VIQ - TEST PAPER 3 Flashcards by Waleed Eldahshan

@# 2.All of the following are associations of Chiari II malformation, except

A. Dysgenesis of corpus callosum

B. Klippel-Feil deformity

C. Syringomyelia

D. Meningomyelocele

E. Tectal beaking

2.B. Klippel-Feil deformity

The hallmarks of Chiari II malformation include caudally displaced fourth ventricle (the fourthventricle is in normal position in Chiari 1 malformation), caudally displaced brain stem, and tonsillar or vermian herniation through the foramen magnum.
Associations include lumbar myelomeningocele, syringohydromyelia, dysgenesis of the corpus callosum, obstructive hydrocephalus, absent septum pellucidum and excess cortical gyration.

It is not associated with any of the bony abnormalities described in Chiari I malformation, like basilar impression, occipitalization of the atlas, platybasia and Klippel-Feil anomaly.

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@# 5. Skeletal survey is indicated as an investigation for all of the following, except

A. Eosinophilic granuloma

B. Multiple myeloma

C. Non-accidental injury

D. Skeletal metastasis

E. Suspected skeletal dysplasia

D. Skeletal metastasis

Eosinophilic granuloma is associated with Langerhans cell histiocytosis and is an indication for a skeletal survey, along with multiple myeloma and non-accidental injury. Skeletal surveys are never performed for skeletal metastasis.
Radiological evaluation of skeletal dysplasia often starts with a skeletal survey for several non-lethal skeletal dysplasia.

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@# 9. A 43-year-old woman currently on treatment for Crohn’s disease needs to have her medication reviewed following the recommendation of the MDT. The gastroenterologist wants to perform a CT enterography to assess her disease status and response to treatment prior to the medication review. Which one of the following CT signs suggests inactive Crohn’s disease?

A. Increased mesenteric fat attenuation

B. Mesenteric fibro-fatty proliferation

C. Target sign

D. A non-enhancing thickened bowel wall

E. Comb sign

B. Mesenteric fibro-fatty proliferation

The main diagnostic purpose of CT enterography in the setting of Crohn’s disease is to differentiate active inflammatory strictures from fibrotic strictures in order to guide therapy.

CT features of active Crohn’s disease include mucosal hyperenhancement, wall thickening (thickness >3 mm), mural stratification with a prominent vasa recta (comb sign) and mesenteric fat stranding, all of which are exquisitely demonstrated at CT enterography.

The capability of CT enterography to depict extra-enteric disease allows the simultaneous diagnosis of complications associated with Crohn’s disease, such as obstruction, sinus tract, fistula and abscess formation.

Mural enhancement is the most sensitive indicator of active Crohn’s disease.

Care should be taken to compare bowel loops with similar distention, since both the jejunum and normal collapsed loops may demonstrate regions of higher attenuation, simulating enhancement.

Inadequately distended bowel loops may be difficult to assess, and secondary signs of active disease, such as mesenteric fat stranding, vasa recta prominence or complications such as fistulas and abscesses should be sought to maximise the accuracy of a diagnosis of active disease.
Prominence of the vasa recta adjacent to the inflamed loop of bowel (comb sign), along with increased mesenteric fat attenuation, is (he most specific CT feature of active Crohn’s disease.

Findings that might be seen in inactive long standing Crohn’s disease include submucosal fat deposition, pseudosacculation, surrounding fibro-fatty proliferation and fibrotic strictures.

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@# 11. A 30-year-old woman is struck over the right cheek during an altercation with another woman. There is bruising and swelling, and a fracture is suspected. What view is the best for demonstrating a zygomatic arch fracture?

A. Townes view

B. Submentovertex view

C. Swimmer’s view

D. Occipitomental view 45 degrees

E. Occipitomental view 30 degrees

B. Submentovertex view’

The submentovertex (SMV) view, also called the bucket-handle view, shows fractures of the zygomatic arch best.

Townes and occipitomental views are for skull and facial bone fractures.

Swimmer’s view is for viewing the cervico-thoracic junction

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@# 13. When can you see the radiographic changes of fat embolism on a chest X-ray?

A. No Yes No

The chest radiographic appearance of fat embolism syndrome is non specific. Normal radiographs can also be seen. Most patients presenting with a normal initial radiograph develop radiographic- evident abnormalities within 72 hours of injury, and most cases show radiographic resolution within 2 weeks of hospitalisation.

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@# 15. A 53-year-old woman with a long-standing history of known Crohn’s disease is referred for a CT enterography for assessment of disease status. Which one of the following statements regarding the CT evaluation of Crohn’s disease is true?

A. Perianal disease is uncommon

B. A thickened hyperenhancing bowel wall is a sign of active disease

C. Mural stratification implies perforation in the bowel wall

D. The comb sign is a specific sign

E. Perienteric stranding is a specific sign

B. A thickened hyperenhancing bowel wall is a sign of active disease.

The main diagnostic purpose of CT enterography in the setting of Crohn’s disease is to differentiate active inflammatory strictures from fibrotic strictures in order to guide therapy.

Mural enhancement is the most sensitive indicator of active Crohn’s disease.

The term mural stratification denotes the visualisation of bowel wall layers at CT. At CT enterography, the oedematous bowel wall has a trilaminar appearance, with enhanced outer serosal and inner mucosal layers and an interposed submucosal layer of lower attenuation. However, this feature is not specific to Crohn’s disease; it is seen also in other inflammatory bowel diseases and even in some cases of bowel ischaemia.

Prominence of the vasa recta adjacent to the inflamed loop of bowel (comb sign) along with increased mesenteric fat attenuation, is the most specific CT feature of active Crohn’s disease.

Findings that might be seen in inactive long standing Crohn’s disease include submucosal fat deposition, pseudosacculation, surrounding fibro-fatty proliferation and fibrotic strictures.

Perianal disease is common in Crohn’s disease.

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@#1 16. A young woman with polycystic ovarian disease is currently under the transplant team, being reviewed and worked up for potential renal transplantation. Regarding renal transplantation, all of the following are true, except

A. US kidney, CT angiography and plain abdominal film provide similar information to MR angiography and MR urography.

B. Pelvicalyceal duplication precludes kidney donation.

C. Twenty percent of kidneys have accessory arterial supply.

D. Right kidney is placed in the left iliac fossa because it is easier technically.

E. Carrel patch is used only for cadaveric kidney.

B. Pelvicalyceal duplication precludes kidney donation.

The aims of preoperative evaluation of living related donors are to show that the donor will retain a normal kidney after unilateral nephrectomy, to demonstrate that the kidney to be transplanted has no major abnormality, and to outline the vascular anatomy.

US assesses the parenchyma, CT angiogram shows the arterial and venous anatomy, and the plain film demonstrates the pelvicalyceal system. MR angiography and MR urography provide similar information.

Conditions that do not preclude donation include pelvicalyceal duplication, solitary renal cyst, unilateral mild reflux nephropathy and only one scar.

In the case of unilateral duplication, the contralateral kidney is donated.

Twenty percent of kidneys have accessory arterial supply.

Kidneys with multiple arterial supply are more likely to have vascular complications.

The transplanted kidney is placed extraperitoneally in the iliac fossa; usually the right kidney is placed in the left iliac fossa because the vascular anastomosis is easier.

When a cadaveric kidney is used, an aortic patch (Carrel patch) is removed with the renal artery.

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@#1 17. A 25-year-old man presents with progressive increase in knee pain. Plain films show features of osteoarthrosis with increased soft-tissue swelling and density. An MRI shows diffuse low signal on T2W images to the synovium of the knee on the background of large joint effusion. What is the likely diagnosis?

A. Amyloid arthropathy

B. Haemophilic arthropathy

C. PVNS

D. Primary synovial osteochondromatosis

E. Rapidly destructive articular disease

B. Haemophilic arthropathy

Radiographic findings vary greatly with the different stages of haemophilic arthropathy (acute, subacute or chronic haemarthrosis) and reflect the presence of haemarthrosis (joint effusion), synovial inflammation and hyperaemia (osteoporosis and epiphyseal overgrowth), chondral erosions and subchondral resorption (osseous erosions and cysts), cartilaginous denudation (joint space narrowing), intraosseous or subperiosteal haemorrhage (pseudotumours) and osseous proliferation (sclerosis and osteophytosis).

Some abnormalities of osseous shape, such as widening of the intercondylar notch, flattening of the condylar surface or squaring of the patella, are very characteristic of chronic haemarthrosis of the knee.

At MR imaging, hypertrophied synovial membrane resulting from repetitive haemarthrosis has characteristic low signal intensity with all pulse sequences, especially with gradient echo sequences, due to the magnetic susceptibility effect caused by haemosiderin.

As in pigmented villonodular synovitis, the signal intensity of the subarticular defects varies and may indicate the presence of fluid (high signal intensity on T2-weighted images), soft tissue (intermediate signal intensity) or synovial tissue with haemosiderin (low signal intensity).

Rapidly destructive articular disease is an unusual form of osteoarthritis that typically involves the hip. The disease is almost always unilateral, but bilateral lesions and involvement of shoulder have also been reported. Serial radiographs show progressive loss of joint space and loss of subchondral bone in the femoral head and acetabulum, resulting in marked flattening and deformity of the femoral head (‘hatchet’ deformity). Superolateral subluxation of the femoral head or intrusion deformity within the ilium can be observed. Most cases demonstrate subchondral defects and mild sclerosis. However, osteophytes are small or absent.

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@#e 20. All of the following are causes of lower zone fibrosis, except

A. Amiodarone

B. Idiopathic pulmonary fibrosis

C. Asbestosis

D. Ankylosing spondylitis

E. Neurofibromatosis I

D. Ankylosing spondylitis

Causes of lower zone fibrosis include asbestosis, aspiration, cryptogenic alveolitis (IPF), neurofibromatosis I and tuberous sclerosis; connective tissue diseases like RA, scleroderma and SLE; and drug toxicity to substances like amiodarone and nitrofurantoin.

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@# 21. All of the following are true for neurocysticercosis, except

A. There arc four recognised stages on CT/MR.

B. The granular nodular stage is not associated with oedema.

C. The vesicular stage does not show any oedema.

D. The vesicular stage shows a nodule with a ‘hole with dot’ appearance.

E. Colloidal stage shows an avid ring-enhancing capsule.

B. The granular nodular stage is not associated with oedema.

Neurocysticercosis has been classified into active and non active forms on the basis of clinical presentation, results of CSF analysis and imaging findings.

The active forms include arachnoiditis with or without ventricular obstruction and vasculitis with or without infarction.

On the basis of radiologic findings, neurocysticercosis is divided into five stages: non-cystic, vesicular, colloidal vesicular, granular nodular and calcified nodular. Of these, all the stages apart from the first (non cystic stage) arc visible on CT/MRI.

Vesicular stage: Cyst signal intensity similar to that of CSF on T1-weighted and T2-weighted images; cyst wall is well defined and thin, with little or no enhancement on gadolinium enhanced images; scolex (hole with dot appearance); iso- or hypointense relative to white matter on T1-weighted images; iso- to hyperintense relative to white matter on T2-weighted images; best seen on PD-weighted images.

Colloidal vesicular stage: Cyst contents are hyperintense on T1-weighted and T2-weighted images (proteinaceous fluid), cyst wall is thick and hypointense, pericystic oedema (best seen on FLAIR), pericystic enhancement on gadolinium-enhanced images.

Granular nodular stage: Similar to the colloidal vesicular stage but with more oedema, thicker ring enhancement.

Calcified nodular stage: Hypointense nodules, no oedema, no enhancement.

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@#1 25. A 2-year-old girl with headache shows a large cyst in the posterior fossa with communicating hydrocephalus; bone windows reveal scalloping of the petrous pyramids. What is the likely diagnosis?

A. Dandy-Walker malformation

B. Dandy-Walker variant

C. Astrocytoma

D. Haemangioblastoma

E. Chiari malformation

A. Dandy-Walker malformation

The characteristic triad of the Dandy Walker malformation includes (1) complete or partial agenesis of the vermis, (2) cystic dilatation of the fourth ventricle and (3) an enlarged posterior fossa with upward displacement of the lateral sinuses, tentorium and torcula. The triad is usually associated with hydrocephalus (most common presentation 80%), but this condition should be considered a common complication and not as pan of the malformation itself. Depending on the degree of hydrocephalus, the age at diagnosis varies from the neonatal period to later childhood.
The skull is enlarged, with characteristic thinning and bulging of the occiput. Pressure from the massively dilated fourth ventricle, along with cerebrospinal fluid pulsations, causes erosive scalloping of the occiput and petrous temporal bones.
The cerebellar hemispheres are typically hypoplastic, and in extreme cases only a small nubbin of compressed cerebellar tissue is identified contiguous laterally with the wall of the posterior fossa cyst. Anomalies of the posterior inferior cerebellar arteries, especially absence of the inferior vermian branches and absence of the inferior vermian vein, help in the angiographic differentiation of a Dandy-Walker cyst from an arachnoid cyst, in which the vessels are displaced but present.
The Dandy-Walker variant is used to describe a cystic posterior fossa malformation with varying degrees of agenesis of the vermis associated with expansion (often considerable) of the fourth ventricle, which communicates freely with the perimedullary subarachnoid space.

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@#1 28. An adolescent with growth disturbance presents with a visual difficulty. A non-calcified, thin-walled cyst with no enhancement is seen in the intrasellar region on MRI.
Which of the following is the most likely diagnosis?

A. Craniopharyngioma

B. Macroadenoma

C. Epidermoid

D. Rathke cleft cyst

E. Metastasis

D. Rathke cleft cyst

Rathke cleft cysts are benign cystic sellar lesions that are generally asymptomatic, but they may be associated with hypopituitarism, visual disturbance and headache. At MR imaging, Rathke cleft cysts have a variable Tl signal, depending on the protein concentration. Cysts with high protein content demonstrate high Tl signal and usually low intracystic water content that leads to T2 signal decrease. Thus, typical Rathke cleft cysts appear as non-enhancing well demarcated intrasellar rounded lesions located exactly at the midline between the anterior and posterior pituitary lobes. The cysts have a homogeneously hyperintense Tl signal and, often, a hypointense T2 signal. Axial images are crucial for identifying the specific location and characteristic kidney shape of a Rathke cleft cyst.
The presence of fluid-fluid level or haemorrhagic debris in an intrasellar lesion suggests a pituitary adenoma, because a Rathke deft cyst almost never bleeds.
Craniopharyngioma typically appears as intrasellar or suprasellar heterogeneously enhancing lesions with a tripartite structure of solid, calcified and cystic components. They are difficult to distinguish from pituitary adenoma, although the fluid fluid level is more likely to suggest a pituitary adenoma.

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@#1 30. A 25-year-old man has injured his knee. Sagittal T2W MRI sequences show a double posterior cruciate ligament (PCL) sign. Which of the following is the most likely injury?

A. Ruptured PCL

B. Bucket-handle tear of meniscus

C. Osteochondral fragmentation

D. Radial tear of meniscus

F. . Anterior cruciate ligament (ACL)

B. Bucket-handle tear of meniscus

Bucket-handle tears of the meniscus involve displacement of the free edge of the meniscus into the intercondylar notch. The free edge can be seen adjacent to the PCL on sagittal images giving a double PCL sign. On coronal imaging, the meniscal fragment is displaced medially. A radial mcniscal tear manifests as a linear collection of high signal in the meniscus that extends to the superior or inferior articular surfaces. Rupture of the ACL or PCL results in the ligament losing die normal position and morphology but not a double PCL sign. When assessing the PCL, be aware that the ligaments of Humphrey and Wrisberg can give the impression of a tear to the inexperienced eye. These ligaments are extensions of the meniscofemoral ligament; the ligament of Humphrey passes anterior to the PCL and the ligament of Wrisberg posteriorly.

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@#1 32. A 67-year-old woman with systemic amyloidosis diagnosed on rectal biopsy presents to her GP with progressive central abdominal pain, bloating, and abdominal distension. All of the following are abnormalities due to amyloid infiltration in the gastrointestinal tract, except

A. Jejunization of the ileum

B. Macroglossia

C. Gastroesophageal reflux

D. Diffuse nodular wall thickening in small bowel

E. Colonic dilatation due to adynamic ileus

A. ‘Jejunisation’ of the ileum

In both primary and secondary amyloidosis, the most commonly involved organ system is the gastrointestinal system, with the colon being the most frequently involved organ. Oesophageal and gastric involvement usually manifests as dysmotility, wall thickening and gastroesophageal reflux disease. This results from amyloid infiltration of the muscularis and/or destruction of the Auerbach plexus. When the small intestine is involved, the most common finding is diffuse or nodular wall thickening. Abdominal pain, malabsorption and haemorrhage are rare complications. Colonic biopsy specimens are positive in 80% of patients with systemic amyloidosis.
Contrary to the high pathologic specificity, radiologic findings are rare and non-specific.
The most common finding is colonic dilatation owing to adynamic ileus and more rarely bowel wall thickening. Even more rarely, intramural bowel haemorrhage or perforation can occur.
Splenomegaly is the only finding associated with splenic involvement This causes increased fragility, and spontaneous rupture can ensue with life threatening consequences. The liver is also commonly involved, but radiologic signs are also non-specific. Diffuse infiltration is the rule, which causes decreased attenuation at CT and hepatomegaly.
Macroglossia can also result from amyloid infiltration of the intrinsic muscles. Jejunisation of the ileum can be seen with coeliac disease.

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@#1 33. A 44-year-old man with a painful right index finger and positive Love’s test undergoes a plain film study, which shows extrinsic erosion involving the terminal phalanx with a preserved sclerotic rim. There is no definite history of previous injury to the index finger. MRI is performed for further characterisation, which shows a homogenously high-signal lesion on T2W images in a subungual location. What is your diagnosis?

A. Epidermoid inclusion cyst

B. Glomus tumour

C. Implantation dermoid cyst

D. Soft-tissue component of osteosarcoma

E. Giant cell tumour of the tendon sheath

B. Glomus tumour

A glomus tumour is a hamartoma arising from the glomus body within the dermis of the finger. The subungual position is characteristic of the lesion, which results in extrinsic erosion of the adjacent terminal phalanx. The tumour can also occur entirely within bone, although this is less common. It exhibits intense high T2 signal with avid contrast enhancement as it is a highly vascular lesion.

Epidermoid inclusion cysts, otherwise known as implantation dermoid cysts, are associated with a history of penetrating trauma.

A giant cell tumour of the tendon sheath lies in close relation to the tendon and does not exhibit such intense T2 signal.

The description is not compatible with a soft-tissue osteosarcoma.

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@#1 34. A 66-year-old man with a palpable mass in the left loin and painless haematuria undergoes a staging CT of the abdomen for renal cell carcinoma. The staging CT shows a 6 cm heterogeneous, solid left renal mass with direct extension into the perinephric fat. Tumour mass is seen in the left renal vein extending into the IVC, but this is confined to below the level of the diaphragm. What is the T stage?

A. T1

B. T2

C. T3a

D. T3b

E. T3c

D. T3b

T-stage
T1a: Limited to kidney, <4 cm
T1b: Limited to kidney, >4 cm but <7 cm
T2a: Limited to kidney, >7 cm but not more than 10 cm
T2b: Limited to kidney, >10 cm
T3a: Spread to perinephric fat
T3b: Spread to renal vein or IVC below diaphragm
T3c: Spread to supra diaphragmatic I VC or invades the wall of the IVC
T4: Involves ipsilateral adrenal gland or invades beyond Gerota’s fascia
N-stage
N0: No nodal involvement N1: Metastasis to one regional lymph node(s)
M-stage
M0: No distant metastases M1: Distant metastases

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@#e 37. A middle-aged man presents with easy fatigability. CT shows an anterior mediastinal mass with areas of calcifications, invading the mediastinal structures. There are multiple small pleural masses. What is the most likely diagnosis?

A. Thymoma

B. Thymic lipoma

C. Lymphoma

D. Teratoma

E. Asbestosis

A. Thymoma

Thymomas are classified as encapsulated, infiltrative and metastasising, with pulmonary and pleural deposits and thymic carcinoma. Half the thymomas are asymptomatic and 30% are associated with myasthenia gravis.
At CT a benign thymoma appears round, oval or lobulated. Focal calcification is seen in 25%, which may be dense, irregular or coarse. Benign thymomas show mild homogenous enhancement; cystic changes are also described. Invasive thymoma are heterogeneous in appearance; pericardial and pleural nodules suggest malignancy. Egg-shell calcification is described in invasive thymoma. Absent fat planes between thymoma and mediastinum does not necessarily reflect invasion.

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@#1 42. A 7-year-old boy presents with acute scrotum. Which one of the following features on ultrasound is more suggestive of a diagnosis other than testicular torsion?

A. Abnormal testicular texture

B. Testicular swelling

C. Coded spermatic cord

D. Scrotal wall oedema

E. Decreased or absent blood flow

D. Scrotal wall oedema

Differential diagnosis of acute scrotum includes testicular torsion (the most important differential) along with torsion of the testicular appendix, epididymitis and epididymo-orchitis. US (including the use of Doppler imaging) plays a vital role in distinguishing between these diagnoses. All of the above features can be seen in testicular torsion, along with such findings as epididymal enlargement and hydrocoele. However, scrotal wall oedema is the only one of these findings that is more commonly seen with alternative causes of acute scrotum than it is with acute testicular torsion. Decreased or absent blood flow is considered the most important finding, although torsion is not excluded if there is normal or increased blood flow, which may occur after spontaneous detorsion.

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@#1 45. A 27-year-old woman is complaining of lower abdominal pain localised to the left iliac fossa. A CT scan raises a suspicion of epiploic appendagitis. All of the following statements about epiploic appendagitis are true, except

A. Treatment is usually medical.

B. It can mimic acute appendicitis or diverticulitis.

C. It is usually associated with change in bowel habits.

D. Most patients have normal inflammatory markers.

E. The most common site of appendagitis is adjacent to the sigmoid colon.

C. It is usually associated with change in bowel habits

The condition most commonly manifests in the fourth to fifth decades of life, predominantly in men. With diagnosis based on clinical manifestations alone, acute epiploic appendagitis is misdiagnosed in the majority of patients. Clinically, acute epiploic appendagitis manifests with acute onset of pain, most often in the left lower quadrant, and this symptom often leads to its being mistaken for acute diverticulitis. Unlike acute epiploic appendagitis, acute diverticulitis is more likely to manifest with evenly distributed lower abdominal pain and to be associated with nausea, fever and leucocytosis. Although most patients with acute epiploic appendagitis do not report any change in their bowel habits, a minority experience constipation or diarrhoea.
Most patients with acute epiploic appendagitis have a normal white blood cell count and body temperature. CT images from less than 8% of patients evaluated for exclusion of sigmoid diverticulitis or appendicitis show features of primary acute epiploic appendagitis. When acute epiploic appendagitis involves the cecum or ascending colon, it may be mistaken clinically for acute appendicitis.

The most common sites of acute epiploic appendagitis, in order of decreasing frequency, are areas adjacent to the sigmoid colon, the descending colon and the right hemicolon.

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@#1 46. A 35 year old man undergoing a plain abdominal X-ray in the A&E department reveals multiple punctuate areas of calcification over both renal areas. Review of the notes reveals a history of upper GI endoscopy and previous psychiatric consultations. Which of the following are you going to suggest in your report?

A. Urology referral and check of serum TSH levels

B. Urology referral and check of serum parathyroid hormone levels

C. Urology referral and check of serum alkaline phosphatase

D. Urology referral and check of serum LDH

E. Urology referral and check of serum calcitonin levels

B. Urology referral and check of serum parathyroid hormone levels.

The most common clinical manifestations of hyperparathyroidism include renal stones and nephrocalcinosis, high blood pressure, acute arthropathy (CPPD), osteoporosis, peptic ulcer, acute pancreatitis, proximal muscle weakness, depression and confusional state (often described in medical text books as ‘stones, groans and moans’). It is diagnosed by raised serum parathormone levels.

Serum TSH levels are related to hyper- and hypothyroidism.

Calcitonin is typically raised in medullary carcinoma of the thyroid.

Serum alkaline phosphatase is a nonspecific enzyme marker, which is raised, in several inflammatory, metabolic and malignant conditions.

LDH is also a non-specific enzyme marker, raised in heart disease and myositis.

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@#1 48. A 2-year-old boy presents with bowing of the left leg. There is no history’ of trauma and the right leg appears normal. Standing anteroposterior radiography is performed. This shows a varus deformity of the left knee with fragmentation of the posteromedial tibial metaphysis and absence of the medial epiphysis. The right leg appears radiographically normal and bony density is preserved throughout. Which of the following is the most likely cause?

A. Neurofibromatosis

B. Blount disease

C. Congenital bowing

D. Developmental bowing

E. Osteogenesis imperfecta

B. Blount disease

All of the answers can lead to leg bowing in paediatric groups. However, the description is that of Blount disease, otherwise known as tibia vara. This is a common condition that is unilateral or asymmetrical and is thought to arise as a result of abnormal stress (such as obesity and walking at an early age) on the posteromedial proximal tibial physis. There are three types: infantile (the most common), juvenile and adolescent. Anteroposterior radiography of both legs is necessary.

Neurofibromatosis may cause anterolateral tibial bowing, possibly with fibular hypoplasia, and one or both bones may fracture to give a pseudarthrosis. Developmental or physiological bowing is where there is exaggeration of varus angulation between the ages of 12 and 24 months, which again may be caused by obesity or early walking. There is metaphyseal beaking but no fragmentation, and it is usually symmetrical and bilateral.

Congenital bowing is usually convex posteromedially (unlike neurofibromatosis). Marked dorsiflexion of the foot is evident at birth, as this condition is thought to arise from an abnormal intrauterine position. Radiography shows thickening of the cortex of the concavity of the curvature.

Osteogenesis imperfecta causes bowing of multiple long bones as a result of osteoporotic softening and fractures; hence bone density reduction and bilateral bowing would be more likely.

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@#1 52. The following are true regarding hyperparathyroidism, except

A. Brown tumours are more common in the primary form.

B. Soft-tissue calcification is typically associated with the secondary form.

C. Chondrocalcinosis is more common in the primary form.

D. Osteosclerosis is more common in the primary form.

E. Bone resorption is equally seen in both primary and secondary conditions.

D. Osteosclerosis is more common in the primary form.

Osteosclerosis, as seen in the rugger jersey spine, is associated with the secondary form of hyperparathyroidism from chronic renal failure. The rest of the statements are true. In summary, the radiological findings, which are more associated with the primary form, include Brown tumours, subperiosteal bone resorption, soft-tissue calcification (although less common than in the secondary forms), and chondrocalcinosis. The findings for secondary hyperparathyroidism include subperiosteal bone resorption, osteosclerosis and soft-tissue calcification.

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@#1 54. A 12-year-old girl with known thalassaemia major undergoes skull radiography. Which area of the skull is least affected by this condition?

A. Facial bones

B. Frontal bone

C. Occipital bone

D. Temporal bone

E. Parietal bone

C. Occipital bone

Thalassaemia major, as with other causes of chronic anaemia, causes widening of the diploic space in the skull as a result of marrow hyperplasia, with thinning of the outer table and thickening of the inner table. A ‘hair on end’ appearance is seen, with periosteal bony spicules extending beyond the outer table. The occipital bone normally has a lower bone marrow content and is therefore not affected to the same extent by these changes. Occasionally, solitary or multiple lytic lesions may be seen in the skull. Paranasal sinuses and mastoids are often absent or underpneumatised owing to frontal, temporal and facial bone marrow hyperplasia.
The ethmoid sinuses are the exception because there is minimal marrow content in the surrounding bones.

@#1 57. Regarding prostatic MRI, which of the following is true?

A. Zonal anatomy is best seen on Tl.

B. The central and transition zones show similar low signal.

C. The transition zone is heterogeneous in the young.

D. The peripheral zone maintains a uniform shape throughout the length of the gland.

E. US is better than MRI for assessing prostate volume.

B. The central and transition zones show similar low signal.

On T1-weighted images, the prostate shows homogenous intermediate signal intensity, and the zones cannot be differentiated. The zonal anatomy is best seen on T2- weighted images with the peripheral zone showing a high signal compared to both the central and the transitional zones.

The central and transitional zones have similar low signal.

At a young age, the transitional zone is homogenous low signal; it gets increasingly heterogeneous with age and BPH changes.

On T2-weighted images, the shape of the peripheral zone changes from the base to apex. At the base, the peripheral zone surrounds the posterolateral aspect of the central zone, while at the apex it concentrically surrounds the central zone. The prostatic capsule separates the peripheral zone from the periprostatic tissue, whereas the surgical pseudocapsule separates the peripheral zone from the transitional zone in the older population.

MRI is recognised to be more accurate than US and CT in assessment of prostate volume.

@#1 58. A 25-year-old woman presents to the A&E department with an acutely painful right hip and difficulty in weight-bearing. A radiograph is obtained in casualty. No fractures are identified but the radiograph reveals a subluxed femoral head on the right with a shallow acetabulum and a centre-edge angle of 18 degrees. What is your diagnosis?

A. Perthes disease

B. Ollier’s disease

C. Developmental dysplasia of the hip

D. Traumatic subluxation

E. Congenital coxa vara with subluxation

C. Developmental dysplasia of the hip

The patient has developmental dysplasia of the hip, which has resulted in subluxation of the femoral head. The centre edge angle is useful in older toddlers up to adulthood to estimate the degree of acetabular over or under coverage. It is the angle between a vertical line drawn up from the centre of the femoral head and the outer edge of the acetabular roof. In an adult, an angle less than 20 degrees indicates underlying dysplasia.

Perthes disease is a paediatric condition characterised by avascular necrosis of the femoral head.

Ollier’s disease is the condition of multiple enchondromas (enchondromatosis).

Isolated traumatic subluxation requires significant trauma in the absence of an underlying dysplasia.

@#1 63. A 75-year-old man undergoing MRI of the prostate for known malignancy reveals low signal intensity in the peripheral zone of the prostate on T2W images extending from the 3 o’clock position to the 8 o’clock position. Further note is also made of bulky low-signal seminal vesicles bilaterally. What is the T stage of the tumour?

A. T2b

B. T2c

C. T3a

D. T3b

E. T4

D. T3b

T staging of prostate cancer
T1: Not palpable via DRE or seen using TRUS.
T1a: Cancer found incidentally during TURP, less than 5% of the gland.
T1b: Cancer found incidentally but over 5% of the gland is involved.
T1c: Found by needle biopsy for a raised PSA.
T2: Palpable on DRE, but confined to the prostate.
T2a: Less than half of one lobe.
T2b: More than half of one lobe.
T2c: Cancer in both lobes of the prostate.
T3: Spread outside the prostate.
T3a: Extracapsular extension (one or both sides).
T3b: Tumour invades the seminal vesicles.
T4: Spread into the adjacent tissues (other than seminal vesicles).

@#1 64. A 52 year-old woman is involved in a RTA. Trauma series radiographs reveal a complex pelvic fracture. There are no other appreciable injuries. She is haemodynamically unstable, and fluid resuscitation is commenced. Which of the following steps is the next most important?

A. Trauma protocol CT scan with angiographic sequences

B. Immediate surgery under the orthopaedic surgeons

C. Discussion with interventional radiologists with view to catheter angiography and possible intervention

D. Placement of a pelvic wrap device

E. Blood transfusion

D. Placement of a pelvic wrap device

All of these steps may be required, but the most important is to place a pelvic wrap device. The purpose of this device is to stabilise the pelvis. If the patient is hypotensive as a result of venous bleeding, a pelvic wrap should stabilise the pelvis sufficiently to cause significant reduction or cessation in the venous haemorrhage and thus avoid unnecessary endovascular intervention.
If this fails to achieve sufficiently prompt haemodynamic stability, there is a significant chance that there is arterial haemorrhage; hence endovascular intervention is likely to be necessary. Many centres use angiographic sequences as part of the trauma CT scan to identify such a bleeding point as part of planning stage of endovascular management. CT would be the next step once die pelvic binder is in situ.

@#1 65. CT brain of a 10 year old girl shows a large cyst in the posterior fossa. All of the following favour pilocytic astrocytoma over haemangioblastoma, except

A. Size greater than 5 cm

B. Calcifications

C. Smaller nodule

D. Thicker-walled lesion

E. No angiographic contrast blush of the mural nodule

C. Smaller nodule

Pilocytic astrocytoma is the most common paediatric cerebellar neoplasm and the most common paediatric glioma. They can be differentiated from haemangioblastoma on the following basis: astrocytomas are more likely to be larger than 5 cm, contain calcification, have a larger mural nodule, are thick walled lesions, do not show angiographic contrast blush to the mural nodule and are not associated with erythrocythaemia.

@#1 67. A 20-year-old man with a history’ of thrombophlebitis and recurrent mouth and genital ulcers undergoes a CXR. A well-defined opacity in the right hilum is noted. Contrast-enhanced CT confirms that the opacity has sharp borders, with intense enhancement in the arterial phase. What is the most likely diagnosis?

A. Pulmonary artery aneurysm

B. Pulmonary vein varix

C. Necrotic hilar node

D. Endobronchial carcinoid

E. Pulmonary AVM

A. Pulmonary artery aneurysm

One of the most common findings of Behcet’s disease at chest radiography is a lung mass attributed to a pulmonary artery aneurysm. The pulmonary artery is the second most common site of arterial involvement, with the aorta being the most common, and aneurysms are more common than thromboembolism. Behcet’s disease is the most common cause of pulmonary artery aneurysms.
Hughes-Stovin syndrome is a rare disorder of unknown aetiology that is characterised by the combination of multiple pulmonary artery aneurysms with mural thrombi and deep venous thrombosis.
Another well-known finding is the mediastinal widening caused by thrombosis of the SVC and accompanying mediastinal oedema. Thrombosis of the brachiocephalic, subclavian and axillary veins may also accompany SVC occlusion.
Arterial involvement may occur in the ascending thoracic aorta and the aortic arch, as well as in the coronary artery and subclavian artery in the thorax. Aneurysm formation occurs more frequently than arterial occlusion.

@#1 68. A 39-year-old woman weighing 22 stone is referred for weight loss surgery’. With regard to bariatric surgical procedures, which one of the following statements concerning complications of the laparoscopic adjustable gastric banding procedure (LAGBP) is false?

A. Lap band misplacement is usually due to inexperience on the part of the surgeon.

B. Stomal stenosis is a rare complication.

C. Band erosion into the gastric lumen is a rare but late complication of laparoscopic adjustable gastric banding.

D. Acute pouch dilation usually results from marked stomal narrowing secondary to overfilling of the band or from distal band slippage and obstruction.

E. Distal band slippage is thought to result from recurrent vomiting, overinflation of the band or faulty surgical technique.

B. Stomal stenosis is a rare complication.

The most common complication after gastric banding is stomal stenosis. This complication occurs when the band is too tight, causing excessive luminal narrowing and obstruction.
Affected individuals usually present with nausea and vomiting, regurgitation, dysphagia or upper abdominal pain. When stomal stenosis is found on barium studies in patients with obstructive symptoms, the band should be deflated to increase luminal calibre and relieve the patient’s symptoms.
Acute pouch dilation usually results from marked stomal narrowing secondary to overfilling of the band or from distal band slippage and obstruction. In this setting, the band should be deflated to prevent further complications, including irreversible pouch dilation and progressive band slippage.
Distal band slippage is thought to result from recurrent vomiting, overinflation of the band or faulty surgical technique.
Malpositioning of the band is an unusual complication that occurs at the time of surgical placement, most often when this procedure is performed by an inexperienced surgeon.
Band erosion into the gastric lumen is a rare but late complication of laparoscopic adjustable gastric banding and results from high pressures generated by the inflated band, with pressure necrosis of the adjacent gastric wall and subsequent erosion of the band into the lumen.

@#1 69. A 31-year-old man involved in an RTA has sustained a pelvic fracture and is investigated with retrograde urethrography to assess urethral injury. There is no opacification of the urinary bladder and contrast is seen to extravasate into the perineum. What is the most likely grade of urethral injury?

A. Grade I - stretching without tear

B. Incomplete tear Grade II - above the urogenital diaphragm

C. Complete tear Grade II - above the urogenital diaphragm

D. Incomplete tear Grade III - at the level of the urogenital diaphragm

E. Complete tear Grade III - at the level of the urogenital diaphragm

E. Complete tear Grade III at the level of the urogenital diaphragm

Urethral injuries associated with a pelvic fracture were classified into five types by Goldman and Sandler and into three types by Colapinto and McCallum, with Types IV and V being exclusive to Goldman and Sandler:

Type I, posterior urethra stretched but intact (no extravasation of contrast);

Type II, urethra disrupted at the membrano-prostatic junction above the urogenital diaphragm (contrast in pelvis);

Type III, membranous urethra disrupted, with extension to the proximal bulbous urethra and/or disruption of the urogenital diaphragm (most common - contrast in pelvis and perineum);

Type IV, bladder neck injury with extension into the urethra;

and Type V, partial or complete pure anterior urethral injury.

Grades II and III are subdivided into complete and incomplete tear depending on the absence or presence of bladder filling.

@#1 70. A 66 year old woman presents with progressive worsening of right shoulder pain and limitation of movement X-ray and MRI show a combination of rotator cuff tear and established arthropathy described as Milwaukee shoulder. All of the following arc recognised features, except

A. Large osteophytes

B. Multiple loose bodies

C. Subacromial abutment of humeral head

D. Large subchondral cysts

E. Subchondral collapse and deformed humeral head

A. Large osteophytes

Milwaukee shoulder consists of the association of complete tear of the rotator cuff, osteoarthritic changes, non-inflammatory joint effusion containing calcium hydroxyapatite and calcium pyrophosphate dihydrate crystals, hyperplasia of the synovium, destruction of cartilage and subchondral bone, and multiple osteochondral loose bodies. This entity most frequently affects older women and manifests clinically as a rapidly progressive and destructive arthritis of the shoulder.
It manifests as joint space narrowing, subchondral sclerosis with cyst formation, destruction of subchondral bone, soft-tissue swelling, capsular calcifications and intra-articular loose bodies. MR imaging demonstrates a large effusion, a complete rotator cuff tear, narrowing of the glenohumeral joint, thinning of cartilage and destruction of subchondral bone.

@#1 75. A 56-year-old woman weighing 22 stone is referred to the bariatric surgeon for a bypass procedure for weight loss. An Roux-en-Y gastric bypass surgery (RYGBP) is performed after discussion about the advantages and disadvantages of the procedure. Regarding complications of this procedure, the following are all true, except

A. Extraluminal leak is the most serious early complication of RYGBP.

B. Transient anastomotic narrowing and obstruction may occur during the early post-operative period.

C. Strictures at the gastrojejunal anastomosis may he caused by post-surgical scarring at the anastomosis or by chronic ischaemia resulting from tension on the gastrojejunostomy.

D. Anastomotic strictures usually appear on upper GI studies as an irregular long segment narrowing at the gastrojejunal anastomosis.

E. Anastomotic leak.

D. Anastomotic strictures usually appear on upper GI studies as irregular long segment narrowing at the gastrojejunal anastomosis.

Extraluminal leak is the most serious early complication of Roux-en-Y gastric bypass, occurring in up to 5% of patients. Between 69% and 77% of leaks involve the gastrojejunal anastomosis, but other less common sites of perforation include the gastric pouch, blind-ending jejunal stump and jejunojejunostomy. Leaks usually occur within 10 days of surgery; early detection is critical because of the risk of abscess formation, peritonitis and sepsis, with a mortality rate of more than 5%. Affected individuals may present with leucocytosis, fever, abdominal pain and tachycardia.

Transient anastomotic narrowing and obstruction may occur during the early post-operative period secondary to residual oedema and spasm in this region. Upper GI examinations may reveal focal narrowing of the gastrojejunal anastomosis and thickened, irregular folds in the Roux limb abutting the anastomosis. These findings usually resolve within several days.

Strictures at the gastrojejunal anastomosis have been reported in 3%-9% of patients. These strictures typically develop 4 weeks or more after surgery; they may be caused by post-surgical scarring at the anastomosis or by chronic ischaemia resulting from tension on the gastrojejunostomy.
Anastomotic strictures usually appear on upper GI studies as short segments of smooth narrowing at the gastrojejunal anastomosis.

Though adhesions arc the most common cause of SBO after open Roux-en-Y gastric bypass, internal hernias are the most common cause after the laparoscopic form of surgery.

@#1 78. Antenatal ultrasound shows an abnormal facial contour with a large cyst without any cortical mantle of cerebral tissue anteriorly. Septum pellucidum, falx cerebri and optic tracts are not identified with evidence of a fused midline thalamus. A single large ventricle is identified. Normal brain stem, midbrain and cerebellum are noted. What is the diagnosis?

A. Alobar holoprosencephaly

B. Lobar holoprosencephaly

C. Hydranencephaly

D. Anencephaly

E. Congenital hydrocephalous

A. Alobar holoprosencephaly

Holoprosencephaly (HPE) is considered the most common malformation of the brain and face in humans. In alobar HPE, prosencephalic cleavage fails, resulting in a single midline forebrain with a primitive monoventricle often associated with a large dorsal cyst. The olfactory bulbs and tracts, the corpus callosum and anterior commissure, the cavum septum pellucidum and the interhemispheric fissure are absent, whereas the optic nerves may be normal, fused or absent. The basal ganglia, hypothalamic and thalamic nuclei are typically fused in the midline, resulting in absence of the third ventricle.
In lobar HPE, the interhemispheric fissure is present along nearly the entire midline, and the thalami are completely or almost completely separated. The corpus callosum may be normal or incomplete, but the cavum septum pellucidum is always absent.
Hydranencephaly is the result of a vascular insult (anterior circulation) with the cerebral hemispheres variably replaced by fluid covered with leptomeninges and dura Falx cerebri is present The cerebellum, midbrain, thalami, basal ganglia, choroid plexus and portions of the occipital lobes, all fed by the posterior circulation, arc typically preserved. It is differentiated from hydrocephalus by absence of an intact rim of cortex (seen with even the most severe hydrocephalus).

@#1 79. Causes of ‘tree in bud’ appearance include all, except

A. Tuberculosis

B. Allergic bronchopulmonary aspergillosis

C. Cystic fibrosis

D. Tumour emboli

E. Chronic pulmonary embolism

E. Chronic pulmonary embolism

The tree-in-bud pattern on HRCT is characterised by small centrilobular nodules of soft-tissue attenuation connected to multiple branching linear structures of similar calibre originating from a single stalk. Initially described in cases of endobronchial Mycobacterium tuberculosis, it has subsequently been reported in peripheral airways diseases such as infection (bacterial, fungal, viral or parasitic), congenital disorders (like cystic fibrosis and Kartagener’s syndrome), idiopathic disorders (obliterative bronchiolitis, panbronchiolitis), aspiration, inhalation, immunologic disorders (like ABPA), connective tissue disorders and peripheral pulmonary vascular diseases such as neoplastic pulmonary emboli.

@#1 82. A 60-year-old man presents with a long-standing, painless mass in his left thigh, which has been increasing in size over recent months. Plain film demonstrates a soft-tissue mass with poorly defined curvilinear calcification and cortical erosion of the underlying femur. MRI demonstrates an inhomogeneous, poorly defined lesion that is isointense to muscle on T1W images and hyperintense on T2W images. Which of the following is the most likely diagnosis?

A. Liposarcoma

B. Pleomorphic undifferentiated sarcoma

C. Rhabdomyosarcoma

D. Lipoma

E. Osteomyelitis

B. Pleomorphic undifferentiated sarcoma

Pleomorphic undifferentiated sarcoma was previously known as malignant fibrous histiocytoma. Malignant fibrous histiocytoma is the most common soft-tissue sarcoma of late adult life.
It typically presents as a painless, soft-tissue mass, which is often located in the thigh and measures 5-10 cm. X-ray demonstrates a non-specific soft-tissue mass with calcification/ossification detected in 5%-20% of patients. Secondary osseous involvement is uncommon. It can be identified as periosteal reaction, cortical erosion and pathological fracture.
CT findings include a non-specific, large, lobulated, soft-tissue mass of predominantly muscle density with nodular and peripheral enhancement of solid portions. There are often central areas of low attenuation, which represent myxoid change, old haemorrhage or necrosis. The lesion does not contain fat
MRI typically reveals an intramuscular mass with heterogeneous signal intensity on all pulse sequences. As with other soft-tissue neoplasms, the signal intensity pattern is non-specific, usually low to intermediate on T1-weighted images and intermediate to high on T2 weighted images. Regions of prominent fibrous tissue (high collagen content) may demonstrate low signal intensity on both T1-weighted and T2-weighted images and calcification may present as foci of low signal on both T1-weighted and T2-weighted sequences.

@#1 83. A 77-year-old woman is sent for a staging scan following a diagnosis of melanoma. All are true for melanoma involving the abdomen, except

A. The small bowel is the most common site of gastrointestinal tract involvement by melanoma.

B. Metastatic disease to the liver is always calcified.

C. Omental and peritoneal deposits occur early in disease.

D. Large bowel lesions are uncommon.

E. Mesenteric involvement could mimic lymphoma

B. Metastatic disease to the liver is always calcified.

The small bowel is the most common site of the gastrointestinal tract involved by melanoma. Appearance can be indistinguishable from that of primary or metastatic adenocarcinoma, lymphoma or other metastasis. Tumour masses may occur as infiltrating lesions with or without ulceration. Mesenteric involvement by melanoma can mimic lymphoma. Involvement of the large bowel is uncommon but can occur as large ulcerating lesions. Lesions in the liver can be single or multiple and may be partly calcified. Larger lesions are often necrotic.

@#1 84. All the following statements regarding testicular tumour are correct, except

A. Testicular lymphoma commonly involves the epididymis and spermatic cord.

B. Testicular microlithiasis is associated with alveolar microlithiasis.

C. Sertoli cell tumour is associated with Peutz-Jeghers syndrome.

D. Primary extragonadal germ cell tumours commonly affect the testes.

E. The testis is a common site of leukaemia recurrence

D. Primary extragonadal germ cell tumours commonly affect the testes.

Lymphoma can occur in the testis in one of three ways: as the primary site, as the initial
manifestation of occult disease or as the site of recurrence. It is the most common bilateral tumour and epididymis and spermatic cord are commonly involved. Primary Leukaemia of the testis is rare. However, the testis is a common site of leukaemia recurrence in children.
Testicular microlithiasis is an uncommon condition but several associations are known, including cryptorchidism, infertility, Klinefelter syndrome. Downs syndrome, atrophy, alveolar microlithiasis and testicular carcinoma.
There is a calcifying subgroup of Sertoli cell tumours that can be multiple and bilateral with large areas of calcification and is known to be associated with Peutz-Jeghers syndrome and Carney syndrome.
Primary germ cell tumours can occur outside the gonads and should be differentiated from regressed germ cell tumours with metastasis. Primary extragonadal germ cell tumours occur in extratesticular locations like the retroperitoneum, mediastinum, sacrococcygeal area and pineal gland. Regressed germ cell tumour may present with widespread metastases even though the primary tumour has involuted. US plays a vital role in the search for the primary regressed tumour. They have a variable appearance, are generally small, and can be hypoechoic, hyperechoic or merely an area of focal calcification.

@#1 90. A 10-year-old boy with history of Down’s syndrome, recurrent chest infection and dyspnoea on exertion presents to the paediatrician. Chest X-ray shows mild cardiomegaly and prominent pulmonary venous markings. What is the most likely diagnosis?

A. Hypertrophic cardiomyopathy

B. Ostium primum ASD

C. Ostium secundum ASD

D. VSD

E. PDA

B. Ostium primum ASD

Ostium primum defects are often seen in Down’s syndrome and are part of endocardial cushion defects, which also include atrioventricular canal defects (ASD + VSD + abnormal AV valves). Most children with small defects are asymptomatic. Those with larger defects are predisposed to recurrent chest infection and heart failure.
Ostium secundum type ASD are well tolerated, and symptoms and complications usually only present in the third decade or later.
VSD can be asymptomatic or present at various age with recurrent chest infection or heart failure and cyanosis at a later stage subject to progressive pulmonary’ hypertension.
HOCM shows cardiomegaly without plethoric lungs. HOCM presents with tiredness, fatigability and is a recognised cause of sudden death.

@#1 91. A 10-year-old boy undergoes a contrast-enhanced CT abdomen following blunt abdominal trauma. Anaphylactic shock is suspected. What is the treatment?

A. 0.5 ml of 1:1000 IM adrenaline

B. 0.5 ml of 1:10,000 IM adrenaline

C. 0.15 ml of 1:1000 IM adrenaline

D. 0.3 ml of 1:1000 IM adrenaline

E. 0.3 ml of 1:1000 IV adrenaline

D. 0.3 ml of 1:1000 1M adrenaline Adrenaline IM dose - adults

0.5 mg IM (= 500 micrograms = 0.5 mL of 1:1000) adrenaline Adrenaline IM dose - children
>12 years: 500 micrograms IM (0.5 mL) - i.e., same as adult dose; (300 micrograms (0.3 mL) if child is small or prepubertal)
>6-12 years: 300 micrograms IM (0.3 mL)
>6 months-6 years: 150 micrograms IM (0.15 mL)
<6 months: 150 micrograms IM (0.15 ml.)

@#1 92. A middle-aged woman with a history of right-sided breast cancer underwent adjuvant radiotherapy following surgery several years ago. She has been symptom free with no features to suggest local recurrence. Over the last few weeks she has developed worsening right-sided chest pain. Chest radiograph shows a partially destroyed right rib with a large eccentric soft-tissue component. Which one of the following is the most likely histology of the lesion?

A. Osteosarcoma

B. Chondrosarcoma

C. Ewing’s sarcoma

D. Angiosarcoma

E. Fibrosarcoma

A. Osteosarcoma

The most common radiation-induced sarcoma is pleomorphic undifferentiated sarcoma, previously described as malignant fibrous histiocytoma (which is a soft tissue sarcoma), followed by osteosarcoma and lastly by fibrosarcoma. In this case, the pathology is centred on the bone, making osteosarcoma the most probable diagnosis.

@#1 93. A 60-vear-old man with sepsis and moderate left hydronephrosis secondary’ to an obstructing left mid-ureteric calculus has been referred to the interventional team for a percutaneous nephrostomy. All of the following statements regarding percutaneous nephrostomy are true, except

A. The Brodel bloodless zone lies just anterior to the lateral convex border of the kidney.

B. The posterior calix of the upper/middle collecting system is best for ureteral negotiation.

C. Large bore drains are used in procedures complicated by gross haematuria.

D. Nephrostomogram and over-distension can cause bacteraemia.

E. Renal arteriovenous fistula are a recognised complication.

A. Brodel bloodless zone lies just anterior to the lateral convex border of the kidney.

Percutaneous access to the urinary tract is used to relive urinary tract obstruction and also allows
the urologists to perform endourological procedures (e.g., stone removal), which is less invasive and associated with fewer complications than open surgery. The renal artery divides into the ventral and dorsal branches, which creates a zone of relative avascularity between the divisions known as the Brodel bloodless line of incision, which lies just posterior lo the lateral convex border of the kidney. A lower pole posterior calix access via a subcostal approach is usually best for simple urinary drainage. A posterior calix of the upper or middle collecting system offers the easiest access to the pelviureteric junction for potential ureteral negotiation. Tubes with self-retaining properties should always be used to lessen the risk of inadvertent dislodgment. Tubes of 8-10 F are usually sufficient for drainage of non-infected urine. Larger tubes (12-14 F) may be necessary for drainage of infected urine or to ensure appropriate urine flow in procedures complicated by gross haematuria. Formal nephrostography should be delayed for 24-48 hours following tube placement in case of infected urine to reduce the chance of bacteraemia.
Transient haematuria occurs in all patients post-nephrostomy. Hydrothorax and pneumothorax can also occur particularly with supracostal entries. Renal arteriovenous fistula, pseudoaneurysm or vessel laceration are recognised vascular complications during nephrostomy.

@#1 95. A 5-year old girl presents with left-sided abdominal pain. On examination, there is a palpable mass in the left flank. CT demonstrates a well circumscribed multiseptated cystic renal mass replacing the lower pole of the left kidney. The intervening septae are thick and enhanced post-contrast, and the cysts appear to be herniating into the renal pelvis. What is the most likely diagnosis?

A. Multicystic dysplastic kidney

B. Multilocular cystic nephroma

C. Nephroblastomatosis

D. Polycystic kidney disease

E. Mesoblastic nephroma

B. Multilocular cystic nephroma

Multilocular cystic nephroma is a benign renal tumour that occurs in children and, less commonly, adult women. There is no known association with Wilms tumour. It is usually a unilateral abnormality that replaces an entire renal pole and presents as a large mass, often around 8 10 cm in diameter. Radiological appearances, while not entirely specific, can help to differentiate this lesion from other renal mass lesions.

A sharply well-circumscribed, multiseptated cystic mass is typical with a thick surrounding capsule. The cysts appear to herniate into the renal pelvis - an appearance that is relatively specific for mesoblastic nephroma. Unsurprisingly, these lesions are excised, as definitive radiological differentiation from malignancy is often not possible.

Multilocular cystic nephroma can be differentiated from multicystic dysplastic kidney by the presence of normal functioning renal parenchyma and symmetrical renal excretion.

Polycystic kidney disease involves the entire kidney, unlike multilocular cystic nephroma, which tends to be localised around a renal pole.

Multicystic dysplastic kidney is the most common cystic renal disease affecting infants and is twice as common in boys. It is a common cause for abdominal masses in this age group and typically involves one kidney. There are strong associations with a range of genitourinary abnormalities, including vesico-ureteric reflux, horseshoe kidney and ureteric anomalies.
The classical ultrasound features are as described above, with near total replacement of the normal renal parenchyma by cysts of varying size and shape. The presence of thin septations can help to differentiate this condition from multilocular cystic nephroma, in which thick septations are typical. Wilms tumour typically presents in children of 3-4 years of age.

@#1 96. CXR shows a large mass in the right lower lobe. Staging CT shows it to be 8 cm invading the right mediastinal pleura with ipsilateral mediastinal and subcarinal nodes. There is also
a contralateral 3 cm mass in the left upper lobe. This would be staged:

A. T3 N2 M1a

B. T4 N2 M1a

C T3 N3 M1b

D. T4 N3 M1b

E. T3 N2 M1b

A. T3 N2 M1a

Primary tumour (T)
Tx: No tumour found on bronchoscopy or imaging.
Tis: Carcinoma in situ.
T1: Tumour size equal to or less than 3 cm not involving the main bronchus Tla: Smaller than 2 cm in longest dimension.
Tib: Larger than 2 cm but smaller than or equal to 3 cm.
T2: Tumour size more than 3 cm but less than/equal to 7 cm or involving the main bronchus but >2 cm from carina or visceral pleural involvement or lobar atelectasis extending to the hilum but not collapse of the entire lung.
T2a: Larger than 3 cm but smaller than 5 cm.
T2b: Larger than 5 cm but smaller than 7 cm.
T3: Tumour size larger than 7 cm or tumour <2 cm from carina but not involving trachea or carina or involvement of the chest wall, including Pancoast tumour, diaphragm, phrenic nerve, mediastinal pleura or parietal pericardium, or separate tumour nodule(s) in the same lobe or atelectasis or post-obstructive pneumonitis of entire lung.
T4: Any size tumour with involvement of the trachea, oesophagus, recurrent laryngeal nerve vertebra, great vessels or heart or separate tumour nodules in the same lung but not in the same lobe.
Nodal status (N)
Nx: Regional nodes cannot be assessed.
N0: No regional nodal metastases.
N1: Ipsilateral peribronchial, hilar or intrapulmonary nodes, including direct invasion N2: Ipsilateral mediastinal or subcarinal nodes.
N3: Contralateral nodal involvement; ipsilateral or contralateral scalene or supraclavicular nodal involvement.
Distant metastasis (M)
Mx: Distant metastases cannot be assessed.
M0: No distant metastases.
Ml: Distant metastases present.
M1a: Presence of a malignant pleural or pericardial effusion, pleural dissemination, or pericardial disease, and metastasis in opposite lung.
M1b: Extrathoracic metastases.

@#1 97. A 74 year-old man with orthopnoea, ankle swelling and paroxysmal nocturnal dyspnoea has had US to evaluate right upper-quadrant pain. The scan shows hepatomegaly with a coarse liver. He subsequently has CT of the liver. All of the following are CT findings of hepatic congestion secondary to congestive heart failure, except

A. Late enhancement of the IVC and central hepatic veins.

B. Heterogeneous mottled mosaic pattern of enhancement on the portal phase.

C. Hepatomegaly and ascites may be present.

D. Dilated hepatic veins.

E. Periportal oedema.

A. Late enhancement of the IVC and central hepatic veins.

Passive congestion occurs with the stasis of blood within liver parenchyma as a result of impaired hepatic venous drainage secondary to cardiac disease. Elevated central venous pressure is directly’ transmitted from the right atrium to the hepatic veins. Passive hepatic congestion may occur with congestive heart failure, constrictive pericarditis, pericardial effusion, cardiomyopathy or right-sided valvular disease involving the tricuspid or pulmonary valve.
Symptoms of congestive heart failure mask gastrointestinal symptoms. Patients may present with asymptomatic elevation of liver enzymes, jaundice, right upper-quadrant pain, hepatomegaly and increased abdominal girth.
In the arterial phase, there is early enhancement of a dilated IVC and central hepatic veins because of the reflux of contrast material from the right atrium into the IVC.
Parenchymal phase images show a heterogeneous, mottled mosaic pattern of enhancement, with linear and curvilinear areas of poor enhancement due to delayed enhancement of small and medium-sized hepatic veins.
There may be peripheral large patchy areas of poor delayed enhancement due to stagnant flow within the periphery of the liver.
Perivascular lymphedema may be seen as linear low-attenuation regions encircling the intrahepatic IVC or portal veins and should not be confused with venous thrombosis. Hepatomegaly and ascites may be present. Chest images may show cardiomegaly, congestive heart failure and pericardial and pleural effusion.

@#1 102. A 7 month old baby is seen at the general paediatric clinic with failure to thrive and irritability. Few clinical signs are present on examination, although the child cries on manipulation of his lower limbs. A plain radiograph of the left leg was performed a few weeks ago for a suspected fracture, but no acute bony injury was identified. The doctor reviews this radiograph again.
It shows generalised osteopaenia of the distal femur and proximal tibia and fibula. A sclerotic rim surrounds the distal femoral epiphysis, which itself is abnormally lucent. A bony spur can be seen arising from the distal femoral metaphysis. What is the most likely diagnosis?

A. Hypoparathyroidism

B. Scurvy

C. Rickets

D. Hypothyroidism

E. 1 lypophosphatasia

B. Scurvy

Scurvy is a dietary deficiency of vitamin C. It typically affects babies from 6 to 9 months and is characterised by non-specific symptoms of irritability, lower limb tenderness and reluctance to move legs normally. Bleeding gums can also occur.

The condition usually manifests at the distal femur and proximal and distal ends of the tibia and fibula, and it can also affect the upper limb bones and the ribs.

There are several key radiographic findings: bony spurs arising from the metaphysis of long bones are eponymously termed Pelkan spurs.

Wimberger line refers to the appearance of a sclerotic line running around the perimeter of the epiphyses, which reflects osteopaenic change.

Ground-glass osteoporosis and cortical thinning are also recognised findings.

In contrast, rickets manifests as cupping and fraying of the metaphyses, periosteal reaction, bowing of the long bones and widening of the growth plates. Hypophosphatasia is often indistinguishable from rickets on imaging.

Hypothyroidism in infancy also results in osteopaenia, with fragmentation of the epiphyses.

@#1 105. A 15-year old man patient presents with pain on the medial aspect of the right elbow.
MRI shows no joint effusion or signal change. The medial collateral ligament is lax,
ill defined, and irregular in appearance. Which of the following is the most likely diagnosis?

A. Acute partial ulnar collateral ligament tear

B. Acute partial radial collateral tear

C. Chronic ulnar collateral ligament injury

D. Chronic radial collateral ligament injury

E. Chronic lateral ulnar collateral ligament injury

C. Chronic ulnar collateral ligament injury

Injury to the ulnar collateral ligament (UCL), also known as the medial collateral ligament or medial ulnar collateral ligament, is a common cause of medial elbow pain and valgus instability in athletes. The UCL is made of anterior, transverse and posterior bundles, and is most often injured following acute or recurrent valgus stress of the elbow.
MRI may demonstrate increased T2 weighted signal within the ligament (commonly within the anterior band) or hyperintensity within the sublime tubercle. Intra-articular contrast may result in a ‘T sign’ when contrast extends in the interval between the sublime tubercle and stripped ligamentous attachment; complete rupture will show extravasation of contrast through the ligamentous defect.
Chronic valgus stress, often secondary to throwing or pitching sports, can result in chronic damage to the UCL, with appearances similar to those described and the UCL often appearing lax, irregular and with poor definition. Plain radiograph findings may include heterotopic new bone formation around the medial epicondyle and local subchondral cysts, sclerosis and osteophyte formation.
The differential diagnosis includes medial epicondylitis and a sublime tubercle fracture. Lateral ulnar collateral ligament forms part of the lateral ligament complex and presents with symptoms of lateral or postero-lateral elbow pain/instability.

@#1 106. A 66-year-old man with a chronic skin condition and progressive painful small joints of the hand has been referred for an X-ray. Plain radiograph reveals extensive arthropathy involving the DIPJs mainly, with some joints showing a pencil-in-cup deformity. Which one of the following statements regarding the condition is false?

A. In 15% 20% of cases, arthropathy precedes the onset of skin rash.

B. Involvement of the sacroiliac joints is often bilateral.

C. The severity of the skin rash correlates with the degree of articular abnormalities.

D. It affects both synovial and cartilaginous joints.

E. Marginal erosions around the joints of the fingers and toes are common.

C. The severity of the skin rash correlates with the degree of articular abnormalities.

If there is joint space narrowing, signs of inflammation, multiple joint involvement
and distal involvement in the hands and feet with added features of bone proliferation, a seronegative spondyloarthropathy is suggested. Approximately 10%—15% of patients with skin manifestations of psoriasis will develop psoriatic arthritis. Usually such manifestations will precede the development of arthritis. The hallmarks of psoriatic arthritis, similar to those of the other seronegative spondyloarthropathies, are signs of inflammatory arthritis combined with bone proliferation, periostitis, enthesitis and a distal joint distribution in the extremities.
Involvement of several joints in a single digit, with soft-tissue swelling, produces what appears clinically as a ‘sausage digit’. The bone proliferation produces an irregular and indistinct appearance to the marginal bone about the involved joint, characterised as a ‘fuzzy’ appearance or ‘whiskering’. Periostitis may take several forms. It may appear as a thin periosteal layer of new bone adjacent to the cortex, a thick irregular layer or irregular thickening of the cortex itself. Because of the degree of bone destruction, an involved joint may take the appearance of a pencil and cup’, with one end of the joint forming a cup and the other a pencil that projects into this cup. One characteristic feature of psoriatic arthritis in the foot is the ‘ivory phalanx’, which classically involves the distal phalanges (especially in the first digit).
Sacroiliac joint involvement in psoriatic arthritis is usually bilateral, either symmetric or asymmetric in distribution. The thoracolumbar spine may show large comma-shaped paravertebral ossifications.
There is no association between the dermatological extent of psoriasis and the musculoskeletal manifestations.

@#1 112. A 17-year-old man with reduced upward gaze on clinical examination reveals a moderate sized heterogeneous mass in the region of the pineal gland in sagittal MRI of the brain. T1W images reveal areas of fat in the tumour, whereas calcification is best seen on CT. What is the diagnosis?

A. Pineoblastoma

B. Pineal teratoma

C. Pineal cyst

D. Pineal teratocarcinoma

E. Pineocytoma

B. Pineal teratoma

Pineal teratomas reveal a multiloculated, lobulated lesion with foci of fat attenuation, calcification and cystic regions on CT scan. T1-weighted MR images may show foci of T1 shortening due to fat and variable signal intensity related to calcification. On T2-weighted images, the soft-tissue component is iso- to hypointense. The soft-tissue component demonstrates enhancement on post contrast images.
Pineocytomas are slow-growing pineal parenchymal neoplasms. At CT they are well demarcated, usually less than 3 cm, and iso- to hyperattenuating. At MR imaging, pineocytomas are well circumscribed lesions that are hypo- to isointense on T1-weighted images and hyperintense on T2-weighted images. On post-contrast images, they typically demonstrate avid, homogeneous enhancement. Cystic or partially cystic changes may occur, occasionally making differentiation from a pineal cyst difficult. However, at immediate post-contrast imaging, cystic-appearing pineocytomas demonstrate internal or nodular wall enhancement.
Pineoblastomas arc highly malignant pineal parenchymal neoplasms. CT reveals a large (typically >3 cm), lobulated, typically hyperattenuating mass, an appearance that reflects its highly cellular histologic features. Nearly 100% of patients have obstructive hydrocephalus.
At MR imaging, pineoblastomas are heterogeneous in appearance, with the solid portion appearing hypo- to isointense on T1-weighted images and iso to mildly hyperintense to the cortex on T2-weighted images. Pineoblastomas demonstrate heterogeneous enhancement on post-contrast images. Necrotic regions and haemorrhage may be present. CSF dissemination is a common finding and necessitates imaging of the entire craniospinal axis.
Ninety percent of patients with pineal germinomas are less than 20 years old. CT demonstrates a sharply circumscribed, hyperattenuating mass that engulfs the pineal calcifications. Hydrocephalus may be present. MR imaging typically reveals a solid mass that may have cystic components. Germinomas are iso- to hyperintense to grey matter on Tl and T2-weighted images and demonstrate avid, homogeneous enhancement on post-contrast images.

@#1 113. A man with previous episodes of PE presents with acute shortness of breath and chest pain. Recurrent PE is suspected. On CTPA, which is the most common finding of chronic PE?

A. Complete occlusion of a vessel

B. Acute angle between the thrombus and the vessel wall

C. Right ventricular dilatation

D. Contrast flowing in an apparently thickened vessel wall

E. Polo mint sign

D. Contrast flowing in an apparently thickened vessel wall

Direct signs of chronic PE include complete occlusion with decrease in the diameter of the vessel distal to the complete obstruction; intimal irregularities, as broad-based, smooth, margined abnormalities that create obtuse angles with the vessel wall; and intraluminal bands or webs. Indirect signs of chronic PE include post-stenotic dilatation, tortuous vessels, enlargement of the main pulmonary artery, enlarged bronchial artery and differential perfusion of lung parenchyma (mosaic pattern). The polo mint sign of acute PE refers to the well-defined central thrombus, which is completely surrounded by contrast material.

@#1 114. A 12-year-old girl presents to her GP with mild fever persistent over a month, myalgia, arthralgia, headache and night sweats. On examination, the GP notes tender nodules in the finger. Blood test shows raised WCC, raised ESR, and raised CRP. What is the primary investigation to confirm the diagnosis?

A. Chest X-ray and blood culture

B. CT of the chest and blood culture

C. MRI of the heart and blood culture

D. Echocardiography and blood culture

E. US of the neck and blood culture

D. Echocardiography and blood culture

Children with turbulent blood flow through the heart or where prosthetic material has been inserted following surgery for PDA, VSD, coarctation and so on are at particular risk of acute and subacute forms of infective endocarditis.
In the early stage symptoms are mild. Children can present with prolonged fever over months accompanied by non-specific symptoms like malaise, myalgia, arthralgia, headache, weight loss, night sweats or an acute episode of fever. Tender nodules in finger suggest Osler’s node. Clubbing, retinal haemorrhage (Roth spots), nail bed haemorrhage and splenomegaly could be other features of infective endocarditis.
Blood culture and echocardiography to demonstrate vegetations is the main modality of investigation. Although MRI and CT would show vegetations, they arc not the primary modality for investigation.

@#1 116. A 16-year-old presents to the A&E department with an acutely painful testicle and is evaluated for possible torsion. US reveals swollen right testes with reduced vascularity on Doppler imaging. What degree of torsion of the spermatic cord is needed to completely occlude the testicular artery?

A. 120

B. 240

C. 480

D. 600

E. 720

E. 720

Testicular torsion causes venous engorgement that results in oedema, haemorrhage and subsequent arterial compromise. The degree of torsion ranges from 180 to 720 degrees. Experimental studies indicate that 720 degree torsion is required to completely occlude the testicular artery. When torsion is 180 degrees or less, diminished blood flow is seen. A nearly 100% salvage rate exists within first 6 hours after onset of symptoms, which drops to 20% within 12-24 hours.

@#1 117. A 27-year-old man presents with back pain. Anteroposterior pelvis radiograph shows bilateral symmetric bone erosions, sclerosis and widening of the sacroiliac joints. All of the following are expected radiographic findings, except

A. Bilateral hip joint involvement

B. Vertebral anterosuperior corner osteitis

C. Discovertebral erosions

D. Large flowing osteophytes

E. Fusion of facet joints

D. Large flowing osteophytes

Sacroiliac involvement is typically bilateral and symmetric, and it usually precedes spinal involvement in ankylosing spondylitis. Initially, there is indistinctness and discontinuity of the thin white subchondral bone plate about the sacroiliac joints. These changes can progress to gross bone erosions. Early erosions of the subchondral bone are often best seen in the inferior aspect of the joints. Along with the bone erosions, the adjacent bone is often sclerotic and joint space narrowing and bone fusion eventually occur. The differential diagnosis of bilateral sacroiliac joint erosions includes inflammatory bowel disease and hyperparathyroidism; however, in hyperparathyroidism, sacroiliac joint space widening is more dramatic.
Early radiographic findings are erosions at the anterior margins of the vertebral body at the discovertebral junction. These focal areas of osteitis become increasingly sclerotic, a finding termed the ‘shiny comer sign’. More extensive discovertebral erosions may also occur (Anderson lesion).
Associated bone proliferation leads to a squared appearance of the vertebral body. Thin and slender syndesmophytes are generally evident, representing ossification of the outer layer of the annulus fibrosis. The differential diagnosis for bone production at the vertebral margins includes diffuse idiopathic skeletal hyperostosis, or DISH, although this latter condition more commonly reveals a flowing and undulating appearance.
As the syndesmophytes thicken and become continuous, the term bamboo spine is used on anteroposterior lumbar spine radiographs. Facet joint inflammation leads to indistinctness and narrowing of the involved joint, and bone fusion of the joints appears later. Ossification of the posterior interspinous ligaments produces a dense radiopaque line, designated the ‘dagger sign’, on anteroposterior radiographs of the lumbar spine. The combination of the fused facets and ossification of the interspinous ligaments produces the ‘trolley-track sign’. Disk calcification may also occur.
Other peripheral joints can be involved in ankylosing spondylitis. Hip involvement is usually bilateral in distribution.

@#1 118. A 43-year-old woman on bromocriptine for pituitary’ adenoma presents to the A&E department with severe headache, stiff neck, visual symptoms and obtundation. CT shows increased density in the sella, but it is not diagnostic. MRI of the brain shows significant enlargement of the pituitary with high signal on T1W images. What is the diagnosis?

A. Pituitary adenoma

B. Pituitary carcinoma

C. Pituitary apoplexy

D. Conversion of micro- to macroadenoma

E. Metastasis involving the pituitary’ gland

C. Pituitary apoplexy

Pituitary apoplexy is a severe and potentially fatal medical condition characterised by the variable association of headache, vomiting, visual impairment, ophthalmoplegia, altered mental state and panhypopituitarism. The syndrome is often related to haemorrhagic infarction of the pituitary gland, usually in a condition of a pre-existing macroadenoma.
CT typically a heterogeneously hyperdense (haemorrhagic components) intrasellar lesion, with significant increase in size in comparison to previous imaging. MRI shows a similar finding, with the appearance of blood varying on T1-weighted and T2-weighted images, based on the interval between haemorrhage and imaging. In the subacute phase (7-21 days), methaemoglobin shortens the T1 relaxation time, and the haemorrhage will appear hyperintense on T1 weighted images as well as on T2-weighted images. In the chronic phase (>21 days), macrophages digest the clot and the presence of haemosiderin and ferritine causes a strong hypointensity on both T1 -weighted and T2-weighted images.

@#1 120. The differential diagnosis for diseases affecting the bowel in paediatric patients can be narrowed by paying attention to specific radiologic signs and the patient’s clinical history. Which of the following findings are incorrectly matched to the underlying pathology?

A. Hyperattenuating wall is seen with haemorrhage.

B. The halo sign is seen in graft versus host disease.

C. The accordion sign is classic in Crohn’s disease.

D. The comb sign suggests active inflammation.

E. The toothpaste sign is seen in chronic bowel disease

C. The accordion sign is classic in Crohn’s disease.

Several patterns of wall attenuation have been described in association with specific diseases.

A hyperattenuating wall is seen with haemorrhage as a result of trauma, purpura or vasculitis.

A submucosal fatty halo has been described as a result of chronic inflammation, such as in inflammatory bowel disease and GVHD. Submucosal oedema is definitive evidence of a bowel wall injury (typically acute), often producing the target sign.

The accordion sign is caused by contrast material trapped between thickened oedematous haustral folds in the colon. Although the accordion sign is most commonly seen in pseudomembranous colitis, it is not pathognomonic.

The comb sign represents hypervascular engorged vasa recta aligned like the teeth of a comb on the mesenteric site of the bowel. This finding is classically seen in inflammatory bowel disease, especially Crohn’s disease, and suggests a clinically active disease. The comb sign can also be seen in vasculitis and purpura.

The toothpaste or lead pipe sign has been associated with chronic diseases leading to a ‘featureless’ bowel. It is commonly seen with Crohn’s disease or chronic GVHD or as the sequela of radiation therapy.

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