Pediatric Radiology — MCQs
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The "triangular cord sign" on ultrasonography is indicative of which condition in a neonate?
A neonate presented on day one of life with bilious vomiting. What is the first investigation to be done?
The lung-head ratio is useful in the diagnosis of which of the following conditions?
Given the provided X-ray of a neonate, what is the diagnosis?
Wimberger's ring is seen in:
A premature infant born at 34 weeks presented with acute onset lethargy and cessation of feeding. What is the imaging modality of choice to screen for intraventricular haemorrhage?
An invertogram is typically taken after how many hours of birth?
Congenital hypertrophic pyloric stenosis is diagnosed by which imaging modality?
Time sector imaging is preferred in infants because:
The diagnostic feature of congenital diaphragmatic hernia on prenatal ultrasonography is:
Pediatric Radiology Indian Medical PG Practice Questions and MCQs
Question 1: The "triangular cord sign" on ultrasonography is indicative of which condition in a neonate?
- A. Galactosemia
- B. Biliary atresia (Correct Answer)
- C. Hepatitis
- D. None of the above
Explanation: **Explanation:** The **triangular cord sign** is a highly specific ultrasonographic finding for **Biliary Atresia (BA)**. It represents a cone-shaped or triangular fibrotic mass of the cranial part of the extrahepatic biliary tree. On ultrasound, it appears as an echogenic (hyperechoic) area located anterior to the bifurcation of the portal vein. A thickness of **>4 mm** is generally considered diagnostic. **Why Biliary Atresia is correct:** In BA, there is progressive fibro-obliterative destruction of the extrahepatic biliary system. The "triangular cord" is the sonographic visualization of this fibrous remnant at the porta hepatis. When combined with an absent or small, irregular gallbladder (ghost gallbladder sign), it is a pathognomonic finding. **Why other options are incorrect:** * **Galactosemia:** This is a metabolic disorder. While it can cause neonatal jaundice and hepatomegaly, it does not involve anatomical obliteration of the bile ducts; diagnosis is via enzyme assays and urine reducing sugars. * **Hepatitis (Neonatal):** This is the primary differential for BA. On ultrasound, neonatal hepatitis typically shows a patent biliary tree and a normal-sized gallbladder. It lacks the specific fibrous cord seen in BA. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** Intraoperative Cholangiogram (IOCG). * **Best Initial Screening:** Ultrasound (looking for the triangular cord sign). * **Functional Imaging:** HIDA scan (shows uptake by the liver but **no excretion** into the bowel even after 24 hours). * **Surgical Management:** Kasai Procedure (Hepatoportoenterostomy), ideally performed before 60 days of life. * **Liver Biopsy:** Shows bile duct proliferation and portal fibrosis.
Question 2: A neonate presented on day one of life with bilious vomiting. What is the first investigation to be done?
- A. Chest skiagram
- B. Babygram (Correct Answer)
- C. Ultrasound
- D. Manometry
Explanation: **Explanation:** The clinical presentation of **bilious vomiting** in a neonate on the first day of life is a surgical emergency until proven otherwise. It indicates an intestinal obstruction distal to the Ampulla of Vater. **Why Babygram is the correct answer:** A **Babygram** (a single-view X-ray including both the chest and abdomen) is the initial screening investigation of choice. It is rapid, non-invasive, and provides immediate clues to the level of obstruction. Characteristic gas patterns on a babygram can diagnose conditions like: * **Double Bubble Sign:** Duodenal atresia. * **Triple Bubble Sign:** Jejunal atresia. * **Gasless Abdomen:** Suggestive of esophageal atresia without fistula or high-level obstruction. * **Pneumoperitoneum:** Indicating perforation. **Analysis of Incorrect Options:** * **Chest Skiagram (A):** While useful for respiratory distress or esophageal atresia, it does not provide sufficient information about the abdominal gas patterns necessary to evaluate bilious vomiting. * **Ultrasound (C):** Though excellent for diagnosing Pyloric Stenosis (which presents with *non-bilious* vomiting) or identifying the "whirlpool sign" in midgut volvulus, it is usually performed after the initial X-ray. * **Manometry (D):** This is used for functional disorders like Hirschsprung disease in older infants; it has no role in the acute emergency management of a neonate with bilious vomiting. **Clinical Pearls for NEET-PG:** * **Gold Standard for Malrotation/Volvulus:** Upper GI Contrast Study (showing "corkscrew" appearance). * **Most common cause of neonatal bowel obstruction:** Duodenal atresia (associated with Down Syndrome). * **Management Rule:** Any neonate with bilious vomiting requires an immediate X-ray to rule out life-threatening **Midgut Volvulus**.
Question 3: The lung-head ratio is useful in the diagnosis of which of the following conditions?
- A. Congenital diaphragmatic hernia (Correct Answer)
- B. Sequestration
- C. Ileal atresia
- D. Esophageal atresia
Explanation: **Explanation:** The **Lung-to-Head Ratio (LHR)** is a critical prenatal ultrasonographic parameter used primarily to assess the severity of pulmonary hypoplasia in fetuses with **Congenital Diaphragmatic Hernia (CDH)**. In CDH, abdominal viscera herniate into the thoracic cavity, compressing the developing lungs. The LHR is calculated by measuring the area of the contralateral (healthy) lung at the level of the four-chamber view of the heart and dividing it by the fetal head circumference. A lower LHR indicates more severe pulmonary hypoplasia and correlates with a poorer prognosis and higher need for postnatal ECMO (Extracorporeal Membrane Oxygenation). **Analysis of Incorrect Options:** * **Sequestration:** While this is a bronchopulmonary malformation, it is characterized by non-functional lung tissue with an anomalous systemic blood supply. Diagnosis is usually based on identifying the feeding systemic artery via Doppler, not LHR. * **Ileal Atresia:** This is a distal bowel obstruction. Antenatal ultrasound typically shows dilated bowel loops and polyhydramnios, but it does not involve lung measurement. * **Esophageal Atresia:** This is suggested prenatally by a "small or absent stomach bubble" and polyhydramnios. It does not directly impact lung volume in a way that requires LHR measurement. **High-Yield Clinical Pearls for NEET-PG:** * **Most common type of CDH:** Bochdalek hernia (Posterolateral, more common on the **Left** side). * **Morgagni Hernia:** Anterior/Retrosternal, usually occurs on the right side. * **Observed/Expected LHR (o/e LHR):** A more modern refinement of LHR that accounts for gestational age to better predict survival. * **Scaphoid abdomen:** A classic physical exam finding in newborns with CDH.
Question 4: Given the provided X-ray of a neonate, what is the diagnosis?
- A. Malrotation
- B. Congenital diaphragmatic hernia (Correct Answer)
- C. Pulmonary sequestration
- D. Pneumatoceles
Explanation: ***Congenital diaphragmatic hernia*** - Classic neonatal chest X-ray shows **bowel loops in the thoracic cavity** with **mediastinal shift** away from the affected side, typically left-sided. - Associated with **pulmonary hypoplasia** and immediate respiratory distress in newborns due to lung compression. *Malrotation* - Primarily an **abdominal condition** affecting bowel positioning around the **superior mesenteric artery**. - Chest X-ray would be normal; diagnosis requires **upper GI series** showing abnormal duodenal positioning. *Pulmonary sequestration* - Shows a **well-defined lung mass** with abnormal **systemic arterial supply** from the aorta. - Does not cause **bowel loops in chest** or immediate severe respiratory distress in neonates. *Pneumatoceles* - Appear as **thin-walled air-filled cysts** within the lung parenchyma, typically following pneumonia. - Do not show **bowel gas patterns** in the chest or cause mediastinal shift.
Question 5: Wimberger's ring is seen in:
- A. Rickets
- B. Scurvy (Correct Answer)
- C. Hemophilia
- D. Pellagra
Explanation: **Explanation:** **Wimberger’s ring sign** is a classic radiological feature of **Scurvy** (Vitamin C deficiency). In Scurvy, there is a failure of osteoid formation due to defective collagen synthesis, but osteoblastic activity continues to deposit calcium. This results in a thin, sclerotic (white) rim of calcification surrounding a central area of extreme radiolucency (rarefaction) in the epiphysis. **Why the other options are incorrect:** * **Rickets:** Characterized by Vitamin D deficiency leading to failure of mineralization of the osteoid. Key findings include cupping, fraying, and splaying of the metaphysis, and an increased "physeal" gap. * **Hemophilia:** Radiological findings typically involve joint destruction (hemophilic arthropathy), such as a widened intercondylar notch in the knee and squared lower pole of the patella. * **Pellagra:** A deficiency of Niacin (Vitamin B3) characterized by the "3 Ds" (Dermatitis, Diarrhea, Dementia). It does not have specific pathognomonic radiological bone signs. **High-Yield Clinical Pearls for Scurvy (NEET-PG):** 1. **Frankel’s Line:** Dense sclerotic line at the metaphysis (Zone of provisional calcification). 2. **Trummerfeld Zone:** A lucent (scorbutic) band proximal to Frankel’s line (site of microfractures). 3. **Pelkan Spur:** Marginal metaphyseal spurs caused by outward protrusion of the zone of provisional calcification. 4. **Subperiosteal Hemorrhage:** Leads to lifting of the periosteum, which becomes visible as it calcifies during healing.
Question 6: A premature infant born at 34 weeks presented with acute onset lethargy and cessation of feeding. What is the imaging modality of choice to screen for intraventricular haemorrhage?
- A. NCCT
- B. Transcranial USG (Correct Answer)
- C. MRI
- D. Plain radiograph
Explanation: **Explanation:** **1. Why Transcranial USG is the Correct Choice:** In premature neonates, the **Germinal Matrix** (a highly vascularized area near the caudate nucleus) is prone to hemorrhage due to fragile vessels and impaired autoregulation. **Transcranial Ultrasonography (USG)** is the gold standard screening modality because: * **Open Fontanelle:** The anterior fontanelle acts as a perfect acoustic window to visualize the periventricular structures. * **Bedside Utility:** It is portable, allowing imaging in the NICU without moving a critically ill, unstable neonate. * **Safety:** It involves no ionizing radiation and requires no sedation. * **Sensitivity:** It is highly sensitive for detecting Germinal Matrix Hemorrhage (GMH) and grading Intraventricular Hemorrhage (IVH) using the **Papile Classification**. **2. Why Other Options are Incorrect:** * **NCCT (A):** While sensitive for blood, it involves significant ionizing radiation, which is avoided in neonates unless there is trauma or a need to rule out posterior fossa bleeds not seen on USG. * **MRI (B):** MRI is the most sensitive for white matter injury (Periventricular Leukomalacia), but it is not a screening tool. It requires transporting the infant and often necessitates sedation, making it impractical for acute screening. * **Plain Radiograph (D):** X-rays cannot visualize soft tissue structures or intracranial hemorrhages. **3. High-Yield Clinical Pearls for NEET-PG:** * **Screening Protocol:** All infants born **<30-32 weeks** or **<1500g** should undergo screening USG at 7–14 days of life. * **Acoustic Window:** The **Anterior Fontanelle** is the primary window; the Mastoid fontanelle is used to view the cerebellum. * **Grading (Papile):** * Grade I: Isolated Germinal Matrix Hemorrhage. * Grade II: IVH without ventricular dilatation. * Grade III: IVH with ventricular dilatation. * Grade IV: IVH with intraparenchymal extension.
Question 7: An invertogram is typically taken after how many hours of birth?
- A. 2 hours
- B. 4 hours
- C. 6 hours (Correct Answer)
- D. 8 hours
Explanation: **Explanation:** The **Invertogram** (also known as the Rice-Wangensteen projection) is a specialized radiographic technique used to evaluate the level of atresia in neonates with **Anorectal Malformations (ARM)**. **Why 6 hours is the correct answer:** The primary goal of an invertogram is to allow swallowed air to act as a natural contrast agent, traveling through the gastrointestinal tract to reach the distal-most end of the rectal pouch. It takes approximately **6 hours** for air to transit from the mouth to the rectum in a newborn. Performing the X-ray earlier may lead to a **false-positive diagnosis** of high-level atresia because the air column has not yet reached its most distal point, or the distal pouch may be collapsed by meconium that hasn't yet shifted. **Analysis of Incorrect Options:** * **2 & 4 hours:** These timeframes are insufficient for gas to reliably reach the distal rectum. Imaging at this stage often results in an underestimation of the pouch length. * **8 hours:** While air would certainly have reached the rectum by this time, 6 hours is the established clinical standard to minimize delay in surgical planning and prevent unnecessary neonatal distress. **High-Yield Clinical Pearls for NEET-PG:** * **Positioning:** The infant is held upside down for 3–5 minutes before the X-ray (lateral view) to allow gas to rise. * **Landmark:** A radio-opaque marker (coin) is placed on the anal dimple. The distance between the gas bubble and the marker determines if the defect is **High, Intermediate, or Low** relative to the **PC line** (Pubococcygeal line). * **Modern Alternative:** In many centers, the **Prone Cross-table Lateral View** is now preferred over the invertogram as it is less stressful for the neonate and provides similar diagnostic accuracy.
Question 8: Congenital hypertrophic pyloric stenosis is diagnosed by which imaging modality?
- A. CT scan
- B. Ultrasound (USG) (Correct Answer)
- C. MRI scan
- D. X-ray
Explanation: **Explanation:** **Congenital Hypertrophic Pyloric Stenosis (CHPS)** is a condition characterized by hypertrophy of the circular muscle of the pylorus, leading to gastric outlet obstruction. **Why Ultrasound (USG) is the Correct Answer:** Ultrasound is the **investigation of choice** for CHPS because it is non-invasive, avoids ionizing radiation (crucial in neonates), and allows for real-time visualization of the pyloric muscle. The diagnostic criteria on USG are: * **Pyloric muscle thickness:** >3 mm (most sensitive). * **Pyloric canal length:** >14–16 mm. * **Target sign:** Seen on transverse sections. * **Antral nipple sign:** Protrusion of redundant mucosa into the antrum. **Why Other Options are Incorrect:** * **A. CT Scan:** Involves high radiation doses and is unnecessary given the superficial location of the pylorus in infants. * **C. MRI Scan:** Too time-consuming, expensive, and often requires sedation in neonates. * **D. X-ray:** While a "single bubble" sign or a distended stomach may be seen, it is non-specific. X-rays are primarily used to rule out other causes of vomiting like intestinal malrotation. **High-Yield Clinical Pearls for NEET-PG:** * **Classic Presentation:** Non-bilious, projectile vomiting in a 3–6 week old male infant (First-born males are most affected). * **Physical Exam:** A palpable, firm, mobile, "olive-shaped" mass in the epigastrium. * **Metabolic Abnormality:** Hypochloremic, hypokalemic, metabolic alkalosis (due to loss of HCl from vomiting). * **Barium Swallow (if USG is inconclusive):** Shows the "String sign" (narrowed canal) or "Shoulder sign" (bulging of muscle into the antrum). * **Treatment:** Ramstedt’s Pyloromyotomy.
Question 9: Time sector imaging is preferred in infants because:
- A. The child is more co-operative
- B. The technique is closer to fontanelles
- C. It is less expensive
- D. All of the above (Correct Answer)
Explanation: **Explanation:** **Time Sector Imaging** (Sector Scanning) is the preferred modality for neonatal and infant neurosonography primarily due to the unique anatomical window provided by the **anterior fontanelle**. 1. **Why the correct answer is "All of the above":** * **Technique and Fontanelles:** Sector transducers have a small "footprint" (contact surface) but produce a wide, fan-shaped field of view. This allows the probe to fit perfectly over the small anterior fontanelle, providing a comprehensive view of the brain's deep structures and hemispheres through a narrow acoustic window. * **Patient Cooperation:** Unlike MRI or CT, which require the infant to remain perfectly still (often necessitating sedation), ultrasound is rapid and can be performed while the child is moving, feeding, or being held. This makes the procedure inherently more "cooperative" for the pediatric age group. * **Cost-Effectiveness:** Ultrasound is significantly less expensive than cross-sectional imaging (CT/MRI) and can be performed bedside in the NICU, avoiding the risks of transporting a critically ill neonate. 2. **Clinical Pearls for NEET-PG:** * **Acoustic Window:** The **Anterior Fontanelle** is the primary window for cranial USG. It typically closes between 9–18 months, after which this technique becomes difficult. * **Primary Indications:** It is the gold standard for screening preterm infants for **Germinal Matrix Hemorrhage (GMH)** and Periventricular Leukomalacia (PVL). * **Safety:** It is non-ionizing, making it the safest repetitive imaging modality for developing brains. * **Transducer Choice:** High-frequency (5–10 MHz) sector or curvilinear probes are used to balance resolution and depth.
Question 10: The diagnostic feature of congenital diaphragmatic hernia on prenatal ultrasonography is:
- A. A cyst behind the left atrium
- B. Mediastinal shift with normal cardiac axis
- C. Peristalsis in the thoracic cavity (Correct Answer)
- D. Absence of gas bubble under the diaphragm
Explanation: **Explanation:** **Congenital Diaphragmatic Hernia (CDH)** occurs due to the failure of the pleuroperitoneal membranes to fuse, most commonly on the left side (Bochdalek hernia). **Why Option C is Correct:** The definitive diagnostic feature on prenatal ultrasonography is the visualization of abdominal viscera within the thoracic cavity. Observing **peristalsis in the thoracic cavity** (bowel loops) is a pathognomonic sign that confirms the presence of herniated intestine. Other common findings include a fluid-filled stomach at the level of the four-chamber view of the heart. **Analysis of Incorrect Options:** * **Option A:** While a fluid-filled stomach may appear as a "cyst" in the chest, it is typically located **lateral** to the heart, not specifically behind the left atrium (which is more characteristic of a hiatal hernia or neurenteric cyst). * **Option B:** CDH causes a significant mediastinal shift, but it is almost always associated with an **abnormal cardiac axis** (levocardia or dextroposition) because the herniated mass displaces the heart. * **Option D:** In utero, the bowel does not contain air; therefore, the "gas bubble" sign is a postnatal radiographic finding, not a prenatal ultrasound feature. **High-Yield Clinical Pearls for NEET-PG:** * **Most Common Type:** Bochdalek (Posterolateral, 85-90%), usually on the **Left side**. * **Morgagni Hernia:** Anterior and retrosternal; less common. * **Key Ultrasound Findings:** Polyhydramnios, mediastinal shift, and herniated stomach/bowel. * **Prognostic Marker:** **Lung-to-Head Ratio (LHR)** is used to predict pulmonary hypoplasia and survival. * **Management:** The primary cause of mortality is **pulmonary hypoplasia** and persistent pulmonary hypertension, not the hernia itself. Stabilization is required before surgical repair.
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