TEST PAPER I Flashcards
@#1 1.A 30-year-old man has been involved in an Road Traffic Accident (RTA). Aortic injury issuspected. CT angiogram shows a fusiform dilatation at the anteromedial aspect of the aorticisthmus with a steep contour superiorly, gently merging with the proximal descendingthoracic aorta inferiorly. What is the likely diagnosis?
A. Pseudoaneurysm
B. Coarctation of the aorta
C. Ductus diverticulum
D. Aortic nipple
E. Avulsed left subclavian artery
1.C. Ductus diverticulum
Ductus diverticulum is a focal bulge at the anteromedial aspect of the aortic isthmus,visualised in 9% of adults. It is critical to identify this normal variant and distinguish it from a post traumatic false aneurysm, which also occurs most commonly at the aortic isthmus (88%).
The classic ductus diverticulum has smooth, uninterrupted margins and gently sloping symmetric shoulders; in contrast, false aneurysms have a variety of shapes and sizes with sharp margins and often contain linear defects.
Compared with the classic ductus diverticulum, the atypical ductus diverticulum has a shorter and steeper slope superiorly and a more classic gentle slope inferiorly.
However, both shoulders have smooth, uninterrupted margins, an important feature that distinguishes this variant from true injury.
Other normal variants that can mimic injury include aortic spindle, which is a smooth circumferential bulge immediately distal to the aortic isthmus; infundibulum at the origin of aortic branches like the brachiocephalic and intercostal arteries, which are spherical or conical in shape but have a vessel at its apex, thereby differentiating them from false aneurysms.
2.A 40-year-old man on the third cycle of chemotherapy for non-Hodgkin’s lymphomapresents with dysphagia and odynophagia. A recent blood count revealed neutropenia.
He is referred for a barium swallow, which shows several linear ulcers with ‘shaggy’ borders’in the upper oesophagus. What is the most likely diagnosis?
A. Candida oesophagitis
B. CMV oesophagitis
C. Post radiotherapy stricture
D. TB oesophagitis
E. Pharyngeal pouch
2.A. Candida oesophagitis
Candida oesophagitis occurs in patients whose normal flora is altered by broad spectrumantibiotic therapy and in patients whose immune systems are suppressed by malignancy, immunosuppressive agents like chemotherapy and radiotherapy, and immunodeficiency states such as AIDS.
When the disease is superficial, the oesophageal mucosa may appear normal radiographically.
Early in the course of Candida oesophagitis, mucosal plaques are the most frequent finding. Later erosions and ulcerations may develop, which together with intramural haemorrhage and necrosis result in the ‘shaggy’ margin seen on esophagograms.
3.A contras! CT scan shows an incidental renal cyst that is hyperdense with thick septationsand a mural nodule. What is the Bosniak classification?
A. Type 1
B. Type 2
C. Type 2F
D. Type 3
E. Type 4
3.D. Type 3
Type 3 cysts have thickened irregular/smooth walls or septa in which measurableenhancement is present. These need surgery in most cases, as neoplasm cannot be excluded. They include complicated haemorrhagic/infected cysts, multilocular cystic nephroma and cystic neoplasms.
Type 2F (F denotes follow-up) cysts may contain multiple hairline-thin septa. Perceived (not measurable) enhancement of a hairline smooth septum or wall can be identified, and there may be minimal thickening of the wall or septa, which may contain calcification that may be thick and nodular. There are no enhancing soft-tissue components; totally intrarenal non enhancing high-attenuation renal lesions (>3 cm) are also included in this category. These lesions are generally well marginated and are thought to be benign but need follow-up.
Type 1 is a benign simple water attenuation cyst with a hairline-thin wall that does not contain septa, calcifications, or solid components and does not enhance.
Type 2 is a benign cystic lesion that may contain a few hairline septa in which perceived (not measurable) enhancement might be appreciated; fine calcification or a short segment of slightly thickened calcification may be present in the wall or septa. Uniformly high-attenuation lesions (<3 cm) that are sharply marginated and do not enhance are included in this group.
No intervention is needed.
Type 4 are clearly malignant cystic masses that can have all of the criteria of Type 3 but also contain distinct enhancing soft-tissue components independent of the wall or septa; these masses need to be removed.
@#1 4.A 33 year old man with short stature and normal intelligence is being investigated for lowerback pain. MRI of the thoracolumbar spine shows marked central stenosis with shortpedicles. A comment of bullet-shaped vertebra with progressive narrowing of the lumbarinterpedicular distance was noted on the report. Which of the following conditions ismost likely?
A. Hurler’s syndrome
B. Congenital pituitary dwarfism
C. Achondroplasia
D. Thanatophoric dysplasia
E. Hunter’s syndrome
- C. Achondroplasia
Spinal stenosis from congenital short pedicles along with reducing interpedicular distance towards the lumbar spine is a classic finding of achondroplasia. Other associated findings include the champagne glass pelvis’, bullet-shaped vertebra (cf. central vertebral beaking in Morquio syndrome and inferior vertebral beaking in Hurler’s and Hunter’s syndromes), trident hand and craniocervical stenosis from a small foramen magnum.
Platyspondyly, loss of vertebral height, specially affecting lumbar vertebra by 2-3 years of age, is a typical feature of Morquio syndrome (cf. vertebral height is normal in Hurler’s syndrome).
- A 75-year-old woman is admitted under the physicians with confusion and dementia. She has a history of spontaneous intracranial haemorrhage and has been diagnosed with amyloid angiopathy. The most specific MR sequence for diagnosis of multifocal intracranial cortical subcortical microhaemorrhages in cerebral amyloid angiopathy is:
A. T1W spin echo
B. STIR
C. T2W spin echo
D. Gradient echo
E. FLAIR
- D. Gradient echo
Cerebral microbleeds are increasingly recognised neuroimaging findings, occurring with cerebrovascular disease, dementia, hypertensive vasculopathy, cerebral amyloid angiopathy and normal ageing. Recent years have seen substantial progress in developing newer MRI methodologies for microbleed detection.
Hemosiderin deposits in microbleeds are super-paramagnetic and thus have considerable internal magnetisation when brought into the magnetic field of MRI, a property defined as magnetic susceptibility. Among available pulse sequences, T2*-weighted GRE MRI is most sensitive to the susceptibility effect.
@#1 6. Regarding sporting injuries involving the upper limbs, all of the following statements are correct, except:
A. Anomalous anconeus epitrochlearis muscle results in Posterior Interosseous Nerve (PIN) entrapment.
B. Atrophy of extensor muscles can be seen in chronic PIN neuropathy.
C. Partial thickness tears of the biceps can involve either the long or short heads.
D. Cubital tunnel syndrome is the most common elbow neuropathy.
E. Oedema of flexor carpi ulnaris and ulnar nerve thickening suggests cubital tunnel nerve entrapment.
- A. Anomalous anconeus epitrochlearis muscle results in PIN entrapment
Cubital tunnel syndrome is the most common entrapment neuropathy of the elbow. It is seen in throwing sports, tennis and volleyball.
Traction injuries to the ulnar nerve can occur secondary to the dynamic valgus forces.
Compression of the ulnar nerve within the cubital tunnel occur secondary to direct trauma, repetitive stresses, or replacement of the overlying retinaculum with an anomalous anconeus epitrochlearis muscle.
Recurrent subluxation of the nerve due to acquired laxity from repetitive stress or trauma can lead to friction neuritis.
Finally, osseous spurring within the ulnar groove caused by overuse and posteromedial impingement in throwers can cause nerve irritation.
Ulnar nerve thickening and increased T2 weighted signal are typical MRI features. Oedema-like signal changes or atrophy of the flexor carpi ulnaris and flexor digitorum profundus muscles may also be secondary to ulnar neuropathy.
Radial nerve entrapment at the elbow can be subdivided into two major categories: radial tunnel syndrome and posterior interosseous nerve syndrome.
The posterior interosseous nerve is a deep branch of the radial nerve in the forearm that can be compressed from repetitive gripping combined with supination in weight-lifters and swimmers. The superficial head of the supinator muscle along the arcade of Frohse is the most common site of nerve entrapment. It is important to note that a small percentage of radial neuropathy cases can be associated with tennis elbow.
MRI manifestations of PIN includes thickening and increased T2-weighted signal of the nerve fibres, as well as oedema-like signal changes in the innervated extensor compartment musculature in the acute and subacute setting and atrophy in the chronic stages.
- An obese 25-year-old man presents with atypical chest pain. Cardiac MR demonstrates asymmetrical hypertrophy of the interventricular septum, primarily affecting the anteroinferior portion. What is the most likely diagnosis?
A. Hypertrophic obstructive cardiomyopathy
B. Restrictive cardiomyopathy
C. Myocardial infarction
D. Dilated cardiomyopathy
E. Constrictive pericarditis
- A. Hypertrophic obstructive cardiomyopathy
Hypertrophic cardiomyopathy (HCM) is defined as a diffuse or segmental left-ventricular hypertrophy with a non-dilated and hyperdynamic chamber, in the absence of another cardiac or systemic disease explaining the degree of cardiac muscle hypertrophy. Dyspnoea on exertion is the most common symptom because the key functional hallmark of hypertrophic cardiomyopathy is an impaired diastolic function with impaired LV filling in the presence of preserved systolic function. Systolic dysfunction occurs at end-stage disease.
Asymmetric involvement of the interventricular septum is the most common form of the disease, accounting for an estimated 60%-70% of the cases of HCM. Other variants include apical, symmetric, midventricular, mass-like and non contiguous
HCM is typically associated with hypertrophy of the muscle to 15 mm or thicker and a ratio of thickened myocardium to normal left ventricular basal myocardium of 1.3-1.5. With MRI and multidetector computed tomography (CT), apical HCM has a characteristic spadelike configuration of the I.V cavity at end diastole, appreciated on vertical long-axis views
- A 65-year-old diabetic with a history of alcohol excess is referred for a barium swallow following a history of dysphagia. The study shows several small, thin, flask-shaped structures along the cervical oesophagus oriented parallel to the long axis of the oesophagus. What is the most likely diagnosis?
A. Feline oesophagus
B. Pseudodiverticulosis
C. Glycogenic acanthosis
D. Traction diverticulum
E. Idiopathic eosinophilic oesophagitis
- B. Pseudodiverticulosis
Oesophageal intramural pseudodiverticulosis is a condition of unknown cause characterised by flask-shaped outpouchings of the mucosa that extend into the muscular layer and show characteristic findings on oesophagograms. They are dilated excretory ducts of deep oesophageal mucous glands resulting from obstruction of excretory ducts by plugs of viscous mucus and desquamated cells or by extrinsic compression of the ducts by periductal inflammatory infiltrates and fibrotic tissue.
It occurs in all age groups predominantly in the sixth and seventh decades with slight male preponderance. It has been reported as a separate entity or in association with diseases such as diabetes, peptic strictures and oesophagitis.
- A 21-year-old woman with infertility undergoes US that shows a 2-cm right adnexal mass with posterior acoustic enhancement. Another multilocular cyst is seen in the left ovary. Further evaluation with MR shows multiple small lesions in both the ovaries and pouch of Douglas, which were hyperintense on fat-suppressed T1W images with shading sign on T2W images. What is the likely diagnosis?
A. Dermoid
B. Endometrioid carcinoma of the ovary
C. Endometriosis
D. PCOS (polycystic ovarian syndrome)
E. Pelvic inflammatory disease
- C. Endometriosis
Endometriosis is a common multifocal gynaecologic disease that manifests during the reproductive years, often causing chronic pelvic pain and infertility. The ovaries are among the most common sites (20%-40% of cases). It manifests either as superficial fibrotic implants or as chronic retention cysts with cyclic bleeding (endometriomas). Endometriomas are thick-walled cysts with a dark, dense content that represents degenerated blood products. The cysts may be solitary or multiple, and they are bilateral in 50% of cases. Endometriomas may include peripheral nodules (blood clots) or fluid-fluid levels; in the latter, the non-dependent portion represents
the freshest bleeding. A multilocular-appearing endometrioma may consist of multiple contiguous cysts. Endometriomas are a marker of severity of deeply infiltrating endometriosis. On MRIs, cystic cavities can appear as simple fluid, with high signal intensity on T2-weighted and low signal intensity on T1 -weighted images. They also may show high signal intensity on 11-weighted and T1-weighted fat-saturated images because of their haemorrhagic content.
The shading sign, a common and unique feature of endometriomas, represents old blood products, which contain extremely high iron and protein concentrations. These haemorrhagic cysts typically show high signal intensity on T1-weighted images and low signal intensity on T2-weighted images. However, endometriomas also may show’ variable signal intensity on T2-weighted images.
- A young man presents to the ENT clinic with deepening of the voice. Going through his history and clinical notes, the consultant reviews a recent plain radiograph report of his
hands, which describes cystic changes in the carpal bones along with enlarged phalangeal tufts and metacarpals. What is the next appropriate imaging investigation?
A. CT brain pre- and post-contrast
B. MRI brain
C. MRI pituitary pre- and post-contrast
D. Chest X-ray
E. Lateral view of the skull
- C. MRI pituitary pre- and post-contrast
The clinical history along with the radiographic findings points towards acromegaly, and in this case evaluating the pituitary gland for the presence of an adenoma along with correlating biochemistry blood profile would be appropriate investigations.
Osseous enlargement of the vertebrae with increased AP diameter can occur with premature loss of disc space. Expansion of the terminal phalangeal tufts and metacarpals contribute to the clinical finding of ‘spadelike hands’. Other features include increased heel pad thickness >25 mm, premature OA, posterior vertebral scalloping, prognathism (elongated mandible), sellar enlargement and enlarged paranasal sinuses, mostly frontal sinus. In the case of pituitary macro adenomas, compression of the optic chiasm can often result in visual field defects.
- A 77-year-old man with gradual onset dementia shows multifocal abnormalities on cranial CT and MRI. He has been recently diagnosed with amyloidosis. All of the following conditions may be present in central nervous system amyloidosis, except:
A. Occurrence in elderly patients
B. Multifocal subcortical intracranial haemorrhages
C Cerebral and cerebellar atrophy
D. Non-communicating hydrocephalus
E. Typical occurrence in normotensive patients
- D. Non-communicating hydrocephalus
Cerebral amyloid angiopathy (CAA) is an important cause of spontaneous cortical-subcortical intracranial haemorrhage (ICH) in the normotensive elderly.
On imaging, multiple cortical- subcortical haematomas are recognised.
Prominence of the ventricular system and enlargement of the sulci representing generalised cerebral and cerebellar atrophy are non-specific imaging findings.
CAA should be considered in the broad differential diagnosis of leukoencephalopathy (high signal intensity of white matter at T2-weighted MRI), especially if associated with cortical- subcortical haemorrhage or progressive dementia.
Leukoencephalopathy may or may not spare U-fibres.
@#1 12. An 11-year-old boy with left shoulder pain has a shoulder X-ray, which shows a lucent lesion in the metaphysis. This has distinct borders and lies in the intramedullary compartment It is orientated along the long axis of the humerus. What is the most likely diagnosis?
A. Aneurysmal bone cyst
B. GCT
C. Simple bone cyst
D. Chondroblastoma
E. Non-ossifying fibroma
- C. Simple bone cyst
SBC affects the young, aged 3-19 years, during the active phase of bone growth and has a slight male preponderance (M:F = 3:1). They are asymptomatic, unless fractured. They are commonly seen in the proximal femur or proximal humerus. They are solitary intramedullary lesions, centred at the metaphyses, adjacent to the epiphyseal cartilage (during the active phase) and migrating into diaphysis with growth (during the latent phase). They do not cross the epiphyseal plate.
On a radiograph, they appear as an oval radiolucency with a long axis parallel to the long axis of the host bone, a fine sclerotic boundary and scalloping of the internal aspect of the underlying cortex. SBC appears as a photopenic area on a bone scan (if not fractured). Classic ‘fallen fragment’ sign if fractured (20%); centrally dislodged fragment falls into a dependent position.
@#1 13. A 50-year -old secretary presents with epigastric pain, nausea and weight loss. She also complains of bilateral swollen ankles. She is referred for a barium meal as she is unable to tolerate an oesophago-gastroduodenoscopy (OGD). The examination shows thickened folds in the fundus and body of the stomach; the antrum was not involved. What is the mast likely diagnosis?
A. Nephrotic syndrome
B. Lymphoma
C. Eosinophilic gastroenteritis
D. Leiomyoma
E. Menetrier’s disease
- E. Ménétrier’s disease
The hallmark of Ménétrier’s disease is gastric mucosal hypertrophy, which may cause the rugae to resemble convolutions of the brain. The thickening of the rugae is predominantly caused by expansion of the epithelial cell compartment of the gastric mucosa.
Patients with Ménétrier’s disease most often present with epigastric pain and hypoalbuminemia secondary to a loss of albumin into the gastric lumen.
Signs and symptoms of Ménétrier’s disease include anorexia, asthenia, weight loss, nausea, gastrointestinal bleeding, diarrhoea, oedema and vomiting.
The disease has a bimodal age distribution.
The childhood form is often linked to cytomegalovirus infection and usually resolves spontaneously. It usually occurs in children younger than 10 years (mean age 5.5 years), predominantly in boys (male-to-female ratio 3:1). The second peak occurs in adulthood, and the disease in adults tends to progress over time.
The average age at diagnosis is 55, and men are affected more often than women.
A diagnosis of Ménétrier’s disease is made by using a combination of upper gastrointestinal fluoroscopic imaging, endoscopic imaging and histologic analysis. On fluoroscopic images, Ménétrier’s
disease is characterised by the presence of giant rugal folds. Rugal folds should normally measure less than 1 cm in width across the fundus and 0.5 cm across the antrum, and they should be parallel to the long axis of the stomach.
@#1 14. A 58-year-old woman undergoes an echocardiogram followed by cardiac MRI for investigation of exertional dyspnoea. The cardiac MRI was reviewed at the X ray meeting, and the radiologist diagnosed concentric hypertrophic cardiomyopathy. Which of the following did the radiologist see?
A. Thickening of the interatrial septum at 7 mm
B. Thickening of the entire LV wall measuring 17 mm at end diastole
C. Nodular high signal in the interventricular septum on T2
D. Thickening of the LV wall measuring 14 mm with normal systolic function
E. Thickened LV with delayed hyperenhancement of mid wall
- B. Thickening of the entire LV wall measuring 17 mm at end diastole
HCM should be differentiated from other causes of symmetric increased thickness of the LV wall, including athlete’s heart, amyloidosis, sarcoidosis, Fabry disease and adaptive LV hypertrophy due to hypertension or aortic stenosis.
HCM is associated with hypertrophy of the muscle to 15 mm or thicker. In cardiac amyloidosis, the amyloid protein is deposited in the myocardium, which leads to diastolic dysfunction and restrictive cardiomyopathy. Because amyloidosis is a systemic process, involvement of all four chambers is common; thus, an increase in the thickness of the interatrial septum and right atrial free wall by more than 6 mm is seen. Dynamic enhanced MRI shows late enhancement over the entire subendocardial circumference.
Sarcoidosis is a non-caseating granulomatous disease that infiltrates any area of the body, but most of the morbidity/mortality is from involvement of the heart. MRI shows nodular or patchy increased signal intensity on both T2-weighted and enhanced images, which often involves the septum (more particularly, the basal portion) and the LV wall, whereas papillary and right-ventricular infiltration are rarely seen.
Fabry disease is a rare X-linked autosomal recessive metabolic storage disorder. At MRI, the LV wall is seen to be concentrically thickened, and delayed hyperenhancement is typically seen mid-wall and has been reported in the basal inferolateral segment.
Differentiation between compensatory hypertrophy and HCM is sometimes difficult. In comparison to HCM, patients with compensatory hypertrophy usually have normal systolic function, rather than hyperdynamic systolic function in HCM, and their LV wall rarely exceeds 15 mm in maximal thickness.
Athlete’s heart can show increased LV wall thickness but end diastolic volume and ejection fraction are normal. Another feature of the cardiac remodelling in athletes is the lack of areas of’ delayed hyperenhancement within the LV myocardium at dynamic enhanced MRI.
@#1 15. A 50-year-old builder is involved in a high speed RTA. CT is performed according to trauma protocol, demonstrating extra-peritoneal rupture of the bladder. Which of the following best describes this?
A. Contrast pooling in the paracolic gutters.
B. Contrast outlining small bowel loops.
C. Flame-shaped contrast seen in the perivesical fat.
D. CT cystogram is usually normal.
E. Intramural contrast on CT cystogram.
- C. Flame-shaped contrast seen in the perivesical fat
Sandler described five types of bladder injuries with conventional cystography.
Type 1: Contusion: Bladder contusion is defined as an incomplete or partial tear of the bladder mucosa. Findings at conventional and CT cystography are normal.
Type 2: Intraperitoneal rupture: CT cystography demonstrates intraperitoneal contrast material around bowel loops, between mesenteric folds and in the paracolic gutters.
Type 3: Interstitial injury: Interstitial bladder injury is rare. CT cystography may demonstrate intramural contrast material without extravasation.
Type 4: Extraperitoneal rupture: Extraperitoneal rupture is the most common type of bladder injury (80%-90% of cases) Extravasation is confined to the perivesical space in simple ruptures (Type 4a), whereas in complex ruptures, contrast extends beyond the perivesical space (Type 4b) and may dissect into thigh, perineum and properitoneal fat planes.
Type 5: Combined rupture: CT cystography usually demonstrates extravasation patterns that are typical for both types of injury.
@#1 16. An elderly patient on long-term dialysis presents to the orthopaedic clinic with right shoulder pain. Plain films show juxta-articular swelling and erosions of the humerus, but the
joint space is preserved. MRI shows a small joint effusion and the presence of low- to intermediate-signal soft tissue on all sequences covering the synovial membrane extending into the periarticular tissue. What is the likely diagnosis?
A. Amyloid arthropathy
B. Gout
C. Calcium pyrophosphate deposition disease (CPPD)
D. Pigmented villonodular synovitis (PVNS)
E. Reticuloendotheliosis
- A. Amyloid arthropathy
Amyloid arthropathy most typically affects the shoulders, carpal hones and hips in a bilateral fashion. It is typically associated with long-term renal dialysis, which results in deposition of the beta-2 microglobulin.
Affected joints demonstrate subchondral cystic lesions with juxta articular swelling.
The presence of low-to-intermediate signal soft tissue within and around the joint clinches the diagnosis, as this represents the signal characteristics of the deposited proteins (cf. other inflammatory/infectious arthropathies, which tend to produce higher water content than soft-tissue changes in the joint). Joint space is also typically preserved until the late stages of disease, similar to gout.
- A 33-year-old woman with recurrent episodes of optic neuritis with waxing and waning upper limb weakness is referred for an MRI brain with high suspicion of demyelination. All of the following are MR features of acute multiple sclerosis (MS) lesions of the brain, except
A. High signal intensity on FLAIR
B. ‘Black hole’ appearance
C. Incomplete ring-like contrast enhancement
D. Increase in size of lesion
E. Mass effect
- B. ‘Black hole’ appearance
MS lesions can occur anywhere in the central nervous system but are most common in the periventricular white matter.
Typical lesions are ovoid, with the long axis perpendicular to the ventricles.
They are better seen on PD and FLAIR than on T2-weighted images because of increased lesion-CSF contrast.
Lesions of the corpus callosum, at callososeptal interface and subcallosal striations are characteristic.
FLAIR is less sensitive than T2-weighted images to infratentorial lesions occurring in the brain stem and middle cerebellar peduncles.
In the acute phase, lesions show increase in size and solid or ring enhancement with IV contrast, which can persist up to 3 months, but generally resolve in weeks.
Large acute lesions, with associated oedema, mass effect and incomplete ring enhancement can mimic glioma (tumefactive MS).
MS lesions show reduced magnetisation transfer ratio (MTR), reflecting decreased myelin content. MTR is also reduced in normal-looking white matter, representing occult tissue damage. Such occult tissue damage is also detected by diffusion tensor imaging, showing reduced fractional anisotropy.
Low-signal lesions on T1 -weighted MRI (black holes), brain and spinal cord atrophy are seen in established MS.
@#1 18. A 14-year-old boy complains of left knee pain and limp. He also has medial thigh pain.
On examination, he has full range of movement with some discomfort on internal rotation. AP and lateral X-rays of the knee and femur arc normal. What is the next investigation?
A. CT
B. Bone scan
C. MRI
D. Frog leg lateral of the hips
E. US
- D. Frog-leg lateral of the hips
Diagnosis of SUFE (slipped upper femoral epiphysis) is made using anteroposterior (AP) pelvis and lateral frog-leg radiographs. CT is rarely needed, although it is very sensitive. MRI depicts the slippage earliest, and MRI can demonstrate early marrow oedema and slippage. It is also useful in identifying pre-slip changes in the opposite hip and shows differentials, for example, infection, tumour, synovitis and so on.
Although some institutions obtain a frog-leg lateral view, it is possible to further displace an acute or acute-on-chronic slip when the hips are placed in this position. Thus some institutions avoid them unless the request comes from an orthopaedic surgeon.
Phraseology is important in all investigation-related questions; while the next investigation is frog-leg lateral in several/most places, the best investigation or the most appropriate examination would be MRI because it will provide the most information and cover all differentials.
- A 30-year-old woman presents with shortness of breath and fatigue. CT shows enlargement of the right atrium, right ventricle and pulmonary artery and normal appearance of the left atrium. What is the most likely diagnosis?
A. VSD - Ventricular Septal Defect
B. ASD - Atrial Septal Defect
C. Bicuspid aortic valve
D. Coarctation of the aorta
E. Mitral valve disease
- B. ASD - Atrial Septal Defect
@#1 20. A 50-year-old man is referred to a gastroenterologist with a 6 month history of intermittent epigastric pain and nausea. He is referred for a barium meal test due to a failed OGD - oesophago-gastroduodenoscopy. The study shows an ulcer along the lesser curve of the stomach. Which of the following is a malignant feature of a gastric ulcer?
A. The margin of the ulcer crater extends beyond the projected luminal surface.
B. Carman meniscus sign.
C. Hampton’s line.
D. Central ulcer within mound of oedema.
E. The ulcer depth is greater than the width.
- B. Carman meniscus sign
The Carman meniscus sign is a curvilinear lens-shaped intraluminal form of crater with convexity of crescent towards the gastric wall and concavity towards the gastric lumen.
- Which of the following characteristics is typical of prostate cancer?
A. Low on T1 High on T2
B. Low on T1 Low on T2
C. Isointense on T1 High on T2
D. High on T1 High on T2
E. Isointense on T1 Isointense on T2
- B. Low on T1 Low on T2
On T1-weighted MRI, the normal prostate gland demonstrates homogeneous intermediate to low signal intensity.
T1-weighted MRI has insufficient soft-tissue contrast resolution for visualising the intraprostatic anatomy or abnormality.
The zonal anatomy of the prostate gland is best depicted on high resolution T2-weighted images.
Prostate lias a homogenous low-signal background on T1 weighted images. On T2-weighted images, prostate cancer usually demonstrates low signal intensity in contrast to the high signal intensity of the normal peripheral zone.
Low signal intensity in the peripheral zone, however, can also be seen in several benign conditions, such as haemorrhage, prostatitis, hyperplastic nodules, or post- treatment sequelae (e.g., as a result of irradiation or hormonal treatment).
- An eccentric expansile lesion in the metaphysis of the humerus is noted incidentally following a routine plain radiograph investigation in a young patient following a rugby tackle. MRI performed for further characterisation shows multiple cystic spaces, some with blood fluid level, with an intact low signal periosteal rim. What is the diagnosis?
A. Unicameral bone cyst
B. Aneurysmal bone cyst
C. Eosinophilic granuloma
D. Enchondroma
E. Fibrous dysplasia
- B. Aneurysmal bone cyst
Aneurysmal bone cysts or ABCs are most commonly seen between the first and third decades of life.
They are typically a metaphyseal lesion and are often located in the humerus, femur, or tibia.
The presence of fluid-fluid levels along with bone expansion, a narrow zone of transition and metaphyseal location in a long bone is characteristic.
Note that fluid-fluid levels can also be found in giant cell tumours, telangiectatic osteosarcomas and simple bone cysts, but the other associated locations and characteristics of the lesion would tend to be different from an ABC.
Eosinophilic granulomas are associated with Langerhans cell histiocytosis.
Enchondromas are typically located in the small long bones of the hands and in the proximal humerus and femur with non-expansile characteristics.
Fluid-fluid levels are not typically associated with fibrous dysplasia, which takes on the commonly described ‘ground glass’ appearance.
- A 34-year-old woman with previous history of upper limb weakness that resolved spontaneously and optic neuritis was referred for an MRI brain. MRI confirms the presence of bilateral periventricular hyperintensities on FLAIR with abnormal signal in the corpus callosum and middle cerebellar peduncles. MRI also shows signal abnormality in the right optic nerve. Which portion of the optic nerve does Multiple sclerosis (MS) most commonly affect?
A. Intra-orbital.
B. Intracanalicular.
C. Intracranial.
D. Chiasmatic.
E. All portions arc equally susceptible.
- A. Intra-orbital
Typically, findings of optic neuritis in MS are seen in the retrobulbar intra-orbital segment of the optic nerve, which appears swollen, with high T2 signal. High T2 signal persists and may be permanent; chronically the nerve will appear atrophied rather than swollen. Contrast enhancement of the nerve is best seen with fat-suppressed T1-weighted coronal images, in >90% of patients if scanned within 20 days of visual loss.
@#1 24. A newborn baby has US of the spine. At which level is the conus expected to be?
A. Above L1
B. Above T12
C. L2 to L3
D. L3 to L4
E. S2
- C. L2 to L3
The conus normally lies at or above the L2 disc space. A normal conus located at the mid-L3 level may be identified, especially in preterm infants; this position is considered the lower limits of normal but is usually without clinical consequence. However, in a preterm infant with a conus that terminates at the L3 mid-vertebral body, a follow-up sonogram can be obtained once the infant attains a corrected age between 40 weeks’ gestation and 6 months of age. In contrast, the thecal sac terminates at S2.
In the preterm group, more than 90% of conus medullaris cases lie above L2; in the term group, more than 92% lie above L2.
- A middle aged woman presents with cough and haemoptysis. Her chest X ray reveals a large ovoid mass in the right lower lobe. She has a known history of Osler-Weber-Rendu syndrome. What is the most appropriate next imaging investigation that you will organise?
A. MRA of the pulmonary artery
B. CTPA
C. CTPA with portal phase images covering the liver
D. Chest HRCT
E. Conventional pulmonary angiography
- C. CTPA with portal phase images covering the liver
Hereditary haemorrhagic telangiectasia, also called Osler-Weber-Rendu syndrome, is an uncommon genetic disorder characterised by arteriovenous malformations in the skin, mucous membranes and visceral organs. The brain, gastrointestinal tract, skin, lung and nose are the primary sites affected. It is associated with the classic triad of epistaxis, telangiectasias and a family history.
Pulmonary AVMs are often discovered initially as a solitary pulmonary nodule or mass on plain chest films. If a pulmonary AVM is suspected, further imaging evaluation should be CT or conventional pulmonary angiography. Although conventional angiography is the gold standard, considering its invasive nature CT is considered a better method of diagnosis. This is more important when screening for AVM.
Portal venous-phase liver images are often obtained at the same time, in case the lesion does turn out to be a solid nodule.
- A nursing home resident is found to have a lung tumour and undergoes CT staging of the chest and abdomen. This reveals a discrete lesion medial to the second part of the duodenum with a fluid-fluid level. What is the most likely diagnosis?
A. Duplication cyst
B. Duodenal diverticulum
C. Duodenal web
D. Annular pancreas
E. Adenocarcinoma of the duodenum
- B. Duodenal diverticulum
Duodenal diverticulosis is a common entity first described by Chomel in 1710. Its prevalence varies depending on the mode of diagnosis. Diverticula are found in 6% of upper gastrointestinal series, 9%-23% of ERCP procedures and 22% of autopsies. Its occurrence has no sex predilection, and the age range for detection varies from 26 to 69 years. Duodenal diverticula may be congenital or acquired, with the latter being more common. Congenital or true diverticula are rare, contain all layers of the duodenal wall, and may be subdivided into intraluminal and extraluminal forms.
The CT appearance of a duodenal diverticulum includes a saccular outpouching, which may resemble a mass-like structure interposed between the duodenum and the pancreas that contains air, an air-fluid level, fluid, contrast material, or debris. A periampullary diverticulum may simulate a pseudocyst or tumour.
- Which of the following is false?
A. Skene cyst Lateral to external urethral meatus
B. Nabothian cyst Lateral to the endocervical canal
C. Gartner’s dust cyst Posterolateral aspect of the upper vagina
D. Bartholin’s cyst Posterolateral aspect of the vagina
E. Urethral diverticulum Posterolateral aspect of mid-urethra
- C. Gartner’s duct cyst Posterolateral aspect of the upper vagina
Multiple paraurethral Skene’s glands are related to the female urethra. There are paraurethral ducts that drain into the distal urethral lumen.
Nabothian cysts are retention cysts in the cervix related to chronic cervicitis.
Gartner’s duct cysts are found at the anterolateral aspect of the proximal third of the vaginal wall.
Bartholin’s gland cysts affect the posterolateral aspect of the lower vaginal wall.
Urethral diverticulum occurs at the posterolateral aspect of the mid-urethra.
- A 31-year-old man who is known to the gastroenterologist and rheumatologist presents to the ophthalmology department with visual disturbances. A pelvic radiograph done a year ago in the emergency department showed whiskering of the ischial tuberosities and greater trochanters, with symmetrical sclerosis of both sacroiliac joints. What is the most likely diagnosis?
A. Reiter syndrome
B. Behcet’s syndrome
C. Ankylosing spondylitis (AS)
I). Rheumatoid arthritis
E. Systemic lupus erythematosus (SLE)
- C. Ankylosing spondylitis (AS)
AS is characterised by the hallmark of bilateral and symmetrical sacroiliac joint involvement, though there may be unilateral involvement in the early stages of disease. Other common findings include periostitis with whiskering of the pelvic bones and the typical ‘bamboo’ spine appearance from syndesmophyte formation. Up to 10% of AS cases are associated with inflammatory bowel disease, and iritis is common in up to 40% of patients. Ninety-six percent of patients are HLA-B 27 positive, the antigen associated with the other seronegative spondyloarthropathies of psoriasis, Reiter’s syndrome and inflammatory bowel disease-associated spondyloarthritis.
Behcet’s syndrome affects the chest and gastrointestinal tracts and doesn’t involve the skeleton primarily.
@#1 29. A 36-year-old woman with resolving limb weakness and previous history of optic neuritis is diagnosed as having relapsing remitting multiple sclerosis (RRMS). Which of the following statements concerning MS imaging is incorrect?
A. Black holes correlate well with clinical outcome.
B. Brain atrophy is higher in MS than normal ageing.
C. The pattern of brain atrophy can mimic Alzheimer’s disease.
D. Diffusion tensor imaging demonstrates structural damage to the white matter.
E. MS lesions have low MTR (Magnetisation Transfer Ratio) representing myelin loss.
- C. The pattern of brain atrophy can mimic Alzheimer’s disease
The T1 lesion load including enhancing lesions or black holes is correlated more closely than T2 lesion load with clinical outcome.
Another imaging hallmark of MS is brain atrophy. Brain atrophy in MS usually appears as enlarged ventricles and reduced size of the corpus callosum. The rate of brain atrophy is higher in MS than in the normal ageing process.
Significant loss of white matter rather than grey matter is seen in the early stage of MS, suggesting a different mechanism of atrophy compared to neurodegenerative diseases such as Alzheimer’s disease.
MS lesions show reduced Magnetisation transfer ratio (MTR), reflecting decreased myelin content.
MTR is also reduced in normal-looking white matter, representing occult tissue damage.
MS lesions usually have a more reduced MTR as compared with ischaemic lesions in small vessel diseases. Such occult tissue damage is also detected by diffusion tensor imaging, showing reduced fractional anisotropy (representing microstructural damage).
- A 3 year-old presents as acutely unwell with a maculopapular rash, lymphadenopathy and erythema of her palms. Her white cell count is normal, and a specific cause for her symptoms is not found. She improves on immunoglobulins and supportive treatment. A follow-up echocardiogram shows cardiomegaly and a coronary artery aneurysm. What is the
likely diagnosis?
A. Takayasu arteritis
B. Kawasaki arteritis
C. Moyamoya syndrome
D. Henoch-Schönlein purpura
E. Churg-Strauss syndrome
- B. Kawasaki arteritis
Kawasaki disease is a systemic vasculitis that is more severe in small and medium arteries, and veins to a lesser extent, with inflammatory’ lesions in virtually all organs. It is a leading cause of acquired heart disease in childhood. The aetiology of KD remains unknown, although the clinical presentation - self-limiting illness manifested by an abrupt onset of fever, rash, exanthema, conjunctival injection and cervical adenopathy - and the epidemiological features - a seasonal peak in winter and spring, age distribution and a geographic wave-like spread of illness during epidemics - strongly suggest an infectious cause.
Fever is usually the first sign of KD. Rash is non-specific and mostly maculopapular. Cervical lymphadenopathy is the last common of the main manifestations. Cardiovascular complications include coronary artery aneurysms, myocarditis, pericarditis with pericardial effusion, systemic arterial aneurysms, valvular disease, mild aortic root dilatation and myocardial infarct.
Takayasu arteritis (TA), also known as pulseless disease, is a granulomatous large vessel vasculitis that predominantly affects the aorta and its major branches, with increased prevalence in Asian women <50 years of age.
Churg Strauss syndrome is a small-to-medium vessel necrotising pulmonary vasculitis, affecting patients in the third and fourth decades with asthma, eosinophilia and systemic symptoms like purpura and arthralgia.
Moyamoya disease is an idiopathic, non-inflammatory, non-atherosclerotic, progressive vasculo- occlusive disease involving the circle of Willis, typically the supraclinoid internal carotid arteries.
It has a bimodal age distribution, affecting children and adults. In children, ischaemic strokes are most pronounced, whereas in adults haemorrhage from the abnormal vessels is more common.
@#1 31. A 76-year-old male patient with chronic inflammatory disease and known history of secondary generalised multisystem amyloidosis showed an abnormal appearance of the heart on echocardiography. Dynamic enhanced cardiac MR imaging was advised for further characterisation. All of the following are imaging findings seen with cardiac amyloidosis, except
A. Left ventricular wall hypertrophy
B. Subendocardial delayed myocardial hyperenhancement
C. Systolic dysfunction
D. Granular echogenic myocardium
E. Interatrial septal thickening
- C. Systolic dysfunction
In cardiac amyloidosis, the amyloid protein is deposited in the myocardium, which leads to diastolic dysfunction that progresses to restrictive cardiomyopathy.
Because amyloidosis is a systemic process, involvement of all four chambers is common; thus, an increase in the thickness of the interatrial septum and right atrial free wall by more than 6 mm has been shown to be a specific finding for cardiac amyloidosis.
Through the use of dynamic enhanced cardiac MRI, a distinct pattern of late enhancement, which was distributed over the entire subendocardial circumference, has been shown to have high specificity and sensitivity for cardiac amyloidosis
Echocardiogram shows concentric LV hypertrophy, with hyperechoic granular sparkling of the ventricular wall.
- A taxi driver has had recurrent episodes of abdominal pain. On CT, a lesion is seen within the head of the pancreas. Pancreatic duct dilatation is noted with a normal CBD and atrophy of the body and tail of the pancreas. ERCP demonstrates thick mucous material discharging from the bulging papilla. What is the most likely diagnosis?
A. Mucinous cystadenocarcinoma
B. Serous cystadenocarcinoma
C. Main duct IPMN (Intraductal Papillary Mucinous Neoplasm)
D. Pancreatic pseudocyst
E. Pancreatic adenocarcinoma
- C. Main duct IPMN (Intraductal Papillary Mucinous Neoplasm)
IPMNs are a group of neoplasms in the biliary duct or pancreatic duct that causes cystic dilatation from excessive mucin production and accumulation. The true incidence of IPMNs is unknown because many are small and asymptomatic. However, in a series of 2,832 consecutive CT
scans of adults with no history of pancreatic lesions, 73 cases of pancreatic cysts (2.6%) were identified. Many of these cases likely were IPMNs, given that IPMNs account for 20%-50% of cystic pancreatic neoplasms. There are three main types of pancreatic IPMNs: main duct, branch duct and combined. A main duct IPMN commonly causes dilatation of the papilla, with bulging of the papilla into the duodenal lumen. Filling defects caused by mural nodules or mucin may be seen at MRCP or ERCP. At CT and MRI, filling defects caused by mural nodules enhance, while filling defects caused by mucin do not enhance.
@#1 33. A 55-year old man with several episodes of epididymo-orchitis in the past has an ultrasound of the scrotum. The radiologist performing the scan notices several hypoechoic structures within the mediastinum testis and incidental epididymal cysts. There was no Doppler flow. What is the most likely diagnosis?
A. Lymphoma of the testes
B. Cystic dysplasia of the testis
C. Seminoma
D. Abscess
E. Cystic transformation of rete testis
- E. Cystic transformation of rete testis
Cystic transformation of rete testis is a benign condition, also known as tubular ectasia, resulting from partial or complete obliteration of the efferent ductules that causes ectasia and, eventually, cystic transformation. The location of the lesion in or adjacent to the mediastinum testis and the presence of epididymal cysts are characteristic.
Cystic dysplasia of the rete testis is a rare benign testicular tumour that is found mainly in the paediatric population.
Abscesses are usually secondary to epididymo-orchitis; however, they appear cystic with shaggy, irregular walls; intratesticular location; low-level internal echoes; and occasionally hypervascular margins.
Teratomas are the most frequent to manifest as cystic masses; however, cystic tumours are rare and, when present, usually have an abnormal rind of parenchyma with increased echogenicity surrounding the cystic lesion.
@#1 34. An elderly woman presents with progressive atraumatic pain within her right knee over the course of the last month, particularly on the medial aspect, associated with functional impairment. Her clinical history includes a meniscal tear, which was treated arthroscopically 10 years ago with a good outcome. An MRI reveals florid marrow oedema within the medial femoral condyle associated with mild flattening of the weight-bearing surface.
What is the diagnosis?
A. Perthe’s disease
B. Sinding Larsen’s disease
C. Blount’s disease
D. Spontaneous osteonecrosis of the knee
E. Osteochondral defect
- D. Spontaneous osteonecrosis of the knee
Spontaneous osteonecrosis of the knee (SONK) is a rapid and painful condition in elderly patients that ultimately results in subchondral collapse of the weight-bearing portion of the medial femoral condyle. It is often idiopathic but can be associated with minor trauma. It is now also increasingly recognised as a subchondral insufficiency fracture resulting in rapid secondary’ subchondral collapse.
Perthes disease is a childhood disease with avascular necrosis of the femoral head.
Sinding-Larsen disease is essentially tendinosis of the proximal origin of the patella tendon.
Blount’s disease is a growth disorder of the tibia resulting in a ‘bow leg’ deformity from disturbance to the medial proximal tibial epiphysis.
An osteochondral defect is a traumatic injury involving the articular cartilage and adjacent subchondral bone.
- A known MS patient has presented to the neurologist with clinical features of involvement of the spinal cord. An MRI of the whole spine has been requested with a view towards assessment of the cord for possible multiple sclerosis (MS) plaques. MS lesions in the spinal cord occur most commonly in the
A. Cervical segment.
B. Thoracic segment.
C. Lumbar segment.
D. Sacral segment.
E. All segments are equally affected.
- A. Cervical segment
MS can show multiple lesions in the spinal cord. Typical spinal cord lesions in MS are relatively small and peripherally located.
They are most often found in the cervical cord and are usually less than two vertebral segments in length.
- A neonate presents with non-bilious vomiting with a palpable upper abdominal lump. Which of the following US findings would not be in keeping with pyloric stenosis?
A. Pyloric muscle thickness 3.5 mm
B. Target sign
C. Pyloric canal length 14 mm
D. Antral nipple sign
E. Cervix sign
- C. Pyloric canal length of 14 mm
Ultrasound is the modality of choice because of its advantages of directly visualising the pyloric muscle and no ionising radiation. The hypertrophied muscle is hypoechoic, and the central mucosa is hyperechoic. Normal measurements of the pylorus are as follows:
Pyloric muscle thickness (i.e., the diameter of a single muscular wall on a transverse image): <3 mm (most accurate)
Length (i.e., longitudinal measurement): <15-17 mm
Pyloric volume: <1.5 cc
Pyloric transverse diameter: <13 mm
Abnormal features on US includes target sign (hypoechoic ring of hypertrophied pyloric muscle around echogenic mucosa centrally on cross section), cervix sign (indentation of muscle mass on fluid-filled antrum on longitudinal section) and antral nipple sign (redundant pyloric channel mucosa protruding into gastric antrum). Other features include increased antral peristalsis and delayed gastric emptying.
Infantile pyloric spasm also shows increased peristalsis and delayed gastric emptying with pyloric muscle thickness between 1.5 and 3 mm.
@#1 37. A child with exertional dyspnoea and abnormal chest X-ray showing a boot-shaped heart and oligaemic lungs is diagnosed as suffering from tetralogy of Fallot. The pulmonary oligaemia is secondary to right ventricular outflow tract (RVOT) obstruction. Which of the following is the most common implicated cause for obstruction of RVOT?
A. Hypoplastic pulmonary annulus
B. Pulmonary valvular stenosis
C. Infundibular stenosis
D. Combined infundibular and pulmonary valvular stenosis
E. Overriding ventricular septum
- C. Infundibular stenosis
Tetralogy of Fallot (TOF) is the most common form of cyanotic congenital heart disease. This disease accounts for approximately 10% of all congenital heart defects, affecting men and women equally. In addition, TOF is the most common cyanotic heart disease that survives to adulthood.
The four components of TOF, first described in 1888 by French physician Etienne-Louis Arthur Fallot, are interventricular communication (ventricular septal defect), right-ventricular outflow tract (RVOT) obstruction, concentric right-ventricular hypertrophy (RVH) and deviation of the origin of the aorta to the right.
Combined infundibular and pulmonary valvular stenosis is the second most common cause.
@#1 38. A 50-year-old man presents with recurrent episodes of abdominal pain. Blood amylase is normal. Chronic pancreatitis is suspected. All of the following statements regarding MRI imaging in chronic pancreatitis are true, except
A. MRI has a poor sensitivity for detecting parenchymal calcification in chronic pancreatitis.
B. MRI allows evaluation of the ductal system for strictures and stones, debris within pseudocysts and fistula.
C. MRI shows good sensitivity for the differential diagnosis of focal chronic pancreatitis from pancreatic carcinoma.
D. Both focal chronic pancreatitis and pancreatic carcinoma demonstrate abnormal post-contrast enhancement on MRI.
E. Both focal chronic pancreatitis and pancreatic carcinoma demonstrate low signal intensity of the pancreas on T1W fat-saturated images.
- C. MRI shows good sensitivity for the differential diagnosis of focal chronic pancreatitis from pancreatic carcinoma.
The diagnosis of chronic pancreatitis on MRI is based on signal intensity and enhancement changes as well as on morphologic abnormalities in the pancreatic parenchyma, pancreatic duct and biliary tract.
The imaging features of chronic pancreatitis can be divided into early and late findings.
Early findings include low-signal-intensity pancreas on T1 -weighted fat-suppressed images, decreased and delayed enhancement after IV contrast administration, and dilated side branches.
Late findings include parenchymal atrophy or enlargement, pseudocysts, and dilatation and beading of the pancreatic duct often with intraductal calcifications.
Differentiating between an inflammatory mass due to chronic pancreatitis and pancreatic carcinoma on the basis of imaging criteria remains difficult.
Decreased Tl signal intensity with delayed enhancement after gadolinium administration as well as dilatation and obstruction of the pancreaticobiliary ducts can be seen in both diseases.
Irregularity of the pancreatic duct, intraductal or parenchymal calcifications, diffuse pancreatic involvement, and normal or smoothly stenotic pancreatic duct penetrating through the mass (‘duct penetrating sign’) favour the diagnosis of chronic pancreatitis over cancer.
In distinction, a smoothly dilated pancreatic duct with an abrupt interruption, dilatation of both biliary’ and pancreatic ducts (‘double-duct sign’) and obliteration of the perivascular fat planes favour the diagnosis of cancer.
- A 60-year-old heavy smoker presents with haematuria. US KUB shows a midline fluid-filled cavity with mixed echogenicity and calcification adjacent to the bladder wall. CT shows a focal low-attenuation enhancing mass along a cord-like structure extending from the bladder to the umbilicus. What is the most likely diagnosis?
A. Complex urachal cyst
B. Vescico urachal diverticulum
C. Urachal adenocarcinoma
D. Transitional cell carcinoma
E. Urachal rhabdomyosarcoma
- C. Urachal adenocarcinoma
Urachal adenocarcinoma is characteristically located at the dome of the bladder in the midline or slightly off midline. Ninety percent of masses occur close to the bladder, with the remainder along the course of the urachus or at the umbilical end. A midline, infra-umbilical, soft-tissue mass with calcification is characteristic and is considered to be urachal adenocarcinoma until proved otherwise. Eighty percent of urachal cancers are adenocarcinoma. At CT, the tumour is mixed solid
and cystic in 84% of cases and solid in the remainder. CT is the most sensitive modality for calcification, which is present in 72% of cases and is more commonly peripheral than stippled. On T2-weighted MRI, focal areas of high signal intensity from mucin are highly suggestive of urachal adenocarcinoma. The solid portions of the tumour are isointense to soft tissue on T1-weighted images and enhance with intravenous contrast material.
@#1 40. A 10 x 7 mm dense ossified focal lesion is noted in the neck of the right femur of a young man incidentally on a pelvic radiograph performed for an unrelated reason. The lesion has benign features and is consistent with a bone island (enostosis). No follow-up is suggested. All of the following are true of bone islands, except
A. If more than 2 cm, they are classified as a giant’ bone island.
B. They have a sclerotic appearance on imaging.
C. They show a characteristic brush border on plain films.
D. They can be positive on a bone scan.
E. Giant bone islands can be locally aggressive
- E. Giant bone islands can be locally aggressive
Bone islands arc benign entities and represent compact bone within the medullary space.
They do not exhibit aggressive features regardless of size.
Classically they are sharply defined with thorny radiations (brush border).
They can occasionally show increase or decrease in size (about a third of them) (cf. osteoblastic metastasis, which shows aggressive features, cortical break/destruction, periosteal reaction or soft-tissue component; osteoid osteoma is associated with typical pain and a nidus).
@#1 41. A patient recently diagnosed with MS has been sent for an MRI of the whole spine to detect possible spinal plaques. All of the following are MR features of spinal cord lesions
in MS, except
A. The sole site of involvement (in some cases).
B. Imaging features similar to those of MS lesions in the brain.
C. Most lesions are centrally located.
D. The length rarely exceeds two vertebral segments.
E. Dorsal column involvement.
- C. Most lesions are centrally located.
Occurrence of spinal cord abnormalities is largely independent of brain lesions in MS. Both focal and disuse lesions affecting the cord arc described, though multiple focal lesion (median 3) is the most common finding. Patients with focally involved spinal cords mostly show multiple small lesions.
Focal lesions have an elongated configuration along the axis of the spinal cord and affect the peripheral part of the cord.
Cervical cord is the most commonly affected segment and the lesions usually extend over fewer than two vertebral segments in length.
@#1 42. Barium enema of a neonate shows an inverted cone shape at the rectosigmoid colon. There is marked retention of the barium on delayed post-evacuation films after 24 hours.
The cause for this is
A. Meconium ileus
B. Meconium plug syndrome
C. Hirschsprung’s disease
D. Imperforate anus
E. Hyperplastic polyp of colon
- C. Hirschsprung’s disease
Hirschsprung’s disease, also called aganglionosis of the colon (absence of parasympathetic ganglia in muscle and submucosal layers secondary to an arrest of craniocaudal migration of neuroblasts), results in relaxation failure of the aganglionic segment.
It affects full-term infants during the first weeks of life, mainly boys. It is extremely rare in premature infants.
It usually affects the rectosigmoid junction and results in short-segment disease (80%). Long-segment disease (20%) and total colonic aganglionosis (5%) are less common.
Barium enema shows a ‘transition zone’ (aganglionic segment), which appears normal in size with dilatation of large and small bowel proximally with marked retention of barium on delayed films after 24 hours.
Normal children show a rectosigmoid ratio of >1, as the rectum is larger in diameter than the sigmoid; in the case of Hirschsprung’s disease, the ratio is reversed (rectosigmoid ratio <1).
- A 3-year-old child with shortness of breath is diagnosed with tetralogy of Fallot. All of the following abnormalities may be associated with this condition, except
A. Transposition of great vessels (TGA)
B. Patent ductus arteriosus (PDA)
C. Anomalous origin of coronary arteries
D. DiGeorge syndrome
E. Right-sided aortic arch
- A. Transposition of great vessels (TGA)
A number of associated features can occur in patients with Tetralogy of Falot (TOF).
Right sided aortic arch is the most common variant, known as Corvisart syndrome.
Coronary artery anomalies, such as the left anterior descending artery arising from the right coronary artery (whose course may run directly across the right ventricular outflow tract) can occur.
Other associations include patent ductus arteriosus, multiple ventricular septal defects and complete atrioventricular septal defect.
Approximately 15% of patients have extracardiac anomalies, including chromosomal abnormalities such as Down’s syndrome, DiGeorge syndrome and Alagille syndrome.
@#e 44. A 40-year old woman presents to her GP with right upper quadrant pain and is referred for an ultrasound of the abdomen. The scan demonstrates a thickened gall bladder wall with several intramural small echogenic foci showing ‘comet tail artefacts’. A few gallstones
are also noted. What is the most common diagnosis?
A. Xanthogranulomatous cholecystitis
B. Strawberry gallbladder
C. Porcelain gallbladder
D. Gallbladder adenomyomatosis
E. Acute cholecystitis
- D. Gallbladder adenomyomatosis
Adenomyomatosis is a benign hyperplastic cholecystosis. Tt is a relatively common condition, identified in at least 5% of cholecystectomy specimens. There is no definite racial or sex predilection. Most diagnoses are made in patients in their fifties, but the age range is wide and case reports exist of paediatric adenomyomatosis. Adenomyomatosis is most often an incidental finding, has no intrinsic malignant potential, and usually requires no specific treatment.
It frequently coexists with cholelithiasis, but no causative relationship has been proved. Adenomyomatosis occasionally produces abdominal pain, and in some cases cholecystectomy may be indicated for relief of symptoms. Cholesterol accumulation in adenomyomatosis is intraluminal, as cholesterol crystals precipitate in the bile trapped in Rokitansky-Aschoff sinuses, intramural diverticula lined by mucosal epithelium. Gallbladder wall thickening and intramural diverticula containing bile with cholesterol crystals, sludge, or calculi are the radiologic correlates of the distinctive multimodality imaging features of adenomyomatosis.
US is a primary modality for biliary imaging, and adenomyomatosis of the gallbladder is frequently identified at sonography. The non-specific finding of gallbladder wall thickening is well demonstrated with US, as are sludge and calculi, when present. Echogenic intramural foci from which emanate V-shaped comet tail reverberation artefacts are highly specific for adenomyomatosis, representing the unique acoustic signature of cholesterol crystals within the lumina of Rokitansky-Aschoff sinuses.
@#1 45. A woman presents with infertility and undergoes a hysterosalpingogram. This demonstrates a uterus with two converging horns. A wide angle is seen at the roof of the uterus.
Which uterine anomaly does the patient have?
A. Uterine didelphys
B. Septate uterus
C. Arcuate uterus
D. Bicornuate uterus
E. Unicornuate uterus
- D. Bicornuate uterus
While the presence of a divided rather than triangular uterine cavity at Hysterosalpingogram (HSG) may suggest the presence of an Mullerian duct anomaly (MDA), it is not possible to differentiate between subtypes. MRI and US provide greater anatomic detail; both of these imaging methods provide information on the external uterine contour, which is an important diagnostic feature of MDAs. Furthermore, both MRI and US may be used to assess for concomitant renal anomalies; renal anomalies occur at a higher rate among MDA patients. Unicornuate uterus appears as a small, oblong, off-midline structure on US and MRI. 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 the uterus with possible duplication of the cervix (bicornuate unicollis or bicornuate bicollis).
HSG demonstrates opacification of two symmetric fusiform uterine cavities (horns) and fallopian tubes. Historically, an intercornual angle of greater than 105° was used for diagnosis of bicornuate uterus.
Septate uterus is the most common form of MDA, accounting for approximately 55% of cases.
Historically, an angle of less than 75° between the uterine horns has been reported to be suggestive of a septate rather than bicornuate uterus.
However, considerable overlap occurs between septate and bicornuate uteri; as such, the angle measurement is not a reliable diagnostic feature.
Arcuate uterus at HSG shows a single uterine cavity with a broad saddle-shaped indentation at the uterine fundus.
@#1 46. A 53-year old woman presents to the A&E department with acute knee pain. She has had two previous similar episodes in the past, which settled with analgesics and anti-inflammatory medications. Plain films show extensive degenerative change, which is worst at the patellofemoral joint with large subchondral cystic change and chondrocalcinosis of the knee menisci. She informs the attending doctor that she is under review with the endocrinologist. What is the likely diagnosis?
A. Calcium pyrophosphate deposition disease (CPPD)
B. Gout
C. Rheumatoid arthritis
D. Ochronosis
E. Psoriasis
- A. Calcium pyrophosphate deposition disease (CPPD)
This is a typical description of CPPD, which can be idiopathic or associated with endocrinological problems such as hyperparathyroidism and hypothyroidism. The joints of the knee, wrist and second/third MCP joints of the hand are most frequently involved.
Differentials would also include gout, but the distribution of erosions are different, with gouty erosions tending to be juxta-articular and punched out (‘rat-bitten’) rather than subchondral. Joint space is also typically preserved in gout until the late stages.
Psoriasis produces enthesitis and periostitis with new bone formation.
Ochronosis, or alkaptonuria, is a metabolic disorder whereby there is abnormal build-up of homogentisic acid in connective tissue with pigmentation of the sclera and urine appearing dark in colour. Diffuse multilevel vertebral disc calcification and early OA changes in multiple joints are associated with this condition.
@#1 47. A 54-year-old man who developed brain metastases almost 9 years after resection of an acral lentiginous melanoma of the distal thumb shows two peripheral nodules in the right frontal lobe. All of the following are features of CNS metastatic melanoma, except
A. Moderate to intense enhancement post-contrast administration
B. Cystic components
C. Subependymal nodules
D. Multiple lesions at the gray white matter junction
E. Miliary pattern
- B. Cystic components
Metastatic malignant melanoma is a commonly encountered neoplasm in the head. Typical appearance of a lesion is high signal intensity on T1-weighted images and low signal on T2-weighted images (melanotic pattern). The other described pattern is the amelanotic pattern. In this pattern, the lesion is hypointense or isointense to the cortex on T1-weighted images and hyperintense or isointense to the cortex on T2-weighted images. Metastatic melanoma presents as multiple brain metastasis, which are located predominantly in the cortex and at the grey matter- white matter junction. They can also present in miliary form or as subependymal nodules. The lesions often appear hyperdense on unenhanced CT. The lesions show moderate to intense contrast enhancement, although larger lesions can show non-enhancing or hypoenhancing necrotic areas. Prominent perilesional oedema is seen.
@#1 48. A child presents with vomiting and sudden onset abdominal pain. Plain X-rays show a target sign in the right upper quadrant. US shows a pseudo kidney sign in keeping with intussusception. Which of the following is false regarding hydrostatic reduction?
A. Free intraperitoneal air is a contraindication.
B. A maximum of two attempts can be made.
C. Air is preferred to Gastrografin water solution in some institutions.
D. The perforation rate is 0.4%-3%.
E. Air enema is associated with a higher perforation rate.
- B. Maximum of two attempts can be made.
Intussusception is one of the most common causes of acute abdomen in infancy.
Perforation may already have occurred before enema therapy or may occur during the reduction process.
There is no agreement on the number and duration of reduction attempts, the efficacy of premedication or sedation, the use of rectal tubes with inflatable retention balloons, or the use of transabdominal manipulation. The classic ‘rule of threes’ is that the number of reduction attempts is capped at three, lasting 3 min each. This rule has been discarded at some institutions, and some authors use a nearly unlimited number of attempts. Use of sedation, rectal tube with balloons and the Valsalva manoeuvre are said to improve the reduction rate achieved.
Absolute contraindications to enema therapy are shock not readily corrected with IV hydration and perforation with peritonitis. Criteria that are linked to a lower reduction rate and a higher perforation rate are age less than 3 months or greater than 5 years, long duration of symptoms, especially if greater than 48 hours, passage of blood via the rectum, significant dehydration, small bowel obstruction and visualisation of the dissection sign during enema therapy. Air enema produces excellent results but is also associated with maximum perforation rates.
- Of the normal uterus signal on MR, which is correct?
- B. High on T2 Intermediate on T2 Low on T2
On T1-weighted images, normal pelvic musculature and viscera demonstrate homogenous low-to-intermediate signal intensity. Zonal architecture is best demonstrated on T2-weighted MRI.
T2 signal reflects the water content, which is highest in the endometrium, intermediate in the myometrium and least in the junctional zone.
- Which of the following is false regarding bronchopulmonary sequestration?
- D. Symptomatic First 6 months Adulthood Bronchopulmonary sequestration
- A 25-year-old music teacher has recently been diagnosed with inflammatory bowel disease. She has an MRI small bowel study for evaluation of her disease status. Regarding features of Crohn’s versus ulcerative colitis on cross-sectional imaging, which of the following options is false?
- E. Skip lesions Yes Yes
In patients with proved or suspected Crohn’s disease, cross-sectional images should be analysed specifically for the presence and character of a pathologically altered bowel segment (wall thickness, pattern of attenuation, degree of enhancement, length of involvement), stenosis and prestenotic dilatation, skip lesions, fistulas, abscess, fibrofatty proliferation, increased vascularity of the vasa recta (comb sign), mesenteric adenopathy and other extra intestinal disease involvement.
- A 30-year old weight-lifter presents with swelling in the right groin. Which of the following is false?
- A. Direct inguinal hernia The hernial sac lies lateral to the inferior epigastric artery and above the pubic tubercle.
There are several sites on the abdominal wall prone to herniation.
The first site is the deep inguinal ring, where an indirect inguinal hernia occurs. Here, herniated structures enter the inguinal canal lateral to the inferior epigastric artery and superior to the inguinal ligament, extending for a variable distance through the inguinal canal.
A second site of herniation is at the inferior aspect of the Hesselbach’s triangle, where a direct inguinal hernia usually occurs. This weakened area is just lateral to the conjoint tendon and medial to the inferior epigastric artery, in contrast to the indirect inguinal hernia, which originates lateral to the inferior epigastric artery.
A third weakened area is inferior in relation to the inguinal ligament and lateral to the lacunar ligament, where a femoral hernia occurs, typically medial and adjacent to the femoral vessels. The fourth area is at the lateral margin of the rectus abdominis muscle, superior to the inferior epigastric artery as it crosses the linea semilunaris, where a spigelian hernia occurs, indirect inguinal hernias are most common regardless of sex; femoral hernias are more common in women.
- A 42-year-old man presents with a high-grade fever, splenomegaly and abdominal pain. CT chest and abdomen done to look for a source of sepsis show multiple small cavitating lesions in both lungs with areas of hypo-attenuation in the spleen and kidneys. Which of the following is the most likely diagnosis?
A. Sarcoidosis
B. Carcinoid heart disease
C. Amyloidosis
D. infective endocarditis
K. Rheumatic heart disease
- I). Infective endocarditis
Extracardiac Complications of Infective Endocarditis
