Neuroradiology — MCQs

Neuroradiology Indian Medical PG Practice Questions and MCQs

Question 431: Investigation of choice for multiple sclerosis

A. CT
B. MRI (Correct Answer)
C. USG
D. PET

Explanation: ***MRI*** - **Magnetic Resonance Imaging (MRI)** is the investigation of choice for **multiple sclerosis** due to its superior ability to visualize **demyelinating plaques** in the brain and spinal cord. - It can detect both **new and old lesions**, crucial for diagnosis and monitoring disease progression, according to the **McDonald criteria**. *CT* - **Computed Tomography (CT) scans** are generally less sensitive than MRI in detecting the subtle **demyelinating lesions** characteristic of multiple sclerosis. - While it can sometimes show larger lesions, it often misses smaller or early-stage plaques, making it less suitable for initial diagnosis. *USG* - **Ultrasound (USG)** is primarily used for visualizing soft tissues and vascular structures, not for detailed imaging of the brain or spinal cord parenchyma. - It has no role in the diagnosis or monitoring of **multiple sclerosis**. *PET* - **Positron Emission Tomography (PET) scans** are used to assess metabolic activity and perfusion, often in oncology or certain neurological disorders like Alzheimer's or Parkinson's disease. - It is not routinely used for the diagnosis of **multiple sclerosis**, as it does not clearly visualize the **demyelinating lesions**.

Question 432: Investigation of choice for intramedullary SOL is -

A. MRI (Correct Answer)
B. USG
C. CT
D. X-ray

Explanation: ***MRI*** - **Magnetic Resonance Imaging (MRI)** is the investigation of choice for intramedullary lesions due to its superior **soft tissue contrast** and ability to visualize the **spinal cord** parenchyma. - It provides detailed information on lesion size, location, and internal characteristics, which is crucial for diagnosis and surgical planning. *USG* - **Ultrasound (USG)** has limited utility for intramedullary lesions as a primary diagnostic tool because **bone impedes sound waves**, making it difficult to visualize structures within the spinal canal. - It might be used for neonatal spinal screening or intraoperative guidance, but not for definitive diagnosis of intramedullary lesions in adults. *CT* - **Computed Tomography (CT)** excels at visualizing **bone structures** and calcifications, but it provides less detailed information about soft tissue elements like the spinal cord compared to MRI. - While it can identify bony changes associated with intramedullary lesions, it is not the preferred initial imaging modality for characterizing the lesion itself. *X-ray* - **X-rays** provide basic imaging of bone but offer essentially **no visualization of soft tissues** such as the spinal cord or intramedullary lesions. - They are primarily used to identify gross bony abnormalities like fractures or severe degenerative changes, not for subtle intraspinal pathologies.

Question 433: Which condition is characterized by the 'Eye of the Tiger' sign on MRI?

A. Wilson's disease
B. Alzheimer's
C. Pantothenate Kinase-Associated Neurodegeneration (PKAN) (Correct Answer)
D. Neurodegeneration with brain iron accumulation (NBIA), excluding PKAN

Explanation: ***Pantothenate Kinase-Associated Neurodegeneration (PKAN)*** - The **'Eye of the Tiger' sign** is a classic MRI finding in PKAN, characterized by a central area of high signal intensity (pallidal necrosis and gliosis) with a surrounding rim of low signal intensity (iron deposition) in the **globus pallidus**. - This sign is highly specific for PKAN, which is caused by a mutation in the *PANK2* gene leading to **iron accumulation** in the brain, particularly the basal ganglia. *Wilsons disease* - Wilson's disease is characterized by **copper accumulation** in various organs, including the brain. - MRI findings may include **basal ganglia lesions** but typically do not exhibit the specific 'Eye of the Tiger' pattern. *Alzheimer's* - Alzheimer's disease is a neurodegenerative disorder primarily characterized by **amyloid plaques** and **neurofibrillary tangles**. - MRI typically shows **cortical atrophy**, particularly in the hippocampus and temporal lobes, but not basal ganglia iron accumulation. *Neurodegeneration with brain iron accumulation (NBIA), excluding PKAN* - While other forms of NBIA (e.g., neuroferritinopathy) involve iron accumulation, the **'Eye of the Tiger' sign** is pathognomonic for **PKAN** and not typically seen in other NBIA subtypes. - The specific pattern of pallidal necrosis and iron rim is unique to PKAN due to its distinct underlying genetic and biochemical pathology.

Question 434: What is the investigation of choice in a patient with traumatic paraplegia?

A. Myelography
B. CT scan
C. MRI scan (Correct Answer)
D. Plain X-ray

Explanation: ***MRI scan*** - An **MRI scan** provides superior imaging of **soft tissues**, including the spinal cord, nerves, and ligaments, which are crucial for assessing damage in **traumatic paraplegia**. - It is essential for detecting **spinal cord compression**, hemorrhage, edema, and ligamentous injuries that may not be visible on other imaging modalities. *Plain X-ray* - A **plain X-ray** primarily visualizes bony structures and can detect major **fractures or dislocations** but offers limited information about the spinal cord or soft tissue damage. - It may miss subtle bony injuries and provides no information on **spinal cord integrity**, which is critical in paraplegia. *Myelography* - **Myelography** involves injecting contrast dye into the spinal canal and then performing X-rays or CT scans, which is an **invasive procedure** with potential risks. - While it can demonstrate **spinal cord compression** indirectly, it has largely been replaced by MRI due to its invasiveness and MRI's direct visualization capabilities. *CT scan* - A **CT scan** is excellent for evaluating **bony injuries**, such as vertebral fractures and alignment, with good detail. - However, it is less effective than MRI for directly visualizing the **spinal cord itself** and assessing soft tissue damage, which is paramount in paraplegia.

Question 435: Which of the following is not a sign of increased intracranial tension?

A. Erosion of dorsum sella
B. Ballooning of sella (Correct Answer)
C. Copper-beaten appearance
D. Sutural diastasis

Explanation: ***Ballooning of sella*** - **Ballooning of the sella** is typically associated with a **pituitary adenoma** or other intrasellar mass, which directly expands the sella turcica. - While a large pituitary tumor can eventually cause increased intracranial pressure, ballooning itself is a sign of local tumor growth rather than generalized increased intracranial tension. *Erosion of dorsum sella* - **Erosion of the dorsum sella** and posterior clinoid processes are classic radiological signs of **chronically elevated intracranial pressure**. - The increased pressure causes remodeling and thinning of these bony structures over time. *Copper-beaten appearance* - The **copper-beaten appearance**, or **convolutional markings**, often seen on skull radiographs, is a sign of long-standing **increased intracranial pressure**. - It results from the cerebral convolutions indenting the inner table of the skull due to chronic pressure. *Sutural diastasis* - **Sutural diastasis**, or widening of the cranial sutures, is a sign of **increased intracranial tension** in infants and young children whose cranial sutures have not yet fused. - The sutures separate as the brain expands against the skull due to elevated pressure.

Question 436: In which of the following diseases is the NAA peak seen?

A. Tuberculoma
B. Canavan disease (Correct Answer)
C. Meningioma
D. Glioblastoma

Explanation: ***Canavan disease*** - **Canavan disease** is a **leukodystrophy** characterized by a deficiency of the enzyme **aspartoacylase**. - This deficiency leads to an accumulation of **N-acetylaspartate (NAA)** in the brain, resulting in a significantly elevated NAA peak on **magnetic resonance spectroscopy (MRS)**. *Tuberculoma* - **Tuberculomas** are granulomatous lesions that typically show reduced or absent NAA, an elevated lipid peak, and sometimes an elevated **lactate peak** on MRS. - The metabolic profile reflects inflammation, necrosis, and cellular destruction rather than elevated NAA. *Glioblastoma* - **Glioblastoma**, a high-grade glioma, is characterized by a significantly elevated **choline** peak (reflecting increased cell membrane turnover) and often an elevated **lipid/lactate peak** (due to necrosis and anaerobic metabolism) on MRS. - The NAA peak is typically decreased or absent due to neuronal destruction and loss. *Meningioma* - **Meningiomas** are extra-axial tumors that originate from the meninges. On MRS, they typically show an elevated **alanine peak**, and sometimes elevated choline, but lack an elevated NAA peak. - Reduced or absent NAA is expected as these tumors are not composed of neuronal cells.

Question 437: On MRI, which of the following shows diffusion restriction?

A. Ependymoma
B. Meningioma
C. Medulloblastoma (Correct Answer)
D. Germinoma

Explanation: ***Medulloblastoma*** - **Medulloblastomas** are highly cellular tumors, leading to **restricted diffusion** on MRI due to the dense packing of cells and reduced extracellular space. - This feature helps distinguish them from other posterior fossa tumors like ependymomas and pilocytic astrocytomas. - They are the **most common malignant posterior fossa tumor in children** and show bright signal on DWI with low ADC values. *Ependymoma* - **Ependymomas** typically show **facilitated diffusion** or no significant diffusion restriction on MRI due to their less cellular nature and higher water content. - They often arise from the ependyma lining the ventricles and can have heterogeneous signal characteristics. - Variable ADC values are seen, generally higher than medulloblastomas. *Meningioma* - **Meningiomas** usually do not show significant **diffusion restriction**; instead, they have an appearance reflecting their fibrous and vascular nature. - They tend to be extra-axial, dural-based tumors that enhance homogenously. - ADC values are typically elevated compared to highly cellular tumors. *Germinoma* - **Germinomas** are also highly cellular tumors and **do show diffusion restriction** similar to medulloblastomas. - However, they are typically located in the **pineal or suprasellar regions**, not the posterior fossa. - In this context, **medulloblastoma** is the best answer as the classic example of a diffusion-restricting posterior fossa tumor commonly tested in examinations.

Question 438: Which of the following conditions is known to cause intracranial calcification visible on a skull X-ray?

A. Dural calcification (associated with metabolic disorders)
B. Pineal calcification (benign physiological process)
C. Tuberculosis (CNS involvement)
D. Cysticercosis (Correct Answer)

Explanation: ***Cysticercosis*** - **Cysticercosis**, caused by the larval stage of the **tapeworm *Taenia solium***, frequently leads to multiple parenchymal or subarachnoid cysts in the brain that often calcify after the larval death. - These calcified lesions are readily visible on skull X-rays and are a hallmark of chronic neurocysticercosis. *Pineal calcification (benign physiological process)* - **Pineal gland calcification** is a very common, often incidental finding that is considered a **normal physiological process** related to aging. - While visible on skull X-rays, it is typically of no clinical significance and not indicative of a disease state. *Dural calcification (associated with metabolic disorders)* - While **dural calcifications** can occur, they are generally rare and not a common or prominent cause of intracranial calcification visible on a skull X-ray in the context of a broadly asked question about conditions causing such findings. - When present, particularly extensive dural calcification, it can be associated with certain **metabolic disorders** (e.g., hyperparathyroidism) or genetic syndromes, but it is less frequently assessed via skull X-ray compared to other imaging modalities. *Tuberculosis (CNS involvement)* - **CNS tuberculosis** can lead to various manifestations, including **tuberculomas** and **tuberculous meningitis**. - While tuberculomas can rarely calcify, it is not as common or characteristic a feature on a skull X-ray as the calcifications seen in cysticercosis, and often requires more advanced imaging like CT or MRI for detailed visualization.

Question 439: Which primary brain parenchymal tumor is most commonly associated with calcifications seen on imaging studies?

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

Explanation: ***Oligodendroglioma*** - **Oligodendrogliomas** are highly associated with **calcifications**, which are observed in **70-90% of cases** on imaging studies like CT scans. - The calcifications appear as **coarse, punctate, or nodular** and are typically located in the **cerebral hemispheres** (frontal and temporal lobes most common). - This is the **classic imaging finding** that helps differentiate oligodendrogliomas from other glial tumors. *Astrocytoma* - While some astrocytomas can calcify, especially low-grade forms, they are **not as consistently calcified** as oligodendrogliomas. - Calcifications occur in only **20-30% of cases** and are typically less prominent. *Medulloblastoma* - **Medulloblastomas** are most commonly found in the **cerebellum** (posterior fossa) and primarily affect children. - Calcifications are **infrequent**, occurring in approximately **10-20% of cases**, and are usually small and inconspicuous. *Craniopharyngioma* - **Craniopharyngiomas** are benign tumors arising from Rathke's pouch remnants, located in the **suprasellar region**. - While they do frequently calcify (especially in children), they are **extra-axial tumors**, not primary brain parenchymal tumors. - This question specifically asks about parenchymal brain tumors, making oligodendroglioma the correct answer among glial neoplasms.

Question 440: Primary investigation of choice in a patient with suspected subarachnoid hemorrhage should be:

A. Non-contrast computed tomography (Correct Answer)
B. Magnetic resonance imaging (MRI)
C. Contrast-enhanced computed tomography
D. Lumbar puncture

Explanation: ***Non-contrast computed tomography*** - **Non-contrast CT** of the head is the primary imaging modality for suspected subarachnoid hemorrhage due to its **rapid availability** and **high sensitivity** in detecting acute blood. - It effectively visualizes blood in the **subarachnoid space** as hyperdense areas, especially within the first 6-12 hours after symptom onset. *Magnetic resonance imaging (MRI)* - While MRI can detect subarachnoid hemorrhage, it is **less readily available** and takes longer to perform than CT in emergency settings. - MRI may be used in cases where CT is negative but suspicion remains high, especially for hemorrhage in the **posterior fossa** or older bleeds. *Contrast-enhanced computed tomography* - **Contrast-enhanced CT** is generally not the initial imaging choice for subarachnoid hemorrhage because fresh blood is highly visible on unenhanced scans. - Contrast administration can obscure the visualization of acute blood in the subarachnoid space and is typically reserved for **CT angiography** to identify the source of bleeding. *Lumbar puncture* - **Lumbar puncture** is performed if a non-contrast CT is negative for subarachnoid hemorrhage but clinical suspicion remains high. - Its purpose is to detect **xanthochromia** (yellow discoloration due to bilirubin from red blood cell breakdown) or an elevated red blood cell count, confirming the presence of blood in the cerebrospinal fluid.

Practice by Chapter

Neuroanatomy for Radiologists

Practice Questions

Cerebrovascular Diseases

Practice Questions

Intracranial Tumors

Practice Questions

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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