Tumor Flashcards
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. surgical approach
b. Anatomical preservation of the facial nerve
c. Surgery for recurrent tumor
d. Tumor size
e. Cystic tumor features
b. Anatomical preservation of the facial nerve
What imaging finding of a sphenoid wing meningioma significantly diminishes the possibility of safe gross-total resection?
a. cerebral edema
b. cavemous sinus invasion
c. Tumor size
d. Infratemporal fossa extension
e. Optic canal extension
b. cavemous sinus invasion
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. Pleomorphic xanthoastrocytoma
b. Ependymoma
c. Pilocytic astrocytoma
d. Ganglioglioma
e. Glioblastoma
d. Ganglioglioma
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. Urine amino acids
b. Lumbar puncture
c. Cerebral angiography
d. Skeletal survey
e. Echocardiography
e. Echocardiography
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. Maxillary and mandibular divisions of trigeminal nerve.
c. Oculomotor nerve and maxillary division of trigeminal nerve.
d. Trochlear nerve and ophthalmic division of trigeminal nerve.
e. Abducens nerve and Oculomotor nerve.
d. Trochlear nerve and ophthalmic division of trigeminal nerve.
What extent of surgical resection of low grade gliomas contributes to a survival benefit?
a. 25-50%
b. 0-25%
c. 50-75%
d. 75-100%
d. 75-100%
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. Whole brain radiation therapy alone
b. Needle biopsy of the largest lesion and subsequent chemotherapy
c. Surgical resection of the largest lesion followed by radiation therapy
d. Stereotactic radiosurgery to all three lesions
e. Surgical resection of all three lesions
c. Surgical resection of the largest lesion followed by radiation therapy
What neurological deficit is most at risk with surgery for the lesion shown (figures 1 and 2)?
a. Gerstmann syndrome
b. Upgaze palsy
c. Expressive aphasia
d. Diplopia
e. Anterograde amnesia
e. Anterograde amnesia
On which chromosome is the gene mutation associated with the syndrome depicted by the MRI shown (figure)?
a. 9
b. 11
c. 17
d. 22
e. 3
d. 22
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. FDG-PET scan
c. Diffusion-weighted MRI
d. Thin cut temporal bone CT
e. CT cisternogram
c. Diffusion-weighted MRI
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. Tumor Targeted Chemotherapy (e.g. EGFR or ALK antagonists)
d. Glucocorticoid Therapy
e. Angiogenesis Inhibitors (€.g. Anti-VEGF antibody)
b. Systemic Immunotherapy (e.g. PD-1 inhibitors)
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. E.Coli
b Staph. aureus
c. Enterococcus sp
d. Streptococcus
e. Propionibacterium acnes
b Staph. aureus
A7-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. Conformal radiotherapy
b. Whole-brain radiation
c. Surgical debulking
d. Gamma-knife
e. Chemotherapy.
a. Conformal radiotherapy
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. Germ cell tumor.
b. Pineocytoma.
c. Pineoblastoma.
d. Metastasis.
e. Meningioma.
b. Pineocytoma.
Following transsphenoidal resection of a large craniopharyngioma, the manifestations of a classic triphasic response are which of the following?
a. Hypemnatremia - Normonatremia or Hyponatremia - Hypernatremia.
b. Hyponatremia - Normonatremia or Hypernatremia - Hyponatremia.
c. Hyponatremia - Hypernatremia - Hyponatremia.
d. Normonatremia - Hyponatremia - Normonatremia.
e. Normonatremia - Hypernatremia - Normonatremia.
a. Hypemnatremia - Normonatremia or Hyponatremia - Hypernatremia.
A 24-year-old woman presents with a history of menstrual iregularity 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. observation
e. dopamine agonist with serial visual fields
e. dopamine agonist with serial visual fields
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. External-beam radiation to the tumor bed at 60Gy
b. Stereotactic radiosurgery to the tumor bed at 12Gy
c. Stereotactic radiosurgery to the tumor bed at 30Gy
d. No adjuvant radiation is indicated
e. Whole-brain radiation at 30Gy
a. External-beam radiation to the tumor bed at 60Gy
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. Abducens fibers
b. Trapezoid body
c. Trochlear nucleus
d. Medial longitudinal fasciculus
e. Abducens nucleus
e. Abducens nucleus
The addition of which chemotherapeutic agent to radiation therapy has been shown to increase overall survival in patients with newly diagnosed anaplastic
oligodendroglioma?
a. Carbotaxol
b. Procarbazine/lomustine/vincristine (PCV)
c. Bevacizumab
d. Lomustine (CCNU)
e. Methotrexate
b. Procarbazine/lomustine/vincristine (PCV)
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. Seizure
b. Direct injury to neural structures
c. Abscess
d. Edema
e. Ischemia
e. Ischemia
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. 6
b. 8
c. 9
d. 7
e. 5
b. 8
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. The anterior condylar vein
b. The dentate ligament
c. Transverse ligament of atlas
d. Jugular bulb
e. The vertebral artery
a. The anterior condylar vein
Neurophysiological monitoring during translabrynthine resection of a vestibular schwannoma with minimal extension into the cerebellopontine angle includes which of
the following?
a. BAERand IX, X, XI nerves
b. BAER and SSEP
c. BAER and VIl nerve
d. SSEP and VIl nerve
e. SSEP and IX, X, XI nerves
d. SSEP and VIl nerve
Which genetic or chromosomal alteration is associated with primary adult glioblastoma?
a. 1p19q chromosomal deletion
b. Wnt signaling pathway mutations
c. TP53 and ATRX mutations
d. SMARCB1/INI1 mutation or deletion
e. EGFR and CDNK2A/CDNK2B mutations
e. EGFR and CDNK2A/CDNK2B mutations
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. Phonemic
b. Semantic
c. Remote
d. Perseverative
e. Neologistic
a. Phonemic
Which of the following indicates a biochemical cure of acromegaly after surgical resection of a GH-secreting pituitary adenoma?
a. IGF-1 increase immediately postoperatively of 100pg/L/day, compared to preoperative levels
b. Random serum GH level of 0.4pg/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 0.4pg/L following oral glucose load
d. Delayed normalization of GH levels which were elevated immediately after surgery
e. Age- and sex- matched normalization of serum GH levels, and fasting morning IGF-1 levels of 0.4pg/L
c. Age- and sex- matched normalization of serum IGF-1 levels and GH level of 0.4pg/L following oral glucose load
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. Germinoma
c. Arachnoid cyst
d. Medulloblastoma
e. Pituitary macroadenoma
a. Craniopharyngioma
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 hom of the lateral ventricle
a. 5
b. 3
c. 2
d. 4
e. 1
c. 2
A neurologically intact 63-year-old man is diagnosed with small-cell lung cancer (SCLC) after biopsy. Brain MRI reveals no evidence of metastatic lesions. He has
mediastinal lymph node involvement and is started on chemotherapy with good systemic response. What additional treatment strategy is helpful to improve odds of
survival?
a. Prophylactic erlotinib treatment
b. No additional treatment necessary
c. Prophylactic bevacizumab treatment
d. Prophylactic cranial radiation
e. Surveillance brain MRI every three months
d. Prophylactic cranial radiation
A 32 year-old man has surgery for a low grade glioma. What genetic profile is associated with the best prognosis?
a. IDH wild type without TERT promoter mutation
b. IDH mutation with 1p19q co-deletion
c. IDH mutation without 1p19q co-deletion
d. IDH wild type without 1p19q co-deletion
e. IDH wild type with TERT promoter mutatio
b. IDH mutation with 1p19q co-deletion
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. tis likely not to affect overall survival
b. There is conflicting evidence regarding c. overall survival
c.. Itis likely to shorten overall survival
d. There is insufficient evidence regarding overall survival
e. tis likely to lengthen overall survival
A 58 year-old man with history of lung adenocarcinoma presents with headaches. MRI of the brain shows 3 supratentorial lesions, the
To which part of the optic pathway would the presence of macular sparing in a hemianopic visual field deficit localize?
a Optic Tract
b. Optic Nerve
c. Primary Visual Cortex
d. Optic Chiasm
e. Optic Radiation
c. 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.Territorial infarct
b. Recurrent tumor
c. Hematoma
d. Abscess
e. Gliosis
e. Gliosis
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. Pituitary apoplexy.
b. Complicated migraine.
c. Myasthenic crisis.
d.Keams-Sayre syndrome.
e. PCOM aneurysm
a. Pituitary apoplexy.
In a patient with the MRI shown in the figure, a tumor in what other location would increase the probability of germinoma?
a. Suprasellar region
b. Fourth ventricle
c. Frontal lobe
d. Orbit
e. Brainstem
a. Suprasellar region
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. Intravenous phenobarbitalO
c. Immediate surgical resection without anti-epileptic drug administration
d. Oral levetiracetam
e. Intravenous fosphenytoin
e. Intravenous fosphenytoin
A pineal mass was completely resected and the pathologist diagnoses a mature teratoma. What is the best treatment for this patient?
a. Craniospinal irradiation
b. Radiosurgery to the resection cavity
c. Observation
d. Fractionated local radiation therapy
e. Chemotherapy
c. Observation
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 motor deficit
c. Post-operative Gerstmann Syndrome
d. Post-operative seizures
e. Post-operative visual deficit
a. Post-operative speech deficit
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. Haloperidol
b. Hydrocortisone
c. Fludricortisone
d. Heparin
e. Fosphenytoin
b. Hydrocortisone
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. Vestibular schwannoma
b. Zoster oticus
c. Facial nerve schwannoma
d. Facial nerve hemangioma
e. Bell palsy
b. Zoster oticus
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 neuroiogical 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. subacute sclerosing panencephalitis
b. Progressive multifocal leukoencephalopathy
c. Demyelinating plaque
d. Glioblastoma multiforme
e. Lymphoma
c. Demyelinating plaque
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. Medulloblastoma
b. Germinoma
c. Arachnoid cyst
d. Craniopharyngioma
e. Pituitary macroadenoma
d. Craniopharyngioma
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. Stereotactic radiosurgery
b. Proton beam radiotherapy
c. Procarbazine, CCNU and vincristine (PCV) chemotherapy
d. Brachytherapy
e. Conventional fractionated radiotherapy
b. Proton beam radiotherapy
AT70-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. central nervous system sarcoidosis.
b. multifocal glioma.
c. multiple sclerosis.
d. multiple metastases.
e. primary central nervous system lymphoma.
e. primary central nervous system lymphoma.
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 Microvascular decompression
b. Stereotactic radiosurgery
c. Addition of a muscle-relaxing agent
d. Magnetic resonance imaging
e. Botox injection
d. Magnetic resonance imaging
What is the most appropriate initial management of newly-diagnosed primary CNS lymphoma in an immunocompetent patient?
a. Stereotactic radiosurgery
b. Gross total resection
c. Oral temozolomide
d. Intrathecal cytarabine
e. IV methotrexate
e. IV methotrexate
Histopathology of a cerebellopontine angle tumor is shown in the figures below. The findings are most consistent with what type of pathology?
a. Psammomatous meningioma
b. cholesteatoma
c. Endolymphatic sac tumor
d. Choroid plexus papilloma
e. Schwannoma
e. Schwannoma
What primary intracranial tumor type has the highest frequency of BRAF-V600E mutations?
a. Pituitary adenomas
b. Meningiomas
c. Gangliogliomas
d. Schwannomas
e. Glioblastomas
c. Gangliogliomas
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. Swallowing difficulty
c. Facial numbness
d. Facial weakness
e. Hearing loss
e. Hearing loss
During endoscopic endonasal transsphenoidal surgery, which of the following vascular structures is most likely to be injured?
a. Sphenopalatine artery
b. Basilar artery
c. Internal maxillary artery
d. Carotid artery
e. Vidian artery
a. Sphenopalatine artery
Which MRI sequence is used to non-invasively assess the structural connectivity of the brain?
a. DWI
b. FIESTA
c. DTl
d. FLAIR
e. T2
c. DTl
What radiotherapy modality for intracranial meningioma is associated with the lowest risk of symptomatic radiation injury?
a. Fractionated radiation therapy
b. Linear accelerator radiosurgery
c. Gamma knife radiosurgery
d. Hypofractionated stereotactic radiotherapy
e. Proton Beam Radiotherapy
a. Fractionated radiation therapy
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 amost likely be the cause of the findings described?
a. Muttiple sclerosis
b. Pineal region tumor
c. Pontine glioma
d. Medulloblastoma
e. Acqueductal stenosis
b. Pineal region tumor
Based on the cerebral angiogram, which vessel is the PRIMARY arterial blood supply for this tumor?
a. Superior cerebellar artery.
b. Meningohypophyseal trunk
c. Middle meningeal artery.
d. Persistent trigeminal artery.
e. Ascending pharyngeal artery.
b. Meningohypophyseal trunk
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. Bilateral vestibular schwannomas
b. Unilateral optic nerve glioma
c. De novo glioblastoma
d. Pheochromocytoma
e. Metastases outside the CNS
e. Metastases outside the CNS
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. toxoplasmosis
b. demyelinating plague
c. meningioma
d. glial neoplasm
e. Dbacterial abscess
d. glial neoplasm
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. Radiotherapy alone
c. Radiotherapy combined with IV methotrexate
d. Complete microsurgical resection followed by adjuvant radiotherapy
e. Complete microsurgical resection alone
e. Complete microsurgical resection alone
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. Middle Cerebral Artery
b. Petrous Internal Carotid Artery
c. Condylar vein.
d. Sigmoid sinus.
e. Vertebral artery.
b. Petrous Internal Carotid Artery
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 Tuberous sclerosis
b. Ataxia-telangiectasia
c. Von Hippel-Lindau
d. Neurofibromatosis-1
e. Neurofibromatosis-2
d. Neurofibromatosis-1
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. Craniotomy for lesion removal
c. Radiation therapy
d. Stereotactic aspiration
e. Cystoperitoneal shunt
b. Craniotomy for lesion removal
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. ApcC
b. TP53
c. SMO
d. Whnt
e. PTCH1
e. PTCH1
What factor may increase the risk of seizures during awake craniotomy procedures starting with general anesthesia as compared to conscious sedation?
a. Allergic reaction to general anesthesia
b. Higher stimulation amplitudes for cortical stimulation
c. Negative seizure history
d. The transition from asleep to awake states
e. Lower seizure thresholds during general anesthesia
b. Higher stimulation amplitudes for cortical stimulation
In the case of an intracanalicular vestibular schwannoma, what is the advantage of the middle cranial fossa approach over the retrosigmoid approach?
a. Improved preservation of vestibular nerve function.
b. Early identification of the distal facial nerve.
c. Decreased risk of injuring the greater superficial petrosal nerve.
d. Decreased risk of CSF leak.
e. Decreased risk of postoperative seizure
b. Early identification of the distal facial nerve.
On histopathology, central neurocytoma has strong positivity with which stain?
a. s100
b. Synaptophysin
c. EMA
d. Vimentin
e. GFAP
b. Synaptophysin
When resecting a brain lesion near the corticospinal tract, what modality is best suited to minimize the risk of motor impairment?
a. Quantitative subcortical motor mapping
b.Direct cortical stimulation motor evoked potential monitoring
c. Somatosensory evoked potential monitoring
d. Phase-reversal mapping
e. Nerve conduction study
a. Quantitative subcortical motor mapping
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. Uncinate fasciculus
b. Arcuate fasciculus
c. superior longitudinal fasciculus Il
d. superior longitudinal fasciculus 11l
e. Frontal aslant tract
e. Frontal aslant tract
What are the borders of Kawase’s triangle?
a. Arcuate eminence, inferior petrosal sinus, V2, V3
b. V2, V3, and a line from the foramen rotundum and foramen ovale
c. GSPN, arcuate eminence, inferior petrosal sinus, V2
d. Foramen spinosum, arcuate eminence, superior petrosal sinus, V3
e. GSPN, arcuate eminence, superior petrosal sinus, V3
e. GSPN, arcuate eminence, superior petrosal sinus, V3
What characteristic histological feature of a meningioma is depicted in the encircled areas of the slide?
a. Endothelial proliferation
b.Vacuolation
c. Verocay bodies
d. Mitotic figures
e. Psammoma bodies
b.Vacuolation
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 optic neuropathy.
b. Contralateral hemianopia.
c. Contralateral hemiparesis.
d. Ipsilateral Horner’s syndrome.
e. Papilledema.
d. Ipsilateral Horner’s syndrome.
Following surgical resection of glioblastoma, standard therapy includes radiotherapy with concomitant temozolomide. What is the standard radiation dose given over 30
fractions?
a. 30 Gy
b. 50 Gy
c. 60 Gy
d. 20 Gy
e. 40 Gy
c. 60 Gy
What is the diagnostic success rate of a stereotactic brainstem biopsy for a suspected tumor?
a. 85-99%
b. 70-84%
c. 25-39%
d. 40-54%
e. 55-69%
a. 85-99%
What combination of IDH and 1p-19q status in diffuse glioma is most predictive of detecting a P53 gene mutation?
a. IDH mutant, 1p-19q co-deleted
b. IDH mutant, 1p-19q intact
c. IDH wild-type, 1p-19q intact
d. IDH wild-type, 1p-19q co-deleted
e. IDH mutant, 1p intact and 19q deleted
b. IDH mutant, 1p-19q intact
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 extent of resection of the cyst walls
b. The extent of resection of the enhancing mass
c. The presence of endothelial proliferation on histology
d. The presence of mitoses on histology
e. The presence of hydrocephalus at presentation
b. The extent of resection of the enhancing mass
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. Percutaneous biopsy and vertebroplasty followed by radiosurgery.
b. Fractionated extemal beam radiotherapy.
c. T12 vertebrectomy with pedicle screw instrumentation followed by radiotherapy.
d. Percutaneous biopsy and vertebroplasty followed by conventional fractionated radiotherapy.
e. Posterior T12 laminectomy with pedicle screw instrumentation followed by radiotherapy.
b. Fractionated extemal beam radiotherapy.
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. Touch a skull reference point
b. Ignore the shift if minor
c. Re-register
d. Use a software correction algorithm
e. Return the reference frame to its previous position
c. Re-register
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. Entamoeba histolytica
b. Taenia solium
c.Toxoplasma gondii
d. Schistosoma mansoni
e. Plasmodium falciparum
b. Taenia solium
What is the next appropriate step in management following resection of an epidermoid tumor?
a. Prophylactic antibiotics
b.Radiographic surveillance
c.Fractionated radiotherapy
d. Brachytherapy
e.Intracystic chemotherapy
b.Radiographic surveillance
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
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.Glioma
c. Non-Small Cell Lung Carcinoma
d. Renal Carcinoma
e. Choriocarcinoma
b.Glioma
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 Facial numbness
b Diplopia that corrects with head tilt
c Monocular blindness
d Periocular numbness
e Ptosis, meiosis and anhydrosis
e Ptosis, meiosis and anhydrosis
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 and systemic chemotherapy
c Surgical resection followed by conformal radiation therapy to the tumor bed
d Surgical resection
e Neo-adjuvant radiation therapy followed by chemotherapy
c Surgical resection followed by conformal radiation therapy to the tumor bed
A 46 year-old woman with recurrent Cushing’s disease after transsphenoidal resection has MR proven extension of tumor into the cavernous sinus without supraseliar
extension. She elects to undergo radiosurgery. What is the MOST likely complication after pituitary adenoma radiosurgery?
a.Carotid artery occlusion
b.Visual loss
c.Diplopia
d.Anterior pituitary insufficiency
e.Diabetes insipidus
d.Anterior pituitary insufficiency
What finding on MRI carries the highest risk for development of seizures in the setting of a newly diagnosed posterior fossa lesion?
a. Extensive T2 hyper-intensity in the surrounding tissue
b.Presence of blood-product on gradient echo imaging
c.Size greater than 3cm
d.Homogenous enhancement after administration of gadolinium
e.Hydrocephalus
e.Hydrocephalus
Paragangliomas of the jugular foramen derive from what cell type?
a. Meningoepithelial cells
b. Epithelial cells of ectodermal origin from the stomodeum
c. Cerebellar stem cells
d. Chromaffin cells of neuro-ectodermal origin
e. Germ cells that migrated aberrantly
d. Chromaffin cells of neuro-ectodermal origin
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. subependymoma
b pilocytic astrocytoma
c meningioma
d glioblastoma multiforme.
e medulloblastoma
a. subependymoma
When a patient with neurofibromatosis type Il (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. Observation until tumor progression
c. Stereotactic radiosurgery (SRS)
d. Fractionated radiotherapy
e. Bevacizumab
b. Observation until tumor progression
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. Ependymoma
b.Low grade glioma
c. Glioblastoma multiforme
d. Primary CNS lymphoma
e. Metastatic adenocarcinoma
d. Primary CNS lymphoma
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 Serial MRI
b Chemotherapy and radiation
c Chemotherapy
d Clinical observation
e Radiation
b Chemotherapy and radiation
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. careful scientific explanation of the histology, while withholding a grave prognosis.
b. Using empathetic communication such as “It could be worse”, “I understand how you feel” or “Nothing more can be done”
c. Giving only best possible scenario to give the patient hope.
d. Demonstration of physician’s compassion, honesty, attention to questions and use of clear language.
e. Physician’s familiarity with the patient and the use of touch (e.g. holding the patient’s hand).
d. Demonstration of physician’s compassion, honesty, attention to questions and use of clear language.
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 Everolimus therapy
b Interhemispheric transcallosal resection
c stereotactic radiosurgery
d Observation
e Transcortical transventricular resection
a Everolimus therapy
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 30 Gy in 20 fractions over 3 weeks
c 50 Gy in 30 fractions over 6 weeks
d 60 Gy in 30 fractions over 6 weeks
e 20 Gy in 10 fractions over 3 weeks
a 40 Gy in 15 fractions over 3 weeks
Telomerase reverse transcriptase (TERT) promoter mutations leading to elevated TERT expression are most closely associated with what genetic alterations in
gliomas?
a MGMT promoter methylation
b EGFRUuIII expression
c Loss of ATRX expression
d P53 overexpression
e 1p19g co-deletion
e 1p19g co-deletion
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 Embryonal carcinoma
b Germinoma
c Choriocarcinoma
d Endodermal sinus tumor
e Meningioma
b Germinoma
During resection of a WHO grade Il insular glioma, what white matter language tracts run through the tumor and under the insula?
a. Superior longitudinal fasciculus Il and arcuate fasciculus
b. Inferior fronto-occipital fasciculus and superior longitudinal fasciculus-temporal parietal portion
c. Uncinate fasciculus and inferior fronto-occipital fasciculus
d. Uncinate fasciculus and arcuate fasciculus
e. Arcuate fasciculus and medial longitudinal fasciculus
c. Uncinate fasciculus and inferior fronto-occipital fasciculus
A 38 year-old woman underwent subtotal resection of a WHO Grade 2 astrocytoma. What is the most appropriate management of this patient?
a Observation
b Radiation
c Radiation and chemotherapy
d Radiation and immunotherapy
e Chemotherapy
c Radiation and chemotherapy
An 84-year-old male has an MR 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 Surgical removal via a restrosigmoid approach
b stereotactic radiosurgery in a single session
c Reassurance and follow-up MRI in 6 months
d stereotactic radiosurgery in 3-5 fractions
e Surgical removal via a translabyrinthine approach
c Reassurance and follow-up MRI in 6 months
A patient is found to have a new hemiparesis after resection of a GBM. How does this finding impact his overall survival?
a Worsens survival if the deficit is temporary
b Improves survival if the deficit is permanent
c Worsens survival if the deficit is permanent
d Unchanged survival if the deficit is permanent
e Improves survival if the deficit is temporary
c Worsens survival if the deficit is permanent
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. Hydrocephalus
b. Blindness
c. seizure disorder
d. Mutism
e. Pan-hypopituitarism
e. Pan-hypopituitarism
A 35-year-old female underwent microscopic transsephenoidal 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. Medical treatment with cabergoline
b. Endoscopic transsphenoidal resection
c. Expectant management
d. Stereotactic radiosurgery of residual nodule
e. Craniotomy for resection of residual tumor
c. Expectant management
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. 1
b. 4
c. 5
d. 2
e. 3
c. 5
