TEST PAPER 2 Flashcards
1.An intracardiac mass was incidentally detected during echocardiography in a patientundergoing preoperative assessment. Chest X-ray was non specific, showing an enlarged heart.Which one of the following statements regarding primary benign cardiac tumours is false?
A. Cardiac fibromas are homogenously low on T2W MRI.
B. Cardiac lipomas are high on T1W MRI.
C. Cardiac rhabdomyomas are associated with tuberous sclerosis.
D. Cardiac fibroelastomas usually arise from the pericardium.
E. Cardiac myxomas show heterogeneous signal on MRI.
1.D. Cardiac fibroelastomas usually arise from the pericardium.
Most lipomas appear to be subepicardial, expanding into the pericardial space. They typically have high signal on T1-weighted images and low signal on fat-suppressed images.
Fibroelastomas occur on cardiac valves, making them the most common neoplasm of the valves.They are hypointense mobile masses situated away from the free edge of the valves.
Fibroma is a neoplasm primarily of infants and children. Fibromas are homogeneouslyhypointense on T2-weighted images and show variable enhancement.
Rhabdomyomas are the most common benign cardiac tumour of childhood associated withtuberous sclerosis. They originate within the myocardium, typically in the ventricles, may be multiple, and are high on T2-weighted images.
The majority of myxomas manifest in adulthood between the fourth and seventh decades.
A minority will constitute part of an autosomal dominant syndrome known as Carney complex, characterised by myxomas, hyperpigmented skin lesions and extracardiac tumours such as pituitary adenomas, breast fibroadenomas and melanotic schwannomas. The classic triad of symptoms attributed to myxomas include cardiac obstructive symptoms related to obstruction to blood flow, embolic events and constitutional symptoms such as fever, malaise and weight loss. At MR imaging, the vast majority of myxomas demonstrate heterogeneous signal intensity.
The main differential diagnoses for myxoma include atrial thrombus or papillary fibroelastoma. Myxomas are more likely to arise anteriorly from the interatrial septum, whereas thrombus is more likely located posteriorly in the left atrium. In addition, myxomas enhance with gadolinium contrast material, whereas thrombi, in most cases, do not.
@# 2.A 40-year-old man undergoes a CT scan of the abdomen for recurrent abdominal pain.
The precontrast scan showed bilateral renal calculi. A post-contrast scan showed severalpancreatic lesions, measuring between 1 and 2 cm. What is the likely unifying diagnosis?
A. MEN I
B. MEN IIA
C. Insulinoma
D. Glucagonoma
E. NF1
2.A. MEN 1
Multiple endocrine neoplasia Type 1 is also known as Wermer syndrome. Inheritance isautosomal dominant with high penetrance. The male to-female ratio is 1:1. Organ involvement includes parathyroid hyperplasia (97%), pancreatic islet cell tumour (30% 80%), anterior pituitary gland tumour (15%—50%) and adrenocortical hyperplasia (33%-40%).
3.A 45-year old woman presents with a rapidly enlarging mildly painful breast mass over
a period of few months. An urgent ultrasound is performed. The ultrasound shows that themass measures 7 cm, filling up almost the entire breast with fluid-filled clefts in thetumour. What is the diagnosis?
A. Inflammatory carcinoma
B. Cystosarcoma phylloides
C. Complex breast cyst
D. Invasive lobular carcinoma
E. Breast lymphoma
- B. Cystosarcoma phyllodes
Phylloides tumour (PT) is a rare breast fibroepithelial neoplasm.
It is now generally accepted that PTs can be classified as benign, borderline or malignant.
Mammography and ultrasound are notorious for their inability to distinguish the benign or malignant histologic nature of PTs.
On US, they can be indistinguishable from fibroadenoma. They appear as an inhomogeneous, solid-appearing mass. A solid mass containing single or multiple, round or cleft-like cystic spaces and demonstrating posterior acoustic enhancement strongly suggests a diagnosis of PTs.Solid components of the tumour show vascularity on Doppler.
On MRI, well-defined margins with a round or lobulated shape and a septate inner structure have been described as characteristic morphologic signs. They are usually low on T1-weighted images and vary from low to very high signal on T2-weighted images. Some have described a silt-like pattern on MRIs of benign PTs; these appear as hyperintense slit-like fluid-filled spaces on T2-weighted images, with a low signal after enhancement. Solid areas of the tumour show enhancement with contrast.
4.Osteoid osteomas:
A. Are aggressive bone lesions with malignant potential
B. Are referred to as osteoblastomas when larger than 3 cm
C. Are typically cortical rather than subcortical based lesions
D. Typically require surgical curettage and resection
E. Are more common in women
- C. Arc typically cortical rather than subcortical-based lesions
Osteoid osteomas are benign and aggressive bone tumours that are more common in men and usually present clinically in patients less than 30 years of age.
They are most commonly based within the cortex, although they can also occur in any other area of the bone.
When larger than 2 cm, they are regarded as osteoblastomas.
Radiofrequency ablation is now a common and viable treatment for these lesions throughout the UK.
5.A 67-year-old known alcoholic man with acute onset neurological symptoms has beenreferred for an urgent CT brain to exclude haemorrhage. CT shows an isodense subdural onthe right, but the history’ of trauma was 24 hours earlier with no previous history of head
injury or fall. All of the following are causes of isodense subdural hacmatoma on CT following head trauma, except
A. A 2-week-old head injury with subdural haemorrhage
B. Acute subdural haematoma in a patient with Hb 7.5 g/dL
C. Chronic haematoma in a patient with coagulopathy
D. Patient with an associated arachnoid tear
E. Patient with leptomeningeal metastasis
- E. Patient with leptomeningeal metastasis
CT attenuation of blood in the subdural space remains denser than brain for 1 week and is less dense after 3 weeks. There is an interim period of 2 weeks when it is isodense to brain tissue.
In addition to variation in appearance over time, subdural haemorrhage may have a variable appearance in a setting of systemic disease like anaemia and coagulopathy.
An acute SDH can appear isodense in the following settings: anaemia with a haemoglobin concentration of <10 g/dL, admixture of CSF in the subdural space caused by an associated tear to the arachnoid layer and disseminated intravascular coagulation.
If there is chronic CSF leakage of venous blood, for example, if the patient has coagulopathy or is on anticoagulants/antiplatelet agents, chronic haematoma may look isodense rather than hypodense.
Meningeal metastasis may appear as hyperdensity on gvri and mimic subarachnoid haemorrhage
- A child presents with intermittent abdominal pain, vomiting, and a right upper-quadrant mass. On clinical examination, blood is noted on rectal examination. A clinical diagnosis of intussusception is made. Where is the most common site of intussusception in this population group?
A. Ileoileal
B. Ileocolic
C. Ileoileocolic
D. Colocolic
E. Jejunoileal
- B. Ileocolic
Intussusception is one of the most common causes of acute abdomen in infancy. Intussusception occurs when a portion of the digestive tract becomes telescoped into the adjacent bowel segment. This condition usually occurs in children between 6 months and 2 years of age. In this age group, intussusception is idiopathic in almost all cases. The vast majority of childhood cases of intussusception arc ileocolic.
US is highly accurate in the diagnosis of intussusception with a sensitivity of 98% 100% and a specificity of 88%-100%. US is also good at demonstrating alternative pathology. Hence, enema could be reserved for therapeutic purposes when US is available.
- A 29 year-old woman with fever, malaise, fatigue, intermittent pain and numbness in both hands and feet, and normal chest radiograph is referred for MRI thorax. MRI shows
wall thickening of the origin of the right subclavian artery and both carotid arteries. What is the diagnosis?
A. Moyamoya disease
B. Takayasu arteritis
C. Churg-Strauss disease
D. PAN
E. Wegener’s granulomatosis
- B. Takayasu arteritis
Takayasu arteritis is a form of granulomatous vasculitis affecting large and medium-sized arteries, characterised by ocular disturbances and weak pulses in the upper extremities (pulseless disease).
It is associated with fibrous thickening of the aortic arch with narrowing of the origins of the great vessels at the arch. Takayasu arteritis can be limited to the descending thoracic and abdominal aorta. It is seen in young and middle-aged patients, especially Asian and women. The diagnosis is confirmed by a characteristic arteriographic pattern of irregular vessel walls, stenosis, post-stenotic dilatation, aneurysm formation, occlusion and evidence of increased collateral circulation.
Polyarteritis nodosa is a fibrinoid necrotising vasculitis that mainly involves small and mediumsized arteries of the muscles. Multiple aneurysm formation is a characteristic finding. The kidney is most commonly involved, followed by the GI tract, liver, spleen and pancreas. Positive ANCA titres (usually pANCA type) are found in variable percentages of patients.
Wegener s granulomatosis is a distinct clinicopathologic entity characterised by granulomatous vasculitis of the upper and lower respiratory tract together with glomerulonephritis.
Churg-Strauss syndrome is characterised by granulomatous vasculitis of multiple organ systems, particularly the lung, and involves both arteries and veins as well as pulmonary and systemic vessels.
Moyamoya disease is a progressive vasculopathy leading to stenosis of the main intracranial arteries. Characteristic angiographic features of the disease include stenosis or occlusion of the arteries of the circle of Willis, as well as the development of collateral vasculature that produces a typical angiographic image called clouds of smoke’ or ‘puff of cigarette smoke’.
@# 8. A slimly built 60-year-old woman presents with anorexia, diarrhoea, and weight loss. Barium meal shows multiple filling defects in the stomach with thickened gastric rugae. Colonoscopy shows multiple colonic polyps. The top differential is
A. Peutz-Jeghers syndrome
B. Familial adenomatous polyposis
C. Cronkhite-Canada syndrome
D. Cowden syndrome
E. Turcot’s syndrome
- C. Cronkhite-Canada syndrome
Cronkhite-Canada syndrome occurs in older patients with an average age of 60 with no familial predisposition.
The histologic appearance of the GI polyps resembles that of juvenile polyps, and they are characteristically distributed throughout the stomach.
They are commonly small, sessile and characterised by cystic dilatation of the glands and inflammation of the lamina propria.
Patients commonly present with abdominal pain, protein-losing diarrhoea, anorexia and weight loss. Dystrophic nail changes and alopecia usually appear after the onset of GI symptoms.
- A middle-aged woman presents to the breast clinic with a few weeks’ history of vague breast pain and lumpiness. On further direct questioning, she reveals a history of trauma to the breast a few months ago. Mammogram show’s a well-defined circular mass with central translucency and eggshell calcification. What is the most likely diagnosis?
A. Cystosarcoma phylloides
B. Complex breast cyst
C. Invasive lobular carcinoma
D. Fat necrosis
E. Fibroadenoma
- D. Fat necrosis
Fat necrosis is a frequently encountered cause of benign calcification, particularly when there is a history of trauma. It appears well circumscribed with translucent areas in the centre (homogenous fat density’ of the oil cyst). Occasionally, it shows curvilinear or eggshell calcification in the wall.
On US, it appears as a hypoechoic or anechoic mass with ill- or well-defined margins, with or without acoustic shadowing or as a complex cyst.
- A 60-year-old patient is admitted for progressive thoracic back pain with a low-grade fever, which has been going on for several weeks. Routine chest radiograph reveals no abnormality. An M RI of the spine reveals minimal intervertebral disc space reduction at T4/5 with hyperin tensity of the disc. There is adjacent vertebral end plate oedema and irregularity. A well-defined and
predominantly high T2W signal collection is noted, extending beneath the anterior longitudinal ligament and cranially to reach the level of T2. What is the most likely diagnosis?
A. Pyogenic discitis
- Insufficiency fracture with ongoing collapse, complicated by chronic vertebral osteomyelitis
C. Degenerative disc disease with Modic Type II end plate changes
D. Pott disease
E. Vertebral lymphoma
- D. Pott disease
Infection usually begins in the anterior part of the vertebral body adjacent to the end plate.
Subsequent demineralisation of the end plate results in loss of definition of its dense margins on conventional radiographs.
These end plate changes allow the spread of infection to the adjacent intervertebral disk, resulting in a classic pattern of involvement of more than one vertebral body together with the intervening disks.
It also allows spread into the paraspinal tissues, resulting in the formation of a paravertebral abscess. However, if there is anterior subligamentous involvement of the spine, infection can extend both superiorly and inferiorly, with sparing of the intervertebral disks.
A normal chest radiograph is present in up to 50% of cases. In the later stages of disease, there is often vertebral collapse with a gibbus deformity.
Tuberculosis rarely affects the posterior vertebral elements (including the pedicles), in contrast to metastatic disease.
Anterior scalloping seen with subligamentous spread of infection can also be seen with paravertebral lymphadenopathy, secondary to metastases or lymphoma.
In differentiating tuberculosis from pyogenic infection, the clinical picture is as important as the radiologic features, with insidious onset of symptoms, a normal erythrocyte sedimentation rate, relevant respiratory symptoms and slow disease progression favouring a diagnosis of tuberculosis.
Radiologic features that favour this diagnosis include involvement of one or more segments; a delay in destruction of the intervertebral disks; a large, calcified paravertebral mass; and the absence of sclerosis.
Sarcoidosis can produce multifocal lesions of vertebrae and disks, along with paraspinal masses that appear identical to tuberculosis.
- A 16 year old boy with progressive extra-pyramidal symptoms, dementia and positive family history was sent for an MRI brain by his neurologist. MRI showed bilaterally symmetric hyperintense signal changes in the anterior medial globus pallidus with surrounding hypointensity in the globus pallidus on T2W images, commonly described as ‘eye of the tiger sign. Caudate was normal and no other areas of signal change was demonstrated. What is the diagnosis?
A. Wilson disease
B. Huntington disease
C. MELAS
I). Hallervorden-Spatz disease
E. CADASIL
- D. Hallervorden-Spatz disease
The ‘eye of the tiger sign represents marked low signal intensity of the globus palladi on T2-weighted MRI, surrounding a central, small hyperintense area. The sign is seen in what was once known as Hallervorden-Spatz (HS) syndrome but is now called neurodegeneration with brain iron accumulation (NBIA) or pantothenate kinase II (PANC2)-associated neurodegeneration.
The low signal is a result of excessive iron accumulation and the central high signal is attributed to gliosis, increased water content and neuronal loss with disintegration. Iron levels in blood and CSF are normal. HS is a neurodegenerative disorder associated with extrapyramidal dysfunction and dementia. The sign can also be seen in other extrapyramidal Parkinsonian disorders such as cortical-basal ganglionic degeneration, Steele-Richardson-Olszewski syndrome, and early onset levodopa-responsive Parkinsonism.
High signal in the basal ganglia, thalamus and midbrain is seen in Wilson disease.
Caudate is atrophic in Huntington disease.
CADASIL shows extensive white matter signal change
and MELAS shows multiple focal white matter signal changes.
- A 2-year-old boy presents with a large abdominal mass and there is suspicion of an underlying neuroblastoma. Which feature would be supportive of this diagnosis with the highest confidence?
A. Calcification is uncommon.
B. Well circumscribed.
C. Displaces major vessels rather than encasing them.
D. Encases major vessels but does not invade them.
E. Claw of renal tissue extends partially around the mass.
- D. Encases major vessels but does not invade them.
Neuroblastoma (NBL) is the most common extracranial tumour in childhood and commonly presents as an abdominal mass. Abdominal and pelvic tumours are usually large and heterogeneous, and approximately 80%-90% demonstrate calcification on CT scans. Low attenuation areas of necrosis or haemorrhage are frequently noted at CT. Vascular encasement and compression of the renal vessels, splenic vein, inferior vena cava, aorta, celiac artery and superior mesenteric artery may occur, and vascular invasion is rare. Regional invasion of the psoas and paraspinal musculature may occur, and invasion of the neural foramen into the epidural space is also frequent; these are better evaluated at MR imaging, as is regional organ invasion. Metastatic disease of the liver and lung are readily evaluated with CT. They are typically heterogeneous, variably enhancing and of relatively low signal intensity on T1 weighted images and high signal intensity on T2-weighted images.
Wilms tumour demonstrates a ‘daw’ of normal renal tissue around the tumour. In contrast to neuroblastoma, vessels are displaced rather than encased and vascular invasion occurs in approximately 5%-10% of cases.
- A 73-year-old woman with previous history of myocardial infarction was referred for a chest radiograph by her GP to exclude chest infection. No infective focus was identified but a focal bulge was noticed in the left heart border, with curvilinear calcification along the edge. What is the diagnosis?
A. Myocardial calcification
B. Right atrial calcification
C. Mitral annulus calcification
D. Calcified vegetations
E. Left ventricular aneurysm calcification
- E. Left ventricular aneurysm calcification
A cardiac false aneurysm is defined as a rupture of the myocardium that is contained by pericardial adhesion. It usually represents a rare complication of myocardial infarction, but it may also occur after cardiac surgery’, chest trauma and endocarditis. True left ventricular aneurysms are discrete, dyskinetic areas of the left ventricular wall with a broad neck. Unlike a true aneurysm, which contains some myocardial elements in its wall, the walls of a false aneurysm are composed of organised haematoma and pericardium only. Both demonstrate focal bulge to the cardiac contour and can calcify.
Marked delayed enhancement of the pericardium on dynamic enhanced MRI may help in differentiating a false aneurysm from a true one.
@# 14. A 70-year-old man presents with rectal bleeding. Flexible sigmoidoscopy shows a circumferential tumour in the upper third of the anal canal. An MRI performed for staging shows locoregional lymphadenopathy. The lymph node group most likely to be involved is
A. Superficial inguinal
B. Common iliac
C. Pudendal
D. External iliac
E. Paraortic
- A. Superficial inguinal
Metastatic spread to regional lymph nodes represents the most common mode of tumour spread from cancer of the anal canal and margin. Nodal metastasis is more likely in cases of larger tumour size or a poorly differentiated anal tumour. Metastasis most commonly occurs to the perirectal nodes, with inguinal nodal spread being the second most common location of nodal metastasis.
- A fit and healthy 25-year-old woman presents to the breast clinic with a small mobile non-tender breast lump that she noticed incidentally. An ultrasound is deemed as the first-line investigation; it reveals an extremely well-defined homogenous, hypoechoic oval mass with posterior acoustic shadowing. What is the most likely diagnosis?
A. Cystosarcoma phylloides
B. Fibroadenoma
C. Complex breast cyst
D. Invasive lobular carcinoma
E. Fat necrosis
- B. Fibroadenoma
Fibroadenomas are the most common cause of benign solid mass in the breast. On US, they appear round or oval, wider than tall, hypoechoic, well-defined and mostly homogenous and show a ‘hump and dip’ sign (small focal bulge to the contour with a contagious small sulcus), a thin echogenic pseudocapsule and rarely cither posterior acoustic enhancement (17%-25%) or posterior acoustic shadow (9%—11%).
- A 35-year-old weightlifter presents to the orthopaedic clinic with pain in the right shoulder. An initial radiograph is normal and no abnormality is identified on US. An MRI is suggested for further evaluation; it reveals increased T2W signal changes with fatty atrophy of the teres minor muscle. What is the likely diagnosis?
A. Parsonage Turner syndrome
B. Spinoglenoid notch paralabral cyst
C. Duchenne’s muscular dystrophy
D. Quadrilateral space syndrome
E. Acute rotator cuff tear
- D. Quadrilateral space syndrome
The anatomy of the suprascapular nerve renders it particularly susceptible to compression at the suprascapular notch and spinoglenoid notch.
The pattern of muscle denervation provides information about the duration of entrapment and can identify the site of neurologic compromise.
Acute denervation presents as hyperintensity of the supraspinatus and infraspinatus or of the infraspinatus muscle alone on fluid-sensitive sequences.
Chronic compression is shown as a reduction in muscle bulk and fatty infiltration of the involved muscles.
Involvement of both the supra- and infraspinatus muscles reflects proximal compression at the suprascapular notch,
whereas isolated infraspinatus denervation suggests compression at the spinoglenoid notch.
Quadrilateral space syndrome is a rare condition referring to an isolated compressive neuropathy of the axillary nerve. It generally results in isolated atrophy of the teres minor and, less commonly, of the deltoid, which appears as a reduction in muscle bulk and fatty infiltration with chronic compression.
Parsonage-Turner syndrome is an uncommon, self-limiting disorder characterised by sudden onset of non-traumatic shoulder pain associated with progressive weakness of the shoulder girdle musculature.
MR] is the technique of choice in patients with shoulder pain and weakness. It is sensitive for the detection of signal abnormalities in the shoulder girdle musculature related to denervation injury.
MRI is also useful in excluding intrinsic shoulder abnormalities that can produce symptoms similar to Parsonage-Turner syndrome such as rotator cuff tears, impingement syndrome and labral tears.
None of the findings or history would be compatible with an acute rotator cuff tear or Duchenne’s muscular dystrophy.
- A 45-year-old male patient with low back pain, rectal bleeding and faecal incontinence is investigated with CT and MRI. CT shows an enhancing soft-tissue mass replacing the sacrum with areas of amorphous calcifications. On MRI, the lesion shows low to intermediate signal on T1W and high signal on T2W images. What is your diagnosis?
A. Sacral meningocoele
B. Sacral chordoma
C. Central dural ectasia
D. Rhabdomyosarcoma
E. Sacrococcygeal teratoma
- B. Sacral chordoma
A chordoma is a tumour that derives from notochordal remnants. At imaging, it typically manifests as a large, destructive sacral mass with secondary soft-tissue extension. Radiographs may show sacral osteolysis with an associated soft-tissue mass and calcifications. CT shows bone destruction with an associated lobulated midline soft-tissue mass. Areas of low attenuation within the mass reflect the myxoid properties (high water content) of the tissue. Areas of punctate calcification often are noted.
At MR imaging, the most striking feature is the high signal intensity seen on T2-weighted images. High T2 signal intensity is a non-specific feature; however, the combination of high T2 signal intensity and a lobulated sacral mass that contains areas of haemorrhage and calcification is strongly suggestive of a chordoma. Chordomas tend to show hypointense or isointense signal relative to that in muscle on T1-weighted images, and contrast-enhanced images show a modest degree of heterogeneous enhancement in the soft-tissue components of the tumour. Areas of intrinsic Tl signal hyperintensity typically represent areas of haemorrhage or mucinous material. The tumour may cross the sacroiliac joint.
- A 3-year-old girl presents with a cough, temperature and hyperinflated left lower zone, elevating the left hilum. What is the likeliest diagnosis?
A. Congenital lobar emphysema
B. Viral pneumonia
C. Cystic fibrosis
D. Pulmonary sequestration
E. Inhaled foreign body
- E. Inhaled foreign body
Most inhaled foreign bodies are organic and may not be visible on chest X-ray. It is recognised that chest X-ray can be normal with inhaled foreign bodies and clinical suspicion needs to be high. The most common findings are unilateral, distal obstructive emphysema, followed by normal X-ray. Lower lobes are most commonly involved. Long-standing unrecognised foreign body may present with recurrent or non-resolving consolidation or unexplained segmental collapse.
- A 72-year-old man presents to the vascular surgeon with abdominal pain 4 months after endovascular repair of an abdominal aortic aneurysm. An emergency dual phase contrast-enhanced CT is performed. The unenhanced images reveal high-density material interposed between the stent and the wall of the aorta. There is further enhancement of this high-density area on arterial phase images. The graft and the attachments look intact.
What is the most likely diagnosis?
A. Type I endoleak
B. Type II endoleak
C. Type III endoleak
D. Type IV endoleak
E. Type V endoleak
- B. Type II endoleak
In a Type I endoleak, there is poor apposition between one of the attachment sites of a stent graft and the native aortic or iliac artery wall, and blood leaks through this defect into the aneurysm sac. A Type I endoleak can be seen immediately after stent-graft deployment On CT, dense contrast collection is usually seen centrally within the sac and is often continuous with one of the attachment sites.
Type 11 endoleaks are the most common. They occur when there is retrograde flow of blood into the aneurysm sac via an excluded aortic branch, most commonly IMA or a lumbar artery. Many Type II endoleaks close spontaneously over time. CT shows peripheral or central location of acute haemorrhage.
Leakage of blood through the body of a stent graft results in a Type III endoleak. Type III endoleaks manifest as collections of haemorrhage or contrast material centrally within the aneurysm sac, usually distant from the attachment sites or native vessels.
Opacification of the aneurysm sac immediately after placement of a stent graft without a discernible source of leakage is designated a Type IV endoleak.
A Type V endoleak, or endotension, is characterised by continued growth of an excluded aneurysm sac without direct radiologic evidence of a leak.
@# 20. A 76-year old woman with 6 months’ history of progressive weight loss and altered bowel habits is referred for a CT scan of the abdomen and pelvis. The examination shows several hypoattenuating lesions on Segments II and III of the liver that are highly suspicious for malignancy. Blood biochemistry with tumour markers shows a normal AFP and CA 19-9 but raised CEA. LFTs are minimally deranged. The case is discussed at MDT.
What is the most likely differential diagnosis and further management plan out of the options given?
A. Primary hepatocellular carcinoma - liver biopsy
B. Hepatic adenoma - liver resection
C. Probable lung cancer - CT chest
D. Metastatic renal carcinoma - renal biopsy
E. Metastasis from colonic adenocarcinoma colonoscopy
- E. Metastasis from colonic adenocarcinoma - colonoscopy
- A late-middle-aged woman undergoes an MRI breast with contrast to investigate a clinically palpable nodularity. Fat-suppressed 3D images show a 3-cm well-defined abnormality with peripheral enhancement. Which of the following statements regarding enhancement pattern is incorrect?
A. Rim enhancement is a non-specific finding.
B. Fat content is a sign of benignity.
C. Homogenous enhancement is a sign of benignity.
D. Centripetal spread of contrast is more common in carcinomas.
E. Homogenous high T2 signal suggests malignancy.
- E.. Homogenous high T2 signal suggests malignancy.
Smooth margins, characterised by well-defined and sharply demarcated borders, are the feature with the highest benign lesion predictive value. Round and oval shapes have also been found to be predictive of benignity.
Homogeneous enhancement is highly suggestive of benign nature.
Fat content is specific to benign lesions, such as hamartoma, fibroadenoma, intramammary lymph nodes or fat necrosis.
In the case of fat necrosis, even if the lesion appears irregular in both shape and margin, with rim enhancement, the key to diagnosis is a fat internal signal on unenhanced sequences without fat suppression.
Strong hypersignal on non fat suppressed T2-weighted sequences is classically considered to be a clear sign of fibroadenoma, but it is non-specific and is seen in mucinous carcinomas, invasive ductal carcinomas, metaplastic carcinomas and intracystic papillary carcinomas (although it does not have a homogenously high T2 signal as fibroadenoma).
Although rim enhancement is regarded as suggestive of malignancy, a regular enhanced rim, which may be thick, may be seen around cysts, seroma (both of which are high T2 fluid signal) and fat necrosis (high T1 signal).
In relation to enhancement kinematics, a centrifugal contrast uptake pattern may help in diagnosing a fibroadenoma, whereas a centripetal spread of contrast is more common in carcinomas.
@# 22. Which statement is not associated with transient patellar dislocation?
A. The medial patellar retinaculum frequently demonstrates high T2W signal changes.
B. A tibial tuberosity to trochlear groove distance of <1.5 cm.
C. Trochlear dysplasia is a predisposing condition.
D. There is an increase in the ratio of the patellar tendon to the patellar length.
E. Bone contusions of the anterolateral aspect of the lateral femoral condyle.
- B. A tibial tuberosity to trochlear groove distance of <1.5 cm.
Transient patellar dislocation is the dislocation of the patella laterally and subsequent relocation.
Trochlear dysplasia, patella alta (increase in the ratio of the patella tendon to the patella length) and an increase in the tibial tuberosity trochlear groove (TT-TG) distance are associated factors.
TT-TG >20 mm is abnormal and 15-20 mm is considered borderline change.
TT-TG less than 15 mm is within normal limits.
Contusional marrow oedema is often seen in the medial patellar facet and the lateral femoral condyle.
The medial patellar retinaculum and/or medial patellofemoral ligament (MPFL) may be torn or show a pattern of strain injury.
- A 45-year-old patient with chronically progressive low back pain is referred for an MRI scan. Sagittal T1W and T2W MRI lumbar spine show dehydration of the L4/5 disc, with low signal to the disc on T2. High signal is noted in the adjacent end plates of the L4 and L5 vertebra on both the T1W and T2W sequences. There is no cortical destruction. How would you report the finding?
A. Modic Type I end plate change
B. Modic Type II end plate change
C. Andersson lesion
D. Modic Type III end plate change
E. Discitis
- B. Modic Type II end plate change
Modic described three types of reactive changes in the cancellous bone adjacent to the vertebral end plates.
Type I change is low on Tl and high on T2, representing oedema secondary to acute fibrovascular tissue invasion.
Type 2 change represents fatty replacement of red marrow, bright on Tl and T2. This leads to bony sclerosis, low on Tl and T2.
Occasionally the end plates become irregular and the degenerative process progresses to a destructive discovertebral lesion, simulating infective discitis. The key differentiation is signal of the disc, which is high in discitis and low in degeneration.
Andersson lesions refer to inflammatory involvement of the intervertebral discs by spondyloarthritis.
- A 4 year-old boy falls off his bike and complains of neck pain. Which of the following features is worrying for a serious injury on plain cervical X-rays?
A. Atlanto axial distance <5 mm
B. Displacement of 6 mm of the lateral masses relative to the dens
C. Absence of lordosis
D. Disruption of the spinolamellar line
E. Anterior subluxation of C2 on C3
- D. Disruption of the spinolamellar line
The atlantoaxial interval is defined as the distance between the anterior aspect of the dens and the posterior aspect of the anterior ring of the atlas. This distance should be 5 mm or less. Pseudospread of the atlas on the axis (‘pseudo-Jefferson fracture’) can be seen on anterior open-mouth radiographs. Up to 6 mm of displacement of the lateral masses relative to the dens is common in patients up to 4 years old and may be seen in patients up to 7 years old. On extension radiographs, overriding of the anterior arch of the atlas onto the odontoid process can be seen in 20% of healthy children.
In children, the C2-3 space and, to a lesser extent, the C3-4 space have a normal physiologic displacement. The absence of lordosis, although potentially pathologic in an adult, can be seen in children up to 16 years of age when the neck is in a neutral position.
In children, the flexion manoeuvre can increase the distance between the tips of the C1 and C2 spinous processes. Normal posterior intraspinous distance is a good indicator of ligamentous integrity and should not be more than 1.5 times greater than the intraspinous distance one level either above or below the level in question. Anterior wedging of up to 3 mm of the vertebral bodies should not be confused with compression fracture. Such wedging can be profound at the C3 level.
A prevertebral space of less than 6 mm at the level of C3 is considered normal in children.
In paediatric patients, widening of the prevertebral soft tissues can be a normal finding that is related to expiration.
Disruption of the spinolamellar line is a sign of injury.
- A 77-year-old man is brought into A&E with progressive increase in back pain. There is
a history of known moderately large aortic aneurysm in the notes. A contrast CT is organised because the patient is haemodynamically stable. CT does not show any evidence of a ruptured aneurysm. All of the following are findings of pending rupture, except
A. Drape sign
B. Tangential calcium sign
C. Focal discontinuous intimal calcification
D. Retroperitoneal haematoma
E. High attenuation crescent
- D. Retroperitoneal haematoma
A retroperitoneal haematoma adjacent to an abdominal aortic aneurysm is the most common imaging finding of abdominal aortic aneurysm rupture.
The most common finding predictive of rupture is increase in aneurysm size, and thus it is the most common indicator for elective surgical management. Decreasing thrombus-lumen ratio is also predictive of increasing aneurysm size. The rest include drape sign, tangential calcium sign, focal discontinuous intimal calcification and high attenuation crescent.
High attenuation crescent represents an internal dissection of blood into either the peripheral thrombus or the aneurysm wall. It is one of the earliest and most specific imaging manifestations of the rupture process.
- A 56-year-old man with a history of PSC has an orthotopic liver transplant. He becomes unwell with a fever and acutely deranged LFTs on Day 4 post-operative. An ultrasound is subsequently performed. What is the likely cause of his symptoms?
A. Hepatic vein thrombosis
B. Portal vein thrombosis
C. Hepatic artery thrombosis
I). CBD ligation and cholangitis
E. Gangrenous cholecystitis with perforation
- C. Hepatic artery thrombosis
In the early post-operative period (<72 hours after transplantation), increased hepatic artery resistance (resistive index of >0.8) is a frequent finding, but resistance ordinarily returns to a normal level within a few days. Increased hepatic artery resistance is associated with older donor age and a prolonged period of ischaemia. Hie estimated incidence of hepatic artery thrombosis among liver transplant recipients is 4%-12% in adults and 42% in children. This is one of the most feared complications, as it may lead to fulminant hepatic necrosis. In addition, in liver grafts, biliary ducts are supplied exclusively by small branches of the hepatic artery; therefore, arterial thrombosis may lead to biliary ischaemia and necrosis. Prompt diagnosis of hepatic artery thrombosis is extremely important because early intervention (with thrombectomy, hepatic artery reconstruction or both) may allow graft salvage. However, most patients ultimately require retransplantation. Even after retransplantation, the mortality rate approaches 30%. Risk factors for hepatic artery thrombosis include a significant difference in hepatic artery calibre between the donor and the recipient, an interpositional conduit for the anastomosis, a previous stenotic lesion of the celiac axis, excessive duration of cold ischaemia time, ABO blood type incompatibility, cytomegalovirus infection and acute rejection.
@# 27. A young woman with a palpable nodule in the breast undergoes a contrast enhanced MRI breast for further evaluation. MRI demonstrates typical multiple non-enhancing internal septations. What is the diagnosis?
A. Fibrocystic change
B. Abscess
C. Atypia
D. Fibroadenoma
E. Hydatid cyst
- D. Fibroadenoma
Non-enhancing internal septations were initially described to have a high specificity in fibroadenoma diagnosis; however, this feature has recently been described in PTs and cancers and thus has little value when considered alone .Although morphological findings are important in lesion characterisation, breast cancers may have a benign appearance. In particular, 30% of familial breast cancers revealed a mass showing benign morphological features with a round or oval shape, smooth margins and homogeneous internal enhancement. It should be considered that all enhancing masses in women with genetic risks are suitable for biopsy when there is a lack of typical cyst or fat necrosis findings.
- A 21-year-old man presents with an acute knee injury following a violent tackle in
a game of ice hockey. He is unable to weight bear. Plain film reveals a small elliptical bone fragment just adjacent to the lateral tibial plateau on the AP view. There is also an accompanying suprapatellar joint effusion. Based on the plain film findings and the mechanism of injury, what is the most commonly injured structure in this injury pattern?
A. Medial meniscus
B. Lateral meniscus
C. Anterior cruciate ligament
D. Posterior cruciate ligament
E. Lateral collateral ligament
- C. Anterior cruciate ligament
This is a classic plain film appearance of a Segond fracture. Segond fracture is an avulsion fracture at the proximal, non-articular aspect of the lateral tibia. The presence of this fracture is strongly associated with injury to other knee structures like the medial meniscus. However, it is the anterior cruciate ligament that is most commonly injured (75%-100%).
- A 36-year-old male patient with acute exacerbation of low back pain shows an 8 x 5 mm intermediate signal fragment lying in the epidural space with signal characteristics closely matching the lower lumbar discs. However, no definite continuity can be established with any of the local discs. Inflammatory markers and white cell count are normal. The most likely cause for this appearance would be
A. Disc extrusion
B. Disc protrusion
C. Meningioma
D. Schmorl node
E. Sequestrated disc
- E. Sequestrated disc
Protrusion is present if the greatest distance between the edges of the disc material presenting outside the disc space is less than the distance between the edges of the base of that disc (wider than tall). Extrusion is present when, in at least one plane, any one distance between the edges of the disc material beyond the disc space is greater than the distance between the edges of the base of the disc material or when no continuity exists between the disc material beyond the disc space and that within the disc space (taller than wide). The latter form of extrusion is best specified as sequestration if the displaced disc material has lost continuity completely with the parent disc. The term migration may be used to signify displacement of disc material away from the site of extrusion.
Herniated discs in the craniocaudal (vertical) direction through a gap in the vertebral end plate are referred to as intravertebral herniations (Schmorl nodes).
- A young boy undergoes an MCUG, which shows reflux of contrast into the right ureter and pelvicalyceal system. The ureter and pelvicalyceal system are not dilated. What grade is the reflux?
A. 1
B. 2
C. 3
D. 4
E. 5
- B. 2
Grading of reflux:
Grade I: Reflux into distal ureters
Grade II: Reflux into collecting system (without calyceal dilatation/blunting)
Grade III: All of the above, plus mild dilatation of the pelvis and calices
Grade IV: All of the above, plus moderate dilatation (clubbing of calices)
Grade V: All of the above, plus severe tortuosity of the ureter
Prognosis: Grades I—III VUR resolve with maturation of the ureterovesical junction; Grades IV and V require surgery to avoid renal scarring, renal impairment and/or hypertension.
@# 31. A 66-year-old man with central chest pain radiating to the back is brought into the A&E department. A chest X-ray is read as unremarkable and a contrast CT is organised. The contrast CT shows an acute dissection flap in the aortic arch at the origin of the left common
carotid trunk extending through the descending thoracic aorta, into the proximal
abdominal aorta at the level of the renal arteries. Which of the following best classifies this dissection type?
A. DeBakey 1 - Stanford A
B. DeBakey 2 - Stanford A
C. DeBakey 3 - Stanford A
D. DeBakey 1 - Stanford B
E. DeBakey 2 - Stanford B
- A. DeBakey 1 - Stanford A
- A 22-year-old man with mucocutaneous skin pigmentation around the lips and hand presents to the A&E department with acute colicky abdominal pain. Plain radiograph and subsequent CT of the abdomen show multiple dilated loops of small bowel with a transition point in the distal ileum associated with an ileo-ileal intussusception. What is the most likely diagnosis?
A. Gardner’s syndrome
B. Peutz-Jeghers syndrome
C. Cowdens syndrome
D. Turcot syndrome
E. TAR syndrome
- B. Peutz-Jeghers syndrome
Peutz-Jeghers syndrome is a disorder characterised by mucocutaneous pigmentation and gastrointestinal hamartomas. The syndrome is an autosomal, dominant, inherited trait and occurs with equal frequency in male and female subjects. Mucocutaneous pigmentation, a characteristic feature of this syndrome, is manifested by melanotic deposits around the nose, lips and buccal mucosa hands and feet.
Peutz-Jeghers polyps can be found from the stomach to the rectum and are most common in the small intestine, particularly the jejunum and ileum.``
@# 33. All of the following are accepted indications for MRI breast in breast cancer imaging, except
A. Response to chemotherapy
B. Patients with breast augmentation
C. High-risk screening
D. Differentiate residual disease from post-surgical scar
F. . Breast cancer recurrence
- D. Differentiate residual disease from post-surgical scar
MRI of the breast has evolved into an important adjunctive tool with multiple indications in breast imaging, as recommended by US and European guidelines. Breast MRI is currently the most sensitive detection technique for breast cancer diagnosis. The indications are staging before treatment planning, screening of high-risk women, evaluation of response to neoadjuvant chemotherapy, patients with breast augmentation or reconstruction, occult primary breast cancer, breast cancer recurrence, identifying residual tumour in positive surgical margins and characterisation of equivocal findings. Differentiating early post-operative scarring from residual breast tumour is not possible because of similar enhancement characteristics of post-surgical scarring.
- A 66-year-old woman presents with back pain that radiates down the left anterior thigh towards the medial aspect of the knee. What are the MRI lumbar spine findings that you may expect based on the clinical history?
A. L1/2 generalised disc bulge with left lateral recess stenosis
B. L1/2 disc bulge with left foraminal stenosis
C. L2/3 generalised disc bulge with left lateral recess stenosis
D. L2/3 generalised disc bulge with left neural foraminal stenosis
E. L3/4 generalised disc bulge with left lateral recess stenosis
- C. L2/3 generalised disc bulge with left lateral recess stenosis
Medial aspect of the knee corresponds to the L3 dermatome. lateral recess stenosis at L2/3 will affect the transiting L3 nerve root, whereas foramina! stenosis will affect the exiting L2 nerve root.
- A CT abdomen done on a 38-year-old woman with pancreatitis incidentally shows the presence of split cord syndrome with a central bony bridge in the vertebra. A horseshoe kidney is evident. All of the following are other well-described associations seen in patients with diastematomyelia, except
A. Thickened filum
B. Club foot
C. Cord tethering
D. Chiari malformation
E. Congenital dislocation of hips
- E. Congenital dislocation of hips
Split cord malformations (SCMs) are relatively rare forms of occult spinal dysraphism and tethered spinal cord syndrome. SCMs are of two types.
Type I consists of two hemicords, each contained within its own dural sheath and separated by a median bony spur,
and Type II consists of two hemicords housed in a single dural tube separated by a fibrous median septum.
There are recognised associations with myelomeningocele, Chiari malformation, tethering of cord, hypertrichosis, nevus, lipoma, dimple or haemangioma overlying the spine, clubfoot (50%), muscle wasting and progressive scoliosis.
- Which of the following is false?
- B. Normal trachea and anterior oesophageal indentation Aberrant right subclavian artery
Aberrant right subclavian artery with a left-sided aortic arch or aberrant left-sided subclavian artery with a right-sided aortic arch both result in posterior impression on the oesophagus on a barium swallow, with normal appearance of the trachea. An aberrant left pulmonary artery or pulmonary vascular sling runs in between the trachea and oesophagus, resulting in an anterior indentation on the oesophagus and a posterior indentation on the trachea. Other entities that can result in anterior indentation on the oesophagus arc a bronchogenic cyst, trachea-oesophageal node or a tracheal neoplasm extending posteriorly.
Anterior tracheal, posterior tracheal and lateral oesophageal impression occurs with double aortic arch. The right arch is higher than the left, resulting in an S-shaped oesophagogram on AP view. Reverse ‘3’ indentation of the oesophagus and normal trachea occurs with coarctation of the aorta.
@# 37. An 8-week old boy presents with profound cyanosis with associated congestive cardiac failure. Imaging demonstrates a localised concurrent aortic coarctation. The likeliest underlying diagnosis would be
A. Tetralogy of Fallot
B. Truncus arteriosus
C. Transposition of the great arteries
D. Hypoplastic left heart syndrome
E. Tricuspid atresia
- D. Hypoplastic left heart syndrome
Hypoplastic left heart syndrome presents with early onset (days) of cyanosis and heart failure, leading to collapse and death in a few weeks of life. Associated cardiac malformations include pre- and post-ductal coarctation of the aorta, PDA, VSD, patent foramen ovale and so on.
Truncus arteriosus presents with minimal cyanosis in newborn infants; signs of heart failure are usually absent. Heart failure is evident in older infants.
Tetralogy of Fallot presents in early infancy with cyanosis, usually not present in early infancy, leading to clubbing; dyspnoea, heart failure, failure to thrive and paroxysmal hypercyanotic spells. X-ray shows a boot-shaped heart with oligaemic lungs.
Transposition of the great arteries is a medical emergency. Infants usually present in the first few hours or days with worsening duct-dependent cyanosis. Hypoxia is severe, but heart failure is not a feature. X-ray shows an ‘egg on end’ or ‘egg on string’ appearance.
Tricuspid atresia presents in the first few days of life with increasing cyanosis; other clinical features are dependent on associated PDA or VSD.
@# 38. All the following are useful features for differentiating true lumen from false lumen, except
A. In case of lumen wrapping, the inner lumen is true.
B. Beak sign indicates a false lumen.
C. A false lumen is often larger than a true lumen.
D. A cobweb sign demarcates the true lumen.
E. Intimal calcification surrounds the true lumen.
- D. A cobweb sign demarcates the true lumen.
The beak sign and a larger cross-sectional area were the most useful indicators of the false lumen for both acute and chronic dissections. Features generally indicative of the true lumen included outer wall calcification and eccentric flap calcification. In cases showing one lumen wrapping around the other lumen in the aortic arch, the inner lumen was invariably the true lumen. Outer wall calcification always indicated the true lumen on scans of acute dissections. False lumen thrombus was significantly more frequent in chronic dissections than acute dissections. Cobwebs are specific for the false lumen but are only rarely observed.
- Contrast enhanced CT performed on a 52 year old man showed a hypodense liver with low attenuation rim around the portal tracts. The following differential diagnoses are recognised causes of periportal halo sigh, except
A. Blunt trauma to the liver
B. Hepatitis
C. Congestive heart disease
D. Obesity
E. Cardiac tamponade
- D. Obesity
Periportal halos are defined as circumferential zones of decreased attenuation identified around the peripheral or subsegmental portal venous branches on contrast-enhanced CT. These halos probably represent fluid or dilated lymphatics in the loose areolar zone around the portal triad
structures. While this CT finding is non-specific, it is abnormal and should prompt close scrutiny of the liver in search of an underlying aetiology.
Periportal halos, which may be due to blood, are commonly seen in patients with liver trauma. Periportal oedema may cause this sign in patients with congestive heart failure and secondary liver congestion, hepatitis, or enlarged lymph nodes and tumours in the porta hepatis, which obstruct lymphatic drainage. This CT sign has also been observed in liver transplants (probably secondary to disruption and engorgement of lymphatic channels) and in recipients of bone marrow transplants, who might develop liver oedema from microvenous occlusive disease. Although the precise pathophysiologic basis of periportal tracking has not been proven, it represents a potentially important CT sign of occult liver disease.
- All of the following are technical requirements for performing an MRI breast, except
A. Supine position
- Breast coil
C. Intravenous contrast
D. Thin slices
E. T1W images
- A. Supine position
There are several prerequisites for maximising the sensitivity and specificity of breast MRI, including the following:
* High magnetic field strength with a highly homogeneous magnetic field.
* Bilateral image acquisition with a prone-positioning bilateral breast coil.
* Unenhanced imaging with a T2-weighted and 3D T1-weighted pre- and post-IV gadolinium.
* Selection of a phase-encoding direction minimises artefacts.
* Homogeneous fat suppression.
* Thin-section acquisitions (section thickness of 3 mm or less).
* Pixel size of less than 1 mm in each in-plane direction.
* Temporal resolution of less than 2 minutes for imaging of both breasts.
@# 41. A 74 year-old man presents with neck pain, with right upper-arm pain and radicular symptoms at the lateral aspect of the forearm and tingling in the thumb. What is the most likely finding on the MRI?
A. Central disc bulge at C3/4 with severe cord compression
B. Right foraminal disc osteophyte at C2/3
C. Right foraminal disc osteophyte at C4/5
D. Right foraminal disc osteophyte at C5/6
E. Right foraminal disc osteophyte at C3/4
- D. Right foraminal disc osteophyte at C5/6
Lateral aspect of the forearm and the thumb corresponds to the C6 dermatome. Foraminal osteophyte at C5/6 will impinge upon the exiting C6 nerve root. (cf. foraminal osteophyte at a thoracic or lumbar level, e.g., T4/5 or L4/5, which will impinge upon the exiting T4 or L4 nerve roots, subject to the discrepancy between number of cervical vertebra and cervical roots. Note that the exiting root at C7/T1 is C8.)
@# 42. A 35-year-old man involved in a major RTA undergoes a lateral view of the cervical spine m the resus on arrival. All of the following are features associated with atlanto occipital dislocation, except
A. Soft-tissue swelling anterior to C2 by >10 mm.
B. Basion dens interval >12 mm.
C. Odd’s ratio >1.
D. X-ray can often be normal.
E. Incongruity of articular surface of atlas and occipital condyles.
- D. X-ray can often be normal.
Atlanto-occipital dislocation shows the following on lateral radiograph of the cervical spine: >10 mm soft-tissue swelling anterior to C2, with pathological convexity (80%), basion-dens interval of >12 mm, odd’s ratio (distance between the basion and the posterior arch of the atlas divided by opisthion and anterior arch of atlas) >1, and basion-posterior axial line interval >12 mm anterior/>4 mm posterior to axial line.
Direct signs include loss of congruity of articular surfaces of atlas and occipital condyle. Normal X-ray in the presence of atlanto-occipital dislocation is rare.
@# 43. A child presents with an abnormally shaped cranium. There is hypertelorism and the skull vault appears short and widened. The anterior cranial fossa appears shortened. Which sutures are likely to have fused early?
A. Sagittal
B. Coronal
C. Metopic
D. Lambdoid
E. Unilateral coronal and lambdoid
- B. Coronal
The appearance here describes brachycephaly. Craniosynostosis is the premature fusion of cranial sutures and may be isolated or may present as part of a craniofacial syndrome. It typically alters the shape of the cranial vault. Broad categories include simple craniosynostosis, involving only one suture, or compound craniosynostosis, where two or more sutures are involved.
@# 44. A 37 year old woman with newly diagnosed hypertension undergoes an MRA, which shows alternate areas of stricture and dilatation to the right renal artery, sparing the origin. Which of the following is the least likely association?
A. String-of-beads appearance of the contralateral renal artery
B. String-of-beads appearance of the extracranial internal carotid artery
C. String of-beads appearance of the retinal artery
D. String-of-beads appearance of the vertebral artery
E. String-of-beads appearance of the SMA
- C. String-of-beads appearance of the retinal artery
Fibromuscular dysplasia (FMD) is an idiopathic, segmentary, non-inflammatory and non atherosclerotic disease that can affect all layers of both small- and medium-calibre arteries. Vascular loops, fusiform vascular ectasia and a string-of-beads aspect are typical presentations. Arterial dissection, aneurysm and subarachnoid haemorrhage are less typical radiologic presentations.
The affected arteries are mainly the renal arteries, extracranial carotid and vertebral arteries, mesenteric arteries and intracranial carotid arteries. Central retinal artery occlusion is a rarely recognised feature of fibromuscular dysplasia.
- A 40 year-old man with a known history of primary haemochromatosis was referred for assessment of the liver with an MRI scan. Which option shows the expected signal characteristics of the liver with iron deposition?
A. Hyperintense liver relative to spleen on T1 and T2
B. Hypointense liver relative to spleen on T1 and T2
C. Isointense liver relative to spleen on T1 and T2
D. Signal drop out in the liver on out-of-phase Tl imaging
E. High-signal liver on the high B-value diffusion-weighted sequences
- B. Hypointense liver relative to spleen on T1 and T2
MR imaging is the best non invasive method for measuring the level of iron in the liver for the purposes of confirming the diagnosis, determining the severity, and monitoring therapy with high sensitivity, specificity, and positive and negative predictive values. The accumulation of iron ions in
the tissues, because of the super-paramagnetic properties of the ions, causes local distortion in the magnetic fields and relaxation of the spins, which results in shortening of the longitudinal relaxation time (T1), the transverse relaxation time (T2) and particularly the transverse relaxation time as affected by magnetic field inhomogeneity (T2). This effect causes a loss of signal intensity in the affected organs that is proportional to the iron deposition. In the general protocol applied to an abdominal study, it is not possible to estimate the hepatic iron concentration, although most of the time it is possible to diagnose iron overload. This can be done by using ‘dual sequence’ (gradient in and out of phase) MR imaging, which demonstrates decreased signal intensity in the affected tissues on the in-phase images compared with the out of-phase images. That effect is the opposite of the effect observed in patients with steatosis. This occurs because the echo time of the in-phase sequence is usually higher than that of the out-of-phase sequence; therefore, the in-phase pulse sequence is more sensitive to iron deposits because of the increased T2 effect.
- A 47-year-old woman presents to the breast clinic with a palpable lump. Mammography shows a well-circumscribed round mass with mixed dense and radiolucent areas surrounded by a thin radiopaque capsule. Targeted ultrasound performed m the clinic shows a sharply defined, encapsulated, round, heterogeneous mass with echo texture similar to surrounding breast MRI breast reveals a lesion heterogeneous on T1W and T2W images. What findings on MRI confirm the diagnosis?
A. Non-enhancing internal septations
B. Slowly enhancing peripheral rim
C. Solid homogenous enhancing lesion with w’ell-defined margins
D. Peripheral hyperintense cystic spaces on T2W images
E. Thin hypointense pseudocapsule and fat content on T1W images
- E. Thin hypointense pseudocapsule and fat content on T1W images
Fat necrosis appears as well circumscribed with translucent areas in the centre (homogenous fat density of the oil cyst). Occasionally, it shows curvilinear or eggshell calcification in the wall.
On US, it appears as a hypoechoic or anechoic mass with ill- or well-defined margins, with or without acoustic shadowing or as a complex cyst. On MRI, even if the lesion appears irregular in both shape and margin, with a rim enhancement, the key to diagnosis is a fat internal signal on unenhanced sequences without fat suppression (high on T1-weighted images).
- What is the primary role of a T2W fluid-sensitive sequence in an MRI shoulder arthrographic study with intra-articular administration of gadolinium?
A. To check for glenoid labral tears
B. To check for articular cartilage integrity
C. To check for extra-articular fluid
D. To determine whether there is a full-thickness rotator cuff tear with communication to the bursae
E. To increase the visual contrast of the soft-tissue structures
- C. To assess for extra-articular fluid
The purpose of the T2-weighted fluid-sensitive sequence in MR shoulder arthrography is the identification of extra-articular fluid, for example, bursal fluid or paralabral cysts, which may not be visualised on the isolated Tl weighted post-contrast sequences, particularly if there is no intra- articular communication.
T2-weighted imaging also helps to identify abnormal fluid in the rotator cuff tendons by eliminating magic angle because of high TE.
- A 35-year-old man involved in a major RTA undergoes a facial series due to marked swelling and bruising of the face. All of the following are true of Lefort fractures, except
A. By definition, the pterygoid plates have to be fractured.
B. Lefort 1 involves the maxilla and medial wall of the orbit.
C. Lefort III involves the maxilla and the medial and lateral wall of the orbit
D. Lefort III is also called craniofacial disjunction.
E. Lefort II fracture is also called pyramidal fracture
- B. Lefort I involves the maxilla and medial wall of the orbit.
Lefort fractures always involve the pterygoid process/plates.
Lefort I fractures are transverse maxillary fractures, involving the alveolar ridge and inferior wall of maxillary sinus. There is detachment of the teeth bearing alveolar process of maxilla. The orbits are not involved.
Lefort II fractures are also called pyramidal fractures and they involve the maxilla and the medial wall of the orbit. They can be unilateral.
Lefort III fractures are also called craniofacial disassociation or disjunction and involves the maxilla and medial and lateral wall of the orbit (zygomatic arch).
- With regard to mammography and MR! breast, which is incorrect?
- E. Needs IV contrast Does not need IV contrast
The advantages of mammograms include their reliable detection of calcification, lower cost than MRI, wide availability and their imaging speed, which is faster than MRI. The disadvantages include difficulty in presence of implants, discomfort caused by compression, difficulty in imaging dense breasts and the need to reposition the breast for different views. The advantages of MRI are its higher sensitivity, ability to be used with implants, good performance with dense breasts, not requiring compression, ability to image both breasts simultaneously and improved tissue resolution. The disadvantages of MRI are that it may not show calcification, is not good for DCIS, leads to many false-positive findings and is expensive.
@# 61. A 72-year-old man with a 5.8 cm aortic aneurysm increasing at a rate of 1.2 cm every year is being worked up for an EVAR. Planning CT with multiformatted images and 3D volume-rendered reconstructed images have been obtained. All of the following measurements need to be provided at the MDT by the vascular radiologist, except
A. Size of aorta at the level of the renal artery
B. Size of aorta at the bifurcation
C. Largest diameter of the aneurysm
D. Size of the common iliac artery
E. Distance from aortic bifurcation to common iliac bifurcation
- A. Size of aorta at the level of the renal artery
Several important characteristics of the aneurysm must be accurately described for standard stent-graft sizing.
The aneurysm is described in terms of the proximal landing zone, the aneurysm sac, the distal landing zone and the vascular access.
Reported diameters should include the aorta at the level of the most inferior renal artery, the aortic neck 15 mm distal to the lowest renal artery, aorta at the bifurcation, the largest aneurysm sac diameter and the size of the common iliac arteries.
Additional measurements include the length of the aneurysm neck, the length from the lowest renal artery to the aortic bifurcation and the length of the aneurysm sac.
The length of the distal landing zone is described as the distance from the aortic bifurcation to the common iliac artery bifurcation.
Minimal diameters should be recorded in the distal landing zone and external iliac artery access vessels.
- A 24-year-old man presents to his family doctor with chronic hindfoot pain. Plain radiographs reveal elongation of the anterior dorsal calcaneus on lateral projection of the foot, often described as anteater’s nose. What is the diagnosis?
A. Talocalcaneal coalition
B. Calcaneonavicular coalition
C. Talonavicular coalition
D. Calcaneocuboid coalition
E. Cubonavicular coalition
- B. Calcaneonavicular coalition
Tarsal coalition is best confirmed with CT. CT and MRI can show direct bony continuity (osseous coalition) or fluid/cartilage intensity on MR/irregular serrated articular surface in case of cartilaginous coalition.
A calcaneonavicular coalition shows the classic anteater’s nose appearance on lateral radiograph.
The C sign is seen on a lateral radiograph in a patient with talocalcaneal coalition. Prominent talar beak is also associated with talocalcaneal coalition. Both calcaneonavicular and talocalcaneal coalition are equally common.
@# 89. An unenhanced CT brain performed on a young man with sudden severe occipital headache shows acute subarachnoid haemorrhage with most of the blood at the foramen magnum. Considering that the source is a ruptured aneurysm, what is the most likely location for the aneurysm in this patient?
A. ACOM
B. PCOM
C. ACA
D. AICA
E. PICA
- E. PICA
The location of blood in cases of subarachnoid haemorrhage from a ruptured aneurysm can pinpoint the site of aneurysm in 70% of cases.
- A 55-year old woman with rectal cancer diagnosed on colonoscopy undergoes a staging MRI. The scan reveals direct extension of the tumour into the vagina and spreading to five pelvic lymph nodes. No distant metastasis were identified on the staging chest and abdomen CT performed at the same visit. The TNM stage of her rectal cancer is
A. Tl N2 MO
B. T2N0M0
C. T3 N2 MO
D. T3 N1 MO
E. T4 N2 MO
- E. T4N2M0
- A 67-year-old man with several episodes of acute variceal bleeding is being investigated prior to TIPS procedure. Which one of the following is not a contraindication to TIPS?
A. Tricuspid regurgitation
B. Severe congestive cardiac failure
C. Multiple hepatic cysts
D. Severe portal hypertension
E. Unrelieved biliar}’ obstruction
- D. Severe portal hypertension
The main risk factors for developing HE include age >65 years, child score >12, prior HE, placement of a large diameter stent (>10 mm) and low PPG (<5 mm Hg).
@# 112. A wrist arthrogram is performed for instability and 5 mL of contrast is injected into the radiocarpal joint. The contrast is seen to extend lateral to the lunate into the mid carpal joint Which of the following is this diagnostic of?
A. Contrast extravasation secondary to the large volume of contrast injected
B. Scapholunate ligament tear
C. Lunatotriquetral ligament tear
D. Distal radioulnar joint (DRUJ) disruption
E. Triangular fibrocartilage (TFC) tear
- B. Scapholunate ligament tear
Single-compartment and three-compartment injection techniques have been described for wrist magnetic resonance arthrography.
In the three compartment technique, the mid-carpal and distal radio ulnar joints are initially injected with approximately 1-1.5 ml. of iodinated contrast under fluoroscopic guidance. About 3 ml. of dilute gadolinium is then injected into the radiocarpal compartment after confirmation of the needle-tip position with the injection of a small volume of iodinated contrast.
Contrast should normally be confined to the radiocarpal joint with no leak of contrast into the DRUJ proximally or the mid carpal joint distally.
If contrast extends lateral to the lunate, between it and the scaphoid this is diagnostic of a full thickness scapholunate ligament tear.
