Neuroradiology Practice Questions

Q: A 12-year-old boy is rushed to the emergency room in a coma after falling from an upper story window of his home. MRI shows a subdural hematoma over the left hemisphere. What is the most likely source of intracranial bleeding in this patient?

Bridging veins. ### Explanation **Correct Answer: A. Bridging veins** **Concept:** A **Subdural Hematoma (SDH)** occurs due to the rupture of the **bridging veins** as they traverse the subdural space to drain into the dural venous sinuses (most commonly the Superior Sagittal Sinus). These veins are susceptible to shearing forces during head trauma, especially in deceleration injuries like a fall. On imaging, SDH typically appears as a **crescent-shaped (concave)** collection that can cross suture lines but is limited by dural reflections (like the falx cerebri). **Analysis of Incorrect Options:** * **B. Charcot-Bouchard aneurysm:** These are microaneurysms of the small perforating arteries (e.g., lenticulostriate arteries) caused by chronic hypertension. Their rupture leads to **intraparenchymal hemorrhage**, typically in the basal ganglia, not a subdural hematoma. * **C. Internal carotid artery:** Rupture of the ICA or its branches (like the ACOM or PCOM) due to a berry aneurysm typically results in a **Subarachnoid Hemorrhage (SAH)**, characterized by blood in the cisterns and sulci ("star-shaped" appearance on CT). * **D. Middle meningeal artery:** This is the classic source of an **Epidural Hematoma (EDH)**. It is usually associated with a temporal bone fracture. On imaging, EDH appears **biconvex (lentiform)** and does not cross suture lines. **NEET-PG High-Yield Pearls:** * **Shape:** SDH = Crescentic/Concave; EDH = Biconvex/Lentiform. * **Sutures:** SDH **crosses** sutures; EDH **does not** cross sutures. * **Demographics:** While common in trauma, chronic SDH is frequently seen in elderly patients and alcoholics due to brain atrophy, which increases the tension on bridging veins. * **Imaging Choice:** Non-contrast CT (NCCT) Head is the initial investigation of choice in acute trauma, though MRI is more sensitive for small collections.

Q: Meningioma on plain radiography reveals which of the following findings?

Calcification. **Explanation:** **Meningiomas** are the most common primary intracranial tumors. On plain radiography (Skull X-ray), the most characteristic and frequent finding is **calcification**, which occurs in approximately 10–15% of cases. This calcification is often psammomatous (sand-like) and can appear as a faint, punctate, or dense amorphous mass. **Why the other options are incorrect:** * **Erosion:** While large meningiomas can cause pressure atrophy of the inner table, it is less characteristic than calcification or hyperostosis. * **Sutural diastasis:** This is a sign of generalized increased intracranial pressure (ICP) in children whose sutures have not yet fused. It is not a specific feature of meningioma itself. * **Osteosclerosis:** While meningiomas often cause **Hyperostosis** (thickening of the overlying bone due to tumor invasion or vascularity), "osteosclerosis" is a more general term for increased bone density and is not the preferred radiological descriptor for the reactive bone changes seen in meningiomas. **High-Yield Clinical Pearls for NEET-PG:** * **Hyperostosis frontalis interna:** A common mimic on X-ray, but usually bilateral and spares the midline. * **Sunburst appearance:** Meningiomas can show a "sunburst" or "radial" pattern of spicules due to periosteal reaction. * **Gold Standard:** Contrast-enhanced MRI is the investigation of choice, showing the classic **"Dural Tail Sign."** * **Histology:** Look for **Psammoma bodies** (laminated calcifications) and whorled patterns of cells. * **Vascularity:** On angiography, they show a characteristic **"Mother-in-law sign"** (comes early, stays late).

Q: What is the best radiographic view for visualizing the mandible?

Orthopantomogram. **Explanation:** The **Orthopantomogram (OPG)**, also known as a panoramic radiograph, is the gold standard and best initial screening tool for visualizing the mandible. **Why OPG is the Correct Answer:** The OPG provides a continuous, curved, two-dimensional panoramic view of the entire mandible, including the body, symphysis, angles, rami, and both condyles. It is particularly superior because it eliminates the superimposition of the cervical spine and the contralateral side of the jaw, which often obscures details in standard plain films. It allows for the assessment of multiple fracture sites (as mandible fractures are often multiple) and the relationship of teeth to the fracture line. **Analysis of Incorrect Options:** * **Anteroposterior (AP) View:** This view suffers from significant superimposition of the base of the skull and the cervical spine, making it difficult to visualize the mandibular body and symphysis clearly. * **Lateral View:** A true lateral view results in the overlap of the right and left halves of the mandible, rendering it nearly useless for diagnostic purposes unless taken as a "Lateral Oblique." * **Oblique View:** While the Lateral Oblique (Body or Ramus) view can help visualize specific segments, it does not provide a comprehensive view of the entire mandibular arch in a single film like the OPG. **Clinical Pearls for NEET-PG:** * **Gold Standard for Trauma:** While OPG is the best *radiographic* view, **NCCT (Non-Contrast CT) with 3D reconstruction** is the overall gold standard for complex maxillofacial trauma. * **Towne’s View:** Best for visualizing the **mandibular condyles** and the subcondylar region. * **Water’s View:** Best for visualizing the **maxilla, maxillary sinuses, and orbital floor**. * **Ring Bone Principle:** The mandible acts like a ring; if you see one fracture, always look for a second (often contralateral) fracture.

Q: The 'Hot Cross Bun' sign on MRI is characteristically seen in which of the following conditions?

Multisystem atrophy. ### Explanation The **'Hot Cross Bun' sign** is a classic neuroimaging finding characterized by a cruciform (cross-shaped) hyperintensity in the **pons** on T2-weighted MRI sequences. #### 1. Why Multisystem Atrophy (MSA) is Correct The sign is highly specific for **Multisystem Atrophy - Cerebellar type (MSA-C)**, formerly known as Olivopontocerebellar atrophy. * **Pathophysiology:** It results from the selective degeneration of the **pontine transverse fibers** and the **median raphe**, while the longitudinal corticospinal tracts are relatively preserved. * **Imaging:** The loss of these fibers leads to gliosis and increased water content, which appears as a bright "cross" against the darker background of the pons on T2 MRI, resembling the traditional spiced bun. #### 2. Analysis of Incorrect Options * **B. Lewy Body Dementia:** Characterized clinically by visual hallucinations and Parkinsonism. Imaging typically shows generalized cortical atrophy but lacks specific brainstem signs like the hot cross bun. * **C. Progressive Supranuclear Palsy (PSP):** Associated with the **'Hummingbird' sign** or **'King Penguin' sign** due to midbrain atrophy with a preserved pons. * **D. Alzheimer's Disease:** Characterized by disproportionate **hippocampal atrophy** (measured by the MTA score) and parietal lobe atrophy. #### 3. NEET-PG High-Yield Pearls * **MSA-P (Parkinsonian type):** Look for the **'Putaminal Slit' sign** (hyperintense rim at the lateral edge of the putamen). * **MSA-C (Cerebellar type):** Look for the **'Hot Cross Bun' sign** and olivopontocerebellar atrophy. * **Differential:** While classic for MSA, the hot cross bun sign can rarely be seen in other conditions like spinocerebellar ataxia (SCA) or secondary to vasculitis, but for exam purposes, **MSA-C** is the primary association.

Q: Premature filling of veins is a manifestation in cerebral angiography of which condition?

Arteriovenous malformation. ### Explanation **Correct Answer: C. Arteriovenous malformation (AVM)** **Underlying Concept:** In a normal physiological state, blood travels from arteries to capillaries and then to veins. This transition creates a "capillary delay," meaning veins visualize on an angiogram several seconds after the arterial phase. In an **Arteriovenous Malformation (AVM)**, there is a direct communication between arteries and veins through a "nidus," bypassing the high-resistance capillary bed. This **shunting** results in rapid, high-pressure blood flow directly into the venous system. Consequently, veins appear prematurely on angiography (often simultaneously with the arteries), which is a pathognomonic sign of AVM. **Analysis of Incorrect Options:** * **A. Trauma:** While trauma can cause vascular injuries like dissections or hematomas, it typically results in extravasation of contrast or vessel narrowing, not a systematic premature venous filling. * **B. Brain tumor:** Highly vascular tumors (like glioblastoma) may show increased vascularity or "tumor blush," but they do not typically demonstrate the rapid, direct arteriovenous shunting seen in AVMs. * **D. Arterial occlusion:** This leads to a **delay** or complete absence of contrast distal to the blockage, the exact opposite of premature filling. **NEET-PG High-Yield Pearls:** * **Gold Standard Investigation:** Digital Subtraction Angiography (DSA) is the gold standard for diagnosing and mapping AVMs. * **Classic Angiographic Triad for AVM:** 1. Dilated feeding arteries. 2. A "nidus" (tangle of vessels). 3. **Early draining veins** (Premature filling). * **Clinical Presentation:** The most common presentations are intracranial hemorrhage (ICH) or new-onset seizures in a young adult. * **Spetzler-Martin Grade:** Used to assess the surgical risk of AVMs based on size, eloquence of adjacent brain tissue, and venous drainage pattern.

Q: What condition is characterized by a "puff of smoke" appearance on contrast CT angiography?

Moya Moya Disease. **Explanation:** **Moya Moya Disease (Option A)** is a chronic, progressive cerebrovascular disorder characterized by the bilateral stenosis or occlusion of the terminal portion of the internal carotid arteries (ICA) and their proximal branches. To compensate for this ischemia, a network of fragile, dilated collateral vessels develops at the base of the brain (lenticulostriate and thalamostriate arteries). On angiography, these fine collaterals create a hazy, smoky appearance, which Japanese radiologists termed "Moya Moya" (meaning **"puff of smoke"**). **Analysis of Incorrect Options:** * **Acrodermatitis Enterohepatica (Option B):** A genetic disorder of zinc absorption characterized by periorificial dermatitis, alopecia, and diarrhea. It has no primary radiological vascular findings. * **Neuromyelitis Optica (Option C):** Also known as Devic’s disease, this is an inflammatory demyelinating condition affecting the optic nerves and spinal cord. MRI typically shows Longitudinally Extensive Transverse Myelitis (LETM). * **Kasabach-Merritt Syndrome (Option D):** A life-threatening condition where a vascular tumor (usually a tufted angioma or kaposiform hemangioendothelioma) leads to consumptive coagulopathy and thrombocytopenia. **High-Yield Clinical Pearls for NEET-PG:** * **Bimodal Age Distribution:** Typically affects children (presenting with TIA/Stroke) and adults in their 30s-40s (presenting with Hemorrhage). * **Imaging Gold Standard:** Digital Subtraction Angiography (DSA) is the gold standard for diagnosis and staging (Suzuki Staging). * **Ivy Sign:** On FLAIR MRI, slow-moving leptomeningeal collateral flow appears as linear hyperintensities in the sulci. * **Treatment:** Surgical revascularization (e.g., EDAS or STA-MCA bypass) is the definitive management.

Q: A 60-year-old male patient presented with spasticity in bilateral lower limbs, gait ataxia, dysarthria, and orthostatic hypotension. An MRI was performed and is shown below. What is the most likely diagnosis?

Multiple system atrophy with predominant cerebellar ataxia. ***Multiple system atrophy with predominant cerebellar ataxia*** - The **hot cross bun sign** on MRI is classically associated with but not specific for MSA-C, showing cruciform hyperintensity in the pons due to selective neuronal loss. - Bilateral lower limb spasticity indicates **pyramidal tract involvement**, which is characteristic of MSA-C along with cerebellar dysfunction. *Multiple system atrophy with predominant parkinsonism* - **MSA-P** typically shows the **putaminal rim sign** on MRI (hyperintense rim around the putamen), not the hot cross bun sign. - Clinical presentation would focus on **parkinsonian features** (bradykinesia, rigidity) rather than predominant spasticity. *Progressive supranuclear palsy* - **PSP** demonstrates the **hummingbird sign** or **penguin sign** on sagittal MRI due to midbrain atrophy. - Clinical features include **supranuclear gaze palsy** and **axial rigidity**, not bilateral lower limb spasticity. *Lewy body dementia* - **MRI findings** in Lewy body dementia are typically **non-specific** with mild cortical atrophy. - Clinical presentation involves **cognitive fluctuations**, **visual hallucinations**, and **REM sleep behavior disorder**, not spasticity.

Q: Bony clival erosion with intracranial calcification is seen in which of the following?

Sella chordoma. **Explanation:** **Chordomas** are rare, slow-growing, but locally aggressive malignant tumors arising from the remnants of the **primitive notochord**. In the skull base, they typically occur at the **clivus** (spheno-occipital synchondrosis). 1. **Why Chordoma is Correct:** * **Bony Erosion:** Because they arise from bone, chordomas are characterized by extensive, irregular **bone destruction/erosion** of the clivus. * **Calcification:** Intracranial calcification is seen in approximately 50–90% of cases. This is often "sequestra" (fragments of destroyed bone) rather than true intratumoral calcification. On MRI, they show a characteristic "honeycomb" appearance with high T2 signal. 2. **Why Other Options are Incorrect:** * **Craniopharyngioma:** While these frequently show calcification (especially the adamantinomatous type in children), they are suprasellar tumors that cause **sellar enlargement** or pressure erosion of the dorsum sellae, not primary clival destruction. * **Medulloblastoma:** This is a posterior fossa tumor arising from the roof of the 4th ventricle. It typically presents as a solid midline mass in children and does not cause clival erosion. * **Papilloma of the Choroid Plexus:** These are intraventricular tumors (lateral ventricles in children, 4th ventricle in adults). They present with hydrocephalus due to CSF overproduction, not bony destruction of the skull base. **High-Yield Pearls for NEET-PG:** * **Most common site for Chordoma:** Sacrococcygeal region (50%), followed by Spheno-occipital/Clival (35%). * **Radiological Sign:** "Thumb sign" (the tumor deforms the pons posteriorly). * **Differential Diagnosis:** Chondrosarcoma (often located off-midline at the petro-occipital fissure, whereas Chordoma is strictly midline). * **Histology:** Characterized by **Physaliphorous cells** (large cells with vacuolated, bubbly cytoplasm).

Question 1

A 12-year-old boy is rushed to the emergency room in a coma after falling from an upper story window of his home. MRI shows a subdural hematoma over the left hemisphere. What is the most likely source of intracranial bleeding in this patient?

Accepted Answer

Bridging veins

Answer

Charcot-Bouchard aneurysm

Answer

Internal carotid artery

Answer

Middle meningeal artery

Question 2

Which of the following findings would distinguish hydrocephalus due to aqueductal stenosis from hydrocephalus due to Dandy-Walker malformation?

Accepted Answer

Posterior fossa volume

Answer

Third ventricle size

Answer

Lateral ventricular size

Answer

Head circumference

Question 3

Meningioma on plain radiography reveals which of the following findings?

Accepted Answer

Calcification

Answer

Erosion

Answer

Sutural diastasis

Answer

Osteosclerosis

Question 4

What is the best radiographic view for visualizing the mandible?

Accepted Answer

Orthopantomogram

Answer

Anteroposterior view

Answer

Lateral view

Answer

Oblique view

Question 5

The 'Hot Cross Bun' sign on MRI is characteristically seen in which of the following conditions?

Accepted Answer

Multisystem atrophy

Answer

Lewy body dementia

Answer

Progressive supranuclear palsy

Answer

Alzheimer's disease

Question 6

Premature filling of veins is a manifestation in cerebral angiography of which condition?

Accepted Answer

Arteriovenous malformation

Answer

Trauma

Answer

Brain tumor

Answer

Arterial occlusion

Question 7

A 37-year-old man with AIDS presents with confusion, lethargy, and memory loss. CT of the brain demonstrates multiple supratentorial enhancing masses. Which imaging feature favors a diagnosis of toxoplasmosis rather than primary CNS lymphoma?

Accepted Answer

Lesions without increased tracer activity on FDG-18 PET imaging

Answer

Subependymal distribution

Answer

Lesions hyperdense on unenhanced CT

Answer

Lesion size >3 cm

Question 8

What condition is characterized by a "puff of smoke" appearance on contrast CT angiography?

Accepted Answer

Moya Moya Disease

Answer

Acrodermatitis Enterohepatica

Answer

Neuromyelitis Optica

Answer

Kasabach-Merritt Syndrome

Question 9

A 60-year-old male patient presented with spasticity in bilateral lower limbs, gait ataxia, dysarthria, and orthostatic hypotension. An MRI was performed and is shown below. What is the most likely diagnosis?

Accepted Answer

Multiple system atrophy with predominant cerebellar ataxia

Answer

Multiple system atrophy with predominant parkinsonism

Answer

Progressive supranuclear palsy

Answer

Lewy body dementia

Question 10

Bony clival erosion with intracranial calcification is seen in which of the following?

Accepted Answer

Sella chordoma

Answer

Craniopharyngioma

Answer

Medulloblastoma

Answer

Papilloma of the choroid plexus

Neuroradiology — MCQs

Neuroradiology — MCQs

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