VIQ - TEST PAPER I

Question 1

@#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

Answer 1

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.

Question 2

@#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

Answer 2

4. 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).

Question 3

@#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.

Answer 3

6. 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.

Question 4

@#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

Answer 4

12. 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.

Question 5

@#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

Answer 5

13. 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.

Question 6

@#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

Answer 6

14. 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.

Question 7

@#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.

Answer 7

15. 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.

Question 8

@#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

Answer 8

16. 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.

Question 9

@#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

Answer 9

18. 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.

Question 10

@#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.

Answer 10

20. 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.

Question 11

@#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

Answer 11

24. 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.

Question 12

@#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.

Answer 12

29. 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).

Question 13

@#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

Answer 13

31. 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.

Question 14

@#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

Answer 14

33. 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.

Question 15

@#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

Answer 15

34. 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.

Question 16

@#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

Answer 16

37. 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.

Question 17

@#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.

Answer 17

38. 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.

Question 18

@#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

Answer 18

40. 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).

Question 19

@#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.

Answer 19

41. 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.

Question 20

@#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

Answer 20

42. 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).

Question 21

@#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

Answer 21

45. 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.

Question 22

@#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

Answer 22

46. 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.

Question 23

@#1 47. A 54-year-old man who developed brain metastases almost 9 years after resection of an acral lentiginous melanoma of the distal thumb shows two peripheral nodules in the right frontal lobe. All of the following are features of CNS metastatic melanoma, except

A. Moderate to intense enhancement post-contrast administration

B. Cystic components

C. Subependymal nodules

D. Multiple lesions at the gray white matter junction

E. Miliary pattern

Answer 23

47. B. Cystic components

Metastatic malignant melanoma is a commonly encountered neoplasm in the head. Typical appearance of a lesion is high signal intensity on T1-weighted images and low signal on T2-weighted images (melanotic pattern). The other described pattern is the amelanotic pattern. In this pattern, the lesion is hypointense or isointense to the cortex on T1-weighted images and hyperintense or isointense to the cortex on T2-weighted images. Metastatic melanoma presents as multiple brain metastasis, which are located predominantly in the cortex and at the grey matter- white matter junction. They can also present in miliary form or as subependymal nodules. The lesions often appear hyperdense on unenhanced CT. The lesions show moderate to intense contrast enhancement, although larger lesions can show non-enhancing or hypoenhancing necrotic areas. Prominent perilesional oedema is seen.

Question 24

@#1 48. A child presents with vomiting and sudden onset abdominal pain. Plain X-rays show a target sign in the right upper quadrant. US shows a pseudo kidney sign in keeping with intussusception. Which of the following is false regarding hydrostatic reduction?

A. Free intraperitoneal air is a contraindication.

B. A maximum of two attempts can be made.

C. Air is preferred to Gastrografin water solution in some institutions.

D. The perforation rate is 0.4%-3%.

E. Air enema is associated with a higher perforation rate.

Answer 24

48. B. Maximum of two attempts can be made.

Intussusception is one of the most common causes of acute abdomen in infancy.
Perforation may already have occurred before enema therapy or may occur during the reduction process.
There is no agreement on the number and duration of reduction attempts, the efficacy of premedication or sedation, the use of rectal tubes with inflatable retention balloons, or the use of transabdominal manipulation. The classic ‘rule of threes’ is that the number of reduction attempts is capped at three, lasting 3 min each. This rule has been discarded at some institutions, and some authors use a nearly unlimited number of attempts. Use of sedation, rectal tube with balloons and the Valsalva manoeuvre are said to improve the reduction rate achieved.
Absolute contraindications to enema therapy are shock not readily corrected with IV hydration and perforation with peritonitis. Criteria that are linked to a lower reduction rate and a higher perforation rate are age less than 3 months or greater than 5 years, long duration of symptoms, especially if greater than 48 hours, passage of blood via the rectum, significant dehydration, small bowel obstruction and visualisation of the dissection sign during enema therapy. Air enema produces excellent results but is also associated with maximum perforation rates.

Question 25

@#1 49. Plain X-ray of a newborn shows a large tubular air shadow behind the trachea. The lungs are clear. The bowels are grossly distended with air. What is the likely type of tracheo-oesophagcal fistula?

A. Type A

B. Type B

C. Type C

D. Type D

E. Type E

Answer 25

49. C. Type C

Different types of oesophageal atresia are identified on the basis of the presence (and location) or absence of a tracheo oesophageal fistula.

Type A is pure oesophageal atresia without fistula,

and Type B is oesophageal atresia with a fistula between the proximal pouch and the trachea.

Type C is oesophageal atresia with a fistula from the trachea or the main bronchus to the distal oesophageal segment.

Type D is oesophageal atresia with both proximal and distal fistulas,

and Type E is an H-shaped tracheo-oesophageal fistula without atresia.

Of these five types, Type C is by far the most common.

Oesophageal atresia is generally suspected on the basis of polyhydramnios, inability to swallow saliva or milk, aspiration during early feedings, or failure to successfully pass a catheter into the stomach. Feeding difficulties with choking occur in infants with Type E (fistula without atresia), but the diagnosis may not be made until several years later when the patient presents with a cough while swallowing, recurrent pneumonia and a distended abdomen.

In Types A and B, there is a complete absence of gas in the stomach and intestinal tract, whereas in Types C and I) the gastrointestinal tract commonly appears distended with air.

Question 26

@#1 52. The causes of medullary nephrocalcinosis include all, except

A. Hyperparathyroidism

B. Renal tubular acidosis

C. Medullary sponge kidney

D. Hypervitaminosis D

E. Alport’s syndrome

Answer 26

52. E. Alport’s syndrome

Causes of medullary nephrocalcinosis include hyperparathyroidism, sarcoidosis, myelomatosis, primary or secondary hyperoxaluria (Crohn’s disease), hyperthyroidism, osteoporosis, idiopathic hypercalciuria, renal tubular acidosis, medullary sponge kidney and drug-induced (hypervitaminosis D, milk-alkali syndrome).
Alport’s syndrome is an autosomal dominant condition also called chronic hereditary nephritis, associated with ocular abnormalities, deafness, small kidneys, cortical calcification and progressive renal failure without hypertension.

Question 27

@#1 56. A 66-year-old joiner presents to his GP with jaundice and abdominal discomfort. He was subsequently referred to a gastroenterologist who requests a liver biopsy due to deranged liver function tests. Which of the following options is not a contraindication for percutaneous liver biopsy?

A. INR above 1.6

B. Platelets less than 60,000/mm3

C. Tense ascites

D. Extra-hepatic biliary obstruction

E. Suspected haemangioma

Answer 27

56. E. Suspected haemangioma

Contraindications for liver biopsy include the following:
1. Uncooperative patient
2. Extrahepatic biliary duct dilatation (except if benefit outweighs the risk)
3. Bacterial cholangitis (relative contraindication due to risk of septic shock)
4. Abnormal coagulation indices (having a normal INR or PT is not a reassurance that the patient will not bleed; however, there is increased incidence of bleeding with INR above 1.5)
5. Thrombocytopenia (platelet count below 60,000/mm3)
6. Presence of ascites
7. Cystic lesion

Question 28

@#1 57. A 40-year-old man who is a known hypothyroid patient, presents with weight loss and dull pain in the flank and back. He undergoes an abdominal CT. Regarding retroperitoneal fibrosis, all of the following is seen on imaging, except

A. Medial deviation of the ureters in the middle third, typically bilateral.

B. CT shows soft-tissue mass displacing the aorta anteriorly.

C. T2W MRI shows variable signal.

D. PET CT has high sensitivity.

E. Hydronephrosis is evident on CT urogram.

Answer 28

57. B. CT shows soft-tissue mass displacing the aorta anteriorly

Intravenous urography usually demonstrates the classic triad of medial deviation of the middle third of the ureters, tapering of the lumen of one or both ureters in the lower lumbar spine or upper sacral region, and proximal unilateral or bilateral hydroureteronephrosis with delayed excretion of contrast material. CT and MRI is the mainstay of non-invasive diagnosis of Retroperitoneal fibrosis (RPF). CT allows comprehensive evaluation of the morphology, location and extent of RPF and involvement of adjacent organs and vascular structures. Moreover, abdominal CT allows detection of diseases often associated with idiopathic RPF (e.g., autoimmune pancreatitis) or demonstrating an underlying cause in cases of secondary RPF (e.g., malignancy). CT shows a well-defined mass, usually anterior and lateral to the aorta, sparing the posterior aspect and not causing aortic displacement. Idiopathic RPF typically has low signal intensity on T1 weighted images. The signal intensity on T2 weighted images is variable and reflects the degree of associated active inflammation (hypercellularity and oedema). After administration of contrast material, early soft-tissue enhancement mirrors the degree of inflammatory activity observed at T2-weighted imaging. The sensitivity of 18F-FDG PET is very high, which allows detection and quantification of the metabolic activity of retroperitoneal lesions. Although sensitivity is high, specificity is low and aortic wall in the elderly can show FDG uptake.

Question 29

@#1 58. A 17-year-old teenager is under investigation for vague pain in the knee associated with a limp. A plain film radiograph shows an oval lucent lesion in the epiphysis of the distal femur. The pain was noticed following an injury sustained during a football match. What would be the next investigation of choice?

A. CT

B. MRI

C. Bone biopsy

D. Tc-99m bone scan

E. No imaging necessary since it looks benign

Answer 29

58. B. MRI

A main differential for a symptomatic lesion in the epiphysis of a long bone in an unfused skeleton is a chondroblastoma. MRI will reveal the presence of marked reactive surrounding marrow’ oedema. In a fused skeleton, the differentials would include clear cell chondrosarcoma, giant cell tumours and other benign causes like subarticular cyst and intraosseous ganglion.
Chondroblastomas are very well defined with sclerotic margin on plain X-ray and low-signal rim on MRI (cf. Langerhans cell histiocytosis, which appears less well defined with variable margins). Often definitive diagnosis requires surgical biopsy.

Question 30

@#1 65. A 58-year-old man with facial fractures shows deformity of the globe on unenhanced axial CT, but it is unclear if there is an open-globe injury. All of the following CT findings suggest an open-globe injury, except

A. Intra-ocular air

B. Lens dislocation

C. Scleral discontinuity

D. Flat tire sign

E. Deep anterior chamber

Answer 30

65. B. Lens dislocation

In blunt traumas, ruptures are most common at the insertions of the intra-ocular muscles where the sclera is thinnest.

CT findings suggestive of an open globe injury include a change in globe contour, an obvious loss of volume, the ‘flat tire sign, scleral discontinuity, intra-ocular air and intra-ocular foreign bodies.

A deep anterior chamber has been described as a clinical finding in patients with a ruptured globe and can also be a clue on CT.

Question 31

@#1 68. A 90-year-old man is admitted following intermittent episodes of bright red rectal bleeding. He is haemodynamically stable on initial assessment. OGD and flexible colonoscopy are normal. He subsequently has another bleed on the surgical ward and is then referred for
a CT mesenteric angiogram. Which of the following statements is false regarding CT mesenteric angiography?

A. Severe bleeding episodes, such as those manifesting with hemodynamic instability, decrease the pretest probability of a positive result for active bleeding at CT angiography.

B. Active bleeding must be present during the time contrast is injected into the vascular system in order to demonstrate the site of bleeding.

C. Portal venous phase imaging depicts extravascular blushes with higher sensitivity than arterial phase imaging does.

D. Retention of previously administered barium in colonic diverticula may be mistaken for, or may obscure, acute extravasation of contrast material.

E. Hyperattenuating material within the bowel lumen on the unenhanced scan without additional findings in the contrast-enhanced phases indicates recent haemorrhage.

Answer 31

68. A. Severe bleeding episodes, such as those manifesting with haemodynamic instability, decrease the pretest probability of a positive result for active bleeding at CT angiography.

Severe bleeding episodes, such as those manifesting with haemodynamic instability, increase the pretest probability of a positive result for active bleeding at CT angiography.

Question 32

@#1 69. A 25-year-old man undergoing abdominal CT shows the presence of bridging renal tissue across the midline at the level of the lower poles, consistent with a horseshoe kidney.
All the following are recognised associations, except

A. Bicornuate uterus

B. Cardiac anomaly

C. Undescended testis

D. Tracheo-oesophageal fistula

E. Anorectal malformation

Answer 32

69. D. Tracheo-oesophageal fistula

Horseshoe kidney is the most common fusion anomaly of the kidneys. There is recognised association with cardiovascular, skeletal, CNS, genitourinary anomalies (undescended testes, bicornuate uterus, duplication of ureter, hypospadias, etc.), anorectal malformations, trisomy 18 and Turner syndrome. Vesico ureteric reflux, hydronephrosis secondary’ to PUJ obstruction and increased frequency of complications like renal stones and infection are recognised.

Question 33

@#1 74. A 5-year-old boy involved in an RTA is referred for a trauma CT scan. The reporting radiologist does not find any acute abnormality. However, there are other incidental findings on the scan suggestive of malrotation. Which of the following options is the most specific feature of gut malrotation on CT?
A. SMV (superior mesenteric vein) anterior to the SMA (superior mesenteric artery)

B. SMV to the right of the SMA

C. Whirl sign around the SMA

D. DJ (duodenojejunal) flexure to the right of the midline

E. SMV to the left of the SMA

Answer 33

74. E. SMV to the left of the SMA

SMV positioned to the left of SMA is the most specific sign of malrotation on CT (80%). Other signs on CT include the ‘whirl sign’ around the SMA and large intestine on the left with small intestine on the right.
Abnormal position of the caecum and duodenum with duodeno jejunal junction over the right pedicle is the most specific sign of malrotation on barium meal studies.

Question 34

@#1 82. A 17-year-old girl presents with a history of acute-on-chronic burning neck pain radiating into the right shoulder and arm. There is associated palmar paraesthesia, easy fatigability and loss of power, exacerbated by elevating the arm to the shoulder level. Sagittal T1W MRI obtained with the arm in the neutral position shows ample fat surrounding the subclavian vessels and brachial plexus. With the arm in abduction, there is compression of the subclavian vessels. What is the diagnosis?

A. Subclavian artery stenosis

B. Parsonage-Turner syndrome

C. Median nerve entrapment

D. Thoracic outlet syndrome

E. Subclavian steal syndrome

Answer 34

82. D. Thoracic outlet syndrome

Thoracic outlet syndrome involves the brachial plexus and the subclavian artery or vein at three anatomic levels where they are vulnerable to entrapment; the interscalene space, the costoclavicular space and the retropectoralis minor space.

Thoracic outlet syndrome may result from post- traumatic fibrosis of the scalene muscles, compression secondary to activities like backpacking, and clavicular fractures with callus formation and exercise-related muscle hypertrophy affecting weightlifters, swimmers, tennis players and so on. Other causes include mass lesions such as lipomas, neurogenic tumours, accessory muscles and fibrous bands.

MRI can help identify specific muscle denervation patterns. Muscle oedema may occur within 24-48 hours. In contrast, fatty atrophy reflects chronic denervation and manifests several months later. In this setting, MRI has an advantage over electromyography, which does not demonstrate signs of muscle denervation until 2-3 weeks after nerve impairment.

Radiographs may reveal a cervical rib or a prominent C7 transverse process. Narrowing has been reported in the costoclavicular and retropectoralis minor spaces during imaging with postural manoeuvres during dynamic MRI.

Sagittal T1-weighted MRI sequences are particularly useful in demonstrating the presence of denervation-related fatty atrophy of muscles, effacement of fat planes around the compressed plexus and an abnormal intramuscular course of the components of the brachial plexus.

The retropectoralis minor space is not frequently affected by entrapment and is more often involved by mass lesions.

Question 35

@#1 84. The most common structure to herniate in Bochdalek hernia is

A. Stomach

B. Spleen

C. Omentum

D. Left lobe of liver

E. Pancreas

Answer 35

84. C. Omentum

Bochdalek hernia represents the commonest type of congenital diaphragmatic hernia. It is more common on the left. The most common structure to herniate on the left is omental fat; on the right is the liver.

Question 36

@#1 86. A 50-year-old woman with long-standing abdominal pain, weight loss and poor appetite undergoes a CT abdomen and pelvis. This shows mesenteric thickening with a fine stellate pattern extending to the bowel border. The mesenteric mass does not displace the mesenteric vessels masses and shows a fat ring sign. The most likely diagnosis is

A. Retroperitoneal fibrosis

B. Carcinoid

C. Sclerosing mesenteritis

D. Epiploic appendagitis

E. Lymphoma

Answer 36

86. C. Sclerosing mesenteritis

Sclerosing mesenteritis is a rare condition of unknown cause that is characterised by chronic mesenteric inflammation. The process usually involves the mesentery of the small bowel, especially at its root, but can occasionally involve the mesocolon. On rare occasions, it may involve the peripancreatic region, omentum, retroperitoneum, or pelvis. Although the cause of sclerosing mesenteritis is unknown, the disorder is often associated with other idiopathic inflammatory disorders such as retroperitoneal fibrosis, sclerosing cholangitis, Riedel thyroiditis and orbital pseudotumour. The CT appearance of sclerosing mesenteritis can vary from subtle increased attenuation in the mesentery to a solid soft-tissue mass. Sclerosing mesenteritis most commonly appears as a soft-tissue mass in the small bowel mesentery, although infiltration of the region of the pancreas or porta hepatis is also possible.

The mass may envelop the mesenteric vessels, and over time collateral vessels may develop. There may be preservation of fat around the mesenteric vessels, a phenomenon that is referred to as the fat ring sign. This finding may help distinguish sclerosing mesenteritis from other mesenteric processes such as lymphoma, carcinoid tumour, or carcinomatosis.

Question 37

@#1 87. A 56-year-old man undergoing CT urogram displays an incidental lesion in his right adrenal gland. He is asymptomatic apart from pain in the left loin, which is currently being investigated. All these features suggest that adrenal carcinoma is more likely than
a benign adenoma, except

A. Size more than 5 cm

B. Delayed washout

C. HU value of <37 on delayed contrast enhanced CT

D. Involvement of right kidney

E. Peripheral nodular enhancement

Answer 37

87. C. HU value of <37 on delayed contrast enhanced CT

Features suggestive of adrenal carcinoma on imaging include large size (>5 cm); invasion of other organs like liver, kidney, IVC, or diaphragm; calcification; central heterogeneous area of low density (tumour necrosis); peripheral nodular enhancement on contrast-enhanced images; and delayed washout.

A HU of <37 on contrast-enhanced CT at 5-15 minutes after contrast injection is diagnostic of a benign adrenal lesion.

Question 38

@#1 88. What type of labral injury is not associated with an anterior shoulder dislocation?

A. Bony Bankart lesion

B. Perthes lesion

C. Clenolabral articular disruption injury (GLAD)

D. Superior labral anterior posterior tear (SLAP)

E. Anterior labroligamentous periosteal sleeve avulsion injury (ALPSA)

Answer 38

88. D. Superior labral anterior-posterior tear (SLAP)

The anteroinferior glenoid labrum is typically injured in an anterior shoulder dislocation.
All of the aforementioned injuries except for the superior labral anterior-posterior (SLAP) tear involve the anteroinferior labrum.

The glenolabral articular disruption (GLAD) lesion is a partial tear of the anteroinferior labrum with an associated glenoid cartilage injury.

Perthes lesion is a complete tear of the labrum, which is still attached to the glenoid periosteum.

An anterior labroligamentous periosteal sleeve avulsion (ALPSA) injury is similar to the Perthes lesion but with medial displacement of the tom labrum, which is still attached to the glenoid scapula periosteal sleeve.

Question 39

@#1 89. A 36-year old woman with non-remitting headache is sent for an MRI brain by the neurologist to investigate the cause of her headache. The MRI brain is mostly unremarkable apart from showing areas of hyperintensity on FLAIR in subarachnoid spaces. All of the following conditions should be included in the differential diagnosis, except

A. Pacchionian granulations

B. Slow arterial flow due to vascular stenosis

C. Subarachnoid haemorrhage

D. Infectious meningitis

E. Leptomeningeal melanosis

Answer 39

89. A. Pacchionian granulations

Hyperintensity on FLAIR in subarachnoid spaces has been well described in a wide range of pathologic conditions, such as subarachnoid haemorrhage (SAH), infectious or malignant meningitis, leptomeningeal spread of malignant disease, Leptomeningeal melanosis (part of the neurocutaneous melanosis congenital phakomatosis), vascular hyperintensity in the subarachnoid space produced by severe (>90%) vascular stenosis or occlusion of major cerebral vessels with resulting slow flow and fat-containing tumours like lipoma of subarachnoid space. Retrograde slow flow of engorged pial arteries through leptomeningeal anastomoses is also seen as high signal intensity in the subarachnoid space on FLAIR in patients with Moyamoya disease, called ivy sign. Other, less common, causes of subarachnoid FLAIR hyperintensity are artefacts.

Question 40

@#1 93. According to Standards of Intravascular Contrast Agent Administration to Adult Patients, second edition (RCR 2015), all are true regarding patients on metformin, except

A. Metformin need not be stopped prior to contrast enhanced CT if serum creatinine is normal.

B. Metformin need not be stopped prior to contrast examination if eGFR is >60.

C. If serum creatinine is above normal range, metformin should be withheld for 24 hours.

D. If eGFR is <60, the decision to withhold metformin should be made in consultation with the clinical team.

E. There is lack of evidence about whether lactic acidosis is really an issue post-iodinated contrast in metformin users.

Answer 40

93. C. If serum creatinine is above normal range, metformin should be withheld for 24 hours.

Metformin is not recommended for use in diabetics with renal impairment because it is excreted exclusively via the kidneys. Accumulation of metformin may result in the development of lactic acidosis - a serious complication. There is lack of any valid evidence that lactic acidosis is really an issue after administration of iodinated contrast media in patients taking metformin. The problems caused to patients and clinicians by stopping the drug and its increasing use in poorly controlled diabetic patients regardless of renal function have been considered when formulating this advice. It does, however, remain the case that renal function should be known in patients taking metformin who require intravenous or intra-arterial iodinated contrast medium administration. There is no need to stop metformin after contrast in patients with serum creatinine within the normal reference range and/or eGFR >60 ml/min/1.73 m2. If serum creatinine is above the normal reference range or eGFR is below 60, any decision to stop metformin for 48 hours following contrast medium administration should be made in consultation with the referring clinic.

Question 41

@#1 94. A motorcyclist is brought into the A&E department with limb fractures and neck pain. Preliminary cervical spine radiographs review mild anterolisthesis (~10%) at C4/5 with slight overlap of the facet joints. CT shows a right ‘naked facet’ sign at this level.
What statement is false in regard to this injury?

A. It is an unstable injury.

B. Anterolisthesis is a common finding.

C. It is a stable injury.

D. There is widening of the interspinous space.

E. It is often associated with a neurological deficit.

Answer 41

94. A. It is an unstable injury.

Unilateral facet joint dislocation occurs from a flexion/distraction injury with a rotatory component. It is a stable form of facet joint dislocation (cf. with highly unstable bilateral facet joint dislocation). The naked facet sign is seen involving one facet joint on CT, and on plain radiograph there is often an overlapping appearance to the facet joints. Mild anterolisthesis and widening of the interspinous space at the level of injury is a common finding. Up to 30% of patients have a neurological deficit.

Question 42

@#1 96. A 10-year-old boy presents with fever and eosinophilia. MRI of the head shows thickening of the infundibular stalk and a markedly enhancing mass in the superior aspect of the stalk. There is also enhancement in the sella extending along the left petrous temporal bone with poorly defined borders. The features arc consistent with

A. Meningioma

B. Petrous apicitis

C. Histiocytosis X

D. Craniopharyngioma

E. Neuroblastoma metastasis

Answer 42

96. C. Histiocytosis X

Space-occupying lesions affect the hypothalamic neurohypophyseal axis, which is the central nervous system site most commonly and often earliest involved in Langerhans cell histiocytosis.

MRI findings have been correlated with symptoms of diabetes insipidus, which is a clinical hallmark of the condition.

Typically, the formation of Langerhans cell histiocytosis granulomas leads to a loss in the normally high signal intensity of the posterior neurohypophysis on T1-weighted images. Furthermore, the hypothalamus, the pituitary stalk or both are frequently- enlarged and demonstrate gradually increasing homogeneous enhancement after an intravenous injection of gadolinium, without subsequent washout.

The differential diagnosis includes other infundibular diseases, such as adenohypophysitis, which can be differentiated from Langerhans ceil histiocytosis by a sharp increase in contrast enhancement and rapid washout after the administration of the intravenous contrast medium.

Granulomatous diseases such as sarcoidosis, Wegener disease and leukaemia must also be considered in the differential.
Rarer differentials are germ cell tumours (germinoma, teratoma) and haemangioblastoma.
These produce the same MR] features, with the same pattern of enhancement at dynamic imaging.

The second most frequent pattern of central nervous system involvement in Langerhans cell histiocytosis is characterised by intra-axial neurodegenerative changes. Bilateral symmetric lesions in the cerebellum, especially the dentate nucleus, basal ganglia, or brainstem, are most often observed.

The differential diagnosis includes ADEM, acute multiphasic disseminated encephalitis, disseminated encephalitis, various metabolic and degenerative disorders, leukoencephalopathy secondary- to chemotherapy or radiation therapy, and paraneoplastic encephalitis.

Less frequently, Langerhans cell histiocytosis granulomas, which resemble tumours, are observed in the extra axial space (in the meninges, pineal gland, choroid plexus and spinal cord).

Question 43

@#1 100. What is a role of ultrasound in the evaluation of a skier’s thumb injury?

A. To evaluate for the presence of a joint effusion

B. To assess joint mobility on dynamic ultrasound

C. To look for an Andersson lesion

D. To look for a Stener lesion

E. To look for associated extensor pollicis tenosynovitis

Answer 43

100. D. To look for a Stener lesion

Skier’s thumb, otherwise known as gamekeeper’s thumb, is an injury to the ulnar collateral ligament (UCL) of the first MCP joint.

Most of the injuries to the UCL are managed conservatively.

However, in complete tears, the UCL may retract and slip to lie superficial to the adductor pollicis aponeurosis or muscle. This prevents healing of the UCL as the adductor pollicis aponeurosis/muscle is now interposed between the torn ends of the UCL, which is known as a Stener lesion. Ultrasound is primarily performed to identify this abnormality, as this requires surgical correction.

Andersson lesion refers to the vertebral end plate changes seen in rheumatic spondylodiscitis.

Question 44

@#1 101. A 76-year-old woman with a recent episode of right-arm weakness is being followed up with an MRI a week after her presentation to the A&E department The current MRI shows changes on T1W images, which were identified as cortical laminar necrosis at the stroke meeting. Which of the following statements regarding cortical laminar necrosis is false?

A. Laminar necrosis is seen as serpiginous high signal on T1W MRI.

B. It is thought to be due to lipid-laden macrophages.

C. It can be seen 3-5 days after stroke.

D. It is never seen beyond 2 weeks.

E. SWI helps differentiate from haemorrhagic transformation.

Answer 44

101. I). It is never seen beyond 2 weeks.

Cortical laminar and pseudolaminar necrosis cause serpiginous cortical Tl shortening, which is not caused by calcium or haemoglobin products; rather, it presumably results from some other unknown substance or paramagnetic material, possibly lipid-laden macrophages.

High cortical signal intensity may be seen on T1-weighted images 3-5 days after stroke, and in many cases it is seen about 2 weeks after stroke. Thereafter, it increases in intensity and fades after about 3 months, but in some cases it may persist for more than a year.

In patients with suspected cortical laminar necrosis, susceptibility-weighted imaging may help differentiate it from haemorrhagic transformation.

Question 45

@#1 102. Regarding Chiari II malformations, which of the following is true?

A. Supratentorial abnormalities arc uncommon.

B. The tentorial attachment is usually normal.

C. It is nearly always associated with failure of neural tube closure.

D. The severity of hydrocephalus nearly always improves after repair of the meningocoele.

E. Batwing appearance of the occipital horns.

Answer 45

102. C. It is nearly always associated with failure of neural tube closure.

Chiari II malformation is characterised by a caudally displaced fourth ventricle and brain stem, as well as tonsilar/vermian herniation through the foramen magnum.
Spinal anomalies are extremely common: lumbar meningomyelocele (>95%) and syringohydromyelia. Supratentorial abnormalities arc common: dysgenesis of corpus callosum (>80%), obstructive hydrocephalus following closure of meningocoele, absent septum pellucidum, to name a few.
CT and MRI show colpocephaly (enlarged occipital horn and atria), ‘batwing’ configuration of frontal horns on coronal view (pointing inferiorly secondary to enlarged caudate nucleus), ‘hourglass ventricle’, excessive cortical gyration (stenogyria), interdigitation of medial cortical gyri, cerebellar peg sign’, thin elongated fourth ventricle exiting below the foramen magnum, dysplastic tentorium, towering cerebellum, tethered cord and cervico medullary kink among multiple other cranial and spinal anomalies.
It is not associated with basilar impression/Cl assimilation/Klippel Feil deformity.

Question 46

@#1 104. A 50-year-old woman has a CT abdomen and pelvis for non-specific abdominal pain. The scan shows a 7-cm low-density lesion in segment VII of the liver with heterogeneous enhancement in arterial and portal venous phase. An MRI liver is performed for further characterisation and shows a large lobulated mass with low signal on T1W and intermediate to high signal on T2W. On the dynamic post-contrast Tl scans, it shows enhancement
in the arterial phase with a non-enhancing central scar, which later enhances in the delayed phase. What is the most likely diagnosis?

A. Focal nodular hyperplasia

B. Fibrolamellar HCC

C. Adenoma

D. Haemangioma

E. Hepatocellular carcinoma

Answer 46

104. A. Focal nodular hyperplasia

Focal nodular hyperplasia (FNil) is the second most common benign liver tumour after haemangioma. FNH is classified into two types: classic (80% of cases) and non-classic (20%). Distinction between FNli and other hypervascular liver lesions such as hepatocellular adenoma, hepatocellular carcinoma and hypervascular metastases is critical to ensure proper treatment.
An asymptomatic patient with FNH does not require biopsy or surgery.

MRI has higher sensitivity and specificity for FNH than does US or CT.

Typically, FNH is iso- or hypointense on T1-weighted images, is slightly hyper- or isointense on T2-weighted images, and has a hyperintense central scar on T2-weighted images.

FNH demonstrates intense homogeneous enhancement during the arterial phase of gadolinium-enhanced imaging and enhancement of the central scar during later phases.

Question 47

@#1 105. A 42-year-old woman is referred to the breast clinic and is due an ultrasound scan to evaluate a suspected lump in the breast. All of the following are ultrasonographic features of a benign breast mass, except

A. Feeding central vessel on Doppler imaging

B. Well-defined smooth margins

C. Three or fewer lobulations

D. Circumferential blood flow pattern on Doppler imaging

E. Uniform hyperechogenicity

Answer 47

105. A. Feeding central vessel on Doppler imaging.

US features characteristic of benign lesions have been described. These include hyperechogenicity compared to fat, an oval or well-defined, lobulated, gently curving shape and the presence of a thin echogenic pseudocapsule. Doppler examination of benign lesions shows displacement of normal vessels around the edge of the lesion. In contrast, malignant lesions show abnormal vessels that are irregular and centrally penetrating

Question 48

@#1 107. A 67-year-old man with a history of head and neck cancer presents with acute stroke symptoms, and MRI is performed SWI images show’ several tiny microbleeds in the basal ganglia at 48 hours. All of the following are true regarding haemorrhagic transformation in stroke, except

A. Microbleeds have worse prognosis than haematoma.

B. Fewer than five microbleeds does not contraindicate thrombolysis.

C. Parenchymal haemorrhage is common in the basal ganglia.

D. Haemorrhagic transformation is rare in the first 6 hours.

E. Parenchymal haemorrhages are rarer than microbleeds.

Answer 48

107. A. Microbleeds have a worse prognosis than haematoma.

Haemorrhagic transformation demonstrates a spectrum of findings ranging from small microbleeds to large parenchymal haematoma.

Several studies have reported that microbleeds are present in one-half to the majority of patients with ischaemic stroke and are seen around 48 hours after onset of symptoms.

Studies have shown that these areas of microbleeding are not associated with a worse outcome, and guidelines state that the presence of fewer than five areas of microbleeding on initial MRIs does not contraindicate thrombolysis.

Parenchymal haematoma is a rarer type of haemorrhagic transformation that results from vessel wall rupture caused by high reperfusion pressure. It is more common with cardio-embolic events, is associated with hyperglycaemia, most commonly occurs in the basal ganglia, and confers a much worse prognosis.

Haemorrhagic transformation is rare in the first 12 hours after stroke onset (the hyperacute stage), particularly within the first 6 hours.

When it occurs, it is usually within the first 24-48 hours and, in almost all cases, is present 4-5 days after stroke. Studies have reported that the presence of early parenchymal enhancement within 6 hours of stroke is associated with a higher risk for clinically significant haemorrhagic transformation.

Question 49

@#1 114. A neonate has an umbilical venous catheter inserted. On an abdominal X-ray, it has advanced up to the level of T10 at the midline. In which structure is the tip of the catheter?

A. Left portal vein

B. Right portal vein

C. Ductus venosus

D. Superior mesenteric vein

E. Splenic vein

Answer 49

114. C. Ductus venosus

The single umbilical vein extends from the umbilicus to the left portal vein. When blood from the umbilical vein reaches the left portal vein, it is directed to the ductus venosus, which originates from the left portal vein immediately opposite the insertion site of the umbilical vein and courses cephalad to the inferior vena cava. The preferred location of the tip of the umbilical venous catheter is typically in the cephalad portion of the inferior vena cava or at the inferior vena caval-right atrial junction.
An umbilical venous catheter can be distinguished from an umbilical arterial catheter as the UVC travels cranially in the umbilical vein while the UAC travels caudally in an umbilical artery to reach a common iliac artery.

Question 50

@#1 115. Which ot the following statements concerning malignant cardiac masses is false?

A. Cardiac metastasis outnumbers primary cardiac malignancy.

B. Angiosarcomas have a high T1 signal due to methaemoglobin.

C. Undifferentiated sarcomas mostly affect the left atrium.

D. Primary cardiac lymphomas mostly affect the left side of the heart.

E. Rhabdomyosarcoma commonly affects the valve.

Answer 50

115. D. Primary cardiac lymphomas mostly affect the left side of the heart.

Secondary malignancies involving the heart are 20-40 times more frequent than primary cardiac neoplasms.
Angiosarcoma is the most common primary cardiac malignancy of adulthood. The tumour typically involves the right atrium, and so presenting symptoms are related to obstruction to right cardiac filling and pericardial tamponade. They are heterogeneously high signal on Tl and T2-weighted images with heterogeneous enhancement.
Undifferentiated sarcoma mostly arises in the left atrium, although they can also involve the cardiac valve. It appears as an isointense irregular mass infiltrating the myocardium.
Primary cardiac lymphomas are exceedingly rare, are typically of the non-Hodgkin B-cell type and are confined to the heart or pericardium. They most commonly involve the right side of the heart, in particular the right atrium, with frequent involvement of more than one chamber and invasion of the pericardium. At MRI, they are isointense on T1-weighted images and heterogeneously hyperintense on T2-weighted images; they demonstrate heterogeneous enhancement after administration of gadolinium contrast material.
Rhabdomyosarcomas do not arise from any specific chamber, but they are more likely than any other primary cardiac sarcomas to involve the valves.

Question 51

@#1 118. A 19 year-old man is reviewed at a clinic for a persistent ache in his lower back that has not improved for over 3 months. He is an avid mountain biker, but there is no history of significant trauma and there are no neurological deficits. The patient is found to have mild increase in thoracic kyphosis with mild wedging of the T4, T5 and T6 vertebrae. MRI reveals the presence of small scattered vertebral end plate lesions with signal characteristics identical to the adjacent intervertebral discs in several thoracic and lumbar vertebrae.

What is the diagnosis?

A. Spondylodiscitis with developing vertebral collapse

B. Congenital kyphosis

C. Metastatic deposits with early vertebral collapse

D. Vertebral insufficiency fractures

E. Scheuermann’s disease

Answer 51

118. E. Scheuermann disease

Scheuermann disease is a spinal disorder named after Dr Holger Scheuermann, who, in 1921, first described a structural thoracic kyphosis mainly affecting adolescents. Its best-known manifestations are multiple wedged vertebrae and thoracic kyphosis known as Scheuermann kyphosis. Its classic diagnostic criterion was ‘3 or more consecutive wedged thoracic vertebrae’. However, the pathological changes also include disc and end plate lesions, primarily Schmorl node and irregular vertebral end plate. Therefore, the diagnosis of ‘atypical Scheuermann disease’ was proposed for patients with only one or two wedged vertebrae and no notable kyphosis but characteristic disc/end plate lesions. Because atypical Scheuermann disease tends to affect the lumbar or thoracolumbar junction region instead of the thoracic spine, it is also called lumbar Scheuermann disease.

Question 52

@#1 120. A 1-year-old boy is brought to the A&E department by his parents with head injury after falling off a sofa. The on-call paediatrician strongly suspects non-accidental injury. Which of the following features on unenhanced CT is most consistent with this?

A. Bilateral occipital extradural haemorrhage

B. Bilateral occipital subdural haemorrhage

C. Subarachnoid haemorrhage

D. Parietal skull fracture

E. Bilateral frontal subdural haemorrhage

Answer 52

120. B. Bilateral occipital subdural haemorrhage

Subdural haemorrhage (SDH) and subarachnoid haemorrhage (SAH) are common abusive injuries. Epidural haematoma is much more often accidental. Probably the most common location of inflicted SAH, and SDH diagnosed radiologically is a layer of hyperattenuating material adjacent to the falx; bleeding at this site represents an interhemispheric extra-axial haemorrhage. In this location, it is often difficult, radiologically, to distinguish SAH from SDH, and SDH and SAH may coexist.

Question 53

@#e 64. A plain lumbar spine radiograph of a 45-year-old woman shows marked posterior scalloping of the vertebral bodies extending over several vertebral lengths. All of the following are diseases associated with this finding, except

A. Marfan

B. Neurofibromatosis

C. Ependymoma

D. Achondroplasia

E. Hypothyroidism

Answer 53

64. E. Hypothyroidism

A common cause of localised posterior vertebral scalloping is increased intraspinal pressure secondary to an expanding mass.

Widening of the interpediculate distance and alteration of the configuration of the pedicles are associated signs.

Relatively large, slow-growing lesions that originate during a period of active skeletal growth (such as ependymomas) are most likely to give rise to posterior vertebral scalloping.

Dural ectasia is thought to cause posterior vertebral scalloping due to loss of the normal protection provided to the vertebral body by a strong, intact dura.

Dural ectasia classically occurs in association with inherited connective-tissue disorders such as Marfan syndrome (classical) and Ehlers-Danlos syndrome.

Posterior vertebral scalloping is also commonly seen in patients with neurofibromatosis, most likely due to dural ectasia but also secondary to neurofibromas or a thoracic meningocoele.

It has also been reported in patients with AS; in these cases, the development of associated arachnoid cysts may give rise to cauda equina syndrome.

Acromegaly has been described as a further cause of diffuse posterior vertebral scalloping, probably because of a combination of soft-tissue hypertrophy in the spinal canal and increased bone resorption.

Question 54

@#1 113. A 49-year-old woman with right lower extremity weakness and rigidity undergoes MRI with DWI, ADC map, FLAIR, T2W and T1W pre- and post gadolinium images. Early hyperacute stroke is diagnosed. All of the following are true about the timing of stroke and MRI, except

A. Low ADC signal suggests that the stroke is less than a week old.

B. FLAIR hyperintensities are seen in 6-12 hours.

C. High signal on T2W MRI is seen >8 hours.

D. Low signal on T1W MRI is seen >8 hours.

E. Parenchymal enhancement generally doesn’t persist beyond 8-12 weeks.

Answer 54

113. D. Low signal on T1W MRI is seen >8 hours.

A good rule of thumb is that if the signal intensity on ADC maps is low, the stroke is less than 1 week old. Most literature indicate that in patients with ischaemic stroke, findings on FLAIR images are positive 6 12 hours after onset of symptoms. Sometimes the presence of restricted diffusion with negative findings at FLAIR imaging alone has been enough to initiate treatment.
High signal intensity is not usually seen at T2-weighted imaging until at least 8 hours after the initial ischaemic insult and continues into the chronic phase. Low signal intensity is not usually seen at T1 weighted imaging until 16 hours after the onset of stroke and persists into the chronic phase.
The pattern of contrast enhancement may help determine the age of the stroke. In ischaemic stroke, enhancement may be arterial, meningeal, or parenchymal. Arterial enhancement, dubbed the ‘intravascular enhancement’ sign, usually occurs first and may be seen as early as 0-2 hours after the onset of stroke. Meningeal enhancement is the rarest type of enhancement.
It occurs within the first week after onset of stroke. If parenchymal enhancement persists longer than 8 12 weeks, a diagnosis other than ischaemic stroke should be sought.

Question 55

@#1 117. All of the following are major indications for ultrasound of the breast except

A. Delineation of cystic from solid breast masses

B. Evaluation of a palpable breast mass in a mammographically dense breast

C. Evaluation of nipple discharge in a mammographically dense breast

D. Evaluation of breast lesions not well seen on mammography

E. Routine breast screening

Answer 55

117. E. Routine breast screening

Ultrasound is not a screening tool. It is used for assessment of a palpable lump, particularly in young patients (below 30 years) and mammographically dense breasts, and in characterisation of a mammographic or palpable mass as solid or cystic. It is used for evaluation of mammographically uncertain lesion or for confirmation of lesion seen on a single projection. It is used for assessing breast discharge, suspected silicone leaks, follow-up of lesions seen on US and for guiding cyst aspiration, biopsy or wire localisation.