Neuroradiology Practice Questions

Q: What is the commonest location for Craniopharyngioma?

Suprasellar. **Explanation:** Craniopharyngiomas are benign but locally aggressive tumors (WHO Grade 1) derived from the remnants of **Rathke’s pouch**. Understanding their embryological origin is key to identifying their location. **1. Why Suprasellar is correct:** The most common location for Craniopharyngioma is the **suprasellar region (approx. 75-90%)**. While they can involve both the sella and the suprasellar space, a purely intrasellar location is rare. They typically arise from the pituitary stalk (infundibulum) and expand upwards into the suprasellar cistern, often compressing the optic chiasm. **2. Analysis of Incorrect Options:** * **Intrasellar:** While Craniopharyngiomas can have an intrasellar component, a purely intrasellar location is seen in only about 5-10% of cases. Pituitary adenomas are the most common purely intrasellar tumors. * **Intraventricular:** Though large tumors can bulge into the floor of the third ventricle, they do not primarily originate there. * **Intracerebral:** These tumors are extra-axial (outside the brain parenchyma). **3. NEET-PG High-Yield Pearls:** * **Bimodal Age Distribution:** Peaks at 5–14 years and 50–75 years. * **Adamantinomatous Type:** Common in children; characterized by "machine oil" fluid, calcification (90%), and a cystic appearance. * **Papillary Type:** Common in adults; usually solid, lacks calcification. * **Imaging Hallmark:** The "Rule of 90s" for pediatric cases—90% are cystic, 90% show enhancement, and 90% show calcification (best seen on CT). * **Clinical Triad:** Visual field defects (Bitemporal hemianopia), endocrine dysfunction (GH deficiency/Diabetes Insipidus), and increased intracranial pressure.

Q: Tigroid pattern on MRI is associated with which of the following diseases?

Metachromatic Leukodystrophy. **Explanation:** The **Tigroid pattern** (also known as the leopard skin pattern) is a classic radiological sign seen in **Metachromatic Leukodystrophy (MLD)**. **1. Why Metachromatic Leukodystrophy is correct:** MLD is an autosomal recessive lysosomal storage disorder caused by a deficiency of the enzyme **Arylsulfatase A**, leading to the accumulation of sulfatides. On T2-weighted MRI, there is confluent symmetrical periventricular white matter hyperintensity. The "Tigroid" appearance occurs because of the **sparing of the perivascular myelin bundles** within the areas of demyelination. These spared dark spots/stripes against a bright background of demyelinated white matter resemble the skin of a tiger or leopard. **2. Why other options are incorrect:** * **Krabbe disease:** Characterized by "thalami hyperdensity" on CT and involvement of the posterior limb of the internal capsule and optic radiations. It does not show the tigroid pattern. * **Niemann-Pick disease:** Primarily a lipid storage disorder affecting the viscera (hepatosplenomegaly) and brain (atrophy), but it is not typically associated with specific leukodystrophy patterns like the tigroid sign. * **Alexander disease:** Characterized by a **frontal lobe predominance** of white matter changes and the presence of Rosenthal fibers on pathology. **3. High-Yield Clinical Pearls for NEET-PG:** * **MLD:** Most common hereditary leukodystrophy; look for "Tigroid pattern" and "Gallbladder wall thickening." * **Adrenoleukodystrophy:** X-linked; involves **posterior** white matter (occipito-parietal) and shows peripheral enhancement. * **Canavan Disease:** Characterized by **elevated N-acetylaspartate (NAA)** on MR spectroscopy and involvement of subcortical U-fibers (macrocephaly). * **Pelizaeus-Merzbacher Disease:** Also shows a tigroid pattern, but MLD is the more common association tested.

Q: Diffusion-weighted imaging typically shows bright signal suggestive of diffusion restriction in all of the following except?

Alzheimer's disease. **Explanation:** Diffusion-Weighted Imaging (DWI) measures the random Brownian motion of water molecules. **Diffusion restriction** (appearing bright/hyperintense on DWI and dark on ADC maps) occurs when this movement is limited by cellular swelling, high cellularity, or viscous material. **Why Alzheimer’s Disease is the correct answer:** Alzheimer’s is a **neurodegenerative disorder** characterized by neuronal loss and brain atrophy. Instead of restriction, there is often an *increase* in the extracellular space due to cell death, leading to **increased diffusion** (facilitated diffusion). Therefore, it does not show the bright signal characteristic of restriction. **Analysis of Incorrect Options:** * **MCA Territory Infarct:** In acute ischemic stroke, the failure of Na+/K+ ATPase pumps leads to **cytotoxic edema**. Water shifts into cells, causing them to swell and narrowing the extracellular space, which severely restricts diffusion. This is the most common clinical use of DWI. * **Brain Abscess:** The central cavity of a pyogenic abscess contains thick, **viscous pus** (inflammatory cells, bacteria, and debris), which significantly restricts the movement of water molecules. * **CNS Lymphoma:** This is a highly **hypercellular tumor** with a high nuclear-to-cytoplasmic ratio. The dense packing of cells leaves little room for water to move, resulting in diffusion restriction. **Clinical Pearls for NEET-PG:** * **DWI "Bright" Mnemonic (ABCD):** **A**bscess, **B**lood (Acute clot), **C**ytotoxic edema (Infarct), **D**ense tumors (Lymphoma, Medulloblastoma). * **ADC Map:** Always correlate DWI with the Apparent Diffusion Coefficient (ADC) map to rule out "T2 shine-through." True restriction must be **Bright on DWI and Dark on ADC.** * **Epidermoid Cyst:** A classic differential for a "bright" DWI signal in the CP angle, distinguishing it from an arachnoid cyst (which follows CSF signal).

Q: Intracranial calcification with cystic lesion in plain X-ray skull is seen in?

Craniopharyngioma. **Explanation:** **Craniopharyngioma** is the most common suprasellar tumor in children and is characterized by a classic triad of **Cysts, Calcification, and Solid components**. On a plain X-ray skull, the presence of suprasellar calcification associated with a cystic lesion is highly suggestive of this diagnosis. Calcification is seen in approximately **90% of pediatric cases** and about 50% of adult cases. These tumors arise from the remnants of **Rathke’s pouch** and often present with visual field defects (bitemporal hemianopia) and endocrine dysfunction. **Why other options are incorrect:** * **Meningioma:** While these are frequently calcified (psammomatous calcification), they are typically **solid, hyperdense** extra-axial tumors. They rarely present as cystic lesions on plain X-rays. * **Glioma:** Low-grade gliomas may show calcification (especially Oligodendrogliomas), but they are primarily parenchymal tumors and do not typically present with the classic "cystic-calcified" appearance in the suprasellar region on a plain radiograph. * **Medulloblastoma:** This is a posterior fossa tumor (involving the cerebellum/fourth ventricle). While it may show faint calcification in 10-20% of cases, it is not a cystic lesion and is not located in the regions typically assessed for calcification on a standard lateral skull X-ray. **High-Yield Clinical Pearls for NEET-PG:** * **Adamantinomatous type:** Common in children; shows "machine oil" fluid within cysts and heavy calcification. * **Papillary type:** Common in adults; usually solid and rarely calcified. * **Imaging Gold Standard:** MRI is preferred to see the "machinery oil" appearance (high T1 signal), but **CT is the most sensitive** for detecting the characteristic calcification.

Q: Which of the following statements is FALSE regarding Multiple Sclerosis (MS)?

T1-weighted images are most diagnostic for acute plaques.. ### Explanation **1. Why Option C is the Correct (False) Statement:** In Multiple Sclerosis (MS), **T2-weighted (T2W) and FLAIR (Fluid-Attenuated Inversion Recovery)** sequences are the most sensitive for detecting plaques. On T1-weighted images, acute plaques are usually isointense or hypointense and are not diagnostic on their own. However, **Gadolinium-enhanced T1 images** are the gold standard for identifying *active* (acute) inflammation, as they show breakdown of the blood-brain barrier. Chronic, irreversible axonal damage appears as "black holes" (hypointensities) on T1. **2. Analysis of Other Options:** * **Option A (True):** Involvement of the **corpus callosum** (specifically the callososeptal interface) is highly characteristic of MS. These are often seen as "Dawson’s Fingers"—ovoid lesions oriented perpendicular to the lateral ventricles. * **Option B (True):** MS plaques typically occur in the **periventricular white matter**. On CT, these appear as areas of **decreased attenuation** (hypodense), though CT is significantly less sensitive than MRI. * **Option D (True):** MS plaques are characterized by edema and demyelination, which increases water content. Therefore, they appear **hyperintense (bright)** on T2-weighted and FLAIR sequences. **3. High-Yield Clinical Pearls for NEET-PG:** * **McDonald Criteria:** The current diagnostic standard focusing on dissemination in space (DIS) and time (DIT). * **Imaging Gold Standard:** MRI is the investigation of choice. * **Dawson’s Fingers:** Pathognomonic T2/FLAIR hyperintensities perpendicular to the ventricles representing perivenular demyelination. * **CSF Findings:** Presence of **Oligoclonal bands** (IgG) not present in the serum. * **Uhtoff’s Phenomenon:** Worsening of neurological symptoms with increased body temperature.

Q: Which of the following intracranial materials appears most dense on computed tomography of the head?

Acute hematoma. **Explanation:** The density of structures on a Computed Tomography (CT) scan is measured in **Hounsfield Units (HU)**, which represents the degree of X-ray attenuation. The higher the HU value, the denser (whiter/more hyperdense) the material appears. 1. **Acute Hematoma (Correct):** Fresh blood is hyperdense on CT, typically ranging from **+60 to +80 HU**. This high density is primarily due to the high concentration of **hemoglobin** and the formation of a fibrin clot, which increases protein density relative to water. As a hematoma ages (chronic stage), it becomes isodense and eventually hypodense as hemoglobin breaks down. 2. **Gray Matter:** Appears slightly denser than white matter due to higher water content and lower lipid content, with values around **+35 to +45 HU**. 3. **White Matter:** Contains high amounts of myelin (fat), which is less dense than cellular gray matter. It typically measures **+20 to +30 HU**. 4. **CSF (Cerebrospinal Fluid):** Being primarily water-based, it has a low density of **0 to +10 HU**, appearing dark (hypodense) on CT. **High-Yield Clinical Pearls for NEET-PG:** * **Density Hierarchy:** Bone (+1000 HU) > Acute Blood (+60 to +80) > Gray Matter (+40) > White Matter (+30) > Water/CSF (0) > Fat (-50 to -100) > Air (-1000). * **The "Lemon" vs. "Banana":** Epidural hematomas (EDH) are biconvex/lentiform, while Subdural hematomas (SDH) are crescent-shaped. * **Hyperdense MCA Sign:** An early sign of ischemic stroke representing an acute thrombus in the Middle Cerebral Artery.

Q: Chang staging is used for which of the following conditions?

Medulloblastoma. **Explanation:** **Chang Staging** is the classic staging system used for **Medulloblastoma**, a common malignant posterior fossa tumor in children. It was developed to categorize the disease based on two main parameters: 1. **T-stage (Tumor):** Based on the size and local extension of the primary tumor (e.g., involvement of the brainstem or fourth ventricle). 2. **M-stage (Metastasis):** Based on the presence of "drop metastases" or dissemination via the cerebrospinal fluid (CSF). **Why Medulloblastoma is correct:** Medulloblastoma has a high propensity for leptomeningeal spread. The Chang system (specifically the M-component) is crucial for risk stratification, ranging from M0 (no subarachnoid dissemination) to M4 (metastasis outside the neuraxis). **Analysis of Incorrect Options:** * **Retinoblastoma:** Staged using the **Reese-Ellsworth** classification (for intraocular tumors) or the **International Classification for Retinoblastoma (ICRB)**. * **Ewing’s Sarcoma:** Typically staged using the **Enneking system** (for bone tumors) or the TNM system. * **Rhabdomyosarcoma:** Uses a unique system combining **TNM Clinical Staging** and the **Intergroup Rhabdomyosarcoma Study (IRS) Post-operative Grouping**. **High-Yield Clinical Pearls for NEET-PG:** * **Modified Chang Staging:** While the T-stage is now less prognostic due to modern neuroimaging, the **M-stage** remains a vital prognostic factor. * **M1 Stage:** Defined as microscopic tumor cells found in the CSF. * **Zuckerman’s Classification:** Another term sometimes associated with the staging of these tumors. * **Molecular Subgroups:** Modern management of Medulloblastoma now focuses on four molecular subgroups (**WNT, SHH, Group 3, and Group 4**), which are increasingly more important than Chang staging for prognosis.

Q: A patient with Miller Dieker syndrome on neuroimaging showed a smooth cortex with no convolutions. What is this condition of the brain where the convolutions are absent called?

Lissencephaly. **Explanation:** The correct answer is **Lissencephaly** (Option B). **1. Understanding the Correct Answer:** Lissencephaly, derived from the Greek words *lissos* (smooth) and *enkephalos* (brain), is a rare gene-linked brain malformation. It is characterized by the **absence of normal convolutions (gyri and sulci)** in the cerebral cortex, resulting in a "smooth brain" appearance. This condition occurs due to **defective neuronal migration** during the 12th to 24th weeks of gestation. * **Miller-Dieker Syndrome** is a classic association, caused by a microdeletion on chromosome 17p13.3 (LIS1 gene). Radiologically, it presents with a "Figure-of-8" appearance on axial sections due to a wide Sylvian fissure and a thickened cortex (pachygyria). **2. Why Other Options are Incorrect:** * **Holoprosencephaly:** A failure of the forebrain (prosencephalon) to divide into two cerebral hemispheres. It is characterized by a single midline ventricle and facial midline defects (e.g., cyclopia). * **Rachischisis:** A severe form of neural tube defect where the spinal column remains open, often associated with an exposed spinal cord (myeloschisis). * **Arhinencephaly:** The congenital absence of the olfactory bulbs and tracts. It is frequently seen as a component of holoprosencephaly. **3. High-Yield Clinical Pearls for NEET-PG:** * **Agyria:** Complete absence of gyri (smooth brain). * **Pachygyria:** Broad, thick, and few gyri. * **Imaging Sign:** The **"Figure-of-8" appearance** or "Hourglass" appearance on MRI/CT is pathognomonic for classic lissencephaly. * **Clinical Triad:** Severe developmental delay, intractable epilepsy (infantile spasms), and microcephaly.

Q: Which MRI sequence is used to detect brain edema?

FLAIR. **Explanation:** **FLAIR (Fluid Attenuated Inversion Recovery)** is the sequence of choice for detecting brain edema and most parenchymal pathologies. In standard T2-weighted images, both edema and normal Cerebrospinal Fluid (CSF) appear bright (hyperintense), making it difficult to distinguish lesions near the ventricles or sulci. FLAIR "nulls" or suppresses the signal from free-flowing water (CSF), making it appear dark, while pathological edema remains bright. This high contrast makes FLAIR the most sensitive sequence for identifying periventricular plaques (Multiple Sclerosis), cortical contusions, and subarachnoid hemorrhage. **Analysis of Incorrect Options:** * **T1WI (T1 Weighted Imaging):** Primarily used for anatomical detail. Edema appears dark (hypointense) on T1, providing poor sensitivity for detecting fluid-related pathology. * **SWI (Susceptibility Weighted Imaging):** Highly sensitive to "blooming" artifacts. It is the gold standard for detecting **microhemorrhages**, calcification, and venous blood (deoxyhemoglobin). * **DWI (Diffusion Weighted Imaging):** Specifically detects restricted diffusion of water molecules. It is the gold standard for **hyperacute ischemic stroke** (cytotoxic edema), but not for general vasogenic edema. **High-Yield Clinical Pearls for NEET-PG:** * **Vasogenic Edema:** Seen in tumors/abscesses; involves white matter; bright on FLAIR. * **Cytotoxic Edema:** Seen in early stroke; involves both gray and white matter; bright on **DWI**. * **STIR (Short Tau Inversion Recovery):** Similar to FLAIR but suppresses **fat** signal; used for orbital and spinal imaging. * **Bright on T1:** Fat, melanin, proteinaceous fluid, and methemoglobin (subacute blood).

Q: Which radiological sign is characteristic of meningioma?

"Mother-in-law" sign. **Explanation:** **1. Why "Mother-in-law" sign is correct:** The **"Mother-in-law" sign** is a classic angiographic description of a meningioma. It refers to the phenomenon where the tumor blush appears early in the arterial phase and **stays late** into the venous phase (much like a mother-in-law who "comes early and stays late"). This occurs because meningiomas are highly vascular tumors, typically supplied by the external carotid artery (e.g., middle meningeal artery), characterized by slow-clearing interstitial contrast. **2. Analysis of Incorrect Options:** * **B. Owl eye sign:** Seen in **CMV encephalitis** (intranuclear inclusions) or on MRI in the spinal cord during **Anterior Spinal Artery Syndrome**. It is also a classic histopathological feature of Reed-Sternberg cells in Hodgkin Lymphoma. * **C. Tiger eye sign:** A characteristic MRI finding (T2-weighted images) in **Pantothenate Kinase-Associated Neurodegeneration (PKAN)**, showing low signal intensity in the globus pallidus with a central high signal. * **D. Inverted Napoleon hat sign:** A radiologic sign seen on frontal lumbar X-rays in cases of severe **Spondylolisthesis** (Grade III or IV), where the L5 vertebra slips forward over the sacrum. **3. Clinical Pearls for NEET-PG:** * **Dural Tail Sign:** The most common MRI finding for meningioma (though not pathognomonic). * **Psammoma Bodies:** Histological hallmark (dystrophic calcification). * **Sunburst/Spoke-wheel appearance:** Pattern of vascular supply on angiography. * **Hyperostosis:** Meningiomas often cause thickening of the overlying bone, unlike most other brain tumors which cause bone erosion.

Question 1

What is the commonest location for Craniopharyngioma?

Accepted Answer

Suprasellar

Answer

Intrasellar

Answer

Intraventricular

Answer

Intracerebral

Question 2

Tigroid pattern on MRI is associated with which of the following diseases?

Accepted Answer

Metachromatic Leukodystrophy

Answer

Krabbe disease

Answer

Niemann Pick disease

Answer

Alexander disease

Question 3

Diffusion-weighted imaging typically shows bright signal suggestive of diffusion restriction in all of the following except?

Accepted Answer

Alzheimer's disease

Answer

CNS lymphoma

Answer

MCA territory infarct

Answer

Brain abscess

Question 4

Intracranial calcification with cystic lesion in plain X-ray skull is seen in?

Accepted Answer

Craniopharyngioma

Answer

Meningioma

Answer

Glioma

Answer

Medulloblastoma

Question 5

Which of the following statements is FALSE regarding Multiple Sclerosis (MS)?

Accepted Answer

T1-weighted images are most diagnostic for acute plaques.

Answer

Lesions in the corpus callosum are characteristic.

Answer

Periventricular white matter distribution with decreased CT attenuation is observed.

Answer

Lesions appear hyperintense on T2-weighted images.

Question 6

Which of the following intracranial materials appears most dense on computed tomography of the head?

Accepted Answer

Acute hematoma

Answer

White matter

Answer

Gray matter

Answer

CSF

Question 7

Chang staging is used for which of the following conditions?

Accepted Answer

Medulloblastoma

Answer

Retinoblastoma

Answer

Ewing's sarcoma

Answer

Rhabdomyosarcoma

Question 8

A patient with Miller Dieker syndrome on neuroimaging showed a smooth cortex with no convolutions. What is this condition of the brain where the convolutions are absent called?

Accepted Answer

Lissencephaly

Answer

Holoprosencephaly

Answer

Rachischisis

Answer

Arhinencephaly

Question 9

Which MRI sequence is used to detect brain edema?

Accepted Answer

FLAIR

Answer

T1WI

Answer

SWI

Answer

DWI

Question 10

Which radiological sign is characteristic of meningioma?

Accepted Answer

"Mother-in-law" sign

Answer

Owl eye sign

Answer

Tiger eye sign

Answer

Inveed Napoleon hat sign

Neuroradiology — MCQs

Neuroradiology — MCQs

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