RD radiodiagnosis 2018 march: formatted

Question 1

1. Clinodactyly enlarged finger
   a. Macrodystrophia
   b. Turners
   c. Mucopolysaccharidosis
   d. Marfans

Answer 1

Macrodystrophia
? localised gigantism with clinodactylyl

**LJS - correct.
Macrodystrophia lipomatosa - localised gigantism. One of the many associations with clinodactyly (curved finger, usually little finger)
Also T21 and other aneuploidy, plus many other syndromes (but none of the other answers that I can find)
Soft marker in isolation

Question 2

2. RUL consolidation with haemoptysis, chronic disease young person, tram track lucency, DSA
   a. Dilated eroded vessel
   b. Aneurysm
   c. Dissection

Answer 2

b. Aneurysm

*ESG - weakly disagree, favour dilated eroded vessel.
Core: Chronic inflammation can lead to hypertrophied bronchial arteries and subsequent hemoptysis. In the USA, cystic fibrosis and thoracic malignancy are the most common causes of hemoptysis. Worldwide, tuberculosis and fungal infection are more common.
StatDx: [Haemoptysis] typically caused by erosion/bleeding of overlying airway mucosa or rupture of hypertrophied bronchial arteries

Question 3

3. Bladder injury least likely on cystogram
   a. Extraperitoneal
   b. Intra
   c. Extra intra
   d. Interstitial injury
   e. Mucosal tear

Answer 3

e. Mucosal tear ?

**LJS - agree. Radiopedia has interstitial tear as serosal surface tear. But stat dx/papers say it is intramural/partial thickness tear with intact serosa

https: //pubs.rsna.org/doi/10.1148/radiographics.20.5.g00se111373
* AJL agree with LJS above. I have listed the main points from the paper.

3. Bladder injury least likely on cystogram
   a. Extraperitoneal - contrast in perivesical space
   b. Intra - contrast in peritoneal space, b/t bowel loops.
   c. Extra intra - Both of above
   d. Interstitial injury - like a dissection of the bladder wall.
   e. Mucosal tear - contusion. Often normal on CT

Question 4

4. Chest pain high on NECT
   a. IMH
   b. Dissection
   c. Other crap

Answer 4

a. IMH

Question 5

5. 60 well marginated

a. High grade IDC
b. Fibroadenoma
c. Cyst
d. Sebaceous
e. Mucinous

Answer 5

could be anything
probably Mucinous

**LJS - mucinous rare and tends to be elderly. ?IDC NOS more likely

CCF - High Grade IDC most likely.

Question 6

7. Liver lesion hypervascular hepatobiliary delayed normal other delayed abnormal

a. One is FNH
b. Other is Adenoma (q said low on opp phase)

Answer 6

FNH

IVM: Weird wording. Favour adenoma if the Q did say low signal on oppsed phase imaging.
FNH should follow background liver parenchyma on delayed studies.

Question 7

8. Sclerotic 50 year old vertebral test

a. Bone scan
b. MRI
c. XR
d. CT

Answer 7

a. Bone scan

Question 8

9. 2 year old not intersusseption

a. HSP
b. Crohns
c. Lymphoma
d. Meckels

Answer 8

**LJS - Crohns. Seems least likely in a 2yo. HSP, Meckels, lymphoma can act as lead points.

9. 2 year old not intersusseption

a. HSP
b. Crohns
c. Lymphoma
d. Meckels

Question 9

10. High MCA PSV/Vmax in baby, rh +

a. Parovirus
b. Rhesus incomp
c. Normal
d. CPAM

Answer 9

**LJS - disagree.
Parvovirus - infects erythroid precursors = aplastic fetal anaemia

Assuming Q states mother is Rh+ve. Rhesus incompatability occurs in Rh -ve mothers.

*LW:
Agree with LJS…
Would depend on rhesus status in question wording, as high MCA Vmax diagnoses fetal anaemia for which parovirus and rhesus incompatability are causes.
Also, would assume rhesus status refers to mother, as although possible to ante natally test fetal blood group, it is difficult and risky with amniocentesis / expensive with latest blood tests (not readily available in NZ / fair game in Oz).

Previous
b. Rhesus incomp

Question 10

11. Nuchal 4mm in first trimester

a. Normal
b. High risk 20/70
c. Confirms T21
d. TV scan needed
e. Associated with cardiac abnormality

Answer 10

B. high risk 20/70

Risk of nuchael translucency vs chromosomal defects:
< 95th centile : 0.2%
95-99th centile : 3.7%

3.5- 4.4mm : 21%
4.5-5.4 mm : 33.3%
5.5 - 6.4 mm : 50%
> 6.5 : 64.5% .

19% fetal death.
46.5% major fetal anomaly. The results of the nuchal translucency scan will not be used alone to calculate the risk of a chromosomal abnormality. All your first trimester screening is combined to calculate your risk. The calculation based on the mother’s age, the nuchal translucency measurement of your baby, the gestational age of the baby, blood tests and the baby’s nasal bone.If your risk is less than 1 in 1000, you are considered low risk. If it is between 1 in 50 and 1 in 1000 you are considered intermediate risk. If it is greater than 1 in 50 you are considered high risk.If abnormal and screening test results show increased risk of less than 1 in 300, further workup may be carried out based on patient’s desire after counseling and which includes:amniocentesis and/or chorionic villus samplingfetal echocardiography

Question 11

12. Men breast cancer

a. IDC
b. ILC

Answer 11

a. IDC

Question 12

13. Men painful unilateral mass, lobulated posterior margin

a. Gynaecomastia

Answer 12

a. Gynaecomastia - often unilateral, painful, under areolar.

*AJL - I presume Male breast cancer is one of the other options.
Discriminators to pick cancer over gynaecomastia:
- Painless, fixed, hard, irregular mass
- Remote from areolar.
- skin thickening.

Question 13

14. 3 cystic masses 40 female in neck, one in parotid 2 in neck, breast cancer

a. Sjogrens
b. HIV
c. Mets

Answer 13

*LW:
Unsure, in setting of breast cancer could represent multiple nodal mets, with parotid met / intra parotid nodal met.

Multiple parotid lesions can be due to Sjogren or HIV epithelial lesions, however, question states 2 lesions in neck, i.e. external to parotid, thus assuming nodes.

**LJS - HIV lymphoepithelial lesions often ass/w cervical lymphadenopathy. And given cystic ?most likely. Breast ca mets to parotid is extremely rare according to google. Radiopedia - mets to intraparotid nodes: melanoma, SCC, rarely testicular seminoma

***Combined preferred answer thus = HIV

*AJL agree HIV

Question 14

15. Mandibular unilocular with nodule

a. OKC
b. Dentigerous
c. Odontoma
d. Ameloblastoma

Answer 14

*LW:
Favoured answer is ameloblastoma.

**LJS agree - 20% unilocular and other things wouldn’t have solid component

Question 15

16. Weak muscle baby, no testis best next test

a. US renal
b. US testes
c. CXR
d. AXR

Answer 15

*AJL - Disagree with LJS/unsure of answer.
Hypotonia and cryptorchidism can be found in a variety of conditions, for example prada willy. The point of the USS is surely to look for the location of the testes? Though I agree it may be useful to look at the renal tracts at the same time.
Also prune belly usually is diagnosed in utero because of large bladder and dilated ureters, rather than hypotonia and cryptorchisism.
https://pubmed.ncbi.nlm.nih.gov/29553044/

• *LJS - renal USS. Hypotonia + undescended testes ?prune belly syndrome. Look for evidence of renal dysplasia to complete the triad
• LW: As always, agree with LJS…. I think this question is going for next step idea such as ?prune belly, why else would they mention weak muscles…..

b. US testes

UltrasoundUltrasound has 45% sensitivity, 78% specificity, and 88% accuracy for localisation of an undescended testis and is more accurate than clinical examination 4,5

.MRI
MRI is the best cross-sectional modality to assess crypto-orchidism (replacing CT). It has a higher sensitivity than ultrasound (~90%) and a higher specificity (100%) 6.

IVM: Stat DX
AUA guidelines do not recommend imaging for localization
Rarely assists decision making as most are palpable by experienced surgeon
For nonpalpable testis, US sensitivity is poor; MR is better for intraabdominal location but cannot exclude congenitally absent testis; therefore exploration always needed
Infants need sedation for MR, increasing risk
When necessary, US for inguinal testis
When necessary, MR study of choice for intraabdominal testes

Question 16

17. Kid unilateral lack of chest wall muscle

a. Polands

Answer 16

a. Polands

Question 17

18. 2cm mass in brain

a. Amyloid angiopathy

Answer 17

*LW:
Amyloid - possible if described blooming sequence, however unlikely if isolated mass as amyloid antipathy usually multi focal.

Question 18

19. Old guy confused BG mass int T1 high T2 what age bleed

a. 3hr
b. Sub early
c. Late sub
d. Chronic >14

Answer 18

*LW: unsure if correct signal details recalled:

Per the spiral graph:
Immediate / hyper acute is T1 iso, T2 iso, although T2 can be slightly hyper intense, with a peripheral rim of hypo intensity. So probably this is correct answer based on details recalled.

Acute (1-2days) is T1 iso, Low T2.
Early sub acute (2-7days) is high T1, low T2.
Late sub acute (7 days - 28days) is high T1 high T2.
Chronic: progressively reduces T1 signal and then T2 signal becoming low T1 and low T2.

*IVM: Crack’s version of the spiral has Intermediate T1 and high T2 for hyperacute.

previous answer:
a. 3hr

Question 19

20. Fibrous dysplasia, which is false

a. Mono less earlier than poly
b. Leontisis ossea extra
c. Spinal involvement 10%
d. Unilateral in mccune albright
e. No calc or ossification distinguish from other bony lesions

Answer 19

c. Spinal involvement 10%

• *LJS:
  a. Mono less earlier than poly - not sure exactly what this means. Type of abn depends on when in embryogenesis mutation happened. Polyostotic syndromic occurs earlier than mono. If this is what is meant then correct.
  b. Leontisis ossea extra - leontiasis ossea is a monoostotic form of FD (no extracranial lesions)
  c. Spinal involvement 10% - rare in monoostotic, bottom of list of Robbins frequency in polyostotic. So could be true.
  d. Unilateral in mccune albright - true
  e. No calc or ossification distinguish from other bony lesions - ?true, inadequately mineralised bone

*IVM: Does GG matrix not count as ossification that distinguishes it from other bony lesions? (relating to amount of woven bone in the lesion).
Favour e *wji agree

Question 20

brain lesion cyst with a nodule

Answer 20

scolex = neurocysticercosis

SCS: depends on stem. Could be JPA, Haemangioblastoma.

Question 21

33. Not seen in MEN 1

a. Phaeochromocytoma.
b. Prolactinoma
c. Pancreatic islet cell tumours
d. Hyperparathyroidism

Answer 21

a. Phaeo

SDA:
MEN 1 - PiParPanc
MEN 2a - PMP (phaeo, medullary thyroid, parathyroid hyperplasia)
MEN 2b - PMMM (Phaeo, medullary, marfan, mucosal neuromas)

*SCS : I have added some extra options for learning.
Prolactinoma- most common subtype of pituitary adenoma
Pancreatic islet cell tumour.
HPT caused by parathyroid hyperplasia or adenoma (and rarely carcinoma)- also seen in MEN IIa (but not IIb)

Question 22

34. Skull base lesion eroding jugular foramen

a. Paraganglioma

Answer 22

glomus jugulare

Question 23

35. Wrong sticker put on request, that patient came up what question to ask
    a. What are you having
    b. Whats you name
    c. DOB
    d. Ward
    e. NHI

Answer 23

b. Whats you nameuhhh

Maybe their number? https://www.youtube.com/watch?v=kTFZyl7hfBw - 3:34

**LJS - what study are you having? Presume if the incorrect patient sticker is on the request form and that patient is brought to dept, then the name on form will match what they say and won’t pick up the error. Clinical hx/study requested won’t match pt hx. Hope the pt isn’t confused!

This happened to me once. 1st year colon heaven and this poor outpatient did full bowel prep as they received a letter stating they should, and didn’t question it. Something tweaked when I spoke to the patient, called the referrer and it was wrong sticker/patient put on form in OP clinic. Ooops.

Question 24

36. Child tracheomalacia
    a. Expiratory wheeze
    b. Wide trachea
    c. Ballooning hypopharynx

Answer 24

• LW:
• no mention of clinical wheeze, but reports expiratory stridor….
• Collapsed trachea in AP diameter
• No mention of ballooning hypo pharynx

**LJS - wide trachea in inspiratory CT (posterior bowing of membranous portion) and narrow cresentic in expiratory.

• Wheeze seems unlikely since it’s upper airway problem = stridor if anything.
• Ballooning occurs in croup

Question 25

37. SVC obstruction enhancing structure right hilum
    a. Lymph node
    b. Azygous
    c. Tumor

Answer 25

c. Tumor

Question 26

38. Antenatal echogenic lesion in right atrium
    a. Fibroma
    b. Rhabdomyoma
    c. Atrial myxoma

Answer 26

b. Rhabdomyoma- cardiac rhabdomyoma: considered the commonest fetal cardiac tumor
- cardiac fibroma: considered second commonest fetal cardiac tumor 3
- cardiac teratoma: considered third commonest fetal cardiac tumor 3

fetal pericardial teratoma- cardiac myxoma- cardiac hemangioma

Question 27

39. Vascular dilation proximal cavernous ICA
    a. Not clinically significant
    b. Urgent surgical referral due to risk of ICH
    c. Rupture may cause proptosis and vision loss

Answer 27

Cavernous carotid aneurysms (CCAs) constitute 2%–9% of all IC aneurysm.[1] These aneurysms are can be idiopathic, traumatic, iatrogenic, or infectious in etiology. Traumatic, iatrogenic, and infectious aneurysms have an aggressive course and need urgent intervention.[2] The natural history of idiopathic cavernous aneurysms is not well known. They often remain asymptomatic and are detected incidentally. They tend to become large to giant in size when they manifest with features of mass effect in the form of cranial nerve palsies of adjacent nerves. This could be in the form of diplopia, ptosis, ophthalmoplegia, or pain or paresthesia along the fifth nerve distribution. A Large transitional variant of these aneurysms which have an intradural component can press against the optic nerve and result in visual symptoms. These intradural variants also carry a risk of subarachnoid hemorrhage (0.2%–0.4%).[3,4] Intracavernous rupture can result in direct caroticocavernous fistula although such instances are rare.[2] Rarely, these aneurysms can erode into the sphenoid sinus and rupture resulting in fatal epistaxis. Spontaneous thrombosis of these aneurysms has also been reported as have been thromboembolic strokes originating from intra-aneurysmal thrombus.[5,6]

Question 28

wells score

Answer 28

Criteria
clinical signs and symptoms of DVT = 3

an alternative diagnosis is less likely than PE = 3

heart rate more than 100 = 1.5

immobilization for 3 or more consecutive days or surgery in the previous 4 weeks = 1.5

previous objectively diagnosed PE or DVT = 1.5

hemoptysis = 1

malignancy (on treatment, treatment in last 6 months or palliative) = 1

Risk either 3 level or 2 levels
3 levels
Score
0-1 low
2-6 moderate
>6 high

2 levels
<4 low
>4.5 high

Question 29

42. Reduce dose to baby in pregnancy
    a. Increase pitch
    b. Decrease MA
    c. Lead shielding to stomach
    d. Omit lateral scout

Answer 29

• AJL - Favour pitch or mA. (tricky to look up so based on prior knowledge as outlined below, let me know if you disagree)
• Increased pitch will decrease dose.
• Decrease mA will decrease dose, this is used in lung cancer screening CT, however typically mA is modulated and automatic. You can reduce the automated minimum amperage.
• Lead shielding - most of the dose to the abdomen come from scatter within the patient (talking about CTPA presumably) therefore lead shield doesn’t do much.
• Lateral scout is used for dose modulation of mA so omitting that may actually lead to an overall increase in dose.

Previous answer:
The answer is controversial

Probably C or D

a - increase pitch -> increase distance between each slice -> decrease dose
b - decrease MA -> decrease dose
c - lead shielding has research evidence to suggest decreased dose
d - omit lateral scout will obviously decrease dose who knows

Question 30

44. Question about DCIS appearances
    a. Calcification 1mm branching
    b. Mass like enhancement on MRI

Answer 30

a. Calcification 1mm branching

**LJS - non-masslike enhancement on MRI

Question 31

47. Mammo screening fine calcification of different sizes

a. DCIS

Answer 31

a. DCIS

Question 32

pivot-shift injury : described

Answer 32

valgus stress to flexed and externally rotated knee
contusion pattern: posterolateral tibial plateau and mid part of lateral femoral condyle associated with anterior cruciate ligament (ACL) tears see also: contrecoup injury of the knee

Question 33

51. Male cholestasis bile duct not dilated

a. Anabolic steroid

Answer 33

a. Anabolic steroid

Question 34

22. Discitis OM

a. Mimic modic 1

Answer 34

**LJS - true

SD:
Modic type I
T1: low signal
T2: high signal
represents bone marrow edema and inflammation
T1+C: enhancement
Modic type II
T1: high signal
T2: iso to high signal
represents normal red haemopoietic bone marrow conversion into yellow fatty marrow as a result of marrow ischemia
Modic type III
T1: low signal
T2: low signal
represents subchondral bony sclerosis

Question 35

23. Thymus false

a. Peaks mass by 10-15
b. Occurs in adolescence
c. XR anterolateral bulge normal variant
d. Decrease in size in stress

Answer 35

Answer - Decrease in size during stress - FALSE

• LW:
• -> with regards to thymus, this is TRUE - in periods of stress thymus may shrink to approx 40% of its size, while in recovery phase may grow back even larger.

Thymus maximal weight in adolescence between 12 and 19 years (35 g)

Fatty replacement starts at puberty and occurs more rapidly in males than females

The thymus is seen as a triangular sail (thymic sail sign) frequently towards the right of the mediastinum

Thymoma > 40 yr (70% present in 40s and 50s)
Thymic hyperplasia is a differential for thymic mass - non neoplastic diffuse enlargement. Enlargement due to stress - rebound after chemo/steroids, burns, severe systemic stress

• *LJS - did they mean thymus - false?
• AJL - I was equally confused and have changed the question to Thymus.

Question previously read:
23. Thymoma false

a. Peaks mass by 10-15
b. Occurs in adolescence
c. XR anterolateral bulge normal variant
d. Decrease in size in stress

Question 36

24. Pulmonary oedema normal heart - false:

a. Acute MI
b. Chronic pericarditis
c. Hydrocephalus
d. Massive PE

Answer 36

• LW:
  a. Acute MI - TRUE

b. Chronic pericarditis - more commonly causes right sided failure and peripheral oedema than pulmonary oedema, so out of options listed, this is my preferred incorrect answer.
c. Hydrocephalus - Rare but true (e.g. obstructed shunt)
d. Massive PE - TRUE

Causes of pulmonary oedema:

1) Hydrostatic edema
- Cardiogenic edema: left-sided heart failure
- Fluid overload: Renal failure
- Pulmonary edema associated with acute asthma
- Postobstructive pulmonary edema
- Pulmonary edema associated with acute and chronic thromboembolism
- Pulmonary edema associated with pulmonary venoocclusive disease
- Near drowning

2) Permeability edema with diffuse alveolar damage (DAD)
- Acute respiratory distress syndrome (ARDS)

3) Permeability edema without DAD
- Opiate overdose edema
- Transfusion-related lung injury (TRALI)
- High-altitude pulmonary edema (HAPE)

4) Mixed edema: Both hydrostatic and permeability edema
- Neurogenic pulmonary edema
- Reexpansion pulmonary edema
- Reperfusion edema
- Edema following lung transplantation
- Postpneumonectomy pulmonary edema

Question 37

25. Blakes pouch cyst:

a. Normal vermis, normal post fossa, no bony expansion, large 4V
b. Variations eg enlarge post fossa = dandy walker, bony expansion = arachnoid cyst, vermian hypoplasia = dandy walker

Answer 37

Normal cerebellar vermis, communicates with 4th V (but not cisterna magna), nearly always hydrocephalus

WJI: in blakes pouch cyst will have normal vermis with sharp fastigial point but vermis is superiorly rotated with increased tegmentovermian angle.
Vermian dysgenesis will have superior rotation with deficient vermis and loss of sharp fastigial point.
DW shows findings of vermian dysgenesis with elevation of torcula.
Mega cisterna magna and posterior fossa arachnoid cyst have normal vermis and tegmentovermian angle with enlarged cisterna magna.

Question 38

26. Biopsy pre-procedural values (repeat)

a. INR <1.6 >50000 plt
b. INR <2.0 >10000 plt
c. INR 1.0 > 100000 plt

Answer 38

a. INR <1.6 >50000 plt

* SCS I have added values to obscure the answer

Question 39

27. Pregnancy painless bleed

a. Previa
b. Acreta
c. Percreta
d. Abruption

Answer 39

a. Previa

Question 40

28. Ectopic

a. Most common symptom is bleeding
b. Interstitial line positive in cornual pregnancy

Answer 40

b. Interstitial line positive in cornual pregnancy

**LJS though depends, some people use “cornual pregnancy” to mean pregnancy in cornua of septate or unicornuate uterus. Can also be used to refer to ectopic pregnancy in cornua of uterus

*LW:
interstitial line sign: an echogenic line from the mass to the endometrial echo complex reportedly has high sensitivity (80%) and specificity (98%), for an interstitial ectopic, which shouldnt be used interchangable with cornual, as are separate per radiopedia (Robbins clumps them together).

I think pain is most common sx

Question 41

29. Andes cyst with nodule

a. Cesticercosis

Answer 41

.

Question 42

30. What other findings may be seen in a patient with patellofemoral arthropathy?

a. Periosteal reaction.
b. Symphysis pubis calcifications
c. T2 hyperintensity of the thigh muscles.
d. Renal mass

Answer 42

*LW:
b. Symphysis pubis calcifications
Likely inferring CPPD disease, as common cause for patellofemoral arthopathy in isolation, so see other areas of chondrocalcinosis

**AJL - I added some other options to the question to help with learning. ‘b’ was the only original option. Feel free to edit.

Question 43

31. Air fluid level crossing thyrohyoid ligament

a. Laryngocelel
b. Tumor
c. Thyroglossal duct cyst

Answer 43

a. Laryngocelel

Question 44

32. Phaeochromoscytoma

a. Carney

Answer 44

**LJS true

Phaeo associations:
VHL 
NF1
MEN2A and 2B (not MEN1) 
TS
Sturge-Weber
Carney syndrome - pulmonary chondroma, gastric leiomyosarcoma, pheo

*LW:
Carney triad:
1) extra-adrenal paraganglioma (e.g. spinal paraganglioma)
2) gastric gastrointestinal stromal tumours (GIST)
3) pulmonary chondroma

Carney syndrome:
familial paraganglioma and gastric stromal sarcoma.

*AJL (just to complete the Carneys…)
Carney complex - Cardiac myxoma and skin pigmentation (blue naevi)