NeuroRadiology Flashcards
What tumor commonly exhibits high signal intensity on
T2-weighted images, low signal intensity on Tl-weighted
images, and high signal intensity (restricted diffusion) on
diffusion MR images?
A. Pineoblastoma
B. Glioblastoma
C. Arachnoid cyst
D. Epidermoid
E. Meningioma
A. Pineoblastoma
B. Glioblastoma
C. Arachnoid cyst
**D. Epidermoid **
E. Meningioma
Epidermoids are usually located off of the midline along
the basilar cisterns. These tumors often resemble CSF, and
thus arachnoid cysts, on T1- and T2-weighted MRI. 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 epidermoids (Osborn ON, pp. 633- 635)
A 12-year-old male presented with symptoms of at~L’(ia
and diplopia and exhibited facial wealmess, hemiparesis, and
internuclear ophthalmoplegia on neurologic examination.
His T2-weighted MRI (Figure 5.2Q) illustrates which of the
following tumors ?
A. Lymphoma
B. Choriocarcinoma
C. Yoll{ sac tumor
D. Ependymoma
E. Infiltrating astrocytoma
A. Lymphoma
B. Choriocarcinoma
C. Yoll{ sac tumor
D. Ependymoma
E. Infiltrating astrocytoma
The most common brainstem tumor encountered in
the pediatric population is an infiltrating 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 (Osborn ON, pp. 555-557).
What MR sequence is the most sensitive in identifying
intracerebral cavernous malformations?
A. Tl-weighted
B. T2-weighted
C. Gradient echo
D. Fast spin echo
E. Diffusion
A. Tl-weighted
B. T2-weighted
C. Gradient echo
D. Fast spin echo
E. Diffusion
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 (Osborn ON , p. 313).
\That is the most common intracranial tumor associated
with neurofibromatosis type 1 ?
A. Optic nerve glioma
B. Ependymoma
C. Neurofibroma
D. Meningioma
E. Medulloblastoma
**A. Optic nerve glioma **
B. Ependymoma
C. Neurofibroma
D. Meningioma
E. Medulloblastoma
Optic nerve gliomas occur in 5 to 15% of all cases of
NF-l. The majority of these tumors are low-grade (pilocytic)
astrocytomas, and they can occur bilaterally. These lesions
are usually hypo- to isointense on T1-weighted images and
hyperintense on T2-weighted images with variable enhancement. Intracranial meningiomas are commonly observed
in NF-2, and neurofibromas usually involve the spinal and
peripheral nerves with NF-1 (Osborn ON , pp. 74-76)
What surgical approach would be most suitable for a
patient with mild tinnitus and the lesion depicted in the
following enhanced Tl-weighted MRI?
A. Retrosigmoid
B. Translabyrinthine
C. Middle fossa
D. Transpetrosal infratemporal fossa
E. Transcochlear
A. Retrosigmoid
B. Translabyrinthine
**C. Middle fossa **
D. Transpetrosal infratemporal fossa
E. Transcochlear
This postcontrasted T1-weighted MRI study depicts
an intracanalicular acoustic neuroma. “There there is an attempt to preserve 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 CPA. 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 labyrinthine segment of the facial
nerve identified medial to the geniculate ganglion. Access
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
(Bernstein, pp. 394- 395, 430).
This lateral internal carotid angiogram (Figure S.6Q) illustrates what persistent fetal circulating
A. Primitive trigeminal artery
B. Persistent otic artery
C. Persistent hypoglossal artery
D. Proatlantal intersegmental artery
E. None of the above
**A. Primitive trigeminal artery **
B. Persistent otic artery
C. Persistent hypoglossal artery
D. Proatlantal intersegmental artery
E. None of the above
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 lCA, the
persistent hypoglossal artery originates from the cervical
lCA, and the proatlantal intersegmental artery can originate
from the internal or external carotid artery (Osborn DCA,
pp. 65, 91-93).
Which of the following ratios is typically decreased with
primary CNS neoplasms on MR spectroscopy?
A. Myoinositol:total creatine
B. CholineN-acetyl aspartate
C. Choline:total creatine
D. N-acetyl aspartate: total creatine
E. MyoinositolN-acetyl aspartate
A. Myoinositol:total creatine
B. CholineN-acetyl aspartate
C. Choline:total creatine
**D. N-acetyl aspartate: total creatine **
E. MyoinositolN-acetyl aspartate
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, neoplasms are
usually associated with decreases in NAA and elevations in
choline and myoinositol (and lactate); total creatine is
largely constant. The ratio of NAA to total creatine is thus
deCl’eased, whereas the ratios in A, B, C, and E are all
increased with CNS neoplasms (Castillo et aI., pp. 1- 5 )
An 8-year-old female presented with symptoms of persistent headaches, nausea , and emesis for 1 week. The patient
was somewhat lethargic and was noted to have a mild left
hemiparesis on examination. A’(ial contrasted Tl-weighted
MRI (Figure S.8Q) illustrates what abnormality?
A. Pilocytic astrocytoma
B. Subependymoma
C. Choroid plexus papilloma
D. Hemangioblastoma
E. .Medulloblastoma
A. Pilocytic astrocytoma
B. Subependymoma
C. Choroid plexus papilloma
D. Hemangioblastoma
**E. .Medulloblastoma **
Medulloblastomas are aggressive, primitive neuroectodermal tumors that occur primarily in the pediatric
population. lVledulloblastomas 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. OnMRI, 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. Sub ependymomas 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 (Osborn ON, pp. 613-618).
‘Which of the following features is usually NOT observed
with oligodendrogliomas on MRI ?
A. Calcihca tion
B. Hemorrhage
C. Cystic
D. Heterogenous signal on Tl-weightecl images
E. Intense homogenous enhancement
A. Calcihca tion
B. Hemorrhage
C. Cystic
D. Heterogenous signal on Tl-weightecl images
E. Intense homogenous enhancement
Oligodendrogliomas generally exhibit mLxed signal
intensity on Tl-weighted images and hyperintensity on
T2-weighted images with mild heterogenous enhancement.
These lesions exhibit calcification 70 to 90% of the time, are
often associated with cysts, and frequently have evidence of
chronic hemorrhage (Osborn ON, pp. 564-566).
Which of the following characteristics is NOT observed
in tuberous sclerosis (Bourneville disease) ?
A. Autosomal recessive inheritance pattern
B. Cortical hamartomas
C. Subepenclymal giant cell astrocytoma
D. Cardiac rhabdomyomas
E. iVlental retardation
**A. Autosomal recessive inheritance pattern **
B. Cortical hamartomas
C. Subepenclymal giant cell astrocytoma
D. Cardiac rhabdomyomas
E. iVlental retardation
Tuberous sclerosis (TS) is an autosomal dominant
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 (Osborn ON, pp. 93- 98).
What is the appropriate management of the lesion depicted
in this lateral internal carotid angiogram (Figure S.l1Q)?
A. Repeat angiography in 6 to 12 months
B. Oral anticoagulation
C. No further treatment is required
D. Urgent surgical treatment
E. Follow up MRA in 6 to 12 months
A. Repeat angiography in 6 to 12 months
B. Oral anticoagulation
C. No further treatment is required
**D. Urgent surgical treatment **
E. Follow up MRA in 6 to 12 months
This angiogram illustrates a dural arteriovenous
fistula (DA VF) with prominent retrograde cortical venous
drainage. lVlost DA VFs originate from the transverse and sigmoid sinuses along the skull base, although the cavernous
sinus is also frequently involved. The presence of retrograde
cortical venous drainage places the patient at significant
risk for subarachnoid hemorrhage, and mandates treatment.
The treatment of DAVF usually consists of preoperative
embolization followed by surgical obliteration of the nidus.
Successful treatment entails disconnection of 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
(Osborn ON, pp. 301- 306).
Which of the following locations is typically NOT
involved with diffuse axonal injuries?
A. Brainstem
B. Deep white matter
C. Cerebellum
D. Corpus callosum
E. Thalamus
A. Brainstem
B. Deep white matter
**C. Cerebellum **
D. Corpus callosum
E. Thalamus
Diffuse 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 (Osborn ON, pp. 212-214)
A 12-year-old male presented with partial complex
seizures. The patient was neurologically intact. MRl revealed
a cystic right mesial temporal lobe lesion that is hYPoil1tense
to brain on T1-weighted images and hyperintense on T2-
weighted images, with mild rim enhancement. The most
likely diagnosis is which of the following?
A. Ganglioglioma
B. Pleomorphic xanthoastrocytoma
C. Pilocytic astrocytoma
D. Germinoma
E. Glioblastoma
**A. Ganglioglioma **
B. Pleomorphic xanthoastrocytoma
C. Pilocytic astrocytoma
D. Germinoma
E. Glioblastoma
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 (Osborn ON,
pp. 580-581).
Match the following MR imaging characteristics
with the appropriate intracranial hematoma . Some letters
may be used once, more than once, or not at all.
Extracellular methemoglobin
A. Hyperacute (up to 4 to 6 hours)
B. Acute (7 to 72 hours)
C. Early subacute (4-7 days)
D. Late subacute (1 to 4 weeks)
E. Early chronic (weeks to months)
F. Late chronic (months to years)
A. Hyperacute (up to 4 to 6 hours)
B. Acute (7 to 72 hours)
C. Early subacute (4-7 days)
**D. Late subacute (1 to 4 weeks) **
E. Early chronic (weeks to months)
F. Late chronic (months to years)
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 Tl-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
Match the following MR imaging characteristics
with the appropriate intracranial hematoma . Some letters
may be used once, more than once, or not at all.
Oxyhemoglobin
A. Hyperacute (up to 4 to 6 hours)
B. Acute (7 to 72 hours)
C. Early subacute (4-7 days)
D. Late subacute (1 to 4 weeks)
E. Early chronic (weeks to months)
F. Late chronic (months to years)
**A. Hyperacute (up to 4 to 6 hours) **
B. Acute (7 to 72 hours)
C. Early subacute (4-7 days)
D. Late subacute (1 to 4 weeks)
E. Early chronic (weeks to months)
F. Late chronic (months to years)
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 Tl-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
Match the following MR imaging characteristics
with the appropriate intracranial hematoma . Some letters
may be used once, more than once, or not at all.
Isointense on T1, hypointense on ‘1’2
A. Hyperacute (up to 4 to 6 hours)
B. Acute (7 to 72 hours)
C. Early subacute (4-7 days)
D. Late subacute (1 to 4 weeks)
E. Early chronic (weeks to months)
F. Late chronic (months to years)
A. Hyperacute (up to 4 to 6 hours)
**B. Acute (7 to 72 hours) **
C. Early subacute (4-7 days)
D. Late subacute (1 to 4 weeks)
E. Early chronic (weeks to months)
F. Late chronic (months to years)
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 Tl-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
Match the following MR imaging characteristics
with the appropriate intracranial hematoma . Some letters
may be used once, more than once, or not at all.
Deoxyhemoglobin, echinocytes
A. Hyperacute (up to 4 to 6 hours)
B. Acute (7 to 72 hours)
C. Early subacute (4-7 days)
D. Late subacute (1 to 4 weeks)
E. Early chronic (weeks to months)
F. Late chronic (months to years)
A. Hyperacute (up to 4 to 6 hours)
**B. Acute (7 to 72 hours) **
C. Early subacute (4-7 days)
D. Late subacute (1 to 4 weeks)
E. Early chronic (weeks to months)
F. Late chronic (months to years)
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 Tl-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
Match the following MR imaging characteristics
with the appropriate intracranial hematoma . Some letters
may be used once, more than once, or not at all.
Hyperintense on T1, hYPointense on T2
A. Hyperacute (up to 4 to 6 hours)
B. Acute (7 to 72 hours)
C. Early subacute (4-7 days)
D. Late subacute (1 to 4 weeks)
E. Early chronic (weeks to months)
F. Late chronic (months to years)
A. Hyperacute (up to 4 to 6 hours)
B. Acute (7 to 72 hours)
**C. Early subacute (4-7 days) **
D. Late subacute (1 to 4 weeks)
E. Early chronic (weeks to months)
F. Late chronic (months to years)
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 Tl-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
Match the following MR imaging characteristics
with the appropriate intracranial hematoma . Some letters
may be used once, more than once, or not at all.
Isointense on ‘1’1, hyperintense on T2
A. Hyperacute (up to 4 to 6 hours)
B. Acute (7 to 72 hours)
C. Early subacute (4-7 days)
D. Late subacute (1 to 4 weeks)
E. Early chronic (weeks to months)
F. Late chronic (months to years)
**A. Hyperacute (up to 4 to 6 hours) **
B. Acute (7 to 72 hours)
C. Early subacute (4-7 days)
D. Late subacute (1 to 4 weeks)
E. Early chronic (weeks to months)
F. Late chronic (months to years)
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 Tl-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
Match the following MR imaging characteristics
with the appropriate intracranial hematoma . Some letters
may be used once, more than once, or not at all.
Intracellular methemoglobin
A. Hyperacute (up to 4 to 6 hours)
B. Acute (7 to 72 hours)
C. Early subacute (4-7 days)
D. Late subacute (1 to 4 weeks)
E. Early chronic (weeks to months)
F. Late chronic (months to years)
A. Hyperacute (up to 4 to 6 hours)
B. Acute (7 to 72 hours)
**C. Early subacute (4-7 days) **
D. Late subacute (1 to 4 weeks)
E. Early chronic (weeks to months)
F. Late chronic (months to years)
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 Tl-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
A 38-year-old male presented with a 2-day history of
severe headache, photophobia, and emesis. On examination,
the patient was neurologically intact. The patient’s CT scan
is pictured below (Figure S.21Q). Which of the following is
NOT necessary in the management of this entity?
A. Angiography
B. Cardiac monitoring
C. Monitoring of electrolytes
D. Hyperdynamic therapy
E. Monitoring for hydrocephalus
A. Angiography
B. Cardiac monitoring
C. Monitoring of electrolytes
**D. Hyperdynamic therapy **
E. Monitoring for hydrocephalus
This CT 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
(Greenberg, pp. 793- 795).
What abnormality is depicted in this a.xial T2-weighted
MRI?
A. Oligodendroglioma
B. Capillary telangiectasia
C. Cavernous malformation
D. Venous angioma
E. Choriocarcinoma
A. Oligodendroglioma
B. Capillary telangiectasia
**C. Cavernous malformation **
D. Venous angioma
E. Choriocarcinoma
Cavernous malformations are circumscribed, multilobulated vascular lesions that often exhibit hemorrhage in
various stages of evolution. The center of a cavernoma frequently contains a mLxed-signal region Imown 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 cavernousmalformations. Although oligodendrogliomas and choriocarcinoma can exhibit hemorrhage, the presence of a reticulated core and surrounding hemosiderin rim is more
consistent with a cavernoma (Osborn ON, pp. 311-313).
A 44-year-old male presented with a cutaneous melanoma. After local resection and radiation therapy, the patient
underwent a CT scan of the chest/abdomen/pelvis, nuclear
bone scan, and lumbar puncture for systemic staging. The
patient had no evidence of systemic metastases and his
CSF cytology was negative . The patient presented 2 weeks
later with new-onset frontal headaches that were exacerbated
with ambulation. The patient underwent an MRI of the brain;
a contrasted axial Tl-weighted image is illustrated below
(Figure 5.23Q). What would be the most appropriate next
step in management of this disorder?
A. Meningeal biopsy
B. Repeat lumbar puncture
C. Epidural blood patch
D. Cerebral angiography
E. None of the above
A. Meningeal biopsy
B. Repeat lumbar puncture
**C. Epidural blood patch **
D. Cerebral angiography
E. None of the above
This patient’s symptoms consist largely of postural
headaches that occurred shortly after a lumbar puncture.
The patient’s MRl 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 MRl; 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 (Greenberg, pp. 63-64;
Zaatreh et aI., pp. 1342-1346).
What is the vessel (arrow) on this lateral internal carotid
angiogram (Figure S.24Q) commonly associated with?
1. Tentorial meningioma
2. Venous angioma
3. Dural arteriovenous fistula
4. Choroid plexus papilloma
A. 1,2, and 3 are correct
B. 1 and 3 are correct
C. 2 and 4 are correct
D. Only 4 is correct
E. All of the above are correct
A. 1,2, and 3 are correct
**B. 1 and 3 are correct **
C. 2 and 4 are correct
D. Only 4 is correct
E. All of the above are correct
The tentorial artery is a branch of the meningohypophyseal artery of the cavernous segment of the internal
carotid artery; it is also Imown 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 (Will~ins, pp. 911, 918-919).
What abnormality is depicted on this axial T2-weighted
MR scan?
A. Herniated disc fragment
B. Neurofibroma
C. Synovial cyst
D. Osteochondroma
E. Neurenteric cyst
A. Herniated disc fragment
B. Neurofibroma
**C. Synovial cyst **
D. Osteochondroma
E. Neurenteric cyst
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 (Osborn ON, pp. 843-
845).
~Which of the following characteristics is NOT associated
with the disorder illustrated in this sagittal T2-weighted MRI?
A. Highest prevalence in the Japanese population
B. 70% of all cases involve the cervical spine
C. Commonly presents with progressive myelopathy
D. C5 radiculopathy is a common complication of anterior surgical approaches
E. COl11monly identified on plain spinal x-rays
A. Highest prevalence in the Japanese population
B. 70% of all cases involve the cervical spine
C. Commonly presents with progressive myelopathy
D. C5 radiculopathy is a common complication of anterior surgical approaches
E. Commonly identified on plain spinal x-rays
This i’vIRI depicts ossification of the posterior longitudinalligament (OPLL). OPLL occurs in 0.12% of all North
Americans, and 2.4% of all Japanese and accounts for 27% of
all cases of cervical myelopathy in Japan. OPLL involves the
cervical spine in 70% of cases and the thoracic (lS%) and
lumbar (lS%) regions less frequently . OPLL is more common
in men and usually presents in the fifth to sLxth decade with
symptoms of progressive myelopathy. OPLL cannot be visualized with plain spinal x-rays; rdRl or CT myelography is required to demonstrate the pathology and cord compression.
Complications of anterior cervical decompression for OPLL
include worsening myelopathy, durotomy, and radiculopathy. Postoperative CS radiculopathy has been reported in
up to 17% of all patients undergOing anterior decompressive
procedures for OPLL. Posterior decompressions, with or without concomitant fusion, have also been utilized in the
treatment of OPLL, with variable success rates (Osborn ON,
p. 848; Will~ins, pp. 3783- 3786)
A 55-year-old female presented with the acute onset of a
mild right hemiparesis. What neoplasm is depicted in the following enhanced Tl-weighted MRI?
A. CNS lymphoma
B. Tera toma
C. Oligodendroglioma
D. Glioblastoma l11ultiforme
E. Melanoma
A. CNS lymphoma
B. Tera toma
C. Oligodendroglioma
**D. Glioblastoma l11ultiforme **
E. Melanoma
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 ‘II-weighted images with surrounding “ring enhancement” and prominent peritumoral edema. GBM 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 i’vIRI. j’v1etastases, however, are most commonly
located at the gray-white junction. Oligodendrogliomas
usually exhibit heterogenous signal patterns on ‘II-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 ‘II-weighted images
with variable enhancement patterns. The ring enhancement,
prominent peri tumoral edema, demographics, and the acute
onset of a focal neurologic deficit are most consistent with a
GBM (Osborn ON, pp. 541- 544, 563-566, 620-622).
Which of the following characteristics is NOT associated
with the abnormality depicted in the following CT scan?
A. Most commonly presents with headaches
B. ~-rost commonly hyperdense on CT scan
C. Most commonly hyperintense to cortex on Tl-weighted
MRl
D. Derived from ectoderm
E. Does not exhibit malignant degeneration
A. Most commonly presents with headaches
B. ~-rost commonly hyperdense on CT scan
C. Most commonly hyperintense to cortex on Tl-weighted
MRl
D. Derived from ectoderm
E. Does not exhibit malignant degeneration
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 ‘II-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 present with intermittent or chronic headaches.
Vertigo, memory loss, diplopia, and even sudden death
can also occur with these lesions (Osborn ON, pp. 642-
645).
What abnormality is depicted in the following enhanced
Tl-weighted MRl?
A. Ependymoma
B. Meningioma
C. Pilocytic astrocytoma
D. Central neurocytoma
E. Choroid plexus papilloma
A. Ependymoma
B. Meningioma
C. Pilocytic astrocytoma
**D. Central neurocytoma **
E. Choroid plexus papilloma
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 ‘II-weighted
images and iso- to hyperintense on T2-weighted images, with
minimal to mild heterogenous enhancement patterns.
Supratentorial ependymomas are generally extraventricular
and exhibit prominent enhancement. Additionally, choroid
plexus papillomas and intraventricular meningiomas also
exhibit prominent enhancement on MRI. Intraventricular
pilocytic astrocytomas are generally cystic lesions that
exhibit heterogenous enhancement. The presence of an intraventricular mass adjacent to the septum pellucidum
that is isointense to surrounding brain on ‘II-weighted
MRI without enhancement is most consistent with a central
neurocytoma (Osborn ON, pp. 570, 582-584)
An 18-year-old male presented with a 6-month history of
progressiv~ occipital headaches and local scalp tenderness
and edema. What abnormality is depicted in this patient’s
unenhanced axial CT scan?
A. Giant ceU tumor
B. Osteoid osteoma
C. Eosinophilic granuloma
D. Aneurysmal bone cyst
E. Osteosarcoma
A. Giant ceU tumor
B. Osteoid osteoma
C. Eosinophilic granuloma
**D. Aneurysmal bone cyst **
E. Osteosarcoma
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 (Osborn ON, pp. 881, 884-885).
Match the labeled region on the following axial
T2-weighted MRl (Figure S.Jl- S.J4Q) with the corresponding cortical structure. Letters may be used more than once or
not at all.
Primary motor cortex
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
anterior to the pars marginalis (E). The precentral gyrus (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
(Naidich et al., pp. 313- 338).
Match the labeled region on the following axial
T2-weighted MRl (Figure S.Jl- S.J4Q) with the corresponding cortical structure. Letters may be used more than once or
not at all.
Postcentral sulcus
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
anterior to the pars marginalis (E). The precentral gyrus (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
(Naidich et al., pp. 313- 338).
Match the labeled region on the following axial
T2-weighted MRl (Figure S.Jl- S.J4Q) with the corresponding cortical structure. Letters may be used more than once or
not at all.
Central sulcus
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
anterior to the pars marginalis (E). The precentral gyrus (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
(Naidich et al., pp. 313- 338).
Match the labeled region on the following axial
T2-weighted MRl (Figure S.Jl- S.J4Q) with the corresponding cortical structure. Letters may be used more than once or
not at all.
Superior frontal sulcus
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
anterior to the pars marginalis (E). The precentral gyrus (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
(Naidich et al., pp. 313- 338).
Which of the following disorders is exhibited in this axial
contrasted TI-weighted MRI?
A. Sturge-\Veber syndrome
B. Tuberous sclerosis
C. Wyburn-Mason syndrome
D. Laurence-Moon-Biedl syndrome
E. Neurofibromatosis type 1
**A. Sturge-\Veber syndrome **
B. Tuberous sclerosis
C. Wyburn-Mason syndrome
D. Laurence-Moon-Biedl syndrome
E. Neurofibromatosis type 1
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 thin-walled
capillaries and venules along the convexity of the ipsilateral
cerebral hemisphere. Sturge-Weber syndrome (SWS) has a
predilection for involving the parietal and occipital regions,
and is associated with prominent gyral calcification (“tramtrack” pattern), progressive cortical atrophy, ipsilateral
calvarial thickening, enlargement of the paranasal sinuses,
and prominent subependymal veins. On MRI, S’VS often
exhibits prominent enhancement of the pial angioma and
subependymal veins of the involved hemisphere, as depicted
here (Osborn ON, pp. 98-103).
Which of the following abnormalities is depicted in this
left carotid artery AP angiogram?
A. Acute embolic occlusion
B. Arterial dissection
C. Dural arteriovenous malformation
D. Moyamoya
E. Vasculitis
A. Acute embolic occlusion
B. Arterial dissection
C. Dural arteriovenous malformation
**D. Moyamoya **
E. Vasculitis
Moyamoya (idiopathic progressive arteriopathy of
childhood) is a progressive cerebrovascular disease that
results in the progressive stenosis/occlusion of the distal
internal carotid arteries and proximal segments of the anterior and middle cerebral arteries. JV1oyamoya usually presents with signs of progressive cerebral ischemia, although hemorrhagic variants can also occur. The angiographic
hallmarks of moyamoya include stenoses and occlusions
of the distal ICA and proximal ACA/lvICA, along with the
development of prominent leptomeningeal coll aterals and
enlarged lenticulostriate arteries, which resembles a “puff of
smoke.” (Osborn ON, pp. 371-372).
Which of the following conditions is NOT associated with
regional hypometabolism with fluorine-IS deoxyglucose
(FOG) positron emissions tomography (PET) imaging?
A. Epileptic foci
B. Radiation necrosis
C. Glioblastoma multiforme
D. Fibrillary astrocytoma
E. None of the above
A. Epileptic foci
B. Radiation necrosis
**C. Glioblastoma multiforme **
D. Fibrillary astrocytoma
E. None of the above
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 (Juhasz
et aI., pp. 705- 716).
A premature infant exhibited infantile spasms shortly
after admission to the neonatal intensive care unit. The
patient’s T2-weighted MRl (Figure 5.38Q) depicts what
abnormality?
A. Cortical dysplasia
B. Bilateral porencephaly
C. Holoprosencephaly
D. Congenital cytomegalovirus infection
E. Hydranencephaly
A. Cortical dysplasia
B. Bilateral porencephaly
C. Holoprosencephaly
**D. Congenital cytomegalovirus infection **
E. Hydranencephaly
Congenital cytomegalovirus (CMV) infection usually
results in premature delivery and is associated with seizures,
mental retardation , hydrocephalus, hearing loss, and optic
atl’Ophy. MRI characteristics of congenital CMV infection
include encephalomalacia, ventriculomegaly, calcifications
of the periventricular and basal ganglia, delayed myelination,
and subependymal paraventricular cysts. CMV is considered
one of the TORCH agents, along with toxoplasmosis, rubella,
and herpes. The above T2-weighted image illustrates pl’Ominent bilateral basal ganglia calcifications (hypointense),
ventriculomegaly, and encephalomalacia (Osborn ON,
pp.674- 675).
'’hat is the approximate age of the hematoma depicted
below on this nonenhanced axial Tl-weighted MRl?
A. Hyperacute
B. Acute
C. Early subacute
D. Late subacute
E. Chronic
A. Hyperacute
B. Acute
**C. Early subacute **
D. Late subacute
E. Chronic
See Table 5.14-5.20A. Subacute hematomas initially
consist largely of intracellular methemoglobin , which results
in hyperintensity on T1-weighted images. This hyperintense
signal is largely peripheral with early subacute hematomas
and gradually progresses toward the isointense 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
(Osborn ON, pp. 166- 167).
A lS-year-old male presented with headaches and
polyuria. Contrasted sagittal Tl-weighted MRI (Figure S.40Q)
depicts what disorder?
A. Histiocytosis X
B. Lipoma
C. Germinoma
D. Hypothalamic glioma
E. Pineo blastoma
A. Histiocytosis X
B. Lipoma
**C. Germinoma **
D. Hypothalamic glioma
E. Pineo blastoma
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. Genninomas are usually
isointense on both T1- and T2-weighted sequences, and they
exhibit intense, homogenous enhancement. Germinomas
rarely occur off 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 (Osborn ON, pp. 476,
607-610).
What abnormality is depicted on the following lateral
internal carotid artery angiogram?
A. Arteriovenous malformation
B. Primary angiitis of the CNS
C. Cavernous malformation
D. Embolic stroke
E. Ivloyamoya
A. Arteriovenous malformation
B. Primary angiitis of the CNS
C. Cavernous malformation
**D. Embolic stroke **
E. Ivloyamoya
Embolic strokes often exhibit an abrupt vessel cutoff
on angiography, with occasional wedge-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 (Osborn
DCA, pp. 383- 388).
A 35-year-old male with a history of AIDS presented with
altered mental status and low-grade fever. Contrasted [Lx ial
TI-weighted MRI (Figure 5.42Q) depicts what abnormality?
A. CNS lymphoma
B. Progressive multifoca lleulwencephalopathy
C. Cryptococcoma
D. Tuberculoma
E. Toxoplasmosis
A. CNS lymphoma
B. Progressive multifoca lleulwencephalopathy
C. Cryptococcoma
D. Tuberculoma
**E. Toxoplasmosis **
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 hypointense on T1-weigbted 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 commonly observed with cryptococcomas, tuberculomas, or lymphoma
(Osborn ON, pp. 698- 700)
A 4-month-old neonate presented with mac rocephaly.
Axial unenhanced CT scan (Figure 5.43Q) depicts what
abnormality ?
A. Pineoblastoma
B. Vein of Ga le n malformation
C. Sinus pericranii
D. Cavernous malformation
E. Teratoma
A. Pineoblastoma
**B. Vein of Ga le n malformation **
C. Sinus pericranii
D. Cavernous malformation
E. Teratoma
Vein of Galen malformations (VOGM) often present
in neonates with macrocephaly, hydrocephalus, and highoutput congestive heart failure . VOGMs 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 MRl, respectively. Germinomas rarely occur in
the neonatal population (Osborn ON , pp. 320- 323, 612).
What abnormality is depicted on the following unenhanced sagittal Tl-weighted MRI?
A. Pituitary adenoma
B. Rathke’s cleft cyst
C. ~I’Ieningioma
D. Chordoma
E. Fibrous dysplasia
A. Pituitary adenoma
B. Rathke’s cleft cyst
C. ~I’Ieningioma
**D. Chordoma **
E. Fibrous dysplasia
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 a re 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 (Osborn ON, pp. 887- 890).
An 8-week-old infant presented with a palpable scalp
mass. What lesion is depicted in the following plain slmll film?
A. Cephalhematoma
B. Dermoid
C. Eosinophilic granuloma
D. Osteochondroma
E. Aneurysmal bone cyst
**A. Cephalhematoma **
B. Dermoid
C. Eosinophilic granuloma
D. Osteochondroma
E. Aneurysmal bone cyst
Cephalhematomas generally result from hemorrhage between the skull and the overlying periosteum at
delivery. Cephalhematomas are initially 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 radiograph 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 nonsclel’Otic
margins surrounding a lytic lesion involving the inner and
outer tables (Osborn ON, p. 516; Will<ins, pp. 2739-2740).
The following axial contrasted Tl-weighted MRI is located at the L3-4 disc space (Figure 5.46Q). What structure
is most likely to be affected by the abnormality depic ted in
this MRI ?
A. L3 nerve root
B. L4 nerve root
C. Both of the above
D. Neither of the above
**A. L3 nerve root **
B. L4 nerve root
C. Both of the above
D. Neither of the above
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 (Greenberg, p. 304).
Match the following locations and demographic
information with the most likely involved primary CNS neoplasm. Letters may be L1 sed more than once or not at all.
Pineal region, 15-year-old male
A. Pilocytic astrocytoma
B. Schwannoma
C. Pineo blastoma
D. Germinoma
E. Meningioma
F. Choroid plexus papilloma
G. Ivied LIllo bIas toma
H. I-Iemangioblastoma
I. None of the above
A. Pilocytic astrocytoma
B. Schwannoma
C. Pineo blastoma
**D. Germinoma **
E. Meningioma
F. Choroid plexus papilloma
G. Ivied LIllo bIas toma
H. I-Iemangioblastoma
I. None of the above
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 (Osborn ON, pp. 412,
429-430,434- 436,441,607- 608).
Match the following locations and demographic
information with the most likely involved primary CNS neoplasm. Letters may be L1 sed more than once or not at all.
Cerebellum, 58-year-old fema le
A. Pilocytic astrocytoma
B. Schwannoma
C. Pineo blastoma
D. Germinoma
E. Meningioma
F. Choroid plexus papilloma
G. Ivied LIllo bIas toma
H. I-Iemangioblastoma
I. None of the above
A. Pilocytic astrocytoma
B. Schwannoma
C. Pineo blastoma
D. Germinoma
E. Meningioma
F. Choroid plexus papilloma
G. Ivied LIllo bIas toma
**H. I-Iemangioblastoma **
I. None of the above
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 (Osborn ON, pp. 412,
429-430,434- 436,441,607- 608).
Match the following locations and demographic
information with the most likely involved primary CNS neoplasm. Letters may be L1 sed more than once or not at all.
Cerebellopontine angle , 42-year-old female
A. Pilocytic astrocytoma
B. Schwannoma
C. Pineo blastoma
D. Germinoma
E. Meningioma
F. Choroid plexus papilloma
G. Ivied LIllo bIas toma
H. I-Iemangioblastoma
I. None of the above
A. Pilocytic astrocytoma
**B. Schwannoma **
C. Pineo blastoma
D. Germinoma
E. Meningioma
F. Choroid plexus papilloma
G. Ivied LIllo bIas toma
H. I-Iemangioblastoma
I. None of the above
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 (Osborn ON, pp. 412,
429-430,434- 436,441,607- 608).
Match the following locations and demographic
information with the most likely involved primary CNS neoplasm. Letters may be L1 sed more than once or not at all.
Posterior fossa, 12-year-old male
A. Pilocytic astrocytoma
B. Schwannoma
C. Pineo blastoma
D. Germinoma
E. Meningioma
F. Choroid plexus papilloma
G. Ivied LIllo bIas toma
H. I-Iemangioblastoma
I. None of the above
**A. Pilocytic astrocytoma **
B. Schwannoma
C. Pineo blastoma
D. Germinoma
E. Meningioma
F. Choroid plexus papilloma
G. Ivied LIllo bIas toma
H. I-Iemangioblastoma
I. None of the above
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 (Osborn ON, pp. 412,
429-430,434- 436,441,607- 608).
Match the following locations and demographic
information with the most likely involved primary CNS neoplasm. Letters may be L1 sed more than once or not at all.
Atrium, 8-year-old male
A. Pilocytic astrocytoma
B. Schwannoma
C. Pineo blastoma
D. Germinoma
E. Meningioma
F. Choroid plexus papilloma
G. Ivied LIllo bIas toma
H. I-Iemangioblastoma
I. None of the above
A. Pilocytic astrocytoma
B. Schwannoma
C. Pineo blastoma
D. Germinoma
E. Meningioma
**F. Choroid plexus papilloma **
G. Ivied LIllo bIas toma
H. I-Iemangioblastoma
I. None of the above
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 (Osborn ON, pp. 412,
429-430,434- 436,441,607- 608).
What is the approximate age of the following hematoma
on this noncontrasted axial CT scan?
A. Hyperacute
B. Acute
C. Early subacute
D. Late subacute
E. Chronic
A. Hyperacute
B. Acute
C. Early subacute
D. Late subacute
E. Chronic
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 lmown as the
“swirl sign.” The lack of clear fluid-fluid levels and clot
density helps eliminate subacute and chronic hematomas
(Osborn ON, pp. 158-160).
Which of the following characteristics is NOT associated
with the disorder depicted in this lateral thoracic spine
radiograph?
A. Craniocervical instability
B. More common in young males
C. Pathologic fractures
D. HLAD15
E. Sacroiliitis
A. Craniocervical instability
B. More common in young males
C. Pathologic fractures
**D. HLAD15 **
E. Sacroiliitis
Ankylosing spondylitis Uvlarie-Strtimpell 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 (Osborn ON, p. 849;
Merritt, p. 884).
What is the most likely histologic appearance of the neoplasm depicted in the following sagittal T2-weightec1 MRl?
A. Small blue cells with prominent mitoses and necrosis
B. Whorls of cells with intermingled fascicular arrangements
C. Elongated cells with prominent cytoplasmic processes
and minimal pleomorphism
D. Clusters of cuboidal cells separated by a prominent
mucoid matrb::
E. Lipid-containing cells within a dense network of vascular channels
A. Small blue cells with prominent mitoses and necrosis
B. Whorls of cells with intermingled fascicular arrangements
C. Elongated cells with prominent cytoplasmic processes
and minimal pleomorphism
D. Clusters of cuboidal cells separated by a prominent
mucoid matrb::
E. Lipid-containing cells within a dense network of vascular channels
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 clusters
of cuboidal cells with occasional hyalinized blood vessels
among a prominent mucoid matrix (Osborn ON , pp. 906-
909).
What is depicted in this noncontrasted axial Tl-weighted
MRI (Figure S.SSQ)? The lesion did not exhibit enhancement with the administration of gadolinium.
A. Pituitary adenoma
B. Craniopharyngioma
C. Lipoma
D. Rathke’s cleft cyst
E. Histiocytosis X
A. Pituitary adenoma
B. Craniopharyngioma
C. Lipoma
**D. Rathke’s cleft cyst **
E. Histiocytosis X
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 intrasellar
and suprasellar components. The appearance of RCC on j’dRI
is variable, but they are usually hyperintense to cortex on
Tl- 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 (Osborn ON, pp. 645-646).
What abnormality is depicted on the following axial
T2-weighted MRI?
A. Arteriovenous malformation
B. Oligodendroglioma
C. Cavernous malformation
D. J’,’Iultiple sclerosis plaque
E. Hemangioblastoma
**A. Arteriovenous malformation **
B. Oligodendroglioma
C. Cavernous malformation
D. J’,’Iultiple sclerosis plaque
E. Hemangioblastoma
Arteriovenous malformations (AVj’l’ls) exhibit prominent flow voids on T2-weighted images with minimal observable intervening brain tissue and prominent enhancement.
A V.Ms 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 lack of significant intranidal brain parenchyma
helps distinguish A V.Ms from vascular tumors (Osborn ON,
pp. 294- 298).
A 48-year-old female presented with headaches, nausea,
and ataxia. The contrasted axial Tl-weighted MRI below
(Figu re S.S7Q) depicts what abnormality?
A. Pilocytic astrocytoma
B. Choroid plexus papilloma
C. Hemangioblastoma
D. Metastatic lesion
E. Ga nglioglioma
A. Pilocytic astrocytoma
B. Choroid plexus papilloma
**C. Hemangioblastoma **
D. Metastatic lesion
E. Ga nglioglioma
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 Hippel-Lindau
syndrome. Hemangioblastomas usually exhibit a cyst that
is hypointense on Tl-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 they 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 (Osborn ON, pp. 555, 574, 605-607).
What lesion is depicted in the following AP cervical spine
radiograph?
A. Eosinophilic granuloma
B. Osteoblastoma
C. Osteoid osteoma
D. Osteosarcorna
E. Osteochondroma
A. Eosinophilic granuloma
B. Osteoblastoma
C. Osteoid osteoma
D. Osteosarcorna
E. Osteochondroma
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.
Osteoblastortla 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 aggressive lesion associated with prominent surrounding bony destluction/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 (Osborn ON, pp. 879-883).
A 5-year-old male presented with generalized seizures
and developmental delay. \That abnormality is depicted on
the patient’s axial T2-weighted MRI?
A. Pachygyria
B. Lobar holoprosencephaly
C. Tuberous sclerosis
D. Nodular heterotopia
E. Septo-optic dysplasia
A. Pachygyria
B. Lobar holoprosencephaly
C. Tuberous sclerosis
**D. Nodular heterotopia **
E. Septo-optic dysplasia
Nodular heterotopias 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 (Osborn ON,
pp.42-51).
Which of the following imaging abnormalities is NOT
associated with neurofibromatosis type I?
A. Optic nerve gliomas
B. Basal ganglia hamartomas
C. Thoracic meningoceles
D. Spinal schwanl10mas
E. Posterior vertebral body scalloping
A. Optic nerve gliomas
B. Basal ganglia hamartomas
C. Thoracic meningoceles
**D. Spinal schwanl10mas **
E. Posterior vertebral body scalloping
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 (Kaye and Laws, pp. 71- 72;
Osborn ON, pp. 73-84).
A 21-year-old female with a prior 2-week history of
nasal congestion and frontal headaches presents with fever,
leukocytosis, and confusion. Based on the patient’s axial
contrasted T1-weighted IvIRI (Figure 5.61Q), what is the
appropriate next step in the management of this condition?
A. Administration of broad-spectrum IV antibiotics
B. Administration of IV steroids
C. Lumbar puncture
D. Emergent surgical evacuation
E. ICU observation with repeat CT scan in 24 hours
A. Administration of broad-spectrum IV antibiotics
B. Administration of IV steroids
C. Lumbar puncture
**D. Emergent surgical evacuation **
E. ICU observation with repeat CT scan in 24 hours
The patient’s MRI 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 ICU observation, however, most authorities
advocate early surgical drainage in all cases (Greenberg,
pp. 223-225; Osborn ON, pp. 684-686).
Which of the following disorders is associated with multiple intracranial arteriovenous malformations, often involving the visual pathways and the mesencephalon?
A. Wyburn-]\,lason syndrome
B. Meningioangiomatosis
C. Blue rubber bleb nevus syndrome
D. Sturge-Weber syndrome
E. None of the above
**A. Wyburn-]\,lason syndrome **
B. Meningioangiomatosis
C. Blue rubber bleb nevus syndrome
D. Sturge-Weber syndrome
E. None of the above
\Vyburn-Mason syndrome is a neurocutaneous syndrome that is characterized by the presence of multiple
in tracranial A VMs, cutaneous va cular 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 \VyburnJ’vIason syndrome or Rendu-Osler-\Veber syndrome (hereditary hemorrhagic telangiectasia). Involvement of the optic
pathways and mesencephalon, however, is more characteristic of Wyburn-Mason syndrome. Meningioangiomatosis is
a rare neurocutaneous disorder that is characterized by
prominent fibroblastic proliferation along the meninges and
Virchow-Robin spaces. Blue rubber bleb nevus syndrome is
also a rare neurocutaneous disorder that is characterized
by vascular malformations of the skin, 01 tract, and CNS.
The CNS manifestations of blue rubber bleb nevus syndrome
include the development of hemangiomas, sinus pericranii,
and venous angiomas. True AVj<Is are not observed with this
disorder (Osborn ON, pp. 106-109,287).
Which of the following characteristics is NOT associated
with the disorder depicted in the following CT myelogram?
A. Tethered cord
B. I<lippel-Feil syndrome
C. Chiari I malformation
D. Scoliosis
E. Spina bifida
A. Tethered cord
B. I<lippel-Feil syndrome
C. Chiari I malformation
D. Scoliosis
E. Spina bifida
Diastematomyelia (split-cord malformation) is characterized by the presence of two hemicords in a sillgle 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 Sl.
Diastematomyelia is associated with Chiari II malformations, hemivertebrae, intersegmental laminar fusion, spina
bifida, scoliosis, tethered cord, and narrowed disc spaces
(Osborn ON, pp. 811- 813).
\Vhich of the following neurologic symptoms would a
patient with the following noncontrasted CT scan (Figure
5.64Q) be most likely to exhibit?
A. Confusion and lethargy
**B. Left hemiparesis **
C. Right homonymous hemianopsia
D. Bilateral temporal hemianopsia
E. Receptive aphasia
A. Confusion and lethargy
**B. Left hemiparesis **
C. Right homonymous hemianopsia
D. Bilateral temporal hemianopsia
E. Receptive aphasia
This noncontrasted CT scan exhibits prominent
intraluminal thrombus within the right IvrCA, which is
known as the “hyperdense MCA sign.” This CT scan was
obtained approximately 4 hours after symptom onset, which
consisted of a moderate left hemiparesis and hemisensory
loss (Osborn ON, pp. 344-345).
What is the most likely etiology of the lesion demonstrated in the following lateral internal carotid angiogram
(mid arterial phase)?
A. Trauma
B. Congenital
C. Infection
D. Dissection
E. Atherosclerosis
A. Trauma
B. Congenital
C. Infection
D. Dissection
E. Atherosclerosis
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 (lCA) or along the fab>: (A2 segment of
the ACA) (Osborn ON, pp. 271-273).
Which of the following disorders is NOT typically associated with agenesis of the corpus callosum
A. Holoprosencephaly
B. Aicardi syndrome
C. Dandy-Walker malformation
D. IGippel-Feil syndrome
E. Trisomy 13
A. Holoprosencephaly
B. Aicardi syndrome
C. Dandy-Walker malformation
**D. IGippel-Feil syndrome **
E. Trisomy 13
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, 15, and 18. Agenesis of the corpus callosum is
not typically associated with IGippel-Feil syndrome (Osborn
ON, pp. 29- 32).
‘Vhich of the following characteristics is commonly
observed on plain skull films in patients with Sturge-Weber
syndrome?
1. Thickened calvarium
2. Enlarged frontal sinus
3. “Tram-track” calcifications
4. Elevation of the petrous temporal bone
A. 1,2, and3 are correct
B. 1 and3 are correct
C. 2 and4 are correct
D. Only 4 is correct
E. All of the above are correct
A. 1,2, and3 are correct
B. 1 and3 are correct
C. 2 and4 are correct
D. Only 4 is correct
E. All of the above are correct
. Skull films in patients with Sturge-Weber syndrome
often exhibit prominent gyral (“tram-track”) calCifications,
and secondary signs of cortical hemiatrophy (thick calvarhU11, elevated petrous temporal bone, enlarged frontal sinus)
(Osborn ON, pp. 98-99).
All of the following are true about basilar impression (El)
EXCEPT?
A. Most common acquired anomaly of the craniocervical
junction
B. Often accompanied by Down’s syndrome, IGippel-Feil
syndrome, and Chiari malformation
C. Characterized by upward displacement of foramen
magnum margins (occipital bone) and cervical spine
(odontoid process) into the posterior fossa
D. McRae’s line can help make the diagnosis
E. May be seen after trauma
**A. Most common acquired anomaly of the craniocervical
junction **
B. Often accompanied by Down’s syndrome, IGippel-Feil
syndrome, and Chiari malformation
C. Characterized by upward displacement of foramen
magnum margins (occipital bone) and cervical spine
(odontoid process) into the posterior fossa
D. McRae’s line can help make the diagnosis
E. May be seen after trauma
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 BI as the upward displacement of the odontoid
process only. It may be associated with Down’s syndrome,
IGippel-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 clivus to opisthion
(should be > 19 mm, average 35 mm). No part of the odontoid should be above this line (most accurate for BI) (Greenberg,
pp.570- 571).
Which of the following spinal neoplasms is typically
found in an intradural-extramedullary location?
1. Neurofibroma
2. Ganglioneuroma
3. Schwannoma
4. Ependymoma
A. 1,2, and 3 are correct
B. 1 and 3 are correct
C. 2 and 4 are correct
D. Only 4 is correct
E. All of the above are correct
**A. 1,2, and 3 are correct **
B. 1 and 3 are correct
C. 2 and 4 are correct
D. Only 4 is correct
E. All of the above are correct
Schwannomas, neurofibromas, ganglioneuromas,
paragangliomas, meningiomas, and neurofibrosarcomas of
the spine are typically intradural extramedullary lesions.
Ependymomas, astrocytomas, and hemangioblastomas are
typically intramedullary lesions (Osborn ON, pp. 895-899).
Match the sellar lesion with the appropriate
imaging characteristic using each answer either once, more
than once, or not at all.
Hypointense on T1-weighted images
A. Pituitary macroadenoma
B. Rathl(e’s cleft cyst
C. Both of the above
D. None of the above
A. Pituitary macroadenoma
B. Rathl(e’s cleft cyst
C. Both of the above
D. None of the above
Pituitary macroadenomas are
generally isointense to gray matter on all MRl sequences,
with intense, heterogenous enhancement. Microadenomas
generally exhibit less rapid enhancement than the surrounding normal pituitary gland, which renders them hypointense
on contrasted T1-weighted MRl. Mixed-density pituitary
adenomas often exhibit hemorrhage, cyst formation , or
necrosis; however, calcifica tion is rare. Rathke’s cleft cysts
are most commonly hyperintense on T1-weighted and ‘1’2-
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 (Osborn ON, pp. 645-646, 650-652).
What is the mechanism of injury in the following spine
fracture (axial CT scan)?
A. Fracture-dislocation
B. A;’(ial compression
C. Flexion-distraction
D. Hyperextension
E. None of the above
A. Fracture-dislocation
**B. A;’(ial compression **
C. Flexion-distraction
D. Hyperextension
E. None of the above
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
concomitant neurologic deficits (Will<ins, pp. 2987- 2989).
What is the most likely etiology for the abnormality
depicted in the following axial FLAIR Mill?
A. Embolic
B. Metabolic
C. Congenital
D. Hypoxic
E. Infectious
A. Embolic
B. Metabolic
C. Congenital
**D. Hypoxic **
E. Infectious
Hypoxic injury often involves the basal ganglia (caudate and lentiform nuclei), as depicted on this Lxi l FLAIR
MRI (Osborn ON, pp. 355-360).
What intramedullary neoplasm is illustrated in this early
arterial phase vertebra l artery angiogram?
A. Astrocytoma
B. Ependymoma
C. Hemangioblastoma
D. Meningioma
E. None of the above
A. Astrocytoma
B. Ependymoma
**C. Hemangioblastoma **
D. Meningioma
E. None of the above
Hemangioblastomas are highly vascular lesions that
exhibit prominent, prolonged tumor blushes on angiography
with large draining veins (Osborn ON, p. 915).
What neoplasm is depicted on this external carotid
angiogram (midarterial phase)?
A. Astrocytoma
B. Choroid plexus papilloma
C. I-lemangioblastoma
D. Meningioma
E. Central neurocytoma
A. Astrocytoma
B. Choroid plexus papilloma
C. I-lemangioblastoma
**D. Meningioma **
E. Central neurocytoma
Meningiomas are generally vascular, dural-based
tumors that receive their blood supply solely from meningeal
vessels. Convexity and parasagittal meningiomas (as depicted here) are usually fed by an enlarged anterior falcine
or middle meningeal artery in a radial (“sunburst”) pattern.
Occasionally large meningiomas also receive blood supply
from pial vessels (dual vascular supply) (Osborn ON, pp. 589-
590).
Which of the following characteristics is NOT associated
with the disorder depicted in this lateral skull radiograph?
A. Craniosynostosis
B. Syndactyly
C. Mental retardation
D. Autosomal dominant inheritance pattern
E. Ptosis
A. Craniosynostosis
B. Syndactyly
**C. Mental retardation **
D. Autosomal dominant inheritance pattern
E. Ptosis
Saethre-Chotzen syndrome is one of the acrocephalosyndactyly syndromes and is an autosomal dominant disorder that is characterized by early fusion of
the cranial sutures, often in an asymmetric fashion, low-set
hairline, syndactyly, brachydactyly, ptosis, and septal deviations. This plain skull x-ray illustrates the typical “cotton
beaten” skull that is characteristic of the syndrome. Patients
with Saethre-Chotzen syndrome generally exhibit normal
IQs (Wm<ins, pp. 3432, 3694).
\Vhat is the most common management of the
lesion depicted in the following 3D CT reconstruction?
A. Surgical resection
B. Focused radiation
C. Chemotherapy
D. IV steroids
E. Observation
A. Surgical resection
B. Focused radiation
C. Chemotherapy
D. IV steroids
E. Observation
Parietal foramina are normally 1 to 2 mm in diameter
and contain emissary veins. Occasionally, these foramina
are larger and are covered by fibrous tissue that is continuous with the pericranium. The majority of parietal foramina
are incidental findings that require no treatment. Cranioplasty
is reserved for large foramina that persist beyond the ages of
3 to 4 years (Wilkins, p. 3570).
What abnormality is depicted in the following lateral
carotid angiogram (midarterial phase)?
A. High-grade astrocytoma
B. Hemangioblastoma
C. Arteriovenous malformation
D. Cavernous malformation
E. Venous angioma
A. High-grade astrocytoma
B. Hemangioblastoma
**C. Arteriovenous malformation **
D. Cavernous malformation
E. Venous angioma
Arteriovenous malformations of the parenchyma
usually appear as focal collections of arterial feeders with
tortuous draining veins on angiography. The angiographic
hallmark of AVMs is ea rly filling of draining veins during the
arterial phases of the study. Venous stenosis or occlusions
are occasionally observed adjacent to the A VM nidus.
Cavernous malformations are generally angiographically
occult, and venous angiomas exhibit radial medullary veins
located around an enlarged transcortical draining vein
(“caput medusae”). Occasionally vascular, high-grade neoplasms can exhibit early draining veins as well, although
the focal collection of multiple arterial feeders without
intervening tissue on imaging studies is more consistent with
anAVM (Osborn ON, pp. 287- 291).
A 72-year-old man presented with bitemporal hemianopsia. The following contrasted Tl-weighted MIU exhibits what
abnormality?
A. Pituitary adenoma
B. Craniopharyngioma
C. Rathke’s cleft cyst
D. Pilocytic astrocytoma
E. Metastatic tumor
**A. Pituitary adenoma **
B. Craniopharyngioma
C. Rathke’s cleft cyst
D. Pilocytic astrocytoma
E. Metastatic tumor
Pituitary macroadenomas are generally isointense
to surrounding brain on all sequences and exhibit
prominent, heterogenous enhancement with contrast.
Craniopharyngiomas are most commonly hypointense on
T1-weighted images and hyperintense on T2-weighted images, with heterogenous enhancement. Craniopharyngiomas
are often cystic and calcified and usually present in children.
A smaller proportion of craniopharyngiomas present in the
fifth to sLxth decades of life. The signal of craniopharyngiomas on T1-weighted images is often heterogenous; they
are suprasellar lesions that often exhibit extension into
the sella. This Il’1Rl exhibits a homogenous, predominantly
intrasellar isointense mass with suprasellar extension, sellar
expansion, and heterogenous enhancement. These MRl
findings in a 72-year-old are most consistent with a pituitary
adenoma (Osborn ON, pp. 649-657).
What is the inheritance pattern of the disorder depicted
in the following nonenhanced axial Tl-weighted MRl?
A. Autosomal dominant
B. Autosomal recessive
C. X-linked
D. Sporadic
E. Mi tochondrial
**A. Autosomal dominant **
B. Autosomal recessive
C. X-linked
D. Sporadic
E. Mi tochondrial
This MRl exhibits hypoplasia of the left sphenoid
wing, with concomitant herniation of the temporal lobe
into the orbit. This is characteristic of NF-1, which is
inherited in an autosomal dominant fashion (Osborn ON,
pp.82- 83).
What abnormality is depicted on this cervical internal
carotid angiogram (Figure S.BSQ)?
A. Arterial dissection
B. Takayasu’s arteritis
C. Marfan’s syndrome
D. Fibromuscular dysplasia
E. None of the above
A. Arterial dissection
B. Takayasu’s arteritis
C. Marfan’s syndrome
**D. Fibromuscular dysplasia **
E. None of the above
Fibromuscular dysplasia (FMD) is a disorder that
commonly involves medium-sized arteries, particularly the
cervical carotid, vertebral, and renal arteries. FMD usually
presents in women between the fourth to sL–.::th decades with
symptoms of ischemia, transient ischemic attacks, or even
subarachnoid hemorrhage (increased incidence of intracranial aneurysms). The classic angiographic appearance of
FMD is alternating regions of stenosis and dilatation (“string
of beads”), as depicted in this angiogram. Catheter-induced
vasospasm can occasionally mimic the angiographic appearance of FMD (Osborn DCA, pp. 341-346).
What neoplasm is depicted on the following contrasted Tl-weighted MRl in an asymptomatic adillt male ?
A. Choroid plexus papilloma
B. Ependymoma
C. Subependymoma
D. Astrocytoma
E. Meningioma
A. Choroid plexus papilloma
B. Ependymoma
C. Subependymoma
D. Astrocytoma
E. Meningioma
The most common neoplasms to occur at the trigone
in adults are intraventricular meningiomas, lymphoma, and
metastases. The most common trigonal mass in children
is the choroid plexus papilloma, although ependymomas
and astrocytomas are also observed at this location in
this population. This MRl exhibits a homogenously enhancing intraventricular meningioma. Approximately 2% of
all meningiomas arise within the ventricles, and these
lesions are thought to originate from the tela choroidea
or choroid plexus stromal cells (Osborn ON, pp. 429- 430,
588).
What abnormality is depicted on the following noncontrasted Tl-weighted MRl?
A. Multiple sclerosis plaque
B. Acute infarct
C. Chronic infarct
D. Astrocytoma
E. None of the above
A. Multiple sclerosis plaque
B. Acute infarct
**C. Chronic infarct **
D. Astrocytoma
E. None of the above
This MRl exhibits a focal region of encephalomalacia
in the distribution of the left middle cerebral artery.
Ipsilateral ventricular dilatation accompanies the temporal
lobe atrophy. It is this prominent lack of mass effect that
helps distinguish a chronic infarct from a neoplasm or an
acute infarction (Osborn ON, pp. 353-354).
A 54-year-old male with diabetes mellitus presented with
complaints of progressive lower back pain. The patient’s neurologic exam was nonnal, and his sagittal T2-weighted Mill
is depicted below. What is the most IH,ely etiology of this
patient’s kyphotic deformity?
A. Isthmic spondylolisthesis
B. Discitis/osteomyelitis
C. Rheumatoid arthritis
D. Intervertebral disc herniation
E. None of the above
A. Isthmic spondylolisthesis
**B. Discitis/osteomyelitis **
C. Rheumatoid arthritis
D. Intervertebral disc herniation
E. None of the above
The patient’s .MRl demonstrates obliteration of the
T12-L1 disc space secondary to a prior history of discitis.
The patient has subsequently developed a kyphotic deformity at this level. This patient’s history of diabetes mellitus
makes the diagnosis of discitis more likely (Osborn ON,
pp. 820-821).
A 38-year-old male experienced transient left upper
extremity sensory changes after a motor vehicle collision.
A CT scan of the head was umemarkable. The patient’s
right internal carotid angiogram (AP view) is exhibited
below (Figure 5.95Q). What is the appropriate next step in
management?
A. Endovascular treatment
B. Anticoagulation
C. Antiplatelet agents
D. Surgical intervention
E. Repeat angiography in 2 to 3 months
A. Endovascular treatment
**B. Anticoagulation **
C. Antiplatelet agents
D. Surgical intervention
E. Repeat angiography in 2 to 3 months
The patient experienced a transient ischemic attack
after blunt injury to the neck and was found to have a pseudoaneurysm of the internal carotid artery on angiograph secondary to blunt dissection. The most appropriate
initial treatment of this lesion is systemic anticoagulation,
initially with heparin and subsequently with warfarin
(CouIlladin). Endovascular treatment is reasonable if the
lesion does not resolve with systemic anticoagulation;
however, this should not be the initial treatment modality
of choice. ‘ Acute pseudoaneurysms are unstable lesions
and the wall of these structures often contains subintima.
This makes stent deployment more dangerous in the acute
setting. Repeat angiography should be performed; however, the initial treatment entails systemic anticoagulation.
Antiplatelet agents should be reserved for patients who have
undergone endovascular stent placement or those in whom
systemic anticoagulation is contraindicated (Osborn DCA,
pp. 410- 411).
A 47-year-old female presents to your office with the MRl
(axial view) exhibited below (Figure S.96Q). What is the
likely diagnosis?
A. Posterior fossa arachnoid cyst
B. Arterial-venous malformation
C. Trigeminal neuralgia
D. Hemifacial spasm
E. Multiple sclerosis
A. Posterior fossa arachnoid cyst
B. Arterial-venous malformation
**C. Trigeminal neuralgia **
D. Hemifacial spasm
E. Multiple sclerosis
It can be very difficult to visualize impingement on
cranial nerve V with imaging studies, although on this axial
MRI there is a clear discrepancy in the appearance of the
trigeminal nerves bilaterally. The fifth cranial nerve is well
illustrated on the left (large arrow), whereas on the right, it is
being pushed medially by what appears to be a blood vessel,
as suggested by the flow voids (smaller arrow). II’lost patients
being evaluated for trigeminal neuralgia do not require imaging studies to confirm a diagnosis, as most patients typically
present with paroxysmal lancinating pain, often triggered by
sensory stimuli, confined to the distribution of one or more
branches of the trigeminal nerve , with no neurologic deficit.
(Greenberg, pp. 373-380).
Match each of the following stages of abscess
formation with the appropriate imaging and/or histologic
characteristics, using each answer once, more than once, or
not at all.
Well-formed collagen capsule and gliotic layer around
abscess
A. Early cerebritis
B. Late cerebritis
C. Early capsule
D. Late capsule
E. None of the above
A. Early cerebritis
B. Late cerebritis
C. Early capsule
**D. Late capsule **
E. None of the above
Match each of the following stages of abscess
formation with the appropriate imaging and/or histologic
characteristics, using each answer once, more than once, or
not at all.
Ring enhancement usually appears by this stag
A. Early cerebritis
B. Late cerebritis
C. Early capsule
D. Late capsule
E. None of the above
A. Early cerebritis
**B. Late cerebritis **
C. Early capsule
D. Late capsule
E. None of the above
Match each of the following stages of abscess
formation with the appropriate imaging and/or histologic
characteristics, using each answer once, more than once, or
not at all.
Inflammatory response poorly demarcated, toxic changes
in neurons, perivascular infiltrates
A. Early cerebritis
B. Late cerebritis
C. Early capsule
D. Late capsule
E. None of the above
**A. Early cerebritis **
B. Late cerebritis
C. Early capsule
D. Late capsule
E. None of the above
Match each of the following stages of abscess
formation with the appropriate imaging and/or histologic
characteristics, using each answer once, more than once, or
not at all.
Neovascularity, necrotic center, reticular matrLx, and
capsule less well developed alongside ventricle
A. Early cerebritis
B. Late cerebritis
C. Early capsule
D. Late capsule
E. None of the above
A. Early cerebritis
B. Late cerebritis
**C. Early capsule **
D. Late capsule
E. None of the above
This is a coronal CTscan through
the right orbit. Match the anatomic structures with the corresponding letterhead using each answer once.
Optic nerve
B
This coronal CT of the face
depicts the anatomy of the right globe as well as the adjacent
paranasal sinuses. Of note, the levator palpebrae superioris muscle (A), innervated by the oculomotor nerve (CN III),
originates superiorly to the annulus tendineus, inserts into
the tarsal plate of the superior eyelid, and acts to draw the
eyelid upward when the eyeball is elevated. Additionally, the
muscles most frequently involved in thyroid ophthalmopathy are the inferior (E) and medial (D) recti. Other muscles
of the globe include the superior rectus (G), lateral rectus
(F), superior oblique (C), and inferior oblique (not shown)
(Grant, p. 491; Adams, p. 1134; April , pp. 460- 462).
This is a coronal CTscan through
the right orbit. Match the anatomic structures with the corresponding letterhead using each answer once.
Levator palpebrae superioris muscle
A
This coronal CT of the face
depicts the anatomy of the right globe as well as the adjacent
paranasal sinuses. Of note, the levator palpebrae superioris muscle (A), innervated by the oculomotor nerve (CN III),
originates superiorly to the annulus tendineus, inserts into
the tarsal plate of the superior eyelid, and acts to draw the
eyelid upward when the eyeball is elevated. Additionally, the
muscles most frequently involved in thyroid ophthalmopathy are the inferior (E) and medial (D) recti. Other muscles
of the globe include the superior rectus (G), lateral rectus
(F), superior oblique (C), and inferior oblique (not shown)
(Grant, p. 491; Adams, p. 1134; April , pp. 460- 462).
This is a coronal CTscan through
the right orbit. Match the anatomic structures with the corresponding letterhead using each answer once.
Superior oblique muscle
C
This coronal CT of the face
depicts the anatomy of the right globe as well as the adjacent
paranasal sinuses. Of note, the levator palpebrae superioris muscle (A), innervated by the oculomotor nerve (CN III),
originates superiorly to the annulus tendineus, inserts into
the tarsal plate of the superior eyelid, and acts to draw the
eyelid upward when the eyeball is elevated. Additionally, the
muscles most frequently involved in thyroid ophthalmopathy are the inferior (E) and medial (D) recti. Other muscles
of the globe include the superior rectus (G), lateral rectus
(F), superior oblique (C), and inferior oblique (not shown)
(Grant, p. 491; Adams, p. 1134; April , pp. 460- 462).
This is a coronal CTscan through
the right orbit. Match the anatomic structures with the corresponding letterhead using each answer once.
Inferior rectus muscle
E
This coronal CT of the face
depicts the anatomy of the right globe as well as the adjacent
paranasal sinuses. Of note, the levator palpebrae superioris muscle (A), innervated by the oculomotor nerve (CN III),
originates superiorly to the annulus tendineus, inserts into
the tarsal plate of the superior eyelid, and acts to draw the
eyelid upward when the eyeball is elevated. Additionally, the
muscles most frequently involved in thyroid ophthalmopathy are the inferior (E) and medial (D) recti. Other muscles
of the globe include the superior rectus (G), lateral rectus
(F), superior oblique (C), and inferior oblique (not shown)
(Grant, p. 491; Adams, p. 1134; April , pp. 460- 462).
This is a coronal CTscan through
the right orbit. Match the anatomic structures with the corresponding letterhead using each answer once.
Superior rectus muscle
G
This coronal CT of the face
depicts the anatomy of the right globe as well as the adjacent
paranasal sinuses. Of note, the levator palpebrae superioris muscle (A), innervated by the oculomotor nerve (CN III),
originates superiorly to the annulus tendineus, inserts into
the tarsal plate of the superior eyelid, and acts to draw the
eyelid upward when the eyeball is elevated. Additionally, the
muscles most frequently involved in thyroid ophthalmopathy are the inferior (E) and medial (D) recti. Other muscles
of the globe include the superior rectus (G), lateral rectus
(F), superior oblique (C), and inferior oblique (not shown)
(Grant, p. 491; Adams, p. 1134; April , pp. 460- 462).
A 42-year-old mY-positive male presented to the
emergency department with a 3-week history of headaches
and confusion. His postcontrast J<IRl scan is depicted below
(Figure S.106-S.107Q). What is the most likely diagnosis?
A. Cryptococcal abscess
B. Toxoplasmosis
C. Lymphoma
D. Progressive multifocalleukoencephalopathy (PML)
E. HIVencephalopathy
A. Cryptococcal abscess
B. Toxoplasmosis
**C. Lymphoma **
D. Progressive multifocalleukoencephalopathy (PML)
E. HIVencephalopathy
Note the homogeneously enhancing lesions
involving the periventricular region in this patient with
primary CNS lymphoma (PCNSL, CD20, and CD79a positive). PCNSL represents approximately 1% of intracranial
neoplasms in immunocompetent patients and has been
described in up to 50% of AIDS patients. The precise role
of Epstein-Barr virus (EBV) in the pathogenesis of PCNSL
remains unclear, although many authors have reported
that between 5 and 38% of PCNSL tumors contained
EBV in immunocompetent patients, while up to 100% of
tumors in AIDS-related patients contained the EBV virus
(Greenberg, pp. 231-234, 238, 441-444; Kaye and Laws,
pp. 915- 927).
A 42-year-old mY-positive male presented to the
emergency department with a 3-week history of headaches
and confusion. His postcontrast J<IRl scan is depicted below
(Figure S.106-S.107Q). What microbial agent is most often associated with this
lesion?
A. Herpes simplex virus
B. JC virus
C. Epstein-Barr virus
D. Treponema paUidwn
E. Toxoplasmagondii
A. Herpes simplex virus
B. JC virus
**C. Epstein-Barr virus **
D. Treponema paUidwn
E. Toxoplasmagondii
Note the homogeneously enhancing lesions
involving the periventricular region in this patient with
primary CNS lymphoma (PCNSL, CD20, and CD79a positive). PCNSL represents approximately 1% of intracranial
neoplasms in immunocompetent patients and has been
described in up to 50% of AIDS patients. The precise role
of Epstein-Barr virus (EBV) in the pathogenesis of PCNSL
remains unclear, although many authors have reported
that between 5 and 38% of PCNSL tumors contained
EBV in immunocompetent patients, while up to 100% of
tumors in AIDS-related patients contained the EBV virus
(Greenberg, pp. 231-234, 238, 441-444; Kaye and Laws,
pp. 915- 927).
A 34-year-old male presents with increasing neck and
back pain, quadriparesis, and bowel and bladder incontinence. His MRl is depicted below (Figure S.108-S.111Q).
These lesions most likely represent
A. Spinal ependymomas
B. Spinal schwannomas
C. Spinal neurofibromas
D. Spinal meningiomas
E. Metastatic disease
A. Spinal ependymomas
B. Spinal schwannomas
**C. Spinal neurofibromas **
D. Spinal meningiomas
E. Metastatic disease
Note the multiple spinal neurofibromas with concomitant enlarged neural foramina on this
contrasted, sagittal MRI depicting a patient with NF-1 (autosomal dominant inheritance). Plexiform neurofibromas are
diagnostic of NF-1, and they occur in approximately 33% of
cases. Bilateral acoustic neuromas are the hallmark of NF-2
(Greenberg, pp. 476- 478; Ramsey, pp. 225- 229).
A 34-year-old male presents with increasing neck and
back pain, quadriparesis, and bowel and bladder incontinence. His MRl is depicted below (Figure S.108-S.111Q).
What is the diagnosis?
A. Sturge-\Veber syndrome
B. Neurofibromatosis type I (NF-l)
C. Neurofibroma tosis type II (NF-2)
D. Metastatic prostate cancer
E. Disseminated medulloblastoma
A. Sturge-\Veber syndrome
**B. Neurofibromatosis type I (NF-l) **
C. Neurofibroma tosis type II (NF-2)
D. Metastatic prostate cancer
E. Disseminated medulloblastoma
Note the multiple spinal neurofibromas with concomitant enlarged neural foramina on this
contrasted, sagittal MRI depicting a patient with NF-1 (autosomal dominant inheritance). Plexiform neurofibromas are
diagnostic of NF-1, and they occur in approximately 33% of
cases. Bilateral acoustic neuromas are the hallmark of NF-2
(Greenberg, pp. 476- 478; Ramsey, pp. 225- 229).
A 34-year-old male presents with increasing neck and
back pain, quadriparesis, and bowel and bladder incontinence. His MRl is depicted below (Figure S.108-S.111Q).
Diagnostic criteria for this condition may include all of
the following EXCEPT?
A. SLx or more cafe-au-lait spots each > 5 mm in greatest
diameter in prepubertal individuals, or > 15 mm in
greatest diameter in postpubertal patients
B. Two or more Lisch nodules
C. Two or more neurofibromas of any type or one plexiform neurofibroma
D. Sphenoid dysplasia
E. Bilateral acoustic neuromas
A. SLx or more cafe-au-lait spots each > 5 mm in greatest
diameter in prepubertal individuals, or > 15 mm in
greatest diameter in postpubertal patients
B. Two or more Lisch nodules
C. Two or more neurofibromas of any type or one plexiform neurofibroma
D. Sphenoid dysplasia
**E. Bilateral acoustic neuromas **
Note the multiple spinal neurofibromas with concomitant enlarged neural foramina on this
contrasted, sagittal MRI depicting a patient with NF-1 (autosomal dominant inheritance). Plexiform neurofibromas are
diagnostic of NF-1, and they occur in approximately 33% of
cases. Bilateral acoustic neuromas are the hallmark of NF-2
(Greenberg, pp. 476- 478; Ramsey, pp. 225- 229).
A 34-year-old male presents with increasing neck and
back pain, quadriparesis, and bowel and bladder incontinence. His MRl is depicted below (Figure S.108-S.111Q).
What is the inheritance pattern?
A. Autosomal recessive
B. Autosomal dominant
C. X-linked recessive
D. X-Hnked dominant
E. Pleiotropic mitochondrial disorder
A. Autosomal recessive
**B. Autosomal dominant **
C. X-linked recessive
D. X-Hnked dominant
E. Pleiotropic mitochondrial disorder
Note the multiple spinal neurofibromas with concomitant enlarged neural foramina on this
contrasted, sagittal MRI depicting a patient with NF-1 (autosomal dominant inheritance). Plexiform neurofibromas are
diagnostic of NF-1, and they occur in approximately 33% of
cases. Bilateral acoustic neuromas are the hallmark of NF-2
(Greenberg, pp. 476- 478; Ramsey, pp. 225- 229).
What is depicted on the gradient echo i’vlRI sequence
below (Figure 5.112-5.114Q)?
A. AmylOid hemorrhage
B. Cavernous malformation
C. Capillary telangiectasia
D. lvletastatic tumor with hemorrhage
E. Hemangioblastoma
A. AmylOid hemorrhage
**B. Cavernous malformation **
C. Capillary telangiectasia
D. lvletastatic tumor with hemorrhage
E. Hemangioblastoma
This gradient echo MR sequence demonstrates a multilobulated lesion with a “popcornlike” pattern
of high signal intensity, which is most consistent with a
cavernoma. The etiology/pathogenesis of this lesion is uncertain, although in some cases it has been shown to arise
de novo adjacent to a venous malformation. Multiple lesions
are more common in patients of Hispanic origin and have
been linked to a mutation in a gene on chromosome 7q.
Isolated cavernomas are associated with venous malformations in 30 to 50% of cases. Angiography is usually negative,
although a subtle vascular blush may occur in a small number of cases (Ramsey, pp. 272- 276).
This lesion may be associated with all of the following
EXCEPT which?
A. Venous malformation
B. 0.5% incidence
C. Multiplicity
D. Mutation in a gene on chromosome 7q
E. Erythropoietin secretion
A. Venous malformation
B. 0.5% incidence
C. Multiplicity
D. Mutation in a gene on chromosome 7q
**E. Erythropoietin secretion **
This gradient echo MR sequence demonstrates a multilobulated lesion with a “popcornlike” pattern
of high signal intensity, which is most consistent with a
cavernoma. The etiology/pathogenesis of this lesion is uncertain, although in some cases it has been shown to arise
de novo adjacent to a venous malformation. Multiple lesions
are more common in patients of Hispanic origin and have
been linked to a mutation in a gene on chromosome 7q.
Isolated cavernomas are associated with venous malformations in 30 to 50% of cases. Angiography is usually negative,
although a subtle vascular blush may occur in a small number of cases (Ramsey, pp. 272- 276).
Angiographic findings may include
A. Vascular blush
B. Associated aneurysm
C. External carotid artery collaterals supplying this lesion
D. An early draining vein
E. All of the above
**A. Vascular blush **
B. Associated aneurysm
C. External carotid artery collaterals supplying this lesion
D. An early draining vein
E. All of the above
This gradient echo MR sequence demonstrates a multilobulated lesion with a “popcornlike” pattern
of high signal intensity, which is most consistent with a
cavernoma. The etiology/pathogenesis of this lesion is uncertain, although in some cases it has been shown to arise
de novo adjacent to a venous malformation. Multiple lesions
are more common in patients of Hispanic origin and have
been linked to a mutation in a gene on chromosome 7q.
Isolated cavernomas are associated with venous malformations in 30 to 50% of cases. Angiography is usually negative,
although a subtle vascular blush may occur in a small number of cases (Ramsey, pp. 272- 276).
What is depicted on the lateral angiogram below?
A. Aneurysm
B. Dural arterial-venous fistula
C. Cavernous malformation
D. Persistent hypoglossal artery
E. Proatlantal intersegmental artery
**A. Aneurysm **
B. Dural arterial-venous fistula
C. Cavernous malformation
D. Persistent hypoglossal artery
E. Proatlantal intersegmental artery
This lateral angiogram demonstrates a PICA
aneurysm between the posterior medullary and supratonsillar (telovelotonsillar) segments of the PICA. The first segment of PICA (anterior medullary) courses posterolaterally
within the medullary cistern at the level of the olivary
nucleus. The second segment (lateral medullary) continues
posteriorly in the cerebellomedullary fissure and loops
caudally for a variable distance along the lateral surface
of the medulla. The third segment (posterior medullary or
tonsillomedullary segment) is formed when the PICA passes
through the fibers of cranial nerves IX, X, and XI to reach the
posterior margin of the medulla and ascend behind the posterior medullary velum. The fourth segment (supratonsillar
or telovelotonsillar) represents the cranial loop of the PICA
as it courses above the cerebellar tonsil. The apex of this loop
is lmown as the choroidal point, and represents the origin of
the aneurysm depicted here. The PICA then turns downward
in the retrotonsillar fissure and terminates by dividing into
the hemispheric and venllian branches. Unlike the proximal
three segments, the distal segments do not give rise to brainstem perforators, a fact that may allow clinicians to sacrifice
the PICA distal to the choroidal point in some specific
instances (Osborn DCA, pp. 176-184; Ramsey, pp. 598-599;
Kaye and Black, pp. 1043-1049).
All of the following may accompany the finding depicted on the I’dRI below (Figure S.116Q) EXCEPT
A. Oroalimentaryautomatisms
B. Epigastric aura
C. Hypermetabolism of the affected temporal lobe on
interictal fluorodeoxyglucose PET scanning
D. Posturing of the contralateral arm
E. History of complicated febrile seizures
A. Oroalimentaryautomatisms
B. Epigastric aura
**C. Hypermetabolism of the affected temporal lobe on
interictal fluorodeoxyglucose PET scanning **
D. Posturing of the contralateral arm
E. History of complicated febrile seizures
Note the increased signal and atrophy of the left
hippocampus compared to the normal appearing right hippocampus on this FLAIR j\,IRI sequence depicting mesial
temporal lobe sclerosis. Although reports indicate a higher
incidence of complicated febrile seizures in patients with
temporal lobe epilepsy and mesial temporal sclerosiS, the
precise etiology remains unclear. There is usually hypometabolism of the affected temporal lobe with interictal
fiuorodeoxyglucose PET scanning (Greenberg, p. 255).
The finding on this CT scan (Figure S.118Q) is most
consistent with
A. Severe closed head injury
B. Neurocysticercosis
C. Child abuse
D. Carbon monoxide poisoning
E. Cryptococcal infection
A. Severe closed head injury
B. Neurocysticercosis
C. Child abuse
**D. Carbon monoxide poisoning **
E. Cryptococcal infection
Note the prominent involvement of the basal ganglia
and adjacent white matter bilaterally on this noncontrasted
CT scan depicting carbon monoxide poisoning (Ramsey,
pp.351-353).
What is the most likely diagnosis depicted on the
diffusion-weighted MRI scan below?
A. Aneurysm
B. Acoustic neuroma
C. Meningioma
D. Epidermoid tumor
E. Arachnoid cyst
A. Aneurysm
B. Acoustic neuroma
C. Meningioma
**D. Epidermoid tumor **
E. Arachnoid cyst
Epidermoids are usually hypointense on Tlweighted imaging, hyperintense on T2-weighted imaging,
and exhibit restricted diffusion (increased signal) on D’\TJ
sequences (as depicted here). Arachnoid cysts are hypointense on DWl sequences. The fatty areas of dermoid
tumors and lipomas will saturate out with fat-suppression
sequences and produce a chemical shift artifact, whereas fat
saturation sequences do not appreciably affect epidermoids
(Ramsey, pp. 118-120)
How would the application of a fat-saturation pulse
during MRI alter the signal characteristics of this lesion?
A. The signal would suppress
B. The signal would remain the same
C. The lesion would show similar characteristics to CSF
D. It would produce increased signal intensity
E. It would result in a chemical shift artifact
A. The signal would suppress
**B. The signal would remain the same **
C. The lesion would show similar characteristics to CSF
D. It would produce increased signal intensity
E. It would result in a chemical shift artifact
Epidermoids are usually hypointense on Tlweighted imaging, hyperintense on T2-weighted imaging,
and exhibit restricted diffusion (increased signal) on D’\TJ
sequences (as depicted here). Arachnoid cysts are hypointense on DWl sequences. The fatty areas of dermoid
tumors and lipomas will saturate out with fat-suppression
sequences and produce a chemical shift artifact, whereas fat
saturation sequences do not appreciably affect epidermoids
(Ramsey, pp. 118-120)
What is depicted in the following contrasted a;’(ial
Tl-weighted MRI?
A. Vestibular schwannoma
B. Duralmetastasis
C. Hemangiopericytoma
D. J-Ieningioma
E. Astrocytoma
A. Vestibular schwannoma
B. Duralmetastasis
C. Hemangiopericytoma
**D. J-Ieningioma **
E. Astrocytoma
This contrasted, axial Tl-weighted MRl depicts
an ovoid lesion centered over the left CPA, which enhances
intensely and homogenously and is most consistent with
a meningioma. Dural metastases are often multiple and
may incite an adjacent inflammatory reaction. Vestibular
schwannomas typically extend into the lAC, have areas
of cyst formation, and often enhance heterogenously.
Hemangiopericytomas cannot be differentiated from meningiomas on neuroimaging alone, but are more scarce then
meningiomas (Ramsey, pp. 115- 117).
What is the diagnosis?
A. Neurofibromatosis type 1 (NF-1)
B. Neurofibromatosis type II (NF-II)
C. Tuberous sclerosis
D. Sturge-Weber syndrome
E. Wyburn-Mason syndrome
A. Neurofibromatosis type 1 (NF-1)
**B. Neurofibromatosis type II (NF-II) **
C. Tuberous sclerosis
D. Sturge-Weber syndrome
E. Wyburn-Mason syndrome
Note the presence of multiple meningiomas on this contrasted Tl-weighted MRI, which is most
consistent with NF-2, an autosomal dominant condition that
results from mutations on chromosome 22 . Multiple intradural spinal cord tumors are also common in this condition
including ependymomas (most common), schwannomas,
and meningiomas. The incidence of NF-2 is 1 per 20,000 to
50,000, while the incidence for NF-l is approximately 1 per
3000 (Greenberg, p. 47).
This disorder most commonly occurs with mutations of
what chromosome?
A. Chromosome 3
B. Chromosome 9
C. Chromosome 16
D. Chromosome 17
E. Chromosome 22
A. Chromosome 3
B. Chromosome 9
C. Chromosome 16
D. Chromosome 17
E. Chromosome 22
Note the presence of multiple meningiomas on this contrasted Tl-weighted MRI, which is most
consistent with NF-2, an autosomal dominant condition that
results from mutations on chromosome 22 . Multiple intradural spinal cord tumors are also common in this condition
including ependymomas (most common), schwannomas,
and meningiomas. The incidence of NF-2 is 1 per 20,000 to
50,000, while the incidence for NF-l is approximately 1 per
3000 (Greenberg, p. 47).
What is the incidence of this condition?
A. 1 per 3000
B. 1 per 10,000
C. 1 per 20,000 to 50,000
D. 1 per 80,000
E. 1 per 100,000
A. 1 per 3000
B. 1 per 10,000
**C. 1 per 20,000 to 50,000 **
D. 1 per 80,000
E. 1 per 100,000
Note the presence of multiple meningiomas on this contrasted Tl-weighted MRI, which is most
consistent with NF-2, an autosomal dominant condition that
results from mutations on chromosome 22 . Multiple intradural spinal cord tumors are also common in this condition
including ependymomas (most common), schwannomas,
and meningiomas. The incidence of NF-2 is 1 per 20,000 to
50,000, while the incidence for NF-l is approximately 1 per
3000 (Greenberg, p. 47).
What is the diagnosis?
A. Retrocerebellar arachnoid cyst
B. Porencephaly
C. Dandy-Walker malformation
D. Mega cisterna magna
E. Chiari III malformation
A. Retrocerebellar arachnoid cyst
B. Porencephaly
C. Dandy-Walker malformation
D. Mega cisterna magna
E. Chiari III malformation
Note the cyst contiguous with the fourth ventricle, the elevation of the torcula, and absence of all cerebellar
tissue in this patient with a Dandy-Walker malformation.
Dandy-Walker malformation is differentiated from other
posterior fossa anomalies such as arachnoid cysts and mega
cisterna magna by the presence of the vermis in these other
anomalies. Cardiac defects are common extra-CNS anomalies seen associated this disorder (Albright, pp. 134-139)
The most common anomalies outside of the CNS occur in what system?
A. Renal
B. Pulmonary
C. Gastrointestinal
D. Endocrine
E. Cardiac
A. Renal
B. Pulmonary
C. Gastrointestinal
D. Endocrine
E. Cardiac
Note the cyst contiguous with the fourth ventricle, the elevation of the torcula, and absence of all cerebellar
tissue in this patient with a Dandy-Walker malformation.
Dandy-Walker malformation is differentiated from other
posterior fossa anomalies such as arachnoid cysts and mega
cisterna magna by the presence of the vermis in these other
anomalies. Cardiac defects are common extra-CNS anomalies seen associated this disorder (Albright, pp. 134-139)
A 28-year-old male presents with right leg weakness
and the sagitta l MRI depicted below
What should be the next diagnostic test performed?
A. Computed tomography (CT)
B. Magnetic resonance angiography (MRA)
C. Myelography
D. Angiography
E. Electromyography
A. Computed tomography (CT)
B. Magnetic resonance angiography (MRA)
C. Myelography
**D. Angiography **
E. Electromyography
Note the presence of multiple flow voids on this
sagittal T2-weighted MRl, which is most consistent with a spinal arteriovenous malformation. The next diagnostic test
performed should be an angiogram for better evaluation of
the region of interest, arterial supply, and venous drainage of
this malformation (Albright, pp. 1071- 1087)
What is the most likely diagnosis?
A. Paraganglioma
B. Ependymoma
C. Cavernoma
D. Arteriovenous malformation
E. Hemangioblastoma
A. Paraganglioma
B. Ependymoma
C. Cavernoma
**D. Arteriovenous malformation **
E. Hemangioblastoma
Note the presence of multiple flow voids on this
sagittal T2-weighted MRl, which is most consistent with a spinal arteriovenous malformation. The next diagnostic test
performed should be an angiogram for better evaluation of
the region of interest, arterial supply, and venous drainage of
this malformation (Albright, pp. 1071- 1087)
What is the diagnosis?
A. Schizencephaly
B. \Tyburn-Mason syndrome
C. Arachnoid cyst
D. Left parietal astrocytoma
E. Porencephaly
A. Schizencephaly
B. \Tyburn-Mason syndrome
C. Arachnoid cyst
D. Left parietal astrocytoma
E. Porencephaly
Note the porencephalic cleft lined predominately by
gliotic white matter (Osborn ON, pp. 54-56)
What is the diagnosis?
A. Chiari I malformation
B. Chiari II malformation
C. Basilar invagination
D. Tuberous sclerosis
E. Pachygyria
**A. Chiari I malformation **
B. Chiari II malformation
C. Basilar invagination
D. Tuberous sclerosis
E. Pachygyria
This sagittal 1I’IRI shows descent of the tonsils
through the foramen magnum without other accompanying
brain malformations, which is most consistent with Chiari I
malformation. Osseous abnormalities may be seen in up to
25% of all patients with Chiari I malformation and include
atlanto-occipital assimilation, platybasia, basilar invagination, and fused cervical vertebrae (Osborn ON , pp. 16-18)
What is the most likely diagnosis (coronal contrasted Tl-weighted MRI) ?
A. Herpes simplex encephalitis
B. Bacterialmeningitis
C. Malignant glioma
D. Coccidioidomycosis
E. Lymphoma
**A. Herpes simplex encephalitis **
B. Bacterialmeningitis
C. Malignant glioma
D. Coccidioidomycosis
E. Lymphoma
Herpes simplex encephalitis (I-ISE) typically results
from infection with herpes simplex virus (I-ISV) 2 in neonates
and HSV 1 in children and adults. Neonatal HSE is a diffuse
encephalitis that is often hemorrhagic and causes significant
morbidity and mortality. I-ISE that is caused by I-ISV 1 is usually a focal infection that involves the limbic system (temporallobes, cingulate gyri, and insular cortex). I-ISE type 1 often
shows subtle low density in the temporal lobes early in the
disease course on CT scans and often exhibits hemorrhage
later in the disease course. On MRI, early I-ISE type 1 exhibits
hyperintensity within the temporal lobe on T2-weighted
images and gyral enhancement on T1-weighted images,
as depicted here. Later in the disease course, contrast
enhancement, subacute hemorrhage, and progressive limbic
system involvement can be observed on MRI (Ramsey,
pp. 157- 160)
What is the most likely
diagnosis?
A. Metastatic disease
B. Multiple sclerosis
C. Multiple lacunar infarcts
D. Canavan’s disease
E. Alexander’s disease
A. Metastatic disease
**B. Multiple sclerosis **
C. Multiple lacunar infarcts
D. Canavan’s disease
E. Alexander’s disease
Note the multiple periventricular white matter
lesions without mass effect in this patient with multiple
sclerosis (Ramsey, pp. 335- 338).
What is the most likely
diagnosis?
A. Odontoid fracture
B. Atlanto-occipital dissociation
C. Hangman’s fracture
D. Condylar fracture
E. Transverse ligament disruption
A. Odontoid fracture
**B. Atlanto-occipital dissociation **
C. Hangman’s fracture
D. Condylar fracture
E. Transverse ligament disruption
Note the longitudinal occipitoatlantal dissociation
with a significant amount of surrounding soft tissue swelling
(Harris, pp. 88-89)
What is the diagnosis ?
A. Sacral lipoma
**B. Meningocele **
C. J’l’lyelomeningocele
D. Lipomyelomeningocele
E. J’dyelocystocele
A. Sacral lipoma
**B. Meningocele **
C. J’l’lyelomeningocele
D. Lipomyelomeningocele
E. J’dyelocystocele
This lumbar meningocele contains prominent
meninges and CSF, but lacks any neural tissue . It is most
often the result of faulty secondary neurulation (4 to 5
weeks) where the notochord and mesodermal elements
induce the formation of dura, pia, vertebrae, and skull
(Osborn ON, pp. 12-13)
This disorder often develops during faulty development
of what embryologic stage?
A. Secondary neurulation
B. Disjunction
C. Ventral induction
D. Neuronal proliferation
E. Cellular migration
**A. Secondary neurulation **
B. Disjunction
C. Ventral induction
D. Neuronal proliferation
E. Cellular migration
This lumbar meningocele contains prominent
meninges and CSF, but lacks any neural tissue . It is most
often the result of faulty secondary neurulation (4 to 5
weeks) where the notochord and mesodermal elements
induce the formation of dura, pia, vertebrae, and skull
(Osborn ON, pp. 12-13)
What is the diagnosis
(axial FLAIRMRl)?
A. Von Hippel-Lindau disease
B. Tuberous sclerosis
C. Sturge-Weber syndrome
D. Multiple metastatic tumors
E. Rendu-Osler-Weber disease
A. Von Hippel-Lindau disease
**B. Tuberous sclerosis **
C. Sturge-Weber syndrome
D. Multiple metastatic tumors
E. Rendu-Osler-Weber disease
Note the presence of multiple regions of
increased signal intensity (cortical tubers) and the presence
of subependymal nodules within the ventricular walls in
this patient with tuberous sclerosis. It is inherited in an autosomal dominant fashion and is frequently associated with
subependymal giant cell astrocytoma (15% of cases) near the
region of the foramen of Monro (Osborn ON, pp. 93-98).
What is the inheritance pattern of this disease ?
A. Autosomal dominant
B. Autosomal recessive
C. X-linked
D. Sporadic
E. Pleiotropic
**A. Autosomal dominant **
B. Autosomal recessive
C. X-linked
D. Sporadic
E. Pleiotropic
Note the presence of multiple regions of
increased signal intensity (cortical tubers) and the presence
of subependymal nodules within the ventricular walls in
this patient with tuberous sclerosis. It is inherited in an autosomal dominant fashion and is frequently associated with
subependymal giant cell astrocytoma (15% of cases) near the
region of the foramen of Monro (Osborn ON, pp. 93-98).
\That is the most common neoplasm associated with
this disorder?
A. Subependymal giant cell astrocytoma
B. Pilocytic astrocytoma of the optic nerve
C. Meningioma
D. Neurofibroma
E. Cutaneous melanoma
**A. Subependymal giant cell astrocytoma **
B. Pilocytic astrocytoma of the optic nerve
C. Meningioma
D. Neurofibroma
E. Cutaneous melanoma
Note the presence of multiple regions of
increased signal intensity (cortical tubers) and the presence
of subependymal nodules within the ventricular walls in
this patient with tuberous sclerosis. It is inherited in an autosomal dominant fashion and is frequently associated with
subependymal giant cell astrocytoma (15% of cases) near the
region of the foramen of Monro (Osborn ON, pp. 93-98).
What is depicted on this la teral angiogram?
A. Atherosclerotic changes
B. Developmental anomaly
C. Traumatic injury
D. Neoplastic process
E. Iatrogenic process
A. Atherosclerotic changes
**B. Developmental anomaly **
C. Traumatic injury
D. Neoplastic process
E. Iatrogenic process
Note the anastomosis between the proximal
cervical ICA and the vertebral artery on this lateral angiOgram, depicting a proatlantal intersegmental artery (Osborn
ON, pp. 65-71)
What should be the next course of treatment?
A. Aspirin therapy and repeat angiogram in 3 months
B. Warfarin therapy with a goal of keeping the INR> 2.0
C. Carotid endarterectomy
D. Carotid stent placement and anticoagulation
E. No treatment
A. Aspirin therapy and repeat angiogram in 3 months
B. Warfarin therapy with a goal of keeping the INR> 2.0
C. Carotid endarterectomy
D. Carotid stent placement and anticoagulation
**E. No treatment **
Note the anastomosis between the proximal
cervical ICA and the vertebral artery on this lateral angiOgram, depicting a proatlantal intersegmental artery (Osborn
ON, pp. 65-71)
What is the diagnosis?
A. Osteomyelitis
B. Hemangioma
C. Eosinophilic granuloma
D. Osteoid osteoma
E . . Metastatic disease
A. Osteomyelitis
**B. Hemangioma **
C. Eosinophilic granuloma
D. Osteoid osteoma
E . . Metastatic disease
Note the classic “polka dot” appearance of this
hemangioma, which is most often an incidental finding that
requires no treatment (Osborn ON, pp. 877-879).
The next course of management should include
A. A serum white blood cell count, sedimentation rate,
andMRI
B. A spinal angiogram
C. CT-guided biopsy
D. Flexion-extension views of spine
E. No further intervention is necessary
A. A serum white blood cell count, sedimentation rate,
andMRI
B. A spinal angiogram
C. CT-guided biopsy
D. Flexion-extension views of spine
E. No further intervention is necessary
Note the classic “polka dot” appearance of this
hemangioma, which is most often an incidental finding that
requires no treatment (Osborn ON, pp. 877-879).
What is the most likely diagnosis in a patient with a long
history of complicated asthma and the unenhanced sagittal
T1-weighted MRI depicted below?
A. Eosinophilic granuloma
B. Burst fracture
C. Epidural hematoma
D. Spinal lipomatosis
E. Osteomyelitis
A. Eosinophilic granuloma
B. Burst fracture
C. Epidural hematoma
**D. Spinal lipomatosis **
E. Osteomyelitis
Note the prominent dOl’sal epidural fat (high signal
intensity) in a patient with epidural lipomatosis and chronic
steroid use for asthma (Osborn ON , pp. 885- 887)
What is the most likely
diagnosis in an 8-year-old male without a history of trauma ?
A. Hemangioma
B. Osteomyelitis
C. Eosinophilic granuloma
D. Giant cell tumor
E. Osteosarcoma
A. Hemangioma
B. Osteomyelitis
**C. Eosinophilic granuloma **
D. Giant cell tumor
E. Osteosarcoma
Eosinophilic granuloma of the spine is most
often seen as a lytic lesion without surrounding sclerosis and
is the classic cause of a Single collapsed vertebral body in
patients between the ages of 5 and 10 years, as depicted
here. Giant cell tumors are highly destructive, lytic masses
in patients between the ages of 20 and 40 years, while
hemangiomas have the characteristic “polka dot” vertebral
body pattern (Osborn ON, pp. 877- 886).
What would be the most likely appearance of this lesion
on an axial CT scan?
A. A lytic lesion without surrounding sclerosis
B. A lytic lesion with surrounding sclerosis
C. An osteolytic lesion surrounded by expanded, thinned,
eggshell-like cortical bone
D. A lytic area surrounding a central area of sclerosis
E. None of the above
**A. A lytic lesion without surrounding sclerosis **
B. A lytic lesion with surrounding sclerosis
C. An osteolytic lesion surrounded by expanded, thinned,
eggshell-like cortical bone
D. A lytic area surrounding a central area of sclerosis
E. None of the above
Eosinophilic granuloma of the spine is most
often seen as a lytic lesion without surrounding sclerosis and
is the classic cause of a Single collapsed vertebral body in
patients between the ages of 5 and 10 years, as depicted
here. Giant cell tumors are highly destructive, lytic masses
in patients between the ages of 20 and 40 years, while
hemangiomas have the characteristic “polka dot” vertebral
body pattern (Osborn ON, pp. 877- 886).
What is the most likely diagnosis?
A. Myelomeningocele
B. Caudal regression syndrome
C. Diastomyelia
D. Spondylosis
E. Spondylolisthesis
A. Myelomeningocele
**B. Caudal regression syndrome **
C. Diastomyelia
D. Spondylosis
E. Spondylolisthesis
Note the absence of the sacrum below S2 on this
lateral plain radiograph depicting caudal regression syndrome, which results from faulty secondary neurulation
(Osborn ON , p. 809).
What is typically the initial treatment for this abnormality?
A. Anticoagulation
B. Superficial temporal artery to middle cerebral artery
bypass
C. High-flow saphenous vein bypass
D. Carotid stenting
E. Carotid endarterectomy
**A. Anticoagulation **
B. Superficial temporal artery to middle cerebral artery
bypass
C. High-flow saphenous vein bypass
D. Carotid stenting
E. Carotid endarterectomy
Note the m’arked narrowing of the proximal
internal carotid artery (distal to the bulb) with a prominent,
elongated, contrast-filled outpouching of the more distal part
of the vessel. This patient has a carotid dissection with pseudoaneurysm formation. Typically, spontaneous dissection
of the cervical carotid artery manifests with symptoms of
headache (most common) and transient ischemic attacks or
strokes. The mainstay of treatment includes anticoagulation,
although carotid artery angioplasty and stenting is a viable
initial treatment option in select patients. Direct surgical
repair is seldom warranted, although surgical options may
include superfiCial temporal artery to middle cerebral artery bypass versus high-flow saphenous vein graft bypass, depending on the intracranial blood flow deficit (Youmans,
pp. 1684- 1686).
What is the diagnosis?
A. Fibromuscular dysplasia
B. Carotid artery dissection and pseudoaneurysl11
formation
C. Tumor encasement of the internal carotid artery
D. Atherosclerotic carotid artery disease
E. None of the above
A. Fibromuscular dysplasia
**B. Carotid artery dissection and pseudoaneurysl11
formation **
C. Tumor encasement of the internal carotid artery
D. Atherosclerotic carotid artery disease
E. None of the above
Note the m’arked narrowing of the proximal
internal carotid artery (distal to the bulb) with a prominent,
elongated, contrast-filled outpouching of the more distal part
of the vessel. This patient has a carotid dissection with pseudoaneurysm formation. Typically, spontaneous dissection
of the cervical carotid artery manifests with symptoms of
headache (most common) and transient ischemic attacks or
strokes. The mainstay of treatment includes anticoagulation,
although carotid artery angioplasty and stenting is a viable
initial treatment option in select patients. Direct surgical
repair is seldom warranted, although surgical options may
include superfiCial temporal artery to middle cerebral artery bypass versus high-flow saphenous vein graft bypass, depending on the intracranial blood flow deficit (Youmans,
pp. 1684- 1686).
What abnormality is depicted on the sagittal MRI below?
A. I<lippel-Feil syndrome
B. Histiocytosis X
C. Basilar invagination
D. Os odontoideuI11
E. None of the above
A. I<lippel-Feil syndrome
B. Histiocytosis X
**C. Basilar invagination **
D. Os odontoideuI11
E. None of the above
Note the upward displacement of the
odontoid process through the foramen magnum in this
patient with Chiari II malformation (basilar invagination).
Another pertinent finding on this MRI is the spinal cord
syrinx, which is partly seen behind the C7 and T1 vertebral
bodies. There are several lines used to evaluate the craniovertebral junction including McRae’s line (line drawn
across the foramen magnum), Chamberlain’s line (line from
posterior hard palate to posterior foramen magnum or
opisthion), McGregor’s line (line from posterior hard palate
to most caudal point of occiput), Wackenheim’s clivuscanal line (line along posterior surface of clivus), Fischgold’s
digastric line (line joining digastric notches), and Fischgold’s
bimastoid line (line joining tips of mastoid process). No part
of the odontoid should be above McRae’s or Wackenheim’s
line, while if more than 6 mm and 4.5 mm of odontoid
lie above Chamberlain’s and i’vlcGregor’s lines, respectively,
a cervicomedullary abnormality is likely to be present
(Will~ins, pp. 3587- 3591).
This abnormality is often associated with all of the
following conditions EXCEPT?
A. Rheumatoid arthritis
B. Chiari malformations
C. Klippel-Feil syndrome
D. Down’s syndrome
E. Dandy-Walker malformation
A. Rheumatoid arthritis
B. Chiari malformations
C. Klippel-Feil syndrome
D. Down’s syndrome
E. Dandy-Walker malformation
Note the upward displacement of the
odontoid process through the foramen magnum in this
patient with Chiari II malformation (basilar invagination).
Another pertinent finding on this MRI is the spinal cord
syrinx, which is partly seen behind the C7 and T1 vertebral
bodies. There are several lines used to evaluate the craniovertebral junction including McRae’s line (line drawn
across the foramen magnum), Chamberlain’s line (line from
posterior hard palate to posterior foramen magnum or
opisthion), McGregor’s line (line from posterior hard palate
to most caudal point of occiput), Wackenheim’s clivuscanal line (line along posterior surface of clivus), Fischgold’s
digastric line (line joining digastric notches), and Fischgold’s
bimastoid line (line joining tips of mastoid process). No part
of the odontoid should be above McRae’s or Wackenheim’s
line, while if more than 6 mm and 4.5 mm of odontoid
lie above Chamberlain’s and i’vlcGregor’s lines, respectively,
a cervicomedullary abnormality is likely to be present
(Will~ins, pp. 3587- 3591).
Reference lines used to evaluate this condition may include
1. IvIcRae’s line
2. Chamberlain’s line
3. McGregor’s line
4. Wackenheim’s clivus-canal line
A. 1,2, and 3 are correct
B. 1 and 3 are correct
C. 2 and 4 are correct
D. Only 4 is correct
E. All of the above
A. 1,2, and 3 are correct
B. 1 and 3 are correct
C. 2 and 4 are correct
D. Only 4 is correct
E. All of the above
Note the upward displacement of the
odontoid process through the foramen magnum in this
patient with Chiari II malformation (basilar invagination).
Another pertinent finding on this MRI is the spinal cord
syrinx, which is partly seen behind the C7 and T1 vertebral
bodies. There are several lines used to evaluate the craniovertebral junction including McRae’s line (line drawn
across the foramen magnum), Chamberlain’s line (line from
posterior hard palate to posterior foramen magnum or
opisthion), McGregor’s line (line from posterior hard palate
to most caudal point of occiput), Wackenheim’s clivuscanal line (line along posterior surface of clivus), Fischgold’s
digastric line (line joining digastric notches), and Fischgold’s
bimastoid line (line joining tips of mastoid process). No part
of the odontoid should be above McRae’s or Wackenheim’s
line, while if more than 6 mm and 4.5 mm of odontoid
lie above Chamberlain’s and i’vlcGregor’s lines, respectively,
a cervicomedullary abnormality is likely to be present
(Will~ins, pp. 3587- 3591).
A 58-year-old male presents with a severe headache
and left-sided hemiparesis. His CT scan is depicted below. What is the most likely diagnosis?
A. Hypertensive hemorrhage
B. Ruptured middle cerebral artery aneurysm
C. Amyloid angiopathy
D. Vasculitis
E. Ruptured arterial-venous malformation
**A. Hypertensive hemorrhage **
B. Ruptured middle cerebral artery aneurysm
C. Amyloid angiopathy
D. Vasculitis
E. Ruptured arterial-venous malformation
Systemic hypertension often weakens blood vessels,
which can rupture in the setting of acute elevations of blood
pressure. Some implicate microaneurysms of deep perforating vessels (Charcot-Bouchard) in the genesis of these
hemorrhages, although this remains controversial. This CT scan shows a characteristic putaminal hemorrhage secondary to hypertension (Ramsey, pp. 264- 267).
What is the diagnosis?
A. Enterogenous cyst
B. Schizencephaly
C. Arachnoid cyst
D. Pi]ocytic astrocytoma
E. Epidermoid tumor
A. Enterogenous cyst
B. Schizencephaly
**C. Arachnoid cyst **
D. Pi]ocytic astrocytoma
E. Epidermoid tumor
Note the cystic structure in the middle cranial fossa
on the left that parallels CSF in Signal intensity and is most
consistent with an arachnoid cyst. Unlike tumors, it has no
internal structure and does not enhance, although occasionally hemorrhage or a high protein count may complicate its
appearance and make diagnosis difficult. It can be differentiated from epidermoid tumors by the fact that epidermoids
engulf adjacent arteries and nerves, whereas arachnoid
cysts displace them. Schizencephalic clefts are lined by
heterotopic gray matter, whereas enterogenous cysts are
rare intraspinal masses that occur even less often intracranially (Osborn DN, pp. 639-649).
What is the diagnosis ?
A. Eosinophilic granuloma
B. Giant cell tumor
C. Hemangioma
D. Parietal foramen
E. Osteosarcoma
A. Eosinophilic granuloma
B. Giant cell tumor
C. Hemangioma
**D. Parietal foramen **
E. Osteosarcoma
This skull radiograph demonstrates an enlarged
parietal foramen, which is most often an incidental finding. In many instances, parietal foramina are no larger
than a burr hole and rarely require treatment. OccaSionally,
they may be large enough to put the brain at risk of mechanica l injury, and cranioplasty may be indicated (Albright,
p.214).
What is depicted on the angiogram below?
A. Transtentorial herniation
B. Transalar herniation
C. Subfalcine herniation
D. Arteria l-venous fistula
E. Persistent trigeminal artery
A. Transtentorial herniation
B. Transalar herniation
**C. Subfalcine herniation **
D. Arteria l-venous fistula
E. Persistent trigeminal artery
Note the abrupt ACA angulation as it returns
to the midline under the faLx in this patient with subfalcine
herniation. This angiographic appearance is usually caused
by a holotemporallobe mass and is described as a “square”
ACA shift, as opposed to the “round” ACA shift often seen
with deep frontal, insular, or basal ganglionic masses (less
abrupt return of the ACA toward the midline) (Osborn DCA,
pp. 314-325).
Where is the lesion responsible for this finding most
likely located?
A. Parietal lobe
B. Frontal lobe
C. Occipital lobe
D. Lateral ventricle
E. Temporal lobe
A. Parietal lobe
B. Frontal lobe
C. Occipital lobe
D. Lateral ventricle
E. Temporal lobe
Note the abrupt ACA angulation as it returns
to the midline under the faLx in this patient with subfalcine
herniation. This angiographic appearance is usually caused
by a holotemporallobe mass and is described as a “square”
ACA shift, as opposed to the “round” ACA shift often seen
with deep frontal, insular, or basal ganglionic masses (less
abrupt return of the ACA toward the midline) (Osborn DCA,
pp. 314-325).
Match each of the following HIV opportunistic
infections and neoplasms with the most likely imaging
characteristic, using each answer either once, more than
once, or not at all.
Lacunar infarctions resulting from “gelatinous pseudocysts”
A. HIVencephalopathy
B. Toxoplasmosis
C. Progressive multifocal encephalopathy
D. Primary CNS lymphoma
E. Cryptococcal disease
F. Cytomegalovirus
G. None of the above
A. HIVencephalopathy
B. Toxoplasmosis
C. Progressive multifocal encephalopathy
D. Primary CNS lymphoma
**E. Cryptococcal disease **
F. Cytomegalovirus
G. None of the above
Match each of the following HIV opportunistic
infections and neoplasms with the most likely imaging
characteristic, using each answer either once, more than
once, or not at all.
Asymmetric, multifocal areas of 1’1 and T2 prolongation in the periventricular and/or peripheral white matter
without sparing of subcortical U fibers
A. HIVencephalopathy
B. Toxoplasmosis
C. Progressive multifocal encephalopathy
D. Primary CNS lymphoma
E. Cryptococcal disease
F. Cytomegalovirus
G. None of the above
A. HIVencephalopathy
B. Toxoplasmosis
**C. Progressive multifocal encephalopathy **
D. Primary CNS lymphoma
E. Cryptococcal disease
F. Cytomegalovirus
G. None of the above
Match each of the following HIV opportunistic
infections and neoplasms with the most likely imaging
characteristic, using each answer either once, more than
once, or not at all.
Parieto-occipital involvement classically described,
but lesions can also affect the basal ganglia, brainstem, and
cerebellum
A. HIVencephalopathy
B. Toxoplasmosis
C. Progressive multifocal encephalopathy
D. Primary CNS lymphoma
E. Cryptococcal disease
F. Cytomegalovirus
G. None of the above
A. HIVencephalopathy
B. Toxoplasmosis
**C. Progressive multifocal encephalopathy **
D. Primary CNS lymphoma
E. Cryptococcal disease
F. Cytomegalovirus
G. None of the above
Match each of the following HIV opportunistic
infections and neoplasms with the most likely imaging
characteristic, using each answer either once, more than
once, or not at all.
Symmetric patchy or confluent areas of high signal
intensity on T2-weighted images involving the centrum
semiovale; frontal predominance
A. HIVencephalopathy
B. Toxoplasmosis
C. Progressive multifocal encephalopathy
D. Primary CNS lymphoma
E. Cryptococcal disease
F. Cytomegalovirus
G. None of the above
A. HIVencephalopathy
B. Toxoplasmosis
C. Progressive multifocal encephalopathy
D. Primary CNS lymphoma
E. Cryptococcal disease
F. Cytomegalovirus
G. None of the above
Match each of the following HIV opportunistic
infections and neoplasms with the most likely imaging
characteristic, using each answer either once, more than
once, or not at all.
“Eccentric target sign”
A. HIVencephalopathy
B. Toxoplasmosis
C. Progressive multifocal encephalopathy
D. Primary CNS lymphoma
E. Cryptococcal disease
F. Cytomegalovirus
G. None of the above
A. HIVencephalopathy
**B. Toxoplasmosis **
C. Progressive multifocal encephalopathy
D. Primary CNS lymphoma
E. Cryptococcal disease
F. Cytomegalovirus
G. None of the above
Match each of the following HIV opportunistic
infections and neoplasms with the most likely imaging
characteristic, using each answer either once, more than
once, or not at all.
Characteristic rim of generalized periventricular
hyperintensity on proton density-weighted images or fluidattenuated inversion recovery (FLAIR)
A. HIVencephalopathy
B. Toxoplasmosis
C. Progressive multifocal encephalopathy
D. Primary CNS lymphoma
E. Cryptococcal disease
F. Cytomegalovirus
G. None of the above
A. HIVencephalopathy
B. Toxoplasmosis
C. Progressive multifocal encephalopathy
D. Primary CNS lymphoma
E. Cryptococcal disease
**F. Cytomegalovirus **
G. None of the above
Match each of the following HIV opportunistic
infections and neoplasms with the most likely imaging
characteristic, using each answer either once, more than
once, or not at all.
Ependymal enhancement often nodular and irregular
A. HIVencephalopathy
B. Toxoplasmosis
C. Progressive multifocal encephalopathy
D. Primary CNS lymphoma
E. Cryptococcal disease
F. Cytomegalovirus
G. None of the above
A. HIVencephalopathy
B. Toxoplasmosis
C. Progressive multifocal encephalopathy
**D. Primary CNS lymphoma **
E. Cryptococcal disease
F. Cytomegalovirus
G. None of the above
What is the diagnosis?
A. Sphenoid wing meningioma
B. Optic nerve glioma
C. Hypothalamic hemartoma
D. Capillary telangiectasia
E. Ophthalmic artery aneurysm
A. Sphenoid wing meningioma
**B. Optic nerve glioma **
C. Hypothalamic hemartoma
D. Capillary telangiectasia
E. Ophthalmic artery aneurysm
Note the presence of a left optic nerve glioma
with diffuse enlargement of the optic nerve in this patient
with NF-1 (un enhanced T1-weighted MRI) (Osborn DN ,
pp. 553-559).
This lesion is most often associated with
A. Neurofibromatosis type 1
B. ]\,10nos0111Y 22
C. Tuberous sclerosis
D. 1 to 3% risk of rupture per year
E. None of the above
**A. Neurofibromatosis type 1 **
B. ]\,10nos0111Y 22
C. Tuberous sclerosis
D. 1 to 3% risk of rupture per year
E. None of the above
Note the presence of a left optic nerve glioma
with diffuse enlargement of the optic nerve in this patient
with NF-1 (un enhanced T1-weighted MRI) (Osborn DN ,
pp. 553-559).
What is the most likely etiology of the findings depicted
on the CT scan below?
A. Hemosiderosis
B. Intrauterine infection
C. Aqueductal stenosis
D. Severe closed head injury
E. Falll”s disease
A. Hemosiderosis
**B. Intrauterine infection **
C. Aqueductal stenosis
D. Severe closed head injury
E. Falll”s disease
This axial noncontrasted CT scan through the
lateral ventricles and basal ganglia reveals a small, agyric
brain with a relatively thin cortical mantle , bilateral calcifications, atrophy, and ventriculomegaly. These findings
are most consistent with an intrauterine TORCH infection affecting sulcation and cellular migration (Osborn DN,
pp.44- 46).
