Neuroradiology Practice Questions

Q: A 35-year-old female presents with a history of seizures and headaches. An MRI shows a well-defined cystic lesion with an enhancing mural nodule in the temporal lobe. What is the most likely diagnosis?

Low-grade astrocytoma. ***Low-grade astrocytoma*** - The **cyst with enhancing mural nodule** appearance in the temporal lobe of a young adult with seizures is highly characteristic of **pleomorphic xanthoastrocytoma (PXA)**, a subtype of low-grade astrocytoma (WHO Grade II). - PXA typically presents as a **superficial, cortically-based cystic mass** with a solid enhancing nodule, often with **dural involvement** ("dural tail" sign). - The patient's age (35-year-old female) and presenting symptoms of **seizures** and **headaches** are consistent with the slow-growing nature of these tumors, which often irritate cortical structures. - PXA has a **favorable prognosis** compared to other astrocytomas and commonly occurs in the **temporal lobe**. *Glioblastoma multiforme* - **Glioblastoma multiforme (GBM)** is a highly aggressive WHO Grade IV tumor that typically presents with **thick irregular ring enhancement**, **central necrosis**, and **extensive surrounding vasogenic edema**. - GBM shows rapid clinical progression and would not typically present as a well-defined cyst with mural nodule. - The imaging appearance described is more consistent with a low-grade tumor. *Meningioma* - **Meningiomas** are **extra-axial (dural-based) tumors** that demonstrate **uniform, homogeneous enhancement** with a characteristic **dural tail** sign. - They are typically **solid masses** (not cystic) that compress rather than infiltrate brain parenchyma. - The described cystic lesion with mural nodule is more consistent with an intra-axial tumor like PXA. *Oligodendroglioma* - **Oligodendrogliomas** characteristically show **calcifications** (present in 70-90% of cases) and are commonly located in the **frontal lobes**. - They typically appear as **heterogeneous, infiltrative masses** rather than well-defined cystic lesions with mural nodules. - While they can cause seizures, the imaging appearance described is not typical for oligodendroglioma.

Q: Identify the condition based on the provided image.

Callosal dysgenesis. ***Callosal dysgenesis*** - This condition is characterized by the **partial or complete absence of the corpus callosum**, which connects the two cerebral hemispheres. - Imaging typically shows widely separated and parallel lateral ventricles, sometimes described as a "bat wing" or "moose horn" configuration, and a high-riding third ventricle. *Dandy-Walker malformation* - This malformation involves the **cerebellum and fourth ventricle**, characterized by agenesis or hypoplasia of the cerebellar vermis and cystic dilation of the fourth ventricle. - It results in an enlarged posterior fossa, which is not depicted in this image. *Aicardi syndrome* - Aicardi syndrome is a rare genetic disorder characterized by the triad of **infantile spasms**, **chorioretinal lacunae**, and **agenesis of the corpus callosum**. - While agenesis of the corpus callosum is present, Aicardi syndrome is a broader diagnosis that also includes specific ocular and seizure findings, which cannot be solely determined from an isolated image showing callosal dysgenesis. *Septo-optic dysplasia* - This condition involves the **hypoplasia of the optic nerves** and **absence or hypoplasia of the septum pellucidum**, along with hypothalamic-pituitary dysfunction. - While the septum pellucidum is absent, the characteristic optic nerve hypoplasia and endocrine dysfunction are essential diagnostic features that cannot be inferred from this image alone.

Q: Stenver's view is used for -

Internal auditory canal. ***Internal auditory canal*** - The **Stenvers position** (Stenvers view) is a specific radiographic projection designed to visualize the **petrous portion of the temporal bone**, with a clear profile of the internal auditory canal. - It is used to evaluate the **internal auditory canals** for abnormalities such as **acoustic neuromas** or other lesions affecting the vestibulocochlear nerve. *Inferior orbital foramen* - The inferior orbital foramen is typically visualized with standard facial bone views or specific orbital projections, not the Stenvers view. - It is a small opening on the floor of the orbit, transmitting the **infraorbital nerve and vessels**. *Sella turcica* - The sella turcica, which houses the pituitary gland, is best visualized using a **lateral skull view** or CT/MRI. - Stenvers view is not designed to provide optimal imaging of the sella turcica. *Superior orbital foramen* - The superior orbital foramen (more commonly referred to as the **superior orbital fissure**) is best seen on standard orbital or skull views. - It transmits cranial nerves III, IV, VI, and the ophthalmic division of V, and is not the primary focus of the Stenvers view.

Q: What condition is shown in the MR angiogram of the skull?

Vein of Galen malformation. ***Vein of Galen malformation*** - The image provided is an **MR angiogram (MRA)**, which clearly shows a **large, dilated vein of Galen**. This is the characteristic appearance of a Vein of Galen malformation. - This congenital vascular malformation involves a direct artery-to-vein shunt, leading to the characteristic aneurysmal dilatation of the vein. *Dandy-Walker malformation* - This is a congenital brain malformation characterized by **agenesis or hypoplasia of the cerebellar vermis** and cystic dilation of the fourth ventricle. - While it affects brain structures, it does not involve the type of vascular abnormality seen in the image. *Pneumocephalus* - **Pneumocephalus** refers to the presence of **air within the intracranial cavity**, often due to trauma or surgery. - It would appear as dark areas on imaging, representing air, not the bright, dilated vascular structures seen here. *Crouzon syndrome* - **Crouzon syndrome** is a genetic disorder characterized by **craniosynostosis**, which is the premature fusion of skull sutures. - This condition primarily affects bone growth and skull shape, with no direct involvement of the cerebral vasculature as depicted in the MRA.

Q: Which diagnosis is most strongly suggested by the numerous, well-circumscribed punched-out lucencies in the skull calvarium on this radiograph?

Multiple myeloma. The radiograph demonstrates numerous discrete, well-circumscribed lytic lesions throughout the calvarium, producing the classic punched-out skull appearance of multiple myeloma. These lesions result from osteoclast activation by neoplastic plasma cells and typically lack a sclerotic rim. Calvarial metastases may also be lytic but are more often variable in size and less uniformly circumscribed. Paget disease typically causes calvarial thickening and a cotton-wool appearance, while osteomyelitis generally produces focal, irregular bone destruction rather than widespread punched-out lesions. Brain metastases are intracranial lesions and cannot be diagnosed from these calvarial findings on a plain skull radiograph.

Q: Which of the following provides excellent details about the chemodectomas?

MRI. ***MRI*** - **Magnetic Resonance Imaging (MRI)** is generally considered the best modality for evaluating **chemodectomas** due to its superior soft tissue contrast. - It can accurately delineate the tumor's extent, its relationship to surrounding structures, and detect any **vascular invasion** or **nerve involvement**. *Xray* - **X-rays** provide limited detail for soft tissue tumors like chemodectomas. - They primarily visualize bone structures and are not effective in characterizing small or non-calcified soft tissue masses. *Ultrasound* - **Ultrasound** can detect the presence of a mass and assess its vascularity, but its utility for chemodectomas is limited by its lower resolution and dependence on operator skill. - It may not provide sufficient detail for precise anatomical localization or differentiation from other neck masses. *CT angiography (can provide useful information regarding vascular involvement)* - **CT angiography** is excellent for visualizing the **vascular supply** to the tumor and assessing its relationship with critical blood vessels. - While useful for surgical planning, it typically offers less detailed soft tissue characterization compared to MRI for the primary tumor itself.

Q: What is the most sensitive investigation for diffuse axonal injury?

MRI. ***MRI*** - **Magnetic Resonance Imaging (MRI)** is the most sensitive imaging modality for detecting **diffuse axonal injury (DAI)** due to its ability to visualize microscopic changes in white matter integrity. - **Susceptibility Weighted Imaging (SWI)** is particularly sensitive for detecting **microhemorrhages** (petechial hemorrhages) at gray-white matter junctions, corpus callosum, and brainstem—characteristic locations for DAI. - **Diffusion Weighted Imaging (DWI)** and **Diffusion Tensor Imaging (DTI)** can demonstrate disruption of axonal tracts by showing restricted diffusion and measuring changes in fractional anisotropy. - Conventional sequences like **T2*-weighted gradient-recalled echo (GRE)** and **FLAIR** also help detect edema and blood products associated with DAI. *CT* - **Computed Tomography (CT) scans** are often the initial imaging modality in acute head injury due to their speed and ability to detect gross abnormalities like **hemorrhages** or **fractures**. - However, CT is **insensitive** to the microscopic axonal shearing and tears characteristic of DAI, typically appearing normal even in severe cases. *X ray* - **X-rays** are primarily used to evaluate **bone structures** and detect **skull fractures**. - They provide no information about soft tissue injury to the brain parenchyma, making them completely insensitive for detecting DAI. *PET scan* - A **Positron Emission Tomography (PET) scan** measures metabolic activity in the brain and can show changes in glucose metabolism or neurotransmitter function. - While PET may reveal **functional deficits** or **metabolic abnormalities** in chronic stages of brain injury, it is not used in the acute setting to diagnose DAI and does not directly visualize axonal damage.

Question 1

A 35-year-old female presents with a history of seizures and headaches. An MRI shows a well-defined cystic lesion with an enhancing mural nodule in the temporal lobe. What is the most likely diagnosis?

Accepted Answer

Low-grade astrocytoma

Answer

Meningioma

Answer

Oligodendroglioma

Answer

Glioblastoma multiforme

Question 2

Identify the condition based on the provided image.

Accepted Answer

Callosal dysgenesis

Answer

Dandy-Walker malformation

Answer

Aicardi syndrome

Answer

Septo-optic dysplasia

Question 3

A 65-year-old patient with long-standing hypertension develops sudden left-sided pure motor weakness without aphasia, neglect, visual-field loss, or other cortical signs. The noncontrast head CT shown demonstrates a hypodense infarct involving the right basal ganglia and adjacent internal-capsular region, without acute hemorrhage. Which stroke subtype best explains these findings?

Accepted Answer

Deep perforator-artery ischemic infarct (lacunar-type stroke)

Answer

Cortical middle cerebral artery infarct

Answer

Primary hypertensive intracerebral hemorrhage

Answer

Subdural hematoma

Question 4

A CT image of the left maxillary sinus shows heterogeneous opacification with a central hyperdense region surrounded by a peripheral rim of lower attenuation soft tissue. The patient has a history of allergic rhinitis. What is the most likely finding in this CT image?

Accepted Answer

Double density

Answer

Ground-glass opacity

Answer

Honeycomb appearance

Answer

Onion peel appearance

Question 5

Stenver's view is used for -

Accepted Answer

Internal auditory canal

Answer

Sella turcica

Answer

Inferior orbital foramen

Answer

Superior orbital foramen

Question 6

How does cerebrospinal fluid (CSF) appear on T1 and T2 weighted MRI images?

Accepted Answer

Hypointense on T1 weighted image and hyperintense on T2 weighted image

Answer

Hyperintense on T1 weighted image and hypointense on T2 weighted image

Answer

Hyperintense on both T1 and T2 weighted images

Answer

Hypointense on both T1 and T2 weighted images

Question 7

What condition is shown in the MR angiogram of the skull?

Accepted Answer

Vein of Galen malformation

Answer

Dandy-Walker malformation

Answer

Pneumocephalus

Answer

Crouzon syndrome

Question 8

Which diagnosis is most strongly suggested by the numerous, well-circumscribed punched-out lucencies in the skull calvarium on this radiograph?

Accepted Answer

Multiple myeloma

Answer

Calvarial metastatic disease

Answer

Paget disease of bone

Answer

Osteomyelitis

Question 9

Which of the following provides excellent details about the chemodectomas?

Accepted Answer

MRI

Answer

X-ray

Answer

Ultrasound

Answer

CT angiography

Question 10

What is the most sensitive investigation for diffuse axonal injury?

Accepted Answer

MRI

Answer

CT

Answer

X ray

Answer

PET scan

Neuroradiology — MCQs

Neuroradiology — MCQs

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