Neuroradiology Practice Questions

Q: What is the most sensitive investigation for diffuse axonal injury?

MRI. ***MRI*** - **Magnetic Resonance Imaging (MRI)** is the most sensitive imaging modality for detecting **diffuse axonal injury (DAI)** due to its ability to visualize microscopic changes in white matter integrity. - **Susceptibility Weighted Imaging (SWI)** is particularly sensitive for detecting **microhemorrhages** (petechial hemorrhages) at gray-white matter junctions, corpus callosum, and brainstem—characteristic locations for DAI. - **Diffusion Weighted Imaging (DWI)** and **Diffusion Tensor Imaging (DTI)** can demonstrate disruption of axonal tracts by showing restricted diffusion and measuring changes in fractional anisotropy. - Conventional sequences like **T2*-weighted gradient-recalled echo (GRE)** and **FLAIR** also help detect edema and blood products associated with DAI. *CT* - **Computed Tomography (CT) scans** are often the initial imaging modality in acute head injury due to their speed and ability to detect gross abnormalities like **hemorrhages** or **fractures**. - However, CT is **insensitive** to the microscopic axonal shearing and tears characteristic of DAI, typically appearing normal even in severe cases. *X ray* - **X-rays** are primarily used to evaluate **bone structures** and detect **skull fractures**. - They provide no information about soft tissue injury to the brain parenchyma, making them completely insensitive for detecting DAI. *PET scan* - A **Positron Emission Tomography (PET) scan** measures metabolic activity in the brain and can show changes in glucose metabolism or neurotransmitter function. - While PET may reveal **functional deficits** or **metabolic abnormalities** in chronic stages of brain injury, it is not used in the acute setting to diagnose DAI and does not directly visualize axonal damage.

Q: In which condition is the 'Eye of the Tiger' appearance typically observed?

Hallervorden-Spatz syndrome. ***Hallervorden-Spatz syndrome*** - The "Eye of the Tiger" sign is characteristic of **pantothenate kinase-associated neurodegeneration (PKAN)**, formerly known as Hallervorden-Spatz syndrome. - This imaging finding refers to a central region of **pallidal hyperintensity** surrounded by a rim of hypointensity on T2-weighted MRI scans due to **iron accumulation**. *Progressive supranuclear palsy* - This condition is characterized by midbrain atrophy, often described as the "**hummingbird sign**" or "**penguin silhouette sign**" on imaging. - It primarily affects eye movements, balance, and gait, but does not typically present with the "Eye of the Tiger" pattern. *Levodopa-responsive dystonia* - This is a rare genetic disorder, often due to mutations in the **GCH1 gene**, affecting dopamine synthesis. - Imaging findings are typically **normal**, and it is not associated with the "Eye of the Tiger" sign. *All of the options* - Since the "Eye of the Tiger" sign is pathognomonic for **Hallervorden-Spatz syndrome (PKAN)**, it is not observed in the other listed conditions. - Therefore, choosing "all of the options" would be incorrect.

Q: Hummingbird sign in brain MRI is seen in ?

Progressive supranuclear palsy. ***Progressive supranuclear palsy*** - The **hummingbird sign** is characteristic of progressive supranuclear palsy, seen as a specific pattern on MRI where the midbrain has atrophy, giving a "hummingbird" appearance. - It correlates with symptoms such as **gait instability**, **ocular dysfunction**, and **progressive neurological decline** typical of this condition. *Multiple sclerosis* - Often presents with **plaques** or **lesions in white matter** on MRI rather than a hummingbird sign. - Symptoms typically include **episodic neurological deficits** and may involve sensory, motor, or visual pathways. *Parkinson's disease* - Primarily features **substantia nigra degeneration**, which does not present a hummingbird sign on imaging. - Symptoms include **resting tremors**, and **bradykinesia**, without the distinct midbrain morphological change associated with progressive supranuclear palsy. *Alzheimer disease* - Characterized by **cortical atrophy** and does not show the hummingbird sign; instead, it features changes more related to **memory loss** and **cognitive decline**. - MRI findings may show **ventricular enlargement** and hippocampal atrophy rather than midbrain changes.

Q: Who is credited with the development of cerebral angiography?

Egas Moniz. ***Egas Moniz*** - **António Egas Moniz** (1874-1955) was a Portuguese neurologist who introduced the technique of **cerebral angiography** in 1927. - He used a **contrast medium** (initially sodium iodide, later thorium dioxide) to visualize the cerebral blood vessels, significantly advancing the diagnosis of brain tumors and other cerebrovascular diseases. - He was awarded the **Nobel Prize in Physiology or Medicine** in 1949 for his work on prefrontal leucotomy. *Sir Walter Dandy* - **Walter Dandy** (1886-1946) was an American neurosurgeon known for his pioneering work in **ventriculography** and **pneumoencephalography**, techniques used to visualize the brain's ventricular system. - While he made significant contributions to neuroimaging, he is not credited with the development of cerebral angiography. *Godfrey Hounsfield* - **Sir Godfrey Hounsfield** (1919-2004) was a British electrical engineer who developed the first **computed tomography (CT)** scanner in 1972. - He shared the **Nobel Prize in Physiology or Medicine** in 1979 with Allan Cormack for this revolutionary contribution to diagnostic imaging. - His work transformed medical imaging, but cerebral angiography predates CT by several decades. *Seldinger* - **Sven-Ivar Seldinger** (1921-1998) was a Swedish radiologist who developed the **Seldinger technique** in 1953. - This technique is a common method for safely obtaining percutaneous access to blood vessels and other hollow organs, widely used in various interventional procedures, including modern angiography. - While his technique revolutionized how angiography is performed, he did not invent cerebral angiography itself.

Q: Presence of delta sign on contrast enhanced CT scan suggests presence of?

Lateral sinus thrombophlebitis. ***Lateral sinus thrombophlebitis*** - The **delta sign** (also known as the "empty delta sign") on a contrast-enhanced CT scan is a classic radiological finding for **venous sinus thrombosis**. This sign is due to the thrombus filling the sinus, surrounded by contrast-enhanced dura. - While the image specifically mentions the sagittal sinus, the principle of a filling defect in a venous sinus due to thrombosis and the resulting "delta sign" applies to other dural venous thromboses, including **lateral sinus thrombophlebitis**. *Cholesteatoma* - A cholesteatoma is an **epidermal cyst** located in the middle ear or mastoid, visualized on CT as a **soft tissue mass**. - Its presence is typically indicated by **bone erosion** of the ossicles or mastoid, not a delta sign in the venous sinuses. *Cerebellar abscess* - A cerebellar abscess is a **collection of pus** within the cerebellar tissue, usually appearing as a **ring-enhancing lesion** on contrast CT. - It does not present with a delta sign, which is specific to venous sinus thrombosis. *Mastoiditis* - Mastoiditis is an **inflammation** or **infection of the mastoid air cells**, often appearing as **opacification of the mastoid air cells**, bone destruction, or periosteal elevation on CT. - While mastoiditis can sometimes lead to lateral sinus thrombosis, the delta sign itself is direct evidence of the **thrombosis**, not the mastoid inflammation.

Q: Identify the condition in the image below?

Lacunar infarct. ***Lacunar infarct*** - The image displays a small, well-demarcated **hypodensity** (darker area) in the basal ganglia region, characteristic of a lacunar infarct. - Lacunar infarcts are typically caused by **occlusion of small perforating arteries** and result in small, deep infarcts, often appearing as precise, round or ovoid lesions on CT. *Embolic infarct* - Embolic infarcts tend to be **larger**, wedge-shaped, and often extend to the cortical surface, unlike the deep, small lesion seen. - They are commonly associated with a **cardiac source** or large artery atherosclerosis leading to distal embolization. *Thrombotic infarct* - Thrombotic infarcts are usually **larger** areas of infarction due to occlusion of a major artery, often preceded by symptoms like TIAs. - While they also appear hypodense, they are typically **more extensive** and less precisely defined than a lacunar infarct in the early stages. *Intracerebral hemorrhage* - Intracerebral hemorrhage would appear as a **hyperdense** (bright white) area on a non-contrast CT scan due to the presence of acute blood. - The image clearly shows a **hypodense lesion**, ruling out acute hemorrhage.

Q: Identify the condition based on the provided image.

Callosal dysgenesis. ***Callosal dysgenesis*** - The image shows **colpocephaly**, characterized by **dilatation of the posterior horns** of the lateral ventricles and narrowing of the anterior horns. This is a classic MRI finding in callosal dysgenesis. - The absence or partial formation of the **corpus callosum** leads to a high-riding third ventricle and parallel lateral ventricles, which are often visualized alongside colpocephaly. *Dandy-Walker syndrome* - Characterized by a **cystic dilatation of the fourth ventricle** that fills the posterior fossa, leading to an upward displacement of the tentorium. - This condition involves agenesis or hypoplasia of the **cerebellar vermis**, which is not depicted in this image. *Aicardi syndrome* - Aicardi syndrome is characterized by the triad of **agenesis of the corpus callosum**, **chorioretinal lacunae**, and **infantile spasms**. - While it includes agenesis of the corpus callosum, the image alone does not provide evidence of the ocular or seizure components of Aicardi syndrome. *Septo-optic dysplasia* - This condition is defined by the **triad of optic nerve hypoplasia**, **pituitary hormone abnormalities**, and **midline brain defects**, specifically hypoplasia or absence of the septum pellucidum. - The image does not show features specific to optic nerve hypoplasia or the typical midline cysts or absent septum pellucidum characteristic of septo-optic dysplasia.

Q: Epidural hematoma on CT scan shows which of the following?

Biconvex hyperdense lesion. ***Biconvex hyperdense lesion*** - An epidural hematoma is characterized by a **biconvex** (lens-shaped) collection of blood between the dura mater and the skull. - Since it is an acute hemorrhage, the blood appears **hyperdense** (bright white) on a CT scan. *Crescent-shaped hyperdense lesion* - A **crescent shape** is characteristic of an **acute subdural hematoma**, not an epidural hematoma. - While acute subdural hematomas are also hyperdense, their crescent shape (following the contour of the brain) distinguishes them from the biconvex epidural hematomas. - Epidural hematomas are limited by suture lines and appear lens-shaped, while subdural hematomas can cross suture lines. *Biconcave hypodense lesion* - A **biconcave** shape is not a standard description in neuroradiology and does not represent epidural hematoma. - **Hypodense** would indicate an older lesion or other pathology, not acute hemorrhage. *Ring-enhancing hypodense lesion* - **Ring-enhancing lesions** are typically associated with abscesses, glioblastoma, or metastatic tumors, not an acute hematoma. - A **hypodense** (darker) center with enhancement would indicate an abscess or necrotic tumor, not a fresh extravasation of blood.

Q: Identify the condition shown in the CT scan image.

Dandy-Walker malformation. ***Dandy-Walker malformation*** - The image shows an enlarged posterior fossa with **cystic dilation of the fourth ventricle** and **absence/hypoplasia of the cerebellar vermis**, which are classic features of Dandy-Walker malformation. - The elevated tentorium and upward displacement of the transverse sinuses are also characteristic, contributing to the distinct appearance. *Cerebellar vermis hypoplasia* - While cerebellar vermis hypoplasia is a component of Dandy-Walker malformation, it is not the sole, defining feature. - Dandy-Walker also includes cystic dilation of the fourth ventricle and an enlarged posterior fossa, which are evident in the image and go beyond isolated vermis hypoplasia. *Mega cisterna magna* - A **mega cisterna magna** is a benign enlargement of the cisterna magna, which is the space between the cerebellum and the medulla oblongata. - Unlike in Dandy-Walker malformation, a mega cisterna magna usually does not involve displacement of the tentorium or hypoplasia of the cerebellar vermis, and the fourth ventricle is typically normal in shape and size. *None of the options* - The image clearly displays the diagnostic hallmarks of Dandy-Walker malformation, making this option incorrect.

Q: Tigroid pattern on MRI is seen in -

Metachromatic leukodystrophy. ***Metachromatic leukodystrophy*** - The **tigroid pattern** on MRI, characterized by **perivascular sparing** within demyelinated white matter, is highly characteristic of metachromatic leukodystrophy. - This pattern results from the accumulation of **sulfatides** in oligodendrocytes and macrophages, leading to central demyelination with spared U-fibers and white matter adjacent to vessels. *Wilson's disease* - Wilson's disease involves **copper accumulation** and typically presents with abnormalities in the **basal ganglia**, thalami, and brainstem. - While it causes neurodegeneration, it does not produce a characteristic tigroid demyelination pattern. *Parkinsonism* - Parkinsonism refers to a group of neurological disorders characterized by motor symptoms like **bradykinesia, rigidity, tremor, and postural instability**. - MRI findings in Parkinsonism often show **nigral degeneration** but do not typically involve a tigroid pattern of leukodystrophy. *GB syndrome* - **Guillain-Barré syndrome (GBS)** is an acute autoimmune peripheral neuropathy affecting the **peripheral nerves and nerve roots**. - It does not involve central nervous system demyelination or display a tigroid pattern on brain MRI.

Question 1

What is the most sensitive investigation for diffuse axonal injury?

Accepted Answer

MRI

Answer

CT

Answer

X ray

Answer

PET scan

Question 2

In which condition is the 'Eye of the Tiger' appearance typically observed?

Accepted Answer

Hallervorden-Spatz syndrome

Answer

Progressive supranuclear palsy

Answer

Levodopa-responsive dystonia

Answer

All of the options

Question 3

Hummingbird sign in brain MRI is seen in ?

Accepted Answer

Progressive supranuclear palsy

Answer

Multiple sclerosis

Answer

Parkinson's disease

Answer

Alzheimer disease

Question 4

Who is credited with the development of cerebral angiography?

Accepted Answer

Egas Moniz

Answer

Sir Walter Dandy

Answer

Godfrey Hounsfield

Answer

Seldinger

Question 5

Presence of delta sign on contrast enhanced CT scan suggests presence of?

Accepted Answer

Lateral sinus thrombophlebitis

Answer

Cerebellar abscess

Answer

Cholesteatoma

Answer

Mastoiditis

Question 6

Identify the condition in the image below?

Accepted Answer

Lacunar infarct

Answer

Embolic infarct

Answer

Thrombotic infarct

Answer

Intracerebral hemorrhage

Question 7

Identify the condition based on the provided image.

Accepted Answer

Callosal dysgenesis

Answer

Dandy-Walker syndrome

Answer

Aicardi syndrome

Answer

Septo-optic dysplasia

Question 8

Epidural hematoma on CT scan shows which of the following?

Accepted Answer

Biconvex hyperdense lesion

Answer

Crescent-shaped hyperdense lesion

Answer

Biconcave hypodense lesion

Answer

Ring-enhancing hypodense lesion

Question 9

Identify the condition shown in the CT scan image.

Accepted Answer

Dandy-Walker malformation

Answer

None of the options

Answer

Cerebellar vermis hypoplasia

Answer

Mega cisterna magna

Question 10

Tigroid pattern on MRI is seen in -

Accepted Answer

Metachromatic leukodystrophy

Answer

Wilson's disease

Answer

Parkinsonism

Answer

GB syndrome

Neuroradiology — MCQs

Neuroradiology — MCQs

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