Neuropathology — MCQs

A 45-year-old female presents with a 2-year history of progressive unilateral hearing loss, tinnitus, and unsteadiness. An MRI scan reveals a well-defined tumor located in the cerebellopontine angle (CPA). A surgical resection is performed, and subsequent histopathological examination of the tumor tissue is given below. Based on these histopathological findings, what is the most likely diagnosis?

Q274

A child presents with visual disturbances and delayed growth. Imaging reveals a suprasellar mass, and histopathology shows the presence of "wet keratin" (compact, eosinophilic anucleate keratin). What is the most likely diagnosis?

Q275

Which of the following are the aetiological factors associated with a communicating hydrocephalus ? I. Post haemorrhagic II. Lesions within the ventricle III. CSF infection IV. Raised CSF protein Select the correct answer using the code given below :

Q276

In diffuse axonal injury all are true EXCEPT:

Q277

A child presenting with leukocoria has an intraocular mass. Microscopic examination shows rosettes with scanty cytoplasm and positive synaptophysin. What is the most likely diagnosis?

Q278

Which of the following is an intracellular marker or deposition found in Alzheimer's disease?

Q279

A child presenting with a whitish pupillary reflex (leukocoria) was treated with enucleation. Histopathology of the specimen showed Flexner-Wintersteiner rosettes. What is the most likely diagnosis?

Q280

Which tumor arises from embryonic neural cells?

Neuropathology Indian Medical PG Practice Questions and MCQs

Question 271: A male presents with a history of vestibular schwannoma and psammoma bodies in the brain. Which of the following is the most likely diagnosis?

A. Oligodendroglioma
B. Pilocytic astrocytoma
C. Meningioma (Correct Answer)
D. GBM (Glioblastoma Multiforme)

Explanation: Correct: Meningioma - The presence of **psammoma bodies** (calcified, laminated, concentric whorls) is a classic histological feature highly characteristic of meningiomas, particularly the meningothelial and transitional subtypes [1], [2]. - The association with a vestibular schwannoma (especially if bilateral) strongly suggests **Neurofibromatosis Type 2 (NF2)**, where patients frequently develop multiple meningiomas alongside bilateral vestibular schwannomas [1]. - This combination of findings makes meningioma the most likely diagnosis. *Incorrect: GBM (Glioblastoma Multiforme)* - This is a highly aggressive, grade IV astrocytoma characterized histologically by pseudopalisading necrosis and microvascular proliferation [3]. - GBM typically occurs in older adults and is not characterized by psammoma bodies or a direct association with vestibular schwannomas observed in NF2 [3], [4]. *Incorrect: Pilocytic astrocytoma* - This is generally a low-grade (Grade I) tumor, prominent in children and young adults, often presenting in the cerebellum [4]. - Histological hallmarks include the presence of Rosenthal fibers (thick, eosinophilic corkscrew fibers) and bipolar cells, distinct from psammoma bodies. *Incorrect: Oligodendroglioma* - Histologically, these tumors are known for calcification and a characteristic 'fried-egg' appearance (round nuclei with clear perinuclear halos) and delicate branching capillaries. - While they can calcify, their characteristic histology does not include psammoma bodies, and they are not typically linked to NF2 or vestibular schwannomas. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Manifestations Of Central And Peripheral Nervous System Disease, pp. 727-728. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Central Nervous System, pp. 1316-1317. [3] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Central Nervous System, p. 1310. [4] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Central Nervous System, pp. 1319-1320.

Question 272: A 40-year-old female presents with frequent headaches. Investigation reveals raised intracranial pressure and the presence of a dural-based tumor. Which of the following histological findings correlate with the diagnosis?

A. Flexner - Wintersteiner rosettes
B. Psammoma bodies with whorling of tumor cells (Correct Answer)
C. Homer - Wright rosettes
D. Fried egg appearance

Explanation: ***Psammoma bodies with whorling of tumor cells***- The clinical picture of a **dural-based tumor** [2] causing symptoms of **raised intracranial pressure** (headache) is highly suggestive of a **Meningioma**.- **Psammoma bodies** (laminated calcified concretions) formed by the degeneration of the whorled cell clusters [1] are the classic histological hallmark of the transitional and **meningothelial meningioma** subtypes.*Fried egg appearance*- This histological appearance, characterized by clear perinuclear halos, is the classic finding for **Oligodendroglioma**, a type of parenchymal brain tumor.- Oligodendrogliomas typically arise within the cerebral **white matter** and are usually not primarily dural-based.*Flexner - Wintersteiner rosettes*- These are specialized structures representing an attempt at **retinal differentiation** and are the characteristic feature of **Retinoblastoma**.- They are also sometimes seen in highly aggressive midline CNS tumors, such as **Pineoblastoma**.*Homer - Wright rosettes*- These are seen in tumors exhibiting divergent **neuroectodermal differentiation** but lack a true central lumen or fenestration.- They are the characteristic histological finding in **Medulloblastoma** (a cerebellar tumor) and **Neuroblastoma** (a tumor of the adrenal medulla or sympathetic chain). **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Manifestations Of Central And Peripheral Nervous System Disease, pp. 727-728. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Central Nervous System, pp. 1316-1317.

Question 273: A 45-year-old female presents with a 2-year history of progressive unilateral hearing loss, tinnitus, and unsteadiness. An MRI scan reveals a well-defined tumor located in the cerebellopontine angle (CPA). A surgical resection is performed, and subsequent histopathological examination of the tumor tissue is given below. Based on these histopathological findings, what is the most likely diagnosis?

A. Meningioma
B. Neurofibroma
C. Ependymoma
D. Schwannoma (Correct Answer)

Explanation: ***Schwannoma*** - The clinical presentation (unilateral hearing loss, tinnitus, CPA mass) is highly characteristic of a **Vestibular Schwannoma** (Acoustic Neuroma), which is the most common tumor of the CPA [2]. - The histopathology image shows the classic biphasic pattern of Schwannoma: cellular **Antoni A tissue** (with hyperchromatic nuclei arranged in palisades forming **Verocay bodies**) alternating with hypocellular, myxoid **Antoni B tissue** [1]. *Ependymoma* - Ependymomas typically arise from the ependymal lining of the **ventricular system** (e.g., fourth ventricle), making their primary location rarely the CPA outside the brainstem. - Histologically, they feature characteristic arrangements like **perivascular pseudorosettes** (tumor cells arranged around blood vessels) or true rosettes, which are absent in this image [3]. *Meningioma* - While meningioma is the second most common CPA tumor, its histology is defined by the formation of **concentric cellular whorls** and often includes laminated calcifications known as **psammoma bodies** [2]. - Meningiomas originate from arachnoidal cells and do not exhibit the distinct **Antoni A and B** tissue architecture seen in the provided slide. *Neurofibroma* - Neurofibromas are characterized by a diverse cellular population (Schwann cells, fibroblasts, mast cells) and lack the highly organized nuclear palisading and **Verocay bodies** seen in the image [1]. - They generally present as a looser, more haphazard proliferation of spindle cells within a prominent, often myxoid stroma, without clear distinction between **Antoni A and B** areas [1]. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Peripheral Nerves and Skeletal Muscles, p. 1250. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Manifestations Of Central And Peripheral Nervous System Disease, pp. 727-728. [3] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Central Nervous System, pp. 1312-1313.

Question 274: A child presents with visual disturbances and delayed growth. Imaging reveals a suprasellar mass, and histopathology shows the presence of "wet keratin" (compact, eosinophilic anucleate keratin). What is the most likely diagnosis?

A. Medulloblastoma
B. Glioma
C. Craniopharyngioma (Correct Answer)
D. Pituitary adenoma

Explanation: ***Craniopharyngioma*** - This tumor is classically located in the **suprasellar region** and presents in children with visual field deficits and **endocrine dysfunction** (e.g., delayed growth, short stature) due to hypothalamic or pituitary stalk compression. - The histopathology description of **"wet keratin"** (or keratin nests with peripheral palisading of epithelial cells) is pathognomonic for the adamantinomatous subtype of craniopharyngioma. *Medulloblastoma* - This is primarily a **posterior fossa tumor** originating in the cerebellum, typically causing signs of increased intracranial pressure and **ataxia**, not primarily suprasellar syndromes. - Histologically, it is a small, round blue cell tumor of **primitive neuroectoderm (PNET)** origin; it does not exhibit keratin formation. *Glioma* - While gliomas (e.g., optic pathway gliomas) can involve the suprasellar area, the cellular morphology would consist of **astrocytic** or oligodendroglial cells. - Gliomas lack the epithelial components and definitive **keratin formation** that are characteristic of craniopharyngioma. *Pituitary adenoma* - Pituitary adenomas are typically **intrasellar** and are much more common in adults, causing symptoms associated with hormone excess or deficiency (hypopituitarism) [1]. - Histology shows sheets and cords of uniform **polygonal cells** derived from pituitary endocrinocytes [2]; they do not contain squamous elements or keratin. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Endocrine System, p. 1081. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Liver And Biliary System Disease, pp. 417-418.

Question 275: Which of the following are the aetiological factors associated with a communicating hydrocephalus ? I. Post haemorrhagic II. Lesions within the ventricle III. CSF infection IV. Raised CSF protein Select the correct answer using the code given below :

A. I, II and III
B. II, III and IV
C. I, II and IV
D. I, III and IV (Correct Answer)

Explanation: ***I, III and IV*** - **Communicating hydrocephalus** occurs when there is impaired CSF absorption in the **subarachnoid space** despite a patent ventricular system. - **Post-hemorrhagic**, **CSF infection** (meningitis), and **raised CSF protein** (e.g., from tumors or inflammation) can all obstruct the arachnoid villi, preventing proper CSF reabsorption [1]. *I, II and III* - While **post-hemorrhagic** and **CSF infection** are causes of communicating hydrocephalus, **lesions within the ventricle** typically cause **non-communicating (obstructive) hydrocephalus** by blocking CSF flow *within* the ventricular system itself [1]. - This option incorrectly includes an obstructive cause and omits **raised CSF protein**, which is a known cause of impaired CSF absorption. *II, III and IV* - This option incorrectly includes **lesions within the ventricle** as a cause of communicating hydrocephalus, which usually leads to **non-communicating hydrocephalus** [1]. - It correctly identifies **CSF infection** and **raised CSF protein** but omits **post-hemorrhagic** causes, which are a common etiology [1]. *I, II and IV* - This option incorrectly includes **lesions within the ventricle**, which typically cause **non-communicating hydrocephalus** [1]. - While **post-hemorrhagic** and **raised CSF protein** are valid causes, the inclusion of an obstructive cause makes this option incorrect for *communicating* hydrocephalus. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Manifestations Of Central And Peripheral Nervous System Disease, pp. 703-704.

Question 276: In diffuse axonal injury all are true EXCEPT:

A. Seen in high energy
B. Form of primary brain injury
C. CT scan shows pathognomonic finding (Correct Answer)
D. Usually causes prolonged coma

Explanation: ***CT scan shows pathognomonic finding*** - While CT scans can sometimes show petechial hemorrhages or small white matter lesions in **diffuse axonal injury (DAI)**, these findings are **not pathognomonic** and can be absent even in severe cases. - **MRI** is more sensitive for detecting microhemorrhages and white matter changes, but even MRI findings are not always definitively diagnostic of DAI, especially in milder forms. - CT scan has **low sensitivity** for DAI, often appearing normal or showing only subtle findings. *Usually causes prolonged coma* - **Diffuse axonal injury (DAI)** is a common cause of **prolonged coma** after traumatic brain injury, as widespread shearing forces disrupt neuronal connections [1]. - The severity and duration of coma correlate with the extent of axonal damage, with severe DAI typically resulting in immediate and prolonged loss of consciousness. *Seen in high energy* - DAI typically results from **high-energy acceleration-deceleration forces**, often seen in motor vehicle accidents or falls from significant heights [1]. - These forces cause differential movement between various parts of the brain, leading to **shearing and stretching of axons** [1]. *Form of primary brain injury* - DAI is considered a **primary brain injury** because the axonal damage occurs at the **moment of impact** due to mechanical forces [1]. - This contrasts with secondary brain injuries, which develop over time due to complications like edema or ischemia. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Central Nervous System, pp. 1262-1264.

Question 277: A child presenting with leukocoria has an intraocular mass. Microscopic examination shows rosettes with scanty cytoplasm and positive synaptophysin. What is the most likely diagnosis?

A. Retinoblastoma (Correct Answer)
B. Medulloblastoma
C. Neuroblastoma
D. Ependymoma

Explanation: ***Retinoblastoma*** - **Leukocoria** (white pupillary reflex) in a child with an **intraocular mass** is the classic presentation of retinoblastoma, the most common primary intraocular malignancy in childhood [3]. - Histologically, the presence of **rosettes** (Flexner-Wintersteiner rosettes are pathognomonic [1]; Homer Wright rosettes may also be seen) with scanty cytoplasm confirms the diagnosis [3]. - **Positive synaptophysin** staining confirms the neuroblastic/neuroectodermal differentiation characteristic of retinoblastoma. - The **intraocular location** is the key differentiating feature from other rosette-forming tumors. *Medulloblastoma* - This is a highly malignant **cerebellar tumor** (posterior fossa), often presenting with **ataxia, headaches, and hydrocephalus**, not leukocoria or an intraocular mass. - While it can form Homer Wright rosettes and is synaptophysin positive, its **CNS location** (not intraocular) distinguishes it from retinoblastoma. *Neuroblastoma* - This is a tumor of the **sympathetic nervous system**, usually arising in the adrenal medulla or sympathetic ganglia, presenting as an abdominal mass, bone metastases, or raccoon eyes (periorbital ecchymoses from orbital metastases) [2], [4]. - It does **not present as a primary intraocular mass** with leukocoria, though it may rarely metastasize to the orbit. - Can also show Homer Wright rosettes and synaptophysin positivity [4]. *Ependymoma* - This is a **glial tumor** of the central nervous system, typically found in the ventricles of the brain or spinal cord. - It presents with symptoms related to its location (e.g., hydrocephalus, spinal cord compression) and does not cause leukocoria or intraocular masses. - Forms **ependymal rosettes** (perivascular pseudorosettes), which are different from the rosettes in retinoblastoma. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Eye, p. 1342. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of Infancy and Childhood, pp. 483-484. [3] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Manifestations Of Central And Peripheral Nervous System Disease, pp. 737-738. [4] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of Infancy and Childhood, pp. 484-485.

Question 278: Which of the following is an intracellular marker or deposition found in Alzheimer's disease?

A. Tau protein (Correct Answer)
B. A β 40 / 42 (Amyloid-beta 40/42)
C. Alpha-synuclein
D. TDP-43

Explanation: ***Tau protein*** - **Tau protein** forms **neurofibrillary tangles** within the neurons, which is a hallmark intracellular lesion in Alzheimer's disease [1]. - These tangles disrupt neuronal transport systems, leading to **synaptic dysfunction** and cell death [1]. *A ̢ 40 / 42 (Amyloid-beta 40/42)* - **Amyloid-beta** peptides aggregate to form **extracellular amyloid plaques**, not intracellular deposits, in Alzheimer's disease [2]. - While central to the pathology, these **plaques** are found outside of the neurons in the brain parenchyma [2]. *Alpha-synuclein* - **Alpha-synuclein** is the primary component of **Lewy bodies**, which are intracellular inclusions characteristic of Parkinson's disease and Lewy body dementia. - It is not a primary marker for Alzheimer's disease pathology. *TDP-43* - **TDP-43 (TAR DNA-binding protein 43)** inclusions are characteristic of **frontotemporal lobar degeneration (FTLD)** and amyotrophic lateral sclerosis (ALS). - While sometimes co-occurs with Alzheimer's, it is not a primary or defining intracellular marker for Alzheimer's disease itself. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Central Nervous System, pp. 1292-1294. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Central Nervous System, pp. 1290-1292.

Question 279: A child presenting with a whitish pupillary reflex (leukocoria) was treated with enucleation. Histopathology of the specimen showed Flexner-Wintersteiner rosettes. What is the most likely diagnosis?

A. Retinoblastoma (Correct Answer)
B. Astrocytoma
C. Medulloblastoma
D. Rhabdomyosarcoma

Explanation: ***Retinoblastoma*** - The presence of **leukocoria** (whitish pupillary reflex) in a child is the most common presenting sign of **retinoblastoma** [2]. - **Flexner-Wintersteiner rosettes** are characteristic histological features of retinoblastoma, confirming the diagnosis [1]. *Astrocytoma* - Astrocytomas are **brain tumors** that typically do not cause leukocoria or originate in the retina [3]. - Their histology involves glial cells and would not show Flexner-Wintersteiner rosettes [3]. *Medulloblastoma* - Medulloblastomas are **malignant brain tumors** of the cerebellum, presenting with symptoms like ataxia and hydrocephalus [4]. - They are not associated with leukocoria or retinal involvement. *Rhabdomyosarcoma* - Rhabdomyosarcoma is a **malignant tumor of skeletal muscle**, most commonly found in the head and neck, genitourinary tract, or extremities. - While it can occur in the orbit, its histology is distinct and involves rhabdomyoblasts, not rosettes, and it's less likely to present purely as leukocoria. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Eye, pp. 1341-1342. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Manifestations Of Central And Peripheral Nervous System Disease, pp. 737-738. [3] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Manifestations Of Central And Peripheral Nervous System Disease, pp. 725-726. [4] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Central Nervous System, pp. 1314-1315.

Question 280: Which tumor arises from embryonic neural cells?

A. Medulloblastoma (Correct Answer)
B. Fibrous astrocytoma
C. Neuroglioma
D. Ependymoma

Explanation: ***Medulloblastoma*** - This tumor arises from **embryonic neural cells** in the **cerebellum**. - It is a highly malignant **brain tumor** most commonly found in children [1]. *Fibrous astrocytoma* - This is a type of **glioma** that arises from **mature astrocytes**, not embryonic neural cells. - It typically occurs in adults and can be found in various locations within the brain. *Neuroglioma* - This is a broad term that refers to **tumors of neuroglial origin**, meaning they arise from glial cells. - It does not specifically refer to a tumor originating from embryonic neural cells. *Ependymoma* - This tumor arises from **ependymal cells**, which line the **ventricles** and **spinal canal**. - While these are technically neural cells, they are more differentiated than the embryonic neural cells that give rise to medulloblastoma. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Central Nervous System, pp. 1314-1315.

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