Tumor Flashcards
On histopathology, central neurocytoma has strong positivity with which stain?
a. GFAP
b. S100
c. Synaptophysin
d. EMA
e. Vimentin
c. Synaptophysin
When a patient with neurofibromatosis type II (NF-2) presents with a small vestibular schwannoma with serviceable hearing, what is the most effective treatment strategy to maximize auditory longevity?
a. Microsurgery
b. Bevacizumab
c. Stereotactic radiosurgery (SRS)
d. Fractionated radiotherapy
e. Observation until tumor progression
e. Observation until tumor progression
A 54 year-old man presents with biopsy-proven esthesioneuroblastoma has a normal neurological exam. MRI shows involvement of the right nasal cavity with minimal intracranial extension through the cribriform plate (Figure 1). There is no cervical adenopathy or evidence of metastatic disease. Which of the following is the best management strategy for this patient?
a. Chemotherapy alone
b. Surgical resection followed by conformal radiation therapy to the tumor bed
c. Surgical resection
d. Surgical resection followed by conformal radiation therapy to the tumor bed and systemic chemotherapy
e. Neo-adjuvant radiation therapy followed by chemotherapy
b. Surgical resection followed by conformal radiation therapy to the tumor bed
A 25-year-old man presents with a new onset of right facial droop associated with horizontal diplopia. MRI of the brain shows a brainstem hyperintensity on T2 and FLAIR images (see figure). What anatomical structure is affected by this lesion causing the diplopia?
a. Medial longitudinal fasciculus
b. Trapezoid body
c. Abducens fibers
d. Abducens nucleus
e. Trochlear nucleus
d. Abducens nucleus
A 48-year-old woman with metastatic colorectal cancer develops worsened left arm and leg weakness. The MRI demonstrates a 2.9 cm enhancing mass in the right pre-motor cortex with extensive associated vasogenic edema and 3 mm of transfalcine herniation as well as two other subcentimeter lesions. Given the patient otherwise has no systemic disease burden, what is the best treatment of this patient’s intracranial disease?
a. Stereotactic radiosurgery to all three lesions
b. Surgical resection of all three lesions
c. Whole brain radiation therapy alone
d. Surgical resection of the largest lesion followed by radiation therapy
e. Needle biopsy of the largest lesion and subsequent chemotherapy
d. Surgical resection of the largest lesion followed by radiation therapy
When resecting a brain lesion near the corticospinal tract, what modality is best suited to minimize the risk of motor impairment?
a. Nerve conduction study
b. Direct cortical stimulation motor evoked potential monitoring
c. Quantitative subcortical motor mapping
d. Phase-reversal mapping
e. Somatosensory evoked potential monitoring
c. Quantitative subcortical motor mapping
A 14-year-old female presents with progressive difficulty writing. An MRI (figure) shows multiple nodular areas running along the cervical nerve roots and brachial plexus. Examination of her eyes also shows iris harmartomas. What is the most likely diagnosis?
a. Neurofibromatosis-2
b. Tuberous sclerosis
c. Ataxia-telangiectasia
d. Neurofibromatosis-1
e. Von Hippel-Lindau
d. Neurofibromatosis-1
Parkinson’s triangle on the lateral wall of the cavernous sinus is bounded by which two cranial nerves or cranial nerve divisions:
a. Ophthalmic and maxillary divisions of trigeminal nerve.
b. Trochlear nerve and ophthalmic division of trigeminal nerve.
c. Maxillary and mandibular divisions of trigeminal nerve.
d. Oculomotor nerve and maxillary division of trigeminal nerve.
e. Abducens nerve and Oculomotor nerve.
b. Trochlear nerve and ophthalmic division of trigeminal nerve.
A 42-year-old man with shock-like right facial pain radiating from pre-auricular area of right ear into the right lower jaw, teeth and tongue. Symptoms are triggered by facial movement, shaving, and chewing. Empiric medical management with carbamazepine gave incomplete pain relief but made him feel woozy. What is the next step in the patient’s management?
a. Addition of a muscle-relaxing agent
b. Stereotactic radiosurgery
c. Magnetic resonance imaging
d. Microvascular decompression
e. Botox injection
c. Magnetic resonance imaging
What combination of IDH and 1p-19q status in diffuse glioma is most predictive of detecting a P53 gene mutation?
a. IDH mutant, 1p intact and 19q deleted
b. IDH wild-type, 1p-19q intact
c. IDH mutant, 1p-19q intact
d. IDH wild-type, 1p-19q co-deleted
e. IDH mutant, 1p-19q co-deleted
c. IDH mutant, 1p-19q intact
A 58 year old woman with a history of breast cancer presents with lower thoracic spine pain. The pain is worse at night and does not worsen with movement. She is neurologically intact. An MRI reveals a contrast-enhancing lytic lesion isolated to the T12 body without evidence of fracture. There are multiple smaller lesions noted throughout her entire spinal axis. She is currently undergoing systemic therapy for her bone only disease. What is the most appropriate treatment option for this patient?
a. Posterior T12 laminectomy with pedicle screw instrumentation followed by radiotherapy.
b. Fractionated external beam radiotherapy.
c. T12 vertebrectomy with pedicle screw instrumentation followed by radiotherapy.
d. Percutaneous biopsy and vertebroplasty followed by radiosurgery.
e. Percutaneous biopsy and vertebroplasty followed by conventional fractionated radiotherapy.
b. Fractionated external beam radiotherapy.
A 41 year-old woman undergoes gross total resection for the lesion shown (Figure). Pathology confirms a grade 2 oligodendroglioma. What is the recommended course of treatment?
a. Chemotherapy and radiation
b. Chemotherapy
c. Clinical observation
d. Radiation
e. Serial MRI
a. Chemotherapy and radiation
A 68 year-old man undergoes resection of a GBM. Post-operative imaging is shown. He awakes from surgery with left arm numbness and mild weakness. What is the most likely cause of his new deficit?
a. Ischemia
b. Abscess
c. Seizure
d. Direct injury to neural structures
e. Edema
a. Ischemia
A 42 year-old man undergoes resection of this tumor (Figure 1). The immunohistochemistry for BRAF V600E mutation is shown (Figure 2). What is the most likely diagnosis?
a. Pilocytic astrocytoma
b. Ganglioglioma
c. Glioblastoma
d. Ependymoma
e. Pleomorphic xanthoastrocytoma
b. Ganglioglioma
On which chromosome is the gene mutation associated with the syndrome depicted by the MRI shown (figure)?
a. 9
b. 22
c. 3
d. 17
e. 11
b. 22
A 47 year old man presents with confusion, agitation, fatigue, fever (104F), hyponatremia, hypoglycemia, and hypotension after resection of a right frontal metastasis lesion 3 weeks ago. Phenytoin and steroids were discontinued at 2.5 weeks post-operatively. Head CT reveals no acute abnormality. What is the most appropriate management of this patient?
a. Heparin
b. Fludricortisone
c. Haloperidol
d. Fosphenytoin
e. Hydrocortisone
e. Hydrocortisone
A 45-year-old male presents with several months of progressive headaches and an intracranial lesion (figure). Following surgical resection, histopathological analysis demonstrates a well-circumscribed, uniformly cellular tumor with no atypia and numerous ectatic, thin-walled branching vessels in staghorn configurations. Which of the following is a possible associated clinical development?
a. De novo glioblastoma
b. Pheochromocytoma
c. Unilateral optic nerve glioma
d. Bilateral vestibular schwannomas
e. Metastases outside the CNS
e. Metastases outside the CNS
During the extended middle fossa approach for a skull base tumor resection, removal of the bone posterior to the foramen ovale and beneath the greater superficial petrosal nerve has a risk of injury to which vascular structure?
a. Petrous Internal Carotid Artery
b. Condylar vein.
c. Vertebral artery.
d. Sigmoid sinus.
e. Middle Cerebral Artery
a. Petrous Internal Carotid Artery
The addition of which chemotherapeutic agent to radiation therapy has been shown to increase overall survival in patients with newly diagnosed anaplastic oligodendroglioma?
a. Bevacizumab
b. Carbotaxol
c. Procarbazine/lomustine/vincristine (PCV)
d. Lomustine (CCNU)
e. Methotrexate
c. Procarbazine/lomustine/vincristine (PCV)
A 47-year-old woman presented with a first seizure and underwent magnetic resonance imaging of the brain with multi-voxel spectroscopy. The spectroscopy shown in Figure 1 is most consistent with what diagnosis?
a. meningioma
b. toxoplasmosis
c. bacterial abscess
d. glial neoplasm
e. demyelinating plaque
d. glial neoplasm
A 4-week-old was transferred to the Trauma Service from an outlying emergency department after an evaluation for a seizure that included a CT scan of the head (Figure 1). What additional diagnostic investigation is most appropriate?
a. Skeletal survey
b. Cerebral angiography
c. Urine amino acids
d. Lumbar puncture
e. Echocardiography
e. Echocardiography
During endoscopic endonasal transsphenoidal surgery, which of the following vascular structures is most likely to be injured?
a. Carotid artery
b. Internal maxillary artery
c. Sphenopalatine artery
d. Vidian artery
e. Basilar artery
c. Sphenopalatine artery
Which form of systemic cancer therapy is associated with an increased risk of radiation necrosis after stereotactic radiosurgery for cerebral metastases?
a. Cytotoxic Chemotherapy (e.g. DNA synthesis / Mitosis Inhibitors)
b. Systemic Immunotherapy (e.g. PD-1 inhibitors)
c. Glucocorticoid Therapy
d. Angiogenesis Inhibitors (e.g. Anti-VEGF antibody)
e. Tumor Targeted Chemotherapy (e.g. EGFR or ALK antagonists)
b. Systemic Immunotherapy (e.g. PD-1 inhibitors)
A 35 year old female presents with headaches and progessive left sided hearing loss. What is the BEST treatment for the lesion depicted in the MR images?
a. Endoscopic fenestration.
b. Radiation therapy
c. Stereotactic aspiration.
d. Craniotomy for lesion removal.
e. Cystoperitoneal shunt.
d. Craniotomy for lesion removal.
A view from above into the anterior third ventricle is shown. The ideal location for performing a third ventriculostomy is indicated by which number?
a. 5
b. 7
c. 9
d. 8
e. 6
d. 8
A 70-year-old man presents with new onset progressive confusion, expressive dysphasia, and right hemiparesis. MRI shows multiple enhancing intracerebral masses with surrounding edema that resolve after a short course of steroids. What is the most likely diagnosis of these lesions?
a. primary central nervous system lymphoma.
b. multifocal glioma.
c. multiple sclerosis.
d. central nervous system sarcoidosis.
e. multiple metastases.
a. primary central nervous system lymphoma.
What radiotherapy modality for intracranial meningioma is associated with the lowest risk of symptomatic radiation injury?
a. Hypofractionated stereotactic radiotherapy
b. Fractionated radiation therapy
c. Proton Beam Radiotherapy
d. Gamma knife radiosurgery
e. Linear accelerator radiosurgery
b. Fractionated radiation therapy
What neurological deficit is most at risk with surgery for the lesion shown (figures 1 and 2)?
a. Gerstmann syndrome
b. Diplopia
c. Anterograde amnesia
d. Expressive aphasia
e. Upgaze palsy
c. Anterograde amnesia
A 59 year-old man presents with high frequency sensorineural hearing loss, near normal speech discrimination (90% at 40 dB), and an MRI showing a uniformly enhancing 10-mm mass extending into the internal auditory canal. What is the most likely complication of stereotactic radiosurgery for this lesion?
a. Diplopia
b. Facial weakness
c. Hearing loss
d. Swallowing difficulty
e. Facial numbness
c. Hearing loss
A 7-year-old child with a two week history of difficulty walking, dysarthric speech and facial weakness has the MRI shown in the figure. What is the most appropriate initial treatment?
a. Gamma-knife.
b. Chemotherapy.
c. Conformal radiotherapy.
d. Surgical debulking.
e. Whole-brain radiation.
c. Conformal radiotherapy.
A 24-year-old woman presents with right arm weakness and the accompanying T1-weighted, contrast-enhanced MRI. Stereotactic needle biopsy demonstrates Rosenthal fibers on histopathological analysis. Which of the following treatment paradigms is associated with long-term disease control?
a. Radiotherapy combined with high-dose corticosteroids
b. Complete microsurgical resection alone
c. Radiotherapy combined with IV methotrexate
d. Radiotherapy alone
e. Complete microsurgical resection followed by adjuvant radiotherapy
b. Complete microsurgical resection alone
Which genetic or chromosomal alteration is associated with primary adult glioblastoma?
a. Wnt signaling pathway mutations
b. TP53 and ATRX mutations
c. SMARCB1/INI1 mutation or deletion
d. 1p19q chromosomal deletion
e. EGFR and CDNK2A/CDNK2B mutations
e. EGFR and CDNK2A/CDNK2B mutations
A 55 year old woman developed a severe headache, acute vision loss, and bilateral ptosis. Examination also reveals complete ophthalmoplegia of both eyes. What is the most likely diagnosis?
a. Complicated migraine.
b. Pituitary apoplexy.
c. Myasthenic crisis.
d. Kearns-Sayre syndrome.
e. PCOM aneurysm.
b. Pituitary apoplexy.
What factor may increase the risk of seizures during awake craniotomy procedures starting with general anesthesia as compared to conscious sedation?
a. Lower seizure thresholds during general anesthesia
b. Negative seizure history
c. The transition from asleep to awake states
d. Allergic reaction to general anesthesia
e. Higher stimulation amplitudes for cortical stimulation
e. Higher stimulation amplitudes for cortical stimulation
A 58 year-old man with history of lung adenocarcinoma presents with headaches. MRI of the brain shows 3 supratentorial lesions, the largest of which is shown (Figure). The patient undergoes stereotactic radiosurgery to each of the three lesions. Based on randomized controlled trials, how is the addition of whole brain radiation therapy likely to affect overall survival?
a. It is likely to shorten overall survival.
b. There is insufficient evidence regarding overall survival.
c. It is likely to lengthen overall survival.
d. There is conflicting evidence regarding overall survival.
e. It is likely not to affect overall survival
e. It is likely not to affect overall survival
A 75-year-old woman presents 3 months after resection of a frontal meningioma with complaints of headache, low grade fevers, and a tender fluctuance under her previous created craniotomy flap. A contrast-enhanced computed tomograpic scan of her head is shown in the figure. What is the most common organism for a post-surgical infection after elective craniotomy?
a. Staph. aureus
b. Streptococcus
c. E. Coli
d. Enterococcus sp
e. Propionibacterium acnes
a. Staph. aureus
An 8 year old boy was evaluated due to short stature and headaches. Sagittal MRI with contrast below is most consistent with which diagnosis?
a. Craniopharyngioma
b. Medulloblastoma
c. Arachnoid cyst
d. Pituitary macroadenoma
e. Germinoma
a. Craniopharyngioma
Gorlin or nevoid basal cell carcinoma syndrome is associated with increased incidence of medulloblastoma. The syndrome is caused by a germ line mutation in which gene?
a. TP53
b. Wnt
c. PTCH1
d. SMO
e. APC
c. PTCH1
A 10 year-old girl presents with signs of accelerated pubertal stage, convergence-retraction nystagmus, and impaired upward gaze. Which of the following lesions would most likely be the cause of the findings described?
a. Pontine glioma
b. Acqueductal stenosis
c. Medulloblastoma
d. Multiple sclerosis
e. Pineal region tumor
e. Pineal region tumor
A 62 year-old right handed woman with a malignant glioma undergoes awake craniotomy and gross total resection of the contrast enhanced tumor. What clinical deficit can have the most negative impact on overall survival?
a. Post-operative speech deficit
b. Post-operative Gerstmann Syndrome
c. Post-operative motor deficit
d. Post-operative seizures
e. Post-operative visual deficit
a. Post-operative speech deficit
A 61-year-old man undergoes resection of a 3.5 cm glioblastoma with 99% extent of resection. He is neurologically intact and has a post-operative Karnofsky Performance Status of 80. What is the most appropriate selection for post-operative adjuvant radiation therapy in this patient?
a.Stereotactic radiosurgery to the tumor bed at 12Gy
b. Stereotactic radiosurgery to the tumor bed at 30Gy
c. External-beam radiation to the tumor bed at 60Gy
d. No adjuvant radiation is indicated
e. Whole-brain radiation at 30Gy
c. External-beam radiation to the tumor bed at 60Gy
A 16-year-old boy presents with headaches, nausea, and blurred vision. His neurological examination is remarkable for impaired upgaze and convergence nystagmus. Contrast-enhanced MRI of the brain is shown (figure). Serum beta-HCG and alpha-fetoprotein levels are normal. What is the most likely diagnosis?
a. Endodermal sinus tumor
b. Embryonal carcinoma
c. Germinoma
d. Choriocarcinoma
e. Meningioma
c. Germinoma
A 58 year-old right handed male presents with bifrontal headaches and a partial left ophthalmoplegia. MRI results are shown. Biopsy revealed this tumor to be a chordoma. An extensive subtotal skull-based resection was performed. Which is the best choice for adjuvant therapy regimen?
a. Proton beam radiotherapy
b. Brachytherapy
c. Stereotactic radiosurgery
d. Conventional fractionated radiotherapy
e. Procarbazine, CCNU and vincristine (PCV) chemotherapy
a, Proton beam radiotherapy
What extent of surgical resection of low grade gliomas contributes to a survival benefit?
a. 50-75%
b. 25-50%
c. 0-25%
d. 75-100%
d. 75-100%
A patient is found to have a new hemiparesis after resection of a GBM. How does this finding impact his overall survival?
a. Improves survival if the deficit is permanent
b. Improves survival if the deficit is temporary
c. Worsens survival if the deficit is permanent
d. Unchanged survival if the deficit is permanent
e. Worsens survival if the deficit is temporary
c. Worsens survival if the deficit is permanent
During resection of a WHO grade II insular glioma, what white matter language tracts run through the tumor and under the insula?
a. Inferior fronto-occipital fasciculus and superior longitudinal fasciculus-temporal parietal portion
b. Arcuate fasciculus and medial longitudinal fasciculus
c. Uncinate fasciculus and inferior fronto-occipital fasciculus
d. Uncinate fasciculus and arcuate fasciculus
e. Superior longitudinal fasciculus III and arcuate fasciculus
c. Uncinate fasciculus and inferior fronto-occipital fasciculus
With respect to microsurgical resection of vestibular schwannomas, when the facial nerve loses intraoperative proximal electrical responsiveness, what factor is most predictive of facial nerve recovery postoperatively?
a. Tumor size
b. Cystic tumor features
c. Surgery for recurrent tumor
d. Surgical approach
e. Anatomical preservation of the facial nerve
e. Anatomical preservation of the facial nerve
An 8-year-old boy was evaluated due to short stature and headaches. Sagittal MRI with contrast (figure) is most consistent with what diagnosis?
a. Craniopharyngioma
b. Medulloblastoma
c. Germinoma
d. Arachnoid cyst
e. Pituitary macroadenoma
a. Craniopharyngioma
The figure is a cadaveric dissection of the anterior portion of the left cavernous sinus. What deficit would be seen with damage to this structure?
a. Monocular blindness
b. Facial numbness
c. Ptosis, meiosis and anhydrosis
d. Periocular numbness
e. Diplopia that corrects with head tilt
c. Ptosis, meiosis and anhydrosis
What are the borders of Kawase’s triangle?
a. OV2, V3, and a line from the foramen rotundum and foramen ovale
b. GSPN, arcuate eminence, inferior petrosal sinus, V2
c. GSPN, arcuate eminence, superior petrosal sinus, V3
d. Foramen spinosum, arcuate eminence, superior petrosal sinus, V3
e. Arcuate eminence, inferior petrosal sinus, V2, V3
c. GSPN, arcuate eminence, superior petrosal sinus, V3
What is the diagnostic success rate of a stereotactic brainstem biopsy for a suspected tumor?
a. 25-39%
b. 70-84%
c. 40-54%
d. 55-69%
e. 85-99%
e. 85-99%
A 48 year old woman presents with a one week history of progressive facial paresis, severe right ear pain, vertigo, imbalance and hearing loss. Her past medical history is unremarkable. She has right beating nystagmus. Based on the MRI scan (figures) what is your diagnosis:
a. Bell palsy
b. Vestibular schwannoma
c. Facial nerve schwannoma
d. Facial nerve hemangioma
e. Zoster oticus
e. Zoster oticus
What is the next appropriate step in management following resection of an epidermoid tumor?
a. Radiographic surveillance
b. Intracystic chemotherapy
c. Prophylactic antibiotics
d. Fractionated radiotherapy
e. Brachytherapy
a. Radiographic surveillance
Paragangliomas of the jugular foramen derive from what cell type?
a. Epithelial cells of ectodermal origin from the stomodeum
b. Meningoepithelial cells
c. Chromaffin cells of neuro-ectodermal origin
d. Germ cells that migrated aberrantly
e. Cerebellar stem cells
c. Chromaffin cells of neuro-ectodermal origin
Following resection of a frontal supplementary motor area (SMA) cortex tumor, the patient develops impaired speech fluency. What pathway connects the inferior frontal lobe with the SMA?
a. Superior longitudinal fasciculus III
b. Uncinate fasciculus
c. Superior longitudinal fasciculus II
d. Arcuate fasciculus
e. Frontal aslant tract
e. Frontal aslant tract
Which MRI sequence is used to non-invasively assess the structural connectivity of the brain?
a. FIESTA
b. DWI
c. DTI
d. FLAIR
e. T2
c. DTI
What is the recommended radiotherapy regimen for GBM patients older than 70 years of age with poor performance status?
a. 40 Gy in 15 fractions over 3 weeks
b. 60 Gy in 30 fractions over 6 weeks
c. 20 Gy in 10 fractions over 3 weeks
d. 30 Gy in 20 fractions over 3 weeks
e. 50 Gy in 30 fractions over 6 weeks
a. 40 Gy in 15 fractions over 3 weeks
Histopathology of a cerebellopontine angle tumor is shown in the figures below. The findings are most consistent with what type of pathology?
a. Endolymphatic sac tumor
b. Cholesteatoma
c. Psammomatous meningioma
d. Schwannoma
e. Choroid plexus papilloma
d. Schwannoma
To which part of the optic pathway would the presence of macular sparing in a hemianopic visual field deficit localize?
a. Optic Chiasm
b. Optic Tract
c. Optic Nerve
d. Primary Visual Cortex
e. Optic Radiation
d. Primary Visual Cortex
Curvilinear restricted diffusion may be seen along the margin of a resection cavity on immediate postoperative MRI after gross total resection of a glioma. What pathological process does this restricted diffusion pattern usually develop into?
a. Abscess
b. Gliosis
c. Recurrent tumor
d. Hematoma
e. Territorial infarct
b. Gliosis
In the case of an intracanalicular vestibular schwannoma, what is the advantage of the middle cranial fossa approach over the retrosigmoid approach?
a. Early identification of the distal facial nerve.
b. Improved preservation of vestibular nerve function.
c. Decreased risk of postoperative seizure
d. Decreased risk of CSF leak.
e. Decreased risk of injuring the greater superficial petrosal nerve.
a. Early identification of the distal facial nerve.
What tumor histology is associated with highest risk of cerebral hemorrhage in patients receiving therapeutic anticoagulation for deep vein thromboses and pulmonary emboli?
a. Melanoma
b. Choriocarcinoma
c. Non-Small Cell Lung Carcinoma
d. Renal Carcinoma
e. Glioma
e. Glioma
A Central American patient presents with new onset seizures. CT shows hydrocephalus, and multiple calcified lesions. MRI demonstrates rim-enhancing cysts throughout the brain. What is the most likely etiology?
a. Plasmodium falciparum
b. Schistosoma mansoni
c. Entamoeba histolytica
d. Taenia solium
e. Toxoplasma gondii
d. Taenia solium
An 18 year old functionally independent girl with tuberous sclerosis presents with progressive headaches. Imaging is shown (figure). What is the best treatment option for this patient?
a. Transcortical transventricular resection
b. Observation
c. Everolimus therapy
d. Interhemispheric transcallosal resection
e. Stereotactic radiosurgery
c. Everolimus therapy
A patient undergoes a stereotactic biopsy of a grade IV astrocytoma. When considering the discussion of the findings and prognosis, patients indicate that the most important factors for effective communication include:
a. Giving only best possible scenario to give the patient hope.
b. Physician’s familiarity with the patient and the use of touch (e.g. holding the patient’s hand).
c. Demonstration of physician’s compassion, honesty, attention to questions and use of clear language.
d. Careful scientific explanation of the histology, while withholding a grave prognosis.
e. Using empathetic communication such as “It could be worse”, “I understand how you feel” or “Nothing more can be done”
c. Demonstration of physician’s compassion, honesty, attention to questions and use of clear language.
A craniotomy using frameless stereotactic guidance is planned. After the surgeon registers the patient and image, the fiducial reference frame moves in relation to the patient. Which of the following is the best option before proceeding with the operation?
a. Re-register
b. Return the reference frame to its previous position
c. Ignore the shift if minor
d. Use a software correction algorithm
e. Touch a skull reference point
a. Re-register
What finding on MRI carries the highest risk for development of seizures in the setting of a newly diagnosed posterior fossa lesion?
a. Hydrocephalus
b. Extensive T2 hyper-intensity in the surrounding tissue
c. Size greater than 3cm
d. Homogenous enhancement after administration of gadolinium
e. Presence of blood-product on gradient echo imaging
a. Hydrocephalus
During a far lateral approach, exposure of what anatomic structure first indicates that more than the posterior one-third of the occipital condyle has been removed?
a. Transverse ligament of atlas
b. The dentate ligament
c. The anterior condylar vein
d. The vertebral artery
e. Jugular bulb
c. The anterior condylar vein
Following surgical resection of glioblastoma, standard therapy includes radiotherapy with concomitant temozolomide. What is the standard radiation dose given over 30 fractions?
a. 40 Gy
b. 20 Gy
c. 60 Gy
d. 50 Gy
e. 30 Gy
c. 60 Gy
A 33 year old woman with no neurological history complains of subtle left upper extremity weakness without headache or other symptoms. She is noted to have a mild left hemiparesis and otherwise normal neurological examination. EEG is normal. The MR scan is shown (figure). A stereotactic biopsy yields no evidence of glioma. What is the most likely diagnosis?
a. Lymphoma
b. Glioblastoma multiforme
c. Demyelinating plaque
d. Progressive multifocal leukoencephalopathy
e. Subacute sclerosing panencephalitis
c. Demyelinating plaque
Telomerase reverse transcriptase (TERT) promoter mutations leading to elevated TERT expression are most closely associated with what genetic alterations in gliomas?
a. 1p19q co-deletion
b. Loss of ATRX expression
c. EGFRvIII expression
d. MGMT promoter methylation
e. P53 overexpression
a. 1p19q co-deletion
A 10-year-old boy presents with headache and imbalance. Examination discloses mild papilledema, right-sided dysmetria, and ataxia. MRI with contrast is shown in the figure. What is the most important prognostic factor for this patient?
a. The presence of hydrocephalus at presentation
b. The extent of resection of the enhancing mass
c. The extent of resection of the cyst walls
d. The presence of endothelial proliferation on histology
e. The presence of mitoses on histology
b. The extent of resection of the enhancing mass
A 35-year-old female underwent microscopic transsphenoidal resection of a non-functioning pituitary macroadenoma. Postoperative MRI demonstrates residual tumor in the right cavernous sinus lateral to the internal carotid artery. She has no neurological deficits. What is the most appropriate next step?
a. Expectant management
b. Endoscopic transsphenoidal resection
c. Stereotactic radiosurgery of residual nodule
d. Craniotomy for resection of residual tumor
e. Medical treatment with cabergoline
a. Expectant management
A 38 year-old woman underwent subtotal resection of a WHO Grade 2 astrocytoma. What is the most appropriate management of this patient?
a. Radiation
b. Radiation and immunotherapy
c. Chemotherapy
d. Radiation and chemotherapy
e. Observation
d. Radiation and chemotherapy
A pineal mass was completely resected and the pathologist diagnoses a mature teratoma. What is the best treatment for this patient?
a. Fractionated local radiation therapy
b. Radiosurgery to the resection cavity
c. Craniospinal irradiation
d. Observation
e. Chemotherapy
d. Observation
Neurophysiological monitoring during translabrynthine resection of a vestibular schwannoma with minimal extension into the cerebellopontine angle includes which of the following?
a. SSEP and IX, X, XI nerves
b. SSEP and VII nerve
c. BAER and IX, X, XI nerves
d. BAER and VII nerve
e. BAER and SSEP
b. SSEP and VII nerve
A 24-year-old woman presents with a history of menstrual irregularity and headache. Magnetic resonance (MR) imaging reveals a nonenhancing 1.6-cm tumor of the sellar/suprasellar region with displacement of the optic chiasm. If the patient was noted to have a prolactin level of 265, which of the following is the most appropriate management strategy?
a. craniotomy for decompression of the optic apparatus.
b. stereotactic radiosurgery
c. transsphenoidal resection.
d. dopamine agonist with serial visual fields.
e. observation
d. dopamine agonist with serial visual fields.
A 46 year-old woman with recurrent Cushing’s disease after transsphenoidal resection has MR proven extension of tumor into the cavernous sinus without suprasellar extension. She elects to undergo radiosurgery. What is the MOST likely complication after pituitary adenoma radiosurgery?
a. Diabetes insipidus
b. Visual loss
c. Diplopia
d. Anterior pituitary insufficiency
e. Carotid artery occlusion
d. Anterior pituitary insufficiency
Which of the following indicates a biochemical cure of acromegaly after surgical resection of a GH-secreting pituitary adenoma?
a. Delayed normalization of GH levels which were elevated immediately after surgery
b. IGF-1 increase immediately postoperatively of 100μg/L/day, compared to preoperative levels
c. Age- and sex-matched normalization of serum IGF-1 levels and GH level of 0.4μg/L following oral glucose load
d. Age- and sex-matched normalization of serum GH levels, and fasting morning IGF-1 levels of 0.4μg/L
e. Random serum GH level of 0.4μg/L, and age- and sex-matched normalization of random IGF-1 serum levels
c. Age- and sex-matched normalization of serum IGF-1 levels and GH level of 0.4μg/L following oral glucose load
In a patient with the MRI shown in the figure, a tumor in what other location would increase the probability of germinoma?
a. Frontal lobe
b. Suprasellar region
c. Orbit
d. Fourth ventricle
e. Brainstem
b. Suprasellar region
A view of the fundus (lateral end) of the internal acoustic meatus is shown in the figure. Which number represent the location of the cochlear nerve segment?
a. 4
b. 5
c. 1
d. 3
e. 2
b. 5
A patient with a history of whole brain radiation for metastatic disease presents with a new 1.5 cm brain metastasis. What is the RTOG criteria for the maximum radiation dose that should be given in a single fraction to the new lesion?
a. 18 Gy
b. 20 Gy
c. 15 Gy
d. 24 Gy
e. 12 Gy
d. 24 Gy
During awake speech mapping, stimulation of a temporal lobe site results in patient saying “gorange” instead of “orange”. This is an example of what type of paraphasia?
a. Semantic
b. Remote
c. Phonemic
d. Neologistic
e. Perseverative
c. Phonemic
In a 50 year old female presenting with a 1 cm pineal region mass, what would be the most likely diagnosis (based upon incidences cited in the literature)?
a. Metastasis.
b. Pineoblastoma.
c. Meningioma.
d. Germ cell tumor.
e. Pineocytoma.
e. Pineocytoma.
A 45 year old man presents with horizontal diplopia consistent with a left abducens nerve palsy. Which of the following findings would BEST localize the lesion to the cavernous sinus?
a. Ipsilateral Horner’s syndrome.
b. Ipsilateral optic neuropathy.
c. Contralateral hemianopia.
d. Papilledema.
e. Contralateral hemiparesis.
a. Ipsilateral Horner’s syndrome.
A 12-year-old boy presents complaining of left eye visual loss and occasional headache. Endocrine evaluation reveals the presence of mild diabetes inspidus and hypothyroidism. His MRI is shown in Figure 1&2. You recommend an attempt at complete tumor resection. Which of the following is the most likely surgical complication?
a. Blindness
b. Hydrocephalus
c. Pan-hypopituitarism
d. Mutism
e. Seizure disorder
c. Pan-hypopituitarism
An 84-year-old male has an MRI that reveals an enhancing lesion involving the left internal acoustic canal (see figure). On exam, he has diminished hearing in his left ear. What is the most appropriate next step in the management of this patient?
a. Stereotactic radiosurgery in a single session
b. Stereotactic radiosurgery in 3-5 fractions
c. Surgical removal via a restrosigmoid approach
d. Surgical removal via a translabyrinthine approach
e. Reassurance and follow-up MRI in 6 months
e. Reassurance and follow-up MRI in 6 months
An 80-year-old male presents with headache, confusion, and the accompanying MR imaging (figure). If the perfusion MRI demonstrates low relative cerebral blood flow, what is the most likely diagnosis?
a. Primary CNS lymphoma
b. Metastatic adenocarcinoma
c. Low grade glioma
d. Glioblastoma multiforme
e. Ependymoma
a. Primary CNS lymphoma
What primary intracranial tumor type has the highest frequency of BRAF-V600E mutations?
a. Pituitary adenomas
b. Gangliogliomas
c. Meningiomas
d. Schwannomas
e. Glioblastomas
b. Gangliogliomas
During a pterional exposure of the sylvian fissure, you encounter significant brain swelling. In order to achieve rapid brain relaxation, identify the most appropriate point on the associated figure through which to place a ventriculosotomy and access the frontal horn of the lateral ventricle.
a. 4
b. 3
c. 2
d. 5
e. 1
c. 2
Based on the cerebral angiogram, which vessel is the PRIMARY arterial blood supply for this tumor?
a. Superior cerebellar artery.
b. Ascending pharyngeal artery.
c. Persistent trigeminal artery.
d. Middle meningeal artery.
e. Meningohypophyseal trunk.
e. Meningohypophyseal trunk.
A 56-year-old man with a 5-cm right temporal glioma presents with a generalized tonic-clonic seizure, which was not broken after two doses of intravenous benzodiazepine administration. What is the most appropriate acute management of this patient’s seizures?
a. Oral oxcarbazepine
b. Oral levetiracetam
c. Intravenous phenobarbital
d. Intravenous fosphenytoin
e. Immediate surgical resection without anti-epileptic drug administration
d. Intravenous fosphenytoin
What characteristic histological feature of a meningioma is depicted in the encircled areas of the slide?
a. Psammoma bodies
b. Mitotic figures
c. Endothelial proliferation
d. Verocay bodies
e. Vacuolation
e. Vacuolation
What is the most appropriate initial management of newly-diagnosed primary CNS lymphoma in an immunocompetent patient?
a. IV methotrexate
b. Oral temozolomide
c. Stereotactic radiosurgery
d. Gross total resection
e. Intrathecal cytarabine
a. IV methotrexate
What imaging finding of a sphenoid wing meningioma significantly diminishes the possibility of safe gross-total resection?
a. Cerebral edema
b. Tumor size
c. Optic canal extension
d. Infratemporal fossa extension
e. Cavernous sinus invasion
e. Cavernous sinus invasion
47-year-old man with history of tympanomastoidectomy for cholesteatoma presents to an otolaryngologist for headaches and fullness in the ear. A temporal bone CT scan was performed which demonstrates a large tegmen defect and soft tissue signal in the mastoid cavity. The otolaryngologist is concerned about a cholesteatoma recurrence and cannot rule out presence of an encephalocele. What would be the most appropriate imaging modality to distinguish the two entities?
a. MR spectroscopy
b. Thin cut temporal bone CT
c. Diffusion-weighted MRI
d. OCT cisternogram
e. FDG-PET scan
c. Diffusion-weighted MRI
A 32 year-old man has surgery for a low grade glioma. What genetic profile is associated with the best prognosis?
a. IDH mutation with 1p19q co-deletion
b. IDH wild type without TERT promoter mutation
c. IDH wild type without 1p19q co-deletion
d. OIDH wild type with TERT promoter mutation
e. OIDH mutation without 1p19q co-deletion
a. IDH mutation with 1p19q co-deletion
A 75-year-old woman presents with a 2-month history of progressive difficulty walking, headache, and memory difficulties. Magnetic resonance imaging is shown (figure). Histopathology shows nests of small blue cells amid a pink fibrillary matrix. What is the most likely diagnosis?
a. meningioma.
b. subependymoma.
c. medulloblastoma.
d. glioblastoma multiforme.
e. pilocytic astrocytoma.
b. subependymoma.
