Pediatric Neuroradiology — MCQs

10 questions

Which of the following is NOT an essential criterion for diagnosing perinatal asphyxia?

Lucid Interval is seen in?

An infant presents with hepatosplenomegaly and thrombocytopenia. Neuroimaging with CT shows periventricular calcifications. What is the most likely diagnosis?

A polytrauma patient's CT brain shows a crescent-shaped extra-axial collection with a concave inner margin. What is the most likely diagnosis?

Most common tumor in the part of the brain shown (arrow) among children is

Porencephaly refers to -

A newborn developed periventricular leukomalacia following ischemic infarction. What can be the most common sequelae in this child?

Suprasellar cystic mass in children is –

Parameningeal Rhabdomyosarcoma is best diagnosed by:

Q10

A 6 month infant was brought with complaints of a failure to gain weight and a large head. On examination, increased head circumference, bounding pulses and features of heart failure were noted. On cranial auscultation loud cranial bruit was heard. MRI head shows? (Recent NEET Pattern 2018-19)

Pediatric Neuroradiology Indian Medical PG Practice Questions and MCQs

Question 1: Which of the following is NOT an essential criterion for diagnosing perinatal asphyxia?

A. Prolonged metabolic alkalosis (Correct Answer)
B. Hypoxic ischemic encephalopathy (HIE) in the immediate neonatal period
C. Evidence of multiorgan dysfunction in the immediate neonatal period
D. Persistence of Apgar score of 0-3 for >5 min

Explanation: ***Prolonged metabolic alkalosis*** - This is **NOT** an essential criterion for diagnosing perinatal asphyxia because asphyxia causes the opposite condition — **metabolic acidosis**, not alkalosis. - During oxygen deprivation, anaerobic metabolism produces lactic acid, leading to **acidosis** (low pH, high lactate). - **Metabolic alkalosis** (excess bicarbonate or loss of acids) is incompatible with the hypoxic-ischemic insult of asphyxia. *Persistence of Apgar score of 0-3 for >5 min* - A **persistently low Apgar score** (0-3 for more than 5 minutes) is a strong indicator of perinatal asphyxia and is one of the **essential criteria**. - It reflects severe cardiorespiratory depression and the infant's inability to establish effective breathing and circulation. *Hypoxic ischemic encephalopathy (HIE) in the immediate neonatal period* - The development of **HIE** is a direct and severe consequence of perinatal asphyxia, signifying brain damage due to lack of oxygen and blood flow. - This is a **critical diagnostic criterion**, as it indicates significant neurological impact from the asphyxial event. *Evidence of multiorgan dysfunction in the immediate neonatal period* - Asphyxia can lead to widespread tissue damage due to oxygen deprivation, affecting organs like the kidneys, heart, lungs, and liver, in addition to the brain. - **Multiorgan dysfunction** is a **key essential criterion** that supports the diagnosis of severe perinatal asphyxia.

Question 2: Lucid Interval is seen in?

A. All of these
B. Subarachnoid hemorrhage
C. Extradural hemorrhage (Correct Answer)
D. Subdural hemorrhage

Explanation: ***Extradural hemorrhage*** - A **lucid interval** is a hallmark feature of an **extradural (epidural) hemorrhage**, where a patient briefly regains consciousness after initial head trauma before deteriorating [3]. - This transient improvement occurs due to a temporary cessation of bleeding or accommodation by the brain before the hematoma expands significantly, compressing the brain. *All of these* - While other forms of intracranial hemorrhage can cause fluctuating consciousness, the classic and most distinct **lucid interval** is traditionally associated with extradural hemorrhage [3]. - It is not a consistent or characteristic feature across all types of intracranial bleeds. *Subarachnoid hemorrhage* - Patients with **subarachnoid hemorrhage** typically present with a sudden, severe headache (**worst headache of life**) and often rapidly develop neurological deficits or loss of consciousness without a clear lucid interval [2]. - The bleeding is usually arterial and rapid, leading to immediate symptom onset. *Subdural hemorrhage* - **Subdural hemorrhages** often present with a more gradual onset of symptoms (hours to days or even weeks), especially in chronic cases, due to venous bleeding [1]. - While fluctuations in consciousness can occur, a distinct **lucid interval** followed by rapid deterioration is less common than in extradural bleeds [3].

Question 3: An infant presents with hepatosplenomegaly and thrombocytopenia. Neuroimaging with CT shows periventricular calcifications. What is the most likely diagnosis?

A. Congenital rubella syndrome
B. Congenital herpes simplex virus infection
C. Congenital toxoplasmosis
D. Congenital cytomegalovirus infection (Correct Answer)

Explanation: ***Congenital cytomegalovirus infection*** - **Periventricular calcifications** on neuroimaging are a classic and highly suggestive finding for congenital CMV infection. - **Hepatosplenomegaly** and **thrombocytopenia** are common systemic manifestations of congenital CMV, which can be severe. *Congenital rubella syndrome* - Rubella typically causes **sensorineural hearing loss**, ocular abnormalities (e.g., cataracts), and congenital heart defects (e.g., patent ductus arteriosus), rather than periventricular calcifications. - While hepatosplenomegaly and thrombocytopenia can occur, the specific brain calcification pattern points away from rubella. *Congenital herpes simplex virus infection* - HSV infection in neonates presents with a variety of symptoms, including skin vesicles, keratoconjunctivitis, and seizures. - Brain imaging often shows **focal necrosis** or **encephalitis**, not typically periventricular calcifications unless it's a very widespread and destructive process. *Congenital toxoplasmosis* - Congenital toxoplasmosis classic triad includes **chorioretinitis**, **hydrocephalus**, and **intracranial calcifications**, but these calcifications are typically scattered or diffuse rather than strictly periventricular. - While hepatosplenomegaly and thrombocytopenia can be present, the specific location of calcifications is a key differentiating factor.

Question 4: A polytrauma patient's CT brain shows a crescent-shaped extra-axial collection with a concave inner margin. What is the most likely diagnosis?

A. EDH
B. SDH (Correct Answer)
C. Contusion
D. Diffuse axonal injury

Explanation: ***SDH*** - The image shows a **crescent-shaped collection** of hemorrhage with a concave inner margin, consistent with a **subdural hematoma** (SDH). - SDHs result from the tearing of **bridging veins** and typically conform to the brain's surface, crossing suture lines but not limited by bony sutures. *EDH* - An **epidural hematoma (EDH)** characteristically appears as a **lenticular** or **biconvex** shape on CT, not crescent-shaped. - EDHs are typically caused by arterial bleeding, often from the **middle meningeal artery**, and are limited by cranial sutures. *Contusion* - A **contusion** is brain tissue bruising that appears as **heterogeneous areas** of hemorrhage and edema within the brain parenchyma itself. - It would not manifest as a distinct extra-axial collection with a smooth, concave margin. *Diffuse axonal injury* - **Diffuse axonal injury (DAI)** involves widespread microscopic damage to axons, often at the gray-white matter junction. - It may appear as *punctate hemorrhages* or **small lesions** at these junctions on CT, but often the CT can be normal, and it would not present as a large extra-axial collection.

Question 5: Most common tumor in the part of the brain shown (arrow) among children is

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

Explanation: ***Astrocytoma*** - The image shows a **brainstem lesion**, which is a common location for astrocytomas in children. - **Pilocytic astrocytoma** is the most common brain tumor in children, often presenting in the cerebellum, brainstem, or optic pathways. *DNET (Dysembryoplastic Neuroepithelial Tumor)* - DNETs are typically found in the **temporal lobe** and are associated with a history of seizures. - While benign, their characteristic location and symptoms do not align with a brainstem mass as the primary finding. *Ependymoma* - Ependymomas frequently arise in the **fourth ventricle** in children, often causing hydrocephalus. - Although they can occur in the brainstem, astrocytomas are generally more common in this specific region in pediatric cases. *Medulloblastoma* - Medulloblastomas are nearly always located in the **cerebellum** (infratentorial region) and are known for their aggressive nature and propensity for CSF dissemination. - The lesion shown appears to be within the brainstem, making medulloblastoma less likely given its typical cerebellar location.

Question 6: Porencephaly refers to -

A. Neural tube defects
B. Fetal alcohol syndrome
C. Dandy-Walker syndrome
D. Vascular lesions due to degenerative vessel disease and head injury (Correct Answer)

Explanation: ***Vascular lesions due to degenerative vessel disease and head injury*** - **Porencephaly** refers to cysts or cavities within the brain parenchyma, which may communicate with the ventricular system or subarachnoid space. - Porencephaly can be **congenital** (developmental) or **acquired** (destructive). This option describes **acquired porencephaly**, which results from destructive processes such as **ischemic or hemorrhagic strokes**, **perinatal hypoxic-ischemic injury**, and **traumatic brain injury** [1]. - These vascular insults and trauma cause tissue necrosis and subsequent cyst formation, which is the hallmark of porencephalic cavities. *Neural tube defects* - These are **congenital malformations** resulting from incomplete closure of the neural tube during early embryonic development (weeks 3-4). - Examples include **spina bifida** and **anencephaly**, which represent failures of neural tube closure rather than destructive cystic lesions in formed brain tissue. *Fetal alcohol syndrome* - This condition results from **maternal alcohol consumption** during pregnancy and causes a spectrum of physical, neurodevelopmental, and behavioral abnormalities. - While it may cause brain structural abnormalities (microcephaly, corpus callosum abnormalities), it does not typically manifest as focal **porencephalic cysts**. *Dandy-Walker syndrome* - This is a **congenital posterior fossa malformation** characterized by hypoplasia/agenesis of the cerebellar vermis, cystic dilatation of the fourth ventricle, and enlarged posterior fossa. - It represents a developmental anomaly of the cerebellum, not a destructive cystic lesion of the cerebral hemispheres. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Central Nervous System, pp. 1260-1261.

Question 7: A newborn developed periventricular leukomalacia following ischemic infarction. What can be the most common sequelae in this child?

A. Hypotonia
B. Spastic quadriplegia
C. Spastic diplegia (Correct Answer)
D. Intellectual disability

Explanation: ***Spastic diplegia*** - **Periventricular leukomalacia (PVL)** primarily damages the **white matter** adjacent to the ventricles, including descending motor tracts controlling leg movement. - This specific damage pattern often leads to **spasticity predominantly in the lower limbs**, characteristic of spastic diplegia. *Hypotonia* - While hypotonia may be present acutely in some hypoxic-ischemic injuries, it is not the **most common chronic sequela** of PVL. - PVL specifically damages **upper motor neuron pathways**, predominantly leading to spasticity rather than hypotonia in the long term. *Spastic quadriplegia* - Spastic quadriplegia implies **severe motor impairment** in all four limbs, usually resulting from more widespread or extensive brain damage. - PVL typically affects the motor tracts to the legs more severely, making spastic diplegia a more common and specific outcome. *Intellectual disability* - While **cognitive impairment** can be a complication of PVL, it is not the most common **motor sequela**. - **Motor disorders**, particularly spastic diplegia, are the hallmark clinical presentation following PVL.

Question 8: Suprasellar cystic mass in children is –

A. Craniopharyngioma (Correct Answer)
B. Medulloblastoma
C. Secondaries
D. Meningioma

Explanation: ***Craniopharyngioma*** - **Craniopharyngiomas** are the most common suprasellar tumors in children and are frequently **cystic with calcifications**, making them a prime consideration for a suprasellar cystic mass. - They arise from remnants of Rathke's pouch and often present with symptoms related to **pituitary hormone deficiencies** and **visual field defects** due to compression of the optic chiasm. *Medulloblastoma* - **Medulloblastomas** are typically located in the **posterior fossa** (cerebellum) of children, not the suprasellar region. - They are usually **solid, highly malignant tumors** and do not characteristically present as cystic suprasellar masses. *Secondaries* - **Metastatic tumors (secondaries)** to the brain, particularly to the suprasellar region, are **rare in children** and typically present as solid masses, not primarily cystic. - When they do occur, they usually originate from primary cancers like leukemia or sarcoma, which would have other systemic manifestations. *Meningioma* - **Meningiomas** are tumors that arise from the **meninges**, most commonly in adults, and while they can occur near the sella, they are typically **solid, dural-based tumors** and are very rare in children. - They do not usually present as a primary cystic suprasellar mass.

Question 9: Parameningeal Rhabdomyosarcoma is best diagnosed by:

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

Explanation: ***MRI*** - **Magnetic Resonance Imaging (MRI)** provides excellent soft tissue contrast, which is crucial for visualizing the extent of **parameningeal rhabdomyosarcoma** and its relationship to critical structures like the **meninges**, **brainstem**, and **cranial nerves**. - It is superior for detecting **intracranial extension**, **bone erosion**, and assessing response to treatment, making it the preferred imaging modality for diagnosis and staging. *CT Scan* - **Computed Tomography (CT) scans** are good for evaluating bone involvement and calcifications but offer less detailed soft tissue resolution compared to MRI. - While it can identify large masses, it may miss subtle extensions or involvement of the **meninges** that are readily seen on MRI. *SPECT* - **Single-Photon Emission Computed Tomography (SPECT)** is a nuclear medicine imaging technique primarily used to assess organ function and blood flow, often in cardiology or neurology for functional studies. - It provides limited anatomical detail for the precise localization and characterization of soft tissue tumors like **rhabdomyosarcoma**. *PET* - **Positron Emission Tomography (PET) scans** are excellent for detecting metabolically active tumors, assessing disease burden, and identifying distant metastases, especially when combined with CT (**PET/CT**). - However, while useful for staging and follow-up, it does not provide the high-resolution anatomical detail of the primary tumor's local extent and its relationship to adjacent structures as effectively as **MRI**.

Question 10: A 6 month infant was brought with complaints of a failure to gain weight and a large head. On examination, increased head circumference, bounding pulses and features of heart failure were noted. On cranial auscultation loud cranial bruit was heard. MRI head shows? (Recent NEET Pattern 2018-19)

A. Vein of Galen malformation (Correct Answer)
B. Arachnoid cyst
C. Arnold-Chiari malformation
D. Dandy-Walker syndrome

Explanation: ***Vein of Galen formation*** - The clinical presentation of **failure to thrive**, **macrocephaly**, **bounding pulses**, **heart failure**, and a **loud cranial bruit** in an infant is highly characteristic of a **Vein of Galen malformation (VOGM)**. The image would show a dilated vein of Galen. - VOGMs are high-flow arteriovenous malformations that can lead to significant hemodynamic stress on the heart and hydrocephalus due to obstruction of CSF pathways. *Arachnoid cyst* - While arachnoid cysts can cause **macrocephaly** and, less commonly, obstructive hydrocephalus, they generally do not present with **heart failure**, **bounding pulses**, or a **cranial bruit**. - MRI would show a CSF-filled cyst that follows CSF signal on all sequences and typically does not enhance. *Arnold-Chiari malformation* - Arnold-Chiari malformations involve downward displacement of cerebellar tonsils or vermis through the foramen magnum and are associated with hydrocephalus, but they do not typically cause **heart failure**, **bounding pulses**, or a **cranial bruit**. - Clinical features usually relate to brain stem compression or hydrocephalus, such as apnea, stridor, or feeding difficulties. *Dandy-Walker syndrome* - Dandy-Walker syndrome is characterized by hypoplasia of the cerebellar vermis and cystic dilation of the fourth ventricle, often leading to **hydrocephalus** and **macrocephaly**. - However, it does not explain the **bounding pulses**, **heart failure**, or **cranial bruit** seen in this patient, which point to a vascular anomaly.

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