TEST PAPER 6 Flashcards
1
Q
1.A Computed tomography (CT) chest is done in a 6-month-old girl with a history ofpremature birth, chronic lung disease and MRSA pneumonia. It shows a large gas-containing,thin-walled cavity in the right lung, consistent with a pneumatocele. All the following aretrue regarding a pneumatocoele, except:
A. They are gas-filled, thin-walled spaces surrounded by lung.
B. They can be associated with lung contusion.
C. Most pneumatocoeles resolve spontaneously.
D. Pneumatocoeles do not cause mediastinal shift.
E. They can have fluid levels.
A
- D. Pneumatocoeles do not cause mediastinal shift.
Pneumatocoeles typically are post-infectious or post-traumatic, discrete, thin-walled,gas-containing collections within the lung parenchyma. They also may result from positive pressure ventilation-related barotrauma and ingestion of caustic material (e.g. hydrocarbons). Post-infectious pneumatocoeles most frequently complicate staphylococcal pneumonia and occur in infants. They typically appear within 1 week of onset of infection and most spontaneously disappear within weeks to months after the infection has resolved. Rarely, persistent pneumatocoeles may require percutaneous catheter drainage or surgical management. Post-traumatic pneumatocoeles result from blunt trauma. Such pneumatocoeles are typically observed within hours of the trauma and spontaneously resolve within 3 weeks. They generally spare the lung apices.
At CT, pneumatocoeles appear as well-defined parenchymal cystic structures, with a thin wall. They may be entirely filled with gas, or an air-fluid level may be seen. Contralateral mediastinal shift may be seen with large pneumatocoeles. They are associated with contusion in blunt trauma and can rupture to cause pneumothorax.
2
Q
2.A 58-year-old patient is reported to have a carcinoid tumour of the gastrointestinal (GI)tract on an abdominal computed tomography scan. What is the most common primary site ofGI carcinoids?
A. Stomach
B. Colon
C. Rectum
D. Small bowel
E. Appendix
A
2.E. Appendix
Carcinoid tumours are the most common primary tumour of the small bowel and appendix.Gastrointestinal carcinoids account for about 85% of all carcinoid tumours, with the remaining 15% occurring in the lungs and bronchi. These tumours arise from the enterochromaffin cells of Kultchitsky; these express serotonin and other histamine-like substances. The appendix is the most common site of carcinoids, accounting for 30%-45%, the small bowel for 25%-35%, the rectum 10%—15%, the colon 5% and the stomach <3%. Most tumours are clinically silent but may cause pain, obstruction, weight loss and, rarely, bowel perforation. In rare cases (7% of small bowel carcinoids), the hormonal load from the tumour may overwhelm the liver’s capacity to metabolise serotonin, causing a carcinoid syndrome recurrent diarrhoea, right-sided endocardial fibroelastosis, wheezing/bronchospasm and flushing of the face and neck.
3
Q
3.A 53-year-old man with history of haematuria which shows a gel-like polypoid filling defecton cystoscopy is sent for an MRI. The MRI shows a low Tl signal, heterogeneous T2 signal(central high and peripheral low) lesion. On post-contrast Tl W FS images, the peripheral portionenhances more than the central potion, resembling a ring-like pattern. What is the diagnosis?
A. Endometriosis
B. Inflammatory pseudotumour
C. Malakoplakia
D. Cystitis glandularis
E. Eosinophilic cystitis
A
3.B. Inflammatory pseudotumour
Inflammatory pseudotumour is an interesting entity that has been reported in every organ of thebody. At imaging, it usually appears as a solitary exophytic or polypoid bladder mass, which may be ulcerated. On T2-weighted MRI, it is heterogeneous, with a central hyperintense component surrounded by a low-signal-intensity periphery; on post-contrast images the periphery enhances, whereas the central region enhances poorly. The central region consists of necrotic tissue, and the periphery comprises fascicles of spindle cells in oedematous stroma with myxoid components, vessels and inflammatory cells (hence the name pseudosarcomatous fibromyxoid tumour). This structure may produce the pattern of ring-like enhancement observed on CT and MR images suggestive of the diagnosis, but histologic confirmation is essential. In young adults, the presence of luminal clot surrounding an enhancing bladder mass may also suggest this diagnosis.
MRI shows single or multiple masses. On T2-weighted images, cystitis glandularis shows low signal intensity with a central branching high-signal pattern. The hyperintense area shows the most contrast enhancement and corresponds to the vascular stalk. Eosinophilic cystitis nodules are hyperintense to muscle on T1, isointense on T2-weighted images, and enhanced after intravenous contrast administration.
4
Q
4.A 33 year-old man presented with fever and sudden-onset back pain. Inflammatorymarkers were slightly raised. MRI spine showed high signal in the L3/4 disc space on T2Wand STIR images, with enhancement of the disc extending to the adjacent end plates onpost contrast sequences. What is the diagnosis?
A. Metastasis
B. Prolapsed intervertebral disc
C. Sequestrated disc
D. Discitis
E. Epidural abscess
A
- D. Discitis
Pyogenic spondylitis most commonly involves the lumbar spine and one spinal segment, which consists of two vertebral bodies and the intervening disk. It typically displays low signal intensity on T1-weighted images, with a loss of definition of the vertebral end plate and of the adjacent vertebral bodies and high signal intensity on T2-weighted images. In the involved disk space, fluid- like signal intensity is seen on both Tl and T2 images. Following the intravenous administration of gadolinium-based contrast material, disk enhancement patterns from homogeneous to patchy nonconfluent to peripheral enhancement may be seen. Infected bone marrow also enhances diffusely after contrast material is administered; contrast-enhanced fat-suppressed MR images are especially useful in demonstrating this marrow abnormality. MR imaging provides better definition of epidural extension of the inflammatory process and compression of the spinal cord and dural sac than other imaging modalities do. Paravertebral and epidural extension may appear in the form of either a phlegmon or an abscess with mixed signal intensity on both T1-weighted and T2-weighted images.
5
Q
- A 65-year-old woman with progressive increase in knee pain and limited mobility is referred by her GP to have a plain X-ray of the knee. Plain films show bilateral chondrocalcinosis along with some other arthritic features. Which one of the following conditions is the most common cause of chondrocalcinosis?
A. Calcium pyrophosphate dihydrate crystal deposition disease
B. Hydroxyapatite crystal deposition disease
C. Primary synovial osteochondromatosis
D. Intraarticular synovial cell sarcoma
E. Chronic renal failure
A
- A. Calcium pyrophosphate dihydrate crystal deposition disease
Pseudogout [calcium pyrophosphate dihydrate (CPPD) deposition disease] is a syndrome caused by the deposition of CPPD crystals in and about the joints of middle-aged or older adults. Three discrete manifestations of this deposition of CPPD crystals are recognised:
(1) chondrocalcinosis, (2) typical arthropathy and (3) the clinical presentation of pain. Any combination of these features may suffice to suggest the diagnosis of pseudogout.
Other causes of chondrocalcinosis include the following:
Hyperparathyroidism Gout
Wilson disease
Haemochromatosis
Ochronosis
Trauma
Osteoarthritis
Hypothyroidism
Hypomagnesaemia
Acromegaly
Oxalosis and hydroxyapatite deposition disease (HADD)
6
Q
- A 14-year-old boy with family history of pulmonary chondroma in his elder brother is investigated with a CT of the chest and abdomen. The CT shows a 3 x 3 cm calcified perihilar lung mass and a large mixed density mass in the left upper quadrant, anterior to the spleen inseparable from the stomach. What other finding(s) would you expect on the CT?
A. Bilateral renal carcinoma
B. Hepatoblastoma
C. Multiple cysts in the lung, kidney and pancreas
D. Wilms tumour on the right
E. Multiple extra-adrenal neuroblastomas
A
- E. Multiple extra-adrenal neuroblastomas
The question describes the Carney triad: pulmonary chondroma, gastric GIST and multiple extra-adrenal neuroblastoma.
Cancer predisposition syndrome (CPS) is the term that is generally reserved to describe familial cancers in which a clear mode of inheritance can be established. Individuals may present with one or more key physical features or congenital anomalies (e.g. hemihypertrophy). Patients may have specific tumours that are known to be highly associated with a CPS (e.g. haemangioblastomas in VHL (Von Hippel-Lindau syndrome) disease).
Some physical features suggesting CPS are cafe-au-lait spots (NF1, NF2, Bloom s), angiofibromas (tuberous sclerosis, TS), pits in palms and soles (Gorlin), macrocephaly (Sotos, Cowden, Gorlin), macroglosia [BWS ( (Beckwith-Wiedemann syndrome)], hyperpigmentation (NF1, Fanconi anaemia, Blooms), spotty skin pigmentation (Carney complex), hemihypertrophy (NF1, BWS, Klippel Trenaunay syndrome), thumb malformation (Fanconi anaemia), aniridia [WAGR (Wilms tumor- anirida syndrome with genitourinary anomalies)] and so on.
Tumours associated with CPS include Wilms tumour (WAGR, BWS and several others), haemangioblastoma (VHL), dear cell renal carcinoma (VHL, TS), pheochromocytoma (VHL, MEN 2B, NF1), hepatoblastoma (BWS, Familial adenomatous polyposis, FAP), adrenocortical and breast carcinoma (Li-Fraumeni syndrome, LFS), optic glioma and neurofibrosarcoma (NF1), retinoblastoma (familial retinoblastoma), gastric cancer and GIST (FAP, NF1, Carney triad, HNPCC (hereditary non-polyposis colorectal cancer] or lynch syndrome, LFS, MEN1), neuroblastoma (NFl, BWS), rhabdomyosarcoma (LFS, NF1, BWS, hereditary retinoblastoma) and so on.
Screening tests and pathways have been established for several of these CPSs. These include US abdomen for BWS, LFS, FAP and VHL; prophylactic thyroidectomy for MEN 2; and so on.
7
Q
- Transverse US image of a foetal thorax with a four-chamber view of the heart demonstrates homogeneous intermediate echogenicity of the right lung. The heart is mildly rotated to the right and there are cystic areas in the left side of the thorax suggesting a diaphragmatic hernia. All of the following are true regarding investigation of congenital lung anomalies, except;
A. Meconium shows high T1 and low T2 signal on MRI.
B. Normal lung reduces in T2 intensity as it matures.
C. Secondary pulmonary hypoplasia is more common than primary’.
D. Interventricular septum determines the cardiac axis.
E. Echogenicity of lung advances as gestation advances
A
- B. Normal lung reduces T2 intensity as it matures.
At US, the foetal lungs normally appear homogeneous and are slightly more echogenic than the liver. The echogenicity of the lung increases as gestation advances. The presence of cysts or focal increased echogenicity of the lung parenchyma indicates a mass. The axis of the heart is determined relative to the interventricular septum.
At MR imaging, the trachea, bronchi and lungs demonstrate high T2 signal intensity relative to the chest wall muscles, because they contain a significant amount of fluid. As the lungs mature, there is increasing production of alveolar fluid, thereby increasing the T2 signal intensity of lung relative to the liver.
Pulmonary hypoplasia can be primary or secondary. Primary pulmonary hypoplasia is less common. The most common intrathoracic cause of secondary pulmonary hypoplasia is congenital diaphragmatic hernia. The herniated liver can be confused with a mass originating in the lung. Colour Doppler imaging may be helpful in identifying the portal and hepatic veins.
Meconium-filled large bowel is hyperintense on T1-weighted images and hypointense on T2 weighted images; therefore, intrathoracic herniation of the large bowel can easily be detected at MR imaging.
The most common extrathoracic cause of pulmonary hypoplasia is severe oligohydramnios, secondary to cither foetal urogenital anomaly or premature rupture of membranes.
8
Q
- A 42-year-old man who sustained a comminuted acetabular fracture underwent a CT of his pelvis for further characterisation and treatment planning. The CT report described it as an anterior column acetabular fracture. Which one of the following anatomic structures must be disrupted on the CT?
A. Ilioischial line
B. Iliopectineal line
C. Sacroiliac joint
D. Anterior wall
E. Posterior wall
A
- B. Iliopectineal line
On radiographs, the iliopectineal (or iliopubic) line represents the border of the anterior column, and the ilioischial line represents the posterior column.
Fracture involvement of the anterior and posterior columns is characterised by disruption of the iliopectineal line and ilioischial line, respectively. However, disruption of these lines may also be seen with other fracture patterns, such as a transverse fracture. Obturator ring and iliac wing involvement must also be present for classification as a both-column acetabular fracture.
9
Q
- A 29 year old woman has come to the A&E department with 3 months’ history of shortness of breath after her second miscarriage. She had an episode of pulmonary embolism during her first pregnancy and epilepsy in her teens. Chest radiograph done in the A&E department shows progressive enlargement of cardiac silhouette and left-sided pleural effusion. What is the likely diagnosis?
A. Systemic lupus erythematosus (SLE)
B. Rheumatoid arthritis
C. Wegner’s disease
D. Polyarteritis nodosa (PAN)
E. Homocystinuria
A
- A. Systemic lupus erythematosus (SLE)
Systemic Lupus Erythematosus (SLE) patients with antiphospholipid antibody (aPL-ab) syndrome present with arterial and veno-occlusive disease, thrombocytopenia and recurrent vascular thromboses and miscarriages. Patients with aPL-ab syndrome can present with recurrent strokes, Budd-Chiari syndrome, dural venous sinus thrombosis, ischaemic bowel and recurrent pulmonary embolism. Exudative pericardial effusions and pericarditis are common. Pleural effusions are the most common manifestation of SLE in the respiratory system and are bilateral in approximately 50% of patients.
Epileptic seizures are seen in 11% patients with SLE, with association of aPL-ab syndrome and stroke.
10
Q
- Abdominal computed tomography (CT) in a 57-year-old patient with non-specific abdominal pain demonstrates an elongated cystic mass in the expected region of the appendix. The lesion appears to be invaginating into the caecum and demonstrates curvilinear calcification in its wall. What is the most likely diagnosis?
A. Lipomatosis of ileocaecal valve
B. Carcinoid tumour of the appendix
C. Mucocoele of the appendix
D. Epiploic appendagitis
E. Myxoglobulosis
A
- C. Mucocoele of the appendix
Mucocoele of the appendix is an umbrella term used for the appearance of a cystic mass within the appendix that has varying pathological cause. Mucocoeles may be secondary to mucosal hyperplasia (25%), mucinous cystadenoma (63%) and mucinous cystadenocarcinoma (12%). The HU (Hounsfield Unit) value of the cystic lesion is variable from water density to soft tissue density depending on the volume of mucin present within it. A CT scan is good at demonstrating the curvilinear or punctate rim-like calcification that is present in approximately 50% of cases. Ultrasound may demonstrate a right lower quadrant lesion with either cystic or mixed internal echogenicity depending on the amount of mucin. Rupture of mucocoeles may lead to pseudomyxoma peritonei with characteristic findings of multiple thin-walled cystic masses of varying sizes in the abdomen, scalloping of the liver and splenic margins and a gelatinous ascites. Myxoglobulosis is a rare variant of mucocoele with characteristic small, rounded calcific spherules.
11
Q
- Tuberculous spondylitis is diagnosed in a 44-year-old woman with progressive neurological deficit with severe discovertebral destruction and compression of the spinal cord at the Tll-12 level on sagittal T2W & STIR MR images. Post-contrast images show a rim-enhancing anterior abscess that does not encase the intercostal arteries. All of the following features are more likely to represent tuberculosis spondylitis compared to pyogenic spondylitis, except:
A. Subligamentous spread
B. Three or more vertebral level involvement
C. Skip lesions
D. Homogenous enhancement of the disc
E. Paraspinal calcification
A
- D. Homogenous enhancement of the disc
Spinal tuberculosis most commonly involves the thoracic spine and less often the lumbar spine. It is often difficult to differentiate between tuberculous and pyogenic spondylitis, both clinically and on images. MR imaging is very helpful for differentiating between tuberculous spondylitis and pyogenic spondylitis. A well-defined paraspinal mass with abnormal signal intensity; a thin, smooth abscess wall; subligamentous spread to three or more vertebral levels; and multiple vertebral or entire-body involvement are findings more suggestive of tuberculous spondylitis than of pyogenic spondylitis. The presence of skip lesions and of a large paraspinal cold abscess is also suggestive of tuberculous spondylitis. However, because they barely penetrate the anterior longitudinal ligament, neither an anterior paraspinal phlegmon or an abscess encasing the intercostal arteries, is seen in spinal tuberculosis. MR imaging is less sensitive than radiography or CT for identifying paraspinal calcifications, which are a distinctive imaging feature of spinal tuberculosis. Pyogenic spondylitis most commonly involves the lumbar spine and one spinal segment.
12
Q
- A CT cystogram is being performed on a 40-year-old man brought to the A&E department, after a fall from a roof. Blood is seen at the external urethral meatus on examination. The CT scan shows focal thickening of the urinary bladder wall, with no extravasation outside the bladder. Which of the following is the most likely injury sustained?
A. Bladder contusion
B. Intraperitoneal bladder rupture
C. Extraperitoneal bladder rupture
D. Combined intraperitoneal and extraperitoneal bladder rupture
E. Subserosal bladder rupture
A
- A. Bladder contusion
Bladder contusion is the most common bladder injury following trauma. Unlike the other choices there is no contrast extravasation. The CT scans can show an intramural haematoma (seen as a focal ellipse-shaped thickening of the bladder wall). This may appear as a crescent-shaped filling defect on cystography. Subserosal bladder rupture is seen as an elliptical contrast extravasation adjacent to the bladder on CT. Both intraperitoneal and extraperitoneal bladder rupture can be seen as extravasation outside the bladder.
13
Q
- A 28-year-old man with sudden-onset of heart murmur and a normal chest radiograph is admitted for progressive shortness of breath on exertion over the recent months. There is a positive family history for heart murmurs and sudden death of a sibling at the age of 30 years. While in the hospital he developed an acute, severe bout of central chest pain, which prompted an urgent CT of the chest. The CT of the chest shows dissection of an enlarged ascending aorta. What is the diagnosis?
A. Homocystinuria
B. Marfan syndrome
C. Ehlers-Danlos syndrome
D. Pseudoxanthoma elasticum
E. Mucopolysaccharidosis
A
- B. Marfan syndrome
Annulo-aortic ectasia, a condition characterised by dilated sinuses of Valsalva with effacement of the sinotubular junction, with normal calibre arch, is most commonly associated with Marfan syndrome. Other causes include homocystinuria, Ehlers-Danlos syndrome and osteogenesis imperfecta; however, annulo-aortic ectasia can be idiopathic, although onset and progression is more rapid in Marfan syndrome. Common cardiovascular manifestations, include annulo-aortic ectasia with or without aortic valve insufficiency, aortic dissection, aortic aneurysm, pulmonary artery dilatation and mitral valve prolapse, most of which are substantial contributors to mortality.
Homocystinuria presents with thromboembolic episodes like stroke. Murmurs related to AR or MR are not commonly associated with the other conditions.
14
Q
- A 59-year-old patient is admitted with general lethargy, weight loss and gradual abdominal distension. Diagnostic work-up included an abdominal CT scan, which demonstrated thickening of the peritoneal surfaces and a large, multiloculated dense ascites, causing secondary scalloping of the liver edge. What is the most likely location of the primary tumour?
A. Stomach
B. Appendix
C. Pancreas
D. Liver
E. Rectum
A
- B. Appendix
The clinical picture and CT findings are characteristic for pseudomyxoma peritonei, a process of gradual accumulation of large amounts of gelatinous/mucinous material within the peritoneum. This accumulation of mucin is secondary to a ruptured mucocoele of the appendix. Characteristic CT findings include omental caking, thickening of the peritoneum and mesentery, large gelatinous ascites and scalloped contour of the liver and/or splenic borders. The ascites may vary from water density to a very thick soft-tissue density, which is dependent on the volume of mucin within the fluid. It is important to always scrutinise the appendix to identify the mucocoele once the secondary features are identified.
15
Q
- A 44-year-old woman with recurrent urinary tract infections is referred for a renal tract ultrasound. This demonstrates normal kidneys and multiple fluid-filled cysts within the bladder wall. Which of the following is the most likely cause?
A. Transitional cell carcinoma
B. Cystitis cystica
C. Emphysematous cystitis
D. Eosinophilic cystitis
E. Interstitial cystitis
A
- B. Cystitis cystica
Cystitis cystica and cystitis glandularis are inflammatory processes of the bladder wall with multiple small, round, cyst-like elevations in the submucosa. They are often associated with irritants such as chronic infection, calculi or bladder outlet obstruction. The hallmark of emphysematous cystitis is gas within the bladder wall. The main risk factors are diabetes mellitus and bladder outflow obstruction. Eosinophilic cystitis can present with a nodular bladder wall, but the nodules would be echogenic on ultrasound in comparison with the fluid-filled cysts of cystitis cystica. In any event, all focal bladder abnormalities seen at imaging should be evaluated cystoscopically. In interstitial cystitis, the bladder wall becomes thick and trabeculated.
16
Q
- A 22-year-old man presents to the A&E department with a painful swollen ankle following a twisting injury’. Plain X-rays showed no fracture, although diffuse soft-tissue swelling was evident. The ankle mortise was intact. Incidental note was made of a benign lesion in the mid- shaft of the fibula, which the reporting radiologist described as a fibrous cortical defect. Which one of the following statements regarding this entity is false?
A. They are smaller than non-ossifying fibromas.
B. Pathological fractures tend to end in non-union.
C. Both show dense sclerotic border on CT.
D. They commonly affect the metaphysis of long bones.
E. They are uncommon in the upper extremity.
A
- B. Pathological fractures tend to end in non-union.
Benign bone tumours in the fibrous group include benign fibrous cortical defect (FCD), non-ossifying fibroma (NOF), osteo-fibrous dysplasia (OFD), fibrous dysplasia (FD) and fibroma. Benign fibrous cortical defects and non-ossifying fibromas are the most common tumours in the benign fibrous group. Benign cortical defects and non ossifying fibromas are eccentric, cortical bone lesions, usually located in the metaphyses of long bones. Non-ossifying fibromas are usually larger than fibrous cortical defects. The most common locations for fibrous cortical defects are the distal femur, proximal tibia and distal tibia. They occur less commonly in the fibula and are relatively uncommon in the upper extremity.
On CT, both benign fibrous cortical defects and non-ossifying fibromas have a dense sclerotic border, and on MRI both are of low signal intensity on T1 weighted and T2-weighted images.
Pathologic fractures arc more common witli the larger non-ossifying fibroma variant. They tend to heal spontaneously.
17
Q
- A 43-year-old man presents to the A&E department with severe headache and is sent for an urgent CT brain, which is normal. MRI shows loss of normal flow void in the basal cisterns with intense enhancement along the cisterns on post-contrast images. What is the likely diagnosis?
A. Subarachnoid haemorrhage
B. Lymphoma
C. TB meningitis
D. Ruptured dermoid cyst
E. Creutzfeldt-Jakob disease (CJD)
A
- C. TB meningitis
Tuberculous meningitis (TBM) is the most common manifestation of CNS tuberculosis across all age groups. The typical radiographic finding is abnormal meningeal enhancement, usually most pronounced in the basal cisterns. These findings are better seen at gadolinium-enhanced MR imaging than at CT. Appearances usually resolve relatively quickly with adequate treatment; however, radiographic resolution is delayed if there are thickened exudates. This appearance is non-specific and has a wide differential diagnosis that includes meningitis from other infective agents; inflammatory diseases such as rheumatoid arthritis and sarcoidosis; and neoplastic causes, both primary and secondary. The presence of high density within the basal cisterns on non-contrast CT scans is a very specific sign for TBM in children.
The most common complication of tuberculous meningitis is communicating hydrocephalus. Ischaemic infarcts are also common, being seen in 20% 40% of patients at CT, mostly within the basal ganglia or internal capsule resulting from vascular compression and occlusion of small perforating vessels. Cranial nerve (2, 3, 4 and 7) involvement is reported.
18
Q
- A 6-year-old child is admitted to the emergency department with a head injury. The emergency department consultant demands an urgent CT of the head. Which of the following risk factors would warrant a CT of the head within 1 hour of the injury?
A. Two episodes of vomiting after the head injury
B. Amnesia of events 10 minutes preceding the head injury
C. Fall from a playground climbing frame of 3 metres in height
D. GCS of 13 on initial clinical assessment
E. Abnormal drowsiness
A
- D. GCS of 13 on initial clinical assessment
According to the latest NICE guidelines, for children who have sustained a head injury’ and have any of the following risk factors, perform a CT head scan within 1 hour of the risk factor being identified;
* Suspicion of non-accidental injury
* Post-traumatic seizure but no history of epilepsy’
* On initial emergency department assessment, GCS less than 14 or, for children under 1 year, GCS (paediatric) less than 15
* At 2 hours after the injury’, GCS less than 15
* Suspected open or depressed skull fracture or tense fontanelle
* Any sign of basal skull fracture (haemotympanum, ‘panda’ eyes, cerebrospinal fluid leakage from the ear or nose, or Battle’s sign)
* Focal neurological deficit
* For children under 1 year, presence of bruise, swelling or laceration of more than 5 cm on the head
For children who have sustained a head injury and have more than one of the following risk factors (and none of those mentioned above), perform a CT head scan within 1 hour of the risk factors being identified:
* Loss of consciousness lasting more than 5 minutes (witnessed)
* Abnormal drowsiness
* Three or more discrete episodes of vomiting
* Dangerous mechanism of injury (high-speed road traffic accident either as pedestrian, cyclist or vehicle occupant; fall from a height of greater than 3 metres; high speed injury from
a projectile or other object)
* Amnesia (antegrade or retrograde) lasting more than 5 minutes
19
Q
- An 8-year-old boy attends the emergency department after his bicycle collides with an oncoming car. The ambulance crew have immobilised his cervical spine and report that the patient was complaining of severe neck ache. All of the following risk factors warrant a CT of the cervical spine without obtaining a plain radiograph, except
A. The patient is already attending the department for a CT of the head.
B. Fall from a height of more than 1 metre.
C. Loss of sensation in the upper arms.
D. GCS of 13 on initial assessment.
E. The child needs to be intubated.
A
- B. Fall from a height of more than 1 metre According to the latest NICE guideline for spinal injury:
Perform MRI for children (under 16s) if there is a strong suspicion of
* Cervical spinal cord injury as indicated by the Canadian C-spine rule and by clinical assessment or
* Cervical spinal column injury as indicated by clinical assessment or abnormal neurological signs or symptoms, or both.
Consider plain X-rays in children (under 16s) who do not fulfil the criteria for MRI in recommendation but clinical suspicion remains after clinical assessment.
For imaging in children (under 16s) with head injury and suspected cervical spine injury, follow the recommendations in the NICE guideline on head injury.
For children with a head injury, perform a CT cervical spine scan if
* GCS is less than 13 on initial assessment
* The patient has been intubated.
* Focal peripheral neurological signs.
* Paraesthesia in the upper or lower limbs.
* A definitive diagnosis is needed urgently (e.g. before surgery).
* The patient is having CT for head injury or multiregion trauma.
* There is strong clinical suspicion of injury despite normal X-rays.
* Plain X rays are technically difficult or inadequate.
* Plain X-rays identify a significant bony injury.
CT is to be performed within 1 hour of the risk factor being identified.
20
Q
- A 34-year-old man with history of measles infection showed marked cerebral atrophy on MRI with high signal in the deep white matter bilaterally on T2 and FLAIR images. What is the most likely diagnosis?
A. Adrenoleukodystrophy
B. Alexander s disease
C. CJD
D. Progressive multifocal leukoencephalopathy (PML)
E. Subacute sclerosing panencephalitis
A
- E. Subacute sclerosing pan encephalitis
Creutzfeldt-Jakob disease (CJD) shows high signal intensities in the basal ganglia (putamen and caudate nucleus) and in the cortex on DW images. The high signal intensities in the basal ganglia are also prevalent on T2-weighted and FLAIR images. The cortical hyperintensities are usually not visualised on T2-weighted and FLAIR images (advantage of DW imaging).
Progressive multifocal leukoencephalopathy (PML) is a demyelinating disease of immunocompromised patients caused by human papovaviruses. Subacute sclerosing panencephalitis (SSPE) occurs several years after measles infection. SSPE typically starts with mental and behavioural abnormalities, myoclonia, tremor and seizures. Multifocal, hyperintense foci in white matter and the basal ganglia have been reported in PML and SSPE on T2-weighted images. On T2-weighted and FLAIR images, PML and SSPE are associated with white matter lesions, whereas CJD is not. The high-signal-intensity cortical lesions on DW images may be also a hallmark of CJD.
21
Q
- A 25-year-old man presents with left hip/groin pain after exercise that worsens on internal rotation of the hip. A plain AP radiograph of the pelvis shows an osseous protrusion at the femoral head-neck junction, and the measured alpha angle is greater than 55 degrees. Which of the following is the most likely diagnosis?
A. Pincer type femoro-acetabular impingement
B. Cam type femoro-acetabular impingement
C. Missed congenital hip dislocation
D. Focal acetabular over-coverage
E. Protrusio acetabuli
A
- B. Cam-type femoro-acetabular impingement
Femoro-acetabular impingement (FAT) is a major cause of premature osteoarthritis of the hip. It is split radiographically into two main types. Pincer-type impingement is the acetabular cause of FA I and is secondary to either focal or generalised over-coverage of the femoral head by the acetabulum. Cam-type impingement is the femoral cause and is secondary to an asphericity of the femoral head and offset of the femoral head-neck junction. Cam impingement is more common in young men and leads to a increased alpha angle (diagnostic > 55 degrees). The osseous bump at the head-neck junction may be located laterally, resulting in the ‘pistol grip’ deformity seen on AP pelvis.
Protrusio acetabuli occurs when the femoral head is overlapping the ilioischial line medially and may be idiopathic or secondary to causes such as rheumatoid arthritis, Paget disease Marians syndrome and osteomalacia.
22
Q
- Chest radiograph of a currently asymptomatic 84-year-old man shows a large well-defined soft tissue density mass in the left apex with a sharp inferior margin. There is underlying rib abnormality, suggesting previous surgery and sheet-like pleural calcification in the left mid and lower zone. What is the diagnosis?
A. Aspergilloma
B. Plombage
C. Pancoast tumour
D. Bronchogenic cyst
E. Lymphoma
A
- B. Plombage
In the pre chemotherapy era, surgical management of pulmonary TB included thoracoplasty or plombage, in which an extrapleural space was created between parietal pleura and the chest wall, which was filled with materials such as fat, oil, wax packs, bone or methyl methacrylate (Incite) balls.
Appearance on chest radiograph depend on the material used, with associated chest wall deformity, resected ribs or stigma of pulmonary TB-like calcified granulomas, lymph nodes or sheets of pleural calcification.
Pancoast tumour when large would often be associated with destroyed ribs, and the description does not fit with an aspergilloma (visible air crescent) or bronchogenic cysts, which are homogenous and mostly located around the carina.
23
Q
- An adult patient was admitted to hospital with abdominal pain, jaundice and a palpable epigastric mass. Ultrasound demonstrated isolated dilatation of the common bile duct with otherwise normal appearance of the proximal biliary tree. What is the most likely diagnosis based on the sonographic findings?
A. Choledochal cyst
B. Caroli disease
C. Choledochocoele
D. Common bile duct diverticulum
E. Impacted common bile duct calculus
A
- A. Choledochal cyst
The Todani classification system is used to differentiate the cystic processes of the biliary tree into five groups. Type 1 cysts, known as choledochal cysts, are responsible for 90% of cystic biliary disease. These cysts are further subclassified into LA (dilation of the entire extrahepatic bile duct), IB (focal segmental dilation of the extrahepatic duct) and IC (dilation only affecting the common duct). Patients may present with the triad of vague abdominal pain, jaundice and a palpable epigastric mass, although this is only reported in 10%-20% of patients. Type 2 ‘cysts’ are true diverticulae of the bile duct. Type 3, known as a choledochocoele, is a focal protrusion of CBD into the duodenum. Type 4, consists of multiple communicating ultra and extra hepatic duct cysts. Type 5, known as Caroli’s disease, represents cystic dilatation of intra-hepatic ducts.
24
Q
- A 40-year-old patient emigrating from an African country is investigated for stone disease because of left-sided renal angle pain. CT of the kidneys, ureters and bladder (KUB) confirms a left renal calculus but also shows thin curvilinear calcification outlining a normal-sized bladder with involvement of the distal ureters only. Which of the following is the most likely cause?
A. Tuberculosis
B. Escherichia coli infection
C. Transitional cell carcinoma
D. Malakopiakia
E. Schistosomiasis
A
- E. Schistosomiasis
This is a classical description of schistosomiasis infection of the bladder, with curvilinear calcification spreading proximally from the bladder into the distal ureters. The bladder wall can otherwise appear normal but is often thick-walled or nodular. In tuberculosis, the calcification starts in the kidney and can then extend more distally. When involved, the bladder is usually contracted, rather than normal size. Escherichia coli infection is associated with emphysematous cystitis; bacterial infection can be associated with bladder calculi but not mural calcification. Calcification of transitional cell carcinoma can be linear, curvilinear or stippled; however, a mass or wall thickening would be expected and 97% of cases occur in over 45-year-olds. Malakoplakia is a rare condition and calcification in affected patients is uncommon.
25
Q
- An asymptomatic military recruit showed a well-defined 2 x 2 cm solitary pulmonary nodule in the right lower zone on a plain chest radiograph. On dose inspection, the nodule showed faint calcification. CT performed for further characterisation showed areas of fat density on pixelometry. What is the diagnosis?
A. Tuberculoma
B. Aspergilloma
C. Hamartoma
D. Carcinoid
E. Haemangioma
A
- C. Hamartoma
Hamartoma is a benign neoplasm composed of mesenchymal tissues such as cartilage, fat, connective tissue, smooth muscle and calcification. Hamartoma are common benign tumours. Typical CT findings consist of a well-defined, smooth, round or lobulated nodule or mass with fat density in nearly two-thirds of cases, and popcorn like calcification or central calcification in a quarter.
26
Q
- You are performing an abdominal ultrasound scan on a woman who has been complaining of chronic abdominal pain. There is a large 20 cm multiloculated, ovoid anechoic mass in the right lobe of liver. The internal septations are well visualised and hyperechoic. Further investigation with CT demonstrates enhancement of its thick wall and internal septations. What is the most likely diagnosis?
A. Simple hepatic cyst
B. Choledochal cyst
C. Echinococcal cyst
D. Caroli disease
E. Biliary cystadenoma
A
- E. Biliary cystadenoma
Biliary cystadenomas are benign neoplasms originating in bile ducts, most commonly seen within the right lobe of liver. They rarely affect the extrahepatic biliary system. Women are affected more than men and typically present with chronic, vague abdominal pain. Biliary cystadenomas can reach up to 35 cm in size and are usually demonstrated as large multiloculated anechoic masses on ultrasound. A CT scan typically demonstrates a water density mass that shows enhancement of its walls and septations following administration of contrast, differentiating these from simple cysts. An echinococcal cyst (hydatid cyst) is a parasitic infection causing cystic transformation in the liver
27
Q
- An intravenous urogram is performed on a 70-year-old diabetic for recurrent E. coli urinary tract infections. This demonstrates multiple small, smooth, plaque-like mural defects of
the bladder and distal ureteric walls. Which of the following is the most likely cause?
A. Emphysematous cystitis
B. Malakoplakia
C. Leukoplakia
D. Haemorrhagic cystitis
E. Bladder outflow obstruction
A
- B. Malakoplakia
Malakoplakia is a rare chronic inflammatory disease primarily affecting the bladder, with decreasing incidence with increasing proximity to the kidney. Small smooth papules, nodules or plaque-like mural defects of the affected urinary tract are characteristic. Malakoplakia can be associated with immunosuppression, diabetes mellitus, renal transplants or long-term corticosteroid use. Leukoplakia is characterised by soft-tissue flakes that can be passed in the urine during micturition. Haemorrhagic cystitis and emphysematous cystitis can occur with E. coli infections but are associated with intraluminal blood clots and gas deposits, respectively. Bladder outflow obstruction results in a thick walled bladder with trabeculations.
28
Q
- A 45 year-old woman presents with right hip pain. An AP radiograph of the hip shows a large lucent lesion with stippled calcification and a wide destructive-appearing zone of transition. Which of the following is the most likely diagnosis?
A. Osteomyelitis
B. Osteosarcoma
C. Chondrosarcoma
D. Fibrous dysplasia
E. Chondromyxoid fibroma
A
- C. Chondrosarcoma
The radiographic description is aggressive and the stippled calcification is suggestive of a chondroid matrix. The most likely diagnosis is therefore a chondrosarcoma. These may be primary or develop from an enchondroma or osteochondroma.
Although chondromyxoid fibroma would be a possibility in this age group, it is an exceedingly rare benign chondral lesion that would normally have well-defined, thickened sclerotic margins.
Chondrosarcomas are quite common tumours that may have relatively benign radiographic appearances. They are normally metaphyseal, located centrally within the skeleton and may exhibit endosteal scalloping. The diagnosis should also be considered in patients with increased pain or growth in centrally located enchondromas or osteochondromas. Surgical resection is the treatment of choice and the 5-year survival rate is approximately 75%.
29
Q
- A 37-year-old woman with progressive worsening of headache had a facial series done following an injury to the face when she fell while skating. PA view of the skull and OM view did not show any fractures. Incidental note was made of enlarged optic canals. All of the following are associated with this, except
A. NF1
B. Optic glioma
C. Sarcoidosis
D. Sphenoid mucocoele
E. Ophthalmic artery aneurysm
A
- C. Sarcoidosis
Causes of optic canal enlargement (more than 6.5 mm in diameter)
Common causes:
* Glioma of the optic nerve
* Meningioma of the optic nerve sheath
* Metastasis
* Neurofibromatosis with or without optic neurofibroma or glioma
Uncommon causes:
* Aneurysm of the ophthalmic artery or cavernous portion of internal carotid artery
* Arteriovenous malformation with ophthalmic artery involvement
* Carcinoma of ethmoid or sphenoid sinus
* Granuloma (e.g. tuberculosis, sarcoidosis)
* Increased intracranial pressure
* Mucocoele of sphenoid sinus
* Mucopolysaccharidoses (especially Hurler syndrome)
* Pituitary adenoma or craniopharyngioma extending anteriorly
* Pseudotumour of orbit
* Retinoblastoma with intracranial extension
30
Q
- A 1 -year-old child is admitted with seizures and found to have bilateral subdural haematomas. There is concern regarding non accidental injury and a full skeletal survey is requested. According to the Royal (College of Radiologists guidelines, which radiograph(s) would not be routinely included in a full skeletal survey?
A. PA radiograph of the right hand
B. AP radiograph of the left tibia and fibula
C. AP radiograph of the cervical spine
D. Lateral radiograph of the lumbar spine
E. Right oblique radiograph of the chest
A
- C. AP radiograph of the cervical spine
The standard child protection skeletal survey for suspected non accidental injury includes the following:
Skull
* AP, lateral and Townes view (the latter if clinically indicated).
* Skull X-rays should be taken even if a CT scan has been or will be performed.
Chest
* AP including the clavicles.
* Two oblique views to show ribs (‘left and right oblique’).
Abdomen
* AP including the pelvis and hips.
Spine
* Lateral: may require separate exposures of the cervical, thoracic and thoraco-lumbar regions.
* AP views of the cervical spine are rarely diagnostic at this age and should only be performed at the discretion of the radiologist.
Limbs
* AP of both upper arms
* AP of both forearms
* AP of both femurs
* AP of both lower legs
* PA of hands
* DP of feet
Where an abnormality is suspected, these views should be supplemented by the following:
* Lateral views of any suspected shaft fracture
* AP and lateral coned views when a fracture is suspected
31
Q
- A term neonate is found in respiratory distress with shortness of breath and tachypnoea on Day 1 of life. An urgent chest radiograph demonstrates a right sided pneumothorax.
There is no history of any antenatal complications. What is the most likely underlying cause?
A. Respiratory distress syndrome (pulmonary surfactant deficiency)
B. Group B streptococcus infection
C. Congenital pulmonary airway malformation (CPAM)
D. Meconium aspiration
E. Congenital diaphragmatic hernia (CDH)
A
- D. Meconium aspiration
Meconium aspiration is the most common cause of neonatal respiratory distress in full-term or post-mature infants (hyaline membrane disease is the most common cause in premature infants).
Chest X-ray shows the following:
* Bilateral diffuse grossly patchy opacities (atelectasis + consolidation). Unlike hyaline membrane disease, air bronchogram is not a typical feature.
* Hyperinflation with areas of emphysema (air trapping).
* Spontaneous pneumothorax + pneumomediastinum (25%) requiring no therapy.
* Small pleural effusions (20%).
* Rapid clearing, usually within 48 hours.
32
Q
- A 58-year-old man who worked in the mines for several years presented with progressive shortness of breath on exertion. Extensive interstitial thickening and small nodules bilaterally with large masses of consolidation in the upper lobes were noted on the most recent chest radiograph. Comparison with previous films suggested central migration of the consolidation like upper lobar masses. What is the diagnosis?
A. Pneumoconiosis with progressive massive fibrosis
B. End-stage sarcoidosis
C. End stage Langerhans Cell Histiocytosis (LCH)
D. Cryptogenic fibrosing alveolitis
E. Old TB
A
- A. Pneumoconiosis with progressive massive fibrosis
On chest radiographs, large opacities (progressive massive fibrosis) may be seen in complicated coal worker pneumoconiosis, as in complicated silicosis.
The large opacities result from nodule coalescence and are observed commonly in the middle lung zone or peripheral one-third of the lung on axial chest images and in the upper lung zone on longitudinal images. The large opacities gradually migrate towards the hilum, leaving emphysematous lung tissue between the fibrotic tissue and the pleural surface.
33
Q
- A patient is admitted to hospital with progressively worsening jaundice and raised bilirubin levels. Ultrasound of the abdomen, demonstrates a large hyperechoic focus casting a shadow within the neck of the gallbladder, causing secondary dilation of the common hepatic and intrahepatic bile ducts proximally. The distal common bile duct (CBD) was normal.
What is the most likely diagnosis?
A. Caroli disease
B. Choledochocoele
C. Caroli syndrome
D. Mirizzi syndrome
E. Cholangiocarcinoma
A
- D. Mirizzi syndrome
The sonographic findings of an impacted gallstone within the neck of bladder causing proximal biliary dilatation are diagnostic for Mirizzi syndrome. Mirizzi syndrome is caused by impaction of a large gallstone in the cystic duct, cystic duct remnant or gallbladder neck. The impacted stone causes external compression of the CBD, resulting in proximal dilation of the biliary tree. A choledochocoele is cystic dilatation of the CBD within the lumen of the duodenum. Caroli disease is a congenital disorder characterised by saccular dilatations of intrahepatic ducts. Caroli disease, in association with congenital hepatic fibrosis, polycystic kidney disease and others, is known as Caroli syndrome.
34
Q
- A 30-year-old man is admitted with lower abdominal pain following a road traffic accident in which he was an unrestrained passenger. Blood is seen in his urine and a bladder injury is suspected. Regarding extraperitoneal bladder rupture, which of the following is incorrect?
A. It is more common than intraperitoneal rupture.
B. A flame shaped extravasation of contrast can often be seen.
C. It is usually caused by puncture from a pelvic fracture.
D. Contrast most commonly extravasates into the retropubic space of Rctzius.
E. The bladder dome is the most common site of injury.
A
- E. The bladder dome is the most common site of injury.
Extraperitoneal bladder rupture accounts for 80% of bladder ruptures. A flame-shaped extravasation of contrast is a classic finding and can be seen to extend into the perivesical fat and into the retropubic space of Retzius, anterior abdominal wall, upper thigh or scrotum.
The most common site of injury is close to the anterolateral aspect of the bladder base. It us usually caused by puncture from pelvic fractures.
35
Q
- A 4 year-old child presents with short stature and failure to grow. Plain radiographs reveal multiple abnormalities, including generalised increased density of long bones with thickened cortices, widened cranial sutures, Wormian bones, a hypoplastic mandible and shortened pointed distal phalanges. Which of the following is the most likely diagnosis?
A. Pyknodysostosis
B. Osteopetrosis
C. Cleidocranial dysostosis
D. Osteosclerosis
E. Kinky hair syndrome
A
- A. Pyknodysostosis
Pyknodysostosis is a congenital abnormality that should be considered in the differential diagnosis of osteosclerosis. The patients are typically short, have hypoplastic mandibles, widened cranial sutures, Wormian bones, brachycephaly, clavicular dysplasia, thick skull base and hypoplasia or non pneumatisation of the paranasal sinuses. The distinguishing feature is aero-osteolysis with sclerosis. The distal phalanges appear as if they have been put in a pencil sharpener - they are pointed and dense.
36
Q
- A man with nasopharyngeal squamous cell carcinoma undergoes MRI staging. A pathological node is seen lateral to the IJV. It lies below’ the hyoid bone but above the vocal cords. At which level is this likely to be located?
A. I
B. II
c. III
D. IV
E. V
A
- C. Ill
Clinical classification of neck nodes Level I: Above hyoid bone Level Ia: Previously called submental nodes Level Ib: Previously called submandibular nodes Level II: from skull base to level of lower body of hyoid bone Posterior to back of submandibular gland Anterior to back of sternocleidomastoid muscle Level IIA: anterior, lateral, medial or posterior to internal jugular vein Inseparable from internal jugular vein (if posterior to vein)
Previously classified as upper internal jugular nodes Level IIB: Posterior to internal jugular vein with fat plane separating nodes and vein previously classified as upper spinal accessory nodes
Level III: Prom level of lower body of hyoid bone to level of lower cricoid cartilage arch, anterior to back of sternocleidomastoid muscle, previously known as mid-jugular nodes.
Level IV: From level of lower cricoid cartilage arch to level of clavicle
Level V: Posterior to back of sternocleidomastoid muscle from skull base to level of lower cricoid arch Level VI: Between carotid arteries from level of lower body of hyoid bone to level superior to top of manubrium
Level VII: Between carotid arteries below level of top of manubrium
37
Q
- CT of the chest in a 68-year-old man who worked for 20 years in a coal mine, showed an ill defined 3-cm spiculated nodule in the apical segment of the lower lobe of the left lung. The lesion was avid on PET and showed high signal on axial T2W MRI thorax.
All of the following are true regarding lung cancer and progressive massive fibrosis except:
A. T2W is useful in differentiating lung cancer from PMF.
B. PET CT is useful in differentiating lung cancer from PMF.
C. PMF shows low signal compared to muscle on T1W MRI.
D. PMF commonly shows peripheral enhancement on contrast MRI.
E. Histopathologic analysis should still be performed for diagnosis.
A
- B. PET CT is useful in differentiating lung cancer from PMP.
It is clinically and radiologically important to differentiate progressive massive fibrosis from lung cancer. MR! is a preferable option because lung cancer appears as high signal lesion on T2 weighted images, whereas progressive massive fibrosis appears as a low-signal abnormality when compared with the signal of muscle on both Tl weighted and T2-weighted images. On post-contrast MR, progressive massive fibrosis appears peripherally enhanced more frequently than not. Histopathologic analysis should still be performed for diagnosis.
PET may show intensive uptake of FDG in the fibrotic mass in progressive massive fibrosis; hence differentiation from cancer may be difficult.
38
Q
- A patient is admitted to hospital with jaundice and recent weight loss. Abdominal ultrasound demonstrates marked dilation of the intrahepatic ducts, extending to the liver surface. Note is also made of an isocchoic mass at the porta hepatis. Which of the following is the most likely diagnosis?
A. Primary sclerosing cholangitis R. Klatskin tumour
C. Mirizzi syndrome
D. Choledochal cyst
E. Caroli disease
A
- B. Klatskin tumour
Klatskin tumours are cholangiocarcinomas that involve the confluence of hepatic ducts and account for up to 70% of cholangiocarcinomas. Dilation of the intrahepatic ducts is the most frequent abnormal finding on ultrasound. Lobar atrophy may be very subtle on ultrasound but may be identified by secondary findings such as extension of dilated ducts to the liver surface and lobar ductal crowding. The tumour itself may be very’ difficult to identify on ultrasound but may present as an isoechoic or hyperechoic mass. Primary sclerosing cholangitis is a fibrotic process that affects the biliary tree causing multifocal strictures and may lead to biliary cirrhosis. Mirizzi syndrome is dilation of the proximal common bile duct and intrahepatic ducts secondary’ to external compression of a large gallstone impacted in the cystic duct/gallbladder neck.
39
Q
- A 17 year-old girl is admitted following a road traffic accident where she was a restrained passenger. She has low-volume haematuria following catheterisation. Pre- and post-intravenous (IV) contrast CT is performed after administering contrast via her urinary catheter. The pre contrast CT shows contrast within the peritoneal cavity around loops of bowel and there is irregularity of the bladder wall at the dome of the bladder. No contrast blushes are seen on the arterial-phase CT. Which of the following is the most likely injury?
A. Extraperitoneal bladder rupture
B. Intraperitoneal bladder rupture
C. Subserosal bladder rupture
D. Iliac artery injury with haemorrhage
E. Pelvic haematuria from occult fracture
A
- B. Intraperitoneal bladder rupture
Intraperitoneal bladder rupture occurs in around 20% of bladder ruptures. It can be caused by a sudden increase in intravesical pressure owing to blunt trauma and usually causes rupture to the bladder dome. Contrast can be seen in the peritoneal cavity, often outlining loops of bowel and
extending up the paracolic gutters. Extraperitoneal bladder rupture is more common and is usually caused by puncture from pelvic fractures. Contrast can be seen in the retroperitoneal space, anterior abdominal wall, upper thighs or even the scrotum. It is important to distinguish between intraperitoneal and extraperitoneal rupture: intraperitoneal rupture requires surgical repair, whereas extraperitoneal rupture is managed conservatively. Contrast outside the bladder would not be seen on the pre IV contrast CT in cases of arterial damage or pelvic haematoma.
40
Q
- A 65-year-old man presents with severe upper thoracic back pain, of insidious onset, with little relief from analgesia. Lateral radiographs of his thoracic spine reveals uniformly increased density within the T7 and T9 vertebral bodies, with retention of the vertebral body size and contour. Which of the following is the most likely cause for this finding?
A. Bone metastasis
B. Osteoid osteoma
C. Tuberous sclerosis
D. Osteopetrosis
E. Fluorosis
A
- A. Bone metastasis
The ‘ivory vertebra’ sign, as described in this case, refers to a diffuse and homogeneous increase in the density of a vertebral body, which retains its size and contours. It can occur in both adults and children but is more common in the former. In adults, ivory vertebra has been associated most commonly with fractures (compression or healing), haemangiomas, lymphoma, myelosclerosis, with metastatic disease (especially prostate, breast and carcinoid), chronic sclerosing osteomyelitis, Paget disease and renal osteodystrophy. An ivory vertebra at one or more vertebral levels in an elderly man is most compatible with a diagnosis of metastatic disease, commonly as the result of prostate carcinoma. The other options are all much less common causes of ivory vertebrae.
41
Q
- A 40-year-old man was punched in the face during an altercation. Clinical examination showed left facial swelling with left-sided ophthalmoplegia and diplopia. X-rays showed a left maxillary fracture. What is the likely cause of the patient’s symptoms?
A. Superior orbital fissure syndrome
B. Cavernous sinus thrombosis
C. Carotico-cavernous fistula
D. Post-traumatic ophthalmoplegia
E. Cerebral venous sinus thrombosis
A
- A. Superior orbital fissure syndrome
Because the upper transverse maxillary buttress forms the orbital floor, fractures of this buttress may cause various orbital complications, including inferior rectus muscle tears, globe rupture or impingement, optic nerve injury and orbital hematoma.
Superior orbital fissure syndrome is caused by extension of the fracture through the superior orbital fissure, with resultant injury to cranial nerves III, IV, VI (the ophthalmic branch of the trigeminal nerve) and VI as they traverse the fissure into the orbit, thus causing ophthalmoplegia or diplopia (extra-ocular muscle paralysis) and ptosis (paralysis of the levator palpebrae superioris, which is supplied by cranial nerve III). Additional injury to the optic nerve (cranial nerve II) at the orbital apex results in orbital apex syndrome, with unilocular visual loss added to the list of signs and symptoms. Orbital apex syndrome is a surgical emergency because prompt intervention is necessary to prevent permanent blindness.
42
Q
- While reporting a plain radiograph of a 10 year-old girl patient’s left hand, you notice that her bone age is delayed. There is no indication of the patient’s underlying condition on the request form. The bones of the hand are otherwise unremarkable.
Which of the following conditions may offer a possible explanation?
A. Hypothyroidism
B. Achondroplasia
C. Haemophilia
D. Cushing syndrome
E. Precocious puberty
A
- A. Hypothyroidism
Causes of delayed bone age include the following:
* Constitutional: Familial and IUGR
* Metabolic: Hypothyroidism, hypopituitarism, hypogonadism (Turner syndrome), Cushing discase/steroid therapy, diabetes mellitus, rickets and malnutrition
* Systemic disease: Congenital heart disease, renal disease, coeliac disease, Crohn’s disease, ulcerative colitis and anaemia
* Syndromes: Trisomies, Noonan disease, Cornelia de Lange, cleidocranial dysplasia, Lesch-Nyhan disease metatrophic dwarfism
Of these, in the absence of any other history or radiological abnormality, hypothyroidism is more likely until proven otherwise. Precocious puberty results in advanced bone age.
43
Q
- A 42 year old man with cough and haemoptysis, swelling of ankles and hand, raised urea, and creatinine on recent blood biochemical profile, presented to the A&E department with bloody nasal discharge. A Chest radiograph was performed. What do you expect the chest radiograph to show given the clinical scenario?
A. Miliary nodules
B. Pew varying sized nodules, some with cavitation
C. Perihilar infiltrates in a batwing pattern
D. Bilateral upper lobe fibrosis
E. Tramline and gloved finger opacities
A
- B. Few varying sized nodules, some with cavitation
Wegener’s granulomatosis, currently called granulomatosis with polyangitis, is a probable autoimmune disease characterised by systemic necrotising granulomatous destructive angitis, with a classic triad of respiratory tract inflammation, systemic small vessel vasculitis and necrotising glomerulonephritis.
Sinus disease classically includes destructive sinusitis, nasal septal ulceration, septal perforation and saddle nose deformity.
Chest radiograph shows interstitial fibrosis at the bases, which is usually asymptomatic. Multiple pulmonary nodules with cavitation are the most common and characteristic manifestation. Pleural effusions and mediastinal nodal enlargement are seen.
There are multiple causes of miliary nodules, described as innumerable small 1-4 mm lung nodules, described in miliary tuberculosis, fungal infection, metastasis (thyroid, renal, breast, melanoma, pancreas, trophoblastic tumour), sarcoidosis, pneumoconiosis, pulmonary haemosiderosis, varicella infection, hypersensitive pneumonitis, histiocytosis etc. Bilateral upper lobe fibrosis are classically described in TB, ankylosing spondylitis, sarcoidosis, silicosis, radiation and histiocytosis.
44
Q
- An 87 year old female patient from a nursing home presents with a history of severe abdominal pain and diarrhoea. She has a past medical history of transient ischaemic attacks and two non-ST elevation myocardial infarctions. Blood results show an elevated lactate level and raised white cell count. CT report states that the most likely cause is ischaemic colitis. What is the most likely CT finding?
A. Thick-walled caecum with distended appendix
B. Dilated loop of bowel in the left iliac fossa with spiralling vessels
C. Thick-walled oedematous loops of bowel with branching lucencies peripherally in liver
D. Thick-walled oedematous colon with ascites
E. Dilated small bowel loops with branching linear lucency at the porta hepatis
A
- C. Thick-walled oedematous loops of bowel with branching lucencies peripherally in the liver The patient in this scenario has a history of atherosclerosis with end organ damage. This would make
them at risk of developing ischaemic colitis. The area of bowel affected in this question is a watershed area and is most susceptible to ischaemic colitis. The other plain film findings described in this question include intramural gas and portal venous gas. These are very worrying signs and usually imply a poor outcome. Sigmoid volvulus would cause a coffee bean sign on plain film. The findings are also not suggestive of caecal volvulus or small bowel obstruction. Necrotising enterocolitis would cause intramural and portal venous gas; however, this is a condition of neonates. Dilated small bowel with gas at the porta hepatis, is classic description of gall stone ileus, with gas being in the biliary tree.
45
Q
- A 60-year-old male smoker attends for a CT scan following an ultrasound scan that showed unilateral hydronephrosis. The scan shows a lobulated irregular bladder wall mass that enhances in the portal venous phase, to a greater extent than the bladder wall. Which of the following is the likely diagnosis?
A. Squamous cell carcinoma
B. Adenocarcinoma
C. Transitional cell carcinoma
D. Leiomyoma
E. Blood clot
A
- C. Transitional cell carcinoma
Transitional cell carcinoma of the bladder is the most common urinary tract malignancy in the UK and appears as a lobulated, irregular bladder wall thickening that enhances more greatly than the normal bladder wall. If hydronephrosis is present, this suggests muscle invasive disease. Squamous cell carcinoma can look like this but accounts for only 4% of all bladder malignancies and is therefore less likely unless there are specific risk factors such as schistosomiasis infection, chronic cystitis, bladder calculi or long term catheterisation. Adenocarcinoma Is rare and associated with urachal remnants or bladder extrophy. Leiomyomas appears as smooth bladder wall masses. Blood clots do not enhance and are often seen to change in size and position on sequential scans.
46
Q
- A 40-year-old man had a cardiac CT and MR! to evaluate suspected cardiomyopathy. This revealed a well-defined incidental lesion within the T10 vertebral body, with coarse vertical trabeculae on CT, and high signal on both T1 and T2 sequences on MRI. The lesion enhanced with contrast on both modalities. What is the most likely diagnosis?
A. Plasmacytoma
B. Osteosarcoma
C. Osteopathia striata
D. Enostosis
E. Haemangioma
A
- E. Haemangioma
Vertebral hemangiomas are present in 5%-11% of all autopsies and are multiple in one-third of these cases. Lesions commonly occur in the vertebral bodies of the lower thoracic and lumbar spine, and radiographic appearances are those of coarse vertical trabeculations, giving a ‘corduroy’ or ‘honeycomb’ appearance. A CT scan may also demonstrate small punctuate areas of sclerosis, giving a ‘polka-dot’ appearance. On MRI, the lesions are of a mottled pattern with a characteristic low to high signal on T1-weighted sequences and high signal on T2-weighted sequences in proportion to the amount of adipose tissue. The lesions enhance strongly on both CT and MRI because of hypervascularity.
47
Q
- A 30-year-old woman presents with a painless neck mass. MRI confirms that this is a thin-walled cyst lying just anterior to the sternocleidomastoid. There is a tract from the bifurcation of the common carotid artery. What is the diagnosis?
A. Lymphangioma
B. Thyroglossal duct cyst
C. First branchial cleft cyst
D. Carotid body tumour
E. Second branchial cleft cyst
A
- E. Second branchial cleft cyst
The vast majority (95%) of branchial cleft anomalies arise from the second cleft. At least three-fourths of these anomalies are cysts, which typically occur between 10 and 40 years of age, in contrast to fistulas or sinuses, which manifest most commonly during the first decade of life. No gender predilection has been reported.
These cysts usually appear as painless, fluctuant masses in the lateral portion of the neck adjacent to the anteromedial border of the sternocleidomastoid muscle at the mandibular angle. The mass enlarges slowly over time and may become painful and tender if secondarily infected.
At US, a second branchial cleft cyst is seen as a sharply marginated, round to ovoid, centrally anechoic mass with a thin peripheral wall that displaces the surrounding soft tissues. The mass is compressible and shows distinct acoustic enhancement. Occasionally, fine, indistinct internal echoes, representing debris, may be seen. The ‘classic’ location of these cysts (at either CT or MR imaging) is at the anteromedial border of the sternocleidomastoid muscle, lateral to the carotid space and at the posterior margin of the submandibular gland. The cyst typically displaces the sternocleidomastoid muscle posteriorly or posterolaterally, pushes the vessels of the carotid space medially or posteromedial and displaces the submandibular gland anteriorly. It may also be seen more medially within the parapharyngeal space after extending through the stylomandibular tunnel and middle constrictor muscle.
MR imaging better depicts the deep tissue extent of a second branchial cleft cyst, which allows accurate preoperative planning. The cyst fluid varies from hypointense to slightly hyperintense relative to muscle on T1 weighted images and is usually hyperintense on T2-weighted images. Mural thickness and enhancement vary, depending of the presence and severity of any associated inflammatory process. Occasionally, a ‘beak sign’ may be seen on axial CT or MR images. This sign represents a curved rim of tissue or ‘beak’ pointing medially between the internal and external carotid arteries. It is considered a pathognomonic imaging feature of a second branchial cleft cyst.
48
Q
- A neonate presents with an imperforate anus and a presacral mass. MRI of the abdomen demonstrates an enhancing lesion with fatty components and T2* susceptibility artefacts. What other imaging finding would you expect?
A. Syrinx within the spinal canal
B. Anterior beaking of the vertebral bodies
C. Sacrococcygeal bony defect
D. Developmental dysplasia of the hips
E. Multiple renal cysts
A
- C. Sacrococcygeal bony defect
Anterior sacral meningocele may occur as part of the Currarino triad, also known as the ASP triad (anorectal malformation, sacrococcygeal osseous defect and presacral mass), a rare syndrome characterised by autosomal dominant genetic inheritance in more than 50% of cases.
The presacral mass in those affected may be a teratoma, anterior sacral meningocoeles, dermoid cyst, hamartoma or enteric duplication cyst, or more than one of these types of masses may be present.
61
Q
- A 5 month-old infant presents with one episode of urinary tract infection. The patient responds well to treatment and urinalysis reveals E. coli as the causative organism. There is no family history of ureteric reflux or renal disease. According to NICE guidelines, what imaging test(s) should be recommended?
A. Urgent urinary tract ultrasound
B. Routine urinary tract ultrasound within 6 weeks
C. Routine urinary tract ultrasound with DMSA within 4-6 months
D. Routine urinary tract ultrasound, DMSA and micturating cystourethrogram
E. Magnetic resonance cystourethrogram
A
- B. Routine urinary tract ultrasound within 6 weeks
Atypical UTI includes the following:
Seriously ill, poor urine flow, abdominal or bladder mass, raised creatinine, septicaemia, failure to respond to treatment with suitable antibiotics within 48 hours, infection with non-E. coli organisms.
Recurrent UTI includes the following:
Two or more episodes of UTI with acute pyelonephritis/upper urinary tract infection, or one episode of UTI with acute pyelonephritis/upper urinary tract infection plus one or more episode of UTI with cystitis/lower urinary tract infection, or three or more episodes of UTI with cystitis/lower urinary tract infection.
Recommended Imaging Schedule for Infants Younger than 6 Months
86
Q
- A 45-vear-old woman is diagnosed with a biopsy-proven cancer. A lymph node is also demonstrated in the upper outer quadrant of the breast. Which of the following features is most suggestive of malignancy in the node?
A. Hyperechoic centre
B. Round and hypoechoic node
C. Posterior acoustic shadowing
D. A 1.5 cm node in the upper outer quadrant
E. Homogeneous enhancement on MRI
A
- B. Round and hypoechoic node
US criteria for benign versus malignant nodes:
