Section 3 Flashcards
A 50-year-old patient presents in OPD with symptoms of mental status changes, increased ICP, generalized seizure, and multiple cranial palsies. Risk factors for CNS lymphomas are immunosuppression (AIDS, transplants), Epstein-Barr virus, and collagen vascular disease. What is the best statement regarding management of these tumors?
● A. Treatment is usually with radiotherapy and steroids with very good response initially to steroids (short-lived disappearance also known as“Ghost Tumors”)
● B. There can be a need for placement of ventricular access reservoir for chemotherapy
● C. Biopsy should be taken prior to commencement of treatment to confirm the diagnosis
● D. Debulking of extremely large tumors causing symptoms should be done
● E. All of the above
E. All of the above
The essential diagnostic criteria for primary diffuse large B-cell lymphoma of the CNS are biopsy-proven mature large B-cell lymphoma confined to the CNS at presentation and expression of one or more B-cell markers (CD20, CD19, CD22, CD79a, PAX5).
Which of the following are other types of CNS lymphoma?
● A. Immunodeficiency-associated CNS lymphoma (AIDS related, EBV related, lymphomatoid granulomatosis)
● B. Intravascular large B-cell lymphoma
● C. Miscellaneous rare lymphomas in the CNS (low grade B-cell lymphomas, T-cell and NK/T-cell lymphomas, anaplastic large lymphoma)
● D. Extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma) of the dura
● E. All of the above
E. All of the above
Following are the conditions with increased risk of CNS lymphoma except?
● A. Collagen vascular disease (SLE, Sjogren’s syndrome, rheumatoid arthritis)
● B. Organ transplant recipients (post-transplant lymphoproliferative disease) and AIDS patient
● C. Low incidence in elderly due to good immune system in these patients
● D. Severe congenital immunodeficiency syndrome
● E. Epstein-Barr virus related
C. Low incidence in elderly due to good immune system in these patients
What are the common sites of primary CNS lymphomas (PCNSL)?
● A. Temporal and occipital lobes of brain
● B. Corpus callosum, basal ganglia, periventricular region, and cerebellum
● C. Brainstem, leptomeninges, and spinal cord
● D. Suprasellar region and pineal region
● E. None of the above
B. Corpus callosum, basal ganglia, periventricular region, and cerebellum
A patient presents with painful skin nodules and plaques in the abdomen and lower extremities, fever, cranial neuropathies, and multifocal cerebrovascular events. Biopsy showed malignant lymphoid cells in the small arteries, veins, and capillaries with little or no parenchymal extension. What is the most likely diagnosis in this patient?
● A. Fungal infection of CNS blood vessels
● B. Inflammation of CNS blood vessels due to chronic infection
● C. Intravascular lymphomatosis or angioendotheliomatosis
● D. B cell lymphoma of CNS vasculature
● E. T cell lymphoma of the CNS
C. Intravascular lymphomatosis or angioendotheliomatosis
Following are the investigations and their findings in PCNSL except?
● A. Multiple hyperdense lesions on CT of brain which are contrast enhancing and shows as fluffy cotton balls
● B. Bright on DWI and isointense to hypointense on ADC map
● C. Low levels of serum lactate dehydrogenase indicates rapid cell turnover and is an independent poor prognosticator
● D. Sensitivity of CSF analysis is higher when more than 10.5 mL of CNS is taken with up to 3 LPs
● E. Immunoglobulin analysis shows a single elevated immunoglobulin heavy chain band with lymphoma
C. Low levels of serum lactate dehydrogenase indicates rapid cell turnover and is an independent poor prognosticator
Radiation therapy for PCNSL consists of whole brain radiation after biopsy with 40 to 50 gray total dose in 1.8 to 3 gray daily fraction while chemotherapeutic agents are methotrexate, which is given through intraventricular access device with
6 doses of 12 mg twice a week combined with IV leucovorin, and rituximab. What is the management for overdosage of methotrexate?
● A. Ventricular lumbar perfusion over several hours with 240 mL of warm saline, 2000 U of carboxypeptidase G2 intrathecally with IV dexamethasone and IV leucovorin
● B. Stopping the drug and start draining CSF through LP
● C. Draining the CSF and IV steroids
● D. Stopping the drug and giving IV steroids with intrathecal (IT) leucovorin
● E. None of the above
A. Ventricular lumbar perfusion over several hours with 240 mL of warm saline, 2000 U of carboxypeptidase G2 intrathecally with IV dexamethasone and IV leucovorin
With no treatment of PCNLS, median survival is 1.8 to 3.3 months following diagnosis. Which statement is correct regarding median survival after radiotherapy?
● A. There is no effect of radiotherapy on median survival
● B. Median survival is 10 months with 47% at 1 year, 16% at 2 years, 8% at 3 years, and 3 to 4% at 5 years
● C. Median survival is 87% at 1 year, 47% at 2 years, 16% at 3 years, 8% at 5 years
● D. Increase in median survival is according to the age of the patient
● E. There is no role of chemotherapeutic agent on recurrence of the tumor
B. Median survival is 10 months with 47% at 1 year, 16% at 2 years, 8% at 3 years, and 3 to 4% at 5 years
The essential diagnostic criteria of immunodeficiency-associated CNS lymphomas are a B cell lymphoma confined to the CNS at presentation, in an immunodeficient patient and EBV positivity of tumor cells. What is the median survival of patients with this disease?
● A. 1 to 3 months
● B. 3 to 5 months
● C. 5 to 7 months
● D. 7 to 9 months
● E. 9 to 11 months
B. 3 to 5 months
A patient presents with tender enlarging skull mass. Skull X-ray shows round or oval, sclerotic, punched-out skull lesion with sharply defined margins, involving both inner and outer tables (the disease begins in the diploic space) often with beveled edges, and a central bone density is occasionally noted. CT of brain showed characteristic appearance of a soft tissue mass
within area of bony destruction having a central density. What is the location of Langerhans cell histiocytosis?
● A. Craniofacial bones and skull base favoring the parietal and frontal bones
● B. Hypothalamic pituitary region
● C. Meninges
● D. Choroid plexus
● E. All of the above
E. All of the above
What is the pathologic difference between primary and secondary CNS lymphomas?
● A. N/C ratio
● B. Mitotic activity
● C. Ki67 index
● D. Hyper-/hypochromasia
● E. No difference
E. No difference
What is the most common supratentorial location of PCNSL?
● A. Frontal lobe
● B. Temporal lobe
● C. Parietal lobe
● D. Occipital lobe
● E. Cerebellum
A. Frontal lobe
Which virus is most frequently associated with PCNSL in AIDS patient?
● A. Epstein Barr
● B. H. influenzae
● C. Human papilloma virus
● D. Norovirus
● E. Respiratory syncytial virus
A. Epstein Barr
What is the histopathologic workup to differentiate B-cell from T-cell variant of PCNSL?
● A. Gram staining
● B. Light microscopy
● C. Frozen section
● D. Electron microscopy
● E. Immunohistochemical stains
E. Immunohistochemical stains
A patient presented with PCNSL. He was sent to ophthalmologist for visual problems and an intraocular lymphoma was diagnosed. At what dose of radiotherapy the ocular lymphoma can be managed?
● A. 5 Gy
● B. 7 Gy
● C. 15 Gy
● D. 45 Gy
● E. 54 Gy
B. 7 Gy
Regarding CSF examination in PCNSL, proteomics may show elevated CSF levels of which of the following?
● A. Antithrombin III
● B. IgG bands
● C. LDH
● D. Lactate
● E. Wide bands
A. Antithrombin III
The standard treatment after tissue biopsy of PCNSL is whole-brain radiation therapy with total dose of how much?
● A. 4 to 5 Gy
● B. 30 to 40 Gy
● C. 40 to 50 Gy
● D. 54 Gy
● E. 50 to 60 Gy
C. 40 to 50 Gy
Regarding chemotherapy for PCNSL, the addition of intraventricular methotrexate delivered through a ventricular access device may result in better survival. What is the rescue drug given intravenously with this regime?
● A. Dexamethasone
● B. Methotrexate
● C. Leucovorin
● D. Avil
● E. Acetaminophen
C. Leucovorin
What is the most common location of Langerhans cell histiocytosis?
● A. Craniofacial bones and skull base
● B. Hypothalamic pituitary region
● C. Occipital bone
● D. Meninges
● E. Choroid plexus
A. Craniofacial bones and skull base
Craniopharyngiomas are thought to develop from residual cells of Rathke’s pouch (craniopharyngeal duct) in the sellar region. These constitute 5 to 11% of pediatric brain tumors, which makes them the most common non-neuroepithelial intracerebral tumor in children. These tumors are considered be-
nign in histology and malignant in behavior. Why these tumors are malignant in behavior?
● A. Because of distant metastasis of these tumors
● B. Because of extensive damage to the bone in sellar region
● C. Due to involvement of neural tissue which makes them difficult to cure
● D. Because it often involves the floor of the third ventricle with resultant hydrocephalus
● E. Because of damage to optic apparatus
C. Due to involvement of neural tissue which makes them difficult to cure
Craniopharyngiomas, with bimodal age distribution (childhood peak age 5–15 years, adult peak age 45–60 years), and solid and cystic squamous epithelial tumor with stellate reticulum, wet keratin, and basal palisades, tend to arise from the superior anterior margin of pituitary. Which statement is incorrect regarding location and imaging of adamantinomatous craniopharyngiomas?
● A. Most occur in the region of sella turcica and pituitary infundibulum
● B. Most are purely sellar lesions, with rare extension into the suprasellar region
● C. Pure involvement of the third ventricle is more common with the papillary craniopharyngiomas
● D. 90% of adamantinomas exhibit at least two of the following C features: cyst formation, prominent calcifications, contrast enhancement in the cyst wall
● E. Fluid in the cyst varies but usually contains cholesterol crystals
B. Most are purely sellar lesions, with rare extension into the suprasellar region
Papillary craniopharyngioma (CP) constitutes 10% of all CPs and occurs almost exclusively in adults with a mean age of 40 to 55 years. These are less frequently cystic than adamantinomas and are most commonly located at which of the following?
● A. Intrasellar region
● B. Infundibular recess and tuber cinereum of the floor of the third ventricle
● C. Invade extensively into sphenoid sinus
● D. Cause destruction of surrounding bones and grow into these
● E. These extend extensively into the parasellar region
B. Infundibular recess and tuber cinereum of the floor of the third ventricle
Arterial feeders that supply the craniopharyngiomas arise from which artery?
● A. Anterior cerebral artery
● B. Anterior communicating artery
● C. Internal carotid artery
● D. Posterior communicating artery
● E. All of the above
E. All of the above
Which of the following statements is incorrect regarding treatment of craniopharyngioma?
● A. With microscope possible approaches through subfrontal and frontotemporal regions include: subchiasmatic (between optic nerves and anterior to chiasma), opticocarotid region, lamina terminalis, transfrontal–transsphenoidal with drilling of tuberculum sellae
● B. Alternatives to frontotemporal approaches include: pure transsphenoidal, transcallosal, combined subfrontal pterional approach and extended transnasal transsphenoidal endoscopic resection
● C. Postoperative radiotherapy (XRT) has no role in preventing regrowth when residual is left behind and also it does not cause endocrine dysfunction, optic neuritis, and dementia
● D. Steroids are given in physiologic doses in all patients as all of these are considered hypoadrenal
● E. Diabetes insipidus often shows up early may be as a part of triphasic response and treated initially with fluid replacement
C. Postoperative radiotherapy (XRT) has no role in preventing regrowth when residual is left behind and also it does not cause endocrine dysfunction, optic neuritis, and dementia
In most series, 5-year survival after craniopharyngioma (CP) operation is 55 to 85% with 5 to 10% mortality. What is the most cause of mortality in these patients?
● A. From injury to brain stem which causes long tract signs and cranial nerve palsies
● B. Damage to hypothalamus bilaterally which may lead to hyperthermia, somnolence, and loss of thirst sensation
● C. Postoperative malignant hydrocephalus
● D. Postoperative sudden brain herniation
● E. All of the above
B. Damage to hypothalamus bilaterally which may lead to hyperthermia, somnolence, and loss of thirst sensation
A patient presents with bitemporal hemianopia, hypopituitarism, headache, and diabetes insipidus. Imaging characteristics of these tumors are similar to that of adenomas with cure requiring gross total resection with a higher recurrence rate. These tumors include pituicytoma, granular cell tumor of the sellar region, and spindle cell oncocytoma. Where do these low-grade tumors originate from?
● A. Pituicytes of the neurohypophysis (posterior pituitary)
● B. Infundibulum/pituitary stalk
● C. Pituicytes of anterior pituitary
● D. Remnants of Rathke’s pouch
● E. Both A and B
E. Both A and B
Pituitary adenoma is a clonal neoplasm of anterior pituitary hormone producing cells which are also called as pituitary neuroendocrine tumors (PitNET). Following are included in the essential diagnostic criteria of pituitary adenoma/PitNET tumors except?
● A. Reticular fiber disruption
● B. Sellar suprasellar location
● C. Histologic features of low-grade neuroendocrine tumors that display destruction of the normal anterior gland acinar structure
● D. Subclassified based on immunoreactivity for pituitary hormones
● E. Subclassified on the basis of lineage-specific transcription factors
A. Reticular fiber disruption
A patient presents with progressive blindness, ophthalmoplegia, CSF rhinorrhea, and hyperprolactinemia in blood. On MRI pituitary tumor with invasion of the surrounding structures was seen with encasement of internal carotid artery and noncontiguous metastasis was seen categorizing this tumor as pituitary carcinoma. What are the suggested management options for invasive pituitary tumors?
● A. Initial surgery by a surgeon with extensive experience in pituitary surgery
● B. If Ki67 index comes out to be more than 3 then p53 immunodetection and mitotic count should be evaluated as potential predictors of tumor’s aggressiveness
● C. Repeat surgery should be considered for residual or recurrent tumors while XRT can also be given for clinically relevant tumor remnant with markers that suggest aggressive behavior
● D. Chemotherapy for tumors showing continued growth on Stupp regimen (temozolomide 150–200 mg/m2 for 5 consecutive days for 28 days with XRT and continued for 6 months if clinical response is evident)
● E. All of the above
E. All of the above
Which of the following is not included in the Hardy’s classification (anatomic classification) of invasive pituitary tumors?
● A. Extension includes suprasellar extension (0, A, B, and C) and parasellar extension (D and E)
● B. 0, A, B, and C denote no tumor extension, extension into suprasellar cistern, extension into anterior recess of the third ventricle, and extension into the floor of the third ventricle, respectively
● C. Invasion/spread includes spread into the floor, into the sphenoid sinus, and distant metastasis
● D. Spread/invasion is classified as 1, 2, 3, 4, and 5 which indicate no sellar expansion with tumor < 10 mm, sellar expansion with tumor > 10 mm, localized perforation of sellar floor, diffuse destruction of sellar floor, and spread via CSF or blood, respectively
● E. All of the above statements are correct
E. All of the above statements are correct
Which craniopharyngioma with epithelium that forms stellate reticulum, wet keratin, and basal palisades and frequently shows CTNNB1 mutations and aberrant nuclear expression of beta-catenin is now considered a distinct tumor differentiated
by gene mutation?
● A. Adamantinomatous
● B. Papillary
● C. Pseudopapillary
● D. Xanthochromic
● E. Malignant
A. Adamantinomatous
In contrast to adamantinomatous craniopharyngioma which of the following is a part of the diagnostic criteria of papillary craniopharyngioma?
● A. Absence of BRAF p. V600E mutation
● B. Immunoreactivity for BRAF p. V600E
● C. Presence of nuclear beta-catenin immunoreactivity
● D. Presence of CTNNB1 mutation
● E. Keratinizing mature squamous epithelium covering fibrovascular cores or a cyst wall
B. Immunoreactivity for BRAF p. V600E
All of the following vessels supply blood to craniopharyngioma except?
● A. ACA
● B. A-comm
● C. ICA
● D. P-comm
● E. Basilar artery (BA) bifurcation
E. Basilar artery (BA) bifurcation
Which of the following is the most common presenting symptom of infundibular tumors?
● A. Hypopituitarism
● B. Headache
● C. Visual field defect
● D. Diabetes insipidus
● E. Secondary amenorrhea
C. Visual field defect
According to Wilson’s anatomic classification for invasive pituitary tumors, what is the grade for localized perforation of the sellar floor?
● A. 1
● B. A
● C. B
● D. 3
● E. C
D. 3
If Ki-67 index of an invasive pituitary tumor comes out to be > 3%, then which further investigation is warranted for decision of XRT?
● A. p53 immunodetection
● B. BRAF immunodetection
● C. EGFR immunodetection
● D. PTCH immunodetection
● E. Rb immunodetection
A. p53 immunodetection
Most primary pituitary tumors are benign and arise from anterior pituitary gland (adenohypophysis). About 50% of pituitary tumors are less than 50 mm at the time of diagnosis, and these may be difficult to find at the time of surgery. What is the size of microadenomas?
● A. Less than 5 mm
● B. Less than 1 cm
● C. Less than or equal to 1 cm
● D. Less than 8 mm
● E. Any size with no mass effects
B. Less than 1 cm
PitNETs arise from the six adenohypophyseal cell types. These comprise 10% of intracranial tumors and peak incidence is in the 3rd and 4th decades of life. What are the most common pituitary tumors?
● A. Prolactinomas
● B. Cortisol producing pituitary tumors
● C. Nonfunctioning PitNETs
● D. Lactotroph tumors
● E. Somatotroph tumors
C. Nonfunctioning PitNETs
A PitNET without cell type specific differentiation based on immunohistochemistry, transcription factors, and negative PAS stain constitutes of 5 to 30% of surgically resected adenomas. These account for 5 to 30% of surgically resected adenomas and typically occur after the age of 60 years. What are
these tumors called?
● A. Null cell tumor
● B. Nonfunctioning adenomas
● C. Undifferentiated adenomas
● D. Acidophil stem cell tumor
● E. Mature PIT1-lineage tumor
A. Null cell tumor
Most PitNET/adenomas are sporadic and arise from a somatic mutation of single progenitor cells. However, PitNET may also occur as part of syndromes including which of the following?
● A. Multiple endocrine adenomatosis or neoplasia
● B. Carney complex
● C. Familial isolated pituitary adenoma
● D. McCune-Albright syndrome
● E. All of the above
E. All of the above
A patient presents with bitemporal hemianopia, hydrocephalus, ptosis, facial pain, diplopia, CSF rhinorrhea, and headache (possibly because of increased intrasellar pressure). On imaging, it comes out to be pituitary macroadenoma causing
mass effects and panhypopituitarism on investigations. Which pituitary hormone becomes decreased first in this case?
● A. Growth hormone
● B. Gonadotropins (LH, FSH)
● C. TSH
● D. ACTH
● E. Prolactin
A. Growth hormone
A patient presents with sudden onset of headache, visual disturbance, and loss of consciousness. A plain CT of the brain was done which showed hemorrhagic mass in sella turcica. CTA was done to rule out aneurysmal bleed which came out to
be positive. MRI showed it to be a case of pituitary apoplexy. What is the recommended management for this condition?
● A. Hydrocortisone 100 to 200 mg IV bolus followed by 2 to 5 mg/h IV bolus
● B. Rapid decompression within 7 days with transcranial or transsphenoidal approach
● C. Complete removal of tumor is usually not necessary
● D. Ventricular drainage for hydrocephalus is generally required
● E. All of the above
E. All of the above
A women presents with amenorrhea-galactorrhea syndrome (also known as Forbes-Albright syndrome, also known as Ahumadadel Castillo syndrome), infertility, and bones mass loss. What is the most common secretory adenoma?
● A. Gonadotropin secreting tumor
● B. Prolactinoma
● C. Growth hormone secreting tumor
● D. Cortisol secreting tumor
● E. None of the above
B. Prolactinoma
A patient presents with increasing hand and foot size, frontal bossing, prognathism, cardiac arrythmias, hypertension, glucose intolerance, peripheral nerve entrapment syndrome, joints pain, and sleep apnea. Brain imaging with endocrine
tests, cardiology consult, and colonoscopy was done in this patient, and surgery is planned for removal of tumor. What is the suggested criteria for biochemical cure of acromegalic patient?
● A. Normal IGF1 level
● B. Growth hormone level less than 5 ng/mL
● C. Growth hormone nadir less than 1 ng/mL after OGST
● D. No residual tumor on MRI of brain
● E. A, B, and C
E. A, B, and C
A patient presents with buffalo hump like shape, striae over lower abdomen, hyperpigmentation, osteoporosis, and generalized muscle wasting. On lab findings, there was elevated 24-hour urine free cortisol, failure to suppress cortisol with low dose (1 mg) dexamethasone test, normal or elevated ACTH, and hyperglycemia. These tumors constitute 10 to 12% of pituitary adenomas. What is the most likely tumor?
● A. Gonadotrophins
● B. Growth hormone producing tumor
● C. Prolactinomas
● D. ACTH secreting tumor
● E. TSH secreting tumor
D. ACTH secreting tumor
Nonfunctioning pituitary tumors present with mass effect and constitute 15 to 30% pituitary tumors (most common pituitary tumors). These tumors are mostly derived from which cells?
● A. Gonadotroph cells
● B. Lactotroph cells
● C. Somatotroph cells
● D. Thyrotroph cells
● E. Acidophil stem cells
A. Gonadotroph cells
Predominant secretion of prolactin over GH is seen in which of the following subtype of PIT1 lineage tumors?
● A. Mammosomatotroph tumor
● B. Mature PIT1 lineage tumor
● C. Lactotroph tumor
● D. Immature PIT1 lineage tumor
● E. Acidophil stem cell tumor
E. Acidophil stem cell tumor
Pituitary tumors represent what percentage of intracranial tumors?
● A. 2%
● B. 5%
● C. 10%
● D. 20%
● E. 30%
C. 10%
A 40-year-old male presented with sudden severe headache, visual disturbance, and loss of consciousness. A better improvement in ophthalmoplegia can be achieved in pituitary
apoplexy if surgery is performed within what time?
● A. 7 days
● B. 10 days
● C. 14 days
● D. 21 days
● E. 1 month
A. 7 days
A 35-year-old female presents with amenorrhea and decreasing vision. Radiology shows pituitary macroadenoma with gross destruction of sellar floor. What is the modified Hardy’s (Wilson’s) classification grade?
● A. I
● B. II
● C. III
● D. IV
D. IV
A 30-year-old female with amenorrhea was referred by endocrinologist to your clinic. What is the most common cause of secondary amenorrhea in women of reproductive potential?
● A. Prolactinoma
● B. OCPs
● C. Pregnancy
● D. Forbes Albright syndrome
● E. Ovarian cysts
C. Pregnancy
A 40-year-old depressive male with centripetal obesity, hypertension, hirsutism, and acne was referred by physician for neurosurgical opinion. Available laboratory reports show decreased ACTH levels. What is the probable source of hypercortisolism in this patient?
● A. Pituitary
● B. Lung/Pancreas tumor
● C. Adrenals
● D. Hypothalamus
● E. Medullary thyroid cancer
B. Lung/Pancreas tumor
A 50-year-old hypertensive male complains of headache, excessive perspiration, joint pains, sleep apnea, and fatigue. What should an acromegalic patient be screened for?
● A. Thyroid cancer
● B. Colon cancer
● C. Seminomas
● D. Uterine fibroids
● E. Chronic pancreatitis
B. Colon cancer
A 35-year-old female with visual field defects was referred by ophthalmologist. Which of the following hormones is least prone to be reduced due to compression of pituitary gland by a
macroadenoma?
● A. GH
● B. FSH
● C. LH
● D. Prolactin
● E. TSH
D. Prolactin
Simmond’s cachexia is associated with which of the following?
● A. Chronic panhypopituitarism
● B. Autoimmune hypophysitis
● C. Acromegaly
● D. Decreased growth hormone levels
● E. Prolactinoma
A. Chronic panhypopituitarism
What is the most common cause of Cushing syndrome?
● A. Iatrogenic
● B. Transsphenoidal excision of pituitary tumor
● C. Pituitary macroadenoma
● D. Adrenal adenoma
● E. Parathyroid gland tumors
A. Iatrogenic
Pituitary tumors can present with endocrine hyperfunctioning or endocrine deficit due to mass effect, visual field deficits classically bitemporal hemianopia, and deficits of cranial nerves. All of the following cranial nerves can be affected by pituitary adenoma except?
● A. Cranial nerve 3
● B. Cranial nerve 4
● C. Cranial nerve 6
● D. Cranial nerves V1 and V2
● E. Cranial nerve V3
Practice guidelines for visual evaluation in patients with pituitary adenoma include evaluation by an ophthalmologist, automatic static perimetry to detect visual field deficits, visual evoked potential, and optical coherence tomography (not a practice standard). Which patients should be advised that the chances of return of vision postoperatively are reduced?
● A. Those with visual loss for more than 7 days
● B. Older patients and patients with visual loss for more than 28 days
● C. Older patients and those with visual loss for more than 4 months
● D. Older patients and those with visual loss for more than 6 months
● E. All patients with complete visual loss for more than 72 hours
Chiasma is located above the sella in most patients but it is posterior to the sella (postfixed chiasma) in 4% and anterior to the sella (prefixed chiasma) in 8% of cases. A patient with pituitary adenoma presents with monocular visual loss in one eye with superior temporal quadrantanopsia in the contralateral eye from compression of anterior knee of Wilbrand (pie in the sky defect or junctional scotoma). This finding is most common in which type of chiasma?
● A. Postfixed chiasma
● B. Prefixed chiasma
● C. Central chiasma
● D. Chiasma pushed toward one side
● E. Chiasma pushed downward
Screening tests for anterior pituitary hormones should be checked in all patients with pituitary tumors. Cortisol level generally peak between 7 and 8 a.m., and the normal level of cortisol is between 6 and 18 μg/100 mL. Following statements regarding interpretation of cortisol level are correct except?
● A. 8 a.m. cortisol level is more accurate for detecting hypocortisolism
● B. 24-hour urine-free cortisol is also accurate for detecting hypocortisolism
● C. 8 a.m. cortisol less than 6 μg/100 mL is suggestive of adrenal insufficiency
● D. 8 a.m. cortisol level between 6 and 14 μg/100 mL is non-diagnostic
● E. 8 a.m. cortisol more than 14 μg/100 mL is suggestive that adrenal insufficiency is unlikely
Selective loss of a single pituitary hormone together with thickening of pituitary stalk is strongly suggestive of which of the following?
● A. Pituitary stalk tumor
● B. Hypothalamic tumor extending to pituitary stalk
● C. Selective pituitary adenoma
● D. Autoimmune hypophysitis
● E. None of the above
Normal value of T4 hormone is 4 to 12 μg/100 mL while that of TSH is 0.4 to 5.5 mcU/100 mL. Normal response of thyrotropin releasing hormone (TRH) stimulation test (500 μg TRH IV) is peak TSH twice baseline value at 30 minutes. What does exaggerated response suggests?
● A. Secondary hypothyroidism
● B. Pituitary deficiency
● C. Primary hypothyroidism
● D. TSH secreting adenoma
● E. Hypothalamus insufficiency
Normal levels of prolactin (ng/mL) are 3–30, 10–400, and 2-20 in nonpregnant, pregnant, and postmenopausal females. Moderate elevation of 25 to 150 suggests prolactinoma or stalk effect while levels more than 150 suggests prolactinoma.
Which of the following statements regarding high prolactin level is correct?
● A. Prolactin is the only pituitary hormone primarily under inhibitory regulation
● B. Stalk effect is due to compression or injury to hypothalamus or pituitary stalk from surgery or from tumor mass
● C. Levels more than 500 usually suggests that surgery alone will not be able to normalize prolactin (PRL)
● D. Hook effect is falsely low levels of PRL in the presence of extremely high levels of PRLs due to formation of PRL antibody signal complexes
● E. All of the above
Dexamethasone 1 mg given orally at 11 p.m., measuring serum cortisol at 8 a.m., and serum sample next morning is a low-dose dexamethasone suppression test. If cortisol is less than 1.8 μg/dL, Cushing syndrome (CS) is ruled out while if cortisol is more than 10 μg/dL CS is probably present. Following tests are used to distinguish Cushing’s disease from ectopic ACTH production except?
● A. Random serum ACTH levels (if less than 5 ng/L, then ectopic ACTH less likely)
● B. Abdominal CT to see ectopic source of ACTH
● C. High-dose dexamethasone suppression test
● D. Metyrapone test
● E. Cosyntropin stimulation test
E. Cosyntropin stimulation test
What is the most useful test for a patient with acromegaly?
● A. Insulin-like growth factor (IGF-1) levels
● B. Oral glucose suppression test
● C. Growth hormone releasing hormone levels
● D. Growth hormone releasing hormone stimulation test
● E. Octreotide scan
A. Insulin-like growth factor (IGF-1) levels
Numerous criteria have been proposed to determine cavernous sinus invasion. Which of the following is correct regarding Knosp et al’s grading of cavernous sinus invasion?
● A. Grade 0: tumor does not cross medial line
● B. Grade 1: tumor crosses the medial line but not the median line
● C. Grade 2: tumor crosses the median line but not the lateral line
● D. Grade 3 (a and b): tumor extends lateral to lateral line superiorly or inferiorly
● E. Grade 4: tumor completely wraps around the intracavernous ICA
● F. All of the above correct
F. All of the above correct
A 30-year-old female presents with palpitations and excessive sweating. Which of the following suggest secondary hyperthyroidism on thyroid function tests?
● A. ↓TSH↑free T4
● B. ↓TSH ↓free T4
● C. ↑TSH ↓free T4
● D. ↑TSH ↑free T4
● E. Thyroid Usg
D. ↑TSH ↑free T4
Desaturation of color is an early sign of which of the following?
● A. Chiasmal compression
● B. Optic nerve compression
● C. Optic nerve atrophy
● D. Papilledema
● E. Ethambutol toxicity
A. Chiasmal compression
A 40-year-old male with pituitary adenoma was referred for ophthalmology consult. Which of the followings is not a screening test but may provide prognosticative information?
● A. Visual Humphrey field test
● B. Goldman field test
● C. Static visual field tests
● D. Optical coherence tomography
● E. Visual acuity
D. Optical coherence tomography
A 35-year-old female with amenorrhea presented with visual disturbance. MRI of brain revealed a 4-cm pituitary tumor. The prolactin levels were within normal range, which may be attributed to which of the following?
● A. Stalk effect
● B. Hook effect
● C. Macroprolactinemia
● D. OCP-induced
● E. Antiplatelet therapy
B. Hook effect
How high the prolactin levels can be in a pregnant female?
● A. 400
● B. 800
● C. 1000
● D. 1200
● E. 1500
A. 400
Which of the followings is not associated with raised prolactin levels?
● A. Primary hypothyroidism
● B. Primary hyperthyroidism
● C. OCPs
● D. Phenytoin
● E. Metocloperamide
B. Primary hyperthyroidism
What is the initial recommended test for suspected acromegaly?
● A. Morning growth hormone levels
● B. 24-hour urine-free cortisol
● C. Somatomedin C
● D. Plasma metanephrines
● E. 11 p.m. growth hormone levels
C. Somatomedin C
What is the screening test for functional assessment of neurohypophysis?
● A. Insulin-like growth factor 1 levels
● B. Oral glucose suppression test
● C. Inferior petrosal sinus sampling
● D. Water deprivation test
● E. Random serum glucose levels
D. Water deprivation test
Serum cortisol levels nadir around what time?
● A. 6 a.m.
● B. 8 a.m.
● C. 11 p.m.
● D. Midnight
● E. Midmorning
C. 11 p.m.
A patient presented with obesity, abdominal striae, hypertension, and easy bruising. His serum cortisol was found to be slightly elevated. A low-dose dexamethasone suppression test was done and was found to be 5 μg/dL. What is the next step in
management?
● A. 2-day low-dose dexamethasone test
● B. High-dose dexamethasone suppression test
● C. Adrenal CT scan
● D. Adrenal MRI
● E. MIBG scan
A. 2-day low-dose dexamethasone test
Inferior petrosal sinus sampling is an invasive test for Cushing disease (CD). What is the level of post corticotropin releasing hormone (CRH) ratio compatible with primary CD?
● A. < 1
● B. < 2
● C. < 3
● D. > 3
● E. > 10
D. > 3
What is the gold standard test for the integrity of hypothalamic pituitary adrenal axis?
● A. Inferior petrosal sampling
● B. Somatomedin C
● C. Insulin tolerance test
● D. MRI of brain
● E. MRI of brain and abdomen
C. Insulin tolerance test
Prolactinoma is the only pituitary tumor for which medical therapy (dopamine agonist) is the primary treatment modality (in certain cases). Which of the following statements is incorrect regarding hormone replacement therapy in patients with
pituitary hormone deficits?
● A. Indication of corticosteroids administration is inadequate cortisol reserve as demonstrated by failing a cosyntropin stimulation test (failure to achieve peak cortisol level of more than 18 μg/dL in response to cosyntropin)
● B. Physiologic replacement dose of cortisol is 20 mg PO every a.m. and 10 mg PO every 4 p.m. and stress doses may be needed
● C. Thyroid replacement is done before giving cortisol in patients with adrenal deficiency
● D. Hypothyroid patients frequently undergo surgery without adequate replacement with no untoward effect
● E. Testosterone replacement can promote tumor growth and should be waited until stabilization of tumor
C. Thyroid replacement is done before giving cortisol in patients with adrenal deficiency
What is the recommended treatment option for tumors secreting growth hormone or ACTH?
● A. An aggressive surgical approach is needed because the secretion product is harmful and effective medical adjuvants are lacking
● B. Growth hormone secreting tumors are pretreated with somatostatin analog therapy to reduce surgical risks
● C. In elderly patients or in tumors more than 4-cm diameter, the tumor is debulked transsphenoidally and then adjuvant radio- or chemotherapy is given
● D. In younger age and tumor size less than 4 cm, radical surgery to remove the whole tumor is done (may utilize cranio-orbito-zygomatic skull base approach)
● E. All of the above
E. All of the above
What is the primary treatment modality for nonfunctioning pituitary adenomas?
● A. Surgical resection
● B. Treatment with dopamine agonists (bromocriptine) and somatostatin analog (octreotide)
● C. Radiotherapy
● D. Only observation
● E. A combination of surgery, radiotherapy, and chemotherapy is needed in all cases
A. Surgical resection
All of the following are included in the surgical indications of nonfunctioning pituitary macroadenomas except?
● A. Tumors causing symptoms by mass effect, for example, visual field deficits
● B. Tumors with no symptoms of endocrine or visual field deficit but elevated chiasma never need surgical intervention at this point of time
● C. Acute or rapid visual or other neurologic deterioration
● D. To obtain tissue for pathological diagnosis
● E. Nelson’s syndrome
B. Tumors with no symptoms of endocrine or visual field deficit but elevated chiasma never need surgical intervention at this point of time
Prolactinomas are essentially the only pituitary adenomas for which medical therapy is sometimes the primary treatment modality. If prolactin levels are more than 500 ng/mL with no acute progression, an initial attempt at purely medical control should be made as the chances of normalizing prolactin surgically with preoperative level more than 500 ng/mL are very low, and these tumors may shrink dramatically with bromocriptine. What are the surgical indications in patients with prolactinomas?
● A. Prolactin levels less than 500 ng/mL in tumors that are not extensively invasive
● B. If there is no significant decrease in prolactin levels in 4 to 6 weeks after medical therapy
● C. If there is no decrease in visual deficits in 4 to 6 weeks after medical therapy
● D. No shrinkage in tumor size on MRI in 4 to 6 weeks after medical therapy
● E. All of the above
E. All of the above
Bromocriptine (Parlodel) is a drug that binds to dopamine receptors (dopamine agonist) on normal and tumor lactotrophs, inhibiting synthesis and secretion of prolactin and other cell processes resulting in decreased cell division and growth. It has side effects of nausea, headache, fatigue, orthostatic hypotension, psychosis, and vasospasm. Following statements regarding bromocriptine therapy are true except?
● A. It frequently reduces the tumor size in 6 to 8 weeks in 75% of patients with macroadenomas
● B. Parlodel is supplied in 2.5 mg scored tablets and 5 mg capsules
● C. Starting dose is 1.25 mg PO every hour, adding 2.5 mg/d as necessary and making dosage change every 2 to 4 weeks for microadenomas and every 3 to 4 days for macroadenomas causing mass effect
● D. To shrink large tumors or for very high prolactin levels, 7.5 mg TID for approximately 6 months is needed, then after that maintenance dose of 5 to 7.5 mg daily is given with initial recheck in about 4 weeks
● E. There is no improvement in tolerance of this medicine with bedtime dosing, with food, or slow dose escalation
E. There is no improvement in tolerance of this medicine with bedtime dosing, with food, or slow dose escalation
Cabergoline (Dostinex) is a selective D2 dopamine agonist with which control of prolactin and resumption of ovulatory cycles may be better than with bromocriptine. It has side effects of headache, GI symptoms, and cardiac valve disease while it is contraindicated in uncontrolled hypertension or in
eclampsia or preeclampsia patients. Which statement regarding its dosage is correct?
● A. It is started at 0.25 mg PO twice weekly and each dose is increased by 0.25 mg every 4 weeks with typical dosage of 0.5 to 1 mg twice weekly
● B. It is started at 0.5 mg PO twice weekly and each dose is increased by 0.25 mg every 4 weeks with typical dosage of 0.5 to 1 mg twice weekly
● C. It is started at 0.25 mg PO twice weekly and each dose is increased by 0.5 mg every 4 weeks with typical dosage of 0.5 to 1 mg twice weekly
● D. It is started at 0.25 mg PO twice weekly and each dose is increased by 0.25 mg every 4 weeks with typical dosage of 5 to 10 mg twice weekly
● E. It is started at 0.25 mg PO twice weekly and each dose is increased by 0.25 mg every 8 weeks with typical dosage of 0.5 to 1 mg twice weekly
A. It is started at 0.25 mg PO twice weekly and each dose is increased by 0.25 mg every 4 weeks with typical dosage of 0.5 to 1 mg twice weekly
If response to dopamine agonist therapy is satisfactory then treatment is given for 1 to 4 years. What is the indication of discontinuation of this drug?
● A. Decrease in size of prolactinoma to the point with no mass effect and prolactin levels to normal
● B. Microadenomas or macroadenomas that are no longer visible on MRI
● C. Prolactin levels less than 20 ng/mL
● D. Decreasing symptoms of mass effect or prolactin levels
● E. None of the above
B. Microadenomas or macroadenomas that are no longer visible on MRI
Asymptomatic elderly patients do not require surgery while for other patients, surgery (transsphenoidal) is currently the best initial therapy, providing more rapid reduction in GH levels and decompression. Which of the following statements is correct regarding medical management of acromegaly?
● A. Medical therapy is reserved for patients who are not cured by surgery or who cannot tolerate surgery
● B. Bromocriptine (Parlodel) decreases GH level to less than 10 ng/mL in 54% of cases and to less than 5 ng/mL in only 5% of cases while tumor shrinkage occurs only in 20% of cases
● C. Octreotide (Sandostatin) is a somatostatin analog that reduces GH levels in 71% of cases, reduces IGF 1 level in 93% of cases, while tumor volume is reduced in only 30% of cases
● D. Pegvisomant (Somavert) reduces IGF 1 levels in 97% of cases with treatment for more than 12 months and is given in case of failure of somatostatin therapy
● E. All of the above
E. All of the above
Which of the following is not included in the medical management of Cushing’s disease?
● A. If pituitary MRI shows a mass, then transsphenoidal surgery is indicated
● B. If pituitary MRI is negative and IPS sampling is positive, surgery is recommended to look for source and its removal
● C. If pituitary surgery is performed but biochemical cure could not be obtained, then re-exploration is never considered
● D. Stereotactic radiosurgery or medical therapy is indicated in case of failure of surgery to remove the whole tumor
● E. Adrenalectomy can also be considered in patients with failure of all options to remove the pituitary source
C. If pituitary surgery is performed but biochemical cure could not be obtained, then re-exploration is never considered
Corticosteroid replacement therapy is indicated when cosyntropin stimulation test fails to achieve a peak cortisol level of what?
● A. > 10 μg/dL
● B. > 12 μg/dL
● C. > 15 μg/dL
● D. > 18 μg/dL
● E. > 20 μg/dL
D. > 18 μg/dL
After cosyntropin test for cortisol reserves, hormone replacement therapy was advised. What is the physiologic replacement dose?
● A. 20 mg a.m., 20 mg 4 p.m.
● B. 20 mg a.m., 10 mg 4 p.m.
● C. 10 mg a.m., 10 mg 4 p.m.
● D. 10 mg a.m., 20 mg 4 p.m.
● E. 0.5 mg PO at 11 p.m.
B. 20 mg a.m., 10 mg 4 p.m.
What is the recommended treatment in an elderly patient or > 4-cm size tumor secreting GH/ACTH?
● A. Radical surgery via FTOZ
● B. Transsphenoidal debulking
● C. Medical treatment only
● D. SRS + somatostatin
● E. Pretreatment with somatostatin followed by transsphenoidal debulking
E. Pretreatment with somatostatin followed by transsphenoidal debulking
What is the typical maintenance dose of Parlodel for prolactinoma?
● A. 1.25 mg
● B. 2.5 to 15 mg
● C. 20 mg
● D. 30 mg in divided doses
● E. 50 mg/wk in divided doses
B. 2.5 to 15 mg
For medical management of acromegaly, Sandostatin long acting release (LAR) depot injections are given initially at 20 mg intramuscularly at what interval?
● A. Alternative days
● B. Twice weekly
● C. Fortnightly
● D. Every month
● E. After 6 months
D. Every month
What is the initial dose of ketoconazole for Cushing’s disease?
● A. 100 mg OD
● B. 100 mg BID
● C. 200 mg BID
● D. 500 mg BID
● E. 1 g OD
C. 200 mg BID
What is the conventional external beam radiotherapy (EXBRT) for pituitary adenomas?
● A. 12 Gy
● B. 40 to 50 Gy
● C. 59.4 Gy
● D. 60 Gy
● E. 30 Gy with 45 Gy to tumor bed
B. 40 to 50 Gy
A patient is incidentally discovered to have a pituitary macroadenoma which is asymptomatic and nonfunctional. When should the patient undergo first surveillance scan to document rapid growth?
● A. 1 month
● B. 3 months
● C. 6 months
● D. 8 months
● E. 12 months
C. 6 months
Surgery for pituitary adenomas require medical management just before and after surgery. Which of the following statements regarding medical management of pituitary adenomas undergoing surgery is incorrect?
● A. A hypothyroid patient cannot tolerate surgery until thyroid replacement is done for at least 4 weeks before surgery
● B. For transsphenoidal surgery, polysporin ointment should be applied in both nostrils a night before surgery
● C. 1 g ampicillin + 0.5 g sulbactam should be given IV at midnight and 6 a.m. before surgery
● D. Hydrocortisone sodium succinate (Solu-Cortef) should be given 50 mg IM at 11 p.m. and 6 a.m. before surgery
● E. On call to OR a drip of dextrose 5% lactated ringer with 20 mEq KCL/L plus 50 mg of Solu-Cortef at 75 mL/h is hung and intraoperative 100 mg hydrocortisone IV every 8 hours is given
A. A hypothyroid patient cannot tolerate surgery until thyroid replacement is done for at least 4 weeks before surgery
What are the indications of transcranial approaches for the surgery of pituitary adenomas?
● A. Minimal enlargement of the sella with a large suprasellar mass, especially if the diaphragma sellae is tightly constricting the tumor (producing a cottage loaf tumor), and the suprasellar component is causing chiasmal compression
● B. Extrasellar extension into the middle fossa that is larger than the intrasellar component
● C. Unrelated pathology that may complicate a transsphenoidal approach, for example, a parasellar aneurysm
● D. Usually fibrous tumor that could not be completely removed on a previous transsphenoidal approach or a recurrent tumor following a previous transsphenoidal surgery
● E. All of the above
E. All of the above
Which of the following statements are correct regarding surgical approaches for pituitary adenomas?
● A. Transsphenoidal approach is indicated for microadenomas, macroadenomas without significant extension laterally beyond the confines of sella turcica, patients with CSF rhinorrhea, and tumors with extension into sphenoid air sinus
● B. Subfrontal approach provides access to both the optic nerves and it may be more difficult in patients with prefixed chiasma
● C. Frontotemporal (pterional) approach places optic nerve and sometimes carotid artery in line of vision of tumor.
There is also limited access to intrasellar components using this approach while it provides good access to tumors with significant unilateral extrasellar extension
● D. Subtemporal approach is usually not a viable choice with poor visualization of optic nerve, chiasma, and carotid artery. It also does not allow total removal of intrasellar component
● E. All of the above
E. All of the above
Transsphenoidal surgery can lead to intraoperative disasters which include injury to carotid artery in the lateral aspect of opening. It needs to be packed with fat, fascia, and woven surgical, which can lead to pseudoaneurysm and needs postoperative detection through CT angiography. This pseudoaneurysm is treated endoscopically or with surgical application of clips above and below the pseudoaneurysm. Other intraoperative disaster is injury to the pons which can occur through which of
the following?
● A. Opening through the floor of the frontal fossa
● B. Opening through the clivus
● C. By reaching deep through the sella and rongeuring blindly
● D. Opening the floor of sella to extreme laterally
● E. Opening through the inferior clinoid
B. Opening through the clivus
Following are the steps in the transsphenoidal surgery to remove pituitary tumor except?
● A. Endoscope is used to locate the middle concha and it is followed posteriorly to identify sphenoid ostium, which is located slightly above the posterior extent of middle concha
● B. Posterior part of the septum is broken and the sphenoid sinus is reached by breaking through the vomer bone
● C. Floor of the sella is opened in the middle using the nasal septum as the midline, using bayoneted chisel or high-speed diamond burr
● D. Dura is opened in plus pattern using bipolar cautery
● E. Tumor is brought into the field using ring curettes and removed with pituitary rongeurs or aspirated with suction
D. Dura is opened in plus pattern using bipolar cautery
What is the most common complication after removal of pituitary adenoma?
● A. Transient alteration in ADH levels with diabetes insipidus
● B. Secondary empty sella syndrome
● C. Hydrocephalus with coma
● D. Pituitary abscess or meningitis
● E. CSF rhinorrhea
A. Transient alteration in ADH levels with diabetes insipidus
In using frontotemporal (pterional) approach for removal of pituitary tumor, right-sided approach is usually employed because of less risk to dominant hemisphere with the exception of which of the following?
● A. When the left eye is the side of worsening
● B. If there is dominant left-sided tumor extension
● C. If there is another pathology on the left side (aneurysm)
● D. If there is some other pathology at that side
● E. All of the above
E. All of the above
Diagnostic criteria for diabetes insipidus is urine output of more than 250 mL/h for 2 hours and urine specific gravity of less than 1.005. Patients after pituitary tumor surgery are placed on DI watch which includes strict intake, output monitoring every 1 hour, urine specific gravity every 4 hour or any
time urine output is more than 250 mL/h, and serum electrolytes every 6 hours. Which statement is incorrect regarding postoperative management of these patients?
● A. Basal IV fluid is 5% dextrose with ½ normal saline plus 20 mEq KCL/L at appropriate rate of 75 to 100 mL/h
● B. If urine output is above the basal, then excess is replaced mL to mL with ½ normal saline
● C. If the urine output is too high (more than 300 mL/h for 4 hours or more than 500 mL/h for 2 hours) and urine specific gravity is also less than 1.005, then vasopressin is started with 5 u aqueous vasopressin IV/IM every 6 hours or desmopressin injection SQ or IV in 0.5 to 1 mL (2–4 μg) in two div-
ided doses
● D. Electrolytes with osmolarity every 6 hours are done
● E. Nasal packing is removed on the second postoperative day
E. Nasal packing is removed on the second postoperative day
After pituitary surgery, hydrocortisone is tapered in 24 to 48 hours postoperatively. 6 a.m. cortisol level is checked after discontinuing hydrocortisone. Which level of cortisol indicates continuation of hydrocortisone?
● A. Less than 12 μg/dL
● B. Less than 15 μg/dL
● C. Less than 9 μg/dL
● D. Less than 18 μg/dL
● E. Less than 21 μg/dL
C. Less than 9 μg/dL
What are the biochemical cure criteria for acromegalic patients after surgery?
● A. IGF 1 levels within age-matched reference range
● B. Basal (morning) serum GH level less than 5 ng/mL
● C. Growth hormone nadir less than 1 ng/mL in OGST
● D. No detectable growth hormone after OGST
● E. A, B, and C
E. A, B, and C
A 40-year-old male presented with features of hypothyroidism. Thyroid function tests showed decreased TSH and T4 levels while MRI showed a pituitary adenoma. Hormone replacement to correct hypothyroidism usually takes how long?
● A. 3 days
● B. 7 days
● C. 10 days
● D. 4 weeks
● E. 3 months
D. 4 weeks
Which of the following transcranial approaches is usually not a viable choice due to poor visualization of optic nerve/chiasm and carotids?
● A. Unifrontal
● B. Subfrontal
● C. Bifrotal
● D. Frontotemporal
● E. Subtemporal
E. Subtemporal
What is the recommended dural opening in endonasal transsphenoidal surgery?
● A. C shaped
● B. Z shaped
● C. Horseshoe shaped
● D. X shaped
● E. + Shaped
D. X shaped
After endonasal transsphenoidal excision of pituitary adenoma, what is the recommended duration for antibiotic cover?
● A. Till nasal pack is removed
● B. Till DI is managed
● C. 24 hours
● D. 7 days
● E. 10 days
A. Till nasal pack is removed
Regarding diagnostic criteria for diabetes insipidus, urinary
specific gravity is which of the following?
● A. > 1.030
● B. > 1.020
● C. > 1.010
● D. < 1.030
● E. < 1.005
E. < 1.005
For treatment of diabetes insipidus, what is the usual dose of intranasal DDAVP?
● A. 10 to 40 μg BID
● B. 10 mg TDS
● C. 50 μg BID
● D. 50 μg TDS
● E. 20 μg q 06 hours
A. 10 to 40 μg BID
Following transsphenoidal excision of pituitary adenoma, MRI to be used as baseline for assessment of recurrence should be obtained after how long?
● A. 24 hours
● B. 48 hours
● C. 72 hours
● D. 3 weeks
● E. 3 months
D. 3 weeks
After pituitary adenoma excision and initial 48 hours surveillance, when should serum sodium levels be re-checked to avoid symptomatic postoperative hyponatremia?
● A. After 72 hours
● B. Daily for 5 days
● C. Every third day
● D. Days 7 to 8
● E. Weekly for 1 month
D. Days 7 to 8
What is the recommended management for tumors demonstrating significant regrowth or symptoms following initial resection?
● A. Surgery
● B. Chemotherapy
● C. Radiotherapy
● D. Chemotherapy with radiotherapy
● E. Watchful waiting
A. Surgery
Following effective treatment of Cushing disease, when does hypertension usually improve?
● A. Does not improve
● B. Within 48 hours
● C. Within a week
● D. Within 6 months
● E. Over a year
E. Over a year
Cerebral metastases are the most common brain tumors seen clinically. Increasing incidence of cerebral metastasis is due to which factor?
● A. Increasing length of survival of cancer patients as a result of improvement in treatment of primary cancer
● B. Enhanced ability to diagnose CNS tumors due to availability of CT and MRI
● C. Many chemotherapeutic agents do not cross blood–brain barrier providing a heaven for tumor growth there
● D. Some chemotherapeutic agents may transiently weaken the blood–brain barrier and allow CNS seeding with tumor
● E. All of the above
E. All of the above
All of the following tumors spread commonly through the CNS pathways except?
● A. Oligodendroglioma
● B. High-grade gliomas
● C. Embryonal tumors like medulloblastomas
● D. Ependymomas
● E. Pineal region tumors like pineocytoma, germ cell tumor, and pineoblastoma
A. Oligodendroglioma
A solitary lesion in the posterior fossa of an adult is considered metastasis until proven otherwise. What is the most common location of cerebral metastasis in the supratentorial region parenchyma?
● A. Occipital lobe
● B. Parietal lobe
● C. Temporal lobe
● D. Behind sylvian fissure near the junction of occipital, parietal, and temporal lobe
● E. Near internal capsule
D. Behind sylvian fissure near the junction of occipital, parietal, and temporal lobe
The most common source of cerebral metastasis in an adult is lungs (44%), which is followed by breast (10%), kidney (7%), and GI (6%). All of the following are sources of cerebral metastasis in pediatric patients except?
● A. Melanoma
● B. Neuroblastoma
● C. Rhabdomyosarcoma
● D. Wilm’s tumor
● E. There is zero incidence of cerebral metastasis in pediatric patients
A. Melanoma
Small cell lung cancer is more likely to produce cerebral metastasis than any other bronchogenic cell type. Which of the following statements is incorrect regarding management of these tumors?
● A. These are radioresistant tumors
● B. Prophylactic cranial irradiation with whole brain irradiation reduces the incidence of symptomatic brain metastasis and increases survival with 25 Gy in 10 fractions
● C. Surgical resection is considered for immediately life-threatening large lesions
● D. For multiple small cell lung carcinoma brain lesions, 30 Gy radiotherapy in 10 fractions plus chemotherapy is given
● E. For recurrent brain metastasis after failure of initial treatment, radiotherapy with 20 Gy in 10 fractions is given
A. These are radioresistant tumors
Non–small cell lung cancer includes adenocarcinoma, and large cell, squamous cell, and bronchoalveolar tumors. What are the staging studies for known primary lung cancer?
● A. PET scan
● B. Chest scan
● C. Bone scan
● D. Brain CT or MRI
● E. All of the above
E. All of the above
What are the surgical indications in a patient with metastatic melanoma to the brain?
● A. Patients with one to four CNS metastases that can be completely resected when systemic disease is absent or slowly progressive
● B. For symptomatic relief, for example, lesion causing painful pressure
● C. Life-threatening lesion, for example, large posterior fossa lesion causing painful pressure
● D. For hemorrhagic lesions causing symptoms by mass effect due to clot
● E. All of the above
E. All of the above
Following are the predictors of poor outcome in a patient with metastatic melanoma of brain except?
● A. Less than three metastatic lesions within the brain
● B. Development of brain metastasis after the diagnosis of extracranial disease
● C. Elevated lactate dehydrogenase by more than twice the normal
● D. Presence of bone metastasis
● E. Multiple brain metastasis and extensive visceral disease
A. Less than three metastatic lesions within the brain
A patient presents with brain metastasis in neurosurgical OPD. What metastatic workup is needed in this patient?
● A. CT of the chest, abdomen, and pelvis
● B. Radionuclide bone scan
● C. Mammogram in women
● D. Prostate-specific antigen in men and PET scan in all patients with metastasis
● E. All of the above
E. All of the above
Which of the following is a highly radioresistant brain metastasis?
● A. Small cell lung cancer
● B. Germ cell tumors
● C. Thyroid cancer
● D. Lymphoma
● E. Leukemia
C. Thyroid cancer
What is the most common primary CNS tumor responsible for extraneural spread mostly to lung, bone marrow, lymph nodes, and abdomen?
● A. Medulloblastoma
● B. Ependymoma
● C. Butterfly tumor
● D. Teratoma
● E. GBM
A. Medulloblastoma
Which of the following has the highest incidence of parenchymal cerebral metastases?
● A. Corpus callosum
● B. Posterior to sylvian fissure
● C. Middle frontal gyrus
● D. Gyrus rectus
● E. Hypophysis
B. Posterior to sylvian fissure
What is the most common source of cerebral metastases in adults?
● A. Lung carcinoma
● B. Breast carcinoma
● C. Renal cell carcinoma
● D. Melanoma
● E. Prostate adenoma
A. Lung carcinoma
Small-cell lung cancer (SCLC) was established as the primary source for a patient admitted with cerebral metastases. He was treated with chemotherapy and radiotherapy with total radiotherapy dose of 25 Gy. Recurrent brain metastases after failure of this initial treatment will be treated with how much total
radiotherapy dose?
● A. 20 Gy
● B. 30 Gy
● C. 50 Gy
● D. 54 Gy
● E. 60 Gy
A. 20 Gy
What is the upper limit of number of melanoma mets that can be surgically removed in patients without systemic disease?
● A. 4
● B. 6
● C. 8
● D. 10
● E. Number is irrelevant
A. 4
Melanoma is quite radioresistant but responds well to chemotherapy with which of the following?
● A. Alkylating agents
● B. Antimetabolites
● C. Microtubule inhibitors
● D. Bleomycin
● E. Doxorubicin
A. Alkylating agents
When multiple lesions are present on CT or MRI of brains with multiple metastases, “Whoever counts the most metastases is right” is?
● A. Chamber’s rule
● B. Collin’s law
● C. Rule of Spence
● D. Steel’s rule of thirds
● E. Chief’s doctrine
A. Chamber’s rule
How should a solitary, symptomatic, large, and accessible metastasis in a patient with stable systemic disease and KPS >70 be treated?
● A. Surgical excision
● B. Whole brain radiation
● C. Stereotactic radiosurgery
● D. Surgery and chemotherapy
● E. Surgery and whole brain radiation
E. Surgery and whole brain radiation
Which of the following cerebral metastases is highly radioresistant to WBXRT?
● A. Small cell lung carcinoma
● B. Germ cell tumors
● C. Lymphoma
● D. Renal cell carcinoma
● E. Multiple myeloma
D. Renal cell carcinoma
Regarding the treatment of spinal epidural metastases, which procedure reduces pain associated with pathologic fractures and is associated with an increase in functional outcome?
● A. Transpedicular screw fixation
● B. Transthoracic costotransverectomy
● C. Transthoracic transpedicular facet sparing
● D. Kyphoplasty
● E. Lumbar interbody fusion
D. Kyphoplasty
Urinary kappa Bence-Jones proteins are associated with which of the following?
● A. Leptomeningeal carcinomatosis
● B. Multiple myeloma
● C. Primary CNS lymphoma
● D. Wilm’s tumor
● E. Neuroblastoma
B. Multiple myeloma
What is spinal metastatic lesion that scores 8 on SINS considered as?
● A. Stable
● B. Impending instability
● C. Unstable
● D. Not applicable
B. Impending instability
What is the modified Kadish grade of an esthesioneuroblastoma extending to paranasal sinus?
● A. A
● B. B
● C. C
● D. D
● E. E
B. B
What is the system used to define all upper respiratory tract carcinomas and describe nuclear pleomorphism, mitotic activity, rosette presence, and necrosis?
● A. Modified Kadish
● B. Biller’s
● C. Dulguerov’s
● D. Calcattera’s
● E. Hyam’s
E. Hyam’s
Regarding differences between craniopharyngioma and Rathke’s cleft cyst, the former has a thicker cyst wall, contains cholesterol crystals within the cyst, and is lined by which epithelium?
● A. Single layer cuboidal
● B. Three-layered cuboidal
● C. Stratified squamous
● D. Parietal and chief cells
● E. Tall columnar
C. Stratified squamous
Which of the following is not associated with higher rates of recurrence in Rathke’s cleft cyst?
● A. Grade of lesion
● B. Purely suprasellar location
● C. Reactive metaplasia in the cyst wall
● D. Infection in the cyst
● E. Use of a fat graft within the cyst cavity
A. Grade of lesion
Which of the following is associated with the risk of sudden death?
● A. Craniopharyngioma
● B. Rathke’s cleft cyst
● C. Colloid cyst
● D. GBM
● E. Small cell tumors
C. Colloid cyst
Which of the following approaches to the third ventricle can only be done in the presence of hydrocephalus and is not suitable with slit ventricles?
● A. Transcallosal
● B. Transcortical
● C. Subfrontal
● D. Subchiasmatic
● E. Lamina terminalis
B. Transcortical
Regarding differences between epidermoid and dermoid cysts, the former is associated with which of the following?
● A. Also includes hair follicles and sebaceous glands
● B. More commonly near midline
● C. More frequently associated with other congenital anomalies
● D. Repeated bouts of bacterial meningitis
● E. Chemical meningitis
E. Chemical meningitis
All of the following are options for treatment of pineal cysts except?
● A. Watchful waiting
● B. Endoscopic third ventriculostomy
● C. Aspiration only (stereotactic or endoscopic): may not get enough tissue for diagnosis
● D. Cyst excision
● E. Chemotherapy
E. Chemotherapy
Visual deterioration due to empty sella syndrome may be treated with which of the following?
● A. Chiasmapexy
● B. Bromocriptine
● C. Fat graft placement
● D. Binoculars
● E. Visual rehab programs
A. Chiasmapexy
Which of the following is a major indication for surgery in primary empty sella syndrome?
● A. CSF leak
● B. Hyperprolactinemia
● C. Hydrocephalus
● D. Headache
● E. Trauma
A. CSF leak
Which of the following is not the cause of secondary empty sella syndrome?
● A. Trauma
● B. Successful surgery for pituitary adenoma
● C. Radiotherapy for pituitary adenoma
● D. Pseudotumor cerebri
● E. Hypothalamic glioma
E. Hypothalamic glioma
Regarding pheochromocytoma, investigations may include genetic testing, plasma metanephrines, 24-hour urinary catecholamines and metanephrines, and CT and MRI of adrenal glands. In the setting of raised urinary markers, which test can be used to differentiate between essential hypertension and
pheochromocytoma?
● A. Serum ionized and free sodium levels
● B. Renal arteriogram
● C. Ankle brachial index
● D. Clonidine suppression test
● E. Low-dose steroids test
D. Clonidine suppression test
In the modified Jackson classification, what is the class for a glomus tumor extending into the petrous apex?
● A. I
● B. II
● C. III
● D. IV
● E. V
C. III
Pseudotumor cerebri syndrome is a group of conditions characterized by increased intracranial pressure with no evidence of intracranial mass, hydrocephalus, infection, or hypertensive encephalopathy. What is the ICP?
● A. ≥ 3 cm CSF
● B. ≥ 5 cm CSF
● C. ≥ 10 cm CSF
● D. ≥ 15 cm CSF
● E. ≥ 25 cm CSF
E. ≥ 25 cm CSF
Secondary pseudotumor cerebri is commonly associated with which of the following?
● A. Spontaneous subarachnoid hemorrhage
● B. Dural sinus thrombosis
● C. Sudden hearing loss
● D. Horner syndrome
● E. CSF pleocytosis
B. Dural sinus thrombosis
Which of the following is not included in the modified Dandy’s criteria for pseudotumor cerebri?
● A. Signs and symptoms of increased ICP
● B. No localizing signs
● C. Increased CSF pressure without chemical or cytological abnormalities
● D. Ventriculomegaly
● E. No intracranial mass
D. Ventriculomegaly
Vision in pseudotumor cerebri should be followed with which of the following?
● A. Perimetry
● B. Optic coherence test
● C. Visual evoked potentials
● D. Measuring intraocular pressures
● E. MRI of globe
A. Perimetry
What is the treatment for improvement of vision in a patient
of pseudotumor cerebri with visual loss without headache?
● A. Lumboperitoneal shunt
● B. Cisterna magna shunt
● C. VP shunt
● D. Optic nerve sheath fenestration
● E. Furosemide
D. Optic nerve sheath fenestration
What is the duration of fulminant PTCS defined as time between onset of symptoms and severe loss of acuity or visual field?
● A. < 2 weeks
● B. < 4 weeks
● C. < 6 weeks
● D. < 8 weeks
B. < 4 weeks
Which of the following drugs is not recommended in PTCS because of associated exacerbation of weight gain and risk of venous thrombosis?
● A. Acetazolamide
● B. Furosemide
● C. Steroids
● D. Topiramate
● E. Methazolamide
C. Steroids
Pseudotumor cerebri is characterized by absence of intracranial mass or infection and presence of papilledema and symptomatic ICP elevation of more than 20 cm H2O?
● A. 3
● B. 5
● C. 10
● D. 15
● E. 25
E. 25
Pseudotumor cerebri is commonly associated with which of the following?
● A. Spontaneous subarachnoid hemorrhage
● B. Dural sinus thrombosis
● C. Sudden hearing loss
● D. Horner syndrome
● E. CSF pleocytosis
B. Dural sinus thrombosis
Which of the following is not included in the modified Dandy’s criteria for pseudotumor cerebri?
● A. Signs and symptoms of increased ICP
● B. No localizing signs
● C. Increased CSF pressure without chemical or cytological abnormalities
● D. Ventriculomegaly
● E. No intracranial mass
D. Ventriculomegaly
Osteoma, hemangioma, dermoid, epidermoid, chondroma, meningioma, and aneurysmal bone cyst are benign tumors of the skull. Malignancy of skull is suggested by a single large lesion or multiple > 6 osteolytic lesions of the skull. These tumors
are ragged, undermined, and lack sclerosis. Which of the following are malignant tumors of the skull?
● A. Bone metastasis to the skull like prostate, breast, lung, kidney, thyroid, and lymphoma
● B. Chondrosarcoma
● C. Osteogenic sarcoma
● D. Fibrosarcoma
● E. All of the above
E. All of the above
A 55-year-old female patient presents with a swelling on cranial vault which she noticed was slow growing. On skull X-ray, it comes out as round, sclerotic, well-demarcated, homogenous dense projection arising from the outer table of the skull.
On nuclear bone scan it comes out to be hot spot. Osteomas are asymptomatic lesions requiring surgery only for cosmetic reasons or pressure on adjacent structures. Which of the following is not included in the triad of Gardner’s syndrome?
● A. Increased density or hyperostosis of calvaria
● B. Multiple cranial osteomas of calvaria, sinuses, or mandible
● C. Colonic polyposis
● D. Soft tissue tumors
● E. None of the above is related to the triad of Gardner’s syndrome
A. Increased density or hyperostosis of calvaria
Hemangiomas are benign tumors which commonly occur in the skull and spine and constitute 7% of the skull tumors. These are of two types, namely, cavernous (common) and capillary (rare). Which of the following is the imaging characteristics of
these tumors?
● A. X-rays show a circular lucency with honeycomb or trabecular pattern (seen in 50% of cases) or radial trabeculations producing a sunburst pattern (seen in 11% of cases), while sclerotic margins are evident in only 33% of cases
● B. CT of brain shows hypodense lesion with sclerotic spaced trabeculations
● C. This lesion is nonenhancing on brain CT
● D. Bone scan is typically hot
● E. All of the above
A. X-rays show a circular lucency with honeycomb or trabecular pattern (seen in 50% of cases) or radial trabeculations producing a sunburst pattern (seen in 11% of cases), while sclerotic margins are evident in only 33% of cases
The gross appearance of hemangioma is a hard tumor with blue doomed mass beneath the pericranium. What is the recommended treatment option for these tumors?
● A. En block excision or curettage with radiation considered for inaccessible tumors
● B. Radiation has no role in these tumors
● C. These tumors require no treatment and resolve on their own
● D. Partial excision is adequate for these tumors
● E. The goal of surgery is decompression only
A. En block excision or curettage with radiation considered for inaccessible tumors
A patient presents with a mass over the calvarium. On X-ray, there appears to be an osteolytic lesion with well-defined and sclerotic margins. CT of brain shows nonenhancing hypodense lesion and on MRI, these are like CSF low intensity on T1 and high signal intensity on T2 but unlike CSF they are high signal
intensity on DWI. What could be the most likely diagnosis in this patient?
● A. Epidermoid tumor of the skull
● B. Dermoid tumors of the skull
● C. Osteoma of brain
● D. Osteosarcoma
● E. Both A and B
E. Both A and B
Epidermoid or dermoid occurs when ectodermal rests are entrapped in the development of skull which causes these tumors to arise from the diploe and expand into both inner and outer tables. What is the recommended option for these tumors?
● A. Radiotherapy
● B. Chemotherapy
● C. Surgical treatment with curettage
● D. Endoscopic treatment
● E. All of the above
C. Surgical treatment with curettage
Which of the following is not a non-neoplastic skull lesion?
● A. Osteopetrosis
● B. Paget’s disease
● C. Hyperostosis frontalis interna
● D. Fibrous dysplasia
● E. Hemangioma
E. Hemangioma
A patient presents with hypertension, seizures, headache, dementia, and irritability. Plain skull X-ray shows thickening of the frontal bone with characteristic sparing of the midline. CT demonstrates a 10-mm bony thickening, and bone scan shows up moderate uptake. What are the most likely conditions associated with hyperostosis frontalis interna?
● A. Morgagni’s syndrome, which includes headache, obesity, virilism and neuropsychiatric disorders
● B. Endocrine abnormalities like acromegaly or hyperprolactinemia
● C. Metabolic abnormalities like hyperphosphatemia and obesity
● D. Diffuse idiopathic skeletal hyperostosis (DISH)
● E. All of the above
E. All of the above
Fibrous dysplasia is a non-neoplastic benign condition in which normal bone is replaced with fibrous connective tissue. Most lesion occurs in ribs, proximal femur, and craniofacial bones?
● A. Cystic, sclerotic, or mixed
● B. Monostotic fibrous dysplasia which is most common
● C. Polyostotic fibrous dysplasia
● D. Polyostotic fibrous dysplasia as part of McCune Albright syndrome (which include the triad of cafe au lait spots, endocrinopathy, and polyostotic fibrous dysplasia)
● E. B, C, and D
E. B, C, and D
A patient presents with local swelling with pain and tenderness over it. He/she also has pathological fracture, decreasing hearing function, seizures, and darkened hair pigmentation.
Management includes which of the following?
● A. Removal of dysplastic bone, curettage, and cranioplasty
● B. Acute visual deterioration is treated with high dose glucocorticosteroids and decompression
● C. Involvement of multidisciplinary team for skull base lesions
● D. Copious amount of irrigation during drilling to avoid thermal injury
● E. All of the above
E. All of the above
Which of the following is not a benign tumor of skull?
● A. Osteoma
● B. Hemangioma
● C. Chondroma
● D. Osteogenic sarcoma
● E. Meningioma
D. Osteogenic sarcoma
What is the most common primary bone tumor of the calvaria?
● A. Osteoma
● B. Hemangioma
● C. Chordoma
● D. Osteogenic sarcoma
● E. Meningioma
A. Osteoma
Skull X-ray showing circular lucency with honeycomb, trabecular, or sunburst pattern is most commonly seen with which of the following?
● A. Osteoma
● B. Hemangioma
● C. Chordoma
● D. Osteogenic sarcoma
● E. Meningioma
B. Hemangioma
Which of the following is a primary malignant tumor of clivus or sacrum showing physaliphorous cells on histopathology?
● A. Osteoma
● B. Hemangioma
● C. Chordoma
● D. Osteogenic sarcoma
● E. Meningioma
C. Chordoma
Fibrous dysplasia is associated with which of the following?
● A. MISME syndrome
● B. McCune-Albright syndrome
● C. Post traumatic
● D. X-linked inheritance
● E. Autosomal dominant inheritance
B. McCune-Albright syndrome
Which of the following is the most frequent site of involvement in the monostotic fibrous dysplasia (MFD)?
● A. Proximal femur
● B. Distal tibia
● C. Zygomatic-maxillary complex
● D. Frontal air sinuses
● E. Skull foramina
C. Zygomatic-maxillary complex
Pain is a common presentation of fibrous dysplasia and in cases of widespread lesions and raised alkaline phosphatase, it responds well to which of the following?
● A. Calcitonin
● B. RANK ligands
● C. Steroids
● D. Radiotherapy
● E. Chemotherapy
A. Calcitonin
In fibrous dysplasia, acute visual deterioration associated with an expansile lesion near the optic canal should be treated with surgical decompression and what?
● A. Calcitonin
● B. RANK ligands
● C. Steroids
● D. Radiotherapy
● E. Chemotherapy
C. Steroids
About 15% of primary CNS tumors are intraspinal and most spinal tumors are benign presenting with compression rather than invasion. Which of the following statements regarding these tumors is not true?
● A. Metastasis is only found in the extradural compartment
● B. 55% are extradural tumors
● C. 40% are intradural extramedullary tumors and arise mostly from leptomeninges or roots
● D. Only 5% are intramedullary spinal cord tumors
● E. Lymphoma may occur in all three compartments and are divided into primary or secondary (metastasis)
A. Metastasis is only found in the extradural compartment
Most of the extradural tumors are metastasis which can be osteolytic like lymphoma, lung, breast, or prostate or these can be osteoblastic like prostate carcinoma (CA) which is most common in men while in females breast CA is most common. Other extradural tumors include the following except?
● A. Chordomas and osteoid osteoma
● B. Osteoblastoma and aneurysmal bone cyst
● C. Chondrosarcoma and osteochondroma
● D. Vertebral hemangioma and giant cell tumors
● E. Meningioma and neurofibromas
E. Meningioma and neurofibromas
Intradural extramedullary tumors include meningiomas, neurofibromas, lipomas, or rarely metastasis. Which of the following are the most common intramedullary spinal cord tumors?
● A. Astrocytoma and ependymoma including myxopapillary ependymoma
● B. Malignant glioblastoma and dermoid
● C. Epidermoid and teratoma
● D. Lipoma and hemangioblastoma
● E. Neuroma and syringomyelia
A. Astrocytoma and ependymoma including myxopapillary ependymoma
A patient presents with an intradural extramedullary spinal cord tumor, which occurs mostly in 40 to 70 years of age and affects females 4 times more than males. These are mostly found in the thoracic region and in 68% of cases, these tumors are lateral to the spinal cord, in 15% they are anterior, while in 18% they are posterior. Which tumor fulfills all these characteristics?
● A. Neurofibroma
● B. Schwannoma
● C. Meningioma
● D. Lipoma
● E. Lymphoma
C. Meningioma
Spinal schwannomas are intradural extramedullary spinal tumors that are mostly slow growing benign tumors and arise mostly (75%) from dorsal (sensory) rootlets with early symptoms of radicular pain. All of the following statements regarding Asazuma et al classification of dumbbell spinal schwannomas are correct except?
● A. Type 1 tumors are intradural and extradural tumors and are restricted to the spinal canal. These can be operated through posterior approach
● B. Type 2 tumors are all extradural and are subclassified as 2a (do not extend beyond the neural foramina), 2b (inside the spinal canal and paravertebral), and 2c (foraminal and paravertebral). Tumors 2a and 2b can be operated posteriorly
● C. Type 3a tumors are intradural and extradural foraminal, and 3b tumors are intradural and extradural paravertebral, with only 3a and some upper cervical 3b operable posteriorly
● D. Type 4 tumors are extradural intravertebral tumors and can be operated posteriorly
● E. Type 5 tumors are extradural, extralaminar with laminar invasion while type 6 tumors are multidirectional with bone erosion
D. Type 4 tumors are extradural intravertebral tumors and can be operated posteriorly
Ependymomas are the intradural spinal cord tumors that require MRI of the entire neuraxis because of potential for seeding. These are slow-growing benign tumors with male predominance and mostly occur in the 3rd to 6th decades of life. These
are mostly found in conus medullaris, filum terminale, or cauda equina where these are called as what?
● A. Papillary tumors
● B. Myxopapillary ependymomas
● C. End spinal cord tumors
● D. Ependymomas at conus
● E. None of the above
B. Myxopapillary ependymomas
What is the most common presentation of an intramedullary spinal cord tumor?
● A. Pain which can be radicular (increases with Valsalva maneuver and spine movements, especially consider SCT if dermatome is unusual for disk herniation), local (pain during recumbency or nocturnal pain is classic for spinal cord tumors),
or medullary (dysesthetic, nonradicular, and often bilateral)
● B. Motor disturbances
● C. Nonpainful sensory disturbances
● D. Sphincters disturbances
● E. Scoliosis or torticollis
A. Pain which can be radicular (increases with Valsalva maneuver and spine movements, especially consider SCT if dermatome is unusual for disk herniation), local (pain during recumbency or nocturnal pain is classic for spinal cord tumors),
or medullary (dysesthetic, nonradicular, and often bilateral)
It is usually difficult to distinguish intramedullary spinal cord tumors from intradural extramedullary or extradural tumors on clinical grounds. How schwannomas can be distinguished from intramedullary tumors on clinical grounds?
● A. Schwannomas often start with radicular pain that later progress to cord involvement
● B. Most intramedullary spinal cord tumors are located posteriorly in the cord which may cause sensory findings to predominate
● C. Intramedullary spinal cord tumors cause dissociative type of sensory loss with decreased pain and temperature and preserved light touch as in Brown-Sequard syndrome
● D. Urogenital symptoms like difficulty evacuating, retention, and incontinence are early signs in conus or cauda equina lesions
● E. All of the above
E. All of the above
Mainstay of diagnosis for intramedullary tumors is MRI in which ependymoma enhance intensely, often associated with hemorrhage and cysts. While plain radiographs show vertebral body destruction, there is enlarged intervertebral foramina or increased interpedicular distance with fusiform cord widening
on myelography. What is the technical consideration while doing surgery on these tumors?
● A. These tumors should be debulked internally using ultrasonic aspirator and laser
● B. An attempt should be made to make a plane between the tumor and the cord
● C. Total excision is must in all these tumors
● D. No radiotherapy is needed for residual tumors
● E. If cystic component is evident, an attempt should be made to aspirate the whole cyst at the start of surgery
A. These tumors should be debulked internally using ultrasonic aspirator and laser
A patient presents with pain localized to one point on back. MRI shows vertebral body lesion, which is focal, round, hyperintense on T1 and T2 with enhancement on contrast. CT of spine shows multiple, high-density dots on axial images (polka
dot sign), while plain radiograph shows vertically oriented striations (corduroy pattern) or honeycomb appearance. What are the management options for these tumors?
● A. Radiotherapy
● B. Embolization
● C. Vertebroplasty
● D. Surgery (which can be through posterior approach if only posterior elements are involved or if there is VB involvement with no expansion, and anterior corpectomy with strut graft if VB is involved with anterior canal compression or extensive anterior and posterior elements and soft tissue involvement)
● E. All of the above
E. All of the above
