Neuroradiology Practice Questions

Q: Investigation of choice in cerebral abscess is -

MRI. ***MRI*** - **MRI with DWI (Diffusion-Weighted Imaging) and contrast** is the **investigation of choice** for cerebral abscess due to its superior sensitivity and specificity. - It can detect **early cerebritis stage** before frank abscess formation, which CT may miss. - MRI provides excellent **characterization of the abscess capsule**, showing smooth, thin, hyperintense rim on T1-weighted images with contrast. - **DWI sequences** show restricted diffusion in the pus-filled cavity (bright on DWI, dark on ADC), which helps differentiate abscess from other ring-enhancing lesions like tumors or cysts. - Superior for detecting **small or multiple abscesses**, posterior fossa lesions, and brainstem involvement. *CT Scan* - **CT with contrast** is widely used as the **initial investigation** in emergency settings due to rapid availability and ability to quickly identify ring-enhancing lesions. - It effectively shows location, size, edema, and mass effect, and is useful for surgical planning. - However, it is **less sensitive than MRI** for early-stage abscesses, small lesions, and differentiating abscess from other pathologies. *Plain X-ray* - **Plain skull X-ray** has no role in diagnosing cerebral abscesses as it cannot visualize brain parenchyma or intracranial fluid collections. - It only shows bone abnormalities or calcifications, which are not diagnostic of acute abscess. *Ultrasound* - **Transcranial ultrasound** has very limited utility in adults due to the skull barrier; it may be used in neonates through the fontanelle or for intraoperative guidance. - Cannot provide the detailed anatomical and pathological information required for diagnosis of cerebral abscess in typical clinical practice.

Q: Shape of post traumatic Epidural hematoma is

Biconvex hyperdense. ***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.

Q: MRI done in a 28yrs old male suffering from Neurofibromatosis 2 showed ice cream cone appearance. On asking he further revealed that it began with ringing sensation in ears which progressed to balance problems and hearing loss. Which of the following is the most likely diagnosis -

Schwannoma. ***Schwannoma*** - The combination of **Neurofibromatosis 2 (NF2)**, **bilateral or potentially asymmetric audiovestibular symptoms** and balance problems, and an MRI showing an **"ice cream cone"** appearance (representing a tumor in the cerebellopontine angle extending into the internal auditory canal) is highly characteristic of **bilateral vestibular schwannomas**. - NF2 is specifically associated with **bilateral vestibular schwannomas**, making this diagnosis even more likely in the context of the patient's age and neurological symptoms. *Ependymoma* - Ependymomas are typically **intraparenchymal tumors** often found in the posterior fossa or spinal cord, particularly in children. - They do not typically present with an "ice cream cone" configuration or originate from the vestibular nerve. *Meningioma* - Meningiomas are **extraparenchymal tumors** arising from the meninges and typically have a **broad dural base** on MRI, distinct from the "ice cream cone" appearance. - While they can occur in the cerebellopontine angle, the clinical presentation with neurofibromatosis and specific symptoms point away from meningioma. *Ganglioneuroma* - Ganglioneuromas are **benign tumors of the autonomic nervous system**, usually found in the mediastinum, retroperitoneum, or adrenal glands. - They are exceptionally rare in the brain and do not cause the described symptoms or imaging findings.

Q: First sign of hydrocephalus in children is:

Sutural diastasis. ***Sutural diastasis*** - In children, especially infants, the **sutures** between skull bones are not yet fused, allowing for expansion of the skull. - As intraventricular pressure increases in hydrocephalus, the **CSF** pushes outwards, causing the sutures to widen or separate, which is known as **sutural diastasis**, an early and key radiographic sign. *Thinned out vault* - This is a **later finding** in chronic hydrocephalus, occurring as sustained increased intracranial pressure remodels and thins the skull bones. - It is not the initial sign because the skull's primary response to acute pressure is to expand at the sutures. *Post clinoid erosion* - **Erosion of the posterior clinoid processes** is a sign of long-standing, increased intracranial pressure affecting the sella turcica. - This occurs **after** the initial compensatory mechanisms like sutural widening have been exhausted or are insufficient. *Large head* - While a **large head (macrocephaly)** is a prominent clinical sign of hydrocephalus in children, particularly infants, it is the **result of sutural diastasis and skull expansion**. - The radiological finding of **sutural diastasis** precedes the clinically observable significant increase in head circumference.

Q: Banana sign seen in the fetal brain suggests ?

Spina Bifida. ***Spina Bifida*** - The **banana sign** refers to the cerebellum being flattened and curved around the brainstem, resembling a banana. This occurs due to the **Chiari II malformation**, which is almost universally associated with open spina bifida. - In spina bifida, there is a defect in the closure of the neural tube, leading to caudal displacement of the brain structures, thus compressing and altering the shape of the cerebellum. *Porencephaly* - This condition involves **cysts or cavities within the brain** parenchyma, which are not directly indicated by the banana sign. - It results from destructive lesions (e.g., ischemia, infection) and is typically identified by anechoic fluid-filled spaces communicating with the ventricular system or subarachnoid space. *Encephalocele* - Encephalocele is a **protrusion of brain tissue and/or meninges through a defect in the skull**. - While it is a neural tube defect, its primary ultrasound finding is the presence of an exocranial mass, not the posterior fossa findings that characterize the banana sign. *Renal agenesis* - **Renal agenesis** refers to the **absence of one or both kidneys** and is identified by the lack of kidneys and often severe oligohydramnios. - This condition is a genitourinary anomaly and has no direct association with the banana sign or fetal brain morphology.

Q: Shape of extradural hematoma on NCCT is?

Lens shaped. ***Lens shaped*** - An **extradural hematoma** (EDH) appears **biconvex** or **lens-shaped** because it is limited by the cranial sutures, where the dura mater is tightly attached to the inner table of the skull. - This characteristic shape helps differentiate it from other intracranial hemorrhages on **non-contrast CT (NCCT)** scans. *Bean shaped* - While descriptive, "bean-shaped" is not the standard or most accurate descriptor for an EDH, which is typically more organized and sharply delineated due to its confinement. - This term might be loosely applied to other lesions but lacks the precision needed for a confident diagnosis of EDH. *Crescent shaped* - A **crescent shape** is characteristic of a **subdural hematoma (SDH)**, which spreads more freely over the brain surface as it is located between the dura and arachnoid mater, not limited by sutures. - This shape indicates bleeding across suture lines, a key differentiator from EDH. *Medially concave* - This describes the typical appearance of a **subdural hematoma** (SDH), where the collection of blood conforms to the curvature of the brain surface and can extend across suture lines. - An EDH is typically **convex** towards the brain parenchyma because of the dura's adherence to the skull at the sutures.

Q: A 32-year-old woman is evaluated in the clinic for symptoms of polyuria and polydipsia. She has no significant past medical history and her only medication is the oral contraceptive pill. Her physical examination is entirely normal. Urine and serum biochemistry investigations are suggestive of central diabetes insipidus (DI). Which of the following is the most likely finding on magnetic resonance imaging (MRI) of the brain?

lack of hyperintense signals from the posterior pituitary. ***lack of hyperintense signals from the posterior pituitary*** - In **central diabetes insipidus**, there is a deficiency in **vasopressin (ADH)** production or release from the posterior pituitary. - The normal **hyperintense signal** from the posterior pituitary on T1-weighted MRI is due to stored ADH-neurophysin granules; its absence suggests depleted ADH stores, consistent with central DI. *agenesis of the corpus callosum* - **Agenesis of the corpus callosum** is a congenital malformation characterized by the partial or complete absence of the corpus callosum, the main commissural pathway connecting the cerebral hemispheres. - This condition is typically associated with neurological symptoms such as seizures or developmental delays, and is **not directly linked** to the pathophysiology of diabetes insipidus. *hyperintense signals in the cerebral cortex* - **Hyperintense signals in the cerebral cortex** on MRI can indicate various pathologies like inflammation, ischemia, or demyelination. - These findings are **non-specific** and would typically point towards neurological conditions affecting brain tissue, not specifically the endocrine dysfunction seen in central DI. *hypothalamic tumor* - A **hypothalamic tumor** could indeed cause central DI by damaging the cells responsible for ADH production or the supraopticohypophysial tract. - However, the question asks for the **most likely finding** specifically related to the posterior pituitary's appearance in central DI, which is the absence of its normal hyperintensity due to ADH depletion. While a tumor is a cause, the direct consequence visible on MRI due to ADH deficiency is the lack of posterior pituitary bright spot.

Q: A middle aged female presents with prolonged history of back pain followed by slowly progressive weakness of both lower limbs, spasticity and recent onset difficulty in micturation. On neurological examination there is evidence of dorsal myelopathy. MRI scan of spine shows a well-defined mid-dorsal intradural homogenous contrast enhancing mass lesion. The likely diagnosis is:

Spinal meningioma. ***Spinal meningioma*** - This diagnosis fits the profile of a **middle-aged female** with a **slowly progressive dorsal myelopathy**, including **spasticity** and **urinary dysfunction**, as meningiomas are common in this demographic. - The MRI finding of a **well-defined, mid-dorsal, intradural, homogenous, contrast-enhancing mass** is highly characteristic of a spinal meningioma. *Dermoid cyst* - Dermoid cysts are typically **congenital lesions** and often present earlier in life with symptoms like **tethered cord syndrome** or related cutaneous stigmata. - While intradural, they usually present as **non-enhancing lesions** on MRI, unless there's an associated rupture or inflammatory reaction. *Epidermoid cyst* - Epidermoid cysts are also usually **congenital** and less common in the dorsal spine as primary lesions; their progression is often more indolent with less overt myelopathic signs early on. - On MRI, epidermoid cysts appear as **non-enhancing lesions** with signal characteristics similar to cerebrospinal fluid (CSF), distinguishing them from enhancing masses. *Intradural Lipoma* - Intradural lipomas are typically **congenital spinal lesions** often associated with **dysraphic states** and usually diagnosed in childhood. - They appear as **fat-containing lesions** on MRI, showing characteristic high signal intensity on T1-weighted images and signal suppression on fat-saturated sequences, and generally **do not show significant contrast enhancement**.

Question 1

Investigation of choice in cerebral abscess is -

Accepted Answer

MRI

Answer

CT Scan

Answer

Plain X-ray

Answer

Ultrasound

Question 2

Shape of post traumatic Epidural hematoma is

Accepted Answer

Biconvex hyperdense

Answer

Biconcave hyperdense

Answer

Biconvex hypodense

Answer

Biconcave hypodense

Question 3

MRI done in a 28yrs old male suffering from Neurofibromatosis 2 showed ice cream cone appearance. On asking he further revealed that it began with ringing sensation in ears which progressed to balance problems and hearing loss. Which of the following is the most likely diagnosis -

Accepted Answer

Schwannoma

Answer

Ependymoma

Answer

Meningioma

Answer

Ganglioneuroma

Question 4

First sign of hydrocephalus in children is:

Accepted Answer

Sutural diastasis

Answer

Thinned out vault

Answer

Post clinoid erosion

Answer

Large head

Question 5

A leukemia patient who has undergone multiple courses of chemotherapy develops herpes simplex encephalitis. Which of the following would you expect a CT scan of the patient's brain to show?

Accepted Answer

Focal edema and hemorrhagic changes selectively in the temporal and frontal lobes

Answer

Generalized edema and hemorrhagic changes

Answer

Focal edema and hemorrhagic changes selectively in the brainstem

Answer

Focal edema and hemorrhagic changes selectively in the basal ganglia

Question 6

Which of the following is not true about non-contrast CT scan in head injury?

Accepted Answer

Subdural hematoma increases in density on serial CT scans over weeks

Answer

Extradural hematomas are usually lens-shaped

Answer

Acute subdural hematoma appears as crescent shadow of increased density

Answer

Subarachnoid hemorrhage appears as areas of increased density in basilar cisterns

Question 7

Banana sign seen in the fetal brain suggests ?

Accepted Answer

Spina Bifida

Answer

Porencephaly

Answer

Encephalocele

Answer

Renal agenesis

Question 8

Shape of extradural hematoma on NCCT is?

Accepted Answer

Lens shaped

Answer

Bean shaped

Answer

Crescent shaped

Answer

Medially concave

Question 9

A 32-year-old woman is evaluated in the clinic for symptoms of polyuria and polydipsia. She has no significant past medical history and her only medication is the oral contraceptive pill. Her physical examination is entirely normal. Urine and serum biochemistry investigations are suggestive of central diabetes insipidus (DI). Which of the following is the most likely finding on magnetic resonance imaging (MRI) of the brain?

Accepted Answer

lack of hyperintense signals from the posterior pituitary

Answer

agenesis of the corpus callosum

Answer

hyperintense signals in the cerebral cortex

Answer

hypothalamic tumor

Question 10

A middle aged female presents with prolonged history of back pain followed by slowly progressive weakness of both lower limbs, spasticity and recent onset difficulty in micturation. On neurological examination there is evidence of dorsal myelopathy. MRI scan of spine shows a well-defined mid-dorsal intradural homogenous contrast enhancing mass lesion. The likely diagnosis is:

Accepted Answer

Spinal meningioma

Answer

Dermoid cyst

Answer

Epidermoid cyst

Answer

Intradural Lipoma

Neuroradiology — MCQs

Neuroradiology — MCQs

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