VIQ - Final Flashcards
@#e2 31. Which of the following are correct regarding benign and malignant adrenal masses: (T/F)
(a) Chemical shift MR utilises T1 weighted sequences.
(b) Approximately one third of benign adenomas have HU of >10 on unenhanced CT.
(c) Adenomas tend to show delayed enhancement with IV contrast.
(d) Adenomas tend to show delayed clearance of IV contrast.
(e) Lesions >4cm tend to be malignant.
Answers:
(a) Correct
(b) Correct
(c) Not correct
(d) Not correct
(e) Correct
Explanation:
Adenomas (benign) show rapid enhancement and rapid washout of contrast media on post contrast study.
@#e2 A 60-year-old nulliparous woman presents with postmenopausal bleeding. On transvaginal ultrasound, her endometrium is 8 mm thick and the endomyometrial junction appeared indistinct. The radiologist suspects invasive endometrial cancer and refers her for an MRI examination. What are the likely findings on MRI?
A On unenhanced Tlw images the endometrial cancer appears of high signal intensity compared to the surrounding myometrium.
B On contrast-enhanced Tlw images, endometrial cancer shows avid enhancement compared with surrounding myometrium.
C On T2w images the normally high signal junctional zone is disrupted.
D Tlw fat-saturated sequences are best used to assess the junctional zone.
E The endometrial cancer demonstrates delayed/little enhancement compared to the normal surrounding myometrium on postcontrast Tlw images
E The endometrial cancer demonstrates delayed/little enhancement compared to the normal surrounding myometrium on postcontrast Tlw images
@#e2 QUESTION 79
A 28-year-old woman has a strong family history of breast cancer and is referred for an MRI examination of the breasts. Regarding MRI of the breast, which one of the following statements is correct?
A Breast MRI should be performed during the middle of the menstrual cycle to improve sensitivity.
B Malignant lesions tend to show poor enhancement following intravenous contrast, compared with surrounding breast tissue.
C MRI has a high sensitivity and specificity for the detection of invasive breast cancer.
D Post radiotherapy, abnormal enhancement patterns return to normal within 3—6 months.
E The patient is imaged in a supine position with the breasts placed in adedicated breast coil to improve signal to noise ratio.
D Post radiotherapy, abnormal enhancement patterns return to normal within 3—6 months.
Malignant breast lesions enhance postcontrast; however, normal hormonally active breast tissue can also enhance, particularly during the middle of the menstrual cycle (6th—17th days). In younger patients it may be helpful to repeat the scan earlier or later in the menstrual cycle to improve specificity
@#e2 28. Which of the following are correct regarding ovarian cancer: (T/F)
(a) It is the commonest gynaecological malignancy.
(b) It is associated with colorectal cancer.
(c) CA-125 is specific for ovarian cancer.
(d) CT only has a pre-operative staging accuracy of 50%.
(e) Doppler ultrasound may help with differentiating benign from malignant disease.
Answers:
(a) Not correct
(b) Correct
(c) Not correct
(d) Not correct
(e) Correct
Explanation:
Endometrial cancer is the most common gynaecological malignancy. CA-125 is not specific for ovarian cancer, it is increased in benign conditions like fibroids, endometriosis and inflammatory pelvic disease. CT only has a pre-operative staging accuracy of 70% - 90%.
@#e2 Cauda equina end level:
A) Above T12
B) Below L1
C) L2/3
D) L3/4
B) Below L1
@#e2 28. A follow-up of a young man under the care of the neurooncologists reveals a drop in metastases. Which statement is most true?
A. Drop metastases tend to be in the upper spine
B. Metastases within the spinal canal are usually ventral
C. Glioblastoma is the commonest cause of drop metastases
D. Are associated with positive CSF cytology in approximately 10% of cases
E. Usually demonstrates homogenous enhancement with contrast
E. Usually demonstrates homogenous enhancement with contrast
Drop metastases are usually dorsal in location in the spinal canal.
Medulloblastomas are the most common cause of drop metastases.
A higher percentage of CSF cytology is positive.
@#e2 42. Which is a cause of solitary dense pedicle rather than erosion/absence?
A. Osteoblastoma
B. Metastatic carcinoma
C. Neurofibroma
D. Tuberculosis with paravertebral abscess
E. Aneurysmal bone cyst
- A Osteoblastoma is a cause of a solitary dense pedicle
@#e2 32 An MR of the spine in a neonate reveals two separate hemichords in two separate dural tubes. Which type of split cord malformation does this represent?
(a) Type I
(b) Type II
(c) Type Ill
(d) Type IV
(e) Type V
(a) Type I
This is a type I malformation, also known as diastematomyelia. A type II of malformation comprises two hemicords within a single dural tube, also known as diplomyelia. There is no type III, IV or V malformations.
@#e2 49. A 52-year-old woman presents with gradually increasing gait disturbance and lower limb sensory symptoms. An MRI of her spine is performed and this shows an anteriorly placed intradural, but extramedullary spinal mass.It is fairly markedly low signal on T1WI and T2WI, and shows only miminal patchy enhancement post administration of intravenous gadolinium. What isthe most likely diagnosis?
A. Neurofibroma.
B. Schwannoma.
C. Lymphoma.
D. Metastasis.
E. Meningioma.
- E. Meningioma.
Spinal meningiomas are typically iso- to hypointense on T1WI and slightly hyperintense onT2WI. There is usually strong and homogeneous enhancement with gadolinium. However, some meningiomas may contain calcification and are typically the only intradural extramedullarytumours to do so.
Some meningiomas can be heavily calcified and such a meningioma is being described in the question. These will remain dark on all MRI sequences and demonstrate onlylittle contrast uptake (in the non-calcified areas).
Schwannomas, neurofibromas, and metastases would not typically be hypointense on T2WI.
Meningeal lymphomas are very rare and usually manifest as diffuse thickening of nerve roots and/or multiple enhancing nodules.
@#e2 50. You are asked to protocol an MRI scan that is specifically being performed to look for vertebral metastatic disease. The radiographer complains that you have asked for too many sequences. Which of the following sagittal sequences is likely to be least helpful for the purposes of your examination?
A. STIR.
B. T2 fast SE with fat saturation.
C. T2 fast SE.
D. T1 fast SE.
E. T1 GE out of phase.
- C. T2 fast SE.
T2 fast SE is probably the least useful sequence when specifically looking for vertebral marrow deposits because the metastases are less conspicuous, typically being high signal on a background of high-signal fatty marrow.
On STIR and T2 fast SE with fat saturation, the metastases typically stand out as being of increased signal on a background of dark marrow because of the fat saturation techniques.
On T1 fast SE sequences, the metastases typically stand out as being lowsignal on a background of high-signal fatty marrow.
Finally, T1 GE out-of-phase imaging is also good for looking for vertebral metastatic disease. This is a sequence with a specific echo time corresponding to the time it takes for water and fat protons to move exactly 180° out of phase. In the normal adult human, the medullary bone of the vertebral bodies contains approximately equal amounts of water and fat protons. In out-ofphase conditions, the signal of both will cancel out, leaving the vertebrae completely black. In the case of vertebral pathology, however, the signal will increase and, as such, vertebral metastases (or other lesions) will clearly stand out.
@#e2 (MSK) 41 A 19-year-old female presented with lower back pain and a lumbosacral X-ray showed an expansile lyric lesion in the right sacrum. The margins were well defined and there was no softtissue mass visible. No other lesions were suspected. What is the most likely diagnosis?
a Multiple myeloma
b Osteoid osteoma
C Chordoma
d Giant cell tumour
e Aneurysmal bone cyst
41 Answer D: Giant cell tumour (GCT)
GCTs are characteristically well defined with a non-sclerotic margin and are most frequently seen in young adults aged between 20 and 40 years. Most GCTs occur in the long bones, but a number do occur in the spine where they tend to affect younger patients and to be three to four times more common in the sacrum than rest of spine.
@#e2 (MSK) 60 A 29-year-old male presented with difficulty walking and was found to have a complex sensory deficit. After investigation he was found to have an astrocytoma of the spinal cord. Which area is most likely to be involved?
a Brainstem
b Cervical spine
C Thoracic spine
d Lumbar spine
e Sacrum
60 Answer C: Thoracic spine
Almost two-thirds occur in the thoracic spinal cord, although half involve the cervical cord as they usually extend over a long region of cord (approximately seven segments on average).
@#e2 68 An 18-year-old boy was involved in a road traffic accident. He had multiple injuries and one month after his accident he still had a right Ti nerve root palsy. MRI of the brachial plexus was normal. A further MRI study of his cervicothoracic spine was performed which showed an absent right Ti nerve root. No conjoint roots were seen at C7 or T2. There was a small, well-defined area of CSF signal at the right Ti neural exit foramina. What is the most likely diagnosis?
a Lateral myelomeningocele
b Traumatic nerve root avulsion
C Tarlov cyst
d Neurogenic cyst
e Synovial cyst from the facet joint
68 Answer B: Traumatic nerve root avulsion
The right Ti nerve root has been avulsed. This most commonly occurs in the cervical region following severe acute traction on the upper limb such as a fall from a motorbike. Imaging typically demonstrates an absent nerve root within the neural foramina and a pseudomeningocele. If patients are not able to have an MRI, a CT myelogram could be performed.
@#e2 (ped) 2 The paediatric team sees a neonate with respiratory distress, bradycardia and poor swallowing. Following imaging investigation the child was found to have a small posterior fossa and dysgenesis of the hindbrain. The fourth ventricle and hindbrain are displaced caudally and the tonsils and vermis are herniating through the foramen magnum. What further CNS abnormalities may be present?
a A funnel-shaped posterior fossa
b Klippel-Feil deformity
C Basilar impression
d Herniation of the cerebellar tonsils
e Lumbar myelomeningocele
2 Answer E: Lumbar myelomeningocele
The child has Arnold Chiari malformation (Chiari II malformation), which has the above characteristic features. It is associated with lumbar myelomeningocele in >95% of cases and syringohydromyelia. In addition it is associated with the following supratentorial anomalies:
* dysgenesis of corpus callosum (80-85%)
* obstructive hydrocephalus secondary to closure of myelomeningocele (50-98%)
* absence of septum pellucidum (40%)
* excessive cortical gyration.
It is notably not associated with basilar impression, Cl assimilation and KlippelFeil deformity
@#e2 60 A 20-year-old man had progressive upper and lower limb weakness, worse in the lower limbs. On MR there was widening of the spinal canal with posterior vertebral scalloping between D3 and D7. On Ti- and T2-weighted imaging a well-defined high-intensity mass was present anterior to the spinal cord with atrophy of the cord at this level. The CSF space was slightly expanded immediately superior to the mass. No high signal was present in the cord on T2. What is the most likely diagnosis?
a Epidural abscess
b Epidural haematoma
C Neuroma
d Neurogenic cyst
e Meningioma
60 Answer D: Neurogenic cyst
The description above describes a chronic process resulting in bone remodelling and atrophy of the cord. Thus an epidural abscess and haematoma are unlikely. This mass is extramedullary but intradural. Although meningiomas and neuromas are intradural they are isointense on Ti hence the best answer is a neurogenic cyst. Neurogenic cyst is an intradural mass, which is commonly seen within the cervical and thoracic region. They are associated with other spinal abnormalities such as diastematomyelia and Klippel-Feil syndrome.
@#e2 62 Following surgery for a herniated L4/L5 disc a 66-year-old obese patient had little symptomatic relief. An MRI scan performed in the second postoperative week revealed extradural soft-tissue material within the spinal canal, which demonstrated little enhancement following contrast. Nerve root enhancement was striking. What is the most likely diagnosis?
a Arachnoiditis
b Epidural haematoma
c Residual disc material
d Epidural fibrosis
e Neuritis
62 Answer C: Residual disc material
Appearances of the post-operative spine can be challenging.
In the early postoperative period, persistent symptoms are usually due to epidural haematoma, retained fragment or recurrent disc.
In the subacute and chronic stage the differential is mainly between a disc and epidural fibrosis.
Osseous abnormalities depend on the specific surgical procedure.
Epidural fibrosis occurs commonly, enhances with contrast administration and the degree of enhancement varies with time since the operation, enhancing most strongly within a year following surgery.
Neuritis, identified as intrathecal enhancement of nerve roots, is seen in approximately 20% of symptomatic patients.
Early postoperative root enhancement is common in asymptomatic patients and is considered significant only if it persists beyond at least six to eight months.
@#e2 18 An elderly, hypertensive man is found collapsed. CT imaging demonstrates a large intracerebral haematoma. The mean CT attenuation is 70 HU, and there are fluid/ fluid levels. How old is the haematoma likely to be?
(a) 0-2 hours
(b) 3-48 hours
(c) 3-7 days
(d) 2-4 weeks
(e) 2 months
(b) 3-48 hours
@#e2 35 An elderly, hypertensive man is found collapsed. MR imaging demonstrates a large intracerebral haematoma, with intermediate. signal intensity on T1W and high signal intensity on T2W. How old is the haematoma likely to be?
(a) 0-12 hours·· ·
(b) 12-72 hours
(c) 4-7 days
(d) 8-30 days c
(e) More than 1 month
(a) 0-12 hours
@#e2 1 A young man presents with a thunderclap headache. A CT examination is performed. Sub-arachnoid blood is seen with a localised clot which has a maximum thickness of 2 mm. No intraventricular nor parenchymal blood is seen. What is the Fisher Grade?
(a) Grade 0
(b) Grade I
(c) Grade II
(d) Grade Ill
(e) Grade IV
(d) Grade Ill
The Fisher scale is useful in communicating the description of SAH.
Grade 1: no haemorrhage evident,
grade 2: SAH < 1 mm,
grade 3: SAH > 1 mm,
grade 4: associated intra-ventricular haemorrhage or parenchymal extension.
@#e2 9. Which brain tumour has the greatest incidence across all age groups?
A. Meningioma
B. Metastases
C. Pituitary adenoma
D. Haemangioblastoma
E. Glioma
E. Glioma
Gliomas consist of astrocytomas, oligodendrogliomas, paragangliomas, ganglogliomas and medulloblastomas
@#e2 26 An elderly man is admitted for assessment of focal neurological symptoms. An incidental supratentorial cystic lesion is demonstrated. Which of the following features would make the diagnosis of subdural hygroma, rather than arachnoid cyst, more likely?
(a) Isointense to CSF on T1W MR imaging
(b) Mass effect
(c) Isointense to CSF on T2W MR imaging
(d) Flattened sulci
(e) Bony remodeling
(e) Bony remodeling
Scalloping of the adjacent bone, possibly through transmitted pulsations, is often seen in arachnoid cysts. This is never seen in subdural hygromas, but can be seen with epidermoid cysts or porencephaly.?
@#e2 47 A 40 year old man presents with a seizure and a CT head reveals an intracranial lesion. An oligodendroglioma is suspected. Which feature would be least expected with this diagnosis?
(a) Ill-defined enhancement
(b) Cystic degeneration
(c) Absence of oedema
(d) Calcification
(e) Hyperdense on unenhanced imaging
(e) Hyperdense on unenhanced imaging
Oligodendrogliomas are slowly growing gliomas, most commonly located in the frontal lobes.
Large nodular calcification is present in approximately 90% of cases.
Cystic degeneration, ill-defined enhancement and a lack of oedema are all common.
Over 80% are either hypo- or iso- dense on unenhanced CT imaging.
@#e2 47 A seven-year-old boy presented with sudden onset gait problems and subtle uncoordination on the finger nose test. CT demonstrated a low density cystic solid lesion with subtle calcification centred on the vermis. Thick heterogeneous enhancement was seen within the solid area along with obstructive hydrocephalus. What is diagnosis?
a Pilocytic astrocytoma
b Medulloblastoma
c Haemangioblastoma
d Ependymoma
e Brainstem glioma
47 Answer A: Pilocytic astrocytoma
Pilocytic astrocytoma is the most likely diagnosis as it is low density on CT with calcification and nodular enhancement. They are commonly located in the vermis (50%) and are complicated by hydrocephalus.
They commonly occur before the age of nine and are characteristically a cyst with an enhancing nodule.
Haemangioblastoma is a serious consideration, but more commonly occurs in the paravermian position; the nodule is hyperdense on non-contrast CT and they virtually never calcify.
Both lesions can be cystic with a solid enhancing nodule.
Haemangioblastomas occur more commonly in adults and as part of VHL syndrome.
@#e2 (Ped) 58 A three-year-old boy is taken to an optician following problems reading. The optician finds the child has a loss of visual acuity and visual fields; he also did not think the boy looked well. He referred the child to the hospital. The paediatrician found the boy to be thin, hyperactive and unusually alert for his age. A CT brain was performed, which showed a mass in the suprasellar region that appeared to be extending into the optic chiasm. This had mixed enhancement with some cystic areas and calcifications. What is the most likely diagnosis?
a Hypothalamic glioma
b Hypothalamic hamartoma
C Craniopharyngioma
d Astrocytoma
e Pituitary adenoma
58 Answer A: Hypothalamic glioma
These are the most common hypothalamic masses accounting for 10-15% of supratentorial tumours in children and present between the ages of two and four years old.
This child is showing visual deficits and diencephalic syndrome, which is present in up to 20% of cases.
The inhomogeneous enhancement is caused by tumour necrosis.
Craniopharyngioma and astrocytomas are uncommon in these sites.
Hypothalamic hamartomas are rare and usually present before the age of two years old. They are round isodense lesions that do not enhance on CT.
@#e2 2.A 38-year-old male with Human Immunodeficiency Virus (HIV) stopped taking his retrovirals 6 months ago and now presents with confusion. CT brain shows non-enhancing hypodensities, with apparent dilated perivascular spaces, although these were not present on a CT brain from 2 years ago. What is the most likely cause?
A. Cryptococcus
B. Progressive multifocal leukoencephelopathy
C. Tuberculosis
D. CMV encephalitis
E. Toxoplasmosis
A. Cryptococcus
More commonly cryptococcus meningitis but Cryptococcus or gelatinous pseudocysts reside in dilated perivascular spaces
@#e2 57. A four month old male undergoes investigation for microcephaly and hearing loss. Unenhanced CT brain shows several periventricular subependymal cysts and multiple coarse periventricular and parenchymal white matter calcifications. There is diffuse hypoplasia of the cerebellum. What is the most likely diagnosis?
a. Tuberous sclerosis
b. Sturge–Weber syndrome
c. Cytomegalovirus infection
d. Venous sinus thrombosis
e. Congenital rubella
- c. Cytomegalovirus infection
This is the most common intrauterine infection and the leading cause of brain disease and hearing loss in children.
Typical imaging findings include periventricular subependymal cysts representing focal areas of necrosis and glial reaction, periventricular postinflammatory calcifications, scattered calcifications in basal ganglia and brain parenchyma, microcephaly due to disturbance of cell proliferation and hypoplasia of the cerebellum. There may also be lissencephaly, cortical dysplasia, polymicrogyria and schizencephaly due to disturbed neuronal migration.
@#e2 (Ped) 25 You are asked to perform a cranial ultrasound scan on a neonate who was born with poor APGAR scores and made a poor inspiratory effort. On the ultrasound you find multiple irregular foci of calcification throughout the periventricular region, the thalamus and basal ganglia. What is the most likely diagnosis?
a Congenital Cytornegalovirus infection
b Tuberous sclerosis
c Congenital toxoplasmosis infection
d Grade IV acute haemorrhage
e Periventricular leukomalacia due to hypoxic injury
25 Answer C. Congenital toxoplasmosis infection
The presentation of congenital toxoplasmosis infection is very non-specific, as with most of the congenital infections.
The ultrasound characteristics are different from congenital Cytornegalovirus in that the calcifications are in the basal ganglia and thalamus as well as the periventricular region.
The calcifications can be lobulated or curvilinear and can be present in the choroid plexus.
The location also differentiates the findings from tuberous sclerosis.
Periventricular leukomalacia findings are a broad zone of periventricular echogenicity.
@#e2 46 A 2 7-year-old HIV positive man was admitted with increasing confusion and lethargy. He had a CD4 count of 150 but had no history of an AIDS-defining illness. Cross-sectional imaging of the head was performed. What features make a diagnosis of toxoplasmosis more likely than lymphoma?
a Corpus callosum involved
b Haemorrhage on CT
C Basal ganglia lesions
d Single lesion
e Subependymal spread
46 Answer B: Haemorrhage on CT
Differentiating toxoplasmosis and cerebral lymphoma can be difficult as both can present as multiple ring enhancing lesions.
Features that are more likely to represent lymphoma are a single lesions, subependymal spread and lesions within the corpus callosum.
Features that are more likely to represent toxoplasmosis are haemorrhage on CT and high signal on T2 W imaging.
Toxoplasmosis has a predilection for the basal ganglia but lymphoma can also be found in this region.
@#e2 70 A 27-year-old female with AIDS presented with a fit and following further investigations, including CT and MRI scans, her symptoms were felt to be attributable to HIV encephalitis. Which region of her brain is most likely to be abnormal on the MRI scan?
a Anteroinferior aspects of the temporal lobes
b White matter of the centrum semiovale
C Corpus striatum (putamen and caudate nuclei)
d Superior cerebellar peduncles
e Hypothalamus
70 Answer B: White matter of the centrum semiovale
Human immunodeficiency virus causes encephalitis in 60% of patients with AIDS.
It predominately affects the white matter, particularly the centrum semiovale and results in gliosis and demyelinating plaques.
These plaques are not dissimilar to plaques in multiple sclerosis as they are in a periventricular position and high signal on T2-weighted images. Unlike plaques in MS they tend not to enhance with contrast. (Acute plaques in MS can enhance for up to six weeks after they first appear.)
Generalised diffuse parenchymal atrophy is a feature.
@#e2 12. Which is the cause of low attenuation in the basal ganglia?
A. Hypoparathyroidism
B. Pseudohypoparathyroidism
C. Hypothyroidism
D. Wilson’s disease
E. Radiation therapy
D. Wilson’s disease
Other causes increase CO poisoning, barbiturate intoxication, hypoxia, hypoglycaemia and lacunar infarcts.
@#e2 31. A 58-year-old patient is found at home with a reduced GCS. CT brain reveals atrophy only. MRI brain reveals hyperintensity in the tegmentum (except for the red nucleus) and hypointensity of the superior colliculus on T2WI, as well as hyperintensity in the basal ganglia. What is the most likely cause?
A. Cocaine abuse.
B. Methanol poisoning.
C. Primary basal ganglia haemorrhage.
D. Wilson’s disease.
E. Carbon monoxide poisoning.
- D. Wilson’s disease.
Hyperintensity in the tegmentum (except for the red nucleus) and hypointensity of the superior colliculus are described as the ‘face of the giant panda sign’ and are seen in axial T2WI sections of the midbrain in Wilson’s disease.
A ‘double panda sign’ has also been described, with a second ‘panda cub face’ in the pons.
Abnormal signal can also be seen in the basal ganglia and thalamus in Wilson’s disease (putamen most commonly).
The signal abnormalities are due to copper deposition. Signal is generally reduced on T1WI sequences, although it may be increased due to the paramagnetic effects of copper and also due to the hepatic component of Wilson’s disease (a portocaval shunt can produce this latter finding). Signal is generally increased on T2WI sequences, but it can be of mixed or reduced intensity.
Similarly carbon monoxide poisoning and methanol poisoning can cause increased or reduced signal on T1WI.
Methanol poisoning typically causes abnormal signal in the putamen, with haemorrhagic necrosis being more typical, whereas carbon monoxide poisoning typically affects the globus pallidus. The latter would be expected to cause low attenuation in the basal ganglia on CT.
The findings on CT exclude basal ganglia haemorrhage.
Amphetamine and cocaine abuse can cause high T2WI signal in the basal ganglia due to small areas of infarction, but are not associated with the midbrain changes.
@#e2 34. A 34-year-old liver transplant recipient presents to hospital with confusion and seizures. A CT brain reveals low attenuation in the deep and subcortical white matter of the occipital and parietal lobes bilaterally. There is no abnormal enhancement post IV contrast administration. As the reporting radiologist, you advise that the clinical team first:
A. measure blood glucose
B. measure serum alpha-feta protein
C. measure blood pressure
D. send coagulation screen
E. measure d-dimer.
- C. Measure blood pressure
The CT findings are consistent with PRES. This is a usually reversible neurological syndrome with a variety of presenting symptoms ranging from altered mental status to seizures, headache, and loss of vision. Common causes include hypertension, eclampsia and preeclampsia, immunosuppressive medications such as cyclosporine, various antineoplastic agents (including interferon), SLE, and various causes of renal failure. Hypertension is common in PRES, but may be mild and is not universally present, especially in the setting of immunosuppression. However, in the vignette given, hypertension is a possible cause and should be sought. Cyclosporin or tacrolimus might be causes; the former is thought to result in PRES both via a direct neurotoxic effect and by causing hypertension. The condition is not always reversible and may result in haemorrhagic infarcts. The classic MRI finding is of hyperintensity on FLAIR in the parieto-occipital and posterior frontal cortical and subcortical white matter. Less commonly the brainstem, basal ganglia, and cerebellum are involved. Atypical imaging appearances include contrast enhancement, haemorrhage, and restricted diffusion on MRI. Abnormalities can often be seen on CT, as described in the vignette.
@#e2 37. A 73-year-old has been referred for assessment of cognitive decline. A CT brain reveals cerebral atrophy and a dementia specialist refers her for PET-CT brain. Which of the following findings is most consistent with early Alzheimer’s disease?
A. Diffuse reduced activity.
B. Reduced activity in the precuneus and posterior cingulate gyrus.
C. Reduced activity in the frontotemporal regions.
D. Reduced activity in the caudate and lentiform nuclei.
E. Reduced activity bilaterally in the occipital cortex.
- B. Reduced activity in the precuneus and posterior cingulate gyrus.
FDG-PET-CT has been shown to have a sensitivity and specificity of 93% for mild to moderate Alzheimer’s disease. The technique has been shown to provide important prognostic information so that a negative PET-CT scan is indicative of unlikely progression of cognitive impairment for a mean follow-up of 3 years in those patients who initially present with cognitive symptoms of dementia.
The more specific findings on PET-CT in Alzheimer’s disease are early reduced activity in the precuneus/posterior cingulate gyrus and the superior, middle, and inferior temporal lobe gyrus, with relative sparing of the primary sensorimotor and visual cortex, and sparing of the striatum, thalamus, and cerebellum.
Diffuse reduced activity of the cortical/subcortical regions and cerebellum is more typical of multiinfarct dementia.
Reduced activity in the fronto-temporal regions is more consistent with fronto-temporal dementia.
Reduced activity in the occipital cortex reflects the visual problems encountered in lewy body dementia.
Reduced activity in the caudate and lentiform nuclei is more typical of Huntingdon’s chorea.
@#e2 (CNS) 9 A plain radiograph is performed on a male child. Unilateral, premature fusion of both the coronal and lambdoid sutures is evident. What is the most appropriate description?
(a) Scaphocephaly
(b) Brachycephaly
(c) Plagiocephaly
(d) Trigonocophaly
(e) Oxycephaly
(c) Plagiocephaly
The common craniosynostoses include:
@#e2 11 A cranial US is performed in a pre-term neonate. There is hyperechoic material within the ventricles consistent with recent haemorrhage, but the ventricles are not dilated. How would you grade this germinal matrix bleed?
(a) Grade I
(b) Grade II
(c) Grade Ill
(d) Grade IV
(e) Grade V
(b) Grade II
Grade I: subependymal haemorrhage,
Grade II: intraventricular haemorrhage, no ventricular dilation (10% mortality),
Grade Ill: intraventricular hemorrhage with ventricular dilation (20% mortality),
Grade ·IV: intraparenchymal haemorrhage (>50% mortality).
There is no Grade V.
@#e2 21 Which of the following is not a cause of secondary craniosynostosis?
(a) Crouzon’s syndrome
(b) Hypothyroidism
(c) Previous shunt procedures
(d) Rickets
(e) Thalassaemia
(b) Hypothyroidism
Craniosynostosis is the premature closure of the sutures, which may be primary (idiopathic) or secondary. Secondary causes include: metabolic (rickets, hypercalcaemia, hyperthyroidism, hypervitaminosis D), haematological (thalassaemia, SCD), and bone dysplasias (achondroplasia, metaphyseal dysplasia). It is also associated with syndromes (Crouzon, Apert, Treacher-Collins), and can occur following shunt surgery for hydrocephalus.
@#e2 49 A 4 week old ex-premature baby has a witnessed seizure. A cranial US is performed which shows cystic structures bilaterally, adjacent to the trigone of the lateral ventricles. Which of the following favours a diagnosis of chronic periventricular leukomalacia over porencephaly?
(a) Anechoic cysts
(b) Persistenae of cysts on follow-up US
(c) Septated cysts
(d) Symmetrical distribution
(e) Watershed territory distribution
(d) Symmetrical distribution
PVL is more common in preterm children, is secondary to ischaemia and usually occurs in the watershed areas. Initially there will be hyperechoic changes which gradually become cystic (>2 wks); the cysts are never septated and usually resolve over time.
Porencephaly can be developmental or due to a vascular or infectious process which destroys brain tissue; it is almost always asymmetrical, rarely disappears over time and is often seen as an extension of the ventricle or sub-arachnoid space. If secondary to ischaemia it can also be in a watershed distribution.
@#e2 53. Regarding rhabdomyosarcoma in the paediatric population. What is the most likely site of origin?
(a) Extremities
(b) Genito-urinary system
(c) Head and neck
(d) Orbits
(e) Retroperitoneal
(c) Head and neck
Rhabdomyosarcoma represents 4-8% of cancers in children and is the 4th commonest after CNS tumours, neuroblastoma and Willl)’s and is the commonest soft tissue sarcoma in children. The sites affected are: head and neck (28%), extremities (24%), genitourinary system, trunk (11%), orbits (7%), and retroperitoneum (6%); other sites in <3%.
@#e2 (MSK) 58 A 30 year old patient presents with multiple bilateral renal angiomyolipomas, one of which has bled. She is also found to have a giant cell astrocytoma in her brain and bilateral interstitial lower lobe fibrosis on CXR. Which of the following bone lesions is most commonly associated with this condition?
(a) Bone cysts
(b) Osteochondroma
(c) Giant cell tumour
(d) Fibrous dysplasia
(e) Adamantinoma
(a) Bone cysts
The underlying condition described is tuberous sclerosis. The associated bone cysts most commonly affect the small bones of the hand. Other skeletal features include sclerotic bone islands which most commonly affect the calvarium (in 45% of cases) and also the pelvis and long bones.
@#e2 37 A 64-year-old lady is being consented for a diagnostic cerebral angiogram for a suspected MCA aneurysm. She asks about the risk of stroke. What is the risk due to the angiogram?
a 4.7%
b 0.2%
c 1.3%
d 10%
e 3.5%
37 Answer C: 1.3%
The risk of stroke due to an angiogram is approximately 1.3 %.