TEST PAPER 5 Flashcards
1.An 18-year-old girl with chronic cough and recurrent chest infections shows symmetricalupper lobe predominant varicoid and cystic bronchiectasis on HRCT Review of olderabdominal plain films shows calcification across the central upper abdomen at the T12/L1level. What is the likely diagnosis?
A. Cystic fibrosis (CF)
B. Sarcoidosis
C. William-Campbell syndrome
D. ABPA
E. Kartagener’s syndrome
1.A. Cystic fibrosis (CF)
The classic diagnostic triad in patients with cystic fibrosis includes an abnormal sweat chloridetest result and manifestations of pulmonary and pancreatic disease. Upper lobe predominance is seen in many but not all cases; a diffuse distribution is also common. Normal to increased lung volumes are typical in CF and indicate air trapping and small airways disease. CT images show extensive cystic and cylindrical bronchiectasis and bronchial wall and peribronchial interstitial thickening. Findings are typically more extensive in patients with bronchiectasis due to cystic fibrosis than in patients with bronchiectasis due to other causes. Nodular opacities throughout the lungs correlate with areas of mucoid bronchial or bronchiolar impaction. Tree in bud nodules indicate the diffuse bronchiolitis that typically occurs in cystic fibrosis. In addition, a mosaic pattern of attenuation secondary to air trapping due to obstructed bronchi and bronchioles is commonly seen
2.A 53-year-old woman with upper abdominal discomfort was sent for an abdominal US,which showed a hypoechoic mass in the pancreas. A CT was performed, which reported apossible serous cystadenoma. Which one of the following statements regarding serouscystadenomas of the pancreas is true?
A. They are rich in mucin.
B. They are rich in glycogen.
C. They have malignant potential.
D. They appear only as a unilocular cyst on CT.
E. They are more common in men than in women.
2.B. They are rich in glycogen.
Serous cystadenomas are benign cystic neoplasms of the pancreas that occur frequently in olderwomen (median age 65 years). Serous cystadenomas are composed of numerous small cysts that are conjoined in a honeycomb-like formation. The size of these cysts ranges from 0.1 to 2.0 cm but typically is less than 1 cm. The cysts are lined by glycogen-rich epithelium and separated by fibrous septa that radiate from a central scar, which may be calcified. This formation has led to the use of the more descriptive term microcystic pancreatic lesion. Serous cystadenomas are usually discovered incidentally at imaging; however, those that are large may cause symptoms such as abdominal pain or, more rarely, jaundice. Progressive enlargement of serous cystadenomas - especially those with a size of 4 cm or more at initial manifestation may be seen at serial follow-up imaging examinations performed over a period of months or years. Multiple serous cystadenomas may occur in von Hippel-Lindau disease.
At MR imaging, a serous cystadenoma appears as a cluster of small cysts within the pancreas, with no visible communication between the cysts and the pancreatic duct. The cysts show signal intensity of simple fluid on T2-weighted images, and the thin fibrous septa between them enhance on delayed contrast-enhanced MR images.
@# 3.A 2-year old boy with proptosis and cats eye was investigated with CT for persistentheadache. Axial images showed a densely calcified mass replacing the right eyeball. The opticnerve was also calcified and surrounded by tumour, which had replaced most of theperiorbital fat. The optic canal was expanded with extension of the mass in the middle cranialfossa. What is the diagnosis?
A. Malignant melanoma of the choroid
B. Rhabdomyosarcoma
C. Coats’ disease
D. Neuroblastoma metastasis
E. Retinoblastoma
3.E. Retinoblastoma
Retinoblastoma is the most common tumour of the globe in children. It is seen in children lessthan 3 years, presenting with leukocoria; 75% are unilateral and unifocal, 25% are bilateral or unilateral multifocal. When seen bilaterally in conjunction with pineoblastoma, it is called trilateral retinoblastoma.
CT is preferred and shows clumped or punctate calcification (95%) in the posterior aspect of the eye, extending into the vitreous humor with minimal enhancement. Absence of calcification makes retinoblastoma unlikely. On MRI, retinoblastomas are hyperintense on T1 -weighted and hypointense on T2-weighted images, possibly due to calcification or paramagnetic tumour protein. MRI is belter at depicting tumour extension along optic nerves and intracranially. CT is better at showing bone dest ruction including expansion of the optic canal
4.A 29-year-old woman with three previous miscarriages, not explained by any hormonal,biochemical or metabolic abnormality, was being investigated for a structural cause to explainthe recurrent miscarriage. A pelvic MRI was scheduled, as it was the most definitiveinvestigation for congenital structural anomalies and/or uterine masses. Which one of thefollowing descriptions would suggest the diagnosis of uterus didelphys?
A. Two separate uterine cavities with two cervices and two proximal vagina
B. Two separate uterine cavities with two cervices
C. Two separate uterine horns with common uterine cavity, with one cervix
D. External indentation of the uterine fundus with one uterine cavity
E. Single uterine horn connected to a single fallopian tube
- A. Two separate uterine cavities with two cervices and two proximal vagina
Uterus didelphys results from complete failure of Mullerian duct fusion. Each duct develops fully with duplication of the uterine horns, cervix and proximal vagina. A fundal cleft greater than 1 cm has been reported to be 100% sensitive and specific in differentiation of fusion anomalies (didelphys and bicornuate) from reabsorption anomalies (septate and arcuate). Bicornuate uterus involves duplication of uterus with possible duplication of cervix (bicornuate unicolhs or bicornuate bicollis).
@# 5. With regard to stress fractures affecting the lower limb in athletes, all of the following statements are correct, except
A. Anterior tibial stress fractures have a higher propensity of non-union.
B. Fibular stress fractures affect the proximal end.
C. Femoral stress fractures can affect the neck or shaft.
D. ‘Female athlete triad’ is associated with femoral and sacral fractures.
E. Tibial stress fracture can be transverse or longitudinal.
- B. Fibular stress fractures affect the proximal end.
The tibia is the most commonly involved bone, accounting for up to almost half of stress fractures reported in some series.
Two types of tibial stress fractures have been described - transverse and longitudinal. Transverse fractures are more common and can occur on the compression side (posterior) or tension side (anterior).
Posterior transverse fractures of the tibial shaft are most commonly seen in long-distance runners.
Tension stress transverse fractures of the anterior tibial shaft occur more commonly in jumpers and have a higher propensity for non-union and progression to an acute complete fracture.
The most coimnon site of fibular stress fracture in runners is the lower fibula, just proximal to the tibiotalar syndesmosis.
Femoral neck stress fractures are associated with the classic ‘female athlete triad’ of amenorrhoea, osteoporosis and eating disorders.
Femoral neck stress fractures are often classified as tension side (superolateral or transverse) or compression side (inferolateral), with the contention that tension side fractures are associated with poorer prognosis and are potentially unstable.
The femoral shaft is particularly susceptible to repetitive stresses on the medial compression side of the femur at the junction of the proximal and middle thirds.
Fractures of the sacrum have predominantly been described in long-distance runners, particularly women, but have also been reported in hockey players. Sacral stress fractures are also associated with the female athlete triad.
@# 6. A 3-year-old girl is referred to an endocrine clinic with unilateral jaw swelling noted at the dentist. Her general practitioner has also reported that she has signs of precocious puberty. An X-ray of the facial bones demonstrates expansion of the frontal bone and right side of the mandible. She is likely to have which other associated condition?
A. Neurofibromatosis
B. Madelung deformity
C. Lisch nodule
D. Hyperthyroidism
E. Hypothyroidism
- D. Hyperthyroidism
The child has McCune-Albright syndrome (MAS), which is defined as the association of polyostotic fibrous dysplasia (PFD), precocious puberty, cafe au lait spots and other endocrinopathies caused by the hyperactivity of various endocrine glands. Among the endocrine syndromes described in association with MAS are (1) hyperthyroidism, (2) acromegaly,
(3) gonadotrophinomas, (4) hyperprolactinaemia, (5) Cushing syndrome,
(6) hyperparathyroidism, (7) gynaecomastia and (8) hypophosphataemic rickets.
Lisch nodules are associated with neurofibromatosis. Fibrous dysplasia in MAS can involve any bone but most commonly affects the long bones, ribs, skull and facial bones. There is no association between Madelung deformity and MAS.
@# 7. A 35-year-old man known to the ENT for sinonasal disease presents to the chest clinic with productive cough. The house officer examining the patient struggled to hear the heart sounds properly. HRCT, among other findings, shows left lower lobe bronchiectasis without any central endobronchial mass to explain the focal bronchiectasis. What is the
likely diagnosis?
A. Cystic fibrosis (CF)
B. Sarcoidosis
C. William-Campbell syndrome
D. Allergic bronchopulmonary aspergillosis (ABPA)
E. Kartagener’s syndrome
- E. Kartagener’s syndrome
Kartagener’s syndrome refers to the clinical combination of situs inversus, chronic sinusitis and bronchiectasis in a subset of patients with ciliary dyskinesia.
Patients with primary ciliary dyskinesia typically have varicoid bronchiectasis preferentially affecting the lower lungs, particularly the right middle lobe and lingula, with chronic volume loss and consolidation. Tree-in-bud nodules related to infection and mucous plugging secondary to impaired clearance are also frequently seen. The associated finding of dextrocardia can be seen at chest radiography in cases of Kartagener’s syndrome.
@# 8. A 56 year old man with gallstone pancreatitis is referred for a CT of the abdomen. The CT shows multiple cysts around the tail of the pancreas with further cysts in the lesser sac and left paracolic gutter. These are reported as pseudocysts. Which one of the following statements regarding pancreatic pseudocysts is false?
A. They usually take 4-6 weeks to mature.
B. They can be multiple.
C. They have an epithelial lining.
D. They may communicate with the pancreatic ductal system.
E. They may be extrapancreatic in location
- C. They have an epithelial lining.
Overall, pseudocysts are the most common cystic lesions of the pancreas. These lesions occur in the setting of pancreatitis, resulting from haemorrhagic fat necrosis and encapsulation of pancreatic secretions by granulation tissue and a fibrous capsule. The MR imaging appearance of pseudocysts may evolve over time; they are often irregularly marginated early in their formation but become well circumscribed, with a thickened enhancing wall, over a period of several weeks. Blood products and necrotic or proteinaceous debris are commonly present and produce intrinsically increased Tl signal intensity. The thickened and enhancing cyst wall seen on images corresponds to a thick rim of granulation tissue and fibrosis that is uniformly seen at histologic analysis. Other changes of acute or chronic pancreatitis are frequently seen in association with pseudocysts, and MR imaging may be the imaging modality of choice for depicting the features of parenchymal pancreatic disease.
MR imaging has proved superior to CT for demonstrating internal complexity in pseudocysts. Furthermore, the signal intensity increase in tissues surrounding a complicated pseudocyst on T2-weighted fat-suppressed images correlates with the degree of inflammation present. However, in patients with a pseudocyst, the cause of inflammation is more likely to be chemical irritation than infection, and it may be impossible to differentiate between an infectious process and other possible causes on the basis of imaging features alone. Clinical manifestations maybe similarly unhelpful, since the symptoms of chemical irritation may be identical to those of sepsis. Moreover, pancreatic pseudocysts may dissect along abdominopelvic fascial planes to sites remote from the pancreas (e.g., liver, pleura or mediastinum).
Fistulation may occur between a pseudocyst and one or more vascular structures.
- A woman who was 20 weeks pregnant was referred to the US department by her midwife for a routine anomaly scan. The scan was reported as showing features consistent with congenital diaphragmatic hernia. All of the following are prenatal US findings suggestive of a diaphragmatic hernia, except
A. Failure to visualise the stomach in the left upper quadrant
B. Cardiac dextroposition
C. Echogenic mass in the left hemithorax
D. Compressed left lung
E. Increased abdominal circumference
- E. increased abdominal circumference
The hallmarks of the diagnosis, in the first trimester as well as later in pregnancy, are the presence of the stomach, bowel or liver in the chest, shift of the mediastinum and displacement of the heart to the contralateral side. Increase in abdominal circumference is not a feature; the contrary can however be observed and can be a clue. In 50% of affected foetuses, there are associated chromosomal abnormalities or other malformation. The hernia results from abnormal formation or fusion of the pleuroperitoneal membranes with the septum transversum, and it is surgically correctable. Neonatal death results from pulmonary hypoplasia and pulmonary hypertension.
@# 10. A 52-year-old woman presents to the orthopaedic outpatient clinic with a painful forefoot. On examination, there was a painful response elicited by Mulder’s manoeuvre. Which one of the following statements concerning Morton neuromas m the forefoot is false?
A. They are often seen in young and middle-aged women.
B. The inter space between the third and fourth toes is the most commonly affected site.
C. The characteristic MR finding is a nodule with low signal intensity on T1W images.
D. Ultrasound is a sensitive modality in identifying the lesion.
E. Gradient echo MR sequences elicit blooming artefact in the lesion.
- E. Gradient echo MR sequences elicit blooming artefact in the lesion.
Morton neuromas are masses composed of interdigital perineural fibrosis and nerve
degeneration. Morton neuroma occurs between the metatarsal heads, most commonly between the third and fourth toes. Morton neuroma is more common in women, and high-heeled shoes have been implicated as a causative factor. Pain at the metatarsal head, often radiating to the toes, is characteristic.
The MRI appearance is that of a tear-drop-shaped soft-tissue mass between the metatarsal heads, projecting inferiorly into the plantar subcutaneous fat and located plantar to the intermetatarsal ligament. The mass is typically intermediate in signal intensity on T1-weighted images. It is iso- or hypointense relative to fat on T2-weighted images, resulting in poor lesion conspicuity. The use of gadopentetate dimeglumine is helpful because intense enhancement typically occurs on fat suppressed T1-weighted images, increasing the conspicuity of the lesion
- A 54-year-old man with suspicious findings on US was recommended for an MRI of the orbits for further evaluation. Sagittal MR images of the globe showed a focal area of thickening in the posterior aspect of the globe with hyperintense signal on T1W sequence and strongly hvpointense signal on T2W sequence. What is the diagnosis?
A. Malignant melanoma of the choroid
B. Rhabdomyosarcoma
C. Coats’ disease
D. Neuroblastoma metastasis
E. Retinoblastoma
- A. Malignant melanoma of the choroid
Primary orbital melanoma is the most common primary’ intraocular malignancy in adults. MR imaging is superior to CT in the evaluation of choroidal melanomas, as melanin has intrinsic Tl and T2 shortening effects, thereby manifesting with increased Tl signal intensity and decreased T2 signal intensity. CT is non-specific, often demonstrating a hyperattenuating choroidal mass.
MR imaging is also valuable for identifying other features, such as large tumour size, extraocular extension and ciliary body infiltration, all of which also portend a poorer prognosis. In addition, MR imaging is superior to CT for identifying retinal detachment and extrascleral spread.
Notably, approximately 20% of melanomas are amelanotic, thereby lacking characteristic Tl and T2 shortening effects on MR images. In addition, MR signal characteristics may not always allow melanoma to be reliably distinguished from ocular metastases.
- A previously healthy 9 month-old is admitted with tachypnoea and fever. His white cell count and neutrophils are elevated. His temperature is 39.2°C. An AP CXR demonstrates a well-defined
5 cm rounded lung opacity with well-formed borders. What is the most likely diagnosis?
A. Bronchogenic cyst
B. Pulmonary metastases
C. Neuroblastoma
D. Congenital cystic adenomatoid malformation
E. Round pneumonia
- E. Round pneumonia
Round pneumonia usually occurs in children under the age of 8 years. It is most commonly seen with bacterial pneumonia (pneumococcus). The mass has an alarming appearance on CXR; however, further investigation is only warranted if there is concern regarding the diagnosis. A CXR as soon as 48 hours later often shows dissipation of the mass into more typical consolidation, or complete resolution following antibiotic treatment. It is most common in the superior segment of the lower lobes. It is important to make the diagnosis to avoid unnecessary CT.
Bronchogenic cyst is often an incidental finding and often has a compressive effect unlike round pneumonia. Thoracic neuroblastoma may be an incidental finding, but the clinical history given is more in keeping with an infective process. Congenital cystic adenomatoid malformation (CCAM) is usually diagnosed antenatally or in the neonatal period. Indeed, in the newborn, 80% of cases of CCAM present with some degree of respiratory distress secondary to mass effect and pulmonary compression or hypoplasia.
@# 13. A 77-year-old man with chronic inflammatory disease and renal failure is known to have secondary amyloidosis. All of the following are features of amyloid involvement of the respiratory system, except
A. Interstitial septal thickening
B. Cavitating nodules
C. Focal amyloidoma
D. Calcification of central airways
E. Calcification in peripheral consolidation
- B. Cavitating nodules
Amyloidosis refers to a group of disorders characterised by the deposition of abnormal protein material in extracellular tissue.
Tracheobronchial amyloidosis generally presents with symptoms of airway obstruction. Classic radiological signs include nodular and irregular narrowing of the tracheal lumen, airway wall thickening and calcified amyloid deposits. Lobar or segmental collapse may be seen.
Pulmonary involvement by amyloid may be localised or diffuse. Radiologically, the diffuse parenchymal and alveolar septal forms of amyloid deposits appear as non-specific diffuse interstitial or alveolar opacities. HRCT reveals interlobular septal thickening with a predominant basilar and peripheral distribution, small well-defined nodules (2-4 mm) and confluent
consolidations located predominantly in the subpleural regions. Some nodules may show calcifications.
Nodular amyloid deposits appear in multiple sites; focal deposits are less common. Amyloid nodules are generally in the lower lobes and peripheral and subpleural areas. They are sharply defined with lobulated contours, contain calcification (in about 50%), are of multiple shapes and sizes and grow slowly with no regression. Cavitation is very rare.
@# 14. An US of the abdomen in a 43-year-old woman with a known underlying chronic condition demonstrates small cysts in the pancreas. She is sent for a dual phase CT for further characterisation. The scan shows multiple true cysts with no obvious suspicious features. Which one of the following conditions is associated with true pancreatic cysts?
A. Tuberous sclerosis
B. Von Hippel-Lindau disease
C. Neurofibromatosis Type 1
D. Autosomal recessive polycystic kidney disease
E. Multiple neuroendocrine neoplasia
- B. Von Hippel-Lindau disease
Pancreatic involvement in VHL disease includes simple pancreatic cysts (50%-91%), serous microcystic adenomas (12%) and rarely adenocarcinomas. Pancreatic neuroendocrine tumours (5%-17%) also occur. Combined lesions occur, but neuroendocrine tumours and cystic lesions only rarely exist together. The reported prevalence of pancreatic involvement in VHL disease varies from 0% in some family groups to 77% in others.
Pancreatic cysts are extremely rare in the general population; therefore, the presence of a single cyst in an individual undergoing VHL disease screening because of a family history makes it highly likely that the person has VHL disease. In general, cystic pancreatic lesions in VHL disease are asymptomatic or associated with only mild symptoms. As a result, they are typically detected during screening examinations and may therefore facilitate the identification of gene carriers. In addition, pancreatic lesions may be the only abdominal manifestation and may precede any other manifestation by several years; thus, recognition permits earlier diagnosis of VHL disease.
@# 15. A woman who is 22 weeks pregnant is referred for routine anomaly scan to the US department. US shows that the ventricular atrium measure 14 mm at the level of the posterior margin of the glomus of the choroids plexus on an axial plain through the level of the thalami. What is the next appropriate step?
A. Repeat US in 4 weeks.
B. Amniocentesis.
C. Foetal MRI.
D. Check maternal oestradiol levels.
E. It is a normal finding
- C. Foetal MRI
Ultrasound imaging is the screening modality of choice for initial evaluation of the foetal central nervous system. However, using MRI additional abnormalities were identified in 50% of the foetuses. Measurement of the hydrocephalus should be in the true axial plane at the atria of the lateral ventricle and glomus of the choroid plexus. The ventricle is measured from the inner margin of the medial ventricular wall to the inner margin of the lateral wall. Ventriculomegaly can be divided into three subgroups, borderline (10-12 mm), mild (>12-15 mm) and severe (>15 mm).
@# 16. Which of the following is not a recognised radiographic finding in a patient with haemochromatosis?
A. Chondrocalcinosis
B. Arthropathy with iron deposition in the synovium
C. General used increased hone density
D. Joint space narrowing
E. Osteophyte formation
- C. Generalised increased bone density
Haemochromatosis may either be primary or secondary. It is most commonly primary and congenital with an autosomal recessive (AR) inheritance. It is relatively common in Caucasian populations with an incidence of 1 in 300 to 1 in 400. Men are affected about 10 times more commonly than women, and at an earlier age.
It is often characterised radiographically by beak-like osteophytes projecting from the second and third metacarpal heads.
The other hallmark radiographic findings of haemochromatosis include the following: generalised osteoporosis (not increased bone density), arthropathy with iron deposition in the synovium (50%), joint space narrowing and enlargement of metacarpal heads. Chondrocalcinosis is also relatively common in this condition, most often affecting the knees and triangular fibrocartilage.
@# 17. A 9-year-old girl with a long history of cough, wheeze, sinusitis, headache and weight loss presented to the GP with an acute history of increasing breathlessness. Sweat test analysis shows 80 mmol/L of sodium chloride in forearm sweat (normal <40 mmol/L). All of the following are typical features on a chest X-ray, except
A. Hyperinflation
B. Bronchial dilatation
C. Cystic areas in the lung
D. Linear interstitial opacities
E. Dextrocardia
- E. Dextrocardia
Cystic fibrosis is an AR disorder leading to a defect in the CF transmembranc receptor (CFTR) protein resulting in defective ion transport in exocrine glands.
In CF, abnormal function of sweat glands result in higher concentrations of sodium chloride in the sweat; >40 mmol/L is suspicious and >60 mmol/L is diagnostic of CF.
Spirometry shows an obstructive pattern with reduced FVC and increased lung volumes. Chest X-ray shows hyperinflation, bronchial dilatation, bronchiectasis and its associated signs, cystic spaces, increases interstitial and linear/reticular opacities, and increased AP dimension on lateral chest X-ray. CF is not routinely associated with dextrocardia.
Dextrocardia is a component of Kartagener’s syndrome (immotile cilia syndrome), which is associated with bronchiectasis and sinusitis but not with an abnormal sweat test.
- A 55 year old woman with asymmetrical bilateral proptosis is referred for an orbital MRI to exclude retro orbital mass lesions. MRI reveals diffuse swelling of all extraocular muscles, with the swelling primarily involving the belly of the muscle without involvement of the tendinous insertions. The muscles are isointense to normal in signal on T1W images and hypointense on T2W images. What is the diagnosis?
A. Orbital pseudotumour
B. Thyroid ophthalmopathy
C. Lymphoma orbit
D. Steroid therapy
E. Obesity
- B. Thyroid ophthalmopathy
Graves ophthalmopathy is the most common cause of exophthalmos in adults. In Graves ophthalmopathy, classically spindle-shaped enlargement of the extraocular muscles is observed, with sparing of the tendinous insertion. The inferior, medial, superior and lateral rectus muscles (listed in order of decreasing frequency of involvement) may be involved. These findings are usually bilateral and symmetric; however, they may also be unilateral.
Idiopathic orbital inflammatory syndrome, also known as orbital pseudotumour, is the second most common cause of exophthalmos. It is a non granulomatous orbital inflammatory process with no known local or systemic cause. In idiopathic orbital inflammatory syndrome, unlike Graves ophthalmopathy, there is tendinous involvement of the extraocular muscles.
@# 19. A 62 year-old man with progressive cough and shortness of breath has bilateral patchy ground-glass change with areas of dependent and non-dependent septal thickening in
the basal lung zones on HRCT. Which of the following is incorrect about drug-induced lung disease?
A. Diffuse alveolar damage occurs with Gold.
B. Chronic nitrofurantoin toxicity results in high-density consolidation.
C High-density liver is seen in amiodarone toxicity.
D. There is no correlation between dose of methotrexate and toxicity.
E. NSIP is generally the most common change on HRCT.
- B. Chronic nitrofurantoin toxicity results in high density consolidation.
Nitrofurantoin is used to treat urinary tract infections. Acute pulmonary toxicity manifests
radiologically with diffuse bilateral, predominantly basal heterogeneous opacities. Non specific interstitial pneumonia (NSIP) is the most common histopathologic manifestation of chronic toxicity.
Methotrexate-induced pulmonary drug toxicity occurs in 5%-10% of patients. There is no correlation between the development of drug toxicity and the duration of therapy or total cumulative dose. NSIP is the most common manifestation; hypersensitivity pneumonitis and cryptogenic organising pneumonia (COP) are less common.
Diffuse alveolar damage and NSIP are the most common manifestations of gold-induced lung disease, with COP being less common.
NSIP is the most common manifestation of amiodarone-induced lung disease. Pleural effusion is recognised. COP is less common and occurs in association with NSIP. A distinctive feature of amiodarone toxicity is focal, homogeneous, peripheral, high-attenuation pulmonary opacities due to incorporation of amiodarone into Type II pneumocytes. The combination of high-attenuation abnormalities within the lung, liver or spleen is characteristic of amiodarone toxicity.
- A 50-year-old man is sent for an urgent contrast CT of the abdomen following a history of abdominal pain. The CT is unremarkable apart from inflammatory stranding in the omentum. All of the following are clinical features of omental infarction, except
A. Occurrence in patients of all ages
B. Massive rectal bleeding
C. Slightly higher incidence in men
D. Acute right-sided abdominal pain
E. Rarely, a palpable mass at the site of abdominal pain
- B. Massive rectal bleeding
Primary omental infarction is often a haemorrhagic infarction resulting from vascular compromise related to the tenuous blood supply to the right edge of the omentum or to kinking of veins, usually those on the right side, deep within the anterior pelvis in the inferior extent of the omentum. Some omental infarcts are related to a combination of the reduced arterial and venous blood flow that occurs in hypercoagulable states, congestive heart failure and vasculitis. Secondary omental infarction may occur after a traumatic injury as a result of surgical trauma or inflammation of the omentum. Often, the site of secondary infarction is near the surgical site rather than in the right lower quadrant, the typical location of primary omental infarction.
Patients with omental infarction usually present with subacute onset of pain in the right lower quadrant, often with a slightly elevated white blood cell count. Other gastrointestinal symptoms such as vomiting, nausea and fever are absent. Establishing a preoperative diagnosis of omental infarction is difficult because it often mimics acute appendicitis or cholecystitis. In most cases, the radiologist makes the diagnosis after cross-sectional imaging has been performed.
Omental infarction demonstrates a variety of imaging appearances at CT. Classically; it appears as a fatty, large (>5 cm) encapsulated mass, with soft-tissue stranding adjacent to the ascending colon. Early or mild infarction may manifest as mild haziness in the fat anterior to the colon.
- A 7-year-old girl with several noticeable skin lesions and reduced unilateral visual acuity, showed fusiform swelling of the optic nerve on a CT of the head performed out of hours, after a fall down a flight of stairs. MRI orbits revealed a thickened optic nerve with signal intensity similar to grey matter on T1W and T2W images, with a variable amount of contrast enhancement. What is the underlying phacomatosis?
A. Neurofibromatosis type 2
B. Neurofibromatosis type 1
C. Von Hippel-Lindau disease
D. Tuberous sclerosis
E. Down’s syndrome
- B. Neurofibromatosis type 1
The imaging appearance of optic nerve gliomas is characteristic, such that biopsy is rarely performed. MR imaging is the modality of choice, particularly for assessing involvement of the orbital apex, optic chiasm, hypothalamus and other intracranial structures. The lesions are typically isointense on T1-weighted images and isointense to hyperintense on T2-\veighted images. Enhancement is variable, and cystic spaces may be seen. Calcifications are rare. A rim of T2 hyperintensity is often observed at the tumour periphery, a finding that may mimic an expanded subarachnoid space. However, this finding corresponds histopathologically to leptomeningeal infiltration and proliferation (so-called arachnoidal gliomatosis).
The appearance of optic nerve gliomas is different in patients with and without NF1. In patients with NF1, the optic nerve often appears tortuous, kinked or buckled and diffusely enlarged. In patients without NF1, gliomas tend to be fusiform. Isolated chiasmal gliomas are more likely in the absence of neurofibromatosis, and chiasmal involvement is also more common in patients who do not have neurofibromatosis.
- Foetal MRI usually is performed in a scanner with a magnet strength of
A. 0.5 Tesla
B. 1.5 Tesla
C. 1 Tesla
D. 3 Tesla
E. 0.1 Tesla
- B. 1.5 Tesla
Foetal MR imaging is routinely performed on 1.5T MR scanners.
- A patient arrives in the A&E department having been involved in a road traffic collision. He is haemodynamically stable. The Glasgow Coma Scale (GCS) at the scene was 14. On arrival in A&E, he is found to have a bruised left forehead. He suddenly becomes unresponsive, with a GCS of 4, and is intubated. As the on-call radiologist you are called to perform a head CT. Which of the following would make an epidural haemorrhage least likely?
A. Biconvex hyperdensity
B. Overlying skull fracture
C. Crossing of suture line
D. Homogenous fluid of 50 HU
E. Homogenous fluid of 80 HU
- C. Crossing of suture line
Epidural (extradural) haematomas do not generally cross suture lines, unless associated with a diastatic fracture of the suture. Extradural haematomas are biconvex, extra axial fluid collections associated with skull vault fracture. Fresh blood is 30-50 HU; coagulated blood is 50-80 HU.
- A 12-month old presents with loss of appetite, fever and shortness of breath. Chest X-ray demonstrates a well-circumscribed paraspinal mass with a sharp pleuro-pulmonary surface. There is some calcification within the mass and the intercostal space at that level is widened. What is the most likely diagnosis?
A. Bronchogenic cyst
B. Neuroblastoma
C. Ganglioneuroma
D. Left lower lobe pneumonia
E. Teratoma
- B. Neuroblastoma
About 34% of mediastinal masses are posterior and 88% of these are neurogenic in origin (most of which arise from the ganglion cells in the paravertebral sympathetic chain). The remaining 12% of posterior mediastinal masses are foregut cysts, malignant lymphoma, Hodgkin disease or non-Hodgkin lymphoma. Neuroblastoma is most common in the under 5 year-olds and ganglioneuroma is most common in those older than 10 years.
Radiographic appearances are as described in the question. Cross-sectional imaging is useful to delineate the extent of the mass and any spinal involvement. Left lower lobe pneumonia can be confused with tumour, and this is a known diagnostic pitfall. Bronchogenic cyst is typically middle mediastinal.
- Foetal MRI is most commonly organised to evaluate inconclusive but potentially significant findings detected on ultrasound or to characterise definite abnormality detected on anomaly scan. Which one of the following MR imaging sequences is the most popular for foetal imaging?
A. Fast spin echo T1W images
B. STIR
C. Fat suppressed T1W images
D. Single-shot, fast spin echo (SS FSE) T2W images
E. FLAIR
- D. Single-shot, fast spin-echo (SS-FSE) T2W images
Because foetal MR imaging is performed without maternal or foetal sedation, image acquisition is susceptible to foetal motion; therefore, foetal MR imaging is performed primarily using ultrafast MR imaging techniques known as single-shot, fast spin-echo (SS-FSE) or half-Fourier acquired single-shot, turbo spin-echo (HASTE). Using these rapid pulse sequences, a single T2-weighted image can be acquired in less than 1 second, reducing the likelihood of foetal motion during image acquisition. Because each image is acquired separately, foetal motion typically affects only the particular image that was acquired while the foetus moved.
- A 45-year-old man with proptosis of the right eye is referred for an MRI for further evaluation. MRI reveals uniform swelling involving all the extraocular muscles and a markedly dilated superior ophthalmic vein. What is the likely diagnosis?
A. AVM of the optic nerve
B. Carotid-cavernous fistula
C. Haemangioma
D. Lymphatic malformation of the orbit
E. Thyroid ophthalmopathy
- B. Carotid-cavernous fistula
Caroticocavernous fistulas are abnormal communications between the carotid artery and the cavernous sinus, either directly or via intradural branches of the internal or external carotid arteries.
The pattern of venous drainage, either anterior into the ophthalmic veins or posterior into the petrosal sinuses, often dictates the clinical findings and radiographic appearance. Anterior drainage typically leads to the most dramatic ocular findings and enlargement of the superior orbital vein, the latter often detectable with CT or MRI. However, superior orbital vein enlargement is not specific to CCF. Additional radiographic findings with variable prevalence include lateral bulging of the cavernous sinus wall and enlargement of extraocular muscles on CT or MRI, and abnormal cavernous sinus flow voids on MRI. Direct visualisation of flow-related hyperintensity on the source images of three-dimensional time-of-flight MRA can be extremely helpful in CCF detection, with 83% sensitivity and 100% specificity, far superior to standard MRI
- A 4 day-old infant presents with poor feeding and lethargy. She was bom at term following premature rupture of membranes. Chest X-ray demonstrates bilateral patchy infiltrates with small effusions. What is the most likely diagnosis?
A. Hyaline membrane disease
B. Meconium aspiration
C. Transient tachypnoea of the new-born
D. Group B streptococcal pneumonia
E. Congenital listeriosis
- D. Group B streptococcal pneumonia
Group B streptococcal pneumonia is associated with premature rupture of the membranes during labour. The disease may have an early onset with septicaemia and fulminant progression to severe respiratory distress, shock and respiratory failure within 24 hours or a late onset 1-12 weeks after birth, which is frequently associated with meningitis. Neonatal pneumonia can closely mimic hyaline membrane disease clinically and is the most frequent cause of septicaemia in the neonate. Infection may resemble hyaline membrane disease very closely, especially in smaller infants. However, extensive granular confluent infiltrates whose distribution is often less uniform than those of hyaline membrane disease are more commonly seen. There is also less atelectasis than in hyaline membrane disease. Pleural effusions are not uncommon and the lung volume is normal.
The differential diagnosis includes hyaline membrane disease, which usually has a uniform distribution of pulmonary opacities, never has pleural effusions and has a decreased lung volume; meconium aspiration, which usually has nodular nonhomogeneous densities, may have pleural effusions and usually has an increased lung volume; and finally, transient tachypnoea of the newborn, which usually has non-homogeneous densities and may have pleural fluid.
@# 28. All the following statements regarding HRCT changes in cytotoxic drug-induced lung disease are true, except
A. Bleomycin toxicity has a poor prognosis.
B. Paclitaxel is associated with pulmonary injury.
C. There is no correlation between carmustine dose and toxicity.
D. Diffuse alveolar damage (DAD) is the most common manifestation.
E. Bleomycin toxicity can be increased by concomitant oxygen therapy.
- C. There is no correlation between carmustine dose and toxicity.
Cyclophosphamide and busulfan are the most common drugs that cause lung injury. Diffuse
alveolar damage (DAD) is the most common manifestation of cyclophosphamide-induced lung disease, with NSIP and COP being less common. There is no relationship between development of lung injury and dose and duration of therapy.
Carmustine is one of the few drugs for which there is a clear relationship between cumulative dose and lung injury. Lung injury can occur at low doses if the patient has undergone thoracic radiation therapy. DAD is the most common manifestation, with NSIP being less common.
DAD is the most common manifestation of bleomycin-induced lung disease, with NSIP and COP being less common. The risk of developing lung injury is increased in the elderly, in patients on oxygen therapy, with a history of prior thoracic irradiation, or in whom therapy is restarted in 6 months of discontinuation. The prognosis is poor, with most patients dying of respiratory failure within 3 months.
Paclitaxel may commonly cause pulmonary toxicity.
@# 29. A 66-year-old person is sent for an urgent CT of the abdomen post-contrast. The CT
is unremarkable apart from inflammatory stranding in the omentum. No peritoneal nodules or ascites are detected on the CT and the report states possible omental infraction. All of the following are expected to be seen on the CT, except
A. Cake-like or whorled structure of mixed attenuation
B. Small amount of free peritoneal fluid
C. The fat-ring sign
D. Minimal reactive lymphadenopathy
E. Haziness of the fat anterior to the colon
- C. The fat ring sign
Omental infarction demonstrates a variety of imaging appearances on CT. Classically; it appears as a fatty, large (>5 cm) encapsulated mass, with soft-tissue stranding adjacent to the ascending colon. Early or mild infarction may manifest as mild haziness in the fat anterior to the colon.
Omental torsion is a rare cause of omental infarction and occurs when a portion of the omentum twists upon itself, leading to vascular compromise. In omental torsion, swirling of the vessels is often visible within the omentum. Although most cases of omental infarction are on the right side, left-sided infarction also may spontaneously occur.
Unusual locations of infarction are more commonly seen in the setting of surgical trauma or post-operative changes that result in altered omental vascular supply and subsequent infarction. Similar to epiploic appendagitis, the adjacent colon is usually spared, although rarely the colonic wall may be thickened, a result of direct extension of omental inflammation.
The fat-ring sign is seen in epiploic appendagitis, not omental infarction.
- A skeletal survey is performed on a 2-year-old boy with short stature. The lateral film of the spine reveals abnormal vertebral bodies with a central anterior ‘beak’ and generalised flattening. Radiographs of the hands shows a pointed proximal fifth metacarpal base with a notch at the ulnar aspect. Which of the following is the most likely diagnosis?
A. Hunter syndrome
B. Hurler syndrome
C. Morquio syndrome
D. Achondroplasia
E. Nail-patella syndrome
- C. Morquio syndrome
The mucopolysaccharidoses are a group of inherited diseases characterised by abnormal storage and excretion in the urine of various mucopolysaccharides. These patients have short stature and characteristic plain film findings. A characteristic finding in the hands is a pointed proximal fifth metacarpal base that has a notched appearance to the ulnar aspect. There is generalised flattening of the vertebral bodies (platyspondyly) (cf. not a feature of Hurler syndrome). Hunter and Hurler syndromes demonstrate an anterior vertebral beak that is inferiorly positioned, whereas Morquio syndrome demonstrates an anterior vertebral beak that is centrally positioned. Although achondroplasia can cause rounded anterior beaking in the vertebra of the upper lumbar spine, the findings described within the hands are more typical of die mucopolysaccharidoses
@# 31. Which one of the following statements regarding rheumatoid arthritis-associated thoracic manifestation is true?
A. Thoracic involvement occurs early in the disease.
B. Pleural effusions is usually bilateral.
C. COP is a recognised pattern on HRCT in rheumatoid lungs.
D. Fibrosis mostly affects the upper lobes.
E. Cavitation in nodules suggests some other disease.
- C. COP is a recognised pattern on HRCT in rheumatoid lungs.
Thoracic involvement develops in patients with disease progression. Pleural disease is the most common thoracic manifestation and pleural thickening is the most common finding, more than pleural effusion. Pleural effusions are usually unilateral and may be loculated. They usually occur late in the disease and are commonly associated with pericarditis and subcutaneous nodules. HRCT shows basal and peripheral predominant fibrosis. Rarely upper lobe fibrosis, mimicking tuberculosis (TB), can occur. There is increased prevalence of lung cancer in fibrotic rheumatoid lung disease. Nodules are multiple and well circumscribed, often forming thick-walled cavities. Obliterative bronchiolitis results in air trapping and mosaic pattern. COP is also seen on HRCT.
- A 39-year-old hypotensive man involved in an RTA was sent for an urgent CT of the abdomen and pelvis to evaluate for solid organ or bowel injury. Which one of the following statements concerning imaging in blunt trauma to the liver is false?
A. Non-surgical treatment has become the standard of care in haemodynamically stable patients with blunt liver trauma.
B. Hepatic lacerations demonstrate jagged edges.
C. CT is the diagnostic modality of choice for the evaluation of blunt liver trauma in haemodynamically stable patients.
D. CT features of blunt liver trauma include lacerations, subcapsular or parenchymal hematomas, active haemorrhage, juxta-hepatic venous injuries, periportal low attenuation and a Hat inferior vena cava.
E. Follow*up MRI is required in patients with high-grade liver injuries to identify potential complications that require early intervention
- E. Follow-up MRI is required in patients with high-grade liver injuries to identify potential
complications that require early intervention.
Non-surgical treatment has become the standard of care in haemodynamically stable patients with blunt liver trauma. The use of helical CT in the diagnosis and management of blunt liver trauma is mainly responsible for the notable shift during the past decade from routine surgical to non-surgical management of blunt liver injuries. CT is the diagnostic modality of choice for the evaluation of blunt liver trauma in haemodynamically stable patients and can accurately help identify hepatic parenchymal injuries, help quantify the degree of haemoperitoneum and reveal associated injuries in other abdominal organs, retroperitoneal structures and the gastrointestinal tract The CT features of blunt liver trauma include lacerations, subcapsular or parenchymal hematomas, active haemorrhage, juxtahepatic venous injuries, periportal low attenuation and a flat inferior vena cava. It is important that radiologists be familiar with the liver injury grading system based on these CT features that was established by the American Association for the Surgery of Trauma. CT is also useful in the assessment of delayed complications in blunt liver trauma, including delayed haemorrhage, hepatic or perihepatic abscess, post-traumatic pseudoaneurysm and haemophilia, and biliary complications such as biloma and bile peritonitis. Follow-up CT is needed in patients with high-grade liver injuries to identify potential complications that require early intervention.
@# 33. A 45 year old man with proptosis of the right eye is referred for an MRI for further evaluation. MRI reveals a moderately large, well-defined intraconal retrobulbar mass, which is isointense to muscle on T1W images and markedly hyperintense to fat on T2W images. What is the most likely diagnosis?
A. Retinoblastoma
B. Rhabdomyoma
C. Haemangioma
D. Orbital pseudotumour
E. Metastatic lymphoma
- C. Haemangioma
Although not true neoplasms, cavernous malformations are the most common benign orbital mass in adults. Although these masses are commonly referred to as cavernous haemangiomas, many pathologists prefer the term cavernous malformation.
On CT images, cavernous malformations are typically well circumscribed, homogeneous and ovoid. The majority occur at the lateral aspect of the intraconal space. Conal and extraconal cavernous malformations are rare. Phleboliths are virtually never seen. Cavernous malformations tend to displace and surround adjacent structures, such as extraconal muscles and the optic nerve, rather than cause direct invasion. Osseous remodelling may be present, although bone erosion is rare. At MRI performed with T1-weighted sequences, cavernous malformations are isointense relative to muscle; the lesions appear uniformly hyperintense on T2-weighted images, with no flow voids. Internal septations may be identified on T2-weighted images. At multiphase CT, enhancement of cavernous malformations is poor on early arterial phase images, owing to the scant arterial supply. Delayed venous phase images demonstrate progressive filling of the mass from periphery to centre, with complete filling within 30 minutes. This enhancement pattern may permit differentiation of cavernous malformations from other vascular lesions with rich arterial supply, such as capillary’ haemangioma (a paediatric diagnosis), haemangiopericytoma and arteriovenous malformations.
Rhabdomyosarcoma is the most common soft-tissue malignancy of childhood and most common primary orbital malignancy. CT shows moderately well-defined to ill-defined margins, irregular shape and mild-moderate contrast enhancement. Adjacent bony destruction occurs in 40%. Globe distortion and extension to the paranasal sinuses may also be seen. Calcification is rare unless posttreatment. MR typically shows bright T2 signal, distinguishing rhabdomyosarcoma from other tumours such as chloroma (granulocytic sarcoma), lymphoma and metastatic neuroblastoma.
@# 34. A 32-year old woman is referred by her family doctor to the gynaecology clinic with history of congestive dysmenorrhoea, dyspareunia, fever and vaginal discharge. She had used a coil regularly in the past, which was later discontinued due to recurrent bouts of pelvic inflammation. Which one of the following statements concerning pelvic inflammatory disease is false?
A. Pyosalpinx can have a high Tl signal.
B. A tubular, fluid-filled structure with enhancing walls suggests pyosalpinx.
C. Delay in treatment can lead to tubo ovarian abscess.
D. Intense enhancement of inflamed areas on contrast-enhanced T1W MRI.
E. High signal m inflammatory stranding in peritubal fat on Tl fat-suppressed images.
- E. High signal in inflammatory stranding in peritubal fat on T1 fat-suppressed images
Pelvic inflammatory disease (PID) affects women of reproductive age and can lead to infertility, ectopic
pregnancy and chronic pelvic pain. In acute cases when dilated fallopian tubes are detected, it is extremely important to be able to differentiate tubal torsion from a pyosalpinx. A tubal torsion and a hematosalpinx may have a similar appearance to that of a fluid-filled tube on T2-weighted and STIR images; on T1-weighted images, however, a fluid filled tube has low signal intensity. Layering is common with haemorrhagic lesions, and tubal torsion may have a comma-shaped appearance. A pyosalpinx may have a similar appearance to that of a hydrosalpinx, but a hydrosalpinx usually has thinner walls. An abscess usually has low T1-weighted and high T2-weighted signal, but there can be a large variation in the signal intensity on T1-weighted and heterogeneity’ on T2-weighted images. Thick, irregular walls are typical of abscesses.
The Tl signal of pyosalpinx/TO abscess varies according to haemorrhagic/proteinaceous content On post-contrast T1-weighted images, pyosalpinx shows wall enhancement. Enhancement of the surrounding inflamed fat can also be evident. Inflammatory fat stranding is also seen on fat-suppressed T2-weighted sequences.
@# 35. A 40-year-old woman with short stature presents with early-onset hearing loss. Diagnostic workup reveals micromelic dwarfism, diffuse demineralisation and thinning of cortical bone, mild scoliosis and old fractures of the vertebral bodies and long bones. There was evidence of poor dentition. Which of the following is the most likely diagnosis?
A. Hypophosphatasia
B. Osteogenesis imperfecta
C. Paget disease
D. Osteoporosis
E. Achondroplasia
- B. Osteogenesis imperfecta
Osteogenesis imperfecta is an inherited disorder that results from mutations in either the COL1A1 or COL1A2 gene of Type I collagen. The disease is usually apparent at birth or in childhood, but more mild forms of the disease may not be apparent until adulthood. The disease is classified into Types I-IV, with Type I, the mildest form, being described in the question. The presenile hearing loss is caused by otosclerosis. The differential diagnosis can be resolved by the extraskeletal manifestations (blue sclerae and dentinogenesis imperfecta). The other types are Type II, lethal perinatal; Type III, severe progressive; and Type IV, moderately severe
@# 36. A macrosomic neonate (secondary to maternal diabetes) is noted to be in mild respiratory distress following delivery by caesarean section (CS). A chest X-ray demonstrates mild cardiomegaly mild hyperexpansion and small pleural effusions of the lungs. No focal lung abnormality is seen. What is the most likely diagnosis?
A. Respiratory distress syndrome
B. Meconium aspiration
C. Staphylococcal pneumonia
D. Group B streptococcal pneumonia
E. Transient tachypnea of the newborn
- E. Transient tachypnoea of the newborn
Although RDS is seen in association with maternal diabetes and caesarean section, hyperexpansion is not a feature of RDS. Transient tachypnoea of the newborn appears soon after birth (<4 hours) and has been identified as occurring with caesarean birth and infant sedation. Longer labour intervals, macrosomia of the foetus, and maternal asthma have also been associated. It may be accompanied by chest retractions, by expiratory grunting, or by cyanosis (which can be relieved with minimal oxygen). Recovery is usually complete within 3 days.
The lungs are usually affected diffusely and symmetrically, and the condition is commonly accompanied by small pleural effusions. The clinical course of transient tachypnoea is relatively benign when compared with the severity suggested by chest films. Radiographic resolution by the second or third day characterises this entity and differentiates it from other possible disorders; if radiographic resolution is not complete by the third day or if respiratory symptoms persist longer than 5 days, an alternative diagnosis should be sought.
Findings of transient tachypnoea of the newborn on chest radiographs may include mild, symmetrical lung overaeration, prominent perihilar interstitial markings and small pleural effusions. The radiographic appearance at times can mimic the diffuse, granular appearance of hyaline membrane disease but without pulmonary under aeration. Neonates with transient tachypnoea are usually delivered at term. Radiographic lung changes may also resemble the coarse, interstitial pattern seen with other causes of pulmonary oedema or the irregular pattern of lung opacification seen in meconium aspiration syndrome.
@# 37. A 6-year-old child is admitted to the emergency department presenting with diffuse abdominal pain, arthralgia and bilateral lower limb palpable purpura. Which of the following findings on an abdominal US examination is least expected?
A. Ileocaecal intussusception
B. Bowel wall thickening
C. Multifocal hepatic lesions
D. Bilaterally enlarged, echogenic renal cortices
E. Ascites
- C. Multifocal hepatic lesions
Henoch-Schönlein purpura is the most common vasculitis of childhood affecting small blood vessels. Clinical manifestations may include non thrombocytopenic purpura, arthritis, abdominal pain, gastrointestinal haemorrhage and glomerulonephritis. Imaging is useful to depict end-organ damage.
Ultrasound findings may include bowel wall oedema, submucosal and intramural haemorrhage, intussusception, hypoperistalsis, bowel dilatation, ascites, normal or enlarged echogenic kidneys, and also possible intramural haematomas within the urinary bladder and ureters. Non-specific findings on scrotal ultrasound may be identified such as hydroceles, scrotal wall thickening and inflammation of the spermatic cord and epididymis.
- All of the following are musculoskeletal manifestations of rheumatoid arthritis that can be seen on chest radiographs, except
A. Subacromial abutment of humeral head
B. Superior rib notching
C. Global loss of shoulder joint space
D. Erosion of medial aspect of clavicle
E. Erosion superolaterally in the humeral head
- D. Erosion of the medial aspect of the clavicle
Bone changes of rheumatoid arthritis seen on chest X-ray include resorption of the lateral end of the clavicles, erosive arthritis of the shoulders (most commonly superolateral aspect of humeral head), global loss of shoulder joint space, superior rib notching, atrophy and rotator cuff tear.
- A 46-year old man with syncopal episodes is found to be profoundly hypoglycaemic on each of the episodes. He is not on any antidiabetic medication. What imaging investigation would you suggest for further evaluation?
A. CT of the chest and liver
B. CT of the brain
C. MRA of the circle of Willis
D. Dual-phase CT of the pancreas
E. US of the abdomen
- D. Dual-phase CT pancreas
Insulinomas are the most common functioning pancreatic endocrine tumours (PET), accounting for just over 40% of all functioning PETs. They have an incidence of two to four per million people each year. They tend to manifest earlier and have a smaller size than other functioning and non-functioning endocrine tumours,
Insulinomas usually are sporadic, but they account for 10% 30% of functioning PETs in patients with Multiple endocrine neoplasia (MEN1) and they have been reported in patients with neurofibromatosis Type 1.
In 1935, Whipple and Frantz described the classic clinical triad of insulinomas: symptoms of hypoglycaemia, low blood glucose and relief of symptoms with administration of glucose. Hypoglycaemia typically manifests during fasting or after exercise, and patients often self-medicate by eating frequent small meals. On CT and MR imaging, insulinomas arc typically homogeneous and hyperenhancing. The use of coronal images may help differentiate these small hyperenhancing lesions from nearby.
@# 40. A 33-year-old woman with progressive congestive dysmenorrhoea, deep dyspareunia and infertility is being evaluated for possible endometriosis. All of the following are typical MR findings of endometriosis, except:
A. Hypointense cysts on T1W images
B. Hyperintense cysts on T2W images
C. Multilocular cysts
D. Thick-walled cysts
E. Hypointense wall thickening on T1W and T2W images
- A. Hypointense cysts on T1W images
Findings of an adnexal mass with high T1-weighted signal and high T2 weighted signal (although slightly lower T2 signal than simple or functional cyst) is highly specific for an endometrioma. The main differential for high T1 -weighted cysts are haemorrhagic functional cysts and mature cystic teratoma. Cystic teratoma is differentiated by means of T1-weighted fat suppressed images. Endometriomas tend to have higher Tl and lower T2 signal than haemorrhagic cysts, due to higher protein content and viscosity (described as T2 shading). Multifocal lesions and bilateral lesions also favour endometriosis. Hemosiderin laden macrophages combined with the fibrous nature of the cyst wall give it a low signal-intensity appearance on both Tl - and T2 weighted images. Wall thickening, septae and nodularity are also recognised.
@# 41. A 6-year-old boy presents with increasing pain within his upper back, which came on insidiously over a few weeks. The child is otherwise well. A radiograph of his thoracic spine reveals collapse of the T9 vertebral body. The disc spaces are preserved; there is no kyphosis, and no involvement of the posterior elements. Which of the following is the most likely diagnosis?
A. Ewing’s sarcoma
B. Metastasis
C. Tuberculosis
D. Fracture
E. Eosinophilic granuloma
- E. Eosinophilic granuloma
The vast majority of ‘vertebra plana’ lesions in relatively healthy children are caused by an eosinophilic granuloma. The other available options are all possible, but less common, differential diagnoses. There is usually preservation of the disc space and no kyphosis. The posterior elements are rarely involved.
- A 6-year-old boy presents with progressive proptosis of the right eye. CT shows a homogenous hypodense mass in the upper outer corner of the right orbit associated with thinning of the roof. No infiltration of the surrounding fat is evident. On MRI, the mass returns a similar signal to that of orbital fat and showed thin ring enhancement. What is the diagnosis?
A. Lymphoma
B. Pleomorphic adenoma of lacrimal gland
C. Epidermoid cyst
D. Dermoid cyst
E. Sebaceous cyst
- D. Dermoid cyst
Dermoid cysts represent the most common congenital lesion of the orbit and account for one-third of all childhood orbital tumours.
CT shows an ovoid, well demarcated cystic lesion; there may be fat (50%) or calcification (15%) present. Bone remodelling and thin rim enhancement is described. The majority occur in the extraconal location, occupying the superolateral aspect of the anterior orbit (related to the frontozygomatic suture). MRI shows high signal on T1-weighted images, if containing fat or proteinaceous material with low to iso intense signal on T2-weighted images. Thin rim enhancement is seen on Tl FS images post administration of gadolinium, unless the lesion has ruptured.
- A 42-year-old man presented with right-sided proptosis with mass in the inner canthus of the eye. An axial CT scan showed soft tissue density and expansion of the right anterior ethmoid air cells bulging into the orbit. The extraocular muscles were displaced but not involved. What is the diagnosis?
A. Encephalocoele
B. Anterior ethmoid mucocoele
C. Destructive midline granuloma
D. Wagner’s disease
E. Esthesioneuroblastoma
- B. Anterior ethmoid mucocoele
Paranasal sinus mucocoeles are benign, expansile cystic masses covered by respiratory epithelium, resulting from accumulation and retention of mucus secretion in cases where the sinus drainage is obstructed. They primarily occur in the frontal sinuses (60%-65%) but may also be found in ethmoid sinuses (20%-25%).
Usually, mucocoeles are seen as an isodense or mildly hyperdense sinus opacity in relation to the cerebral tissue, but in cases of acute infection it may appear as a more dense and peripherally enhanced image. The neighbouring bone structure is remodelled with areas of thickening, expansion and erosion. Additionally, in the areas of greater fragility, one may observe herniation into adjacent structures, displacing structures rather than invading them. Invasion would suggest malignancy.
The radiological appearance at MRI varies with the time of evolution of the disease. Initially, the contents will be predominantly aqueous, so the corresponding image will be hypointense on T1-weighted sequences and hyperintense on T2-weighted sequences. Over time, the protein contents may increase, resulting in hyperintense images both on T1-weighted and T2-weighted sequences.
@# 44. A 62-year-old man, who has undergone solid organ transplant, is found to be profoundly neutropaenic and presents with progressive fever, cough and shortness of breath. He is acutely unwell. Chest X-ray shows bilateral patchy air space opacities and bronchoalveolar lavage showed Aspergillus organisms. HRCT is organised to confirm pulmonary invasive aspergillosis. All the following are typical imaging features, except:
A. Nodules with surrounding ground-glass change
B. Pulmonary sequestra
C. Peripheral wedge shaped consolidation
D. Air crescent sign
E. Central bronchiectasis
- E. Central bronchiectasis
Angioinvasive pulmonary aspergillosis occurs almost exclusively in immunocompromised patients with severe neutropenia. Characteristic CT findings include nodules surrounded by a halo of ground-glass attenuation (halo sign) or pleura-based, wedge-shaped areas of consolidation. In neutropenia patients, the halo sign is highly suggestive of angioinvasive aspergillosis. However, a similar appearance has been described in infection by Mucorales, Candida, herpes simplex virus (HSV), cytomegalovirus (CMV), Wegener’s granulomatosis, Kaposi’s sarcoma and haemorrhagic metastases. Separation of fragments of necrotic lung (pulmonary sequestra) from adjacent parenchyma results in air crescents similar to those seen in mycetomas. The air crescent sign is usually seen after initiation of treatment and with resolution of the neutropenia. Airway invasive aspergillosis shows multiple centrilobular nodules and the tree-in-bud pattern.
@# 45. A 2-year-old child presents with fever, erythema of the oral mucosa with chest and abdominal pain. Echocardiography reveals the presence of a coronary arterial aneurysms. An underlying vasculitis is suspected. Which of the following statements is least accurate in this clinical setting?
A. Aneurysms are typically seen in the proximal segments of the coronary arteries.
B. Aneurysms less than 5 mm in diameter are considered small.
C. Smaller aneurysms have a higher likelihood of thrombosis.
D. Multiple coronary artery aneurysms are more common than isolated aneurysms.
E. The most common site for a coronary aneurysm is in the left anterior descending artery.
- C. Smaller aneurysms have a higher likelihood of thrombosis
Kawasaki’s disease is a common paediatric vasculitis of medium-sized vessels, with coronary vasculitis being the hallmark manifestation. It is the leading cause of acquired heart disease in children in developed countries.
Coronary arterial aneurysms typically occur within the subacute phase of the disease and may be associated with sudden cardiac death. The aneurysms typically develop in the proximal segments of major coronary arteries and affect the left anterior descending artery followed by the proximal right coronary arteries in frequency of location. Smaller aneurysms, (<5 mm in diameter) are more likely to regress than larger aneurysms (>8 mm in diameter), which have a higher likelihood of thrombosis and infarction.
@# 46. A 61 -year old man with difficulty in swallowing was sent by his family doctor for a barium swallow. The examination showed a smooth filling defect in the mid lower oesophagus with minor hold up of contrast and proximal oesophageal dilatation.
CT performed for further evaluation did not show any extra oesophageal organ involvement or lymphadenopathy. The most common mesenchymal tumour of the oesophagus is
A. Lipoma
B. Gastrointestinal stromal tumour
C Haemangioma
D. Leiomyosarcoma
E. Leiomyoma
- E. Leiomyoma
Leiomyomas are neoplasms of mature smooth muscle cells and are the most common benign oesophageal neoplasm, although they are about 50 times less common than oesophageal carcinoma. They are also the most common mesenchymal tumours of the oesophagus, unlike in the remainder of the gastrointestinal tract, where GISTs predominate.
Oesophageal leiomyomas are nearly twice as common in men as m women and have been reported in patients between 4 and 81 years of age, although they rarely occur in the paediatric population. Most patients are asymptomatic, but dysphagia and pain may develop, depending on the size of the lesion and amount of encroachment on the oesophageal lumen, in contrast to patients with malignant oesophageal tumours.
Affected individuals usually have long-standing symptoms, with a duration of more than 2 years in most cases. Treatment options include endoscopic resection, surgical enucleation and observation. Oesophageal leiomyomas have a benign clinical course and typically do not recur after surgery.
@# 47. A 22 year old woman who had undergone a caesarean section presents with cyclic voiding symptoms hut no haematuria. Cystoscopy shows a filling defect and MRI is performed. Axial T2W MRI shows hypointense irregular focal wall thickening on the left posterolateral aspect of the bladder, without any fat stranding or associated lymph nodes, suggesting intrinsic bladder endometriosis. Which of the following statements is false, regarding deep pelvic endometriosis?
A. Subperitoneal invasion of endometriotic tissue must exceed 5 mm.
B. Endometriotic nodules can have high T2W’ signal.
C. Low signal nodular thickening of utcrosacral ligament on T2W images.
D. Ureteric endometriosis is mostly intrinsic.
E. Obliteration of pouch of Douglas is recognised in advanced disease.
- D. Ureteric endometriosis is mostly intrinsic.
Deep pelvic endometriosis is defined as subperitoneal invasion by endometriotic lesions that exceeds 5 mm in depth. Involvement of anatomic structures such as the uterosacral ligaments or the vaginal or rectal wall should be suspected when these structures have a hypointense thickened or nodular appearance on T2-weighted images. Intermingled high T2 signal would be secondary to ectopic endometrial glands. On T1-weighted or fat-suppressed T1 -weighted MR images, these foci may have either high or low signal intensity, depending on the presence or absence of bloody content. Some endometriomas may show restricted diffusion on DWI, probably due to intracystic blood clots. Enhancement may or may not occur post-contrast, depending on the proportions of inflammatory reaction, glandular tissue and fibrosis. Bladder endometriosis should be considered in anyone who presents with urinary tract symptoms after having undergone hysterectomy or other gynaecologic surgical procedure. Because vesical endometriosis seldom invades the mucosa, MR imaging may show abnormalities although cystoscopy is normal. As with bladder involvement, extrinsic endometriosis is the most common form of ureteral involvement. On MR imaging, ureteral endometriosis usually appears as irregular hypointense nodules on T2-weighted images. Deep retroperitoneal endometriotic lesions of the posterior compartment involve the rectovaginal pouch, retrocervical area, uterosacral ligaments, posterior vaginal fornix, rectovaginal septum and rectum. Obliteration of the pouch of Douglas occurs when retrocervical lesions extend to the anterior rectal wall.
@#e 48. A 7 year-old boy fell off a bike onto his outstretched left hand. X-ray showed a fracture of the left distal radius involving the epiphyseal plate that extends into the metaphysis. The epiphysis was split into two fragments. What is the Salter-Harris classification?
A. 1
B. 2
C. 3
D. 4
E. 5
- D. 4
Physeal Salter-Harris fractures are divided into two categories on the basis of the involved physeal regions: (1) horizontal fractures without involvement of the germinal or proliferative zone of the physis and (2) longitudinal fractures that extend through all zones of the physis into the epiphysis.
Horizontal fractures (Salter Harris Types I and II) result in bridge formation in 25% of cases, whereas longitudinal fractures (Salter-Harris Types III and IV) result in bridge formation in 75% of cases.
