Neuroradiology Practice Questions

Q: Which of the following conditions typically presents with spinal cord edema on MRI?

Myelomalacia. ***Myelomalacia*** - Myelomalacia refers to softening or liquefaction of the spinal cord, which is often a result of **ischemia** or **trauma**, and it typically presents with **edema** on MRI in its acute phase. - The edema observed on MRI is indicative of **acute tissue injury** and can later progress to cystic changes or atrophy. - MRI shows **T2 hyperintense signal** throughout the affected cord segment without mass effect. *Myelodysplasia* - Myelodysplasia refers to a group of **congenital developmental anomalies** of the spinal cord and vertebral column, such as spina bifida. - While it involves structural abnormalities, it does not primarily present with acute spinal cord **edema** as a defining feature. *Myeloschisis* - Myeloschisis is a severe form of **spina bifida aperta** where the neural plate fails to fuse and remains open to the surface, resulting in an exposed spinal cord. - This is a gross structural defect and does not typically involve spinal cord **edema** as its primary imaging characteristic. *Cord tumors* - Spinal cord tumors (intramedullary or extramedullary) often cause **perilesional edema**, but the primary imaging finding is an **enhancing mass lesion** on post-contrast MRI. - Unlike myelomalacia, which shows diffuse edema without a discrete mass, cord tumors present as a focal **expansile lesion** with associated edema, making the tumor itself the defining feature rather than isolated edema.

Q: What is the imaging modality of choice for determining the etiology of subarachnoid hemorrhage?

Four vessel DSA. ***Four vessel DSA*** - **Four-vessel Digital Subtraction Angiography (DSA)** is considered the gold standard for identifying the source of subarachnoid hemorrhage (SAH). - It provides high-resolution images of the **cerebral vasculature**, enabling the detection of small aneurysms, arteriovenous malformations, or other vascular lesions. *Non-contrast CT* - **Non-contrast CT** is the imaging modality of choice for the initial diagnosis of SAH itself. - However, it primarily identifies the presence of blood and its location, but is not as effective in determining the **underlying cause** of the hemorrhage in many cases. *CECT* - **Contrast-enhanced CT (CECT)** can help identify some vascular abnormalities by highlighting vessels, but its sensitivity for detecting small aneurysms or complex vascular lesions is lower than DSA. - It is often used as an alternative or supplementary study when DSA is not immediately available or contraindicated. *MRI* - **MRI** is highly sensitive for detecting intraparenchymal and subtle SAH in later stages but is less effective than CT for acute blood detection, especially within the first few hours. - While MRA (Magnetic Resonance Angiography) can identify vascular lesions, its resolution and ability to detect smaller aneurysms are generally inferior to DSA.

Q: Tear-drop appearance on a PNS x-ray is seen in?

Fracture of the floor of the orbit. ***Fracture of the floor of the orbit*** - A **tear-drop appearance** on an X-ray is a classic sign of an **orbital floor (blowout) fracture**. It represents **herniation of orbital contents** (fat and/or inferior rectus muscle) into the maxillary sinus. - This finding indicates that soft tissues have prolapsed through the fractured orbital floor, appearing as a dependent, rounded opacity within the sinus. *Fracture of medial wall of the orbit* - While fractures of the medial orbital wall (often involving the **ethmoid sinus**) can occur, they typically lead to **orbital emphysema** due to air dissection from the sinus into the orbit, rather than a tear-drop sign. - Medial wall fractures do not typically feature the characteristic prolapse of orbital contents into the maxillary sinus that creates the tear-drop appearance. *Fracture of maxillary sinus* - A fracture of the maxillary sinus can result in **fluid accumulation** (hemorrhage) within the sinus, which would appear as opacification, but not specifically the distinct "tear-drop" shape indicative of orbital contents prolapsing. - Isolated maxillary sinus fractures do not involve the orbital floor or its contents extruding into the sinus. *Fracture of ethmoidal sinus* - Fractures involving the ethmoidal sinus, often associated with medial orbital wall fractures, are more likely to cause **orbital emphysema** if the fracture communicates with the orbit. - These fractures typically cause opacification of the ethmoid air cells if there is bleeding or fluid, but they do not produce a "tear-drop" sign in the maxillary sinus.

Q: Which of the following tumors shows a radiological sign called "pneumosinus dilatans"?

Meningiomas. ***Meningiomas*** - **Pneumosinus dilatans** is a radiological finding characterized by an abnormal enlargement of a paranasal sinus or mastoid air cells without cortical bone destruction or hyperostosis. - Meningiomas, particularly those located near the **skull base** or paranasal sinuses, are classically associated with this phenomenon due to chronic pressure and possible osteoblastic stimulation. *Ependymomas* - These are typically **intracranial** or **intraspinal tumors** arising from ependymal cells lining the ventricles and central canal. - They are not associated with **pneumosinus dilatans** as they do not typically interact with paranasal sinuses. *Medulloblastomas* - These are highly malignant embryonal tumors found in the **cerebellum** of children. - They do not cause **pneumosinus dilatans** due to their posterior fossa location and aggressive growth pattern. *Hemangioblastomas* - These are benign, highly vascular tumors typically found in the **cerebellum**, **brainstem**, or **spinal cord**, often associated with **von Hippel-Lindau disease**. - They do not lead to **pneumosinus dilatans** as their location and growth characteristics do not involve the paranasal sinuses.

Q: Absent swallow tail sign is seen in which of the following conditions?

Parkinson's disease. ***Parkinson's disease*** - The **swallow tail sign** refers to the appearance of the dopaminergic neurons in the **substantia nigra pars compacta** on **magnetic resonance imaging (MRI)**. - In Parkinson's disease, the degeneration of these neurons leads to the **loss of the typical bidentate shape** (like a swallow's tail) and is replaced by a more uniform, often hypointense, appearance on susceptibility-weighted imaging. *Wilson's disease* - This is a disorder of **copper metabolism** leading to copper accumulation, primarily affecting the liver, brain, and cornea. - While it can cause neurological symptoms, the **absent swallow tail sign** is not a characteristic imaging finding for Wilson's disease. *Alzheimer's disease* - Characterized by the progressive degeneration of neurons, particularly in the **hippocampus** and **cerebral cortex**, leading to cognitive decline. - While brain atrophy is common, the **swallow tail sign** is not an imaging marker used in the diagnosis or evaluation of Alzheimer's disease. *Progressive supranuclear palsy* - A neurodegenerative disorder characterized by problems with balance, movement, vision, and speech, often associated with generalized brain atrophy, particularly in the midbrain. - While it can cause changes in the midbrain structures, the **hummingbird sign** or **Mickey Mouse sign** (due to midbrain atrophy) are more characteristic, rather than the specific swallow tail sign which is related to the substantia nigra.

Q: Which condition is associated with a 'wine glass' appearance on T2-weighted MRI of the brain?

Normal Pressure Hydrocephalus. ***Normal Pressure Hydrocephalus*** - The "wine glass" appearance on **T2-weighted MRI** of the brain is characteristic of **Normal Pressure Hydrocephalus (NPH)**, particularly seen when visualizing the **temporal horns** of the lateral ventricles. - This appearance suggests the **symmetric dilation** of the lateral ventricles, with disproportionate enlargement of the temporal horns, due to increased CSF volume without significantly increased intracranial pressure. *Multiple Sclerosis* - Characterized by **demyelinating plaques** that appear as **hyperintense lesions** on T2-weighted MRI, often in the periventricular, juxtacortical, infratentorial, and spinal cord regions. - These lesions are typically **ovoid** or round and often perpendicular to the ventricular surface (Dawson's fingers), not presenting as a "wine glass" shape. *Leukodystrophy* - A group of genetic disorders that affect the **white matter** of the brain, leading to diffuse and often symmetric abnormalities on T2-weighted MRI. - While they show widespread white matter changes, these do not typically present as a distinct "wine glass" configuration of the ventricles. *Binswanger's Disease* - A form of **subcortical vascular dementia** characterized by diffuse, irregular **white matter hyperintensities** and lacunar infarcts on T2-weighted MRI due to chronic ischemia. - The ventricular enlargement, if present, is usually due to **global brain atrophy** rather than a specific, disproportionate temporal horn dilation forming a "wine glass" shape.

Q: A 63-year-old man complains of worsening headache and right-sided weakness. Based on the CT head shown, the most likely diagnosis is:

Glioblastoma. ***Glioblastoma*** - The combination of **worsening headache** (suggesting increased intracranial pressure) and **focal neurological deficits** like right-sided weakness in a 63-year-old is highly characteristic of a **high-grade primary brain tumor**, such as glioblastoma. - CT scans typically show an **irregular, ring-enhancing mass** with surrounding **vasogenic edema**, confirming a likely glioblastoma. *Subarachnoid hemorrhage* - Presents with a **sudden-onset, severe "thunderclap" headache** and often **meningeal irritation**, not typically a progressive worsening of symptoms over time followed by focal weakness. - CT imaging would show **blood in the subarachnoid spaces**, not a distinct mass with perilesional edema. *Cerebral abscess* - While it can present with headache and focal deficits, it often includes features of **infection** such as **fever, chills, and elevated inflammatory markers**. - CT scans typically show a **ring-enhancing lesion** with a well-defined capsule, but usually in a context of predisposing infection or immunocompromised state. *Meningioma* - These are typically **slow-growing, benign tumors** that can cause symptoms due to mass effect if large enough, but the progression of symptoms tends to be much slower. - On CT, it often appears as a **well-circumscribed, dural-based mass** that homogeneously enhances.

Q: Widened neural foramina are frequently seen in:

Neurofibromatosis. ***Correct: Neurofibromatosis*** - **Neurofibromatosis Type 1 (NF1)** often leads to the development of **neurofibromas** along nerve roots, which can erode bone and cause widening of the neural foramina. - This erosion is a classic skeletal manifestation of NF1, particularly in the **spinal column**. - Widened neural foramina are a **characteristic radiological finding** in neurofibromatosis. *Incorrect: Tuberous sclerosis* - Characterized by the growth of **benign tumors (hamartomas)** in the brain and other organs, such as the skin, kidneys, and heart. - While it has neurological manifestations, **widened neural foramina** are not a typical or frequent finding. - Typical imaging findings include cortical/subcortical tubers and subependymal nodules. *Incorrect: Sturge-Weber syndrome* - A rare congenital neurological and skin disorder characterized by a **port-wine stain** on the face and neurological problems such as seizures and glaucoma. - It primarily affects the brain's blood vessels and skin, with characteristic **tram-track calcifications** in the brain. - Does not commonly result in **widened neural foramina**. *Incorrect: Klippel-Feil syndrome* - A congenital condition characterized by the **fusion of two or more cervical vertebrae**, leading to a short neck, low hairline, and restricted neck movement. - While it involves vertebral abnormalities, it does not typically cause **widening of the neural foramina**. - More commonly associated with narrowing of neural foramina or other spinal deformities.

Question 1

Which of the following conditions typically presents with spinal cord edema on MRI?

Accepted Answer

Myelomalacia

Answer

Myeloschisis

Answer

Cord tumors

Answer

Myelodysplasia

Question 2

What is the imaging modality of choice for determining the etiology of subarachnoid hemorrhage?

Accepted Answer

Four vessel DSA

Answer

Non-contrast CT

Answer

CECT

Answer

MRI

Question 3

Tear-drop appearance on a PNS x-ray is seen in?

Accepted Answer

Fracture of the floor of the orbit

Answer

Fracture of medial wall of the orbit

Answer

Fracture of maxillary sinus

Answer

Fracture of ethmoidal sinus

Question 4

Which of the following tumors shows a radiological sign called "pneumosinus dilatans"?

Accepted Answer

Meningiomas

Answer

Ependymomas

Answer

Medulloblastomas

Answer

Hemangioblastomas

Question 5

Absent swallow tail sign is seen in which of the following conditions?

Accepted Answer

Parkinson's disease

Answer

Wilson's disease

Answer

Alzheimer's disease

Answer

Progressive supranuclear palsy

Question 6

Which condition is associated with a 'wine glass' appearance on T2-weighted MRI of the brain?

Accepted Answer

Normal Pressure Hydrocephalus

Answer

Multiple Sclerosis

Answer

Leukodystrophy

Answer

Binswanger's Disease

Question 7

A 63-year-old man complains of worsening headache and right-sided weakness. Based on the CT head shown, the most likely diagnosis is:

Accepted Answer

Glioblastoma

Answer

Subarachnoid hemorrhage

Answer

Cerebral abscess

Answer

Meningioma

Question 8

Widened neural foramina are frequently seen in:

Accepted Answer

Neurofibromatosis

Answer

Tuberous sclerosis

Answer

Sturge-Weber syndrome

Answer

Klippel-Feil syndrome

Neuroradiology — MCQs

Neuroradiology — MCQs

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