INBR 7 - Neuroradiology

Question 1

1.  Tumor apakah yang lazimnya menunjukkan intensitas sinyal yang tinggi pada pencitraan T2 weighted, intensitas sinyal yang rendah pada pencitraan T1  weighted, dan intensitas sinyal yang tinggi (restriksi difusi) pada pencitraan MR difusi?  
A.  Pineoblastoma 
B. Glioblastoma     
C. Kista Arachnoid 
D.  Epidermoid 
E.  Meningioma

Answer 1

D. Epidermoids are usually located off of the midline along the basilar cisterns. These tumors often resemble CSF, and thus arachnoid cysts, on Tl- and T2-weighted t-IRI. However, diffusion-weighted MRI is helpful in differentiating epidermoids from arachnoid cysts, because the former exhibit restricted diffusion (high signal, similar to brain parenchyma) and the latter exhibit normal diffusion (similar to CSF). Pineoblastomas, glioblastomas, and meningiomas are rarely confused with epiderrnoids

Question 2

2. Seorang anak usia 12 tahun dibawa dengan gejala-gejala ataksia dan diplopia, serta menunjukkan kelemahan fasial, hemiparesis, dan Optalmoplegia internuklear. Tumor berikut mana sesuai yang dengan hasil pencitraan MRI T-2 weighted di bawah ini ?

 A.  Limpoma  
B.  Koriokarsinoma 
C. Tumor kantung Yolk        
D.  Ependimoma  
E. Astrositoma yg menginfiltrasi

Answer 2

E. The most common brainstem tumor encountered in the pediatric population is an infi!trating astrocytoma . These are most commonly located in the pons ( as in this case) , and they are usually malignant. Pontine gliomas often present with cranial nerve palsies, extraocular muscle findings , and pyramidal signs. They rarely present with obstructive hydrocephalus, as this is usually a late finding that occurs after the tumors have grown considerably. Pontine gliomas are often hypointense on T1-weighted images and hyperintense on T2- weighted images, with variable enhancement. The prognosis for pontine tumors is much worse than for tumors located in the medulla or mesencephalon

Question 3

3.  Sekuen MR yang manakah yang paling peka dalam mengidentifikasikan Malformasi Kavernosa Intraserebral?  
A.  T1-weighted   
B.  T2-weighted  
C. Echo gradient 
D.  Fast spin echo
E.  Difusi

Answer 3

C. Gradient echo sequences are the most sensitive in identifying any intracerebral lesions that exhibit chronic hemorrhage (such as cavernomas ) . Cavernomas often exhibit a “reticulated core” of mixed-signal intensity on T1-weighted images due to the presence of hemorrhage of varying ages. These lesions also often exhibit a hypointense rim on T1-weighted images, T2-weighted images, and gradient echo sequences that corresponds to hemosiderin deposits. Fast-spin echo sequences are T2-weighted sequences that are not very sensitive in the detection of chronic hemorrhage

Question 4

4.  Tumor intrakranial manakah yang paling lazim berasosiasi dengan neurofibromatosis tipe 1?  
A.   Glioma saraf optic  
B.  Ependimoma 
C. Neurofibroma 
D.  Meningioma 
E.  Meduloblastoma

Answer 4

A. Optic nerve g

Question 5

5. Pendekatan bedah manakah yang akan paling tepat untuk pasien dengan tinnitus ringan dan
   kelainan sebagaimana yang ditunjukkan oleh enhance-T1 weighted pada MRI ?

A.  Retrosigmoid 
B.   Transiabirintin 
C.  Fossamedia  
D.  Fossa infratemporal transpetrosal   
E. Transkoklear

Answer 5

C. This postcontrasted T1-weighted MRI study depicts an int racanalicular acoustic neuroma. Where there is an attempt to presetTe the patient’s hearing. either the suboccipital or middle fossa approach is used, because the translabyrinthine or transcochlear approaches sacrifice hearing. The suboccipital (retrosigmoid) approach is the most commonly used procedure bY neurosurgeons for lesions mostly located within the CPA. It provides excellent control of the lower cranial nerves, brainstem, and vascular structures within the C PA. However, only the proximal twothirds of the lAC can be safely exposed without traversing the inner ear. The middle fossa approach allows access to the labyrinthine segment of the facial nerve without sacrificing hearing and is the procedure most commonly used for small intracanalicular lesions. The dura is elevated from the floor of the middle fossa and the labirinthine segment of the facial nerve identified medial to the geniculate ganglion. Acces to the posterior fossa and CPA is somewhat limited and retraction of the temporal lobe is necessary for exposure. The transpetrosal infratemporal fossa corridor is not typically used for CPA tumors but instead for tumors of the jugular foramen such as paragangliomas and meningiomas

Question 6

6. Sirkulasi fetal persisten manakah yang tampak dalam angiogram karotid interna posisi lateral ini ?

 A.   Arteri trigeminal primitif    
B. Arteri otis persisten  
C. Arteri hipoglosal persistent  
D.  Arteri intersegmental proatlantal 
E. Salah semua

Answer 6

A . The primitive trigeminal artery ( PTA) represents a persistence of the embryonic anastomosis between the cavernous segment of the internal carotid artery and the paired longitudinal neural arteries (Vertebrobasilar system). The PTA is the most cephalad of the persistent fetal circulations; it is also the most common. The PTA is associated with an increased incidence of intracranial aneurysms. The persistent otic artery originates from the petrous ICA, the persistent hypoglossal artery originates from the cervical lCA, and the proatlantal intersegmental artery can originate from the int e rnal or external carotid artery

Question 7

7.  Di antara rasio-rasio di bawah ini, manakah yang biasanya menurun dengan adanya neoplasma SSP primer pada MR spektroskopi  
A.   Mionositol : Total kreatin  
B.   Koline : N-asetil aspartate  
C.   Koline : total kreatin  
D.  N -asetil aspartate : total keratin 
E. Mionositol : N-Asetil aspartate

Answer 7

D . N-acetyl aspartate (NAA) is a neuronal marker and is generally decreased in most CNS pathologic conditions. Total creatine is generally constant within the brain regardless of the presence of disease. Elevations of choline indicate increased plasma membrane turnover and synthesis . which is commonly observed with neoplasms. Thus, neoplasm ar usually associated with decreases in NA.A and elevations of choline and myoinosirol (and lactate) ; total creatine is largely constant. The ratio of NAA to total creatine is thus decreased. Whereas rhe ratios in A, B, C, and E are all increased with CNS neoplasms

Question 8

8. Seorang anak perempuan dibawa dengan gejala sakit kepala persisten, mual dan muntah selama 1 minggu. Pasien merasa agak lesu dan hasil pemeriksaan menunjukkan tanda hemiparesis kiri ringan. MRI T1 aksial dengan kontras menunjukkan kelainan yang mana?

A.  Astrositoma pilositik   
B.  Subependimoma  . 
C. Papiloma pleksus koroid  
D.  Hemangioblastoma  
E. Meduloblastoma

Answer 8

E. Medulloblastomas are aggressive, primitive neuroectodermal tumors that occur primarily in the pediatric population. Medulloblastomas are found exclusively in the posterior fossa and usually reside in the midline (vermis) . Occasionally these lesions are found in the lateral cerebellum, but this usually occurs in adults and older children. Medulloblastomas are aggressive tumors that frequently metastasize throughout the CNS via spinal fluid pathways. On MRI, medulloblastomas are generally isointense on T1-weighted images, with variable signal on T2-weighted images and intense enhancement with contrast. The lesions usually occupy most of the fourth ventricle and are often associated with communicating hydrocephalus. The history and MRI findings in this case are most consistent with a medulloblastoma. Choroid plexus papillomas are predominantly supratentorial lesions in the pediatric population, and pilocytic astrocytomas are usually cystic. Subependymomas do not typically enhance, and they are found almost exclusively in adults. Hemangioblastomas are also rare in children and occur most frequently in the brain parenchymas

Question 9

9. Ciri manakah yg biasanya TIDAK tampak pada Oligodendroglioma berdasarkan MRI?
   A. Pengapuran
   B. Hemorase
   C. Kistik
   D. Sinyal heterogen pada citra T1-tertimbang
   E. Penyengatan homogen

Answer 9

E. Oligodendrogliomas generally exhibit mixed signal intensity on T1 -weighted images and hyperintensity on T2-weighted images with m ild heterogenous enhancement . These lesions exhibit calcification 70 to 90% of the time , are often associated with cysts, and frequently have evidence of chronic hemorrhage

Question 10

10. Karakteristik berikut yang mana TIDAK tampak pada ‘Tuberous Sclerosis’ (Penyakit 
BOURNEVILLE) ?  
A.   Pola keturunan resesif autosomal  
B. Hamartomas kortikal    
C. Astrositoma sel besar subependimal  
D.  Keterbelakangan mental  
E. Ramdoniomas jantung

Answer 10

A . Tuberous sclerosis (TS) is an autosomal domi nant neurocutaneous disorder associated with the triad of seizures, mental retardation, and adenoma sebaceum. TS has variable expressivity and very high penetrance. Patients with TS often exhibit cortical tubers, subependymal nodules along the lateral ventricles, and benign foci of dysmyelination in the deep white matter on MRI . Subependymal giant cell astrocytoma develops in 15% of all patients with TS; it frequently occurs near the foramen of Monro and typically presents with obstructive hydrocephalus. TS is also associated with retinal phakomas, subungual fibromas, cardiac rhabdomyomas, and aneurysms

Question 11

11. Pengelolaan manakah yang paling tepat untuk lesi yang ditunjukan pada angiogram karotid internal lateral di bawah ini ?

A. Ulangi Angiografi dalam waktu 6 sampai dengan 12 bulan.
B. Antikoagulasi oral
C. Tidak diperlukan perawatan lebih lanjut
D. Perlakuan bedah segera
E. Tindak lanjuti MRA dalam jangka waktu 6 – 12 bulan.

Answer 11

D. This angiogram illustrates a dural arteriovenous fistula (DAVF) with prominent ret rograde conical venous drainage. Most DAVFs originate from the transverse and sigmoid sinuses along the skull base. although cavernous sinus is also frequently involved. The presence of retrograde cortical venous drainage places the ;patient at significam risk for subarachnoid hemorrhage, and mandates treatment. The treatment of DAVF usually consist of preoperative embolization followed by surgical obliteration oi the nidus . Successful treatment entails disconnection oi the cortical venous drainage from the nidus. Follow up angiography may be appropriate with DAVF without retrograde cortical venous drainage but would be inappropriate in this case

Question 12

12. Di antara lokasi-lokasi di bawah ini, lokasi manakah yang biasanya TIDAK terlibat dalam cedera aksonal difus (DAI) ?  
A.   Brainstem   
B. Deep white matter   
C.  Serebelum  
D.  Corpus callosum 
E.  Thalamus

Answer 12

C. D iffuse axonal injury most commonly involves the corticomedullary junction of the frontal and temporal lobes or the corpus callosum. DAI can also occur in the deep white matter (usually at gray-white junctions), dorsolateral brainstem, caudate nuclei, thalamus, and internal capsule. DAI rarely involves the cerebellum

Question 13

13. Anak, 12 tahun dibawa dengan kejang komplek parsial. Pasien secara neurlogis intak. MRI adanya lesi kistik di mesial kanan lobus temporalis dengan gambaran hipointens pada T1 dan hiperintens pada T-2, dengan mild rim enhancement. Diagnosisnya yang paling mungkin adalah…  
A.   Ganglioglioma   E.  Glioblastoma   
B.   Ksantoastrositoma pleomorfik    
C. Astrositoma pilositik  
D.  Germinoma

Answer 13

A. Gangliogliomas are generally cystic supratentorial tumors that present in pediatric patients with seizures or elevated intracranial pressure. They are most commonly located in the temporal lobes and are hypointense on T1 - weighted images and hyperintense on T2-weighted images, with variable enhancement patterns. Pleomorphic xanthoastrocytoma (PXA) can also present in children with epilepsy, although it is more typically found in a superficial location adjacent to the leptomeninges. PXA is usually cystic with an enhancing mural nodule. Germ cell tumors (including germinomas) are usually found in the pineal or parasellar regions, and pilocytic astrocytomas are usually located in the posterior fossa or third ventricle in children

Question 14

14. Methemoglobin ekstraselular
    A. Hiper-akut ( sampai dengan 4-6 jam)
    B. Akut (7 sampai dengan 72 jam)
    C. Sub-akut dini (4 – 7 hari)
    D. Akhirnya aub-akut (1 sampai 4 minggu)
    E. Sub-kronis dini (mingguan sampai bulanan)
    F. Sub-kronis lambat (bulanan sampai tahunan)

Answer 14

D. The appearance of hyperacute hematomas (up to 4 to 6 hours ) on MRI is due to the presence of large amounts of oxyhemoglobin, which is diamagnetic and does not influence T1 and T2 relaxation times . Hyperacute clots have a high concentration of water, which renders them isointense on T1-weighted images and hyperintense on T2-weighted images. Acute hematomas (7 to 72 hours) consist primarily of deoxyhemoglobin, which is paramagnetic and has pronounced effects upon T2 relaxation times but no significant effects on T1 relaxation time. Acute hematomas are therefore isointense on T1-weighted images and hypointense on T2-weighted images. The precise reason for the dramatic T2 effect remains unclear but is believed to result from phase dispersion and subsequent preferential T2 proton relaxation enhancement. During this stage, the red blood cells shrink, lose their spherical shapes, become trapped in blood vessels, and acquire irregular Spiculated projections and form “echinocytes .” Early subacute hematomas (4 to 7 days) consist of intracellular methemoglobin, which is paramagnetic and renders subacute hematomas hyperintense on T 1-weighted images and hypointense on T2- weighted images. With late subacute hematomas (1 to 4 weeks), methemoglobin becomes mostly extracellular (secondary to hemolysis), resulting in a progressively more hyperintense clot on T2-weighted images. Early chronic hematomas (months) generally consist of a pool of dilute-free methemoglobin surrounded by a ferritin- and hemosiderin-containing vascularized wall. At this stage, clots are generally similar in appearance to late subacute clots (hyperintense on both T1- and T2-weighted images), with a thin-rimmed wall of pronounced hypointensity on T2-weighted images (ferritin and hemosiderin deposits) . \Vith time (late chronic hematomas, months to years), ferritin- and hemosiderin-containing substances are further deposited throughout the clot, producing hypointense T1- and T2-weighted images

Question 15

15. Oksihemoglobin
    A. Hiper-akut ( sampai dengan 4-6 jam)
    B. Akut (7 sampai dengan 72 jam)
    C. Sub-akut dini (4 – 7 hari)
    D. Akhirnya aub-akut (1 sampai 4 minggu)
    E. Sub-kronis dini (mingguan sampai bulanan)
    F. Sub-kronis lambat (bulanan sampai tahunan)

Answer 15

A. The appearance of hyperacute hematomas (up to 4 to 6 hours ) on MRI is due to the presence of large amounts of oxyhemoglobin, which is diamagnetic and does not influence T1 and T2 relaxation times . Hyperacute clots have a high concentration of water, which renders them isointense on T1-weighted images and hyperintense on T2-weighted images. Acute hematomas (7 to 72 hours) consist primarily of deoxyhemoglobin, which is paramagnetic and has pronounced effects upon T2 relaxation times but no significant effects on T1 relaxation time. Acute hematomas are therefore isointense on T1-weighted images and hypointense on T2-weighted images. The precise reason for the dramatic T2 effect remains unclear but is believed to result from phase dispersion and subsequent preferential T2 proton relaxation enhancement. During this stage, the red blood cells shrink, lose their spherical shapes, become trapped in blood vessels, and acquire irregular Spiculated projections and form “echinocytes .” Early subacute hematomas (4 to 7 days) consist of intracellular methemoglobin, which is paramagnetic and renders subacute hematomas hyperintense on T 1-weighted images and hypointense on T2- weighted images. With late subacute hematomas (1 to 4 weeks), methemoglobin becomes mostly extracellular (secondary to hemolysis), resulting in a progressively more hyperintense clot on T2-weighted images. Early chronic hematomas (months) generally consist of a pool of dilute-free methemoglobin surrounded by a ferritin- and hemosiderin-containing vascularized wall. At this stage, clots are generally similar in appearance to late subacute clots (hyperintense on both T1- and T2-weighted images), with a thin-rimmed wall of pronounced hypointensity on T2-weighted images (ferritin and hemosiderin deposits) . \Vith time (late chronic hematomas, months to years), ferritin- and hemosiderin-containing substances are further deposited throughout the clot, producing hypointense T1- and T2-weighted images

Question 16

16. Isointens pada T1, hipointens pada T2
    A. Hiper-akut ( sampai dengan 4-6 jam)
    B. Akut (7 sampai dengan 72 jam)
    C. Sub-akut dini (4 – 7 hari)
    D. Akhirnya aub-akut (1 sampai 4 minggu)
    E. Sub-kronis dini (mingguan sampai bulanan)
    F. Sub-kronis lambat (bulanan sampai tahunan)

Answer 16

B. The appearance of hyperacute hematomas (up to 4 to 6 hours ) on MRI is due to the presence of large amounts of oxyhemoglobin, which is diamagnetic and does not influence T1 and T2 relaxation times . Hyperacute clots have a high concentration of water, which renders them isointense on T1-weighted images and hyperintense on T2-weighted images. Acute hematomas (7 to 72 hours) consist primarily of deoxyhemoglobin, which is paramagnetic and has pronounced effects upon T2 relaxation times but no significant effects on T1 relaxation time. Acute hematomas are therefore isointense on T1-weighted images and hypointense on T2-weighted images. The precise reason for the dramatic T2 effect remains unclear but is believed to result from phase dispersion and subsequent preferential T2 proton relaxation enhancement. During this stage, the red blood cells shrink, lose their spherical shapes, become trapped in blood vessels, and acquire irregular Spiculated projections and form “echinocytes .” Early subacute hematomas (4 to 7 days) consist of intracellular methemoglobin, which is paramagnetic and renders subacute hematomas hyperintense on T 1-weighted images and hypointense on T2- weighted images. With late subacute hematomas (1 to 4 weeks), methemoglobin becomes mostly extracellular (secondary to hemolysis), resulting in a progressively more hyperintense clot on T2-weighted images. Early chronic hematomas (months) generally consist of a pool of dilute-free methemoglobin surrounded by a ferritin- and hemosiderin-containing vascularized wall. At this stage, clots are generally similar in appearance to late subacute clots (hyperintense on both T1- and T2-weighted images), with a thin-rimmed wall of pronounced hypointensity on T2-weighted images (ferritin and hemosiderin deposits) . \Vith time (late chronic hematomas, months to years), ferritin- and hemosiderin-containing substances are further deposited throughout the clot, producing hypointense T1- and T2-weighted images

Question 17

17. Deoksihemoglobin, ekinosit
    A. Hiper-akut ( sampai dengan 4-6 jam)
    B. Akut (7 sampai dengan 72 jam)
    C. Sub-akut dini (4 – 7 hari)
    D. Akhirnya aub-akut (1 sampai 4 minggu)
    E. Sub-kronis dini (mingguan sampai bulanan)
    F. Sub-kronis lambat (bulanan sampai tahunan)

Answer 17

B. The appearance of hyperacute hematomas (up to 4 to 6 hours ) on MRI is due to the presence of large amounts of oxyhemoglobin, which is diamagnetic and does not influence T1 and T2 relaxation times . Hyperacute clots have a high concentration of water, which renders them isointense on T1-weighted images and hyperintense on T2-weighted images. Acute hematomas (7 to 72 hours) consist primarily of deoxyhemoglobin, which is paramagnetic and has pronounced effects upon T2 relaxation times but no significant effects on T1 relaxation time. Acute hematomas are therefore isointense on T1-weighted images and hypointense on T2-weighted images. The precise reason for the dramatic T2 effect remains unclear but is believed to result from phase dispersion and subsequent preferential T2 proton relaxation enhancement. During this stage, the red blood cells shrink, lose their spherical shapes, become trapped in blood vessels, and acquire irregular Spiculated projections and form “echinocytes .” Early subacute hematomas (4 to 7 days) consist of intracellular methemoglobin, which is paramagnetic and renders subacute hematomas hyperintense on T 1-weighted images and hypointense on T2- weighted images. With late subacute hematomas (1 to 4 weeks), methemoglobin becomes mostly extracellular (secondary to hemolysis), resulting in a progressively more hyperintense clot on T2-weighted images. Early chronic hematomas (months) generally consist of a pool of dilute-free methemoglobin surrounded by a ferritin- and hemosiderin-containing vascularized wall. At this stage, clots are generally similar in appearance to late subacute clots (hyperintense on both T1- and T2-weighted images), with a thin-rimmed wall of pronounced hypointensity on T2-weighted images (ferritin and hemosiderin deposits) . \Vith time (late chronic hematomas, months to years), ferritin- and hemosiderin-containing substances are further deposited throughout the clot, producing hypointense T1- and T2-weighted images

Question 18

18. Hiperintens pada T1, Hipointens pada T2
    A. Hiper-akut ( sampai dengan 4-6 jam)
    B. Akut (7 sampai dengan 72 jam)
    C. Sub-akut dini (4 – 7 hari)
    D. Akhirnya aub-akut (1 sampai 4 minggu)
    E. Sub-kronis dini (mingguan sampai bulanan)
    F. Sub-kronis lambat (bulanan sampai tahunan)

Answer 18

C. The appearance of hyperacute hematomas (up to 4 to 6 hours ) on MRI is due to the presence of large amounts of oxyhemoglobin, which is diamagnetic and does not influence T1 and T2 relaxation times . Hyperacute clots have a high concentration of water, which renders them isointense on T1-weighted images and hyperintense on T2-weighted images. Acute hematomas (7 to 72 hours) consist primarily of deoxyhemoglobin, which is paramagnetic and has pronounced effects upon T2 relaxation times but no significant effects on T1 relaxation time. Acute hematomas are therefore isointense on T1-weighted images and hypointense on T2-weighted images. The precise reason for the dramatic T2 effect remains unclear but is believed to result from phase dispersion and subsequent preferential T2 proton relaxation enhancement. During this stage, the red blood cells shrink, lose their spherical shapes, become trapped in blood vessels, and acquire irregular Spiculated projections and form “echinocytes .” Early subacute hematomas (4 to 7 days) consist of intracellular methemoglobin, which is paramagnetic and renders subacute hematomas hyperintense on T 1-weighted images and hypointense on T2- weighted images. With late subacute hematomas (1 to 4 weeks), methemoglobin becomes mostly extracellular (secondary to hemolysis), resulting in a progressively more hyperintense clot on T2-weighted images. Early chronic hematomas (months) generally consist of a pool of dilute-free methemoglobin surrounded by a ferritin- and hemosiderin-containing vascularized wall. At this stage, clots are generally similar in appearance to late subacute clots (hyperintense on both T1- and T2-weighted images), with a thin-rimmed wall of pronounced hypointensity on T2-weighted images (ferritin and hemosiderin deposits) . \Vith time (late chronic hematomas, months to years), ferritin- and hemosiderin-containing substances are further deposited throughout the clot, producing hypointense T1- and T2-weighted images

Question 19

19. Isointens pada T1, hiperintens pada T2
    A. Hiper-akut ( sampai dengan 4-6 jam)
    B. Akut (7 sampai dengan 72 jam)
    C. Sub-akut dini (4 – 7 hari)
    D. Akhirnya aub-akut (1 sampai 4 minggu)
    E. Sub-kronis dini (mingguan sampai bulanan)
    F. Sub-kronis lambat (bulanan sampai tahunan)

Answer 19

A. The appearance of hyperacute hematomas (up to 4 to 6 hours ) on MRI is due to the presence of large amounts of oxyhemoglobin, which is diamagnetic and does not influence T1 and T2 relaxation times . Hyperacute clots have a high concentration of water, which renders them isointense on T1-weighted images and hyperintense on T2-weighted images. Acute hematomas (7 to 72 hours) consist primarily of deoxyhemoglobin, which is paramagnetic and has pronounced effects upon T2 relaxation times but no significant effects on T1 relaxation time. Acute hematomas are therefore isointense on T1-weighted images and hypointense on T2-weighted images. The precise reason for the dramatic T2 effect remains unclear but is believed to result from phase dispersion and subsequent preferential T2 proton relaxation enhancement. During this stage, the red blood cells shrink, lose their spherical shapes, become trapped in blood vessels, and acquire irregular Spiculated projections and form “echinocytes .” Early subacute hematomas (4 to 7 days) consist of intracellular methemoglobin, which is paramagnetic and renders subacute hematomas hyperintense on T 1-weighted images and hypointense on T2- weighted images. With late subacute hematomas (1 to 4 weeks), methemoglobin becomes mostly extracellular (secondary to hemolysis), resulting in a progressively more hyperintense clot on T2-weighted images. Early chronic hematomas (months) generally consist of a pool of dilute-free methemoglobin surrounded by a ferritin- and hemosiderin-containing vascularized wall. At this stage, clots are generally similar in appearance to late subacute clots (hyperintense on both T1- and T2-weighted images), with a thin-rimmed wall of pronounced hypointensity on T2-weighted images (ferritin and hemosiderin deposits) . \Vith time (late chronic hematomas, months to years), ferritin- and hemosiderin-containing substances are further deposited throughout the clot, producing hypointense T1- and T2-weighted images

Question 20

20. Metemoglobin intraseluler
    A. Hiper-akut ( sampai dengan 4-6 jam)
    B. Akut (7 sampai dengan 72 jam)
    C. Sub-akut dini (4 – 7 hari)
    D. Akhirnya aub-akut (1 sampai 4 minggu)
    E. Sub-kronis dini (mingguan sampai bulanan)
    F. Sub-kronis lambat (bulanan sampai tahunan)

Answer 20

C. The appearance of hyperacute hematomas (up to 4 to 6 hours ) on MRI is due to the presence of large amounts of oxyhemoglobin, which is diamagnetic and does not influence T1 and T2 relaxation times . Hyperacute clots have a high concentration of water, which renders them isointense on T1-weighted images and hyperintense on T2-weighted images. Acute hematomas (7 to 72 hours) consist primarily of deoxyhemoglobin, which is paramagnetic and has pronounced effects upon T2 relaxation times but no significant effects on T1 relaxation time. Acute hematomas are therefore isointense on T1-weighted images and hypointense on T2-weighted images. The precise reason for the dramatic T2 effect remains unclear but is believed to result from phase dispersion and subsequent preferential T2 proton relaxation enhancement. During this stage, the red blood cells shrink, lose their spherical shapes, become trapped in blood vessels, and acquire irregular Spiculated projections and form “echinocytes .” Early subacute hematomas (4 to 7 days) consist of intracellular methemoglobin, which is paramagnetic and renders subacute hematomas hyperintense on T 1-weighted images and hypointense on T2- weighted images. With late subacute hematomas (1 to 4 weeks), methemoglobin becomes mostly extracellular (secondary to hemolysis), resulting in a progressively more hyperintense clot on T2-weighted images. Early chronic hematomas (months) generally consist of a pool of dilute-free methemoglobin surrounded by a ferritin- and hemosiderin-containing vascularized wall. At this stage, clots are generally similar in appearance to late subacute clots (hyperintense on both T1- and T2-weighted images), with a thin-rimmed wall of pronounced hypointensity on T2-weighted images (ferritin and hemosiderin deposits) . \Vith time (late chronic hematomas, months to years), ferritin- and hemosiderin-containing substances are further deposited throughout the clot, producing hypointense T1- and T2-weighted images

Question 21

21. 38 th, dg riw 2 hari sakit kepala parah. fotopobia, dan emesis. Hasil pemeriksaan pasien secara neurologis intak. Hasil CT digambarkan di bawah ini. Hal apa yang TIDAK perlu dilakukan pada pengelolaan entitas ini?

A.   Angiografi  
B.  Pemantauan jantung  
C. Pemantauan elektrolit 
D.  Terapi hiperdinamis 
E. Pemantauan hidrosepalus

Answer 21

D. This C T scan illustrates perimesencephalic subarachnoid hemorrhage, which usually involves subarachnoid blood within the prepontine, interpeduncular, crural, or ambient cisterns. This is generally a benign entity, thought to result from rupture of a small vein. Angiography is required, however, because ruptured basilar apex aneurysms can exhibit a similar hemorrhage pattern. Patients with perimesencephalic hemorrhage can exhibit cardiac and electrolyte abnormalities. Although this disease is not associated with intraventricular hemorrhage, approximately 1% of cases can eventually develop hydrocephalus. Empiric calcium channel blockers, anticonvulsants, and hyperdynamic therapy is not indicated due to the rarity of vasospasm and seizures with this entity. Repeat angiography is controversial and is generally not indicated if the diagnosis is clear

Question 22

22. Kelainan manakah yang ditunjukkan pada MRI T2 aksial di bawah ini?  
A.   Oligodendroglioma  
B. Relangiestasia kapilaris   
C. Malformasi cavernous 
D.  Angioma venus 
E.  Koriokarsinoma

Answer 22

C. Cavernous malformations are circumscribed, multilobulated vascular lesions that often exhibit hemorrhage in n1rious stages of evolution. The center of a cavernoma frequently contains a mixed-signal region known as a “reticulated ( popcorn-like) core” The periphery of cavernomas is usually surrounded by a low-signal rim on T2-weighted images that corresponds to a peripheral rim of hemosiderin deposition from remote hemorrhages. Cavernomas can be located anywhere within the brain, although 80% are supratentorial parenchymal lesions, and they are often multiple. Gradient echo sequences are the most sensitive for detecting cavernomas. Capillary telangiectasias are usually small lesions that are hypointense on T2-weighted images and rarely exhibit hemorrhage. Venous angiomas are radial collecting veins that drain normal brain and rarely hemorrhage. venous angiomas are occasionally associated with cavernous malformations. Although oligodendrogliomas and choriocarcinoma can exhibit hemorrhage, the presence of a reticulated core and surrounding hemosiderin rim is more consistent with a cavernoma

Question 23

23. Tn.X, 44 tahun datang dg melanoma kutanus. Setelah reseksi lokal dan terapi radiasi pasien menjalani CT scan pada dada/abdomen/pelvis, bone scan nuklir, dan lumbar puncture untuk systemic staging. Hasilnya menunjukkan tidak ada bukti metastase sistemik dan sitologi CSF negatif. Pasien yang bersangkutan datang kembali 2 minggu kemudian dengan keluhan baru sakit kepala parah di frontal disertai dengan ambulasi. Pasien kemudian menjalani MRI pada otak; di bawah ini kami sajikan citra T1 setelah diperjelas kontrasnya. Langkah berikutnya yang paling tepat dalam mengelola gangguan ini….

A.  Biopsi meningeal  
B. Ulangi lumbar puncture  
C. Patch darah Epidural  
D.  Angiografi Serebral  
E. Jawaban A, B, C dan D semuanya salah

Answer 23

C . This patient’s symptoms consist largely of postural headaches that occurred shortly after a lumbar puncture. The patient’s MRI shows evidence of diffuse pachymeningeal thickening with enhancement. These features are consistent with primary intracranial hypotension as a consequence of lumbar puncture. Meningeal carcinomatosis can exhibit similar features on MRI; however, this is unlikely in light of the negative cytologic examination of the CSF. Additionally, although melanoma frequently metastasizes to the CNS, this is unlikely in the absence of any other systemic metastases. Therefore an epidural blood patch will likely treat the source of the intracranial hypotension and result in cessation of headaches. The lack of focal neurologic signs and symptoms makes the diagnosis of CNS vasculitis unlikely; thus, cerebral angiography would not be indicated

Question 24

24. Dg apakah pembuluh (tanda panah) pada angiogram karotid internal lateral ini lazimnya berasosiasi?
25. Meningioma tentorial
26. Angioma venous
27. Fistula arteriovenus dural
28. Papiloma pleksus koroid

Answer 24

B. The tentorial artery is a branch of the meningohypophyseal artery of the cavernous segment of the internal carotid artery; it is also known as the artery of Bernasconi and Cassinari, or the Italian artery. This artery was classically described in reference to a tentorial meningioma, but it is commonly observed with dural arteriovenous malformations of the tentorium as well

Question 25

25. Kelainan apakah yang ditunjukkan pada MR 
Scan T2 dibwh ini  
A.  Fragmen piring herniasi  
B. Neurofibrima  
C. Kista sinovieal  
D.  Osteokondroma  
E. Kista Neurenteris

Answer 25

C . Juxtafacet (synovial) cysts commonly exhibit hyperintense signal on T2-weighted images with a hypointense capsule. These cysts originate from the facet joint and can present with lumbar radiculopathy secondary to nerve root compression. The signal intensity of the cyst contents is variable on MRI and depends largely upon the protein concentration within the cyst. Synovial cysts occasionally enhance with contrast administration

Question 26

26. Ciri manakah yang TIDAK berasosiasi dg gangguan yang ditunjukkan pada MRI T2-sagital dibwh?

A. Prevalensi tertinggi di kalangan penduduk Jepang
B. 70 persen kasus melibatkan sumsum servik
C. Lazim ada bersama-sama Mielopati progresif
D. Redikulopati C5 merupakan komplikasi yang lazim dari pendekatan bedah depan.
E. Lazim diidentifikasikan pada x-ray polos spinal

Answer 26

E. This MRI depicts ossification of the posterior longitudinal ligament (OPLL). OPLL occurs in 0 . 1 2% of all North Americans, and 2.4% of all Japanese and accounts for 27% of all cases of cervical myelopath' in Japan. OPLL involves the cervical spine •in 70% of cases and the thoracic ( 1 5%) and lumbar ( 15%) regions less frequently OPLL is more common in men and usually presents in the fifth to sixth decade with symptoms of progres!sive myelopathy. OPLL cannot be visualized with plain spinal x-rays; MRI or CT myelography is required to demonstrate the pathology and cord compression. Complications of anterior cervcal decompression for OPLL include worsening myelopathy. durotomy, and radiculopathy. Postoperative CS radiculopathy has been reponed in up to 1 7% of all patients undergoin g anterior decompre. si,procedures for OPLL. Posterior decoii:q!ressions, with up 170 Intensive Neurosurgery Board Review without concomitant fusion, have also been utilized in the treatment of OPLL, with variable success rates

Question 27

27. Ny. X, 55 th dg gejala awal hemiparesis kanan ringan akut. Neoplasma manakah yang ditunjukkan pada MRI T1-tertimbang yg telah diperjelas di bawah ini ?
    C. Oligodendroglioma
    D. Glioblastoma multiforme
    E. Melanoma

Answer 27

D. Glioblastoma multiforme (GBM) is usually observed in the fifth to sixth decades of life and is most commonly located in the deep white matter of the frontal or temporal lobes. GBM often exhibits a central hypointense (necrotic) core on T l-weighted images with surrounding “ring enhancement” and prominent peri tumoral edema. GBlvl can be multifocal, as depicted above, in approximately 1 to 5% of all cases. GBM is associated with exposure to hydrocarbons and radiation and often results in progressive neurologic symptoms and signs. Metastases are frequent in the adult population, and they can exhibit variable enhancement patterns on CT and MRI. lvletastases, however, are most commonly located at the gray-white junction. Oligodendrogliomas usually exhibit heterogenous signal patterns on T1-weighted MRI, with patchy enhancement and calcification. CNS lymphoma is also often multiple and is usually found in the periventricular white matter or basal ganglia. CNS lymphoma is usually iso- to hypointense on T1-weighted images with variable enhancement patterns. The ring enhancement, prominent peritumoral edema, demographics, and the acute onset of a focal neurologic deficit are most consistent with a GBM

Question 28

28. Ciri manakah yang TIDAK berasosiasi dengan kelainan yang dijelaskan pada CT scan di bawah ini ?
    A. Hampir lazim ada bersama-sama dengan sakit kepala
    B. Hampir lazim hiperdensi pada CT scan
    C. Hampir lazim hiperdensi dengan korteks pada MRI T-1tertimbang
    D. Berasal dari ectoderm
    E. Tidak menundukkan degenerasi ganas

Answer 28

D. Colloid cysts are cystic, encapsulated lesions that occur at the foramen of Monro in the anterior aspect of the third ventricle. These lesions are usually hyperdense on CT scans ( 66%), hyperintense to cortex on Tl-weighted images, and hypointense to cortex on T2-weighted images, although the MRI characteristics of these cysts are quite variable. Colloid cysts do not exhibit calcification or malignant degeneration; however, they occasionally show mild peripheral enhancement. Colloid cysts are derived from endoderm and usually pres.ent with intermittent or chronic headaches. Vertigo, memory loss, diplopia, and even sudden death can also occur with these lesions

Question 29

29. Kelainan manakah yang ditunjukkan pada MRI T1-tertimbang yang telah diperjelas di bawah ini ?

A.Ependymoma
B.Meningioma
C. Astrositoma pilositik  
D.  Neurositoma sentral  
E. Papiloma pleksus koloid

Answer 29

D. Central neurocytoma is a lobulated, intraventricular tumor that usually occurs adjacent to the septum pellucidum or at the foramen of Monro within the lateral ventricle. Central neurocytoma usually presents in the second to third decades and is iso- to slightly hyperdense on CT scans. Central neurocytoma is generally isointense on T1-weighted images and iso- to hyperintense on T2-weigjued images, with minimal to mild heterogenous enhane,ement patterns. Supratentorial ependymomas are generally extraventricular and exhibit prominent enhancement. Additionally, choroid plexus papillomas and intraven tricular meningioma also exhibit prominent enhancement on MRI. lnterventricular pilocytic astrocy.tomas are generally cystic lesions that exhibit heterogeUllllls enhancement. The presence of an intraventricular mass adjacent to the septum pellucidum that is isointense to surrounding brain on T1-weighted MRI without enhancement is most consistent with a central neurocytoma

Question 30

30. Laki-laki, 18 tahun dibawa dengan riwayat 6 bulan sakit kepala oksipital progresif dan kulit kepala nyeri dan edema lokal. Kelainan apa yang dijelaskan pada CT scan aksial tdk enhance di bawah ini?

B. Osteoma ostenoid
C. Granuloma eosinopilik
D. Kista tulang aneurismal
E. Osteosarkoma

Answer 30

D. Aneurysmal bone cysts (ABCs) are benign lesions that can occur in all parts of the skeleton and often involve the posterior elements of the cervical and thoracic spine. ABCs usually occur in patients less than 20 years of age, and present with pain, edema, symptoms of neurologic compression, or pathologic fractures. ABCs are osteolytic lesions that often contain multiple lobulations and fluid-fluid levels secondary to hemorrhage at various stages of evolution. Eosinophilic granuloma, osteosarcoma, and osteoid osteoma rarely exhibit fluid-fluid levels and multiple lobulations. Giant cell tumors are also highly vascular, lytic lesions, however, they usually involve the vertebral body and present in patients in the third to fourth decades of life. The CT scan above exhibits prominent fluid-fluid levels within an osteolytic lesion, which is most consistent with an aneurysmal bone cyst

Question 31

31. Korteks motorik primer

Answer 31

F. The central sulcus (A) is generally the most prominent sulcus that approaches the interhemispheric fissure, and it is usually located adjacent to or just an terior to the pars marginal is (E) . The precentral gvrus (primary motor cortex) is generally thicker than the postcentral gyrus and exhibits a sigmoid-shaped “hook” laterally ( F) that corresponds roughly to the motor hand region. The postcentral sulcus is generally bifid (D) and is intersected by the intraparietal sulcus laterally. The superior frontal sulcus (B) generally courses posteriorly to join the precentral sulcus

Question 32

32. Sulcus post-sentral

Answer 32

D. The central sulcus (A) is generally the most prominent sulcus that approaches the interhemispheric fissure, and it is usually located adjacent to or just an terior to the pars marginal is (E) . The precentral gvrus (primary motor cortex) is generally thicker than the postcentral gyrus and exhibits a sigmoid-shaped “hook” laterally ( F) that corresponds roughly to the motor hand region. The postcentral sulcus is generally bifid (D) and is intersected by the intraparietal sulcus laterally. The superior frontal sulcus (B) generally courses posteriorly to join the precentral sulcus

Question 33

33. Sulcus-sentral

Answer 33

A. The central sulcus (A) is generally the most prominent sulcus that approaches the interhemispheric fissure, and it is usually located adjacent to or just an terior to the pars marginal is (E) . The precentral gvrus (primary motor cortex) is generally thicker than the postcentral gyrus and exhibits a sigmoid-shaped “hook” laterally ( F) that corresponds roughly to the motor hand region. The postcentral sulcus is generally bifid (D) and is intersected by the intraparietal sulcus laterally. The superior frontal sulcus (B) generally courses posteriorly to join the precentral sulcus

Question 34

34. Sulcus frontal superior

Answer 34

B. The central sulcus (A) is generally the most prominent sulcus that approaches the interhemispheric fissure, and it is usually located adjacent to or just an terior to the pars marginal is (E) . The precentral gvrus (primary motor cortex) is generally thicker than the postcentral gyrus and exhibits a sigmoid-shaped “hook” laterally ( F) that corresponds roughly to the motor hand region. The postcentral sulcus is generally bifid (D) and is intersected by the intraparietal sulcus laterally. The superior frontal sulcus (B) generally courses posteriorly to join the precentral sulcus

Question 35

35. Gangguan manakah yang dijelaskan pada MRI T1 dg kontras di bawah ini ?

A.  Sindroma STURGE-WEBER  
B.  Sklerosis tuberus  
C.  Sindroma WYBURN-MASON  
D.  Sindroma LAURENCE-MOON-BIEDL  
E. Neurofibromatosis Tipe 1

Answer 35

A. Sturge-Weber syndrome (encephalotrigeminal angiomatosis) is a sporadic neurocutaneous syndrome that is associated with development of a port-wine stain in the distribution of the trigeminal nerve and multiple thi n-walled capillaries and venules along the convexity of the ipsilateral cerebral hemisphere. Sturge-Weber svndrome ( SWS) has a predilection for involving the parietal and occipital regions, and is associated with prominent gyral calcification (“tramtrack” pattern ) , progressive cortical atrophv, ipsilateral calvarial thickening. enlargement of the paranasal sinuses, and prominent subepenclymal veins. On MRI, SWS often exhibits prominent enhancement of the pial angioma and subependymal veins of the involved hemisphere, as depicted here

Question 36

36. Kelainan manakah yg ditunjukkan pada angiogram AP arteri karotid kiri…

 A.   Oklusi embolik akut         
B.   Diseksi arterial           
C.   Malformasi Arteriovenus dural  
D. Moyamoya 
E. Vaskulitis

Answer 36

D . Moyamoya (idiopathic progressive arteriopathy of childhood) is a progressive cerebrovascular disease that results in the progressive s tenosis/occlusion of the distal internal carotid arteries and proximal segments of the anterior and middle cerebral arteries. Mamoya usually presents ith signs of progressive cerebral ischem ia. Although hemorrhagic variants can also occur. The angiographic hallmarks of moyamoya include stenoses and occlusions of the distal ICA and proximal ACA/MCA, along with the development of prominent leptomeningeal collaterals and enlarged lenticulostriate arteries, which resembles a “puff of smoke . “

Question 37

37. Di antara kondisi di bawah ini, manakah yang TIDAK berasosiasi dengan hipometabolisme regional pada pencitraan tomografi emisi positron (PET) dengan deoksiglukose fluorin-18 (FDG) di bawah ini?  
A.   Foci epileptis   
B.   Nekrosis radiasi     
C.   Multiforme glioblastoma  
D.  Astrositoma fibrilaris 
E. A, B, C dan D salah

Answer 37

C. FDG PET imaging techniques usually exhibit focal hypometabolism in regions of radiation necrosis, low grade neoplasms, and epileptic foci. In contrast, recurrent or highgrade neoplasms usually exhibit hypermetabolism

Question 38

38. Seorang bayi prematur menunjukkan infantil spasms begitu masuk ke unit gawat darurat neonatal. MRI T2- tertimbang pasien di bawah ini ?

A.  Displasia kortikal  
B.  Porensepali bilateral  
C. Holoprosensepali  
D.  Infeksi sitomegalovirus kongenital;  
E. Hidranensepali

Answer 38

D. Congenital cytomegalovirus (CMV) infection usually results in premature delivery and is associated with seizures, mental retardation, hydrocephalus, hearing loss, and optic atrophy. MRI characteristics of congenital GMV infection include encephalomalacia, ven triculomegaly, calcifications of the periventricular and basal ganglia , delayed mvelination, and subependymal paraventricular cysts. CMV is considered one of the TORCH agents, along with toxoplasmosis, rubella, and herpes. The above T2-weighted image illustrates prominent bilateral basal ganglia calcifications (hypointense), ventricul omegaly, and encephalomalacia

Question 39

39. Berapa taksiran umur hematoma yg dijelaskan pada MRI T2-tertimbang aksial tanpa pertegasan…

A.  Hiperakut  
B.  akut  
C.  Subakut di awal  
D.  Sub akut di akhir  
E. Kronis

Answer 39

C. Subacute hematomas initially consist largely of intracellular methemoglobin, which results in hyperintensity on T1-weighted images. This hyperintense signal is la rgely peripheral with early subacute hematomas and gradually progresses toward the isointcnse central region of the hematoma. Early subacute hematomas are markedly hypointense on T2-weighted and gradient echo sequences. Late subacute hematomas are largely characterized by extracellular methemoglobin, which results in hyperintensity on both T1- and T2-weighted MRI sequences

Question 40

40. Laki-laki, 15 tahun dg sakit kepala dan poliuria. MRI T1 sagital dg kontras menjelaskan gangguan…

A.  Histiositosis X  
B.  Lipoma  
C. Germinoma  
D.  Glioma Hipotalamis  
E. Pineoblastoma

Answer 40

C. Germinomas present in patients between the second and fourth decades and usually involve the pineal or suprasellar regions (midline locations). Suprasellar germinomas often present with headaches. diabetes insipidus, and panhypopituitarism in children. Germ inomas are usually isointense on both T1 - and T2-weighted sequences, and they exhibit intense, homogenous enhancement . Germinomas rarely occur of the midline, and the presence of this lesion in nonmidline locations usually indicates metastasis, although the thalamus and basal ganglia are occasionally involved from local invasion. The MRI in this case exhibits synchronous suprasellar and pineal lesions, which can occur in 10% of all intracranial germinomas

Question 41

41. Kelainan manakah yang dijelaskan oleh angiogram arteri karotid internal lateral di bawah ini?

A. Malformasi Arteriovenus  
B. Angiitis primer dari SSP  
C. Malformasi kavernus  
D.  Stroke embolis  
E. Moyamoya

Answer 41

D. Embolic strokes often exh ibit an abrupt vessel cutoff on angiography . With occasionally edge-shaped regions that are devoid of blood flow and surrounding luxury perfusion (vascular blush) on late arterial phases. Occasionally an intravascular thrombus is also visualized, with slow distal antegrade flow. This lateral angiogram demonstrates a marked paucity of filling of the candelabra of the MCA, which is most consistent with embolic occlusion

Question 42

42. Tn. X, 35 tahun dengan riwayat AIDS dibawa dengan status mental menurun dan demam derajat rendah. MRI T1-tertimbang aksial dengan kontras di bawah ini menunjukkan kelainan apa?

A.  Limpoma SSP  
B.  Leukoenselopalopati multifokal progresif  
C. Kriptokokoma  
D.  Tuberkuloma  
E. Toksoplasmosis

Answer 42

E. Toxoplasmosis is the most common opportunistic infection of the CNS in AIDS patients. Toxoplasmosis usually involves the basal ganglia or gray-white junction, and is iso- to hypoin tense on T l-weighted images. Toxoplasmosis exhibits prominent ring enhancement, as well as a central enhancing region that imparts a “target” appearance, as depicted here. This target appearance is not commonl y observed with cryptococcomas, tuberculomas, or lymphoma

Question 43

43. Bayi, 4 bulan dibawa dengan makrosepali. CT
    scan axial tdk enhance di bawah ini menunjukkan kelainan apa?

A.  Pineoblastoma  
B. Malformasi vein Galen  
C.  Sinus pericranii  
D. Malformasi kavernus  
E. Teratoma

Answer 43

B. Vein of Galen mal forma tions (VOGM) often presenr in neonates with macrocephaly, hydrocephalus. and highoutput congestive heart fa ilure.VOGM ls appear as iso- to hyperdense midline masses located posterior to the third ventricle on CT scan, often with associated hydrocephalus. Neonatal teratomas can also involve the third ventricle, however, they usually exhibit heterogenous density and intensity on CT and MEl, respectively . Germinomas rarely occur in the neonatal population

Question 44

44. Kelainan apa yang ditunjukkan oleh MRI T1 unenhance di bawah ini ?

A.  Adenoma Hipofise  
B.  Kista celah Rathke  
C. Meningioma  
D.  Kordoma  
E. Displasia fibrus

Answer 44

D. Chordomas arise from the clivus in approximately 35% of all cases and are typically slow-growing, lobulated extradural lesions. Calcification is often observed in chordomas; they are usually heterogenous lesions with hypointensity on T1-weighted images and hyperintensity on T2-weighted images, with variable enhancement patterns. The sella is not expanded in this example, which eliminates pituitary neoplasms from the differential, and en plaque meningiomas of the clivus are typically less lytic and invasive than chordomas. The surrounding hyperintensity (edema) of the clivus is consistent with a chordoma arising from within the clivus itself

Question 45

45. Bayi, 8 minggu dibawa dengan perabaan massa kulit kepala. lesi apa yang ditunjukkan pada foto di bawah ini ?

A.  Cephal hematoma  
B. Dermoid  
C. Granuloma eosinopilik  
D.  Osteokondroma  
E. Kista tulang aneurismal

Answer 45

A . Cephalhematomas gene r.ally result from hemorrhage between the skull and the overlYing periosteum at delivery . Cephalhematomas are in itially hard and typically exhibit progressive softening as the hematoma is absorbed. Approximately 3 to 5% of all cephalhematomas exhibit calcification. usually after 6 weeks which can require surgical resection. Cephalhematomas do not cross suture lines. The AP skull radiography in this case illustrates a calcifying cephalhematoma . Dermoid tumors often exhibit surrounding calcification and are located in the midline. Osteochondromas typically involve long bones or the spine, and eosinophilic granuloma often exhibits beveled nonsclerotic margins surrounding a lytic lesion involving the inner and outer tables

Question 46

46. MRI T1-tertimbang dengan kontras aksial di bawah ini berlokasi di ruang piringan L3-4. Struktur mana yang paling mungkin terkena kelainan yang ditunjukkan pada MRI ini?

A. akar saraf L3
B. Akar saraf L4
C. A dan B
D. Bukan A dan B

Answer 46

A. Far lateral ( extraforaminal) disc herniations typically compress the nerve root that is exiting at that level, as opposed to typical paracentral disc herniations, which often impinge upon the nerve root exiting at the level below. CT myelography does not typically identify far lateral disc herniations

Question 47

47. Daerah pineal, laki-laki 15 tahun  
A.  Astrositoma pilositik   
B.  Schwannoma   
C. Pineoblastoma   
D.  Germinoma   
E. Meningioma  
 F. Papiloma pleksus koroid 
G. Meduloblastoma
H.Hemangioblastoma 
I.  Bukan, A-H

Answer 47

D. Germinoma accounts for approximately 66% of all germ cell tumors of the pineal region and 40% of pineal region neoplasms overall. The most common posterior fossa tumor in children is the pilocytic astrocytoma; in adults, it is the hemangioblastoma (cerebellum). Approximately 75% of all cerebellopontine angle tumors are acoustic schwannomas. Tumors of the atrium are most commonly choroid plexus papillomas in children and meningiomas or lymphoma in adults

Question 48

48. Serebelum, perempuan usia 58 tahun 
A.  Astrositoma pilositik   
B.  Schwannoma   
C. Pineoblastoma   
D.  Germinoma   
E. Meningioma  
 F. Papiloma pleksus koroid 
G. Meduloblastoma
H.Hemangioblastoma 
I.  Bukan, A-H

Answer 48

H. Germinoma accounts for approximately 66% of all germ cell tumors of the pineal region and 40% of pineal region neoplasms overall. The most common posterior fossa tumor in children is the pilocytic astrocytoma; in adults, it is the hemangioblastoma (cerebellum). Approximately 75% of all cerebellopontine angle tumors are acoustic schwannomas. Tumors of the atrium are most commonly choroid plexus papillomas in children and meningiomas or lymphoma in adults

Question 49

49. Sudut serebelopontine, perempuan usia 42 tahun
A.  Astrositoma pilositik   
B.  Schwannoma   
C. Pineoblastoma   
D.  Germinoma   
E. Meningioma  
 F. Papiloma pleksus koroid 
G. Meduloblastoma
H.Hemangioblastoma 
I.  Bukan, A-H

Answer 49

B. Germinoma accounts for approximately 66% of all germ cell tumors of the pineal region and 40% of pineal region neoplasms overall. The most common posterior fossa tumor in children is the pilocytic astrocytoma; in adults, it is the hemangioblastoma (cerebellum). Approximately 75% of all cerebellopontine angle tumors are acoustic schwannomas. Tumors of the atrium are most commonly choroid plexus papillomas in children and meningiomas or lymphoma in adults

Question 50

50. Fosa posterior, laki-laki usia 12 tahun 
A.  Astrositoma pilositik   
B.  Schwannoma   
C. Pineoblastoma   
D.  Germinoma   
E. Meningioma  
 F. Papiloma pleksus koroid 
G. Meduloblastoma
H.Hemangioblastoma 
I.  Bukan, A-H

Answer 50

A. Germinoma accounts for approximately 66% of all germ cell tumors of the pineal region and 40% of pineal region neoplasms overall. The most common posterior fossa tumor in children is the pilocytic astrocytoma; in adults, it is the hemangioblastoma (cerebellum). Approximately 75% of all cerebellopontine angle tumors are acoustic schwannomas. Tumors of the atrium are most commonly choroid plexus papillomas in children and meningiomas or lymphoma in adults

Question 51

51. Atrium, laki-laki usia 8 tahun
A.  Astrositoma pilositik   
B.  Schwannoma   
C. Pineoblastoma   
D.  Germinoma   
E. Meningioma  
 F. Papiloma pleksus koroid 
G. Meduloblastoma
H.Hemangioblastoma 
I.  Bukan, A-H

Answer 51

F. Germinoma accounts for approximately 66% of all germ cell tumors of the pineal region and 40% of pineal region neoplasms overall. The most common posterior fossa tumor in children is the pilocytic astrocytoma; in adults, it is the hemangioblastoma (cerebellum). Approximately 75% of all cerebellopontine angle tumors are acoustic schwannomas. Tumors of the atrium are most commonly choroid plexus papillomas in children and meningiomas or lymphoma in adults

Question 52

52. Berapa taksiran usia hematoma pada CT scan aksial non-kontras di bawah ini

A.   Hiperakut  
B.   Akut   	
C.  Sub-akut di awal 
D.  Kronis  
E.  Sub-akut di akhir

Answer 52

A. The appearance of acute epidural hematomas is generally hyperdense on noncontrasted CT scans. The observance of central regions of low density in an epidural hematoma is usually secondary to the rapid accumulation of unretracted semiliquid blood clots and is known as the “swirl sign .” The lack of clear fluid-fluid levels and clot density helps eliminate subacute and chronic hematomas

Question 53

53. Ciri manakah yang TIDAK berasosiasi dengan gangguan yang ditunjukkan pada foto di bawah ini ?

A.  Instabilitas kranioservikal  
B.  Lebih lazim pada laki-laki muda  
C.  retak-retak patologis  
D.  HLA D15  
E. Sakroilitis

Answer 53

D. Ankylosing spondylitis (Marie-Stri.impell disease) is an inflammatory disorder that primarily affects the spine of young males and is associated with HLA B27. Autofusion of the apophyseal joints and anterior and posterior longitudinal ligaments is commonly observed in ankylosing spondylitis. This progressive ossification is often referred to as a “bamboo” spine, which is depicted in this case. Patients with ankylosing spondylitis are prone to develop spinal fractures and craniocervical instability over time

Question 54

54. Penampilan histologis Neoplasma manakah pada MRI T2-tertimbang sagital di bawah ini yang paling mungkin?

A. Sel-sel biru kecil dengan mitosis dan nekrosis prominen?
B. Himpunan sel dengan susunan faskikular selang seling
C. Sel-sel yang memanjang dengan proses-proses sitoplasmik prominen dan pleomorfisme menial
D. Gumpalan-gumpalan sel kubodial yang dipisahkan oleh matriks mukoid prominen
E. sel-sel mengandung lipid di dalam jaringan padat saluran vaskular

Answer 54

D. Myxopapillary ependymomas are located in the conus medullaris or filum terminale and are usually isointense to spinal cord on Tl-weighted images and isoto hyperintense on T2-weighted images, with prominent enhancement. Myxopapillary ependymomas exhibit cl usters of cuboidal cells with occasional hyalinized blood Yessels among a prominent mucoid matrix

Question 55

55. Apa yang dijelaskan oleh MRI T1 aksial non-kontras di bawah ini ? Lesi tdk enhance setelah pemberian gadolidium.

A.  Adenoma Hipofise  
B.  Kranioparingioma   
C.  Lipoma  
D.  Kista celah Rathke 
E.  Histiokistis X

Answer 55

D. Rathke’s cleft cysts (RCC) result from persistence of a cleft that is found between the pars distalis and pars nervosa during the development of the pituitary gland. RCC are usually asymptomatic, and they often contain both imrasellar and suprasellar components. The appearance of RCC on MRl is variable, but they are usuallY hyperintense to cortex on T1- and T2-weighted images without enhancement. RCC can be differentiated from craniopharyngiomas by the lack of calcification and from pituitary adenomas by the lack of enhancement

Question 56

56. Kelainan apa yang ditunjukkan pada MRI T2- aksial di bwh ini ?

A. Malformasi Arteriovenus     
B.   Oligodendroglioma     
C.   Malformasi kavernus  
D.  Plak Sklerosis majemuk 
E. Hemangioblastoma

Answer 56

A. Arteriovenous malformations (AVMs) exhibit prominent flow voids on T2-weighted images with minimal observable intervening brain tissue and prominent enhancement. A VMs are not associated with surrounding edema unless they have recently hemorrhaged, although variable signal intensities can be observed in and around the nidus due to the presence of microhemorrhages of various ages and vascular thrombosis. The prominent flow voids, lack of surrounding edema, and lacli: of significant intranidal brain parenchyma helps distinguish AVMs from vascular tumors

Question 57

57. Ny.X, 48 tahun dibawa dg sakit kepala, mual dan ataksia. MRI T1 dg kontras, menunjukkan kelainan…

A.  Astrositoma pilositik  
B.  Papiloma pleksus koroid  
C. Hemangioblastoma  
D.  Luka metastatis  
E. Ganglioglioma

Answer 57

C. Hemangioblastomas are well-circumscribed, often cystic lesions that are usually (80%) located within the cerebellum. Hemangioblastomas typically present in adults in the third to fifth decades of life, and they represent the most common primary neoplasm of the cerebellum in adults and often occur in conjunction with von Rippel-Lindau syndrome. Hemangioblastomas usually exhibit a cyst that is hypointense on T1-weighted images and hyperintense on T2-weighted images. The cystic component is usually associated with a mural nodule that is isointense to brain on Tlweighted images and hyperintense on T2-weighted images, with occasional flow voids. Solid hemangioblastomas often exhibit prominent enhancement, and the mural nodule of cystic lesions usually enhances as well . Choroid plexus papillomas can also occur in the fourth ventricle in adults, although thev are usually solid, lobulated masses with homogenous, intense enhancement. Pilocytic astrocytomas can also exhibit prominent cyst formation with an enhancing mural nodule, although they usually occur in children and young adults

Question 58

58. Lesi apa yang dijelaskan pada radiograf servikal AP dibwh ini ?

A.  Granuloma eosinopilik  
B. Osteoblastoma  
C. Osteoma osteroid  
D.  Osteosarkoma  
E. Osteokondroma

Answer 58

E. Osteochondromas are pedunculated lesions that can arise from the spinous or transverse processes of the cervical or thoracic spine. Osteochondromas are rarely symptomatic, usually present in the third to fourth decade of life, and a cartilaginous cap that exhibits calcification covers them. Osteoblastoma is an expansile lytic mass that usually involves the neural arch, is associated with night pain, and exhibits matrix mineralization. Osteoid osteoma is similar to osteoblastoma, although smaller (< 2 cm) and usually associated with more prominent surrounding sclerosis. Osteosarcoma is an aggr essive lesion associated with prominent surrounding bony destruction/invasion and has a very poor prognosis . The lesion depicted in this x-ray is exophytic and originates from the neural arch, which is most consistent with osteochondroma

Question 59

59. Anak, 5 tahun dibawa dengan kejang umum dan pertumbuhan yang lambat. Kelainan apa yang ditunjukkan pada MRI T2-tertimbang aksial pasien di bawah ini

A.  Pakigiria
B. Holoprosensepali lobar  
C.  Sklerosis tuberus  
D.  Heterotopia nodular  
E. Displasia septo-optik

Answer 59

D. Nodular hete;otopias are neuronal migration disorders that exhibit prominent subcortical collections of gray matter in various locations. Nodular heterotopias are often located in periventricular regions, as exhibited on the MRI above. Nodular heterotopias resemble normal gray matter on all sequences and do not enhance. These disorders can be differentiated from tuberous sclerosis (TS) because the cortical tubers of TS are often calcified, slightly hyperintense to cortex, and exhibit mild enhancement. The presence of a normal septum pellucidum eliminates holoprosencephaly and septo-optic dysplasia from the differential

Question 60

60. Di antara kelainan pencitraan di bawah ini, manakah yang TIDAK berasosiasi dengan neurofibromatosis tipe 1?  
A.  Gioma saraf optik  
B. Hamartomas ganglia basal  
C. Meningoseles torasik  
D.  Schwannoma Spinal  
E. Scalloping batang vertebral belakang

Answer 60

D. Neurofibromatosis type 1 (NF-1) is associated with optic nerve gliomas, hamartomas of the basal ganglia and deep white matter, plexiform neurofibromas, spinal cord neurofibromas, kyphoscoliosis, meningoceles, intramedullary astrocytomas, and scalloping of the posterior aspects of the vertebral bodies. Spinal and cranial schwannomas are not observed in NF-1, however

Question 61

61. Nn. X, 21 th dg riw 2 mgg hidung tersumbat dan sakit kepala frontal, demam, leukositosis,
    dan bingung. Berdasarkan hasil MRI T1 dengan kontras aksial di bwh ini, langkah apakah yg paling tepat mengelola kondisi ini?

A. Pemberian antibiotik spektrum luas IV
B. Pemberian steroid IV
C. Lumbar puncture
D. Pengangkatan bedah darurat
E. Observasi UGD dengan pengulangan ct Scan dalam 24 jam

Answer 61

D. The patient’s MIRI exhibits enhancement of the mucous membranes of the frontal sinus with an adjacent subdural empyema that has spread laterally along the convexity and along the interhemispheric fissure. Subdural empyemas are associated with a high rate of cortical vein thrombosis and cerebritis, which results in their relatively high mortality (10 to 20%) . Emergent surgical evacuation is indicated in almost all cases of subdural empyema, especially with the development of neurologic symptoms. Approximately two-thirds of all cases of subdural empyema result from adjacent spread of infections of the frontal sinus. Nonsurgical management has been reported in asymptomatic patients with the initiation of early IV antibiotics and close JCU observation, however, most authorities advocate early surgical drainage in all cases

Question 62

62. Di antara gangguan di bawah ini, manakah yang berasosiasi dengan multipel Malformasi
    Arteriovenus intrakranial, dan seringkali melibatkan jalas visual dan mesensepalon?
    A. Sindroma WYBURN-MASON
    B. Meningioangiomatosis
    C. sindroma blue rubber bleb
    D. Sindroma STURGE-WEBER
    E. Jawaban A, B, C dan D semuanya salah.

Answer 62

A. Wyburn-Mason syndrome is a neurocutaneous syndrome that is characterized by the presence of multiple intracranial AVMs, cutaneous vascular nevi, and vascular malformations of the retina and optic nerves. The presence of multiple, discrete intracranial AVMs is extremely rare (2% of all cases) , and usually occurs in the context of Wyburn:-. lason svndrome or Rendu-Osler-Weber syndrome (hereditary hemorrhagic telangiectasia ) . Involvement of the optic pathways and mesencephalon, however, is more characteristic ot’ wyburn-Mason syndrome. Meningioangiomatosis is a rare ncu rocutaneous disorder that is characterized by prominent tibroblastic proliferation along the meninges and 'irchm,•-Rohin spaces. Blue rubber bleb nevus syndrome is also a rare neurocutaneous disorder that is characterized by vascular malformations of the skin, GI tract, and CNS. The CNS manifestations of blue rubber bleb nevus syndrome include the development of hemangiomas, sinus pericranii, and venous angiomas . True AVMs are not observed with this disorder

Question 63

63. Di antara ciri di bawah ini, manakah yang TIDAK berasosiasi dengan gangguan yg ditunjukkan pada CT mielogram di bwh ini

A.  urat tethered  
B.  Sindroma KLIPPEL-FEIL  
C. Malformasi Chiari I  
D.  Skoliosis  
E. Spina bifida

Answer 63

C. Diastematomyelia (split-cord malformation) is characterized by the presence of two hemicords in a single or separate dural enclosure. When the hemicords occupy different dural enclosures, they are often separated by a septum consisting of bone, fibrous, or osteocartilaginous tissue. The hemicords usually reunite into a solitary spinal cord above and below the level of the diastematomyelia. Cutaneous stigmata often overlie the level of the split cord malformation, and it usually occurs between the levels of T9 and S1. Diastematomyelia is associated with Chiari Jl malformations, hemivertebrae, intersegmental laminar fusion, spina bifida, scoliosis, tethered cord, and n arrowed disc spaces

Question 64

64. Di antara gejala neurologis dibwh ini, manakah yg paling mungkin ditunjukkan oleh pasien dengan CT scan non-kontras dibwah ini ?

A.  Pusing-pusing dan lesu  
B. Hemiparesis kiri  
C. Hemianopsia homonimus kanan  
D.  Hemianopsia temporal bilateral  
E. Apasia reseptif

Answer 64

B. This noncontrasted CT scan exhibits prominent intraluminal thrombus within the right MCA, which is known as the ‘hyperdense MCA sign.” This CT scan was obtained approximately 4 hours after sympt

Question 65

65. Etiologi manakah yang paling mungkin berdasarkan lesi yang ditunjukkan oleh angiogram karotid internal lateral sebagai berikut (fase midarterial) ?

 A.  Trauma  
B.  kongenital  
C.  Infeksi  
D.  Diseksi  
E. Aterosklerosis

Answer 65

C. This angiogram illustrates an aneurysm along one of the distal branches of the middle cerebral artery. Aneurysms of the distal MCA are infrequent, and are usually secondary to infections of the arterial wall (mycotic aneurysm). Traumatic aneurysms that result from blunt trauma usually occur at the skull base (ICA) or along the falx (A2 segment of the ACA)

Question 66

66. Di antara gangguan di bawah ini, manakah yang biasanya TIDAK berasosiasi dengan agenesis dari corpus callosum?  
A.   Holoprosensepali  
B.  Sindroma Aleardi   
C. Malformasi Dandy-Walker 
D.  Sindroma KLIPPEL-FEIL 
E. Trisomi 13

Answer 66

D. Agenesis of the corpus callosum can be partial or complete and is associated with several disorders, including Chiari II malformations, Dandy-Walker malformation, Aicardi syndrome, holoprosencephaly, heterotopias, schizencephaly, intracranial lipomas, encephaloceles, and trisomy 13, 1 5 , and 18. Agenesis of the corpus callosum is not typically associated with Klippel-Feil syndrome

Question 67

67. Di antara ciri-ciri di bawah ini, manakah yang lazimnya tampak pada plain foto pasien dengan Sindroma Sturge-Weber?
68. Kalvarium menebal
69. Sinus frontal melebar
70. Pengapuran “Tran-track”
71. Elevasi tulang temporal petrous

Answer 67

E . Skull films in patients with Sturge-Weber syndrome often exhibit prominent gyral (“tram-track”) calcifications, and secondary signs of cortical hemiatrophy (thick calvarium, elevated petrous temporal bone, enlarged frontal sinus)

Question 68

68. Semua pernyataan di bawah ini adalah benar mengenai impresi basilar (BI), KECUALI
    A. Anomali bawaan paling lazim pada sambungan kranioservikal
    B. Seringkali disertai dengan sindroma Down, sindroma Klippel-Feil dan Malformasi Ciari
    C. Ditandai oleh pergeseran ke atas dari margin-margin foramen magnum (tulang okipital) dan rusuk servikal (proses odontoid) ke dalam fosa belakang.
    D. Garis McRae dapat membantu memastikan Diagnosisnya
    E. Mungkin akan tampak setelah trauma

Answer 68

A. Basilar impression ( BI) is characterized by upward displacement of the foramen magnum margins and cervical spine (odontoid process) into the posterior fossa . Some may refer to Bl as the upward displacement of the odontoid process only. It may be associated with Down’s syndrome, Klippel-Feil syndrome, Chiari malformation, syringomyelia, rheumatoid arthritis, and trauma. It is the most common congenital (not acquired) anomaly of the craniocervical junction. McRae’s line is described as a line drawn across the foramen magnum from the tip of the clints to opisthion (should be > 19 mm, average 35 mm) part of the odontoid should be above this line (most accurate for BI)

Question 69

69. Diantara neoplasma berikut ini, neoplasma spinal manakah yang biasanya ditemukan pada lokasi intradural ekstramedularis?  
1,  Neurofibroma  
2.  Ganglioneuroma  
3. Schwannoma 
4. Ependimoma

Answer 69

A. Schwannomas, neurofibromas, ganglioneuromas, paragangliomas, meningiomas, and neurofibrosarcomas of the spine are typically intradural extramedullary lesions. Ependymomas, astrocytomas, and hemangioblastomas are typically intramedullary lesions

Question 70

70. Hipointense pada citra dengan T1-tertimbang  
A. Makroadenoma pituitaris      
B. Kista celah Rathke  
C.  A dan B  
D. Bukan A dan B

Answer 70

D. Pituitary macroadenomas are generally isointense to gray matter on all MRl sequences, with intense, heterogenous enhancement. lvlicroadenomas generally exhibit less rapid enhancement than the surrounding normal pituitary gland, which renders them hypointense on contrasted T1-weighted MRI . Mixed-density pituitary adenomas often exhibit hemorrhage, cyst formation, or necrosis; however: calcification is rare. Rathke’s cleft cysts are most commonly hyperintense on Tl-weighted and T2- weighted MRl , with no enhancement, although their appearance is variable. Rathke’s cleft cysts are usually intrasellar lesions with suprasellar extension, and they lack calcification

Question 71

71. Enhance dengan pemberian gadolinium  
A. Makroadenoma pituitaris      
B. Kista celah Rathke  
C.  A dan B  
D. Bukan A dan B

Answer 71

A. Pituitary macroadenomas are generally isointense to gray matter on all MRl sequences, with intense, heterogenous enhancement. lvlicroadenomas generally exhibit less rapid enhancement than the surrounding normal pituitary gland, which renders them hypointense on contrasted T1-weighted MRI . Mixed-density pituitary adenomas often exhibit hemorrhage, cyst formation, or necrosis; however: calcification is rare. Rathke’s cleft cysts are most commonly hyperintense on Tl-weighted and T2- weighted MRl , with no enhancement, although their appearance is variable. Rathke’s cleft cysts are usually intrasellar lesions with suprasellar extension, and they lack calcification

Question 72

72. Hiperintens pada citra T2-tertimbang    
A. Makroadenoma pituitaris      
B. Kista celah Rathke  
C.  A dan B  
D. Bukan A dan B

Answer 72

B. Pituitary macroadenomas are generally isointense to gray matter on all MRl sequences, with intense, heterogenous enhancement. lvlicroadenomas generally exhibit less rapid enhancement than the surrounding normal pituitary gland, which renders them hypointense on contrasted T1-weighted MRI . Mixed-density pituitary adenomas often exhibit hemorrhage, cyst formation, or necrosis; however: calcification is rare. Rathke’s cleft cysts are most commonly hyperintense on Tl-weighted and T2- weighted MRl , with no enhancement, although their appearance is variable. Rathke’s cleft cysts are usually intrasellar lesions with suprasellar extension, and they lack calcification

Question 73

73. Menunjukkan pengapuran
A. Makroadenoma pituitaris      
B. Kista celah Rathke  
C.  A dan B  
D. Bukan A dan B

Answer 73

D. Pituitary macroadenomas are generally isointense to gray matter on all MRl sequences, with intense, heterogenous enhancement. lvlicroadenomas generally exhibit less rapid enhancement than the surrounding normal pituitary gland, which renders them hypointense on contrasted T1-weighted MRI . Mixed-density pituitary adenomas often exhibit hemorrhage, cyst formation, or necrosis; however: calcification is rare. Rathke’s cleft cysts are most commonly hyperintense on Tl-weighted and T2- weighted MRl , with no enhancement, although their appearance is variable. Rathke’s cleft cysts are usually intrasellar lesions with suprasellar extension, and they lack calcification

Question 74

74. Terutama lokasi interstellar  
A. Makroadenoma pituitaris      
B. Kista celah Rathke  
C.  A dan B  
D. Bukan A dan B

Answer 74

C. Pituitary macroadenomas are generally isointense to gray matter on all MRl sequences, with intense, heterogenous enhancement. lvlicroadenomas generally exhibit less rapid enhancement than the surrounding normal pituitary gland, which renders them hypointense on contrasted T1-weighted MRI . Mixed-density pituitary adenomas often exhibit hemorrhage, cyst formation, or necrosis; however: calcification is rare. Rathke’s cleft cysts are most commonly hyperintense on Tl-weighted and T2- weighted MRl , with no enhancement, although their appearance is variable. Rathke’s cleft cysts are usually intrasellar lesions with suprasellar extension, and they lack calcification

Question 75

75. Mekanisme cedera pada fracture di bawah ini (CT scan aksial)?

A.   Retak-dislokasi     
B.   Kompresi aksial     
C. Distraksi-Fleksi 
D.  Hiperekstensi 
E. A, B, C & D salah

Answer 75

B. Thoracolumbar burst fractures are secondary to axial compression injuries, and they usually occur between the levels of T12 and L2. Burst fractures can result in significant retropulsion of bony fragments (as depicted here), with concom itant neurologic deficits