Neuroradiology Practice Questions

Q: A middle aged female presents with prolonged history of back pain followed by slowly progressive weakness of both lower limbs, spasticity and recent onset difficulty in micturation. On neurological examination there is evidence of dorsal myelopathy. MRI scan of spine shows a well-defined mid-dorsal intradural homogenous contrast enhancing mass lesion. The likely diagnosis is:

Spinal meningioma. ***Spinal meningioma*** - This diagnosis fits the profile of a **middle-aged female** with a **slowly progressive dorsal myelopathy**, including **spasticity** and **urinary dysfunction**, as meningiomas are common in this demographic. - The MRI finding of a **well-defined, mid-dorsal, intradural, homogenous, contrast-enhancing mass** is highly characteristic of a spinal meningioma. *Dermoid cyst* - Dermoid cysts are typically **congenital lesions** and often present earlier in life with symptoms like **tethered cord syndrome** or related cutaneous stigmata. - While intradural, they usually present as **non-enhancing lesions** on MRI, unless there's an associated rupture or inflammatory reaction. *Epidermoid cyst* - Epidermoid cysts are also usually **congenital** and less common in the dorsal spine as primary lesions; their progression is often more indolent with less overt myelopathic signs early on. - On MRI, epidermoid cysts appear as **non-enhancing lesions** with signal characteristics similar to cerebrospinal fluid (CSF), distinguishing them from enhancing masses. *Intradural Lipoma* - Intradural lipomas are typically **congenital spinal lesions** often associated with **dysraphic states** and usually diagnosed in childhood. - They appear as **fat-containing lesions** on MRI, showing characteristic high signal intensity on T1-weighted images and signal suppression on fat-saturated sequences, and generally **do not show significant contrast enhancement**.

Q: A young adult presents with proptosis and pain in eye after 4 days of trauma to eye. Chemosis, conjunctival congestion and extraocular muscle palsy with inability to move eye are seen.Investigation of choice -

Digital subtraction angiography. ***Digital subtraction angiography*** - The combination of **proptosis**, **pain**, **chemosis**, **conjunctival congestion**, and **extraocular muscle palsy** following trauma strongly suggests a **carotid-cavernous fistula (CCF)**. - **Digital subtraction angiography (DSA)** is the **gold standard** for diagnosing and characterizing CCFs, providing detailed visualization of arterial and venous flow. *MR angiography* - While MRA can provide information about vascular structures, it is less sensitive and specific than DSA for detecting and characterizing subtle shunts in **carotid-cavernous fistulas**. - It might miss smaller fistulas or provide insufficient detail for therapeutic planning. *CT* - **Computed tomography (CT)** is useful for assessing orbital bony structures, but it offers limited information regarding the dynamic blood flow and shunt characteristics crucial for diagnosing **carotid-cavernous fistulas**. - **CT angiography** can provide some vascular detail, but it is generally less comprehensive than DSA for this specific condition. *MRI* - **Magnetic Resonance Imaging (MRI)** can show orbital soft tissue changes and identify potential vascular abnormalities, but it lacks the real-time, high-resolution vascular detail of DSA, especially for depicting the exact location and flow dynamics of an **arteriovenous shunt**. - It is often used as a preliminary imaging modality but is not the definitive diagnostic tool for **carotid-cavernous fistulas**.

Q: Which one of the following is the most preferred route to perform cerebral angiography?

Transfemoral route. **Transfemoral route (Correct Answer)** - The **transfemoral** route is the **most preferred** and widely used method for cerebral angiography due to its **safety**, ease of access, and lower complication rates. - It allows for the safe cannulation of **cerebral vessels** using a catheter inserted into the **femoral artery** and advanced up to the aortic arch. - This is the **gold standard approach** (Seldinger technique) for diagnostic and interventional cerebral angiography. *Direct carotid puncture (Incorrect)* - This method is more invasive and carries a higher risk of complications, such as **hematoma**, **stroke**, or **carotid artery dissection**. - It is typically reserved for cases where other routes are inaccessible or when very specific and localized imaging is required. - Largely of **historical significance** now that safer endovascular techniques are available. *Transaxillary route (Incorrect)* - The **transaxillary** route is an alternative but carries a higher risk of complications like **brachial plexus injury** and **bleeding** compared to the transfemoral approach. - It may be considered when the femoral access is not feasible, for example, in patients with severe peripheral vascular disease affecting the femoral arteries. *Transbrachial route (Incorrect)* - The **transbrachial** (or **transradial**) route is also an alternative but is generally less preferred due to the risk of **radial or brachial artery spasm** or damage, and it can be technically more challenging. - This route is typically avoided if possible, especially when the transfemoral route is readily available and safe. - May be considered in patients with severe aortoiliac disease or morbid obesity.

Q: Investigation of choice for lumbar prolapsed disc -

MRI. ***MRI*** - An **MRI** provides the best visualization of **soft tissues**, including the intervertebral discs, spinal cord, and nerve roots, making it the **gold standard** for diagnosing lumbar prolapsed disc. - It can accurately show the **degree of disc herniation**, its impact on neural structures, and associated edema, which are crucial for treatment planning. *CT Scan* - While a **CT scan** provides good bony detail and can show disc herniation, its ability to visualize soft tissues is inferior to MRI for this specific condition. - It involves **ionizing radiation** and may miss subtle nerve root compression or spinal cord abnormalities apparent on MRI. *Myelogram* - A **myelogram** involves injecting contrast dye into the spinal canal and then performing X-rays or CT scans to outline the spinal cord and nerve roots. - Though effective in showing **nerve compression**, it is an **invasive procedure** with potential complications and has largely been replaced by MRI as a first-line diagnostic investigation. *X-ray* - **X-rays** primarily visualize **bony structures** and are useful for detecting fractures, spinal alignment issues, or severe degenerative changes. - They **cannot directly visualize intervertebral discs** or nerve compression, making them unsuitable for diagnosing a prolapsed disc.

Q: The investigation of choice for vestibular schwannoma is

Gadolinium enhanced MRI. ***Gadolinium enhanced MRI*** - **Gadolinium-enhanced MRI** is the gold standard due to its superior spatial resolution for soft tissues, allowing for clear visualization of the tumor within the **internal auditory canal** and **cerebellopontine angle**. - It effectively detects even small **vestibular schwannomas**, which are typically missed by other imaging modalities. *PET scan* - **PET scans** are primarily used for assessing metabolic activity in tumors and are more relevant for distinguishing between benign and malignant lesions, or for staging cancer, rather than purely anatomical localization of a **vestibular schwannoma**. - Its resolution is often insufficient to precisely delineate small lesions in the **internal auditory canal**. *SPECT* - **SPECT** uses gamma-ray emitting radiotracers and is more commonly employed in nuclear medicine for functional imaging of organs or to assess blood flow, particularly in cardiac or neurological conditions like epilepsy, rather than for detailed anatomical imaging of tumors such as **vestibular schwannomas**. - Its spatial resolution is generally lower than MRI, making it less suitable for detecting small lesions in complex anatomical regions. *Contrast enhanced CT scan* - While a **contrast-enhanced CT scan** can show larger tumors and bony erosion, its soft tissue contrast is inferior to MRI, which means it may miss smaller **vestibular schwannomas**. - It also exposes the patient to **ionizing radiation**, and its primary role in vestibular schwannoma detection is often limited to cases where MRI is contraindicated.

Q: New born male baby presented with congestive heart failure. On examination enlarged fontanelles, a loud cranial bruit and following radiological finding was noted - the most likely diagnosis:

Vein of Galen malformation. ***Vein of Galen malformation*** - The clinical presentation of **congestive heart failure** in a newborn with **enlarged fontanelles** and a **loud cranial bruit** is classic for a Vein of Galen malformation (VOGM). The radiological finding, showing a dilated structure acting as a large arteriovenous shunt, confirms this. - VOGMs are **high-flow arteriovenous fistulas** within the brain, leading to increased cardiac output and often resulting in severe heart failure in infants due to the significant shunting of blood. *Pneumocephalus* - **Pneumocephalus** refers to the presence of air or gas within the cranial cavity, which would appear as dark areas on MRI. - It does not typically cause **congestive heart failure** or a **cranial bruit**, nor does it present with the characteristic dilated vascular structure seen in the image. *Dandy-Walker syndrome* - **Dandy-Walker syndrome** is a congenital brain malformation involving the **cerebellum** and **fourth ventricle**, leading to **hydrocephalus** and an enlarged posterior fossa. - While it can cause enlarged fontanelles due to hydrocephalus, it typically does not present with signs of **congestive heart failure** or a **cranial bruit**. *Crouzon syndrome* - **Crouzon syndrome** is a genetic disorder characterized by **craniosynostosis** (premature fusion of skull sutures), leading to an abnormal head shape and facial features. - It mainly affects bone development and is not directly associated with **congestive heart failure** or **intracranial vascular malformations** causing bruits.

Q: Newborn male baby presented with congestive heart failure. On examination enlarged fontanelles, a loud cranial bruit and following radiological findings were noted - the most likely diagnosis is:

Vein of Galen malformation. ***Vein of Galen malformation*** - The combination of **congestive heart failure** in a newborn, **enlarged fontanelles**, and a **loud cranial bruit** is highly suggestive of a Vein of Galen malformation due to the significant **arteriovenous shunting**. - This malformation causes **high-output cardiac failure** because the large vascular shunt bypasses resistance, forcing the heart to work harder. *Sinus pericranii* - This condition involves an **abnormal connection between intracranial and extracranial venous systems** and typically presents as a soft, compressible scalp mass that enlarges with crying or Valsalva maneuver. - While it can manifest in infancy, it does not typically cause **congestive heart failure** or a **loud cranial bruit**. *Dandy-Walker malformation* - This is a **congenital brain malformation** characterized by hypoplasia of the cerebellar vermis and cystic dilation of the fourth ventricle, leading to **hydrocephalus**. - It does not cause **congestive heart failure** or **cranial bruits**. *Arachnoid cyst* - These are **benign, fluid-filled cysts** that develop between the arachnoid membrane and the brain surface, often causing symptoms related to mass effect such as **headache**, **seizures**, or **hydrocephalus**. - They do not cause **congestive heart failure** or **cranial bruits**.

Q: Dawson's fingers are seen in -

Multiple sclerosis. ***Multiple sclerosis*** - **Dawson's fingers** are a characteristic imaging finding in **multiple sclerosis (MS)**, seen as finger-like demyelinating lesions radiating perpendicularly from the corpus callosum on MRI. - These lesions represent perivenular inflammation and demyelination, a hallmark of **MS pathology**. *Multiple myeloma* - This is a **hematological malignancy** characterized by the proliferation of plasma cells in the bone marrow, leading to bone lesions, renal failure, and hypercalcemia. - It does not involve demyelinating lesions in the brain and therefore would not show Dawson's fingers on imaging. *SACD* - **Subacute combined degeneration (SACD)** is primarily caused by **vitamin B12 deficiency**, affecting the posterior and lateral columns of the spinal cord and peripheral nerves. - While it causes neurological symptoms, it does not involve brain demyelination in the pattern of Dawson's fingers. *Friedreich's ataxia* - This is a **hereditary neurodegenerative disorder** primarily affecting the spinal cord, cerebellum, and peripheral nerves, leading to ataxia, dysarthria, and scoliosis. - It is not characterized by demyelinating brain lesions and therefore would not present with Dawson's fingers.

Q: A 45-year-old female complains of progressive lower limb weakness, spasticity, and urinary hesitancy. MRI shows an intradural enhancing mass lesion in the spinal cord. MOST likely diagnosis is:

Meningioma. ***Meningioma*** - Intradural enhancing mass lesion in the **spinal cord** with progressive neurological symptoms like **lower limb weakness**, **spasticity**, and **urinary hesitancy** are highly suggestive of a **spinal meningioma**, which is the most common intradural extramedullary tumor in middle-aged females. - Meningiomas are typically **dural-based tumors** that enhance homogeneously with contrast on MRI and cause spinal cord compression. *Intradural lipoma* - Intradural lipomas are typically **non-enhancing** lesions on MRI, composed of fat with high T1 signal intensity. - They are often congenital and may not present with such acute, progressive neurological deficits. - They do not show contrast enhancement. *Neuroepithelial cyst* - Neuroepithelial cysts, such as **arachnoid cysts**, are typically **non-enhancing** and follow cerebrospinal fluid (CSF) signal intensity on MRI. - They rarely present as an enhancing mass and are more likely to be asymptomatic or cause symptoms due to mass effect without enhancement. *Dermoid cyst* - Dermoid cysts are typically **non-enhancing** lesions that contain **fatty components** and other ectodermal derivatives. - While they can cause neurological symptoms due to mass effect, they do not present as an enhancing lesion on MRI. - They show restricted diffusion and may have a chemical meningitis if ruptured.

Q: Corpus callosum involvement on MRI is usually seen in which of the following conditions?

Butterfly glioblastoma. ***Butterfly glioblastoma*** - This is a highly malignant brain tumor (WHO Grade IV) that characteristically **crosses the corpus callosum**, allowing it to spread across both cerebral hemispheres, creating a **butterfly-like appearance** on MRI. - The corpus callosum acts as a pathway for tumor spread, leading to bilateral neurological deficits. - This is the **classic and most characteristic** imaging finding associated with corpus callosum involvement. *SSPE (Subacute Sclerosing Panencephalitis)* - SSPE is a rare, progressive brain disorder caused by persistent measles virus infection. - While advanced stages may show periventricular and corpus callosum lesions, the **more characteristic findings** are diffuse white matter T2/FLAIR hyperintensities in the parietotemporal and occipital regions. - Corpus callosum involvement is not the primary or most specific feature. *Phytanic acid deficiency (Refsum disease)* - This is a rare peroxisomal disorder characterized by accumulation of phytanic acid. - MRI typically shows **cerebellar atrophy** and nonspecific white matter changes. - **Corpus callosum is typically spared** in Refsum disease. *Krabbe's disease* - This is a galactocerebrosidase deficiency causing leukodystrophy. - While Krabbe's disease can involve the corpus callosum (particularly the splenium), the **more characteristic and earlier findings** involve the **cerebellar white matter, corona radiata, thalami, and pyramidal tracts**. - Butterfly glioblastoma remains the **most specific** and **most classic** condition associated with corpus callosum involvement on MRI.

Question 1

A middle aged female presents with prolonged history of back pain followed by slowly progressive weakness of both lower limbs, spasticity and recent onset difficulty in micturation. On neurological examination there is evidence of dorsal myelopathy. MRI scan of spine shows a well-defined mid-dorsal intradural homogenous contrast enhancing mass lesion. The likely diagnosis is:

Accepted Answer

Spinal meningioma

Answer

Dermoid cyst

Answer

Epidermoid cyst

Answer

Intradural Lipoma

Question 2

A young adult presents with proptosis and pain in eye after 4 days of trauma to eye. Chemosis, conjunctival congestion and extraocular muscle palsy with inability to move eye are seen.Investigation of choice -

Accepted Answer

Digital subtraction angiography

Answer

MR angiography

Answer

CT

Answer

MRI

Question 3

Which one of the following is the most preferred route to perform cerebral angiography?

Accepted Answer

Transfemoral route

Answer

Direct carotid puncture

Answer

Transaxillary route

Answer

Transbrachial route

Question 4

Investigation of choice for lumbar prolapsed disc -

Accepted Answer

MRI

Answer

CT Scan

Answer

Myelogram

Answer

X-ray

Question 5

The investigation of choice for vestibular schwannoma is

Accepted Answer

Gadolinium enhanced MRI

Answer

PET scan

Answer

SPECT

Answer

Contrast enhanced CT scan

Question 6

New born male baby presented with congestive heart failure. On examination enlarged fontanelles, a loud cranial bruit and following radiological finding was noted - the most likely diagnosis:

Accepted Answer

Vein of Galen malformation

Answer

Pneumocephalus

Answer

Dandy-Walker syndrome

Answer

Crouzon syndrome

Question 7

Newborn male baby presented with congestive heart failure. On examination enlarged fontanelles, a loud cranial bruit and following radiological findings were noted - the most likely diagnosis is:

Accepted Answer

Vein of Galen malformation

Answer

Sinus pericranii

Answer

Dandy-Walker malformation

Answer

Arachnoid cyst

Question 8

Dawson's fingers are seen in -

Accepted Answer

Multiple sclerosis

Answer

Multiple myeloma

Answer

SACD

Answer

Friedreich's ataxia

Question 9

A 45-year-old female complains of progressive lower limb weakness, spasticity, and urinary hesitancy. MRI shows an intradural enhancing mass lesion in the spinal cord. MOST likely diagnosis is:

Accepted Answer

Meningioma

Answer

Intradural lipoma

Answer

Neuroepithelial cyst

Answer

Dermoid cyst

Question 10

Corpus callosum involvement on MRI is usually seen in which of the following conditions?

Accepted Answer

Butterfly glioblastoma

Answer

SSPE

Answer

Phytanic acid deficiency

Answer

Krabbe's disease

Neuroradiology — MCQs

Neuroradiology — MCQs

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