soal gambar Flashcards
- What is depicted in the photomicrograph below (Figure 8.2Q)?
A. Palisading cells around a necrotic region in a patient
with glioblastoma
B. Spongiform change in a patient with prion disease
C. Homer-Wright rosette in a 3-year-old male with
medulloblastoma
D. Acute infarct in a patient with myoclonic epilepsy with
ragged red fibers (MERRF)
E. Fibrinoid necrosis in a patient with acute hemorrhagic
leukoencephalopathy
- A. Note the “picket fence” arrangement (pseudopalisading) of the nuclei surrounding a region of necrosis in this
photomicrograph, which depicts a glioblastoma (Ellison,
pp. 628-631).
QUESTIONS 4-9
Directions: Match each of the following spinal cord lesions
with the appropriate clinical syndrome (Figure 8.4-8.9Q),
using each answer once, more than once, or not at all.
FIGURE 8.4-9Q
4. Early subacute combined degeneration
5. Syringomyelia
6. Tabes dorsalis
7. Poliomyelitis
8. Amyotrophic lateral sclerosis
9. Familial spastic paraplegia
4-E; 5-F; 6-D; 7-A; 8-C; 9-B.
- Which of the following tumors may share certain
histopathologic features with the lesion depicted below
(Figure 8.10Q)?
FIGURE 8.10Q - Clear cell ependymoma
- Central neurocytoma
- Dysembryoplastic neuroepithelial tumor
- Fibrous meningioma
A. 1,2, and 3
B. land 3
C. 2 and 4
D. Only 4 is correct
E. All of the above
- A. The differential diagnosis of oligodendroglial tumors includes clear cell ependymoma, central neurocytoma, and dysembryoplastic neuroepithelial tumor. All of these entities exhibit the presence of neoplastic cells with a uniform round
nucleus and clear cytoplasm. A rare differential diagnosis of oligodendroglioma is clear cell meningioma (not fibrous meningioma), which can be differentiated from oligodendroglioma by abundant diastase-sensitive PAS positivity and immunoreactivity for EMA. Note the prominent calcification, “chicken wire” capillaries (prominent branching), “fried egg” cells with round monomorphic nuclei, and peri-
nuclear halos arranged in a back-to-back fashion in this photomicrograph depicting an oligodendroglioma (Ellison, pp. 641-644; WHO, p. 59).
- Refer to Figure 8.12Q.. What is the diagnosis?
A. Fatty filum with tethered cord
B. Myxopapillary ependymoma
C. Dermal sinus tract
D. Epidural hematoma
E. Dermoid tumor
- A. Note the cord tethering and fatty filum on this sagittal MRI (Ramsey, pp. 104-106).
- Which of the following is correct about the lesion
depicted on the angiogram below (Figure 8.13Q.)?
FIGURE 8.13Q
A. Annual risk of bleeding is approximately 3% per year
B. Associated with cranial bruit and congestive heart
failure during the neonatal period
C. The loss of a tumor suppressor gene on chromosome 22
D. This lesion is usually found within normal brain
parenchyma
E. Represents an extreme anatomic variant of cortical
arterial blood supply
- D. This angiogram depicts the classic “caput medusae” pattern of a venous angioma, which is an extreme anatomic variant of medullary (white matter) venous drainage. The precise etiology of this lesion remains unclear, although some authors have proposed that it results from arrested development of parts of the venous vasculature at a time when normal arterial development is nearly complete. This results in the retention of primitive venous channels that typically empty into a single large draining vein (Osborn, pp. 294-295).
QUESTIONS 17-24
Directions: Match the following structures with the appropriate letterhead on the following axial CT scans (Figures 8.178.24Q a, b, c) of the right petrous temporal bone, using each answer only once.
- Vestibule
- Cochlea
- Posterior semicircular canal
- Lateral semicircular canal
- Vestibular aqueduct
- Facial nerve
- Superior semicircular canal
- Endolymphatic duct
17-F; 18-H; 19-E; 20-A; 21-D; 22-G; 23-B; 24-1. These three axial GT scans (Figures 8.17-8.24 Qa, b, c) illustrate critical por¬tions of the petrous temporal bone and progress sequentially in a superior-inferior direction. In these figures, A represents the lateral semicircular canal, B the superior semicircular canal, G the internal auditory canal, D the vestibular aque¬duct, E the posterior semicircular canal, F the vestibule, G the facial nerve, H the cochlea, and I the endolymphatic sac. Notice the labyrinthine and anterior tympanic portions of the facial nerve, separated by the geniculate ganglion, in figure B. Figure G depicts the horizontal segment of the facial nerve and the vestibular aqueduct joining the endolymphatic sac at the posterior aspect of the petrous temporal bone (Som, pp. 13 19-1325).
- Refer to Figure 8.26-8.27Q. What is the diagnosis?
FIGURE 8.26-27Q
A. Porencephaly
B. Cortical dysplasia
C. Open-lip schizencephaly
D. Arachnoid cyst
E. Closed-lip schizencephal y - This abnormality is believed to result from failure of
what embryologic stage of development?
A. Primary neurulation
B. Secondary neurulation
C. Disjunction
D. Cellular migration
E. Myelination
26-C; 27-D. The process of cellular migration typically occurs between the second and fifth gestational months. Faulty cellular migration can result in heterotopias, callosal agene¬sis, lissencephaly, pachygyria/polymicrogyria, and open-or closed-lip schizencephaly. Note the prominent cleft (open-lip) that is lined entirely by gray matter on this sagittal MPd. Porencephalic clefts are predominately lined by gliotic white matter (Osborne DN, pp. 52-55).
- What is depicted on the EEC below (Figure 8.30QJ?
FIGURE 8.30Q
A. Absence seizure
B. Left temporal lobe spike-and-wave discharges
C. Alpha rhythm
D. Theta rhythm
E. K complexes
- C. This EEG depicts normal posterior dominant rhythm (“alpha rhythm”) in a healthy adult man, maximal in the posterior head regions when the eyes are closed (Rowan, pp. 25-26).
- A 28-year-old obese male presents with a 2-month history of headaches and diplopia. He is found to harbor thelesion depicted in the photomicrograph below (Figure 8.32-8.33Q). What should be the next course of treatment after surgical resection of this lesion?
FIGURE 8.32-33Q
A. Whole-brain radiation therapy
B. Radiosurgery
C. Chemotherapy
D. Observation and serial MRI
E. Proton-beam radiotherapy - What does the arrow in this photomicrograph depict?
A. Capillary telangiectasia
B. Gemistocytes
C. Rosenthal fibers
D. Normal blood vessels
E. Melanin granules
32-D; 33-C. One of the hallmarks of pilocytic astrocytomas is their relatively indolent growth rate with low mitotic activ¬ity. Management typically includes gross total resection, if possible, followed by radiation therapy for recurrence. In some cases, invasion of the brainstem and/or cranial nerves precludes gross total resection. Macroscopic features com¬mon to these tumors include the formation of a cyst with a solid mural nodule. Tumors without cyst wall enhancement are typically adequately treated with mural nodule excision alone, while tumors with a thickened, enhancing cyst wall are best managed with gross total excision. Microscopically, these tumors show a biphasic pattern consisting of bipolar, highly fibrillated (or piloid) cells with Rosenthal fibers and a loose-knit cystic component associated with granular bodies or protein droplets. The arrow depicts Rosenthal fibers, which are ubiquitin a(3 crystallin, and GFAP-positive (Greenberg, pp. 401-403; Ellison, pp. 630-635; WHO, pp. 45-51).
- A 42-year-old male underwent a therapeutic interven-
tional neuroradiologic procedure. What is depicted on his
angiogram below (Figure 8.42Q)?
FIGURE 8.42Q
A. Intraprocedural aneurysmal rupture
B. Poor distal middle cerebral artery perfusion
C. An enlarged tentorial artery supplying a lateral pontine
arterial-venous malformation
D. A dural arterial-venous fistula
E. Type II carotid-cavernous fistula
- A. The angiogram depicts a right posterior carotid wall aneurysm as well as extravasation of contrast dye from the aneurysm in a patient about to be treated with GDC embolization (microcatheter evident in internal carotid artery). Intraprocedural aneurysmal rupture is reported to occur in 2 to 8% of patients treated with GDC embolization.
It seems to be more prevalent during treatment of smaller aneurysms, especially in the acute phase following SAIL It may occur during several phases of the embolization procedure. When the microcatheter is responsible for the rupture, it is important to avoid withdrawing the device prematurely, as the offending device often plugs the ruptured site and prevents additional extravasation of blood. Similarly, if the
aneurysm ruptures during the coiling phase, it is important that the clinician deploy the coil in an attempt to seal the leak. In general, once rupture occurs, the remaining aneurysmal sac should be packed as quickly as possible. In refractory cases, temporary or permanent balloon occlusion of the parent vessel or immediate surgical clipping may be warranted (Youmans, pp. 2071-2072) .
- What is depicted on the ECG below (Figure 8.43QJ?
A. Myocardial infarction
B. Hyperkalemia
C. Torsades de pointes
D. Digoxin toxicity
E. Atrial flutter
. The angiogram depicts a right posterior carotid wall aneurysm as well as extravasation of contrast dye from the aneurysm in a patient about to be treated with GDC embolization (microcatheter evident in internal carotid artery). Intraprocedural aneurysmal rupture is reported to occur in 2 to 8% of patients treated with GDC embolization. It seems to be more prevalent during treatment of smaller aneurysms, especially in the acute phase following SAIL It may occur during several phases of the embolization proce¬dure. When the microcatheter is responsible for the rupture, it is important to avoid withdrawing the device prematurely, as the offending device often plugs the ruptured site and prevents additional extravasation of blood. Similarly, if the aneurysm ruptures during the coiling phase, it is important that the clinician deploy the coil in an attempt to seal the leak. In general, once rupture occurs, the remaining aneurysmal sac should be packed as quickly as possible. In refractory cases, temporary or permanent balloon occlusion of the parent vessel or immediate surgical clipping may be warranted (Youmans, pp. 2071-2072).
QUESTIONS 44-45
Scenario: A 16-year-old male with the MPJ depicted
below (Figure 8.44-8.45Q) is referred to your office for
surgical evaluation. His laboratory studies reveal that he has hypothyroidism, Cortisol deficiency, and a prolactin level of 69. His family states that they have noted behavior changes and a recent increase in his weight. He has no vision with the left eye and a dense temporal field cut of the right eye.
FIGURE 8.44-45Q
44. What is the most likely diagnosis?
A. Pituitary macroadenoma
B. Metastatic tumor invading the posterior pituitary gland
C. Craniopharyngioma
D. Sphenoid sinusitis
E. Invasive mucocele of the sphenoid sinus
- The prolactin level is elevated most likely secondary to
what process?
A. Hook effect
B. Stalk effect
C. Avengaard effect
D. Tumor secretion
E. Prolactin-secreting lung nodule
44-C; 45-B. The clinical history and MPd are most consistent with a cystic craniopharyngioma. The modestly elevated prolactin level is likely the result of the “stalk effect,” whereby injury of the hypothalamus or pituitary stalk (i.e., from large tumors) results in modest elevations of prolactin from reduced prolactin inhibitory factor levels (dopamine). As a general rule, prolactin levels > 150 ng/mL are rarely secondary to a stalk effect, whereas levels < 90 usually suggest a stalk injury. Large components of this tumor extend inferiorly into the sphenoid sinus and superiorly into the suprasellar space. Moreover, the optic chiasm appears draped over the rostral margin of the tumor. Although these are worrisome findings that warrant special concern, they are not uncommon with craniopharyngioma. This sagittal MPJ shows that the posterior component of this tumor has eroded through a significant portion of the tuberculum sella and clivus, a relatively rare but significant finding. This latter detail is especially concerning, since failure to recognize this degree of bony erosion on preoperative MPd may result in inadvertent injury to major posterior fossa structures (basilar artery, perforating vessels) during transsphenoidal tumor resection. Thyroxin (T4) is generally preferred over thyroid extract (T3) because blood levels are often more pre¬dictable. This is especially true for patients with concomitant liver injury, as T3 is converted to T4 in the liver. Patients with cirrhosis may remain hypothyroid even while taking T3. Although it is preferable to correct hypothyroidism preoper-atively, it is important to correct any Cortisol deficiency as well, as premature thyroid replacement can precipitate an adrenal crisis in this group of patients. Thyroxine has been shown to decrease phenytoin levels (Committee on Education in Neurological Surgery, p. 102; Greenberg, pp. 419-436).
- A 13-year-old boy with a lytic skull lesion presents
with diabetes insipidus and the coronal MRI depicted below (Figure 8.52-8.54Q.). What is the most likely diagnosis?
A. Granular cell tumor
B. Sarcoidosis
C. Pituitary adenoma
D. Langerhans’ cell histiocytosis
E. Germinoma
- This disorder is marked by proliferation of what cell type?
A. Fibroblasts
B. T-cell lymphocytes
C. Antigen-presenting dendritic cells
D. Eosinophils
E. Cells derived from Rathke’s pouch
- A pathognomonic finding of this condition on microscopy includes the presence of
A. Birbeck granules
B. Junctional complexes
C. Cholesterol crystals
D. Keratohyaline granules
E. Stippled chromatin
52-D; 53-C; 54-A. Note the abnormally thickened stalk with high signal intensity on this coronal MRI depicting Langerhans’ cell histiocytosis. The etiology of this condition is unknown, but it is believed to result from overproliferation of an antigen-presenting dendritic cell of bone marrow origin. Although it is usually treated as a neoplastic process, some speculate that it is due to malfunction of the immune system. Other manifestations of this disease may include lytic skull lesions (approximately 80% of cases) as well as hematopoietic, hepatic, and pulmonary abnormalities. A pathognomic finding of this condition on electron microscopy is the presence of Birbeck granules, a unique organelle of the Langerhans’ cell (Ramsey, pp. 381-385; Merritt, p. 87 2).
- What is depicted in the photomicrograph below (Fig-
ure 8.55-8.56Q)?
FIGURE 8.55-56Q
A. Neurofibroma
B. Transitional meningioma
C. Acoustic neuroma
D. Pilocytic astrocytoma
E. Pleomorphic xanthoastrocytoma - What does the arrow depict?
A. Verocay body
B. Whorls
C. Psammoma body
D. Pseudopalisading
E. Antoni B area
55-C; 56-A. Acoustic neuroma. Note the palisading of nuclei (picket fence-like arrangement) separated by an anuclear area (arrow) on this photomicrograph, which depicts a Verocay body (Ellison, pp. 695-699).
QUESTIONS 58-63
Directions: Match the following peripheral nerve injuries
with the appropriate hand abnormality (Figure 8.58-8.63Q),using each answer once, more than once, or not at all.
FIGURE 8.58-63Q
58. Injury of the median nerve at the level of the elbow
59. Injury of the ulnar nerve at the elbow
60. Injury of the ulnar nerve at the wrist
61. Anterior interosseous nerve injury
62. Klumpke’s paralysis
63. C8 root lesion
58-B; 59-A; 60-A; 61-C; 62-D; 63-C. Compressive lesions of the ulnar nerve at the level of the elbow, forearm, or wrist can produce a “claw hand” (A) in severe cases. The ulnar half of the flexor digitorum profundus, lumbricals 3 and 4, the dorsal and palmar interossei, and the hypothenar muscles are typically paralyzed. When the metacarpophalangeal joints are extended, the distal and proximal interphalangeal joints cannot be extended because the interossei and half the lumbricals are not functional, which results in a “claw-like” posture. Laceration of the ulnar nerve in the wrist leaves the innervation of the ulnar side of the flexor digitorum profundus intact but can also result in a claw hand. There is also loss of abduction of the thumb, so that a piece of paper cannot be held between the side of the thumb and the index finger.
Lesions of the median nerve near the elbow can produce paralysis of the flexor digitorum superficialis, the flexor digi-torum profundus I and II, the flexor pollicis longus, as well as the thenar muscles and lumbricals 1 and 2. This produces the “sign of benediction,” in which the index and middle fingers cannot flex and the thumb cannot be opposed. In addition, there may be numbness over the radial side of the palm and of the digits lateral to the center of the ring finger.
C8 nerve root or anterior interosseous nerve injury causes weakness of the long flexors of the thumb (flexor polli-cis longus), index and middle fingers (weak flexor digitorum profundus I and II), and the pronator quadratus. In trying to pinch the index finger and thumb, the terminal phalanges extend and instead of the tips, the pulps touch (“pinch sign,” C) (April, pp. 98-100; Patten, pp. 285-2 96; Greenberg, p. 540).
