Neuroradiology Practice Questions

Q: What is the most likely diagnosis in an imaging study showing a large posterior fossa?

Dandy-Walker malformation. ***Dandy-Walker malformation*** - Characterized by **hypoplasia of the cerebellar vermis** and cystic dilation of the fourth ventricle. - This leads to a **markedly enlarged posterior fossa**, often with upward displacement of the tentorium. *Arnold-Chiari malformation* - Involves **downward displacement of the cerebellar tonsils** through the foramen magnum. - This condition typically presents with a **small posterior fossa**, not an enlarged one. *Hydrocephalus* - Refers to an **accumulation of cerebrospinal fluid (CSF)** within the brain's ventricles. - While it can cause ventricular enlargement, it doesn't primarily involve an **enlarged posterior fossa** as a defining feature. *Platybasia* - A congenital anomaly where the **base of the skull is flattened**, leading to an upward angulation of the clivus. - This condition affects the skull base but does not directly cause a **large posterior fossa**; it can be associated with other congenital anomalies.

Q: The MRI image shows a brain surface with broad, thick gyri and shallow sulci. What is the diagnosis?

Pachygyria. ***Pachygyria*** - The image clearly displays **broad, thick gyri** with **shallow sulci**, characteristic of pachygyria - This appearance reflects a less severe form of neuronal migration disorder along the lissencephaly spectrum, where gyral formation is present but markedly simplified and reduced - Associated with developmental delay, seizures, and intellectual disability - Caused by mutations in genes like LIS1, DCX, and TUBA1A *Incorrect: Lissencephaly* - Features a **completely smooth brain surface** with total or near-total **absence of gyri and sulci** (agyria) - Would show no visible gyri or sulci, unlike the broad but present gyri seen here *Incorrect: Schizencephaly* - Characterized by **clefts or splits** extending from the ventricles to the cortical surface, lined by gray matter - Would show a clear **CSF-filled cleft**, not broad shallow gyri *Incorrect: Polymicrogyria* - Features **excessive small gyri** with abnormal cortical layering - Brain surface appears bumpy or irregular with too many small folds, not broad thick gyri with shallow sulci

Q: A 60-year-old male presents with bone pain and fatigue. X-ray skull shows: (Recent NEET Pattern 2016-17)

Multiple myeloma. ***Multiple myeloma*** - The image shows a skull with multiple, sharply demarcated **"punched-out" lytic lesions** scattered diffusely across the calvarium, which is the classic radiographic appearance of **multiple myeloma**. - These lesions lack a sclerotic rim and represent discrete areas of osteolytic bone destruction caused by proliferating plasma cells. *Silver-beaten appearance* - A silver-beaten (or copper-beaten) skull shows diffuse **gyral impressions** on the inner table of the skull, caused by the brain's convolutions pressing against the bone in the setting of **chronically increased intracranial pressure**. - This pattern produces a bumpy, undulating inner table contour — distinctly different from the discrete, rounded punched-out lytic lesions seen in this image. *Histiocytosis-X* - Histiocytosis-X (now called Langerhans cell histiocytosis) can cause lytic skull lesions, but these typically occur in **children and young adults**, whereas multiple myeloma predominantly affects patients over 50 years of age. - Radiographically, Histiocytosis-X lesions characteristically show a **"beveled edge"** appearance due to unequal involvement of the inner and outer tables of the skull, and lesions tend to be fewer and more geographically distributed. - In contrast, multiple myeloma produces **numerous, uniform, rounded punched-out lesions** without beveling and without sclerotic rims, distributed diffusely across the calvarium as seen in this image. *Letterer-Siwe disease* - Letterer-Siwe disease is an aggressive, disseminated form of **Langerhans cell histiocytosis** affecting infants. - While it can cause bone lesions, including in the skull, it typically manifests as generalized lytic lesions rather than the "silver-beaten" pattern indicative of chronic elevated intracranial pressure.

Q: What is shown in this skull X-ray?

Pepper pot skull. ***Pepper pot skull*** - The X-ray image displays a classic "pepper pot" appearance, characterized by diffuse **punctate lucencies** evenly distributed throughout the skull vault, resembling numerous small holes. - This finding is highly suggestive of **hyperparathyroidism**, where excessive parathyroid hormone leads to increased bone resorption, visible as demineralization and multiple small lytic lesions. *Artifacts* - **Artifacts** are extraneous marks or distortions on an image that do not represent true anatomical structures. - The observed pattern is a consistent, diffuse change in bone density, indicating a **pathological condition** rather than a technical error or imaging artifact. *Silver-beaten appearance* - A "silver-beaten" or **convolutional impression** refers to the undulating pattern on the inner table of the skull caused by increased **intracranial pressure** in children. - This appearance is characterized by broad, shallow indentations, which is distinct from the multiple small, sharply defined lucencies seen in pepper pot skull. *Hair-on-end appearance* - The **hair-on-end** or "crew-cut" appearance shows **perpendicular bony trabeculae** radiating outward from the skull vault, creating a spiculated pattern. - This finding is classically associated with **chronic hemolytic anemias** (thalassemia, sickle cell disease) due to marrow hyperplasia, not the diffuse lucencies seen here.

Q: What is the radiographic appearance shown below the image?

Silver-beaten skull. **_Silver-beaten skull_** - The image displays a "beaten copper" or "silver-beaten" appearance of the skull, characterized by prominent convolutional markings caused by impressions of the cerebral gyri on the inner table of the skull. that resemble gyri and sulci impressions due to increased intracranial pressure. - This finding is often associated with conditions causing **chronic increased intracranial pressure** in children with open sutures. *Multiple myeloma* - Multiple myeloma typically presents with widespread, discrete, well-defined **lytic lesions** ("punched-out" lesions) in the skull, unlike the diffuse impression pattern seen here. - It is a plasma cell malignancy and usually affects older adults. *Histiocytosis-X* - Histiocytosis-X (now Langerhans cell histiocytosis) can cause lytic skull lesions, which are usually solitary or multiple, but often have a characteristic **beveled edge** or "hole within a hole" appearance, not the diffuse gyral impressions. - These lesions are typically more destructive and erosive. *Craniosynostosis* - Craniosynostosis involves premature fusion of cranial sutures, which can restrict brain growth and lead to increased intracranial pressure, producing a silver-beaten appearance on skull radiographs. - However, craniosynostosis is the underlying structural cause, whereas silver-beaten skull refers specifically to the radiographic sign of prominent convolutional markings on the inner table.

Q: Which is correct about the intracranial bleeding shown below?

Chronic subdural hematoma, hypodensity. ***Chronic subdural hematoma, hypodensity*** - The image displays a crescent-shaped collection of fluid with **hypodense characteristics** (darker than brain parenchyma) that crosses suture lines, which is typical for a subdural hematoma. - The **hypodensity indicates older, chronic blood** where the hemoglobin has degraded, differentiating it from acute (hyperdense) or subacute (isodense) collections. *Acute subdural hematoma, hypodensity* - An **acute subdural hematoma** would typically appear **hyperdense** (bright) on CT due to fresh blood. - The observed collection is clearly hypodense, ruling out an acute presentation. *Chronic epidural hematoma, hyperdensity* - An **epidural hematoma** is typically **lenticular (lens-shaped)** and does not cross suture lines, unlike the crescent shape seen here. - While chronic blood *can* be hypodense, an epidural hematoma by definition is outside the dura mater and would not present with this morphology. *Acute epidural hematoma, hyperdensity* - An **acute epidural hematoma** is characterized by a **lenticular (lens-shaped) hyperdense** collection of blood, which is distinctly different from the crescent-shaped, hypodense collection in the image. - Epidural hematomas occur between the dura mater and the skull, typically from arterial injury, and are bound by sutures.

Q: A 55-year-old diabetic patient develops sudden onset hemiparesis and facial asymmetry. NCCT scan shows:

Hyperdense MCA sign. ***Hyperdense MCA sign*** - The image exhibits a **bright (hyperdense) area** within the Sylvian fissure, indicated by the white arrow, representing a **thrombus occluding the middle cerebral artery (MCA)**. This is a direct sign of acute **ischemic stroke**. - Clinical presentation of sudden onset hemiparesis and facial asymmetry in a diabetic patient strongly suggests an **ischemic stroke**, and the hyperdense MCA sign on NCCT confirms a proximal vessel occlusion. *Cystic encephalomalacia* - This refers to the **end stage of an infarct**, where brain tissue is replaced by **CSF-filled cysts** and gliosis, appearing as hypodense areas. - This finding would indicate an **old stroke**, not an acute event causing sudden neurological deficits. *Subarachnoid hemorrhage* - This condition involves **blood in the subarachnoid space**, appearing as hyperdensity within the **sulci and basal cisterns**. - While it features hyperdensity, the location in the image (within the Sylvian fissure, consistent with MCA) and the patient's symptoms are not typical for isolated subarachnoid hemorrhage. *Lobar hemorrhage* - A lobar hemorrhage is an **intraparenchymal bleed** within a lobe of the brain, appearing as a **focal, well-defined hyperdense lesion within the brain parenchyma**. - The hyperdensity in the image is linear and located within a vascular structure, consistent with an occluded vessel rather than a parenchymal bleed.

Q: Eye of the tiger appearance in T2-weighted MRI is seen in:

Pantothenate kinase-associated neurodegeneration. ***Pantothenate kinase-associated neurodegeneration*** - The **"eye of the tiger" sign** on T2-weighted MRI is highly characteristic of **Pantothenate kinase-associated neurodegeneration (PKAN)**, previously known as Hallervorden-Spatz disease. - This sign is characterized by a central region of **pallidal hyperintensity** surrounded by a rim of hypointensity in the globus pallidus, reflecting iron accumulation and neuronal loss. *Huntington chorea* - Huntington's chorea is characterized by **atrophy of the caudate and putamen** seen on NCCT or MRI, leading to an enlargement of the frontal horns of the lateral ventricles. - It does not present with the "eye of the tiger" sign, which is specific to iron deposition in the globus pallidus. *Multiple system atrophy* - Multiple system atrophy (MSA) typically shows **atrophy of the cerebellum**, brainstem, and putamen, along with the "hot cross bun" sign in the pons in some variants. - The "eye of the tiger" sign is not a feature of MSA; it is characterized by different imaging findings related to neurodegeneration in specific brain regions. *Multiple sclerosis* - Multiple sclerosis (MS) is characterized by **demyelinating lesions** in the white matter of the brain and spinal cord, which appear as hyperintense lesions on T2-weighted MRI. - These lesions are distributed throughout the central nervous system, and the "eye of the tiger" sign is not associated with MS.

Question 1

What is the most likely diagnosis in an imaging study showing a large posterior fossa?

Accepted Answer

Dandy-Walker malformation

Answer

Hydrocephalus

Answer

Platybasia

Answer

Arnold-Chiari malformation

Question 2

The MRI image shows a brain surface with broad, thick gyri and shallow sulci. What is the diagnosis?

Accepted Answer

Pachygyria

Answer

Lissencephaly

Answer

Schizencephaly

Answer

Polymicrogyria

Question 3

A 60-year-old male presents with bone pain and fatigue. X-ray skull shows: (Recent NEET Pattern 2016-17)

Accepted Answer

Multiple myeloma

Answer

Histiocytosis-X

Answer

Letterer-Siwe disease

Answer

Silver-beaten appearance

Question 4

What is shown in this skull X-ray?

Accepted Answer

Pepper pot skull

Answer

Artifacts

Answer

Silver-beaten appearance

Answer

Hair-on-end appearance

Question 5

What is the radiographic appearance shown below the image?

Accepted Answer

Silver-beaten skull

Answer

Multiple myeloma

Answer

Histiocytosis-X

Answer

Craniosynostosis

Question 6

Which is correct about the intracranial bleeding shown below?

Accepted Answer

Chronic subdural hematoma, hypodensity

Answer

Acute subdural hematoma, hypodensity

Answer

Chronic epidural hematoma, hyperdensity

Answer

Acute epidural hematoma, hyperdensity

Question 7

A 55-year-old diabetic patient develops sudden onset hemiparesis and facial asymmetry. NCCT scan shows:

Accepted Answer

Hyperdense MCA sign

Answer

Cystic encephalomalacia

Answer

Subarachnoid hemorrhage

Answer

Lobar hemorrhage

Question 8

What is the correct diagnosis based on the image shown below?

Accepted Answer

Dense MCA sign

Answer

Lacunar stroke

Answer

Subarachnoid hemorrhage

Answer

Intraventricular hemorrhage

Question 9

Which of the following is correct about the image shown below?

Accepted Answer

$A=$ Extradural hemorrhage, $B=$ Contusion, $C=$ Subdural hemorrhage

Answer

$A=$ Extradural hemorrhage, $B=$ Subdural hemorrhage, $C=$ Contusion

Answer

$A=$ Subdural hemorrhage, $B=$ Extradural hemorrhage, $C=$ Contusion

Answer

$A=$ Contusion, $B=$ Subdural hemorrhage, $C=$ Extradural hemorrhage

Question 10

Eye of the tiger appearance in T2-weighted MRI is seen in:

Accepted Answer

Pantothenate kinase-associated neurodegeneration

Answer

Multiple system atrophy

Answer

Huntington chorea

Answer

Multiple sclerosis

Neuroradiology — MCQs

Neuroradiology — MCQs

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