Emergency Radiology Practice Questions

Q: Most sensitive investigation for abdominal trauma in a hemodynamically stable patient is-

CT Scan (Computed Tomography). ***CT Scan (Computed Tomography)*** - **CT scans** offer superior anatomical detail and can accurately detect organ damage, hemorrhage, and other injuries in **hemodynamically stable** patients with abdominal trauma. - It is considered the **most sensitive** and specific imaging modality for evaluating blunt and penetrating abdominal trauma when the patient can tolerate the study. *Ultrasonography (FAST)* - While effective for detecting **free fluid** (blood) in specific abdominal areas, **Focused Assessment with Sonography for Trauma (FAST)** has lower sensitivity for solid organ injuries or bowel perforations. - Its primary role is rapid assessment for **hemoperitoneum** to guide immediate management in unstable patients, not detailed injury characterization. *Diagnostic peritoneal lavage (DPL)* - **DPL** is an invasive procedure with high sensitivity for detecting **intraperitoneal bleeding**, but it does not identify specific organ injuries or retroperitoneal hemorrhage. - It is rarely used in hemodynamically stable patients due to its invasiveness and the availability of more detailed imaging techniques. *MRI (Magnetic Resonance Imaging)* - **MRI** provides excellent soft tissue contrast but is typically too **time-consuming** and less accessible in urgent trauma settings compared to CT. - It's generally not the first-line investigation for acute abdominal trauma due to motion artifacts and limited utility in detecting air or bone injuries.

Q: In a hemodynamically stable patient with abdominal trauma, which imaging modality is considered the gold standard for diagnosing and grading solid organ injuries?

CT scan. ***CT scan (Correct Answer)*** - **Contrast-enhanced CT (CECT)** is the **gold standard** for diagnosing and grading solid organ injuries in hemodynamically stable patients with abdominal trauma - Provides **high sensitivity (95-100%)** and specificity for detecting injuries to liver, spleen, kidneys, and pancreas - Enables accurate **injury grading** using the AAST (American Association for the Surgery of Trauma) classification system - Can detect **active hemorrhage** (contrast extravasation) and guide decisions between operative vs non-operative management - Recommended by **ATLS (Advanced Trauma Life Support)** protocols for stable trauma patients *Ultrasound (Incorrect)* - **FAST (Focused Assessment with Sonography for Trauma)** is excellent for rapid detection of **free intraperitoneal fluid** in unstable patients - However, it has **limited sensitivity (28-50%)** for solid organ parenchymal injuries and cannot grade injury severity - Highly **operator-dependent** with performance affected by body habitus, bowel gas, and subcutaneous emphysema - Best used as a triage tool, not for definitive diagnosis or grading *MRI (Incorrect)* - Offers excellent **soft tissue contrast** but is not suitable for acute trauma evaluation - Major limitations include **long acquisition time** (30-60 minutes), limited emergency availability, and challenges with monitoring critically ill patients - May be used in **specific scenarios** such as pregnant patients where radiation exposure is a concern, or for delayed evaluation of pancreatic/bowel injuries *X-ray (Incorrect)* - **Plain radiographs** have minimal role in evaluating solid organ injuries due to poor soft tissue resolution - Primarily useful for detecting **skeletal fractures**, **pneumoperitoneum** (free air under diaphragm), or **pneumothorax** in trauma patients - Cannot visualize parenchymal injuries, hematomas, or assess organ integrity - Has been largely replaced by CT in modern trauma protocols

Q: A 45-year-old female presents with the acute onset of a severe headache and vomiting. A non-contrast CT shows a crescent-shaped hyperdense area crossing suture lines. What is the most likely diagnosis?

Subdural hematoma. ***Subdural hematoma*** - A **crescent-shaped hyperdense area** on a non-contrast CT that **crosses suture lines** is the classic imaging finding for a subdural hematoma. - This typically results from the tearing of **bridging veins** and can present acutely or chronically. *Epidural hematoma* - This typically appears as a **lenticular (lens-shaped) hyperdense collection** on CT. - Epidural hematomas characteristically **do not cross suture lines** because the dura is tightly adherent to the skull at these points. *Subarachnoid hemorrhage* - Identified by the presence of blood within the **subarachnoid space**, appearing as **hyperdensity in the sulci and basal cisterns** on CT. - While it causes severe headache, its CT appearance is diffuse and does not form a contained crescent or lenticular shape. *Intracerebral hemorrhage* - Appears as a **focal, hyperdense collection of blood within the brain parenchyma** itself. - It does not conform to the shape of an extra-axial collection like a crescent or lenticular shape.

Q: What is the investigation of choice for diagnosing solid organ injuries in abdominal trauma?

CT scan. ***CT scan*** - A **CT scan** is the investigation of choice for diagnosing solid organ injuries due to its high sensitivity and specificity in detecting **hemoperitoneum**, organ lacerations, and active bleeding. - It provides detailed cross-sectional images, allowing for precise localization and grading of injuries, crucial for **surgical planning**. *Ultrasound* - While useful for rapid assessment of **free fluid** (FAST scan), it has limited sensitivity for detecting parenchymal organ injuries and cannot reliably assess the extent of damage or active bleeding. - Its utility is primarily in the **initial triage** of hemodynamically unstable patients to identify the presence of significant intra-abdominal bleeding. *MRI* - **MRI** offers excellent soft tissue contrast but is typically too time-consuming and often impractical in the acute trauma setting, especially for **unstable patients**. - Its role is usually reserved for specific indications, such as spinal cord injuries, or when **CT scans** are contraindicated for certain reasons, like **pregnancy**. *X-ray* - **X-rays** are primarily used to detect skeletal injuries, such as fractures, or to visualize air under the diaphragm indicating **hollow viscus perforation**, rather than solid organ damage. - They provide very limited information regarding the **parenchyma of solid organs** and are not sufficient for diagnosing or staging solid organ injuries.

Q: A 75-year-old male with a history of hypertension presents with sudden-onset severe abdominal pain radiating to the back. Which diagnostic tool would be most beneficial in differentiating between a ruptured abdominal aneurysm and acute pancreatitis?

CT angiography. ***CT angiography*** - **CT angiography** is the most beneficial tool for differentiating a **ruptured abdominal aortic aneurysm (AAA)** from acute pancreatitis due to its ability to visualize the aorta and detect active extravasation or hematoma [2]. - It clearly identifies the presence, size, and rupture status of an AAA, which is crucial for immediate surgical planning [1]. *MRI abdomen with contrast* - While MRI can provide detailed soft tissue imaging, it is generally **less rapid** and **more expensive** than CT in emergent situations, especially for suspected rupture [2]. - **Motion artifacts** from abdominal breathing can also degrade image quality, and it may not be as readily available in emergency settings as CT. *Endoscopic ultrasound* - **Endoscopic ultrasound (EUS)** is primarily used for detailed imaging of the pancreas, bile ducts, and upper gastrointestinal tract, but it is **invasive** and not suitable for an acute emergency like a suspected AAA rupture. - EUS would not be effective in assessing the aorta for rupture or dissecting an aneurysm. *CT abdomen with oral contrast* - A standard **CT scan of the abdomen with oral contrast** is useful for evaluating the bowel and other intra-abdominal structures, but **oral contrast does not enhance vascular structures sufficiently** to diagnose an AAA rupture. - It would not provide the clear arterial phase imaging necessary to detect active bleeding or the integrity of the aortic wall as effectively as CT angiography [3].

Q: Investigation of choice to evaluate intracranial hemorrhage of less than 48 hours is -

CT scan. ***CT scan*** - **Non-contrast CT** is the most sensitive and rapid imaging modality for detecting acute intracranial hemorrhage, appearing as a **hyperdense** (bright) area within the brain parenchyma or subarachnoid space. - It is readily available in emergency settings and is crucial for immediate diagnosis to guide management, especially within the first **48 hours**. *MRI* - While MRI can detect hemorrhage, its sensitivity for **acute hemorrhage** (especially within the first few hours) is less than CT, and it is more time-consuming. - MRI is superior for detecting older hemorrhage or subtle lesions, but it is not the **first-line investigation** for acute bleeding. *PET* - **Positron Emission Tomography** (PET) scans are primarily used to assess metabolic activity and blood flow in the brain, often for conditions like cancer, epilepsy, or dementia. - It does not directly visualize fresh blood and therefore is not used for the diagnosis of **acute intracranial hemorrhage**. *SPECT* - **Single-Photon Emission Computed Tomography** (SPECT) is used to evaluate cerebral blood flow and neuronal activity, similar to PET but with different tracers and resolution. - It is not indicated for the rapid assessment of **acute intracranial hemorrhage** as it does not directly image blood.

Q: Tear drop sign is seen in?

Blow out fracture. ***Blow out fracture*** - The **tear drop sign** on imaging (often CT scan) is characteristic of an **orbital blow-out fracture**, indicating herniation of orbital contents (fat, muscle) into the maxillary sinus. - This fracture typically involves the **orbital floor** or medial wall, often caused by a blunt force trauma to the eye. *Fracture zygomatic arch* - A fracture of the zygomatic arch is often associated with a **flattening of the malar prominence** rather than a "tear drop" sign. - It might lead to restricted jaw movement if the arch impinges on the coronoid process. *Fracture maxilla* - Maxillary fractures (e.g., Le Fort fractures) involve the midface bones and cause **facial deformity**, malocclusion, and mobility of the maxilla. - The tear drop sign is not a primary diagnostic feature of maxillary fractures. *Fracture mandible* - Mandibular fractures present with pain, swelling, and **malocclusion** of the teeth. - Imaging would reveal a break in the mandible, not a tear drop sign associated with orbital contents.

Q: A polytrauma patient's CT brain shows a crescent-shaped extra-axial collection with a concave inner margin. What is the most likely diagnosis?

SDH. ***SDH*** - The image shows a **crescent-shaped collection** of hemorrhage with a concave inner margin, consistent with a **subdural hematoma** (SDH). - SDHs result from the tearing of **bridging veins** and typically conform to the brain's surface, crossing suture lines but not limited by bony sutures. *EDH* - An **epidural hematoma (EDH)** characteristically appears as a **lenticular** or **biconvex** shape on CT, not crescent-shaped. - EDHs are typically caused by arterial bleeding, often from the **middle meningeal artery**, and are limited by cranial sutures. *Contusion* - A **contusion** is brain tissue bruising that appears as **heterogeneous areas** of hemorrhage and edema within the brain parenchyma itself. - It would not manifest as a distinct extra-axial collection with a smooth, concave margin. *Diffuse axonal injury* - **Diffuse axonal injury (DAI)** involves widespread microscopic damage to axons, often at the gray-white matter junction. - It may appear as *punctate hemorrhages* or **small lesions** at these junctions on CT, but often the CT can be normal, and it would not present as a large extra-axial collection.

Q: The most appropriate investigation to diagnose and determine the extent of renal injury in a 15-year-old boy who presents with hematuria and left-sided abdominal pain 48 hours after sustaining a blunt abdominal injury, with a pulse rate of 96/minute, blood pressure of 110/70 mmHg, hemoglobin of 10.8 gm%, and packed cell volume of 31%, would be-

Contrast enhanced computed tomography. ***Contrast enhanced computed tomography*** - **CT with intravenous contrast** is the gold standard for evaluating **renal trauma**, providing detailed anatomical information on the extent of injury, including lacerations, hematomas, and urinary extravasation, which might be missed by other modalities. - It rapidly assesses the **parenchyma**, **collecting system**, and surrounding structures, allowing for proper staging of the injury and guiding management decisions. *Sonographic evaluation of abdomen* - **Ultrasound** is useful for rapidly detecting **free fluid** (e.g., blood) in the abdomen and assessing major organ integrity, but its ability to characterize renal parenchymal injuries or urinary extravasation is limited. - It is **operator-dependent** and often insufficient for detailed staging of renal trauma compared to CT. *Intravenous pyelography* - **IVP** primarily evaluates the **collecting system** and ureteral patency but has limited sensitivity for assessing renal parenchymal injuries or perinephric hematomas. - It involves radiation exposure and a contrast load, and generally provides **less anatomical detail** than modern CT scans. *MR urography* - **MR urography** provides excellent soft tissue contrast without ionizing radiation, but it is typically **less readily available** in an emergency setting and takes longer to perform than CT. - Its role in acute trauma is usually reserved for cases where **iodinated contrast is contraindicated** (e.g., severe allergy, renal insufficiency) or when specific soft-tissue detail is crucial for follow-up.

Q: Thumb sign in lateral X-ray of the neck is seen in?

Epiglottitis. ***Epiglottitis*** - The **thumb sign** on a lateral neck X-ray is a classic finding in **acute epiglottitis**, caused by the severely swollen epiglottis. - This swelling can lead to severe **airway obstruction** due to its critical location. *Internal hemorrhage* - Internal hemorrhage in the neck might cause soft tissue swelling, but it typically does not produce the specific **"thumb sign" morphology** seen in epiglottitis. - Diagnosis relies more on **clinical signs of bleeding** and potentially imaging like CT scans to localize blood collections. *Saccular cyst* - A **saccular cyst** (or laryngocele) is a benign air-filled or fluid-filled sac - It would appear as a well-defined, often air-filled, or soft-tissue mass, not typically resembling the diffuse, inflamed "thumb" appearance of a swollen epiglottis. *Carcinoma of the epiglottis* - While a **carcinoma of the epiglottis** could cause epiglottic swelling or mass effect, it usually presents as a more irregular or focal mass rather than the uniform, bulbous swelling characteristic of the "thumb sign" in acute epiglottitis. - Carcinoma is also typically a chronic process, unlike the acute, rapidly progressing inflammation of epiglottitis.

Question 1

Most sensitive investigation for abdominal trauma in a hemodynamically stable patient is-

Accepted Answer

CT Scan (Computed Tomography)

Answer

Ultrasonography (FAST)

Answer

Diagnostic peritoneal lavage (DPL)

Answer

MRI (Magnetic Resonance Imaging)

Question 2

In a hemodynamically stable patient with abdominal trauma, which imaging modality is considered the gold standard for diagnosing and grading solid organ injuries?

Accepted Answer

CT scan

Answer

Ultrasound

Answer

MRI

Answer

X-ray

Question 3

A 45-year-old female presents with the acute onset of a severe headache and vomiting. A non-contrast CT shows a crescent-shaped hyperdense area crossing suture lines. What is the most likely diagnosis?

Accepted Answer

Subdural hematoma

Answer

Epidural hematoma

Answer

Subarachnoid hemorrhage

Answer

Intracerebral hemorrhage

Question 4

What is the investigation of choice for diagnosing solid organ injuries in abdominal trauma?

Accepted Answer

CT scan

Answer

Ultrasound

Answer

MRI

Answer

X-ray

Question 5

A 75-year-old male with a history of hypertension presents with sudden-onset severe abdominal pain radiating to the back. Which diagnostic tool would be most beneficial in differentiating between a ruptured abdominal aneurysm and acute pancreatitis?

Accepted Answer

CT angiography

Answer

MRI abdomen with contrast

Answer

Endoscopic ultrasound

Answer

CT abdomen with oral contrast

Question 6

Investigation of choice to evaluate intracranial hemorrhage of less than 48 hours is -

Accepted Answer

CT scan

Answer

MRI

Answer

PET

Answer

SPECT

Question 7

Tear drop sign is seen in?

Accepted Answer

Blow out fracture

Answer

Fracture zygomatic arch

Answer

Fracture maxilla

Answer

Fracture mandible

Question 8

A polytrauma patient's CT brain shows a crescent-shaped extra-axial collection with a concave inner margin. What is the most likely diagnosis?

Accepted Answer

SDH

Answer

EDH

Answer

Contusion

Answer

Diffuse axonal injury

Question 9

The most appropriate investigation to diagnose and determine the extent of renal injury in a 15-year-old boy who presents with hematuria and left-sided abdominal pain 48 hours after sustaining a blunt abdominal injury, with a pulse rate of 96/minute, blood pressure of 110/70 mmHg, hemoglobin of 10.8 gm%, and packed cell volume of 31%, would be-

Accepted Answer

Contrast enhanced computed tomography

Answer

Sonographic evaluation of abdomen

Answer

Intravenous pyelography

Answer

MR urography

Question 10

Thumb sign in lateral X-ray of the neck is seen in?

Accepted Answer

Epiglottitis

Answer

Internal hemorrhage

Answer

Saccular cyst

Answer

Carcinoma of the epiglottis

Emergency Radiology — MCQs

Emergency Radiology — MCQs

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