Neuroradiology Practice Questions

Q: The NCCT shows the presence of which of the following?

Right intra-parenchymal hemorrhage. ***Right intra-parenchymal hemorrhage*** - **NCCT** shows a **hyperdense lesion** within the right cerebral parenchyma, indicating acute blood within brain tissue. - The hemorrhage is confined to the **brain parenchyma** rather than ventricular spaces, with characteristic **mass effect** and surrounding edema. *Left intraventricular hemorrhage* - Blood would be confined to the **ventricular system** on the left side, appearing as hyperdensity within ventricles. - **NCCT** would show blood filling the **lateral ventricles** rather than parenchymal tissue involvement. *Right intraventricular hemorrhage* - Blood would be limited to the **right ventricular system**, not extending into brain parenchyma. - Appears as **hyperdense material** within ventricles without the parenchymal mass effect seen here. *Left intra-parenchymal hemorrhage* - Would show **hyperdense lesion** in the left cerebral hemisphere, not the right side. - **Laterality** is incorrect based on the NCCT findings showing right-sided parenchymal involvement.

Q: In cerebral angiography, in which vessel is the dye injected?

Carotid artery. **Explanation:** **Correct Answer: D. Carotid Artery** Cerebral angiography is the gold standard for visualizing the vascular anatomy of the brain. To obtain high-resolution images of the intracranial circulation, the contrast medium (dye) must be delivered as close to the target area as possible to prevent dilution. Therefore, the dye is injected into the **Carotid artery** (specifically the Internal Carotid Artery for the anterior circulation) or the **Vertebral artery** (for the posterior circulation). **Analysis of Incorrect Options:** * **A. Brachial artery:** While historically used in some retrograde techniques, it is not the standard site for dye injection in modern cerebral angiography as it does not provide direct, selective access to the cerebral vessels. * **B. Cubital vein:** Injection into a vein (Intravenous) results in significant dilution of the contrast by the time it reaches the heart and lungs before entering the arterial system. This is used for CT Angiography (CTA), but not for conventional Digital Subtraction Angiography (DSA). * **C. Femoral artery:** This is the most common **access site** (Seldinger technique) for inserting the catheter. However, the dye itself is not "injected" here for brain imaging; the catheter is threaded from the femoral artery up to the carotid or vertebral arteries before the injection occurs. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard:** Digital Subtraction Angiography (DSA) remains the gold standard for diagnosing cerebral aneurysms and Arteriovenous Malformations (AVMs). * **Seldinger Technique:** The standard method for arterial access, usually via the Common Femoral Artery. * **Complication:** The most feared complication of cerebral angiography is an embolic stroke (dislodging a plaque during catheter manipulation). * **Contrast:** Non-ionic, low-osmolar iodinated contrast is preferred to minimize neurotoxicity.

Q: Basal ganglia calcification is seen in all of the following conditions, EXCEPT:

Wilson's disease. Explanation: Basal ganglia calcification (BGC) is a radiological finding often associated with metabolic, infectious, or genetic disorders. Why Wilson’s Disease is the correct answer: Wilson’s disease is characterized by the toxic accumulation of copper in the liver and brain (specifically the putamen and caudate) [1]. On MRI, it typically presents with the "Face of the Giant Panda" sign (hyperintensity in the midbrain) and gliosis or cystic necrosis, but not calcification. Therefore, it is the exception among the listed options. [1] Analysis of other options: * Hypoparathyroidism: This is the most common cause of pathological BGC. Low PTH levels lead to hyperphosphatemia, which results in the deposition of calcium-phosphate complexes in the small vessels of the basal ganglia. * Fahr’s Syndrome: A rare, genetically dominant condition characterized by idiopathic, massive, and symmetric intracranial calcifications, primarily affecting the basal ganglia, thalamus, and cerebellum. * Perinatal Hypoxia: Ischemic insults in the neonatal period can lead to dystrophic calcification in the basal ganglia (specifically the status marmoratus of the basal ganglia) as the damaged neural tissue mineralizes. NEET-PG High-Yield Pearls: * Most common cause of BGC: Hypoparathyroidism (and Pseudohypoparathyroidism). * Physiological Calcification: Often seen in the pineal gland, choroid plexus, and occasionally the globus pallidus in elderly patients (usually incidental and asymptomatic). * Infectious causes of BGC: TORCH infections (especially CMV and Toxoplasmosis) and HIV. * Wilson’s Disease Key Finding: Low serum ceruloplasmin, high urinary copper, and Kayser-Fleischer (KF) rings [1].

Q: The 'delta sign' on CT is characteristic of which of the following conditions?

Sagittal sinus thrombosis. ### Explanation The **'Delta sign'** (also known as the **Empty Delta sign**) is a classic neuroimaging finding pathognomonic for **Superior Sagittal Sinus Thrombosis**. **1. Why Sagittal Sinus Thrombosis is correct:** On a **contrast-enhanced CT (CECT)**, the dural venous sinus normally enhances brightly. In the presence of a thrombus, the contrast outlines the triangular perimeter of the sinus (the collateral venous channels and the dura), while the central clot remains non-enhancing (lucent). This creates a dark triangle surrounded by a bright border, resembling the Greek letter delta (Δ). This sign is typically seen on axial cuts at the posterior aspect of the superior sagittal sinus. **2. Why the other options are incorrect:** * **Grandenigo syndrome:** This is a triad of petrous apicitis (suppurative otitis media), abducens nerve (CN VI) palsy, and retro-orbital pain (CN V involvement). Imaging typically shows enhancement or opacification of the petrous apex, not a delta sign. * **Subdural hematoma (SDH):** Characterized by a **crescent-shaped (concave)** hyperdensity that crosses suture lines but is limited by dural reflections (like the falx). * **Extradural hematoma (EDH):** Characterized by a **biconvex/lens-shaped** hyperdensity that does not cross suture lines. **3. High-Yield Clinical Pearls for NEET-PG:** * **Dense Triangle Sign:** This is the non-contrast CT equivalent of the delta sign, where the fresh thrombus appears hyperdense before contrast is administered. * **Gold Standard Investigation:** While CT is often the first-line screening tool, **MR Venogram (MRV)** is the investigation of choice for diagnosing dural venous sinus thrombosis. * **Common Presentation:** A young female (often postpartum or on OCPs) presenting with a severe headache, seizures, and papilledema. * **Cord Sign:** A hyperdense linear appearance of a thrombosed cortical vein on non-contrast CT.

Q: Which of the following is not true regarding ossified posterior longitudinal ligament (OPLL)?

Most commonly involves the thoracic spine. **Explanation:** **1. Why Option A is the correct (false) statement:** Ossified Posterior Longitudinal Ligament (OPLL) most commonly involves the **cervical spine** (specifically C4–C6), not the thoracic spine. While it can occur in the thoracic and lumbar regions, the cervical predominance is a classic hallmark, particularly in East Asian populations. **2. Analysis of incorrect options:** * **Option B (Gradient Echo MRI):** GRE sequences are highly sensitive to magnetic susceptibility effects. The mineralized/ossified ligament causes "blooming" artifacts, which makes the ossification appear larger than it is, thus **overestimating** the degree of canal stenosis. * **Option C (MRI is best for diagnosis):** This is technically the **incorrect** statement in clinical practice, as **Non-Contrast CT (NCCT)** is the gold standard for diagnosing and characterizing the pattern of ossification. However, in the context of this specific question format, Option A is the "most" false. *Note: MRI is superior for evaluating associated cord changes (myelomalacia).* * **Option D (Low signal intensity):** Because the ligament has undergone ossification and lacks mobile protons, it typically appears as a **hypointense (dark) band** on both T1 and T2-weighted images. **Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** NCCT Spine (shows the "double layer" sign). * **Associations:** Strongly associated with **Diffuse Idiopathic Skeletal Hyperostosis (DISH)** and Diabetes Mellitus. * **Classification:** Can be continuous, segmental, mixed, or circumscribed. * **Clinical Presentation:** Often leads to compressive myelopathy or radiculopathy.

Q: The dense middle cerebral artery (MCA) sign is seen in which of the following conditions?

Acute infarct. **Explanation:** The **Hyperdense MCA sign** is one of the earliest radiological markers of an **acute ischemic stroke** on a non-contrast CT (NCCT) scan. **1. Why Acute Infarct is correct:** The sign represents a **thrombus or embolus** lodged within the first segment (M1) of the Middle Cerebral Artery. Because a fresh blood clot has a higher protein concentration and lower water content than flowing blood, it appears hyperattenuating (whiter) compared to the surrounding brain tissue and the contralateral vessel. It is typically seen within the first **0–6 hours** of symptom onset, often before parenchymal changes like "loss of insular ribbon" or "sulcal effacement" become visible. **2. Why other options are incorrect:** * **Subacute Infarct:** By this stage (24 hours to 2 weeks), the clot has usually started to lyse or organize, and the primary CT findings are vasogenic edema and mass effect (hypodensity), not vascular hyperdensity. * **Subacute Hemorrhage:** While blood is dense, a subacute hemorrhage refers to intraparenchymal or extra-axial collections. The "Dense MCA sign" specifically refers to an intravascular phenomenon. * **Chronic Infarct:** Chronic strokes are characterized by encephalomalacia and gliosis, appearing as CSF-filled cystic spaces (hypodense/black) with associated ventricular dilatation (ex-vacuo). **Clinical Pearls for NEET-PG:** * **High Specificity:** The sign is 90–100% specific for MCA occlusion but has low sensitivity (approx. 30%). * **Dot Sign:** A variation seen when the clot is in the M2 or M3 branches within the sylvian fissure, appearing as a high-density "dot." * **False Positives:** High hematocrit (polycythemia) or calcification of the arterial wall (atherosclerosis) can mimic this sign. Always compare with the opposite side. * **Prognostic Value:** Its presence often indicates a large territory infarct and a poorer functional prognosis.

Q: Widened Bat wing sylvian fissures are associated with which of the following conditions?

Glutaric aciduria. **Explanation:** **Glutaric Aciduria Type 1 (GA-1)** is an autosomal recessive metabolic disorder caused by a deficiency of glutaryl-CoA dehydrogenase. The hallmark neuroimaging finding is the **"Bat-wing appearance"** of the Sylvian fissures. This occurs due to significant frontotemporal atrophy and hypoplasia, leading to failure of opercularization (the brain tissue fails to cover the Insula). This creates wide, open CSF spaces in the temporal regions, resembling the wings of a bat. Additionally, these patients often show signal abnormalities in the basal ganglia (especially the putamen) and are prone to subdural hematomas. **Analysis of Incorrect Options:** * **Maple Syrup Urine Disease (MSUD):** Characterized by "MSUD edema," which involves intramyelinic cytotoxic edema. On MRI, this presents as restricted diffusion in the myelinated tracts (brainstem, cerebellar peduncles, and internal capsule). * **Galactosemia:** Typically presents with non-specific white matter changes, cerebral atrophy, and sometimes neonatal brain edema, but does not feature the characteristic bat-wing fissures. * **Canavan Disease:** A leukodystrophy characterized by diffuse, symmetric white matter involvement (including subcortical U-fibers) and **macrocephaly**. The classic finding is an elevated **NAA peak** on MR Spectroscopy. **Clinical Pearls for NEET-PG:** * **Bat-wing appearance:** Pathognomonic for Glutaric Aciduria Type 1. * **Macrocephaly + High NAA:** Canavan Disease. * **Macrocephaly + Rosenthal Fibers:** Alexander Disease. * **Tiger-eye appearance:** Pantothenate Kinase-Associated Neurodegeneration (PKAN). * **Molar Tooth Sign:** Joubert Syndrome.

Q: What is the investigation of choice for the diagnosis of a posterior fossa tumor?

MRI. **Explanation:** **MRI (Magnetic Resonance Imaging)** is the investigation of choice for posterior fossa tumors due to its superior soft-tissue contrast and multiplanar imaging capabilities. The posterior fossa is a small, bony compartment containing the brainstem and cerebellum. MRI allows for precise localization, assessment of brainstem invasion, and detection of associated complications like hydrocephalus or tonsillar herniation. **Why MRI is superior:** * **No Bone Artifact:** Unlike CT, MRI does not suffer from "beam-hardening artifacts" caused by the dense petrous temporal bone and occipital bone, which often obscure details in the posterior fossa. * **Multiplanar Imaging:** Sagittal and coronal views are essential to visualize the relationship of the tumor to the foramen magnum and tentorium cerebelli. * **Contrast Enhancement:** Gadolinium-enhanced MRI helps differentiate between various tumor types (e.g., Medulloblastoma vs. Ependymoma). **Why other options are incorrect:** * **CT Scan:** While useful in emergencies to detect acute hydrocephalus or calcification, it provides poor visualization of the posterior fossa due to significant bony artifacts. * **Angiography:** Primarily used to assess vascularity or for preoperative embolization (e.g., in Hemangioblastoma), but not for primary diagnosis. * **Myelography:** Used for spinal canal pathology; it has no role in diagnosing intracranial posterior fossa masses. **High-Yield Clinical Pearls for NEET-PG:** * **Most common posterior fossa tumor in children:** Cerebellar Astrocytoma (overall), but Medulloblastoma is the most common *malignant* one. * **"Step-off" sign on MRI:** Characteristic of Ependymomas as they tend to squeeze through the foramina of Luschka and Magendie. * **Investigation of choice for most CNS pathologies:** MRI (except for acute intracranial hemorrhage, where NCCT is preferred).

Q: Tear drop sign is seen in:

Fracture of floor of orbit. **Explanation:** The **Tear Drop Sign** is a classic radiological finding seen on a Water’s view (occipitomental projection) X-ray, indicating a **blow-out fracture of the orbital floor**. **Why it occurs:** When a blunt object (larger than the orbital rim, like a tennis ball or fist) strikes the eye, the intraorbital pressure increases suddenly. This pressure is transmitted to the weakest part of the orbit—the floor (maxillary bone). The fracture allows orbital fat and the **inferior rectus muscle** to herniate downward into the maxillary sinus. On imaging, this herniated soft tissue mass appears as a "tear drop" hanging from the roof of the maxillary sinus. **Analysis of Incorrect Options:** * **B. Fracture of lateral wall of nose:** Usually presents with epistaxis and localized deformity; it does not involve the maxillary sinus roof or orbital contents. * **C. Le Fort’s fracture:** These are complex midface fractures. While Le Fort II and III involve the orbit, they are characterized by specific patterns of craniofacial dissociation rather than the isolated "tear drop" herniation. * **D. Fracture of zygomatic arch:** Typically presents with a "V-shaped" deformity on a Submentovertex view (Jug-handle view) and does not involve the orbital floor. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site of orbital blow-out fracture:** Orbital floor (specifically medial to the infraorbital groove). * **Clinical Presentation:** Enophthalmos (sunken eye), diplopia (due to inferior rectus entrapment), and anesthesia in the distribution of the **infraorbital nerve**. * **Imaging Gold Standard:** Non-contrast CT (NCCT) of the Orbits (Coronal sections are best for visualizing the floor). * **Black Eyebrow Sign:** Another radiological sign of orbital fracture representing intraorbital air (orbital emphysema).

Question 1

The NCCT shows the presence of which of the following?

Accepted Answer

Right intra-parenchymal hemorrhage

Answer

Left intraventricular hemorrhage

Answer

Right intraventricular hemorrhage

Answer

Left intra-parenchymal hemorrhage

Question 2

In cerebral angiography, in which vessel is the dye injected?

Accepted Answer

Carotid artery

Answer

Brachial artery

Answer

Cubital vein

Answer

Femoral artery

Question 3

Basal ganglia calcification is seen in all of the following conditions, EXCEPT:

Accepted Answer

Wilson's disease

Answer

Hypoparathyroidism

Answer

Perinatal hypoxia

Answer

Fahr's syndrome

Question 4

The 'delta sign' on CT is characteristic of which of the following conditions?

Accepted Answer

Sagittal sinus thrombosis

Answer

Grandenigo syndrome

Answer

Subdural hematoma

Answer

Extradural hematoma

Question 5

Which of the following is not true regarding ossified posterior longitudinal ligament (OPLL)?

Accepted Answer

Most commonly involves the thoracic spine

Answer

Gradient echo MR sequence may overestimate the canal stenosis

Answer

MRI is best for diagnosis

Answer

Low signal intensity on all MR sequences

Question 6

The dense middle cerebral artery (MCA) sign is seen in which of the following conditions?

Accepted Answer

Acute infarct

Answer

Subacute infarct

Answer

Subacute hemorrhage

Answer

Chronic infarct

Question 7

Widened Bat wing sylvian fissures are associated with which of the following conditions?

Accepted Answer

Glutaric aciduria

Answer

Maple Syrup urine disease

Answer

Galactosemia

Answer

Canavan disease

Question 8

A child presents with raised ICT; on CT scan, a lesion is seen around the foramen of Monro and multiple periventricular calcific foci are noted. What is the most probable diagnosis?

Accepted Answer

Subependymal giant cell astrocytoma

Answer

Central neurocytoma

Answer

Ependymoma

Answer

Ganglioglioma

Question 9

What is the investigation of choice for the diagnosis of a posterior fossa tumor?

Accepted Answer

MRI

Answer

CT scan

Answer

Angiography

Answer

Myelography

Question 10

Tear drop sign is seen in:

Accepted Answer

Fracture of floor of orbit

Answer

Fracture of lateral wall of nose

Answer

Le Fort's fracture

Answer

Fracture of zygomatic arch

Neuroradiology — MCQs

Neuroradiology — MCQs

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