RD 2021 Chch and Auck combined

Question 1

Hysterosalpingogram:
A. Spillage in 1 tube and not the other definitely means tube is blocked
B. If lipiodol is used thyroid status should be checked
C. Good for differentiating bicornuate and septate uterus
D. Can be safely performed at any stage of menstrual cycle

Answer 1

CCF - I would favour B
1. http://www.thyroid.org/wp-content/uploads/publications/ctfp/volume8/issue6/ct_public_v86_7_8.pdf
2. https://pubmed.ncbi.nlm.nih.gov/18958768/

This study (1) shows that thyroid hormone levels can be
affected by the administration of Lipiodol. HSG during a fertility evaluation puts women at risk of developing mild hypothyroidism at a time when they are trying for a pregnancy. The paper suggests that
women getting lipiodol as part of HSG should have thyroid function monitored closely for at least 24 weeks after the procedure. Another paper suggested to check pre-procedure (2).

As WJI states below - widely accepted that HSG should be preformed during proliferation phase both for increased visualisation and reduced risk of pregnancy. Therefore can we infer that HSG is less safe post ovulation due to pregnancy risk making D less correct?

WJI B. Agree CCF.
Should be performed in proliferation phase as endometrium is thinnest and unlikely to be pregnant.
-can have tubal spasm or underfilling
-hyperthyroidism is a contraindication to lipiodol
-endometrial cavity of bicornuate and septate uteri look the same

Question 2

Which is most typical location:
A. Myxopapillary ependymoma at filum terminale
B. Central neurocytoma temporal horn
C. Ganglioglioma frontal lobe
D. Paediatric haemangioblastoma parietal lobe

Answer 2

WJI A. Myxopapillary ependymoma at filum terminale
MM - agree

B body of LV
C temporal lobe
D posterior fossa

Question 3

Golfers elbow:
A. Tear in deep aspect
B. Chronic micro tear and repetitive injury of pronator and flexors
C. Tear on medial aspect more common then lateral
D. Most common in college athletes
E. Only seen in golfers

Answer 3

WJI, MM B. Chronic micro tear and repetitive injury of pronator and flexors

Lateral epicondylitis (tennis elbow) is more common
Most common in 4th, 5th decades

Question 4

In overhead throwers pain in the elbow is secondary to:
A. Acromial impingement of supraspinatus
B. Medial compression and lateral ligament strain
C. Valgus injury reported in baseball and javelin sport people
D. Cumulative stress

Answer 4

WJI C. Valgus injury reported in baseball and javelin sport people

Throwers get valgus stress injury with medial strain (medial epicondyle apophysitis/avulsion/ucl tear/medial epicondylitis) and lateral compression (osteochondral fracture). “Throwers elbow”, “little leaguer’s elbow”

Question 5

Stenner lesion:
A. Migrates proximal to adductor pollicis
B. Migrates proximal to abductor pollicis
C. Requires MRI for diagnosis

Answer 5

WJI, MM A. Migrates proximal to adductor pollicis

UCL avulsion injury where the distal insertion is entrapped superficial to the adductor pollicis aponeurosis. This can be diagnosed on US.

Question 6

Right retrocardiac mass in a 3yo on CXR; which is not a cause?
A. Left atrium normal variant
B. Ganglioneuroblastoma
C. Medulloblastoma met
D. Duplication cyst
E. Round pneumonia

Answer 6

WJI A. Left atrium normal variant
Medulloblastoma commonly shows zuckerguss or drop metastases. Pulmonary metastases are rare but possible.

Question 7

Petroclival lesion, mildly T1 hyper intense, homogeneously T2 hyperintense, mild enhancement?
A. Cholesteatoma
B. Chlesterol granuloma
C. Myxoid chondrosarcoma
D. Fibrous dysplasia
E. Asymmetrical marrow

Answer 7

CCF . Would probably favour B. Myxoid Chondrosarcoma over FD.

Rationale.
- Rare for FD to only involve petroclival junction. – typically more diffuse and if so why would stem use “petroclival junction” in the question stem (buzz word for chondrosarc.
- Neither options fit with provided T1 characteristics But T2 more in keeping with Chondrosarcoma.
FD Heterogenous low/intermediate T2 (but sometimes heterogenous high T2 regions). (Stat dx and Radiopediia).
Chondrosarcoma Homogenously high T2 hyperintense– classic feature and stated verbatim in stem, note can have punctate low T2 If Ca2+ (Radiopedia and stat Dx).
Myxoid type Chondrosarcomas can arise from skull base (although rare)
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3505352/
https://pubmed.ncbi.nlm.nih.gov/1545025/

** SCS agree w CCF.
Location and signal characteristics favour chondosarc. Myxoids are intermediate lesions with patchy C+
- Fibrous dysplasia is heterogeneously avid contrast enhancement. Intermediate to Low T1 (hence Fibrous)

Question 8

Hyperdense cyst 3.8cm with thin enhancing septations, what is Bosniak grade?

Answer 8

WJI: 3

1: simple cyst
2. Few hairline septae or calcifications. May have perceived enhancement. OR non enhancing high attenuation cyst <3cm without enhancement
2F: multiple hairline septa or smooth walls or nodular calcifications or >3cm high attenuation without enhancement. This requires FU
3: enhancing walls or septae. This requires excision.
4: enhancing soft tissue components

Question 9

Creutzfeldt-Jacob; false?
A. Cortical T2 hyperintensity
B. Basal ganglia and striatum T2 hyperintensity
C. Dentate nuclei T2 hyperintensity
D. Cerebellum atrophy

Answer 9

WJI C. Dentate nuclei T2 hyperintensity
Non enhancing DWI/FLAIR hyperintensity of cortex and basal ganglia/thalamus followed by rapidly progressive atrophy

Question 10

Cystic and peri cystic lung disease get which cancers?
A. Adenocarcinoma
B. SCC
C. Small cell
D. Large cell
E. Carcinoma

Answer 10

WJI, MM: a. Adenocarcinoma
Nodular wall thickening of a cystic space is an invasive mutinous adenocarcinoma spectrum lesion

Question 11

Adenocarcinoma; which is false?
A. Minimally invasive is <3cm
B. Atypical adenomatous hyperplasia is a small GG nodule
C. Lepidic predominant has necrosis/haemorrhage
D. Invasive mucinous has >5mm invasion

Answer 11

WJI

A. Minimally invasive is <3cm - true
B. Atypical adenomatous hyperplasia is a small GG nodule -true ( <5mm).
C. Lepidic predominant has necrosis/haemorrhage - false, microinvasive spread along normal alveolar tissue framework
D. Invasive mucinous has >5mm invasion - true (this feature distinguishes ‘invasive’ from ‘minimally invasive’, which is <5mm invasion)

**SCS: “lepidic” = a pathologic term referring to growth pattern along the lining the alveolar structures. Can be seen in AIS, MIC and invasive carcinoma.
-Necrosis is a histological feature of invasive ca.

Question 12

Jaw pain, lucent mandibular lesion 37 and 38 roots, expansile and non-enhancing?
A. Giant radicular cyst
B. Follicular cyst
C. Odontogenic keratocyst
D. Ameloblastoma

Answer 12

** SCS: I favour OKC. Causes jaw pain vs periapical cysts are asymptomatic. Associated with TWO roots thus insinuating/spaying the roots. Classic location adjacent to 3rd molar. Expansile buzzword not associated w periapical cyst.
No mention of “non-vital tooth”/associated caries.
Radicular cysts generally <10mm. Only giant in case reports…. No mention of giant in radiopaedia or StatDx.
Does the non-enhancing imply “no solid component” to distinguish from Ameloblastoma?

WJI - favour C over possibly alse A

Question 13

Bladder TCC best seen on?
A. T1FS
B. T2
C. T1
D. DWI
E. STIR

Answer 13

WJI: T2 is used for staging. Or DWI ?

SCS: Agree T2 gives good anatomical delineation. Note DWI good road map… TCC diffusion restricts. As with most pelvic MR use DWI to localise pathology/nodes and use other sequences to characterise.

Question 14

Prostate cancer <50% of 1 lobe, what is T stage?

Answer 14

WJI: T2a

T1 non palpable
T2 palpable; t2a-<50% 1 lobe, t2b>50% 1 lobe, t2c: bilateral
T3a-extraprostatic, t3b-seminal vesicles
T4-invades any other structures

Question 15

Atrial myxoma; which is least likely?
A. Associated with carney syndrome
B. Characteristically T2 hypointense
C. Commonly pedunculated
D. Heterogeneous enhancement
E. Often attached to atrium

Answer 15

WJI
A and b are both wrong. Should be T2 hyperintense and it is associated with Carney Complex (myxoma and blue naevus). Carney syndrome is paraganglioma and gastrointestinal stromal sarcoma. Carney triad is paraganglioma, GIST and pulmonary chondroma

Question 16

Well defined breast mass 56yo woman, most likely? (Auckland recall: well circumscribed on mammogram and solid on US)
A. Phylloides tumour
B. Mucinous
C. High grade IDC
D. DCIS
E. Fibroadenoma

Answer 16

**SCS: I favour HG IDC.
-Stat Dx: Circumscribed margins more common in High grade IDC. -Radiopaedia “circumscribed lesions more common in grade 3 [(high grade)] IDC”
In this age group always think canker.
A bit old for phyllodes. No hx of rapid expansion.
Mucinous is in older group (StatDX mean age 71)
This sort of question has come up on several prior recall sets. I suspect it’s trying trick people into relaxing and calling it benign.

Question 17

Regarding phylloides?
A. Indistinguishable on mammogram and US from fibroadenoma
B. Most common in post-menopausal women

Answer 17

WJI: A. Indistinguishable on mammogram and US from fibroadenoma
Median age 45-49, mean 39.

Question 18

Solid breast mass; which feature most likely suggests benign lesion?
A. Foci of T1 hyperintensity
B. T2 hyperintensity
C. Non-mass like enhancement
D. Non-enhancing septations

Answer 18

WJI
Either A or D. Probably A as lesions containing fat are benign and other causes of T1 hyperintensity (melanin, blood, proteinaceous fluid) would be unusual. Non-enhancing septations are a feature of fibroadenoma but lesion must also be well circumscribed with type 1 curve to diagnose FA.
T2 hyperintense lesions are typically benign except mucinous type carcinoma.

(Auckland recall a. As “high T1” and d. As “enhancing septations”. This would support A. As correct.

Question 19

Most suggestive of high grade DCIS with comedonecrosis?
A. Non mass like enhancement on MRI
B. Dilated calcified ducts on US
C. Mass
D. Lucent centre calcifications

Answer 19

WJI
A. Non mass like enhancement on MRI

Calcified ducts also suggestive but could be papilloma or ducts ectasia/plasma cell mastitis

** SCS:
Stat Dx: MRI extremely sensitive for HG DCIS cf mammo. “Non-mass, clumped linear enhancement”. 98% sensitive.
USS: echogenic intraductal Ca++ visible + Mass in 43% of HG DCIS. But could be other things as above.

Question 20

Immune drug of some description (IC something) not associated with?
A. Bronchiolitis
B. NSIP
C. UIP
D. COP
E. Acute interstitial pneumonia

Answer 20

WJI:
Immune checkpoint inhibitor therapy related pneumonitis can have following patterns:
-OP, NSIP, HSP, AIP, bronchiolitis, radiation recall pneumonitis; so maybe the answer is C. UIP

Or maybe it’s a trick because an OP pattern with a known cause wouldn’t be cryptogenic.
**SCS agree-> COP is idiopathic, probably a trick question

Question 21

Posterolateral corner injury is not associated with injury to:
A. ACL
B. PCL
C. Popliteus
D. Actuate complex
E. Semitendinosus tendon

Answer 21

WJI:
E. Semitendinosus tendon
PLC injuries are strongly associated with cruciate injuries. C. and D. are PLC structures.

*SCS:
Biceps Femoris and LCL form conjoint tendon and are the marjor PLC structures.
Semitendinosis is other side- > pes anseriunus.
Bone marrow oedema: medial femoral condyle and tibia

Question 22

Knee; which is false?
A. Discoid meniscus most likely medial
B. Radial vertical tears are associated with insufficiency fractures
C. Degenerative meniscal tears are usually vertical longitudinal

Answer 22

WJI:
A. Discoid meniscus most likely medial
* Usually affects the lateral meniscus

**SCS: other random trivia from StatDx:
Parameniscal cysts; assoc w meniscus tears, most commonly posterior horn medial meniscus. Always arises along peripheral border of the meniscus.
Menisculocapsular separation: posterior horn medial meniscus. Look for vertical hyper-intensity along the periphery of post meniscus (best seen Sagittal). Assoc. MCL superficial fibre injury.

Question 23

Acute mesenteric ischaemia; which is least likely?
A. Bowel wall thickening
B. Intense mucosal hyperenhancement with submucosal oedema
C. High attenuation on NECT
D. Hypoenhancement of bowel wall
E. Pneumatosis
F. Pneumoperitoneum

Answer 23

WJI
B. Intense mucosal hyperenhancement with submucosal oedema
This is a feature of shocked bowel
Submucosal haemorrhage can give c.

Question 24

Most specific sign in bowel wall trauma?
A. Intense mucosal hyperenhancement with submucosal oedema
B. Bowel wall thickening
C. Mesenteric oedema
D. IVC collapse
E. Intraperitoneal and retroperitoneal free fluid

Answer 24

WJI
B. Bowel wall thickening

Question 25

Spina bifida on US? A. 20% no overlying membrane B. Extent most accurately visualised on sagittal C. Normal posterior fossa excludes closed spina bifida D. Lipomyelomeningocoele is a closed defect E. More commonly sacrococcygeal than lumbosacral

Answer 25

WJI: c. And E. Are false. A. 20% no overlying membrane - 90% open, of this 20% myelocoele/myeloschisis so this is probably correct. B. Extent most accurately visualised on sagittal - true C. Normal posterior fossa excludes closed spina bifida - false, it essentially excludes an open spinal dysraphism D. Lipomyelomeningocoele is a closed defect - true E. More commonly sacrococcygeal than lumbosacral - false: lumbar>sacral>thoracic>cervical Open Spinal Dysraphism - Myelomeningocele (98%) - Myelocele Closed spinal Dysraphism - With subcutaneous mass - Lipoma, Lipomyleomenigocele, Lipomyelocele

Question 26

Lesion next to the epididymis in a 5yo with acute scrotal pain? A. Torted appendix testis B. Rhabdomyosarcoma C. Chronic torsion D. Adenomatoid

Answer 26

WJI: A. Torted appendix testis - most common cause of acute scrotal pain in children

Question 27

Physiological periostitis, which is true? A. Lateral aspect of tibia more common than medial B. Unilateral involvement is a described feature C. Commonly age <1 month D. Should be >3mm thick E. Most commonly metaphyseal

Answer 27

WJI D. A, C and E are false. B and D probably false. Perhaps incomplete recall and either C or D have >/< back to front? The usual appearance on radiograph is single-layered, thin periosteal reaction (commonly but not exclusively <2 mm) involving one aspect of the long bones. DDx Caffeys; (infantile cortical hyperostosis) which tends to favour the flat bones. Prostaglandin use for ductal patency.

Question 28

Max pressure for air reduction of intussusception? A. 80mmhg B. 100 C. 120 D. 140

Answer 28

WJI C. 120mmHg

Question 29

Not a contraindication for ablation of a renal lesion? A. Renal vein invasion B. Hilar location C. 32mm size D. Uncorrectsble coagulopathy E. Active sepsis

Answer 29

WJI C. 32mm size

Question 30

Antenatal US brain findings at 20/40; true? A. Fornices may be mistaken for CSP B. CSP not seen until 24/40 C. Cingulate gyrus readily seen D. Cisterns Magna measured as accurately on coronal plane as standard views

Answer 30

WJI A. Fornices may be mistaken for CSP (Stat Dx)

Question 31

Radial scar most commonly presents as? A. Architectural distortion B. Calcifications C. Non-mass enhancement D. Well circumscribed mass

Answer 31

WJI A. Architectural distortion

Question 32

Acute unilateral ophthalmoplegia in all directions with proptosis, which is most likely imaging finding? A. Non-opacified cavernous sinus B. Central pons infarct C. Medulla infarct D. Ophthalmic artery occlusion E. Occipital infarct

Answer 32

WJI A. Non-opacified cavernous sinus SCS: note caroticocavernous fistula can also do this (ie cause CN 3, 4 6 palsy and proptosis))

Question 33

Eye presentable oedema, painful, asymmetric bilateral involvement, periscleral involvement infiltration mass involving intracranial fat? A. Sarcoid B. Pseudotumour C. Panophthalmitis D. Thyroid eye disease

Answer 33

WJI B. Pseudotumour SCS: Agree. Note Sarcoidosis looks similar. Often can’t tell on just orbital imaging alone. CXR next best test? ADB:annoyingly usually unilateral, RPD-->Patients typically present with rapid-onset, usually unilateral (~90% of cases), painful proptosis and diplopia.

Question 34

IgG4 related arteriopathy, least likely involved? A. Thoracic aorta B. Infrarenal aorta C. Iliac artery D. Suprarenal artery E. Popliteal artery

Answer 34

WJI E. Popliteal artery Causes aortitis and large to medium vessel vasculitis. Peripheral arterial involvement is rare.

Question 35

Renal artery stenosis and occluded infra-aortic vessels in 20yo man? A. Buerger B. Takayasu C. PAN D. GCA E. FMD F. Kawasaki

Answer 35

CCF - Favour B -Takayasu -- Takayasu average onset 15-30 years old. Can effect the renal arteries causing renovascular HTN (esp. type IV). Chronic inflammatory and obliterative changes in the aorta and its branches. There are often reduced or absent peripheral pulses, giving rise to its alternative name of "pulseless disease" (Radiopeida). - FMD prob doesn't account for occur for infra-aortic vessels (rare anything other than carotid and renal, although RP does say can involve the iliac but occlusion not really primary a sequelae of FMD). SCS: agree CCF. This is very similar to a recall from a previous year.

Question 36

30yo female with irregular carotid artery stenosis and HTN? A. PAN B. FMD C. Other vasculitis

Answer 36

FMD

Question 37

Non perfusing upper pole of kidney in a trauma case, no extravasation or free fluid? A. Segmental arterial avulsion B. Renal venous thrombosis C. Renal venous dissection D. Renal artery dissection

Answer 37

WJI: D. Renal artery dissection Best guess. I think avulsion would likely have bleeding or free fluid. Renal vein thrombosis and arterial dissection are both described in trauma.

Question 38

Young adult male. Cystic floor of mouth (Auckland recall “sublingual”) lesion; low T1, high T2 with intrinsic nodular foci of intracystic T1 low/T2 low? A. Epidermoid B. Dermoid C. Lymphatic malformation D. Ranula E. Warthins cyst F. Pleiomorphic adenoma E. 2nd branchial cleft cyst

Answer 38

WJI As written I would choose b. As dermoids can calcify but should also show fat lobules (hypodense and T1/T2 hyperintense) Epidermoid, lymphatic malformation, ranula and BCC do not often calcify. If it said T1 high foci answer would be B. If it said venolymphatic malformation foci could be phleboliths. Auckland also recalled pleomorphic adenoma as an option. As this is benign it is less common in the minor glands but appears T1 dark/T2 bright with calcifications so is another plausible answer. ** SCS agree. As written I favour Dermoid. I acknowledge lack of T1 HYPERintense foci to indicate fat (a defining feature for dermoid) makes this hard to go with BUT stat dx states that if there is complex signal then the lesion most likely represents dermoid (if deciding dermoid vs epidermiod- which should only contain fluid)

Question 39

44yo with neck mass. Parapharyngeal space displaced anteromedially, low T1/high T2, homgenously enhancing? A. Benign mixed tumour B. Warthin C. Schwannoma D. Paragangioma E. 2nd BCC

Answer 39

WJI could be parotid space (medial) or carotid (anterior) so best answer D.

Question 40

True of gastrograffin? A. Correct dose paeds GI study under 5yo is 30ml 1:1diluted B. Safe in lactation as not expressed C. Can use orally, enema and IV D. Safe in tracheo-oesophageal fistula E. Used in enema as non ionic

Answer 40

WJI: A. Correct dose paeds GI study is 30ml 1:1diluted - I can find 2:1dilution but I guess this is best answer B. Safe in lactation as not expressed -is expressed in breastmilk C. Can use orally, enema and IV -nope D. Safe in tracheo-oesophageal fistula -nope (SCS: will cause prompt pulmonary oedema if accidentally introduced into Bronchial tree) E. Used in enema as non ionic -nope SCS: summary from our local paediatric Fluoro streamliners: -Don’t use GG in upper GI. -Lower GI: we use Omnipaque 300 neat for <6mo, diluted 150mL saline: 50mL omni for larger children (same as MCU mix)

Question 41

Barium swallow; annular distal oesophageal stricture with a small hiatal hernia and reflux in a smoker and drinker? A. Adenocarcinoma B. Barrett’s C. Schatzki D. Reflux oesophagitis E. Peptic stricture

Answer 41

A: Schtazki or Reflux Appearances **Adenocarcinoma**: Irregular, circumferential narrowing with nodular shoulders is most typical. **Barrett's**: Mid oesophageal stricture with hiatal hernia and reflux is essentially pathognomic **Schatzki**: Thin (2-4 mm in height), web-like constriction at the GOJ with smooth and symmetric margins, with sliding hiatal hernia seen below ring. **Reflux oesophagitis**: Mucosal nodularity, foreshortening of the esophagus. Small smooth sacculations and fixed transverse folds are characteristic. >95% have hiatal hernia. **Peptic stricture**: similar to Barrett's.

Question 42

Not a manifestation of thoracic leukaemia? A. Adenopathy B. NSIP C. Pleural effusion D. Amyloidosis E. PAP

Answer 42

WJI: B. NSIP A. and C. Are features and D. and E. Are associations or leukaemia. **SCS: Radiopaedia article “Leukaemia (thoracic manifestations)” states: -Adenopathy: most frequent manifestation, most commonly in lymphoid leukaemias -Pleural leukaemia infiltrates cause pleural effusions (with soft tissue masses sometimes too) -Some conditions affecting the chest without clear mechanism or connection have been reported: Amyloidosis (pulmonary and cardiac) PAP- particularly in myeloid forms.

Question 43

Least likely in thoracic outlet syndrome? A. Subclavian artery dissection B. Subclavian artery pseudoaneurysm C. Subclavian vein thrombosis D. Subclavian artery thrombosis E. Subclavian artery stenosis

Answer 43

WJI: A. Subclavian artery dissection

Question 44

Cystic lesion in 30/40 week foetus on US; false? A. In RUQ could be a choledochal cyst B. Bowel wall signature implies duplication cyst C. Daughter cyst strongly implies (Auckland recall “could be”) ovarian lesion D. Ovarian lesion only present in the pelvis

Answer 44

WJI: D. Ovarian lesion only present in the pelvis

Question 45

Endometrial polyp; true? A. Seen low in endometrial cavity B. 20% have foci of atypical or carcinoma C. 50% are multiple D. Cystic foci more likely if post menopausal E. Associated with tamoxifen but not HRT

Answer 45

A: Cystic foci more likely if post menopausal Other facts - Most commonly cornual or fundal origin - 3% have hyperplasia with atypia, 1% have cancerous foci - 20% multiple - Atrophic polyps composed of atrophic cystically dilated glands vs Hyperplastic polpys composed of glands in endometrial hyperplasia - Develop in 8-36% of postmenopausal women on tamoxifen. Also associated with HRT use

Question 46

Unicameral bone cyst? A. More common in humerus than femur B. Epiphyseal origin C. 50% have fluid fluid levels on MRI

Answer 46

WJI: A. More common in humerus than femur Metaphyseal. C. May be true (“often”) but A is definitely true

Question 47

Boutonnière’s deformity is due to injury of? A. Lateral slip extensor mechanism B. Central slip extensor mechanism D. DIP E. Volatile plate MCPJ

Answer 47

A: Central slip extensor mechanism Boutonniere deformity: PIPJ flexion with DIPJ extension due to extensor tendon central slip injury at or near insertion on middle phalanx.

Question 48

Increased risk of breast cancer in 60yo female, most likely? A. Extremely dense breasts on mammogram B. 6 months HRT

Answer 48

WJI: A. Extremely dense breasts on mammogram I feel like the risk of 6 months HRT is negligible and is via proliferation of breast tissue which A. already has.

Question 49

Low SWI in nigrosome 1? A. Parkinson B. Wilson C. Alzheimer D. CJD

Answer 49

WJI: A “Causes the high SWI signal within nigrosome-1 to be absent” SCS: cluster of dopamine rich cells within substantia nigra, five have been described, largest being NG-1. Absence = loss of dopa neurons hence Parkinson’s. “Absent swallow tail sign” -posterior third of substantia nigra

Question 50

Prior stomach surgery, staples at the GOJ, irregular ‘mass’ on barium at the cardia, lots of reflux; cause? A. Fundoplication unwrapped B. Bilroth 2 with afferent limb syndrome C. Partial gastrectomy D. Slipped gastric band E. Sleeve gastrectomy complicated by stricture

Answer 50

A: Fundoplication unwrapped Review - **Fundoplication unwrapped** is a "Hinder type I" complication, resulting in recurrent hernia and reflux. - **Bilroth 2 with afferent limb syndrome**: U-shaped loop of dilated bowel adjacent to pancreas with dilated bile ducts - **Partial gastrectomy**: Staples not congregated at GOJ - **Slipped gastric band**: more likely to lead to obstruction - **Sleeve gastrectomy complicated by stricture**: Staples not congregated at GOJ

Question 51

Lesions around basal ganglia, meninges and basilar enhancement? TB

Answer 51

WJI: typical Features of CNS Tuberculosis: -basilar leptomeningitis -supratentorial tuberculomas Don’t know what other options were; lymphoma,sarcoidosis? with meninges metastases could appear similar

Question 52

Woman 40yo acute cerebellum symptoms, triangular T2 hyperintense lesion in pons, T2 high in striatum, subcortical WM, restricts? A. methanol B. MS C. central myelinolysis

Answer 52

WJI: C. central myelinolysis

Question 53

Empty pituitary fossa is most common in? A. Idiopathic intracranial hypertension

Answer 53

WJI: IIH: Dural venous sinus narrowing, vertical tortuosity optic nerves, papilloedema, slit like ventricles in fat middle aged women Differentials are secondary intracranial hypertension, pituitary apoplexy and arachnoid cyst

Question 54

Central neurocytoma; where is this located?

Answer 54

Bubbly mass in the frontal horn or body of the lateral ventricle near foramen of Munro, may extend into V3. Typically attached to septum pellucidum. Both lateral ventricles 13%, V3 only 5%, V4 only extremely rare. Mixed solid/cystic with calcification Heterogeneously T2 hyperintense, T1 hypointense, enhances and restricts Rarely haemorrhages, hydrocephalus common Ages 20-40 WHO 2

Question 55

Which location is not true? A. Ganglioglioma most commonly parietal

Answer 55

A. Ganglioglioma most commonly parietal -cortically based cyst with a nodule in the temporal lobe -50% calcify -may remodel calvarium -age 10-20 with epilepsy -WHO 1 or 2

Question 56

Which is not temporal lobe? A. Alzheimer’s B. HSV C. Ganglioglioma D. DNET

Answer 56

WJI -maybe incorrect recall; these all most commonly involve the temporal lobes

Question 57

PXA location?

Answer 57

Supratentorial mass involving temporal cortex and meninges with an enhancing dural tail Cyst with an enhancing nodule is typical Child or young adult with epilepsy WHO 2 Calcifications or haemorrhage are rare

Question 58

Liver lesion, mildly hyper enhancing on CT, T2 iso, mildly arterial hyperenhancing on MRI, iso on PV and hepatobiliary? A. FNH B. THAD C. Adenoma D. HCC E. Met

Answer 58

WJI A. FNH If it was wedge shaped and said hyperenhancing on arterial phase CT I would choose THAD

Question 59

Retroperitoneal mass, 60 to -60 HU, encases the adrenal and the intact kidney? A. Ruptured xanthogranulomatous pyelonephritis B. Myxoid liposarcoma C. Renal AML D. Adrenal myelolipoma

Answer 59

WJI: if it is encasing the kidney and adrenal I would chose b. Although this in more common in the extremities. C and D. are differentials but arise from either the kidney or adrenal respectively.

Question 60

Which is least likely to cause moderate or massive splenomegaly? A. Right HF B. EBV C. Disseminated colon cancer D. Thalassaemia E. Portal HTN

Answer 60

WJI: C. Disseminated colon cancer “Space occupying masses in the spleen very rarely cause splenomegaly, instead replacing splenic parenchyma”

Question 61

Most likely to cause splenic infarct? A. Sickle cell B. Alpha thalassaemia C. Beta thalassaemia D. HS E. TB

Answer 61

WJI A. Sickle cell

Question 62

7yo with prior neuroblastoma and normal liver US 2yrs ago, now has 4x hypoechoic well defined lesions? A. Abscess B. FNH C. New malignancy D. Mets

Answer 62

WJI: D. Mets

Question 63

PJP? A. Often coexists with CMV B. Gallium is more sensitive than CXR C. Apical pattern D. Has lymphadenopathy E. Has pleural effusion

Answer 63

WJI: PJP? A. Often coexists with CMV -true B. Gallium is more sensitive than CXR -true C. Apical pattern -more commonly central perihilar but may show apical predominance if on aerosolise pentamidine prophylaxis D. Has lymphadenopathy -uncommon E. Has pleural effusion -rare

Question 64

Post stereotactic radiotherapy what is not likely to represent recurrence on CXR? A. GGO B. Loss of linear margin C. Bulging margin D. Loss of air bronchograms E. Increasing soft tissue mass with air bronchograms

Answer 64

WJI: A. GGO

Question 65

Placental abruption; what is true? A. US is sensitive for diagnosis B. No increase in echogenicity of amniotic fluid unless C. Apparent placentomegaly can be a feature on US D. Marginal placenta unlikely to have clot near os

Answer 65

WJI C. Apparent placentomegaly can be a feature on US

Question 66

What reduces the dose on fluoro? A. Remove grid B. Decrease collimation C. Increase magnification D. Use wider FOV

Answer 66

WJI: A. Remove grid

Question 67

Cyst in 15yo between SCM and SM gland? A. Type 1 BCC B. Type 2 BCC C. Not a branchial cleft cyst

Answer 67

WJI b. Type 2 BCC Type 1: middle aged women. 7% of BCCs. In/near parotid/external auditory canal T2: 95%. Early adulthood. Typically anterior to SCM below angle of mandible. Can occur anywhere between pharyngeal mucosa and skin passing inferolaterally between ICA and ECA. T3: rare. Posterior to SCM in superior posterior triangle. Differential for lymphatic malformation/cystic hygroma. T4: very rare. Along the course of the recurrent laryngeal nerve. typically adjacent to the thyroid.

Question 68

Achilles tendinosis; least likely on US: A. Convex margins B. Hyperechoic fat pad C. Hypoechoic nodules in tendon D. Fluid in tendon sheath

Answer 68

SCS: D; Kagers fat pad demonstrates increased echogenicity (see Radiopaedia article for Achilles tendinopathy). Achilles doesn’t have a tendon sheath.

Question 69

Rotator cuff injur; most important to report for surgery? A. ACJ degeneration B. Fatty atrophy C. Subscromial bursitis D. Oedema rotator interval E. Joint effusion

Answer 69

B. Fatty atrophy

Question 70

Pineal cyst in a child; false? A. Should always follow up as are rare B. Should not be followed up if <7mm C. Increased risk of pineoblastoma if have hereditary retinoblastomas D. Greater than 1cm associated with increased complications

Answer 70

WJI: A. Should always follow up as are rare

Question 71

Lady treated for UTI now has abdo pain, fever and diarrhoea. Caecum and ascending colon are thick walled with pericolonic stranding and ascites?

Answer 71

A. Pseudomembranous colitis

Question 72

Ulnar impaction is associated? A. Negative variance B. Lunotriquetral ligament injury C. Scapholunate injury D.cystic change radial aspect lunate

Answer 72

WJI: B. Lunotriquetral ligament injury **SCS: Neg ulna variance ass/w Kienboch and ulnar impingement syndrome

Question 73

Peritoneal inclusion cyst? A. Increases in size on serial imaging B. Clearly defined from imaging C. Has mass effect on pelvic structures D. Multicystic and anechoic

Answer 73

WJI: a and d are true

Question 74

Sacrococcygeal teratoma; true? A. Hydrops confers poor prognosis B. Cystic higher mortality C. Easily differentiated from anterior myelocoele D. high HCG

Answer 74

WJI: A. Hydrops confers poor prognosis Can have elevated levels of: alpha-fetoprotein (AFP) beta HCG

Question 75

Textured breast implant associated cancer? A. Lobular B. SCC C. melanoma D. ALL E. Anaplastic large cell lymphoma

Answer 75

WJI: E. Anaplastic large cell lymphoma

Question 76

Diabetic with fever, hyper dense sinus, bony erosion, orbital stranding? A. Acute invasive fungal B. Chronic invasive fungal C. Allergic acute fungal D. Chronic granulomatous

Answer 76

WJI: A. Acute invasive fungal **SCS: agree. - Acute seen in diabetics esp in ketoacidosis and immunocompromised people. -acute can cause bony erosion; Prometheus… mucormycosis eating a fat diabetics face off” -Just note that Radiopaedia says: “Unlike chronic invasive fungal sinusitis, acute infection generally does not demonstrate hyperdense material within the sinus on non-contrast CT” - in practice the big discriminator would be bony thickening/sclerosis to indicate chronicity.

Question 77

Soft tissue mass nasal cavity with unilateral maxillary effusion, turbinate smooth remodelling, hyperostosis? A. Mucocoele B. Inverted papilloma C. Mucoepidermoid carcinoma D. Lymphoma

Answer 77

WJI: B. Inverted papilloma

Question 78

3yo with otalgia, ct shows middle ear and mastoid effusions; best imaging? A. MRI mandibular condyle B. MRI skull base and nasopharynx C. PSMA PET

Answer 78

WJI: B. MRI skull base and nasopharynx SCS: this exact question was recalled in 2021 Path set but with a different stem saying an adult. In this context - nasopharyngeal carcinoma until proven otherwise. ? Poor recall/ wrong exam as children always get ear aches….

Question 79

Young woman with 3/12 diarrhoea, featureless jejunum, dilated, stricture and fistula to terminal ileum? A. Scleroderma B. Coeliac C. Crohns

Answer 79

WJI: C. Crohns Featureless jejunum implies Coeliac, but Coeliac wouldn't have strictures and fistulas to the terminal ileum.....

Question 80

Fatty atrophy infraspinatus? A. Supraspinous notch lesion B. Spinoglenoid ganglion C. Supraspinatus notch tear

Answer 80

WJI: B. Spinoglenoid ganglion

Question 81

64yo with bicuspid aortic valve and exertional syncope? A. Heart size normal B. Aortic calcification C. Downward cardiac apex

Answer 81

WJI: b and c could both be true Note a similar recall in 2021 Path. They had similar answers, except ascending aorta dilatation was correct answer.

Question 82

Orthostatic hypotension, dizziness with diffusion restriction triangle in the pons, striatum? A. Osmotic demyelination B. CJD C. MS D. Multiple systems atrophy

Answer 82

WJI: D. favour osmotic demyelination - orthostatic hypotension suggests MSA but i dont think this diffusion restricts

Question 83

Adolescents with periphyseal oedema? A. Peripheral B. Trauma C. After closure D. Females

Answer 83

WJI: focal periphyseal oedema (FOPE) zones are regions of bone marrow oedema at the phases adjacent to the knee. Seen in females age 11-12 and males age 13-14 around the time of expected skeletal maturation and physical fusion. Thought to occur with the first osseous bars altering mechanical stresses across the physis. May be painful. May have a history or trauma. Considered normal. Depending on wording any of above options could be the answer.

Question 84

Twitching or orbicularis oculi? A. Compression in CPA of CNVII B. Other options CN V

Answer 84

WJI: innervated by CN7

Question 85

Lateral condyle elbow fracture: A. <2mm displacement good prognosis B. Most common paediatric elbow fracture pattern C. Is a salter Harris T2 fracture

Answer 85

WJI: A. <2mm displacement good prognosis. Weiss type 1; can be managed non-operatively; can assume cartilaginous hinge is intact *SCS: this is a SH4

Question 86

MCA Doppler which is true? A. 3mm sampling zone B. Sample at origin C. If not 0 degrees needs angle correction D. .MoM 1.2 is abnormal E. Don’t need zoom

Answer 86

Answer: If not 0 degrees, needs angle correction As per NZMFMN Doppler guidelines * Position a small (0.5-1mm) sample volume 2 mm beyond the MCA origin * Move anteriorly and angle back to align the MCA flow direction with the Doppler beam * Less than 5th precentile is abnormal * Use high definition zoom * Assess the MCA which is closer to the transducer * Start with BPD view

Question 87

Multiple small liver and splenic lesions A. Candidiasis

Answer 87

Hypodense, T1 dark, T2 bright, +/- rim enhancement Differentials are: Metastases - larger, uncommon to involve spleen Lymphoma - may involve spleen, usually larger Biliary hamartomas or Caroli disease

Question 88

RLQ pain, blind ending duct, echogenic focus

Answer 88

Appendicitis

Question 89

Crazy paving false? A. Lipoid B. Pap C. PCP D. Adenocarcinoma E. RB-ILD

Answer 89

WJI: E. RB-ILD Although this gives you GGO and you can get crazy paving in anything that gives you GGO the others are all classic causes

Question 90

MERS mild encephalopathy? A. Splenium RD B. Confluence enhancing mass subcortical white matter C. Influenza a D. Anti epileptics

Answer 90

WJI: mild encephalitis with a reversible isolated selenium of the CC lesion, now called cytotoxic lesions of the corpus callosum. Nonspecific inflammatory cytotoxic oedema with multiple causes including: -seizures and antiepiletics -metabolic disturbances (wernicke/Wilson/machiafavi-bignami/osmotic demyelination) -infections -cns malignancy -drugs -subarachnoid haemorrhage So a/cand d could be true, b is false.

Question 91

Contrast agent MRI? A. Only linear agents cause neurogenic deposition B. Severe renal failure most get NSF C. Dose >0.1mmol/L associated with nsf

Answer 91

WJI: a is probably true gadolinium based contrast agents can be divided into linear vs macrocyclic, ionic and non-ionic and are grouped into group 1: essentially all cases on NSF Group 2: few, if any cases Group 3: few, if any cases but limited data. Group 1s are all linear. They are omniscan, Megavist and optimark. Doltarem which we use is group 2. Primovist (biliary) is group 3. New guidelines are depending on local practice it is basically optional whether or not you check eGFR before giving group 2s as the risk is so low, and withholding it when eGFR is known to be <30 is probably more harmful in most situations. For groups 1 and 3 avoid if eGFR <30 and caution if <60. If you have to give it then need consent, adequate hydration and max dose 0.1mmol/kg. If on dialysis hen dialyse straight after. The absolute risk with eGFR <30 is still <1/10,000

Question 92

6 month old with firm skin nodules, multiple well defined lyric bone lesions with sclerotic rim? A. LCH B. TB C. Burkitt lymphoma

Answer 92

WJI: A. LCH

Question 93

Ankylosing spondylitis? A. Romanus lesion posterior corner B. 60% HLAB27 C. Chronic romanus fat signal on MRI D. New York classification based on MRI

Answer 93

WJI: C. Is true A. Anterior corner B. 90% of caucasians with AS are HLAB27 (50% African Americans). This confers a 5% risk of developing AS. D. Clinical features (lumbar stiffness and pain, reduced chest expansion) and sacroiliitis on XR

Question 94

Ataxia, incontinence, delirium? A. Callosal angle 120 degrees B. Decreased csf flow cerebral aqueduct C. Narrowing of CSF spaces at vertex D. Evans index 0.2

Answer 94

Answer: Narrowing of the CSF spaces at the vertex NPH - Callosal angle is <100 degrees (normal is 100-120) - Increased CSF flow (Stroke volume) - Increased sylvian fissure space but decreased CSF spaces at vertex - Evans index >0.3 (normal <0.3)

Question 95

Malignant coronary artery? A. Left main from R ostium going inter-arterial B. Left main from R accessory ostium C. Left circumflex from left cusp

Answer 95

WJI: A. Left main from R ostium going inter-arterial