Neuroradiology — MCQs

A 6-year-old boy presented with complex seizures per day in spite of an adequate 4-drug antiepileptic regimen. He had a history of repeated high-grade fever in childhood. MRI for epilepsy protocol revealed a normal brain scan. Which of the following will not be helpful for functional imaging of the brain?

Q317Easy

Which of the following is a supratentorial tumor?

Q318Easy

MRI is the investigation of choice in all of the following except:

Q319Easy

What is the investigation of choice for subdural hemorrhage?

Q320Medium

What is the best method to evaluate a discrepancy in the articular disc of the temporomandibular joint (TMJ)?

Neuroradiology Indian Medical PG Practice Questions and MCQs

Question 311: Suprasellar calcification is a feature of which of the following tumors?

A. Craniopharyngioma (Correct Answer)
B. Astrocytoma
C. Oligodendroglioma
D. Meningioma

Explanation: **Explanation:** **Craniopharyngioma** is the most common suprasellar tumor in children and is classically associated with calcification. Derived from remnants of **Rathke’s pouch**, these tumors are typically cystic and contain "machinery oil" fluid. Calcification is a hallmark feature, seen in approximately **90% of pediatric cases** and about 50% of adult cases. On imaging, the classic triad includes a suprasellar location, cystic components, and peripheral/nodular calcification. **Analysis of Incorrect Options:** * **Astrocytoma:** While pilocytic astrocytomas can occur in the optic chiasm (suprasellar region), they rarely calcify compared to craniopharyngiomas. * **Oligodendroglioma:** This tumor is famous for having the highest incidence of calcification (70-90%), but it is typically **supratentorial/cortical** (frontal lobe), not suprasellar. * **Meningioma:** While meningiomas can occur at the tuberculum sellae and may show hyperostosis or psammomatous calcification, they are primarily solid, enhancing dural-based masses in adults, not the classic cause of suprasellar calcification in the pediatric population. **High-Yield Clinical Pearls for NEET-PG:** * **Adamantinomatous type:** Common in children; shows "machinery oil" fluid and frequent calcification. * **Papillary type:** Common in adults; usually solid and rarely calcifies. * **Differential Diagnosis for Suprasellar Mass (Sellar/Suprasellar):** Remember the mnemonic **SATCHMO** (Sarcoid/Sellar adenoma, Aneurysm, Teratoma/Tuberculosis, Craniopharyngioma/Cleft cyst, Hypophysitis/Hamartoma, Meningioma/Metastasis, Optic glioma). * **Radiological sign:** "Eggshell calcification" in the suprasellar region is highly suggestive of craniopharyngioma.

Question 312: Which of the following signs is classic for CT scanning in Graves ophthalmopathy?

A. Nodular muscle enlargement
B. Solitary muscle enlargement
C. Fusiform muscle enlargement with sparing of tendons (Correct Answer)
D. Kinking of extraocular muscles

Explanation: **Explanation:** **Graves’ Ophthalmopathy (Thyroid-Associated Orbitopathy)** is the most common cause of both unilateral and bilateral proptosis in adults. The hallmark finding on CT or MRI is the enlargement of the extraocular muscle bellies. 1. **Why Option C is Correct:** In Graves’ disease, there is an accumulation of glycosaminoglycans and edema within the muscle fibers. This characteristically involves the **muscle belly** while **sparing the tendinous insertions** at the globe. This creates a classic **"fusiform" or "coke-bottle" appearance**. This tendon-sparing is a crucial radiological differentiator from orbital pseudotumor. 2. **Why Incorrect Options are Wrong:** * **Option A & B:** Enlargement in Graves is typically smooth and symmetric, not nodular. While it can be unilateral, it most commonly involves multiple muscles (bilateral). * **Option D:** "Kinking" is not a standard radiological descriptor for Graves. Instead, severe enlargement may cause optic nerve compression at the orbital apex. **High-Yield Clinical Pearls for NEET-PG:** * **Order of Muscle Involvement:** Remember the mnemonic **I’M SLOW** (Inferior Rectus > Medial Rectus > Superior Rectus > Lateral Rectus > Obliques). The Inferior Rectus is the most commonly affected. * **Differential Diagnosis:** **Orbital Pseudotumor (Idiopathic Orbital Inflammation)** typically involves the **tendon** (Tendon-loading), which helps distinguish it from Graves. * **Clinical Sign:** **Dalrymple sign** (widened palpebral fissure due to lid retraction) is a classic clinical finding. * **Imaging Choice:** CT is excellent for visualizing muscle enlargement and bony decompression planning; MRI is superior for evaluating optic nerve compression and active edema.

Question 313: The 'eye of tiger' sign on MRI is characteristic of which of the following conditions?

A. Hallervorden-Spatz syndrome
B. Progressive supranuclear palsy
C. Early onset levodopa-responsive Parkinsonism
D. All of the above (Correct Answer)

Explanation: The **'Eye of the Tiger' sign** is a classic neuroradiological finding seen on **T2-weighted MRI** of the brain. It is characterized by a central area of hyperintensity (representing gliosis and spongiosis) surrounded by a rim of marked hypointensity (representing excessive iron deposition) in the **globus pallidus**. ### **Explanation of Options:** * **Hallervorden-Spatz Syndrome:** Now more commonly known as **Pantothenate Kinase-Associated Neurodegeneration (PKAN)**, this is the most classic association. It is an autosomal recessive disorder involving the *PANK2* gene, leading to abnormal iron accumulation in the basal ganglia. * **Progressive Supranuclear Palsy (PSP):** While PSP is more classically associated with the 'Hummingbird' or 'Mickey Mouse' sign, rare variants and specific cases of atypical parkinsonism can demonstrate the Eye of the Tiger pattern due to iron deposition in the globus pallidus. * **Early-onset Levodopa-responsive Parkinsonism:** Certain genetic forms of juvenile parkinsonism (such as those involving *PLA2G6* mutations) can present with similar iron-related signal changes on MRI. Because the sign is most famously associated with PKAN but can be observed in these other neurodegenerative conditions involving iron metabolism, **"All of the above"** is the most accurate choice for a competitive exam. ### **High-Yield Clinical Pearls for NEET-PG:** 1. **Imaging Sequence:** The sign is best visualized on **T2-weighted** or **T2* (Gradient Echo/SWI)** sequences because iron causes "blooming" artifacts. 2. **Anatomy:** The specific site involved is the **Globus Pallidus** (medial segment). 3. **Differential Diagnosis:** If you see a "Tiger's Eye" in a pediatric patient with dystonia, think **PKAN**. 4. **Other Basal Ganglia Signs:** * **Hummingbird/Penguin Sign:** Midbrain atrophy in PSP. * **Hot Cross Bun Sign:** MSA-C (Multiple System Atrophy). * **Face of the Giant Panda:** Wilson’s Disease.

Question 314: What is the earliest method for diagnosing a pituitary tumor?

A. CT scan (Correct Answer)
B. Visual field charting
C. Visual evoked potential
D. X-ray skull

Explanation: **Explanation:** The diagnosis of pituitary tumors has evolved significantly with imaging advancements. Among the options provided, **CT scan** is the earliest method for detecting the tumor mass itself, especially when evaluating bony changes in the sella turcica or identifying microcalcifications (common in craniopharyngiomas). While MRI is currently the "Gold Standard" for pituitary imaging due to its superior soft-tissue resolution, CT remains a primary radiological modality for early structural diagnosis when MRI is unavailable. **Analysis of Options:** * **CT Scan (Correct):** It provides high-resolution cross-sectional imaging that can detect small adenomas, bony erosion of the sella, and tumor extension. * **Visual Field Charting (Incorrect):** This is a clinical functional assessment, not a primary diagnostic tool for the tumor itself. Bitemporal hemianopia occurs only when the tumor is large enough (macroadenoma) to compress the optic chiasm. * **Visual Evoked Potential (Incorrect):** This measures the electrical conduction along the visual pathway. While it can detect subclinical compression, it is non-specific and cannot diagnose the presence or nature of a pituitary mass. * **X-ray Skull (Incorrect):** This was historically used to see "Sellar enlargement" or "Ballooning," but it can only detect large tumors that have already caused significant bony remodeling. It lacks the sensitivity to detect microadenomas. **High-Yield Pearls for NEET-PG:** * **Gold Standard Investigation:** MRI with gadolinium enhancement (specifically Dynamic Contrast MRI). * **Earliest Clinical Sign:** Hormonal imbalance (e.g., hyperprolactinemia) often precedes visual symptoms. * **Classic Visual Deficit:** Bitemporal hemianopia (due to compression of the decussating fibers at the optic chiasm). * **Best Imaging for Calcification:** CT scan (highly relevant for differentiating Craniopharyngioma from Pituitary Adenoma).

Question 315: Cavernous hemangioma is characterized by which of the following radiological findings?

A. Reticulated popcorn-like calcification pattern (Correct Answer)
B. A well-defined nidus of abnormal vessels
C. A well-defined arterial feeder
D. Dilatation of phleboliths

Explanation: **Explanation:** **Cavernous Hemangiomas** (also known as Cavernomas or Cavernous Malformations) are low-flow vascular malformations consisting of a "mulberry-like" cluster of dilated, thin-walled capillaries without intervening brain parenchyma. 1. **Why Option A is Correct:** On MRI (the gold standard), cavernomas typically present with a **"popcorn-like" appearance**. This is due to a central reticulated core of varying signal intensities (representing blood products in different stages of degradation) surrounded by a characteristic **hypointense rim of hemosiderin** (best seen on T2W or Gradient Echo/SWI sequences). Calcification is common within these lesions, contributing to the reticulated pattern. 2. **Why Incorrect Options are Wrong:** * **Options B & C:** A well-defined **nidus** and **arterial feeders** are classic hallmarks of **Arteriovenous Malformations (AVMs)**, which are high-flow lesions. Cavernomas are angiographically occult (they do not show up on conventional angiography) because they lack large feeding arteries or rapid flow. * **Option D:** While phleboliths (calcified thrombi) are seen in soft tissue hemangiomas, they are not a defining radiological feature of intracranial cavernomas in the context of "dilatation." **NEET-PG High-Yield Pearls:** * **Imaging Gold Standard:** MRI is the investigation of choice. * **Most Sensitive Sequence:** **Gradient Echo (GRE)** or **Susceptibility Weighted Imaging (SWI)** due to the "blooming effect" caused by hemosiderin. * **Angiography:** Characteristically **"Angiographically Occult"** (Normal DSA). * **Clinical Presentation:** Most commonly presents with **seizures** or focal neurological deficits due to micro-hemorrhages. * **Association:** Often associated with **Developmental Venous Anomalies (DVA)**; when seen together, it is termed a mixed vascular malformation.

Question 316: A 6-year-old boy presented with complex seizures per day in spite of an adequate 4-drug antiepileptic regimen. He had a history of repeated high-grade fever in childhood. MRI for epilepsy protocol revealed a normal brain scan. Which of the following will not be helpful for functional imaging of the brain?

A. MDCT (Correct Answer)
B. SPECT imaging
C. Interictal 18F-FDG PET
D. Video EEG with ictal 99mTc-HMPAO study of brain

Explanation: **Explanation:** The clinical presentation of a 6-year-old with drug-resistant epilepsy (DRE) and a normal structural MRI (non-lesional epilepsy) necessitates **functional neuroimaging** to localize the epileptogenic focus for potential surgical intervention. **Why MDCT is the correct answer:** Multi-Detector Computed Tomography (MDCT) is a **structural** imaging modality. While excellent for detecting acute hemorrhage, calcifications, or bony abnormalities, it lacks the physiological sensitivity to map brain metabolism or blood flow changes associated with seizure activity. Therefore, it has no role in the functional evaluation of epilepsy. **Analysis of functional imaging options:** * **Interictal 18F-FDG PET:** This measures glucose metabolism. In the interictal state (between seizures), the epileptogenic focus typically appears as an area of **hypometabolism**. * **Ictal SPECT (99mTc-HMPAO):** This measures regional cerebral blood flow (rCBF). During a seizure (ictal state), the focus shows **hyperperfusion**. Comparing ictal SPECT with interictal SPECT (SISCOM) is a highly sensitive method for localization. * **Video EEG:** This is the gold standard for correlating electrical activity with clinical semiology, providing essential functional data. **Clinical Pearls for NEET-PG:** * **Drug-Resistant Epilepsy (DRE):** Defined as failure of adequate trials of two tolerated, appropriately chosen, and used antiepileptic drug schedules. * **PET vs. SPECT:** Remember, PET shows **interictal hypometabolism**, whereas SPECT shows **ictal hyperperfusion**. * **MRI Protocol:** The "Epilepsy Protocol" includes thin-slice coronal FLAIR and T2 sequences perpendicular to the long axis of the hippocampus to rule out Mesial Temporal Sclerosis (MTS).

Question 317: Which of the following is a supratentorial tumor?

A. Craniopharyngioma (Correct Answer)
B. Medulloblastoma
C. Astrocytoma
D. Ependymoma

Explanation: ### Explanation The **tentorium cerebelli** is a dural fold that separates the cerebrum (supratentorial) from the cerebellum and brainstem (infratentorial). Distinguishing between these compartments is a fundamental step in neuro-radiological diagnosis. **1. Why Craniopharyngioma is the Correct Answer:** Craniopharyngiomas are benign (WHO Grade I) tumors derived from remnants of **Rathke’s pouch**. They are located in the **sellar or suprasellar region**, which is anatomically situated above the tentorium cerebelli. Therefore, they are strictly **supratentorial** tumors. **2. Analysis of Incorrect Options:** * **Medulloblastoma:** This is the most common malignant brain tumor in children. It arises from the cerebellar vermis and is located in the posterior fossa (**infratentorial**). * **Astrocytoma:** While astrocytomas can occur anywhere, in the context of pediatric board exams (where this distinction is most commonly tested), the **Pilocytic Astrocytoma** is the most common pediatric brain tumor and typically occurs in the cerebellum (**infratentorial**). * **Ependymoma:** In children, these most commonly arise from the floor of the **fourth ventricle**, making them **infratentorial** lesions. (Note: In adults, they are more common in the spinal cord). **High-Yield Clinical Pearls for NEET-PG:** * **Rule of Thumb:** In children, 70% of brain tumors are **infratentorial** (e.g., Medulloblastoma, Astrocytoma). In adults, 70% are **supratentorial** (e.g., Gliomas, Meningiomas). * **Craniopharyngioma Triad:** Growth retardation (endocrine), bitemporal hemianopia (visual), and **suprasellar calcification** on CT (seen in 90% of pediatric cases). * **Imaging Hallmark:** Craniopharyngiomas often show a "machinery oil" appearance (cholesterol crystals) within cystic components on MRI.

Question 318: MRI is the investigation of choice in all of the following except:

A. Syringomyelia
B. Brain stem tumors
C. Skull bone tumors (Correct Answer)
D. Multiple sclerosis

Explanation: **Explanation:** The core principle of neuroimaging is that **MRI** is superior for soft tissues and posterior fossa structures, while **CT** is superior for cortical bone and acute hemorrhage. **Why Skull Bone Tumors is the correct answer:** MRI has poor signal intensity for cortical bone because bone contains very few mobile hydrogen protons. For evaluating **skull bone tumors** (like osteomas or fibrous dysplasia) and bony destruction, **Computed Tomography (CT)** is the investigation of choice. CT provides excellent spatial resolution and contrast for mineralized tissues, allowing for the precise assessment of cortical integrity and trabecular patterns. **Why the other options are incorrect:** * **Syringomyelia:** MRI is the gold standard as it can clearly visualize the syrinx (fluid-filled cavity) within the spinal cord and identify associated causes like Chiari malformations. * **Brain stem tumors:** The brain stem is located in the posterior fossa. CT often suffers from "bone hardening artifacts" in this region due to the surrounding dense petrous bones. MRI provides superior contrast resolution and multiplanar imaging, making it the choice for brain stem lesions. * **Multiple Sclerosis (MS):** MRI is the most sensitive modality for detecting demyelinating plaques. It is essential for demonstrating "dissemination in space and time" (McDonald Criteria). **High-Yield Clinical Pearls for NEET-PG:** * **IOC for Acute Stroke:** Non-contrast CT (to rule out hemorrhage); however, **Diffusion-Weighted MRI (DWI)** is the most sensitive for early ischemic changes (within minutes). * **IOC for Head Trauma:** Non-contrast CT (to detect fractures and acute bleeds). * **IOC for Posterior Fossa lesions:** MRI. * **Calcification:** CT is more sensitive than MRI for detecting intracranial calcification.

Question 319: What is the investigation of choice for subdural hemorrhage?

A. Angiography
B. Non-contrast Computed Tomography (NCCT) (Correct Answer)
C. Contrast-Enhanced Computed Tomography (CECT)
D. Magnetic Resonance Imaging (MRI)

Explanation: **Explanation:** **Non-contrast Computed Tomography (NCCT) Head** is the investigation of choice (IOC) for acute subdural hemorrhage (SDH) because it is rapid, widely available, and highly sensitive to acute blood. In an emergency setting, NCCT is preferred over MRI to quickly differentiate between hemorrhagic and ischemic strokes or to identify life-threatening mass effects. * **Why NCCT is correct:** Acute blood appears **hyperdense (white)** on NCCT. A subdural hemorrhage typically presents as a **crescentic (concave)** collection that crosses suture lines but is limited by dural reflections (like the falx cerebri). * **Why others are incorrect:** * **Angiography:** Used to identify vascular malformations or aneurysms (e.g., in Subarachnoid Hemorrhage), but not for primary diagnosis of SDH. * **CECT:** Contrast can mimic the appearance of acute blood (extravasation) or mask small hemorrhages; it is generally avoided in the initial trauma/stroke protocol. * **MRI:** While more sensitive for chronic SDH or diffuse axonal injury, it is time-consuming and less accessible in acute trauma settings. **High-Yield Clinical Pearls for NEET-PG:** * **Shape:** SDH is **Crescentic/Concave** (vs. Epidural Hemorrhage which is Biconvex/Lens-shaped). * **Source of Bleed:** Tearing of **Bridging Veins** (vs. Middle Meningeal Artery in EDH). * **Density Evolution:** * *Acute:* Hyperdense (White) * *Subacute:* Isodense (Grey - may be difficult to see) * *Chronic:* Hypodense (Black) * **Risk Groups:** Elderly patients and alcoholics (due to brain atrophy stretching the bridging veins).

Question 320: What is the best method to evaluate a discrepancy in the articular disc of the temporomandibular joint (TMJ)?

A. Transpharyngeal projection
B. MRI (Correct Answer)
C. Arthrography
D. Arthroplasty

Explanation: **Explanation:** The **Temporomandibular Joint (TMJ)** is a complex bicondylar joint containing a fibrocartilaginous articular disc. Evaluating "discrepancies" (such as internal derangement, disc displacement, or perforation) requires high-quality visualization of soft tissue structures. **Why MRI is the Correct Answer:** **MRI (Magnetic Resonance Imaging)** is the **gold standard** for TMJ evaluation. It provides superior soft-tissue contrast, allowing for the precise visualization of the articular disc, its position relative to the condyle (in both open and closed mouth positions), and the surrounding ligaments and muscles. It is non-invasive and does not use ionizing radiation. **Analysis of Incorrect Options:** * **Transpharyngeal projection (Parchman’s view):** This is a plain radiographic technique. While useful for identifying gross bony changes or fractures of the condyle, it cannot visualize the radiolucent articular disc. * **Arthrography:** This involves injecting contrast into the joint spaces. While it was historically used to diagnose disc perforations or adhesions, it is invasive and has been largely replaced by MRI. * **Arthroplasty:** This is a **surgical procedure** (treatment) to repair or replace the joint, not a diagnostic imaging method. **High-Yield Clinical Pearls for NEET-PG:** * **Best initial investigation for TMJ bony changes:** Non-contrast CT (NCCT) or Cone Beam CT (CBCT). * **Best investigation for TMJ soft tissue/disc:** MRI. * **Most common disc displacement:** Anterior displacement (often associated with "clicking" sounds). * **T1-weighted sequences** are excellent for anatomy, while **T2-weighted sequences** help identify joint effusion or inflammation.

Practice by Chapter

Neuroanatomy for Radiologists

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Cerebrovascular Diseases

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Intracranial Tumors

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CNS Infections

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Demyelinating and Degenerative Diseases

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Head Trauma Imaging

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Spine Imaging: Trauma and Degenerative Disease

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Spine Tumors and Infections

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Pediatric Neuroradiology

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Congenital CNS Anomalies

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Functional Neuroimaging

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Neurointerventional Procedures

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