Neuroradiology — MCQs

Neuroradiology Indian Medical PG Practice Questions and MCQs

Question 331: A patient with CSOM presented to the OPD with seizures. On examination, homonymous hemianopia was present. Identify the condition based on the CT scan given below.

A. Meningitis
B. Cerebellar abscess
C. Extradural abscess
D. Temporal abscess (Correct Answer)

Explanation: ***Temporal abscess*** - The patient's history of **CSOM** (Chronic Suppurative Otitis Media) is a classic risk factor for an **otogenic brain abscess**, with the temporal lobe being the most common site due to its proximity to the middle ear and mastoid. - The clinical signs of **seizures** and **homonymous hemianopia** (from involvement of optic radiations), combined with the characteristic **ring-enhancing lesion** on the CT scan, are pathognomonic for a temporal lobe abscess. *Cerebellar abscess* - A cerebellar abscess would present with signs of **cerebellar dysfunction**, such as **ataxia**, **nystagmus**, and **dysmetria**, which are absent in this patient's presentation. - While also a potential complication of otitis media, the focal neurological deficit of **homonymous hemianopia** localizes the lesion to the cerebrum, not the cerebellum. *Extradural abscess* - An extradural abscess is located between the dura mater and the skull and appears as a **lens-shaped (biconvex)** collection on CT, which is morphologically distinct from the **intraparenchymal, ring-enhancing lesion** shown. - Such an abscess is less likely to cause focal signs like hemianopia unless there is significant mass effect on the underlying brain parenchyma. *Meningitis* - Meningitis involves diffuse inflammation of the meninges and does not typically form a **focal, ring-enhancing mass** on a CT scan; findings are often normal or show diffuse meningeal enhancement. - The presence of a specific focal neurological deficit like **homonymous hemianopia** strongly points towards a localized lesion like an abscess rather than diffuse meningitis.

Question 332: Which of the following conditions is associated with Holman-Miller sign in the CT image given below?

A. Nasal polyp
B. Rhinosporidiosis
C. Maxillary sinusitis
D. Juvenile nasopharyngeal angiofibroma (Correct Answer)

Explanation: ***Juvenile nasopharyngeal angiofibroma***- Holman-Miller sign refers to the classic imaging finding of **anterior bowing** of the posterior wall of the **maxillary sinus** due to the aggressive expansion of this benign tumor originating in the **sphenopalatine foramen**.- This highly **vascular** tumor typically affects **adolescent males** and presents with unilateral, recurrent, and severe epistaxis and nasal obstruction.*Maxillary sinusitis*- CT findings usually include non-specific features like **mucoperiosteal thickening**, air-fluid levels, or complete opacification, without significant displacement of the bony walls.- It is an inflammatory condition, caused by infection or allergy, which does not produce the bone displacement characteristic of aggressive local tumor growth like **JNA**.*Nasal polyp*- Nasal polyps arise from the nasal and sinus mucosa (often the **ethmoids**) and cause pressure-induced **bone erosion** or remodeling, but not the specific **anterior bowing** of the posterior maxillary wall.- They are typically associated with conditions such as **allergic rhinitis** or aspirin-exacerbated respiratory disease.*Rhinosporidiosis*- This condition is characterized by proliferative, **friable, strawberry-like masses** within the nasal cavity, caused by the organism *Rhinosporidium seeberi*.- Imaging usually shows only soft tissue masses within the nasal cavity or nasopharynx without the extensive **bony displacement** needed to produce Holman-Miller sign.

Question 333: A 30-year-old female patient involved in a road traffic accident had nausea and vomiting. She was brought unconscious to the emergency room. The NCCT brain reveals the following findings. What is the most likely diagnosis? ![img-49.jpeg](img-49.jpeg)

A. a. Extradural hemorrhage (Correct Answer)
B. b. Subdural hemorrhage
C. c. Intra-parenchymal hemorrhage
D. d. Subarachnoid hemorrhage

Explanation: ***Extradural hemorrhage*** - The NCCT image displays a classic **biconvex** or **lens-shaped** hyperdense collection of blood, which is the hallmark radiological feature of an extradural (epidural) hemorrhage. - This type of hemorrhage is most commonly caused by trauma leading to a skull fracture that tears the **middle meningeal artery**, and the hematoma is confined by suture lines where the dura is tightly attached to the skull. *Subdural hemorrhage* - A subdural hemorrhage typically appears as a **crescent-shaped** collection of blood on a CT scan, as it spreads along the contour of the cerebral hemisphere. - It is usually caused by the tearing of **bridging veins** and, unlike an extradural hemorrhage, it can cross suture lines but is limited by dural reflections. *Intra-parenchymal hemorrhage* - This refers to bleeding **within the brain tissue** itself, which would appear as a hyperdense lesion located inside the brain parenchyma, often with surrounding edema. - While it can be caused by trauma (contusion), it is frequently associated with non-traumatic causes like **hypertension** or **amyloid angiopathy**. *Subarachnoid hemorrhage* - A subarachnoid hemorrhage is characterized by blood in the **subarachnoid space**, appearing as hyperdensity within the cerebral **sulci**, **fissures**, and **basal cisterns** on a CT scan. - It is commonly caused by the rupture of a **berry aneurysm** or trauma, but its appearance is distinctly different from the localized, lens-shaped collection seen in the image.

Question 334: A child presents with seizures. Contrast-enhanced CT reveals a cystic lesion with a dot sign. What is the most likely diagnosis?

A. Tuberculoma
B. Neurocysticercosis (Correct Answer)
C. Brain abscess
D. Cerebral metastasis

Explanation: **Neurocysticercosis (Correct Answer)** - This is the most common parasitic infection of the central nervous system, caused by the larval stage of the pork tapeworm, *Taenia solium* - The contrast-enhanced CT shows a cystic lesion with an eccentric hyperdense focus, which is the **pathognomonic "hole-with-dot" sign**, representing the scolex within the cyst - This imaging finding is highly specific for neurocysticercosis and is commonly seen in endemic areas *Tuberculoma (Incorrect)* - Tuberculomas typically present as single or multiple ring-enhancing lesions, often with a central nidus of calcification, known as the **"target sign"** - They are usually associated with significant vasogenic edema and are more common in patients with a history of tuberculosis or immunosuppression - The "dot sign" is not characteristic of tuberculomas *Brain abscess (Incorrect)* - A brain abscess appears as a well-defined, smooth, ring-enhancing lesion with a central area of necrosis and is typically surrounded by marked vasogenic edema - Clinically, patients often present with fever, headache, and focal neurological deficits - The pathognomonic scolex ("dot sign") is absent in brain abscesses *Cerebral metastasis (Incorrect)* - Metastases typically appear as multiple solid or ring-enhancing lesions located at the gray-white matter junction, often with edema out of proportion to the lesion size - While they can be cystic, the "hole-with-dot" sign is not a feature - Cerebral metastases are less common in children compared to adults with a known primary malignancy

Question 335: Eye of the tiger appearance on MRI is associated with:

A. Pantothenate kinase-associated degeneration (Correct Answer)
B. Wilson disease
C. Krabbe disease
D. Huntington chorea

Explanation: ***Pantothenate kinase-associated degeneration*** - The "eye of the tiger" sign is pathognomonic for **Pantothenate kinase-associated neurodegeneration (PKAN)**, a form of Neurodegeneration with Brain Iron Accumulation (NBIA). - It appears as a central area of high signal intensity (oedema/gliosis) surrounded by a rim of low signal intensity (iron deposition) in the **globus pallidus** on T2-weighted MRI. ***Wilson disease*** - Characterized by **copper deposition** in the liver, brain (e.g., basal ganglia, thalamus), and cornea (**Kayser-Fleischer rings**). - MRI findings typically show increased T2 signal intensity in the putamen, midbrain, and basal ganglia, but do not produce the classic "eye of the tiger" sign. ***Krabbe disease*** - This is a lysosomal storage disease (leukodystrophy) caused by a deficiency of the enzyme **galactocerebrosidase**. - MRI typically shows extensive white matter abnormalities and atrophy, but it is not associated with the **globus pallidus** changes seen in the "eye of the tiger" sign. ***Huntington chorea*** - A progressive brain disorder characterized by prominent atrophy of the **caudate nucleus** and putamen (striatum). - MRI primarily demonstrates severe **caudate atrophy** and is not associated with the characteristic PKAN finding in the globus pallidus.

Question 336: A 30-year-old male patient presents to OPD with complaints of recurrent headache and nausea, MRI of brain shown below. What is the diagnosis?

A. Meningioma (Correct Answer)
B. Glioma
C. Pilocytic astrocytoma
D. Ependymoma

Explanation: ***Meningioma*** - The MRI displays a classic **extra-axial mass** (meaning outside the brain parenchyma) arising from the convexity dura. - Key imaging features supporting this diagnosis are the **well-circumscribed, lobulated shape** and the **intense, homogenous enhancement** post-contrast. *Glioma* - Gliomas, such as **Glioblastoma Multiforme (GBM)**, are **intra-axial tumors** (arising within the brain tissue) and typically have irregular, infiltrating margins. - High-grade gliomas commonly show **ring enhancement** with central necrosis, which is not characteristic of the lesion depicted. *Ependymoma* - Ependymomas are typically found within the **ventricular system** (especially the fourth ventricle in adults, or lateral ventricles in children) or the spinal cord. - They are **intra-axial** tumors (ventricular location being the defining feature) and rarely present as extra-axial convexity lesions. *Pilocytic astrocytoma* - This tumor is predominantly seen in children and adolescents, often located in the **cerebellum** or along the optic pathways, usually presenting as an **intra-axial** tumor. - Radiologically, it typically appears as a large **cyst with an enhancing mural nodule**, which differs significantly from the solid, extra-axial lesion shown.

Question 337: History of pulsatile mass in the neck. Digital angiography image shown. Not filling on carotid compression. But refilling on releasing pressure. What is the diagnosis?

A. Haemangioma
B. Carotid Aneurysm
C. Carotid Body tumour (Correct Answer)
D. AV fistula

Explanation: ***Carotid Body tumour*** - The angiography image shows a classic **"splaying"** or **"lyre sign"** of the carotid bifurcation (Common Carotid Artery splitting into Internal and External Carotid Arteries), which is **pathognomonic for a Carotid Body Tumour** (Paraganglioma). - The tumor is **highly vascular** (tumour blush on angiography) and receives its blood supply from the **External Carotid Artery (ECA)**, thus explaining the pulsatile nature. - **Fontaine test positive**: The described finding of "not filling on carotid compression but refilling on releasing pressure" is characteristic of a carotid body tumor, as temporary compression reduces flow but the highly vascular tumor refills from collateral circulation when pressure is released. - Carotid body tumors are **paragangliomas** arising from chemoreceptor cells at the carotid bifurcation. *Carotid Aneurysm* - A carotid artery aneurysm would appear as a **localized, saccular, or fusiform dilatation** of the carotid vessel lumen on angiography, not demonstrating the splaying of the bifurcation. - While also pulsatile, its filling on angiography would be purely arterial flow within the dilated vessel, not a pathological tumor blush. - Would not show the characteristic lyre sign. *AV fistula* - An Arteriovenous (AV) fistula would typically show **early venous opacification** (rapid shunting of contrast from artery to vein), which is not the primary finding here. - The mass is described as a localized tumor mass causing splaying of the bifurcation, not the flow-related abnormalities typical of a fistula. - Would present with continuous bruit rather than pulsatile mass. *Haemangioma* - A large, highly vascular haemangioma in the neck might be pulsatile but typically presents as a less defined mass and does **not characteristically cause the splaying of the carotid bifurcation** seen in a Carotid Body Tumour. - While both can show a tumor blush, the **location** (at carotid bifurcation) and **specific radiological presentation** (lyre sign) strongly favor the Carotid Body Tumour (a type of **paraganglioma**).

Question 338: Which of the following is the investigation of choice for spinal TB?

A. Ultrasound
B. MRI (Correct Answer)
C. CT scan
D. CBNAAT

Explanation: ***MRI*** - **Magnetic Resonance Imaging (MRI)** is the investigation of choice, as it provides excellent visualization of soft tissues, including the **spinal cord**, nerve roots, and early features like **bone marrow edema** and **paraspinal abscesses**. - It can clearly define the extent of the disease, including disc involvement, **epidural space compression**, and neural compromise, which is crucial for surgical planning. *Ultrasound* - **Ultrasound** is primarily used for assessing soft tissue masses and guiding aspirations but has limited ability to image deep structures like the **vertebral column** and spinal canal. - It cannot adequately assess the extent of **bone destruction**, vertebral body involvement, or **intradural pathology** associated with spinal TB. *CT scan* - **CT scan** is superior to conventional radiography for demonstrating **lytic bone destruction**, calcification, and fine bony detail associated with TB. - However, it is less effective than MRI in visualizing **soft tissue involvement**, **early marrow changes**, or the degree of **cord compression**. *CBNAAT* - **CBNAAT (Cartridge-Based Nucleic Acid Amplification Test)** is a **microbiological test** used for the rapid diagnosis of TB and detection of rifampicin resistance. - It requires a **tissue or fluid sample** (e.g., from aspiration or biopsy) and is used for **pathological confirmation**, not as the primary radiological investigation of choice.

Question 339: A child with intellectual disability and glaucoma was subjected to NCCT. CT scan findings are?

A. Lissencephaly
B. Agyria
C. Tram track calcification (Correct Answer)
D. West syndrome

Explanation: ***Tram track calcification*** - The combination of **intellectual disability**, **glaucoma**, and the characteristic **tram track calcifications** on NCCT are classic features of **Sturge-Weber syndrome**. - **Tram track calcifications** refer to the curvilinear calcifications seen in the cerebral cortex, paralleling the gyral contours, which are visible on the image. *Lissencephaly* - **Lissencephaly** is characterized by a **smooth brain surface** due to absent or decreased gyri and sulci. - This condition does not typically present with glaucoma or tram track calcifications. *Agyria* - **Agyria** is an extreme form of lissencephaly, meaning literally "without gyri." - It describes a completely smooth cerebral surface and is not associated with the calcifications or glaucoma seen in this presentation. *West syndrome* - **West syndrome** is an age-dependent epileptic encephalopathy characterized by **infantile spasms**, **developmental arrest**, and a **hypsarrhythmia** pattern on EEG. - While it can be associated with intellectual disability, it does not typically involve glaucoma or tram track calcifications.

Question 340: The image shows presence of:

A. Holoprosencephaly
B. Encephalocele (Correct Answer)
C. Anencephaly
D. Dandy-Walker syndrome

Explanation: ***Correct: Encephalocele*** The image clearly shows an **extrusion of brain tissue and meninges through a defect in the skull**, particularly in the occipital region, which is characteristic of an encephalocele. The arrow points directly to this **sac-like protrusion of brain material** extending beyond the normal skull contour. This represents a neural tube defect where the cranial bones failed to close completely during development, allowing brain tissue to herniate through the defect. *Incorrect: Holoprosencephaly* Holoprosencephaly is characterized by a **failure of the prosencephalon to cleave into two cerebral hemispheres**, resulting in a single ventricular cavity and associated facial anomalies. This is an **internal structural abnormality** affecting brain division and differentiation, not an external protrusion. The image does not show incomplete hemispheric separation or midline fusion defects. *Incorrect: Anencephaly* Anencephaly is a severe neural tube defect characterized by **absence of a major portion of the brain, skull, and scalp**. In anencephaly, the cranial vault is largely absent with exposed, rudimentary brain tissue. The image shows a **substantially intact cranial cavity with normal brain tissue** and an external sac, which is completely different from the massive tissue absence seen in anencephaly. *Incorrect: Dandy-Walker syndrome* Dandy-Walker syndrome involves a **malformation of the cerebellum and posterior fossa**, specifically characterized by cystic dilation of the fourth ventricle, hypoplasia or agenesis of the cerebellar vermis, and an enlarged posterior fossa. This is an **internal posterior fossa anomaly** without external herniation of brain tissue through a skull defect. The imaging finding shown is external to the skull, not an internal cerebellar/fourth ventricle malformation.

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