Differential Diagnosis by Location or Radiographic Finding—Intracranial

Question 1

The differential diagnosis of a solitary intraparenchymal lesion in an adult p-fossa is what until proven otherwise?
● A. Abscess
● B. Metastasis
● C. Hemangioma
● D. Hemorrhage
● E. Medulloblastoma

Answer 1

B. Metastasis

Question 2

PHACES syndrome: acronym for a group of findings including which of the following?
● A. Posterior fossa malformations
● B. Truncal hemangioma
● C. Arterial anomalies of the head and neck
● D. Coarctation of the aorta and cardiac defects
● E. Eye anomalies and sternal cleft

Answer 2

B. Truncal hemangioma

Question 3

Differentiating feature of medulloblastoma and ependymoma are all of the following except?
● A. Ependymoma which tends to grow into the 4th ventricle from the floor
● B. Ependymoma may grow through the foramen of Luschka and/or Magendie
● C. Ependymomas tend to be inhomogeneous on T1WI MRI
● D. The exophytic component of ependymomas tends to be high signal on T2WI MRI
● E. Calcifications are more common in medulloblastoma

Answer 3

E. Calcifications are more common in medulloblastoma

Question 4

Tumor passing from the posterior fossa to the middle fossa though the incisura is highly suggestive of which of the following?
● A. Vestibular schwannoma
● B. Epidermoid cyst
● C. Cysticercosis
● D. Arachnoid cyst
● E. Lipoma

Answer 4

B. Epidermoid cyst

Question 5

All of the following are long tract signs found in foramen magnum lesion except?
● A. Brisk muscle stretch reflexes
● B. Loss of abdominal cutaneous reflexes
● C. Neurogenic bladder
● D. Contralateral Horner syndrome
● E. Nystagmus: classically downbeat

Answer 5

D. Contralateral Horner syndrome

Question 6

Which of following is not included in D/Dx of corpus callosum lesion?
● A. Lymphoma
● B. MS plaque
● C. Lipoma
● D. Diffuse axonal injury from trauma
● E. None of the above

Answer 6

E. None of the above

Question 7

Following conditions can lead to pituitary pseudotumor formation except?
● A. Primary hyperthyroidism
● B. Primary hypogonadism
● C. Pregnancy
● D. Ectopic GHRH secretion
● E. Intracranial hypotension

Answer 7

A. Primary hyperthyroidism

Question 8

Differentiating features of juxta sellar meningioma from macroadenoma are all except?
● A. Homogenous contrast enhancement
● B. Dural tail
● C. Suprasellar epicenter
● D. Pushing the carotids laterally
● E. None of the above

Answer 8

D. Pushing the carotids laterally

Question 9

All of the following are included in metastatic workup of intracranial lesions except?
● A. CT of chest
● B. CT of abdomen
● C. Bone scan
● D. PSA
● E. Mammogram

Answer 9

C. Bone scan

Question 10

What is the most common malignancy of the skull?
● A. Osteogenic sarcoma
● B. Chondrogenic sarcoma
● C. Hemangiosarcoma
● D. Fibrosarcoma
● E. None of the above

Answer 10

A. Osteogenic sarcoma

Question 11

Classic X-ray finding of “starburst” appearance is seen in which of the following?
● A. Hemangioblastoma
● B. Metastasis
● C. Multiple myeloma
● D. Lymphoma
● E. Brown tumor of hyperparathyroidism

Answer 11

A. Hemangioblastoma

Question 12

Meningiomas of CPA present with which of the following?
● A. Early facial nerve involvement
● B. Early hearing loss
● C. Less trigeminal neuralgia like pain than VS
● D. Tinnitus
● E. Rarely calcified

Answer 12

A. Early facial nerve involvement

Question 13

Which of the following features favor nasal glioma in contrast to encephalocele?
● A. Pulsatile
● B. Positive Furstenberg sign
● C. Absence of stalk
● D. Probe can be passed laterally
● E. Presence of hypertelorism

Answer 13

C. Absence of stalk

Question 14

Which of the following are the non-neoplastic thalamic lesions in pediatric and adult patients?
● A. Cavernous angioma
● B. Granuloma
● C. Heterotopias
● D. AVM
● E. Hamartoma

Answer 14

E. Hamartoma

Question 15

A patient presents with 2 months history of short-term memory deficit, seizures, and psychiatric symptoms of anxiety, depression, and behavioral changes. His MRI shows bilateral abnormalities highly restricted to medial temporal lobes on T2
FLAIR and CSF shows pleocytosis: WBCs > 5/mm3. On EEG, epileptic or slow-wave activity involving the temporal lobes is seen. What is the most likely diagnosis?
● A. Mesial temporal sclerosis
● B. Herpes encephalitis
● C. Autoimmune limbic encephalitis
● D. Temporal hamartoma
● E. PCA ischemic infarct

Answer 15

C. Autoimmune limbic encephalitis

Question 16

By the rule of thumb “the differential diagnosis of a
solitary intraparenchymal lesion in an adult posterior fossa is metastasis, metastasis, metastasis until proven otherwise.” Other differential diagnoses in P-fossa of adults include hemangioblastoma, cerebellar astrocytoma, brainstem glioma, choroid plexus tumor, cerebellar liponeurocytoma, abscess, cavernous hemangioma, or hemorrhage. Differential in pediatric posterior fossa includes medulloblastoma (27%), cerebellar astrocytoma (27%), brain stem gliomas (28%), ependymoma, choroid plexus papilloma, and metastasis. How can medulloblastoma be differentiated from ependymoma?
● A. Medulloblastoma arise from the roof of the 4th ventricle and most are solid while ependymoma arise from the floor of the 4th ventricle
● B. The 4th ventricle drapes around the medulloblastoma forming “banana sign” while ependymoma tends to grow through the foramen of Luschka or/and Magendie
● C. Ependymoma tends to homogenous on T1WI while medulloblastoma tends to be heterogenous
● D. The exophytic component of ependymomas tends to be high signal on T2WI MRI while medulloblastoma is only mildly hyperintense
● E. Calcifications are more common in ependymomas while in MB these are less than 10%
● F. All of the above

Answer 16

F. All of the above

Question 17

What is the most common cerebellopontine (CP) angle lesion among the following CP angle lesions listed below?
● A. Vestibular schwannoma
● B. Meningioma
● C. Epidermoid
● D. Arachnoid cyst
● E. Trigeminal neuroma or facial nerve neuroma

Answer 17

A. Vestibular schwannoma

Question 18

How can vestibular schwannoma be differentiated from meningioma in CP angle region?
● A. VS presents with progressive unilateral hearing loss usually with tinnitus, and facial nerve signs and symptoms occur late. In case of CP angle meningioma, early facial nerve involvement is more common, and hearing loss is usually late
● B. Trigeminal neuralgia like pain is more common with CP angle meningioma as compared to VS
● C. On imaging VS shows heterogenous signal and nonuniform enhancement while VP angle meningioma shows homogenous signal and enhancement
● D. Medium size tumor in case of VS look like ice cream in the cone (trumpet sign) with the tumor forming an acute angle between the tumor and petrous bone and enlargement of IAC is often present while in case of meningioma, IAC is usually not enlarged with the tumor flat against the petrous bone forming an obtuse angle with the bone
● E. Calcifications and bony hypertrophy may occur in case of meningioma while in case of VS these are often absent
● F. All of the above

Answer 18

F. All of the above

Question 19

A patient presents in neurosurgical OPD with complaints of craniocervical junction pain in the neck and occiput with increase in pain with increased head movement. This patient also has numbness and tingling in fingers with dissociated sensory loss (loss of pain and temperature contralateral to the lesion with preservation of tactile sensation). There is spastic weakness of the extremities which usually starts in the ipsilateral
upper limb, then the ipsilateral lower limb, then the contralateral lower limb, and finally contralateral upper limb (rotatory paralysis). Following are the differential diagnosis of foramen magnum lesion except?
● A. Meningioma
● B. Chordoma
● C. Ependymoma
● D. Neurilemmoma
● E. Epidermoid
● F. Chondroma
● G. Chondrosarcoma

Answer 19

C. Ependymoma

Question 20

Enhancing ring of tumor may be incomplete and irregular while in case of abscess, the ring is usually complete, often thinner and smoother than the tumor. Abscess is usually brighter than the tumor on DWI MRI. MR spectroscopy is ideal for differentiating the tumor from the abscess with the abscess
showing reduced NAA, Cr, and choline while the tumor shows increased choline peak. What are the differential diagnoses in case of ring-enhancing lesions?
● A. Metastasis (including lymphoma)
● B. Abscess
● C. Glioma (astrocytoma usually glioblastoma)
● D. Infarct
● E. Contusion
● F. Demyelination
● G. Radiation
● H. All of the above

Answer 20

H. All of the above

Question 21

Differential diagnosis of tumors in sellar, suprasellar, or parasellar region includes pituitary tumors (adenohypophyseal tumors and neurohypophyseal tumors), pituitary pseudotumors (thyrotroph hyperplasia, gonadotroph hyperplasia, somatotroph hyperplasia), juxtasellar or suprasellar tumors, or masses (craniopharyngioma, Rathke cleft cyst, meningioma, germ cell tumors, hypothalamic tumors, optic nerve or chiasma tumors). Which of the following are the differentiating points between
hypophysitis and adenoma?
● A. Enlargement of hypophyistis is symmetric while in case of adenoma it is asymmetric
● B. Pituitary stalk is thickened and nontapering in case of hypophysitis while it is not thickened, tapering, and deviated in case of adenoma
● C. Sellar floor is spared in hypophysitis while it may be eroded in case of tumor
● D. Enhancement is intense and may be heterogenous in case of adenoma, while it is less intense and usually homogenous in case of hypophysitis
● E. Mean size at the time of presentation of hypophysitis is 3-cm cube in case of hypophysitis, while it is 10-cm cube in case of adenoma

Answer 21

D. Enhancement is intense and may be heterogenous in case of adenoma, while it is less intense and usually homogenous in case of hypophysitis

Question 22

Differential of orbital tumors in adults include neoplastic lesions (cavernous hemangioma, capillary hemangioma, lymphangioma, melanoma, retinoblastoma, lymphoma), congenital lesion (retinopathy of prematurity, persistent hyperplastic
primary vitreous), infectious, inflammatory, and vascular lesions. What is the most common orbital lesion in pediatric patients among the following?
● A. Dermoid cyst
● B. Hemangioma
● C. Rhabdomyosarcoma
● D. Optic nerve glioma
● E. Lymphangioma

Answer 22

A. Dermoid cyst

Question 23

Following statements are correct regarding the type of intraventricular lesion by location except?
● A. Meningioma is the most common tumor in the atrium of lateral ventricle (trigone) in adults more than 30 years of age while in case of children less than 5 years of age, choroid plexus papilloma is the most common lesion at this location
● B. Astrocytoma is the most common lesion in the frontal horn of ventricle and then meningioma
● C. At the foramen of Monro region, SEGAs are most common in people 6 to 30 years of age with pilocytic astrocytoma in the second and CPP in the third number at this location, while in case of adults more than 30 years, metastasis is the most common tumor at this location
● D. The most common lesion at the 3rd ventricle is colloid cyst, then craniopharyngioma, and then astrocytoma
● E. Epidermoid is the most common lesion in the 4th ventricle and then comes medulloblastoma and ependymoma

Answer 23

E. Epidermoid is the most common lesion in the 4th ventricle and then comes medulloblastoma and ependymoma

Question 24

What is the most common periventricular solid enhancing lesion?
● A. Ependymoma
● B. Lymphoma
● C. Metastatic carcinoma
● D. Ventriculitis
● E. Medulloblastoma

Answer 24

B. Lymphoma

Question 25

How can an encephalocele be differentiated from nasal glioma?
● A. Encephalocele is frequently pulsatile while nasal glioma is nonpulsatile
● B. Encephalocele swells with Valsalva maneuver while nasal glioma does not
● C. Presence of hypertelorism suggests encephalocele while it does not correlate with nasal glioma
● D. Probe can be passed lateral to encephalocele while it cannot be passed lateral to a nasal glioma
● E. Encephalocele is attached to the CNS with a stalk while nasal glioma does not
● F. All of the above

Answer 25

F. All of the above