Head Trauma Imaging — MCQs

10 questions

What is the most common cause of subarachnoid hemorrhage?

Which of the following is not a type of skull fracture?

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

Which is an ominous sign in case of severe head injury?

Shape of post traumatic Epidural hematoma is

Diffuse axonal injury is characterized by lesion at:

After rupture of middle meningeal artery bleeding occurs in which region?

Lucid interval is most commonly seen in -

Palpable femur head on per rectal exam is a feature of which of the following conditions?

Q10

A middle-aged person is rushed to the emergency department with a history of loss of motor power in the left upper and lower limb since the last 30 minutes. The imaging modality of choice to plan appropriate treatment would be

Head Trauma Imaging Indian Medical PG Practice Questions and MCQs

Question 1: What is the most common cause of subarachnoid hemorrhage?

A. Rupture of berry aneurysm (Correct Answer)
B. Non-aneurysmal hemorrhage
C. Arteriovenous malformation
D. Vertebral artery dissection

Explanation: ***Rupture of berry aneurysm*** - **Rupture of a berry (saccular) aneurysm** is responsible for approximately 85% of all non-traumatic subarachnoid hemorrhages [1]. - These aneurysms are typically located at the **bifurcations of cerebral arteries** within the Circle of Willis. *Arteriovenous malformation* - **Arteriovenous malformations (AVMs)** are abnormal connections between arteries and veins, bypassing the capillary system. - While AVMs can cause subarachnoid hemorrhage, they are a less common cause compared to ruptured berry aneurysms. *Vertebral artery dissection* - **Vertebral artery dissection** involves a tear in the inner lining of the vertebral artery, often leading to stroke or other posterior circulation symptoms. - Subarachnoid hemorrhage from vertebral artery dissection is rare and typically associated with an intramural hematoma extending into the subarachnous space. *Non-aneurysmal hemorrhage* - **Non-aneurysmal subarachnoid hemorrhage** (also known as perimesencephalic subarachnoid hemorrhage) accounts for a small percentage of cases, with no identifiable aneurysm on angiography [1]. - The bleeding is usually confined to the perimesencephalic cisterns and generally has a better prognosis than aneurysmal hemorrhage.

Question 2: Which of the following is not a type of skull fracture?

A. Linear
B. Depressed
C. Basal
D. Diffuse axonal injury (Correct Answer)

Explanation: ***Diffuse axonal injury*** - **Diffuse axonal injury (DAI)** is a type of **traumatic brain injury** caused by shearing forces that damage axons. - It is a **microscopic brain injury** and does not involve a fracture of the skull bones. *Linear* - A **linear skull fracture** is a break in a cranial bone that appears as a thin line without bone displacement. - It is a common type of skull fracture, often occurring from low-energy blunt trauma. *Depressed* - A **depressed skull fracture** occurs when pieces of fractured bone are driven inward towards the brain. - This type of fracture often requires surgical intervention to elevate the bone fragments and reduce pressure on the brain. *Basal* - A **basal skull fracture** involves a break in the bones at the base of the skull. - It is often associated with signs like **raccoon eyes**, **Battle's sign**, and cerebrospinal fluid (CSF) leakage from the nose or ears.

Question 3: A polytrauma patient's CT brain shows a crescent-shaped extra-axial collection with a concave inner margin. What is the most likely diagnosis?

A. EDH
B. SDH (Correct Answer)
C. Contusion
D. Diffuse axonal injury

Explanation: ***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.

Question 4: Which is an ominous sign in case of severe head injury?

A. Depressed skull fracture
B. Development of diabetes insipidus
C. New focal deficit
D. Anisocoria (Correct Answer)

Explanation: ***Anisocoria*** - **Anisocoria** (unequal pupil size) in the setting of severe head injury indicates uncal herniation, a life-threatening condition where the temporal lobe compresses the **oculomotor nerve (CN III)**. - This compression leads to ipsilateral pupillary dilation that is **non-reactive to light**, signifying severe brainstem compromise and poor prognosis. *Depressed skull fracture* - A **depressed skull fracture** is a significant injury but does not inherently indicate immediate life-threatening brainstem compression or herniation. - While it can lead to neurological deficits or infection, it is usually amenable to surgical intervention and does not carry the same immediate ominous prognosis as anisocoria. *Development of diabetes insipidus* - **Diabetes insipidus** can occur due to damage to the posterior pituitary or hypothalamus affecting **ADH secretion**, but it typically develops days after the injury. - While a serious complication indicating **hypothalamic-pituitary axis damage**, it is not an immediate sign of impending brain herniation or brainstem failure like anisocoria. *New focal deficit* - A **new focal deficit** (e.g., hemiparesis) signifies localized brain injury or worsening intracranial pathology (like hematoma expansion). - While concerning and requiring urgent evaluation, it is generally less immediately ominous than anisocoria, which specifically points to **brainstem compression and herniation**, often indicating an irreversible process if not promptly treated.

Question 5: Shape of post traumatic Epidural hematoma is

A. Biconvex hyperdense (Correct Answer)
B. Biconcave hyperdense
C. Biconvex hypodense
D. Biconcave hypodense

Explanation: ***Biconvex hyperdense*** - An **epidural hematoma** is typically shaped like a **biconvex** (lens-shaped) lesion because the blood collects between the skull and the dura mater, which is tightly adherent to the cranial sutures. - The fresh blood is **hyperdense** (bright white) on a CT scan due to its high protein content. *Biconcave hyperdense* - **Biconcave** hematomas are characteristic of **subdural hematomas**, which spread diffusely over the brain surface within the subdural space. - While acute subdural hematomas are also **hyperdense**, their shape is distinctly different from epidural hematomas. *Biconvex hypodense* - A **biconvex shape** is consistent with an epidural hematoma, but **hypodense** (darker) would suggest an older, chronic hematoma where blood products have degraded. - Acute epidural hematomas are always **hyperdense** due to fresh blood. *Biconcave hypodense* - This description aligns with a **chronic subdural hematoma**, which is typically **biconcave** (crescent-shaped) and **hypodense** due to the breakdown of blood products over time. - It does not describe an acute post-traumatic epidural hematoma.

Question 6: Diffuse axonal injury is characterized by lesion at:

A. Basal ganglia
B. Corpus callosum
C. White matter
D. Junction of gray and white matter (Correct Answer)

Explanation: ***Junction of gray and white matter*** - Diffuse axonal injury (DAI) is characteristically located at the **gray-white matter junction** (interface between cortex and subcortical white matter) [1] - The differential density and movement between gray and white matter during **rotational acceleration-deceleration injuries** creates maximum shearing forces at this junction [1] - This is the **classic and most characteristic location** of DAI lesions, particularly in the **parasagittal white matter** of cerebral hemispheres - Other common sites include corpus callosum and dorsolateral brainstem, but the gray-white junction is the hallmark location *White matter* - While DAI does involve damage to white matter tracts and axons, simply stating "white matter" is too non-specific [1] - Many other conditions affect white matter (demyelination, ischemia, etc.) - The **distinguishing feature of DAI** is its predilection for the gray-white interface, not white matter in general *Corpus callosum* - The corpus callosum is indeed a common site for **visible macroscopic DAI lesions** and hemorrhages [1] - However, this is just one specific location rather than the characteristic pattern - DAI is more broadly characterized by lesions at gray-white junctions throughout the brain *Basal ganglia* - The basal ganglia are deep gray matter structures not typically involved in classic DAI - These structures may be affected by other traumatic injuries like **contusions** or **deep hemorrhages** - DAI predominantly affects the interface zones and white matter tracts, not deep gray matter nuclei **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 7: After rupture of middle meningeal artery bleeding occurs in which region?

A. Subdural bleed
B. Subarachnoid bleed
C. Extradural bleed (Correct Answer)
D. Intracerebral bleed

Explanation: ***Extradural bleed*** - A rupture of the **middle meningeal artery** is the classic cause of an **extradural (epidural) hematoma**. - This type of bleed occurs between the **dura mater** and the **inner surface of the skull**. *Subdural bleed* - A **subdural bleed** typically results from tearing of **bridging veins**, not arteries. - This bleeding occurs between the **dura mater** and the **arachnoid mater**. *Subarachnoid bleed* - A **subarachnoid bleed** most commonly results from the rupture of an **aneurysm** or arteriovenous malformation. - This bleed occurs in the space between the **arachnoid mater** and the **pia mater**, where cerebrospinal fluid circulates. *Intracerebral bleed* - An **intracerebral bleed** involves bleeding directly into the **brain parenchyma**. - This is often caused by **hypertension**, trauma, or an underlying vascular malformation, not typically a ruptured meningeal artery.

Question 8: Lucid interval is most commonly seen in -

A. Subarachnoid hemorrhage
B. Acute extradural hemorrhage (Correct Answer)
C. Acute Subdural Hemorrhage
D. Chronic Subdural Hemorrhage

Explanation: ***Acute extradural hemorrhage*** - A **lucid interval** is a classic feature where the patient initially loses consciousness from the injury, regains consciousness and appears relatively normal, only to deteriorate rapidly later due to the expanding hematoma. [1] - This is due to the arterial bleeding, typically from the **middle meningeal artery**, which quickly accumulates blood, compressing the brain. [1] *Subarachnoid hemorrhage* - Patients with subarachnoid hemorrhage typically present with a **sudden, severe headache** (thunderclap headache) and often do not experience a distinct lucid interval. [2] - The bleeding occurs within the **subarachnoid space** and is usually diffuse, causing immediate widespread neurological symptoms. [2] *Acute Subdural Hemorrhage* - While loss of consciousness occurs, a clear **lucid interval** is less common or prominent compared to extradural hemorrhage. [1] - Bleeding is usually venous, causing a slower but steady accumulation of blood, and the patient's neurological status tends to **deteriorate more gradually** or remain continuously impaired. [3] *Chronic Subdural Hemorrhage* - This typically occurs in older individuals or alcoholics, often following minor trauma, and symptoms develop **insidiously over weeks**. [3] - There is generally no acute **lucid interval**; instead, patients experience a gradual onset of headache, confusion, and neurological deficits.

Question 9: Palpable femur head on per rectal exam is a feature of which of the following conditions?

A. Inferior hip dislocation
B. Central hip dislocation
C. Posterior hip dislocation (Correct Answer)
D. Anterior hip dislocation

Explanation: ***Posterior hip dislocation*** - In **posterior hip dislocation**, the femoral head is displaced posteriorly and superiorly, often lying in the **gluteal region**. - A palpable femoral head on **per rectal exam** suggests the head has displaced medially enough to be felt through the rectal wall, which can occur in severe posterior dislocations where the head impinges on the pelvis. *Inferior hip dislocation* - In **inferior hip dislocation**, the femoral head displaces **inferiorly and anteriorly**, often lying below the acetabulum. - The femoral head would typically be palpable in the **perineum** or groin, not via per rectal exam. *Central hip dislocation* - **Central hip dislocation** involves the femoral head pushing through the **acetabular floor** into the pelvis. - This type of dislocation causes internal displacement, but the femoral head would not typically be palpable per rectally as it remains contained within the acetabular breach, rather it would be the **pelvic fracture** that would be palpable. *Anterior hip dislocation* - In **anterior hip dislocation**, the femoral head displaces **anteriorly**, often into the obturator foramen or pubic region. - The femoral head would be palpable in the **groin** or anterior thigh, not through a per rectal exam.

Question 10: A middle-aged person is rushed to the emergency department with a history of loss of motor power in the left upper and lower limb since the last 30 minutes. The imaging modality of choice to plan appropriate treatment would be

A. CT scan of the head (Correct Answer)
B. MRI of the brain
C. Carotid doppler study
D. EEG

Explanation: ***CT scan of the head*** - A **non-contrast CT scan of the head** is the immediate imaging modality of choice in acute stroke symptoms to quickly rule out a **hemorrhagic stroke**. - This rapid assessment guides treatment decisions; if hemorrhage is absent, **thrombolytic therapy (tPA)** can be considered within the critical time window. *MRI of the brain* - While **MRI** offers superior detail for detecting ischemic stroke, it is **unsuitable for initial emergency assessment** due to longer acquisition times and limited availability. - The delay in obtaining an MRI could critically hinder the initiation of time-sensitive therapies like **thrombolysis**. *Carotid doppler study* - A **carotid Doppler study** is useful for identifying **carotid artery stenosis**, which can be a cause of ischemic stroke but is not an acute diagnostic tool for stroke itself. - It does not provide information about the presence of hemorrhage or acute ischemic changes within the brain parenchyma. *EEG* - An **EEG (electroencephalogram)** measures electrical activity in the brain and is primarily used to diagnose conditions like **seizures** or evaluate altered mental status. - It provides no structural information and is not indicated for the initial evaluation of acute motor deficits indicative of a stroke.

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