VIQ - TEST PAPER I Flashcards
@#1 1.A 30-year-old man has been involved in an Road Traffic Accident (RTA). Aortic injury issuspected. CT angiogram shows a fusiform dilatation at the anteromedial aspect of the aorticisthmus with a steep contour superiorly, gently merging with the proximal descendingthoracic aorta inferiorly. What is the likely diagnosis?
A. Pseudoaneurysm
B. Coarctation of the aorta
C. Ductus diverticulum
D. Aortic nipple
E. Avulsed left subclavian artery
1.C. Ductus diverticulum
Ductus diverticulum is a focal bulge at the anteromedial aspect of the aortic isthmus,visualised in 9% of adults. It is critical to identify this normal variant and distinguish it from a post traumatic false aneurysm, which also occurs most commonly at the aortic isthmus (88%).
The classic ductus diverticulum has smooth, uninterrupted margins and gently sloping symmetric shoulders; in contrast, false aneurysms have a variety of shapes and sizes with sharp margins and often contain linear defects.
Compared with the classic ductus diverticulum, the atypical ductus diverticulum has a shorter and steeper slope superiorly and a more classic gentle slope inferiorly.
However, both shoulders have smooth, uninterrupted margins, an important feature that distinguishes this variant from true injury.
Other normal variants that can mimic injury include aortic spindle, which is a smooth circumferential bulge immediately distal to the aortic isthmus; infundibulum at the origin of aortic branches like the brachiocephalic and intercostal arteries, which are spherical or conical in shape but have a vessel at its apex, thereby differentiating them from false aneurysms.
@#1 4.A 33 year old man with short stature and normal intelligence is being investigated for lowerback pain. MRI of the thoracolumbar spine shows marked central stenosis with shortpedicles. A comment of bullet-shaped vertebra with progressive narrowing of the lumbarinterpedicular distance was noted on the report. Which of the following conditions ismost likely?
A. Hurler’s syndrome
B. Congenital pituitary dwarfism
C. Achondroplasia
D. Thanatophoric dysplasia
E. Hunter’s syndrome
- C. Achondroplasia
Spinal stenosis from congenital short pedicles along with reducing interpedicular distance towards the lumbar spine is a classic finding of achondroplasia. Other associated findings include the champagne glass pelvis’, bullet-shaped vertebra (cf. central vertebral beaking in Morquio syndrome and inferior vertebral beaking in Hurler’s and Hunter’s syndromes), trident hand and craniocervical stenosis from a small foramen magnum.
Platyspondyly, loss of vertebral height, specially affecting lumbar vertebra by 2-3 years of age, is a typical feature of Morquio syndrome (cf. vertebral height is normal in Hurler’s syndrome).
@#1 6. Regarding sporting injuries involving the upper limbs, all of the following statements are correct, except:
A. Anomalous anconeus epitrochlearis muscle results in Posterior Interosseous Nerve (PIN) entrapment.
B. Atrophy of extensor muscles can be seen in chronic PIN neuropathy.
C. Partial thickness tears of the biceps can involve either the long or short heads.
D. Cubital tunnel syndrome is the most common elbow neuropathy.
E. Oedema of flexor carpi ulnaris and ulnar nerve thickening suggests cubital tunnel nerve entrapment.
- A. Anomalous anconeus epitrochlearis muscle results in PIN entrapment
Cubital tunnel syndrome is the most common entrapment neuropathy of the elbow. It is seen in throwing sports, tennis and volleyball.
Traction injuries to the ulnar nerve can occur secondary to the dynamic valgus forces.
Compression of the ulnar nerve within the cubital tunnel occur secondary to direct trauma, repetitive stresses, or replacement of the overlying retinaculum with an anomalous anconeus epitrochlearis muscle.
Recurrent subluxation of the nerve due to acquired laxity from repetitive stress or trauma can lead to friction neuritis.
Finally, osseous spurring within the ulnar groove caused by overuse and posteromedial impingement in throwers can cause nerve irritation.
Ulnar nerve thickening and increased T2 weighted signal are typical MRI features. Oedema-like signal changes or atrophy of the flexor carpi ulnaris and flexor digitorum profundus muscles may also be secondary to ulnar neuropathy.
Radial nerve entrapment at the elbow can be subdivided into two major categories: radial tunnel syndrome and posterior interosseous nerve syndrome.
The posterior interosseous nerve is a deep branch of the radial nerve in the forearm that can be compressed from repetitive gripping combined with supination in weight-lifters and swimmers. The superficial head of the supinator muscle along the arcade of Frohse is the most common site of nerve entrapment. It is important to note that a small percentage of radial neuropathy cases can be associated with tennis elbow.
MRI manifestations of PIN includes thickening and increased T2-weighted signal of the nerve fibres, as well as oedema-like signal changes in the innervated extensor compartment musculature in the acute and subacute setting and atrophy in the chronic stages.
@#1 12. An 11-year-old boy with left shoulder pain has a shoulder X-ray, which shows a lucent lesion in the metaphysis. This has distinct borders and lies in the intramedullary compartment It is orientated along the long axis of the humerus. What is the most likely diagnosis?
A. Aneurysmal bone cyst
B. GCT
C. Simple bone cyst
D. Chondroblastoma
E. Non-ossifying fibroma
- C. Simple bone cyst
SBC affects the young, aged 3-19 years, during the active phase of bone growth and has a slight male preponderance (M:F = 3:1). They are asymptomatic, unless fractured. They are commonly seen in the proximal femur or proximal humerus. They are solitary intramedullary lesions, centred at the metaphyses, adjacent to the epiphyseal cartilage (during the active phase) and migrating into diaphysis with growth (during the latent phase). They do not cross the epiphyseal plate.
On a radiograph, they appear as an oval radiolucency with a long axis parallel to the long axis of the host bone, a fine sclerotic boundary and scalloping of the internal aspect of the underlying cortex. SBC appears as a photopenic area on a bone scan (if not fractured). Classic ‘fallen fragment’ sign if fractured (20%); centrally dislodged fragment falls into a dependent position.
@#1 13. A 50-year -old secretary presents with epigastric pain, nausea and weight loss. She also complains of bilateral swollen ankles. She is referred for a barium meal as she is unable to tolerate an oesophago-gastroduodenoscopy (OGD). The examination shows thickened folds in the fundus and body of the stomach; the antrum was not involved. What is the mast likely diagnosis?
A. Nephrotic syndrome
B. Lymphoma
C. Eosinophilic gastroenteritis
D. Leiomyoma
E. Menetrier’s disease
- E. Ménétrier’s disease
The hallmark of Ménétrier’s disease is gastric mucosal hypertrophy, which may cause the rugae to resemble convolutions of the brain. The thickening of the rugae is predominantly caused by expansion of the epithelial cell compartment of the gastric mucosa.
Patients with Ménétrier’s disease most often present with epigastric pain and hypoalbuminemia secondary to a loss of albumin into the gastric lumen.
Signs and symptoms of Ménétrier’s disease include anorexia, asthenia, weight loss, nausea, gastrointestinal bleeding, diarrhoea, oedema and vomiting.
The disease has a bimodal age distribution.
The childhood form is often linked to cytomegalovirus infection and usually resolves spontaneously. It usually occurs in children younger than 10 years (mean age 5.5 years), predominantly in boys (male-to-female ratio 3:1). The second peak occurs in adulthood, and the disease in adults tends to progress over time.
The average age at diagnosis is 55, and men are affected more often than women.
A diagnosis of Ménétrier’s disease is made by using a combination of upper gastrointestinal fluoroscopic imaging, endoscopic imaging and histologic analysis. On fluoroscopic images, Ménétrier’s
disease is characterised by the presence of giant rugal folds. Rugal folds should normally measure less than 1 cm in width across the fundus and 0.5 cm across the antrum, and they should be parallel to the long axis of the stomach.
@#1 14. A 58-year-old woman undergoes an echocardiogram followed by cardiac MRI for investigation of exertional dyspnoea. The cardiac MRI was reviewed at the X ray meeting, and the radiologist diagnosed concentric hypertrophic cardiomyopathy. Which of the following did the radiologist see?
A. Thickening of the interatrial septum at 7 mm
B. Thickening of the entire LV wall measuring 17 mm at end diastole
C. Nodular high signal in the interventricular septum on T2
D. Thickening of the LV wall measuring 14 mm with normal systolic function
E. Thickened LV with delayed hyperenhancement of mid wall
- B. Thickening of the entire LV wall measuring 17 mm at end diastole
HCM should be differentiated from other causes of symmetric increased thickness of the LV wall, including athlete’s heart, amyloidosis, sarcoidosis, Fabry disease and adaptive LV hypertrophy due to hypertension or aortic stenosis.
HCM is associated with hypertrophy of the muscle to 15 mm or thicker. In cardiac amyloidosis, the amyloid protein is deposited in the myocardium, which leads to diastolic dysfunction and restrictive cardiomyopathy. Because amyloidosis is a systemic process, involvement of all four chambers is common; thus, an increase in the thickness of the interatrial septum and right atrial free wall by more than 6 mm is seen. Dynamic enhanced MRI shows late enhancement over the entire subendocardial circumference.
Sarcoidosis is a non-caseating granulomatous disease that infiltrates any area of the body, but most of the morbidity/mortality is from involvement of the heart. MRI shows nodular or patchy increased signal intensity on both T2-weighted and enhanced images, which often involves the septum (more particularly, the basal portion) and the LV wall, whereas papillary and right-ventricular infiltration are rarely seen.
Fabry disease is a rare X-linked autosomal recessive metabolic storage disorder. At MRI, the LV wall is seen to be concentrically thickened, and delayed hyperenhancement is typically seen mid-wall and has been reported in the basal inferolateral segment.
Differentiation between compensatory hypertrophy and HCM is sometimes difficult. In comparison to HCM, patients with compensatory hypertrophy usually have normal systolic function, rather than hyperdynamic systolic function in HCM, and their LV wall rarely exceeds 15 mm in maximal thickness.
Athlete’s heart can show increased LV wall thickness but end diastolic volume and ejection fraction are normal. Another feature of the cardiac remodelling in athletes is the lack of areas of’ delayed hyperenhancement within the LV myocardium at dynamic enhanced MRI.
@#1 15. A 50-year-old builder is involved in a high speed RTA. CT is performed according to trauma protocol, demonstrating extra-peritoneal rupture of the bladder. Which of the following best describes this?
A. Contrast pooling in the paracolic gutters.
B. Contrast outlining small bowel loops.
C. Flame-shaped contrast seen in the perivesical fat.
D. CT cystogram is usually normal.
E. Intramural contrast on CT cystogram.
- C. Flame-shaped contrast seen in the perivesical fat
Sandler described five types of bladder injuries with conventional cystography.
Type 1: Contusion: Bladder contusion is defined as an incomplete or partial tear of the bladder mucosa. Findings at conventional and CT cystography are normal.
Type 2: Intraperitoneal rupture: CT cystography demonstrates intraperitoneal contrast material around bowel loops, between mesenteric folds and in the paracolic gutters.
Type 3: Interstitial injury: Interstitial bladder injury is rare. CT cystography may demonstrate intramural contrast material without extravasation.
Type 4: Extraperitoneal rupture: Extraperitoneal rupture is the most common type of bladder injury (80%-90% of cases) Extravasation is confined to the perivesical space in simple ruptures (Type 4a), whereas in complex ruptures, contrast extends beyond the perivesical space (Type 4b) and may dissect into thigh, perineum and properitoneal fat planes.
Type 5: Combined rupture: CT cystography usually demonstrates extravasation patterns that are typical for both types of injury.
@#1 16. An elderly patient on long-term dialysis presents to the orthopaedic clinic with right shoulder pain. Plain films show juxta-articular swelling and erosions of the humerus, but the
joint space is preserved. MRI shows a small joint effusion and the presence of low- to intermediate-signal soft tissue on all sequences covering the synovial membrane extending into the periarticular tissue. What is the likely diagnosis?
A. Amyloid arthropathy
B. Gout
C. Calcium pyrophosphate deposition disease (CPPD)
D. Pigmented villonodular synovitis (PVNS)
E. Reticuloendotheliosis
- A. Amyloid arthropathy
Amyloid arthropathy most typically affects the shoulders, carpal hones and hips in a bilateral fashion. It is typically associated with long-term renal dialysis, which results in deposition of the beta-2 microglobulin.
Affected joints demonstrate subchondral cystic lesions with juxta articular swelling.
The presence of low-to-intermediate signal soft tissue within and around the joint clinches the diagnosis, as this represents the signal characteristics of the deposited proteins (cf. other inflammatory/infectious arthropathies, which tend to produce higher water content than soft-tissue changes in the joint). Joint space is also typically preserved until the late stages of disease, similar to gout.
@#1 18. A 14-year-old boy complains of left knee pain and limp. He also has medial thigh pain.
On examination, he has full range of movement with some discomfort on internal rotation. AP and lateral X-rays of the knee and femur arc normal. What is the next investigation?
A. CT
B. Bone scan
C. MRI
D. Frog leg lateral of the hips
E. US
- D. Frog-leg lateral of the hips
Diagnosis of SUFE (slipped upper femoral epiphysis) is made using anteroposterior (AP) pelvis and lateral frog-leg radiographs. CT is rarely needed, although it is very sensitive. MRI depicts the slippage earliest, and MRI can demonstrate early marrow oedema and slippage. It is also useful in identifying pre-slip changes in the opposite hip and shows differentials, for example, infection, tumour, synovitis and so on.
Although some institutions obtain a frog-leg lateral view, it is possible to further displace an acute or acute-on-chronic slip when the hips are placed in this position. Thus some institutions avoid them unless the request comes from an orthopaedic surgeon.
Phraseology is important in all investigation-related questions; while the next investigation is frog-leg lateral in several/most places, the best investigation or the most appropriate examination would be MRI because it will provide the most information and cover all differentials.
@#1 20. A 50-year-old man is referred to a gastroenterologist with a 6 month history of intermittent epigastric pain and nausea. He is referred for a barium meal test due to a failed OGD - oesophago-gastroduodenoscopy. The study shows an ulcer along the lesser curve of the stomach. Which of the following is a malignant feature of a gastric ulcer?
A. The margin of the ulcer crater extends beyond the projected luminal surface.
B. Carman meniscus sign.
C. Hampton’s line.
D. Central ulcer within mound of oedema.
E. The ulcer depth is greater than the width.
- B. Carman meniscus sign
The Carman meniscus sign is a curvilinear lens-shaped intraluminal form of crater with convexity of crescent towards the gastric wall and concavity towards the gastric lumen.
@#1 24. A newborn baby has US of the spine. At which level is the conus expected to be?
A. Above L1
B. Above T12
C. L2 to L3
D. L3 to L4
E. S2
- C. L2 to L3
The conus normally lies at or above the L2 disc space. A normal conus located at the mid-L3 level may be identified, especially in preterm infants; this position is considered the lower limits of normal but is usually without clinical consequence. However, in a preterm infant with a conus that terminates at the L3 mid-vertebral body, a follow-up sonogram can be obtained once the infant attains a corrected age between 40 weeks’ gestation and 6 months of age. In contrast, the thecal sac terminates at S2.
In the preterm group, more than 90% of conus medullaris cases lie above L2; in the term group, more than 92% lie above L2.
@#1 29. A 36-year-old woman with resolving limb weakness and previous history of optic neuritis is diagnosed as having relapsing remitting multiple sclerosis (RRMS). Which of the following statements concerning MS imaging is incorrect?
A. Black holes correlate well with clinical outcome.
B. Brain atrophy is higher in MS than normal ageing.
C. The pattern of brain atrophy can mimic Alzheimer’s disease.
D. Diffusion tensor imaging demonstrates structural damage to the white matter.
E. MS lesions have low MTR (Magnetisation Transfer Ratio) representing myelin loss.
- C. The pattern of brain atrophy can mimic Alzheimer’s disease
The T1 lesion load including enhancing lesions or black holes is correlated more closely than T2 lesion load with clinical outcome.
Another imaging hallmark of MS is brain atrophy. Brain atrophy in MS usually appears as enlarged ventricles and reduced size of the corpus callosum. The rate of brain atrophy is higher in MS than in the normal ageing process.
Significant loss of white matter rather than grey matter is seen in the early stage of MS, suggesting a different mechanism of atrophy compared to neurodegenerative diseases such as Alzheimer’s disease.
MS lesions show reduced Magnetisation transfer ratio (MTR), reflecting decreased myelin content.
MTR is also reduced in normal-looking white matter, representing occult tissue damage.
MS lesions usually have a more reduced MTR as compared with ischaemic lesions in small vessel diseases. Such occult tissue damage is also detected by diffusion tensor imaging, showing reduced fractional anisotropy (representing microstructural damage).
@#1 31. A 76-year-old male patient with chronic inflammatory disease and known history of secondary generalised multisystem amyloidosis showed an abnormal appearance of the heart on echocardiography. Dynamic enhanced cardiac MR imaging was advised for further characterisation. All of the following are imaging findings seen with cardiac amyloidosis, except
A. Left ventricular wall hypertrophy
B. Subendocardial delayed myocardial hyperenhancement
C. Systolic dysfunction
D. Granular echogenic myocardium
E. Interatrial septal thickening
- C. Systolic dysfunction
In cardiac amyloidosis, the amyloid protein is deposited in the myocardium, which leads to diastolic dysfunction that progresses to restrictive cardiomyopathy.
Because amyloidosis is a systemic process, involvement of all four chambers is common; thus, an increase in the thickness of the interatrial septum and right atrial free wall by more than 6 mm has been shown to be a specific finding for cardiac amyloidosis.
Through the use of dynamic enhanced cardiac MRI, a distinct pattern of late enhancement, which was distributed over the entire subendocardial circumference, has been shown to have high specificity and sensitivity for cardiac amyloidosis
Echocardiogram shows concentric LV hypertrophy, with hyperechoic granular sparkling of the ventricular wall.
@#1 33. A 55-year old man with several episodes of epididymo-orchitis in the past has an ultrasound of the scrotum. The radiologist performing the scan notices several hypoechoic structures within the mediastinum testis and incidental epididymal cysts. There was no Doppler flow. What is the most likely diagnosis?
A. Lymphoma of the testes
B. Cystic dysplasia of the testis
C. Seminoma
D. Abscess
E. Cystic transformation of rete testis
- E. Cystic transformation of rete testis
Cystic transformation of rete testis is a benign condition, also known as tubular ectasia, resulting from partial or complete obliteration of the efferent ductules that causes ectasia and, eventually, cystic transformation. The location of the lesion in or adjacent to the mediastinum testis and the presence of epididymal cysts are characteristic.
Cystic dysplasia of the rete testis is a rare benign testicular tumour that is found mainly in the paediatric population.
Abscesses are usually secondary to epididymo-orchitis; however, they appear cystic with shaggy, irregular walls; intratesticular location; low-level internal echoes; and occasionally hypervascular margins.
Teratomas are the most frequent to manifest as cystic masses; however, cystic tumours are rare and, when present, usually have an abnormal rind of parenchyma with increased echogenicity surrounding the cystic lesion.
@#1 34. An elderly woman presents with progressive atraumatic pain within her right knee over the course of the last month, particularly on the medial aspect, associated with functional impairment. Her clinical history includes a meniscal tear, which was treated arthroscopically 10 years ago with a good outcome. An MRI reveals florid marrow oedema within the medial femoral condyle associated with mild flattening of the weight-bearing surface.
What is the diagnosis?
A. Perthe’s disease
B. Sinding Larsen’s disease
C. Blount’s disease
D. Spontaneous osteonecrosis of the knee
E. Osteochondral defect
- D. Spontaneous osteonecrosis of the knee
Spontaneous osteonecrosis of the knee (SONK) is a rapid and painful condition in elderly patients that ultimately results in subchondral collapse of the weight-bearing portion of the medial femoral condyle. It is often idiopathic but can be associated with minor trauma. It is now also increasingly recognised as a subchondral insufficiency fracture resulting in rapid secondary’ subchondral collapse.
Perthes disease is a childhood disease with avascular necrosis of the femoral head.
Sinding-Larsen disease is essentially tendinosis of the proximal origin of the patella tendon.
Blount’s disease is a growth disorder of the tibia resulting in a ‘bow leg’ deformity from disturbance to the medial proximal tibial epiphysis.
An osteochondral defect is a traumatic injury involving the articular cartilage and adjacent subchondral bone.
@#1 37. A child with exertional dyspnoea and abnormal chest X-ray showing a boot-shaped heart and oligaemic lungs is diagnosed as suffering from tetralogy of Fallot. The pulmonary oligaemia is secondary to right ventricular outflow tract (RVOT) obstruction. Which of the following is the most common implicated cause for obstruction of RVOT?
A. Hypoplastic pulmonary annulus
B. Pulmonary valvular stenosis
C. Infundibular stenosis
D. Combined infundibular and pulmonary valvular stenosis
E. Overriding ventricular septum
- C. Infundibular stenosis
Tetralogy of Fallot (TOF) is the most common form of cyanotic congenital heart disease. This disease accounts for approximately 10% of all congenital heart defects, affecting men and women equally. In addition, TOF is the most common cyanotic heart disease that survives to adulthood.
The four components of TOF, first described in 1888 by French physician Etienne-Louis Arthur Fallot, are interventricular communication (ventricular septal defect), right-ventricular outflow tract (RVOT) obstruction, concentric right-ventricular hypertrophy (RVH) and deviation of the origin of the aorta to the right.
Combined infundibular and pulmonary valvular stenosis is the second most common cause.
@#1 38. A 50-year-old man presents with recurrent episodes of abdominal pain. Blood amylase is normal. Chronic pancreatitis is suspected. All of the following statements regarding MRI imaging in chronic pancreatitis are true, except
A. MRI has a poor sensitivity for detecting parenchymal calcification in chronic pancreatitis.
B. MRI allows evaluation of the ductal system for strictures and stones, debris within pseudocysts and fistula.
C. MRI shows good sensitivity for the differential diagnosis of focal chronic pancreatitis from pancreatic carcinoma.
D. Both focal chronic pancreatitis and pancreatic carcinoma demonstrate abnormal post-contrast enhancement on MRI.
E. Both focal chronic pancreatitis and pancreatic carcinoma demonstrate low signal intensity of the pancreas on T1W fat-saturated images.
- C. MRI shows good sensitivity for the differential diagnosis of focal chronic pancreatitis from pancreatic carcinoma.
The diagnosis of chronic pancreatitis on MRI is based on signal intensity and enhancement changes as well as on morphologic abnormalities in the pancreatic parenchyma, pancreatic duct and biliary tract.
The imaging features of chronic pancreatitis can be divided into early and late findings.
Early findings include low-signal-intensity pancreas on T1 -weighted fat-suppressed images, decreased and delayed enhancement after IV contrast administration, and dilated side branches.
Late findings include parenchymal atrophy or enlargement, pseudocysts, and dilatation and beading of the pancreatic duct often with intraductal calcifications.
Differentiating between an inflammatory mass due to chronic pancreatitis and pancreatic carcinoma on the basis of imaging criteria remains difficult.
Decreased Tl signal intensity with delayed enhancement after gadolinium administration as well as dilatation and obstruction of the pancreaticobiliary ducts can be seen in both diseases.
Irregularity of the pancreatic duct, intraductal or parenchymal calcifications, diffuse pancreatic involvement, and normal or smoothly stenotic pancreatic duct penetrating through the mass (‘duct penetrating sign’) favour the diagnosis of chronic pancreatitis over cancer.
In distinction, a smoothly dilated pancreatic duct with an abrupt interruption, dilatation of both biliary’ and pancreatic ducts (‘double-duct sign’) and obliteration of the perivascular fat planes favour the diagnosis of cancer.
@#1 40. A 10 x 7 mm dense ossified focal lesion is noted in the neck of the right femur of a young man incidentally on a pelvic radiograph performed for an unrelated reason. The lesion has benign features and is consistent with a bone island (enostosis). No follow-up is suggested. All of the following are true of bone islands, except
A. If more than 2 cm, they are classified as a giant’ bone island.
B. They have a sclerotic appearance on imaging.
C. They show a characteristic brush border on plain films.
D. They can be positive on a bone scan.
E. Giant bone islands can be locally aggressive
- E. Giant bone islands can be locally aggressive
Bone islands arc benign entities and represent compact bone within the medullary space.
They do not exhibit aggressive features regardless of size.
Classically they are sharply defined with thorny radiations (brush border).
They can occasionally show increase or decrease in size (about a third of them) (cf. osteoblastic metastasis, which shows aggressive features, cortical break/destruction, periosteal reaction or soft-tissue component; osteoid osteoma is associated with typical pain and a nidus).
@#1 41. A patient recently diagnosed with MS has been sent for an MRI of the whole spine to detect possible spinal plaques. All of the following are MR features of spinal cord lesions
in MS, except
A. The sole site of involvement (in some cases).
B. Imaging features similar to those of MS lesions in the brain.
C. Most lesions are centrally located.
D. The length rarely exceeds two vertebral segments.
E. Dorsal column involvement.
- C. Most lesions are centrally located.
Occurrence of spinal cord abnormalities is largely independent of brain lesions in MS. Both focal and disuse lesions affecting the cord arc described, though multiple focal lesion (median 3) is the most common finding. Patients with focally involved spinal cords mostly show multiple small lesions.
Focal lesions have an elongated configuration along the axis of the spinal cord and affect the peripheral part of the cord.
Cervical cord is the most commonly affected segment and the lesions usually extend over fewer than two vertebral segments in length.
@#1 42. Barium enema of a neonate shows an inverted cone shape at the rectosigmoid colon. There is marked retention of the barium on delayed post-evacuation films after 24 hours.
The cause for this is
A. Meconium ileus
B. Meconium plug syndrome
C. Hirschsprung’s disease
D. Imperforate anus
E. Hyperplastic polyp of colon
- C. Hirschsprung’s disease
Hirschsprung’s disease, also called aganglionosis of the colon (absence of parasympathetic ganglia in muscle and submucosal layers secondary to an arrest of craniocaudal migration of neuroblasts), results in relaxation failure of the aganglionic segment.
It affects full-term infants during the first weeks of life, mainly boys. It is extremely rare in premature infants.
It usually affects the rectosigmoid junction and results in short-segment disease (80%). Long-segment disease (20%) and total colonic aganglionosis (5%) are less common.
Barium enema shows a ‘transition zone’ (aganglionic segment), which appears normal in size with dilatation of large and small bowel proximally with marked retention of barium on delayed films after 24 hours.
Normal children show a rectosigmoid ratio of >1, as the rectum is larger in diameter than the sigmoid; in the case of Hirschsprung’s disease, the ratio is reversed (rectosigmoid ratio <1).
@#1 45. A woman presents with infertility and undergoes a hysterosalpingogram. This demonstrates a uterus with two converging horns. A wide angle is seen at the roof of the uterus.
Which uterine anomaly does the patient have?
A. Uterine didelphys
B. Septate uterus
C. Arcuate uterus
D. Bicornuate uterus
E. Unicornuate uterus
- D. Bicornuate uterus
While the presence of a divided rather than triangular uterine cavity at Hysterosalpingogram (HSG) may suggest the presence of an Mullerian duct anomaly (MDA), it is not possible to differentiate between subtypes. MRI and US provide greater anatomic detail; both of these imaging methods provide information on the external uterine contour, which is an important diagnostic feature of MDAs. Furthermore, both MRI and US may be used to assess for concomitant renal anomalies; renal anomalies occur at a higher rate among MDA patients. Unicornuate uterus appears as a small, oblong, off-midline structure on US and MRI. Uterus didelphys results from complete failure of Mullerian duct fusion. Each duct develops fully with duplication of the uterine horns, cervix and proximal vagina.
A fundal cleft greater than 1 cm has been reported to be 100% sensitive and specific in differentiation of fusion anomalies (didelphys and bicornuate) from reabsorption anomalies (septate and arcuate).
Bicornuate uterus involves duplication of the uterus with possible duplication of the cervix (bicornuate unicollis or bicornuate bicollis).
HSG demonstrates opacification of two symmetric fusiform uterine cavities (horns) and fallopian tubes. Historically, an intercornual angle of greater than 105° was used for diagnosis of bicornuate uterus.
Septate uterus is the most common form of MDA, accounting for approximately 55% of cases.
Historically, an angle of less than 75° between the uterine horns has been reported to be suggestive of a septate rather than bicornuate uterus.
However, considerable overlap occurs between septate and bicornuate uteri; as such, the angle measurement is not a reliable diagnostic feature.
Arcuate uterus at HSG shows a single uterine cavity with a broad saddle-shaped indentation at the uterine fundus.
@#1 46. A 53-year old woman presents to the A&E department with acute knee pain. She has had two previous similar episodes in the past, which settled with analgesics and anti-inflammatory medications. Plain films show extensive degenerative change, which is worst at the patellofemoral joint with large subchondral cystic change and chondrocalcinosis of the knee menisci. She informs the attending doctor that she is under review with the endocrinologist. What is the likely diagnosis?
A. Calcium pyrophosphate deposition disease (CPPD)
B. Gout
C. Rheumatoid arthritis
D. Ochronosis
E. Psoriasis
- A. Calcium pyrophosphate deposition disease (CPPD)
This is a typical description of CPPD, which can be idiopathic or associated with endocrinological problems such as hyperparathyroidism and hypothyroidism. The joints of the knee, wrist and second/third MCP joints of the hand are most frequently involved.
Differentials would also include gout, but the distribution of erosions are different, with gouty erosions tending to be juxta-articular and punched out (‘rat-bitten’) rather than subchondral. Joint space is also typically preserved in gout until the late stages.
Psoriasis produces enthesitis and periostitis with new bone formation.
Ochronosis, or alkaptonuria, is a metabolic disorder whereby there is abnormal build-up of homogentisic acid in connective tissue with pigmentation of the sclera and urine appearing dark in colour. Diffuse multilevel vertebral disc calcification and early OA changes in multiple joints are associated with this condition.
