soal 81 - 120 Flashcards
- What is the most common management of the
lesion depicted in the following 3D CT reconstruction
(Figure 5.81Q)?
A. Surgical resection
B. Focused radiation
C. Chemotherapy
D. IV steroids
E. Observation
JAWABANNYA : E
- E. Parietal foramina are normally 1 to 2 mm in diameter and contain emissary veins. Occasionally, these foramina are larger and are covered by fibrous tissue that is continuous with the pericranium. The majority of parietal foramina are incidental findings that require no treatment. Cranioplasty is reserved for large foramina that persist beyond the ages of
3 to 4 years (Wilkins, p. 3570).
82. What abnormality is depicted in the following lateral carotid angiogram (midarterial phase) (Figure 5.82Q)?
A. High-grade astrocytoma
B. Hemangioblastoma
C. Arteriovenous malformation
D. Cavernous malformation
E. Venous angioma
JAWABANNYA : C
- C. Arteriovenous malformations of the parenchyma usually appear as focal collections of arterial feeders with tortuous draining veins on angiography. The angiographic hallmark of AVMs is early filling of draining veins during the arterial phases of the study. Venous stenosis or occlusions are occasionally observed adjacent to the AVM nidus.
Cavernous malformations are generally angiographically occult, and venous angiomas exhibit radial medullary veins located around an enlarged transcortical draining vein (“caput medusae”). Occasionally vascular, high-grade neoplasms
can exhibit early draining veins as well, although
the focal collection of multiple arterial feeders without
intervening tissue on imaging studies is more consistent with an AVM (Osborn DN, pp. 287-291).
- A 72-year-old man presented with bitemporal hemianopsia. The following contrasted Tl-weighted MPJ exhibits what abnormality (Figure 5.83QJ?
A. Pituitary adenoma
B. Craniopharyngioma
C. Rathke’s cleft cyst
D. Pilocytic astrocytoma
E. Metastatic tumor
JAWABANNYA : A
- A. Pituitary macroadenomas are generally isointense to surrounding brain on all sequences and exhibit prominent, heterogenous enhancement with contrast. Craniopharyngiomas are most commonly hypointense on Tl-weighted images and hyperintense on T2-weighted images, with heterogenous enhancement. Craniopharyngiomas are often cystic and calcified and usually present in children. A smaller proportion of craniopharyngiomas present in the fifth to sixth decades of life. The signal of craniopharyngiomas on Tl-weighted images is often heterogenous; they are suprasellar lesions that often exhibit extension into the sella. This MRI exhibits a homogenous, predominantly intrasellar isointense mass with suprasellar extension, sellar expansion, and heterogenous enhancement. These MRI
findings in a 72-year-old are most consistent with a pituitary adenoma (Osborn DN, pp. 649-657).
- What is the inheritance pattern of the disorder depicted in the following nonenhanced axial Tl-weighted MRI (Figure 5.84QJ?
A. Autosomal dominant
B. Autosomal recessive
C. X-linked
D. Sporadic
E. Mitochondrial
JAWABANNYA : A
- A. This MRI exhibits hypoplasia of the left sphenoid
wing, with concomitant herniation of the temporal lobe
into the orbit. This is characteristic of NF-1, which is inherited in an autosomal dominant fashion (Osborn DN,
pp. 82-83).
- What abnormality is depicted on this cervical internal
carotid angiogram (Figure 5.85Q)?
FIGURE 5.85Q
A. Arterial dissection
B. Takayasu’s arteritis
C. Marian’s syndrome
D. Fibromuscular dysplasia
JAWABANNYA: D
85. D. Fibromuscular dysplasia (FMD) is a disorder that commonly involves medium-sized arteries, particularly the cervical carotid, vertebral, and renal arteries. FMD usually presents in women between the fourth to sixth decades with symptoms of ischemia, transient ischemic attacks, or even subarachnoid hemorrhage (increased incidence of intracranial aneurysms). The classic angiographic appearance of FMD is alternating regions of stenosis and dilatation ("string of beads"), as depicted in this angiogram. Catheter-induced vasospasm can occasionally mimic the angiographic appearance
of FMD (Osborn DCA, pp. 341-346).
- What is the most common T2-weighted image appearance and location, respectively, of an arachnoid cyst?
A. Hyperintense, suprasellar cistern
B. Hyperintense, middle cranial fossa
C. Hypointense, suprasellar cistern
D. Hypointense, middle cranial fossa
E. Isointense, cerebellopontine angle
JAWABANYA : B
- B. Arachnoid cysts resemble CSF on all MR sequences and are thus hypointense on Tl-weighted images and hyperintense on T2-weighted images without enhancement. Arachnoid cysts are usually located in the middle cranial fossa (50 to 65%), suprasellar cistern (5 to 10%), quadrigeminal
cistern (5 to 10%), or cerebellopontine angle (5 to 10%)
(Osborn DN, pp. 640-642).
- What neoplasm is depicted on the following contrasted Tl-weighted MRI in an asymptomatic adult male (Figure 5.87QJ?
A. Choroid plexus papilloma
B. Ependymoma
C. Subependymoma
D. Astrocytoma
E. Meningioma
JAWABANNNYA : E
- E. The most common neoplasms to occur at the trigone in adults are intraventricular meningiomas, lymphoma, and metastases. The most common trigonal mass in children is the choroid plexus papilloma, although ependymomas and astrocytomas are also observed at this location in this population. This MRI exhibits a homogenously enhancing intraventricular meningioma. Approximately 2% of all meningiomas arise within the ventricles, and these lesions are thought to originate from the tela choroidea or choroid plexus stromal cells (Osborn DN, pp. 429-430,
588) .
- What abnormality is depicted on the following noncontrasted Tl-weighted MRI (Figure 5.88QJ?
A. Multiple sclerosis plaque
B. Acute infarct
C. Chronic infarct
D. Astrocytoma
E. None of the above
JAWABANNYA: C
- C. This MRI exhibits a focal region of encephalomalacia in the distribution of the left middle cerebral artery. Ipsilateral ventricular dilatation accompanies the temporal lobe atrophy. It is this prominent lack of mass effect that helps distinguish a chronic infarct from a neoplasm or an acute infarction (Osborn DN, pp. 353-354).
- Which of the following imaging characteristics is NOT
associated with fibrous dysplasia?
A. Sclerotic bone on CT scan
B. Hypointense signal of bony lesions on Tl-weighted
imaging
C. Hyperintense signal of bony lesions on T2-weighted
imaging
D. Variable enhancement patterns
E. Cystic components
JAWABANNYA : C
- C. Fibrous dysplasia is characterized by the presence of prominent sclerotic bone on CT scan (“ground glass” appearance) with occasional cystic components early in the disease course. Bony lesions of fibrous dysplasia are generally hypointense on both Tl- and T2-weighted images, with variable enhancement patterns. Fibrous dysplasia is usually monostotic; however, polyostotic forms are also fairly common (Osborn DN, pp. 509-510)
- Which of the following imaging characteristics is NOT
typically associated with primary CNS lymphoma?
A. Isodense on unenhanced CT scans
B. Prominent enhancement
C. Slightly hyperintense on T2-weighted imaging
D. Multifocal
E. Often involves the basal ganglia
JAWABANNYA : A
- A. Primary CNS lymphoma is generally hyperdense on CT scans and is often located in the corpus callosum, basal ganglia, and periventricular regions. Primary CNS lymphoma is often multifocal. It is generally isointense to gray matter on Tl-weighted images and slightly hyperintense on T2- weighted images (Osborn DN, pp. 620-622).
- What is the mechanism of injury for the condition depicted in this axial CT scan (Figure 5.91Q)?
A. Hyperflexion
B. Hyperextension
C. Axial loading
D. Flexion/rotation
E. Distraction
JAWABANNYA : A
- A. This axial CT scan depicts bilateral jumped (locked) facets, with a concomitant fracture of the lamina. Bilateral jumped facets result from severe hyperflexion injuries and are usually associated with concomitant spinal cord injury. With jumped facets, the facet capsule, apophyseal joints, ligamentum flavum, and interspinous ligaments are dis¬rupted. Unilateral jumped facets result from flexion/rotation injury mechanisms (Greenberg, pp. 712-713).
- Which of the following neoplasms are generally hypointense on Tl-weighted images and hyperintense on T2- weighted images with variable enhancement patterns?
- Pilocytic astrocytoma
- Pleomorphic xanthoastrocytoma
- Ganglioglioma
- Dysembryoplastic neuroepithelial tumor
A. 1,2, and 3 are correct
B. 1 and 3 are correct
C. 2 and 4 are correct
D. Only 4 is correct
E. All of the above are correct
JAWABANNYA : E
92. E. Gangliogliomas are often located within the temporal lobe and result in poorly controlled epilepsy in children and young adults. The imaging characteristics of ganglioglioma are variable and include solid enhancing masses or cystic masses with enhancing mural nodules, usually with prominent calcification. Most gangliogliomas are hypointense to
surrounding brain parenchyma on Tl-weighted images and hyperintense on T2-\veighted images. Gangliogliomas are rarely associated with significant surrounding edema or hemorrhage. Dysembryoplastic neuroepithelial tumors can
also involve the temporal lobe; they are usually hypointense on Tl-weighted images and hyperintense on T2-weighted images with variable enhancement. Pleomorphic xanthoastrocytoma is also a cystic tumor that can occur in the temporal lobe, and it is predominantly hypointense on Tl-weighted images and hyperintense on T2-weighted images, with prominent enhancement of solid portions of the tumor. Pilocytic astrocytomas are usually found in the cerebellum or hypothalamic region in children, and they are generally hypointense (or isointense) on Tl-weighted images and hyperintense on T2-weighted images with variable enhancement (Osborn DN, pp. 556, 561, 580-582).
- Which of the following characteristics is NOT observe
with acoustic neuromas on MRI?
A. Hypointense to brain on Tl-weighted images
B. Hypointense to brain on T2-weighted images
C. Variable enhancement patterns
D. Cystic degeneration
E. Hemorrhage
JAWABANNYA : B
- B. Acoustic neuromas are generally slightly hypointense to brain on Tl-weighted images and hyperintense on T2- weighted images. Acoustic neuromas usually exhibit uniform, prominent enhancement, although heterogenous enhancement is occasionally observed. Acoustic neuromas can exhibit cystic degeneration, and rarely hemorrhage within the neoplasm. Smaller acoustic neuromas can be confined within the internal auditory canal (Osborn DN,
pp. 629-630).
- A 54-year-old male with diabetes mellitus presented with complaints of progressive lower back pain. The patient’s neurologic exam was normal, and his sagittal T2-weighted MRI is depicted below. What is the most likely etiology of this patient’s kyphotic deformity (Figure 5.94Q)?
A. Isthmic spondylolisthesis
B. Discitis/osteomyelitis
C. Rheumatoid arthritis
D. Intervertebral disc herniation
E. None of the above
JAWABANNYA C
94. C. The patient’s MRI demonstrates obliteration of the
T12-L1 disc space secondary to a prior history of discitis.
The patient has subsequently developed a kyphotic deformity at this level. This patient’s history of diabetes mellitus makes the diagnosis of discitis more likely (Osborn DN, pp. 820-821).
- A 38-year-old male experienced transient left upper
extremity sensory changes after a motor vehicle collision.
A GT scan of the head was unremarkable. The patient’s
right internal carotid angiogram (AP view) is exhibited
below (Figure 5.95Q). What is the appropriate next step in management?
A. Endovascular treatment
B. Anticoagulation
C. Antiplatelet agents
D. Surgical intervention
E. Repeat angiography in 2 to 3 months
JAWABANNYA : B
- B. The patient experienced a transient ischemic attack after blunt injury to the neck and was found to have a pseudoaneurysm of the internal carotid artery on angiography secondary to blunt dissection. The most appropriate initial treatment of this lesion is systemic anticoagulation, initially with heparin and subsequently with warfarin (Coumadin). Endovascular treatment is reasonable if the lesion does not resolve with systemic anticoagulation; however, this should not be the initial treatment modality of choice. Acute pseudoaneurysms are unstable lesions and the wall of these structures often contains subintima. This makes stent deployment more dangerous in the acute setting. Repeat angiography should be performed; however,
the initial treatment entails systemic anticoagulation.
Antiplatelet agents should be reserved for patients who have undergone endovascular stent placement or those in whom systemic anticoagulation is contraindicated (Osborn DCA, pp. 410-411).
- A 47-year-old female presents to your office with the MRI (axial view) exhibited below (Figure 5.96Q). What is the likely diagnosis?
A. Posterior fossa arachnoid cyst
B. Arterial-venous malformation
C. Trigeminal neuralgia
D. Hemifacial spasm
E. Multiple sclerosis
JAWABANNYA : C
- C. It can be very difficult to visualize impingement on cranial nerve V with imaging studies, although on this axial MRI there is a clear discrepancy in the appearance of the trigeminal nerves bilaterally. The fifth cranial nerve is well illustrated on the left (large arrow), whereas on the right, it is being pushed medially by what appears to be a blood vessel, as suggested by the flow voids (smaller arrow). Most patients being evaluated for trigeminal neuralgia do not require imaging studies to confirm a diagnosis, as most patients typically present with paroxysmal lancinating pain, often triggered by sensors’ stimuli, confined to the distribution of one or more branches of the trigeminal nerve, with no neurologic deficit.
(Greenberg, pp. 373-380).
97-D; 98-B; 99-A; 100-C. Refer
QUESTIONS 97-100
Directions: Match each of the following stages of abscess formation with the appropriate imaging and/or histologic characteristics, using each answer once, more than once, or not at all.
A. Early cerebritis
B. Late cerebritis
C. Early capsule
D. Late capsule
E. None of the above
- Well-formed collagen capsule and gliotic layer around abscess
- Ring enhancement usually appears by this stage
- Inflammatory response poorly demarcated, toxic changes in neurons, perivascular infiltrates
- Neovascularity, necrotic center, reticular matrix, and capsule less well developed alongside ventricle
JAWABANNYA
97-D;
98-B;
99-A;
100-C.
Refer to Table 5.97-5.100A. (Osborn
DN, pp. 688-693; Greenberg, pp. 217-223).
QUESTIONS 101-105
Directions: Figure 5.101-5.105Q is a coronal GT scan through the right orbit. Match the anatomic structures with the corresponding letterhead using each answer once.
- Optic nerve
- Levator palpebrae superioris muscle
- Superior oblique muscle
- Inferior rectus muscle
- Superior rectus muscle
JAWABANNYA
101-B;
102-A;
103-C;
104-E;
105-G.
This coronal CT of the face depicts the anatomy of the right globe as well as the adjacent paranasal sinuses. Of note, the levator palpebrae superioris
muscle (A), innervated by the oculomotor nerve (CN III), originates superiorly to the annulus tendineus, inserts into the tarsal plate of the superior eyelid, and acts to draw the eyelid upward when the eyeball is elevated. Additionally, the muscles most frequently involved in thyroid ophthalmopathy are the inferior (E) and medial (D) recti. Other muscles of the globe include the superior rectus (G), lateral rectus (F), superior oblique (G), and inferior oblique (not shown)
(Grant, p. 491; Adams, p. 1134; April, pp. 460-462).
QUESTIONS 106-107
106. A 42-year-old HIV-positive male presented to the
emergency department with a 3-week history of headaches and confusion. His postcontrast MPJ scan is depicted below (Figure 5.106-5.107Q).
What is the most likely diagnosis?
A. Cryptococcal abscess
B. Toxoplasmosis
C. Lymphoma
D. Progressive multifocal leukoencephalopathy (PML)
E. HIV encephalopathy
JAWABANNYA
106-C;
107-C.
Note the homogeneously enhancing lesions involving the periventricular region in this patient with primary CNS lymphoma (PCNSL, CD20, and CD79a positive).
PCNSL represents approximately 1% of intracranial
neoplasms in immunocompetent patients and has been described in up to 50% of AIDS patients. The precise role of Epstein-Barr virus (EBV) in the pathogenesis of PCNSL remains unclear, although many authors have reported that between 5 and 38% of PCNSL tumors contained EBV in immunocompetent patients, while up to 100% of
tumors in AIDS-related patients contained the EBV virus (Greenberg, pp. 231-234, 238, 441-444; Kaye and Laws, pp. 915-927).
- What microbial agent is most often associated with this lesion?
A. Herpes simplex virus
B. JG virus
C. Epstein-Barr virus
D. Treponema pallidum
E. Toxoplasma gondii
JAWABANNYA
106-C;
107-C.
Note the homogeneously enhancing lesions involving the periventricular region in this patient with primary CNS lymphoma (PCNSL, CD20, and CD79a positive).
PCNSL represents approximately 1% of intracranial
neoplasms in immunocompetent patients and has been described in up to 50% of AIDS patients. The precise role of Epstein-Barr virus (EBV) in the pathogenesis of PCNSL remains unclear, although many authors have reported that between 5 and 38% of PCNSL tumors contained EBV in immunocompetent patients, while up to 100% of
tumors in AIDS-related patients contained the EBV virus (Greenberg, pp. 231-234, 238, 441-444; Kaye and Laws, pp. 915-927).
QUESTIONS 112-114
112. What is depicted on the gradient echo MPJ sequence below (Figure 5.112-5.114QJ?
A. Amyloid hemorrhage
B. Cavernous malformation
C. Capillary telangiectasia
D. Metastatic tumor with hemorrhage
E. Hemangioblastoma
- This lesion may be associated with all of the following EXCEPT which?
A. Venous malformation
B. 0.5% incidence
C. Multiplicity
D. Mutation in a gene on chromosome 7q
E. Erythropoietin secretion - Angiographic findings may include
A. Vascular blush
B. Associated aneurysm
C. External carotid artery collaterals supplying this lesion
D. An early draining vein
E. All of the above
JAWABANNYA
112-B;
113-E;
114-A.
This gradient echo MR sequence demonstrates
a multilobulated lesion with a “popcornlike” pattern
of high signal intensity, which is most consistent with a cavernoma. The etiology/pathogenesis of this lesion is uncertain, although in some cases it has been shown to arise de novo adjacent to a venous malformation. Multiple lesions are more common in patients of Hispanic origin and have been linked to a mutation in a gene on chromosome 7q. Isolated cavernomas are associated with venous malformations in 30 to 50% of cases. Angiography is usually negative, although a subtle vascular blush may occur in a small number of cases (Ramsey, pp. 272-276).
- What is depicted on the lateral angiogram below (Figure 5.115QJ?
A. Aneurysm
B. Dural arterial-venous fistula
C. Cavernous malformation
D. Persistent hypoglossal artery
E. Proatlantal intersegmental artery
JAWABANNYA : A
- A. This lateral angiogram demonstrates a PICA
aneurysm between the posterior medullary and supratonsillar (telovelotonsillar) segments of the PICA. The first segment of PICA (anterior medullary) courses posterolaterally within the medullary cistern at the level of the olivary nucleus. The second segment (lateral medullary) continues posteriorly in the cerebellomedullary fissure and loops caudally for a variable distance along the lateral surface of the medulla. The third segment (posterior medullary or
tonsillomedullary segment) is formed when the PICA passes through the fibers of cranial nerves IX, X, and XI to reach the posterior margin of the medulla and ascend behind the posterior medullary velum. The fourth segment (supratonsillar or telovelotonsillar) represents the cranial loop of the PICA as it courses above the cerebellar tonsil. The apex of this loop
is known as the choroidal point, and represents the origin of the aneurysm depicted here. The PICA then turns downward in the retrotonsillar fissure and terminates by dividing into the hemispheric and vermian branches. Unlike the proximal three segments, the distal segments do not give rise to brainstem perforators, a fact that may allow clinicians to sacrifice the PICA distal to the choroidal point in some specific instances (Osborn DCA, pp. 176-184; Ramsey, pp. 598-599;
Kaye and Black, pp. 1043-1049).
- All of the following may accompany the finding depicted on the MRI below (Figure 5.116Q) EXCEPT?
A. Oroalimentary automatisms
B. Epigastric aura
C. Hypermetabolism of the affected temporal lobe on
interictal fluorodeoxyglucose PET scanning
D. Posturing of the contralateral arm
E. History of complicated febrile seizures
JAWABANNYA : C
- C. Note the increased signal and atrophy of the left
hippocampus compared to the normal appearing right hippocampus on this FLAIR MRI sequence depicting mesial temporal lobe sclerosis. Although reports indicate a higher incidence of complicated febrile seizures in patients with temporal lobe epilepsy and mesial temporal sclerosis, the precise etiology remains unclear. There is usually hypometabolismof the affected temporal lobe with interictal fluorodeoxyglucose PET scanning (Greenberg, p. 255).
- The finding on this CT scan (Figure 5.1180;) is most
consistent with ?
A. Severe closed head injury
B. Neurocysticercosis
C. Child abuse
D. Carbon monoxide poisoning
E. Cryptococcal infection
- D. Note the prominent involvement of the basal ganglia
and adjacent white matter bilaterally on this noncontrasted
GT scan depicting carbon monoxide poisoning (Ramsey,
pp. 351-353).
QUESTIONS 119-120
119. What is the most likely diagnosis depicted on the
diffusion-weighted MRI scan below (Figure 5.119-5.120Q)?
A. Aneurysm
B. Acoustic neuroma
C. Meningioma
D. Epidermoid tumor
E. Arachnoid cyst
- How would the application of a fat-saturation pulse during MRI alter the signal characteristics of this lesion?
A. The signal would suppress
B. The signal would remain the same
C. The lesion would show similar characteristics to GSF
D. It would produce increased signal intensity
E. It would result in a chemical shift artifact
JAWABANNYA
119-D;
120-B.
Epidermoids are usually hypointense on Tlweighted
imaging, hyperintense on T2-weighted imaging,
and exhibit restricted diffusion (increased signal) on DWI sequences (as depicted here). Arachnoid cysts are hypointense on DWI sequences. The fatty areas of dermoid tumors and lipomas will saturate out with fat-suppression sequences and produce a chemical shift artifact, whereas fat saturation sequences do not appreciably affect epidermoids
(Ramsey, pp. 118-120).
