Neuroimaging in Pediatrics — MCQs
Ideal imaging method for diagnosis of hydrocephalus in infant is
Investigation of choice in an unstable patient with suspected intra-abdominal injury is -
Which imaging modality is most sensitive for detecting early ischemic stroke?
A man presents to the emergency department with a head injury following a vehicular accident. What is the investigation of choice?
Most specific finding of acute stroke on CT
A child presented with blunt abdominal trauma, the first investigation to be done is -
Best method to diagnose hydrocephalus in a fetus at 24 weeks gestation is:
A sick intubated neonate is having bilateral jerk of both right and left upper limbs with some occasional twitching of neck as well. Likely type of seizures:
A 35-year-old man has a headache, sleepiness, and poor balance that have worsened over the past week. The patient is known to be HIV-seropositive. On examination, his responses are slow and he has some difficulty in sustaining attention. He has right hemiparesis with increased reflexes on the right. Routine cell counts and chemistries are normal. What is the most appropriate next step?
A newborn male infant presents with the findings shown in the image. The clinical diagnosis is?
Neuroimaging in Pediatrics Indian Medical PG Practice Questions and MCQs
Question 1: Ideal imaging method for diagnosis of hydrocephalus in infant is
- A. X-Ray
- B. MRI
- C. CT Scan
- D. USG (Correct Answer)
Explanation: ***USG*** - **Ultrasound (USG)** is the preferred initial imaging method for diagnosing hydrocephalus in infants due to their **open fontanelles**, which allow for excellent visualization of intracranial structures without radiation exposure. - It's **non-invasive**, portable, and can be performed at the bedside, making it ideal for critically ill or unstable infants. *X-Ray* - **X-rays** provide limited detail of soft tissues and are generally unable to directly visualize the ventricles or cerebrospinal fluid accumulation, making them unsuitable for diagnosing hydrocephalus. - While skull X-rays might show signs of increased intracranial pressure in chronic cases (e.g., **suture diastasis**), they are not a primary diagnostic tool for hydrocephalus. *MRI* - **MRI** offers superior soft tissue contrast and detailed anatomical information, making it excellent for characterizing hydrocephalus and its underlying causes in older children and adults. - However, it typically requires **sedation** in infants due to the need for prolonged immobility and is less readily available or rapid than ultrasound for initial diagnosis. *CT Scan* - **CT scans** provide good bony detail and can quickly identify ventricular enlargement, but they involve **ionizing radiation**, which is a significant concern in infants due to their radiosensitivity. - While useful in acute emergencies where rapid assessment is critical and USG is inconclusive, it's generally avoided as the first-line diagnostic tool for hydrocephalus in infants.
Question 2: Investigation of choice in an unstable patient with suspected intra-abdominal injury is -
- A. USG (FAST) (Correct Answer)
- B. CT scan
- C. X-ray abdomen
- D. DPL
Explanation: ***USG*** - **Focused assessment with sonography for trauma (FAST) exam** is the investigation of choice in an **unstable patient** due to its rapid, non-invasive nature and ability to detect free fluid (blood) in the peritoneal, pericardial, and pleural spaces. - It can be performed at the **bedside** without moving the patient, making it ideal for hemodynamically unstable individuals with suspected intra-abdominal injury. *CT scan* - While a **CT scan** provides detailed anatomical information, it requires the patient to be stable enough for transport to a radiology suite and prolonged scanning time. - It is often difficult to obtain in **unstable patients** who may require continuous resuscitation and monitoring. *X-ray abdomen* - An **X-ray abdomen** has limited utility for detecting intra-abdominal injuries and primarily identifies issues like free air under the diaphragm (suggesting hollow organ perforation) or foreign bodies. - It is **not sensitive** for detecting free fluid (hemoperitoneum) or solid organ injuries, which are critical in trauma. *DPL* - **Diagnostic peritoneal lavage (DPL)** is an invasive procedure that involves inserting a catheter into the peritoneal cavity to detect blood or other fluid. - While sensitive, it is **invasive**, can complicate subsequent imaging, and has largely been replaced by the FAST exam due to the latter's non-invasive nature and comparable diagnostic accuracy for free fluid.
Question 3: Which imaging modality is most sensitive for detecting early ischemic stroke?
- A. Ultrasound
- B. PET scan
- C. CT
- D. MRI with DWI (Correct Answer)
Explanation: ***MRI with DWI*** - **Diffusion-weighted imaging (DWI)** within an MRI scan is highly sensitive in detecting **cytotoxic edema** within minutes of **ischemic stroke** onset. This makes it crucial for early diagnosis and treatment decisions. - DWI can identify areas of restricted water diffusion, which is a hallmark of acute cellular injury due to **ischemia**, even before changes are visible on conventional T1 or T2-weighted MRI sequences. *CT* - While frequently used in acute stroke settings, **non-contrast CT** is primarily used to **rule out hemorrhagic stroke** and may only show subtle or no signs of acute ischemia in the first few hours. - Early ischemic changes on CT, often referred to as the **"ischemic penumbra"**, may appear hours after stroke onset, making it less sensitive for very early detection compared to DWI. *Ultrasound* - **Transcranial Doppler (TCD) ultrasound** can evaluate blood flow velocities in intracranial arteries and detect stenoses or occlusions but is not a primary imaging modality for directly visualizing brain parenchymal ischemia. - Cervical ultrasound (e.g., **carotid duplex**) assesses extracranial vessels but cannot directly detect **ischemic changes** within the brain tissue itself. *PET scan* - **PET (Positron Emission Tomography)** can assess brain metabolism and blood flow but is typically not the preferred or most sensitive modality for **early detection of acute ischemic stroke** due to its complexity, cost, and limited availability in emergency settings. - PET is more commonly used in research or for assessing chronic conditions and **metabolic abnormalities**, rather than acute stroke diagnosis.
Question 4: A man presents to the emergency department with a head injury following a vehicular accident. What is the investigation of choice?
- A. MRI
- B. CECT
- C. NCCT (Correct Answer)
- D. X-ray
Explanation: ***NCCT*** - **Non-contrast Computed Tomography (NCCT)** of the head is the **investigation of choice** for acute head trauma due to its rapid acquisition, wide availability, and excellent sensitivity for detecting acute hemorrhage, fractures, and mass effects. - It rapidly identifies life-threatening conditions such as **epidural, subdural, and intracerebral hemorrhages**, which require immediate intervention. *MRI* - **MRI** is superior for detecting subtle brain tissue injuries, diffuse axonal injury, and non-hemorrhagic lesions but is generally **not the first-line investigation** in acute trauma due to longer scan times, limited availability in the emergency setting, and inability to detect acute hemorrhage as clearly as CT. - Its use is typically reserved for follow-up studies or when CT findings are inconclusive or specific soft tissue detail is required. *CECT* - **Contrast-enhanced CT (CECT)** of the head is reserved for specific indications like evaluating vascular lesions (e.g., aneurysms, arteriovenous malformations) or tumors, which are generally **not the primary concern** in the initial assessment of acute head trauma. - Administering contrast agents can delay imaging, may pose risks to patients with renal impairment or allergies, and does not significantly improve the detection of acute traumatic hemorrhage compared to NCCT. *X-ray* - **X-rays** of the skull are useful for detecting **skull fractures**, but they provide **limited information** regarding intracranial injuries or soft tissue damage, which are critical in head trauma. - They have largely been superseded by CT scans, which offer a more comprehensive view of both bony structures and intracranial contents.
Question 5: Most specific finding of acute stroke on CT
- A. Sulcal effacement
- B. Hyperdense MCA sign (Correct Answer)
- C. Mass effect
- D. Loss of gray-white differentiation
Explanation: ***Hyperdense MCA sign*** - The **hyperdense middle cerebral artery (MCA) sign** is a direct visualization of a **thrombus** within the MCA, making it highly specific for an acute ischemic stroke caused by large vessel occlusion. - This sign indicates an acute arterial occlusion, which is key to early diagnosis and determining eligibility for **thrombolytic therapy**. *Sulcal effacement* - **Sulcal effacement** (loss of the normal grooves in the brain surface) may be an early sign of **brain edema** secondary to ischemia. - However, it is a non-specific finding and can be seen in other conditions causing brain swelling, such as trauma or infection. *Mass effect* - **Mass effect**, such as midline shift or effacement of ventricles, typically occurs later in the course of a large ischemic stroke due to significant edema. - In the acute phase, especially within the first few hours, mass effect is usually not evident, and its presence might suggest a different pathology or a more advanced stroke. *Loss of gray-white differentiation* - **Loss of gray-white differentiation** is an indirect sign of early cerebral ischemia, reflecting developing cytotoxic edema in the affected brain tissue. - While an important early indicator, it is less specific than the hyperdense MCA sign, as various acute brain injuries can cause similar changes.
Question 6: A child presented with blunt abdominal trauma, the first investigation to be done is -
- A. USG (Correct Answer)
- B. CT Scan
- C. Complete Hemogram
- D. Abdominal X-ray
Explanation: ***USG*** - An **ultrasound (USG)** is the **first-line imaging investigation** for blunt abdominal trauma in children due to its **non-invasive nature**, lack of radiation exposure, and rapid bedside availability. - **FAST (Focused Assessment with Sonography for Trauma)** effectively identifies the presence of **free fluid** (indicating internal bleeding/hemoperitoneum) and can assess solid organ injuries, particularly the **spleen and liver**. - It is the **preferred initial investigation in hemodynamically stable pediatric patients**. *CT Scan* - A **CT scan** is more sensitive and provides detailed anatomical information but involves significant **radiation exposure**, which is a major concern in children. - It is usually reserved for cases where USG is inconclusive, there is a **high clinical suspicion of severe injury**, or when determining the need for surgical intervention in hemodynamically stable patients. *Complete Hemogram* - A **complete hemogram** assesses blood components like hemoglobin and hematocrit, which are crucial for evaluating blood loss, but it is a **laboratory test, not an imaging investigation**. - While important for initial assessment and serial monitoring, it doesn't provide immediate information about the **location, type, or extent of internal abdominal injuries**. *Abdominal X-ray* - An **abdominal X-ray** has limited utility in blunt abdominal trauma as it is primarily useful for detecting **hollow viscus perforation (free air)** or bony fractures. - It does not effectively visualize soft tissue injuries, fluid collections, or solid organ damage, making it unsuitable as the primary diagnostic tool in blunt abdominal trauma.
Question 7: Best method to diagnose hydrocephalus in a fetus at 24 weeks gestation is:
- A. Ultrasound (Correct Answer)
- B. X-ray
- C. CT scan
- D. MRI
Explanation: ***Ultrasound*** - **Fetal ultrasound** is the primary and most effective imaging modality for diagnosing hydrocephalus in a 6-month-old fetus due to its **safety**, accessibility, and ability to visualize the developing brain. - It allows for the measurement of **ventricular size** and observation of characteristic features of hydrocephalus, such as **ventriculomegaly** and **dangling choroid plexus**. *X-ray* - **X-rays** use ionizing radiation, which is generally avoided in pregnant women due to potential risks to the developing fetus. - They provide limited detail of **soft tissues** like the brain and would not be effective in diagnosing hydrocephalus. *CT scan* - **CT scans** also involve significant **radiation exposure**, posing risks to the fetus and limiting their use in prenatal diagnosis. - While capable of visualizing brain structures, the benefits do not outweigh the **radiation risk** when safer and equally effective alternatives like ultrasound are available. *MRI* - **Fetal MRI** can provide detailed imaging of the fetal brain but is typically reserved for **further characterization** of anomalies identified by ultrasound or when ultrasound findings are inconclusive. - It is more expensive and less readily available than ultrasound, making it a **secondary imaging tool** rather than the primary diagnostic method for initial screening.
Question 8: A sick intubated neonate is having bilateral jerk of both right and left upper limbs with some occasional twitching of neck as well. Likely type of seizures:
- A. Multifocal clonic (Correct Answer)
- B. Multifocal tonic clonic
- C. Focal tonic
- D. Focal clonic
Explanation: ***Multifocal clonic*** - This description fits **multifocal clonic seizures**, characterized by **migratory clonic activity** observed in different body parts at varying times, sometimes simultaneously. - The **bilateral jerk** of upper limbs and occasional neck twitching point to this pattern, as the involvement is not uniform or generalized, but rather appears in multiple, distinct locations. *Multifocal tonic clonic* - This option incorrectly combines multifocal activity with a **tonic component**, which is described as stiffening or sustained contraction, not just jerking. - While activity may be multifocal, the specific description of "jerk" primarily suggests a **clonic nature**, without a clear tonic phase. *Focal tonic* - **Focal tonic seizures** involve sustained **stiffening or contraction** of muscles in a specific, localized area of the body, which is not described. - The term "jerk" indicates a **clonic movement**, and the involvement of multiple areas (bilateral upper limbs, neck) rules out a single focal onset. *Focal clonic* - **Focal clonic seizures** are characterized by rhythmic jerking movements limited to a **single, localized part** of the body without spreading to other areas. - The presence of jerking in **both upper limbs** and occasional neck twitching indicates activity in multiple sites, not restricted to a single focal area.
Question 9: A 35-year-old man has a headache, sleepiness, and poor balance that have worsened over the past week. The patient is known to be HIV-seropositive. On examination, his responses are slow and he has some difficulty in sustaining attention. He has right hemiparesis with increased reflexes on the right. Routine cell counts and chemistries are normal. What is the most appropriate next step?
- A. Perform a lumbar puncture
- B. Start antiretroviral therapy
- C. Start intravenous heparin
- D. Get a head CT with contrast (Correct Answer)
Explanation: The patient's symptoms (headache, sleepiness, poor balance, hemiparesis, focality) and **HIV-positive status** strongly suggest a **central nervous system (CNS) lesion**, such as **Toxoplasmosis** [1] or **primary CNS lymphoma** [1]. A **head CT with contrast** is essential to identify and characterize such lesions before considering invasive procedures like lumbar puncture, which could be dangerous if there is significant mass effect [4]. While a lumbar puncture might be relevant for some CNS infections, performing it without prior imaging in a patient with **focal neurological deficits** and potential **increased intracranial pressure** carries a risk of **herniation** [2]. Areas of low density in the white matter on CT [3] or space-occupying lesions with ring enhancement [1] are key findings required for diagnosis.
Question 10: A newborn male infant presents with the findings shown in the image. The clinical diagnosis is?
- A. Hypospadias
- B. Micro-penis
- C. Mauriac syndrome
- D. Epispadias (Correct Answer)
Explanation: ***Epispadias*** - The image depicts a severe form of **epispadias**, characterized by the exposed **bladder mucosa (exstrophy)** and a penile shaft that is short, dorsally curved, and has the urethral opening on the dorsal surface. - This congenital anomaly results from a failure of the abdominal wall and bladder to close properly during fetal development, often presenting with a **widened pubic symphysis**. *Hypospadias* - **Hypospadias** is a condition where the **urethral opening** is located on the **ventral** (underside) surface of the penis, not the dorsal surface as seen in the image. - While it can involve chordee (penile curvature), it typically does not present with bladder exstrophy. *Micro-penis* - **Micropenis** refers to a penis that is **abnormally small** in length, but otherwise structurally normal. - It describes the size of the penis, not an anomalous opening or exposed internal organs, and is not consistent with the image. *Mauriac syndrome* - **Mauriac syndrome** is a rare complication of poorly controlled **Type 1 diabetes** in children, characterized by growth retardation, delayed puberty, hepatomegaly, and Cushingoid features. - It is an **endocrine disorder** and has no direct relevance to the anatomical abnormality shown in the image.
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