Pediatric Radiology Practice Questions

Q: Regarding neuroimaging in the neonatal period, all are true except?

MRI cannot detect abnormalities on the first day of life.. **Explanation** The correct answer is **D**, as it is a false statement. Modern neuroimaging, particularly **Diffusion-Weighted Imaging (DWI)** on MRI, is highly sensitive and can detect cytotoxic edema and ischemic changes within hours of an insult, often on the first day of life. **Analysis of Options:** * **Option D (Incorrect Statement):** MRI is the most sensitive modality for neonatal brain injury. DWI sequences can identify restricted diffusion (indicative of acute ischemia) much earlier than conventional T1/T2 sequences or CT scans, making it possible to detect abnormalities within the first 24 hours. * **Option A & C (True Statements):** In term infants with Hypoxic-Ischemic Encephalopathy (HIE), both Cranial Ultrasound (USG) and CT scans are frequently normal or show non-specific findings during the first 24 hours. Edema and structural changes often take time to become radiologically apparent on these modalities. * **Option B (True Statement):** On CT, the "reversal sign" or decreased attenuation in the basal ganglia and thalamus typically becomes more prominent after the first 24 hours as cerebral edema evolves. These changes usually persist for about a week before transitioning to chronic stages. **NEET-PG High-Yield Pearls:** * **Investigation of Choice (IOC):** For screening germinal matrix hemorrhage in preterm neonates, **Cranial Ultrasound** (via the anterior fontanelle) is the IOC. * **Most Sensitive Sequence:** **DWI (MRI)** is the gold standard for early detection of HIE. * **CT Findings in HIE:** Look for the **"Reversal Sign"** (low attenuation of cerebral cortex/white matter with relative sparing of the cerebellum and brainstem) and the **"White Cerebellum Sign."** * **Timing:** The optimal window for conventional MRI to show the full extent of HIE injury is typically **3 to 5 days** after birth.

Q: What is the name of the study performed on a newborn with an inability to pass stools, often visualized in an X-ray?

Invertogram. **Explanation:** The correct answer is **Invertogram (Wangensteen-Rice technique)**. This specialized radiographic study is primarily used to evaluate **Anorectal Malformations (ARM)**, such as imperforate anus, in newborns who fail to pass meconium within the first 24–48 hours of life. **Why Invertogram is correct:** In this procedure, the neonate is held upside down (inverted) for 3–5 minutes to allow bowel gas to rise to the distal-most end of the rectal pouch. A radio-opaque marker (coin) is placed on the anal dimple. The distance between the gas bubble and the marker helps classify the anomaly as **High, Intermediate, or Low**, which dictates the surgical approach (e.g., primary anoplasty vs. colostomy). **Why other options are incorrect:** * **Enteroclysis:** A double-contrast study of the small bowel where contrast is infused via a nasojejunal tube. It is used for detecting small bowel obstructions or Crohn’s disease, not neonatal ARM. * **Graham Cole Test:** An obsolete oral cholecystography technique used to visualize the gallbladder. * **Digital X-ray:** A general modality of imaging, not a specific diagnostic study for stool-passing issues. **NEET-PG High-Yield Pearls:** * **Timing:** An invertogram should only be performed **after 18–24 hours** of birth to allow sufficient time for air to reach the distal rectum. * **Reference Line:** The **Kelly’s line** (at the level of the ischium) or the **PC line** (Pubococcygeal line) is used to differentiate high vs. low anomalies. * **Modern Alternative:** Prone cross-table lateral X-ray is now often preferred over the invertogram to avoid respiratory distress in the neonate.

Q: What condition is associated with a soap bubble appearance on abdominal radiography?

Meconium ileus. **Explanation:** **Meconium Ileus (Correct Answer):** The "soap bubble" appearance (also known as **Neuhauser’s sign**) is a classic radiographic finding in meconium ileus. It occurs when air bubbles become trapped within the thick, tenacious meconium in the distal ileum. This creates a mottled, granular appearance on an abdominal X-ray. Meconium ileus is the earliest clinical manifestation of **Cystic Fibrosis** (seen in ~90% of cases). **Analysis of Incorrect Options:** * **Achalasia Cardia:** Characterized by a "Bird’s beak" or "Rat-tail" appearance on a Barium swallow, caused by the failure of the lower esophageal sphincter to relax. * **Duodenal Atresia:** Classically presents with the **"Double bubble" sign** on X-ray, representing air in the dilated stomach and the proximal duodenum, with no distal gas. * **Hirschsprung’s Disease:** Typically shows dilated bowel loops (megacolon) proximal to an aganglionic segment. On a contrast enema, a "transition zone" is the hallmark finding. **High-Yield Clinical Pearls for NEET-PG:** * **Ground-glass appearance:** Another term used interchangeably with soap bubble appearance for meconium ileus. * **Microcolon:** On a contrast enema, meconium ileus will show a "unused" microcolon distal to the obstruction. * **Target Population:** Always suspect meconium ileus in a neonate with abdominal distension, failure to pass meconium within 48 hours, and a family history of Cystic Fibrosis. * **Management:** Gastrografin (hyperosmolar water-soluble contrast) enema is both diagnostic and therapeutic.

Q: Vesicoureteric reflux is commonly diagnosed by which of the following methods?

Micturating cystography. **Explanation:** **Vesicoureteric Reflux (VUR)** is the retrograde flow of urine from the bladder into the ureters and kidneys, primarily due to an incompetent vesicoureteric junction. **1. Why Micturating Cystourethrogram (MCU/VCUG) is the Correct Answer:** MCU is the **gold standard investigation** for diagnosing and grading VUR. The procedure involves catheterizing the bladder, filling it with contrast, and taking fluoroscopic images during the act of voiding (micturition). This is crucial because VUR often occurs only when intravesical pressure rises during voiding. It allows for the definitive grading of reflux (Grades I-V) based on the extent of filling and dilation of the ureter and renal pelvis. **2. Why Other Options are Incorrect:** * **Radioisotope Renography (e.g., DTPA/MAG3):** These are used to assess renal function and drainage/obstruction, not primarily for diagnosing VUR. While *Radionuclide Cystography (RNC)* can detect reflux with less radiation, it lacks the anatomical detail of MCU required for grading. * **Intravenous Urography (IVU):** IVU is poor at detecting VUR because it is a "downward" study. It may show indirect signs (like dilated ureters), but it cannot demonstrate the "upward" reflux of urine. * **CT Scan:** CT is not a primary modality for VUR due to high radiation and lack of dynamic voiding information. **Clinical Pearls for NEET-PG:** * **Grading:** VUR is graded I to V (International Reflux Study classification). * **Initial Screening:** Ultrasound is often the first step in a child with a UTI to look for hydronephrosis, but **MCU** is required for definitive diagnosis. * **DMSA Scan:** This is the gold standard for detecting **renal scarring** (a complication of VUR/Pyelonephritis). * **Posterior Urethral Valves (PUV):** MCU is also the investigation of choice for PUV, showing a dilated posterior urethra.

Q: The "triple bubble sign" is characteristic of which of the following conditions?

Jejunal atresia. **Explanation:** The **"Triple Bubble Sign"** is a classic radiological finding seen on an abdominal X-ray, representing gas-filled pockets in the **stomach, duodenum, and the proximal jejunum**. It occurs due to a high-grade intestinal obstruction at the level of the jejunum. **1. Why Jejunal Atresia is Correct:** In jejunal atresia, the obstruction is distal to the duodenum. Air swallowed by the newborn distends the stomach (first bubble), the duodenum (second bubble), and the proximal-most segment of the jejunum (third bubble). This sign is highly specific for **proximal jejunal atresia** or occasionally a midgut volvulus. **2. Analysis of Incorrect Options:** * **Duodenal Atresia:** Characterized by the **"Double Bubble Sign"** (stomach and duodenum). There is no third bubble because the obstruction is at the level of the duodenum, preventing air from reaching the jejunum. * **Ileal Atresia:** Typically presents with **multiple dilated loops** of small bowel (more than three) and air-fluid levels, as the obstruction is much further down the gastrointestinal tract. * **Congenital Hepatic Fibrosis:** This is a liver pathology associated with portal hypertension and renal cystic disease; it does not cause acute neonatal bowel obstruction or specific "bubble" signs on X-ray. **High-Yield Clinical Pearls for NEET-PG:** * **Single Bubble:** Hypertrophic Pyloric Stenosis (stomach only). * **Double Bubble:** Duodenal Atresia (associated with Down Syndrome), Annular Pancreas, Malrotation. * **Triple Bubble:** Jejunal Atresia. * **Ground Glass Appearance/Soap Bubble Sign:** Meconium Ileus (associated with Cystic Fibrosis). * **Vascular Accident Theory:** Unlike duodenal atresia (recanalization failure), jejunal and ileal atresias are usually caused by an **in-utero vascular accident** (ischemic necrosis).

Q: Reversal of SMA and SMV relationship is seen in which condition?

Midgut Volvulus. **Explanation:** The reversal of the normal relationship between the Superior Mesenteric Artery (SMA) and Superior Mesenteric Vein (SMV) is a classic radiological hallmark of **Malrotation with Midgut Volvulus**. **1. Why Midgut Volvulus is correct:** In normal anatomy, the SMV lies to the **right** of the SMA. In malrotation, the normal 270° counter-clockwise rotation of the midgut fails to occur. This results in a narrow mesenteric base, allowing the bowel to twist around the SMA axis. On ultrasound or CT, this manifests as the **"Whirlpool Sign"** (vessels wrapping around each other) and the **reversal of the SMA/SMV relationship**, where the SMV is found to the **left** of the SMA. **2. Why other options are incorrect:** * **Duodenal Atresia:** Characterized by the "Double Bubble" sign on X-ray. It is a failure of recanalization, not a rotational anomaly. * **Annular Pancreas:** A congenital anomaly where pancreatic tissue encircles the second part of the duodenum, causing extrinsic obstruction. It does not involve mesenteric vessel transposition. * **Ileal Atresia:** An in-utero vascular accident leading to bowel discontinuity. While it presents with neonatal intestinal obstruction, the SMA/SMV relationship remains normal. **Clinical Pearls for NEET-PG:** * **Gold Standard Investigation:** Upper GI Contrast Study (Barium Swallow/Meal). Look for the **"Corkscrew appearance"** of the distal duodenum/jejunum. * **Ladd’s Procedure:** The definitive surgical treatment. It involves detorsion (counter-clockwise), division of Ladd’s bands, broadening the mesentery, and performing an appendectomy. * **Ladd’s Bands:** Peritoneal bands crossing the duodenum from the cecum, causing extrinsic obstruction. * **Position of Bowel post-surgery:** Small bowel is placed on the right, and the large bowel is placed on the left.

Q: Ground glass appearance is not seen in which of the following conditions?

Left to right shunts. **Explanation:** The "Ground Glass Appearance" (GGA) on a chest X-ray represents a fine, granular opacification of the lung parenchyma where underlying pulmonary vessels are still visible. It typically signifies **alveolar collapse (atelectasis)** or **fluid/exudate** within the distal airspaces. **Why "Left to Right Shunts" is the correct answer:** In conditions like VSD, PDA, or ASD (Left-to-right shunts), there is increased pulmonary blood flow (**active hyperemia**). This manifests radiologically as **prominent pulmonary vascular markings** (plethora) and cardiomegaly, rather than the diffuse, hazy granularity of ground glass. **Analysis of Incorrect Options:** * **Hyaline Membrane Disease (HMD/RDS):** This is the classic cause of GGA. It occurs due to surfactant deficiency leading to widespread micro-atelectasis. The "granular" look is created by collapsed alveoli interspersed with dilated alveolar ducts. * **Pneumonia:** In neonates, especially Group B Streptococcus pneumonia, the radiological presentation can be indistinguishable from HMD, often showing diffuse GGA due to inflammatory exudates in the alveoli. * **Obstructive TAPVC (Total Anomalous Pulmonary Venous Connection):** This condition leads to severe **pulmonary venous congestion** and interstitial edema. The resulting fluid accumulation in the interstitium and alveoli produces a classic diffuse ground-glass pattern with a small heart. **NEET-PG High-Yield Pearls:** * **HMD Triad on X-ray:** Low lung volumes, diffuse ground-glass opacities, and prominent air bronchograms. * **Obstructive TAPVC:** Characterized by GGA with a **normal-sized heart**, unlike non-obstructive TAPVC which shows the "Snowman" or "Figure of 8" appearance. * **Transient Tachypnea of Newborn (TTN):** Shows "starburst" appearance or perihilar streaking, not typically classic GGA.

Q: Cobblestone appearance on barium enema in a neonate is a characteristic feature of which condition?

Hirschsprung disease. ### Explanation **1. Why Hirschsprung Disease (HD) is Correct:** Hirschsprung disease is characterized by the congenital absence of ganglion cells (Auerbach’s and Meissner’s plexuses) in the distal colon. While the classic barium enema finding is a **transition zone** (narrow aganglionic segment with proximal dilation), a **"cobblestone" or "serrated" appearance** can occur due to irregular mucosal contractions or superficial ulcerations in the aganglionic segment. Additionally, in cases complicated by **Hirschsprung-associated enterocolitis (HAEC)**, mucosal edema and ulceration further accentuate this cobblestone pattern. **2. Analysis of Incorrect Options:** * **Anorectal Malformation (ARM):** Diagnosis is primarily clinical (absent anal opening). Imaging (Invertogram or Cross-table lateral X-ray) focuses on the distance between the perineal skin and the rectal pouch, not mucosal patterns. * **Mucoviscidosis (Cystic Fibrosis):** In neonates, this typically presents as **Meconium Ileus**. Barium enema would show a **"Microcolon"** (unused colon) due to proximal obstruction in the terminal ileum, not a cobblestone appearance. * **Patent Allantois (Urachus):** This is a urological anomaly where the connection between the bladder and umbilicus remains open. It presents with urine leaking from the umbilicus and is unrelated to colonic mucosal findings. **3. NEET-PG High-Yield Pearls:** * **Gold Standard Diagnosis:** Rectal Suction Biopsy (shows absence of ganglion cells and increased Acetylcholinesterase staining). * **Initial Screening:** Plain X-ray shows dilated bowel loops; Barium enema shows the **Transition Zone** (most common finding). * **Clinical Sign:** Failure to pass meconium within the first 24–48 hours and a positive "squirt sign" (explosive release of stool on digital rectal exam). * **Associated Condition:** Down Syndrome (Trisomy 21) is seen in ~10% of HD cases.

Q: A preterm baby suffered perinatal asphyxia and was found to have Periventricular leucomalacia on CNS imaging. Which imaging modality was used?

Transcranial ultrasound. **Explanation:** **Periventricular Leukomalacia (PVL)** is a form of white matter brain injury characterized by necrosis of the white matter near the lateral ventricles, commonly seen in preterm infants following hypoxic-ischemic insults (perinatal asphyxia). **Why Transcranial Ultrasound (TUS) is the correct answer:** In the neonatal period, **Transcranial Ultrasound** is the **initial and preferred screening modality** for PVL. It is highly effective because the **anterior fontanelle** is still open, serving as an acoustic window to visualize the periventricular area. TUS is portable (bedside), non-invasive, does not require sedation, and involves no ionizing radiation, making it ideal for unstable preterm babies in the NICU. Early PVL appears as "flaring" or increased echogenicity, which later progresses to cystic changes (Cystic PVL). **Why other options are incorrect:** * **MRI Brain:** While MRI is the most sensitive modality for detecting subtle white matter changes, it is not the primary screening tool in the acute neonatal phase due to the need for transport and sedation of a fragile neonate. * **CECT Head:** CT is generally avoided in neonates due to high radiation risks and poor contrast between gray and white matter in the unmyelinated newborn brain. * **SPECT Brain:** This is a functional imaging tool used for blood flow studies and is not indicated for the structural diagnosis of PVL. **High-Yield Clinical Pearls for NEET-PG:** * **Acoustic Window:** The **Anterior Fontanelle** is the most common window used for TUS. * **Classic Finding:** Increased periventricular echogenicity (greater than the choroid plexus) persisting for >7 days is highly suggestive of PVL. * **Long-term Sequelae:** PVL is the most common cause of **Spastic Diplegia** (Cerebral Palsy) in preterm infants. * **Timing:** Screening TUS is typically performed at 1 week of age and repeated at 4–6 weeks to look for cystic changes.

Question 1

Regarding neuroimaging in the neonatal period, all are true except?

Accepted Answer

MRI cannot detect abnormalities on the first day of life.

Answer

Sonographic studies are generally normal on the day of birth.

Answer

Decreased density in the thalamus or basal ganglia is seen after 24 hours and persists for 5 to 7 days on CT.

Answer

CT scans are usually normal on the first day of life in term infants.

Question 2

What is the name of the study performed on a newborn with an inability to pass stools, often visualized in an X-ray?

Accepted Answer

Invertogram

Answer

Enteroclysis

Answer

Graham cole test

Answer

Digital X-ray

Question 3

What condition is associated with a soap bubble appearance on abdominal radiography?

Accepted Answer

Meconium ileus

Answer

Achalasia cardia

Answer

Duodenal atresia

Answer

CongenitalHD Hirschsprung's disease

Question 4

Extraluminal abdominal calcification in a newborn may be seen in which of the following conditions?

Accepted Answer

Meconium peritonitis

Answer

Meconium aspiration

Answer

Hirschsprung's disease

Answer

Meconium plug syndrome

Question 5

Vesicoureteric reflux is commonly diagnosed by which of the following methods?

Accepted Answer

Micturating cystography

Answer

Radioisotope renography

Answer

Intravenous urography (IVU)

Answer

CT scan

Question 6

The "triple bubble sign" is characteristic of which of the following conditions?

Accepted Answer

Jejunal atresia

Answer

Congenital hepatic fibrosis

Answer

Duodenal atresia

Answer

Ileal atresia

Question 7

Reversal of SMA and SMV relationship is seen in which condition?

Accepted Answer

Midgut Volvulus

Answer

Duodenal Atresia

Answer

Annular pancreas

Answer

Ileal Atresia

Question 8

Ground glass appearance is not seen in which of the following conditions?

Accepted Answer

Left to right shunts

Answer

Hyaline membrane disease

Answer

Pneumonia

Answer

Obstructive TAPVC

Question 9

Cobblestone appearance on barium enema in a neonate is a characteristic feature of which condition?

Accepted Answer

Hirschsprung disease

Answer

Anorectal malformation

Answer

Mucoviscidosis

Answer

Patent allantois

Question 10

A preterm baby suffered perinatal asphyxia and was found to have Periventricular leucomalacia on CNS imaging. Which imaging modality was used?

Accepted Answer

Transcranial ultrasound

Answer

MRI brain

Answer

CECT head

Answer

SPECT brain

Pediatric Radiology — MCQs

Pediatric Radiology — MCQs

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