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Flashcards in INBR 7 - Neuroradiology Deck (75)
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1. Tumor apakah yang lazimnya menunjukkan intensitas sinyal yang tinggi pada pencitraan T2 weighted, intensitas sinyal yang rendah pada pencitraan T1 weighted, dan intensitas sinyal yang tinggi (restriksi difusi) pada pencitraan MR difusi?
A. Pineoblastoma
B. Glioblastoma
C. Kista Arachnoid
D. Epidermoid
E. Meningioma

D. Epidermoids are usually located off of the midline along the basilar cisterns. These tumors often resemble CSF, and thus arachnoid cysts, on Tl- and T2-weighted t-IRI. However, diffusion-weighted MRI is helpful in differentiating epidermoids from arachnoid cysts, because the former exhibit restricted diffusion (high signal, similar to brain parenchyma) and the latter exhibit normal diffusion (similar to CSF). Pineoblastomas, glioblastomas, and meningiomas are rarely confused with epiderrnoids

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2. Seorang anak usia 12 tahun dibawa dengan gejala-gejala ataksia dan diplopia, serta menunjukkan kelemahan fasial, hemiparesis, dan Optalmoplegia internuklear. Tumor berikut mana sesuai yang dengan hasil pencitraan MRI T-2 weighted di bawah ini ?

A. Limpoma
B. Koriokarsinoma
C. Tumor kantung Yolk
D. Ependimoma
E. Astrositoma yg menginfiltrasi

E. The most common brainstem tumor encountered in the pediatric population is an infi!trating astrocytoma . These are most commonly located in the pons ( as in this case) , and they are usually malignant. Pontine gliomas often present with cranial nerve palsies, extraocular muscle findings , and pyramidal signs. They rarely present with obstructive hydrocephalus, as this is usually a late finding that occurs after the tumors have grown considerably. Pontine gliomas are often hypointense on T1-weighted images and hyperintense on T2- weighted images, with variable enhancement. The prognosis for pontine tumors is much worse than for tumors located in the medulla or mesencephalon

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3. Sekuen MR yang manakah yang paling peka dalam mengidentifikasikan Malformasi Kavernosa Intraserebral?
A. T1-weighted
B. T2-weighted
C. Echo gradient
D. Fast spin echo
E. Difusi

C. Gradient echo sequences are the most sensitive in identifying any intracerebral lesions that exhibit chronic hemorrhage (such as cavernomas ) . Cavernomas often exhibit a "reticulated core" of mixed-signal intensity on T1-weighted images due to the presence of hemorrhage of varying ages. These lesions also often exhibit a hypointense rim on T1-weighted images, T2-weighted images, and gradient echo sequences that corresponds to hemosiderin deposits. Fast-spin echo sequences are T2-weighted sequences that are not very sensitive in the detection of chronic hemorrhage

4

4. Tumor intrakranial manakah yang paling lazim berasosiasi dengan neurofibromatosis tipe 1?
A. Glioma saraf optic
B. Ependimoma
C. Neurofibroma
D. Meningioma
E. Meduloblastoma

A. Optic nerve g

5

5. Pendekatan bedah manakah yang akan paling tepat untuk pasien dengan tinnitus ringan dan
kelainan sebagaimana yang ditunjukkan oleh enhance-T1 weighted pada MRI ?

A. Retrosigmoid
B. Transiabirintin
C. Fossamedia
D. Fossa infratemporal transpetrosal
E. Transkoklear

C. This postcontrasted T1-weighted MRI study depicts an int racanalicular acoustic neuroma. Where there is an attempt to presetTe the patient's hearing. either the suboccipital or middle fossa approach is used, because the translabyrinthine or transcochlear approaches sacrifice hearing. The suboccipital (retrosigmoid) approach is the most commonly used procedure bY neurosurgeons for lesions mostly located within the CPA. It provides excellent control of the lower cranial nerves, brainstem, and vascular structures within the C PA. However, only the proximal twothirds of the lAC can be safely exposed without traversing the inner ear. The middle fossa approach allows access to the labyrinthine segment of the facial nerve without sacrificing hearing and is the procedure most commonly used for small intracanalicular lesions. The dura is elevated from the floor of the middle fossa and the labirinthine segment of the facial nerve identified medial to the geniculate ganglion. Acces to the posterior fossa and CPA is somewhat limited and retraction of the temporal lobe is necessary for exposure. The transpetrosal infratemporal fossa corridor is not typically used for CPA tumors but instead for tumors of the jugular foramen such as paragangliomas and meningiomas

6

6. Sirkulasi fetal persisten manakah yang tampak dalam angiogram karotid interna posisi lateral ini ?

A. Arteri trigeminal primitif
B. Arteri otis persisten
C. Arteri hipoglosal persistent
D. Arteri intersegmental proatlantal
E. Salah semua

A . The primitive trigeminal artery ( PTA) represents a persistence of the embryonic anastomosis between the cavernous segment of the internal carotid artery and the paired longitudinal neural arteries (Vertebrobasilar system). The PTA is the most cephalad of the persistent fetal circulations; it is also the most common. The PTA is associated with an increased incidence of intracranial aneurysms. The persistent otic artery originates from the petrous ICA, the persistent hypoglossal artery originates from the cervical lCA, and the proatlantal intersegmental artery can originate from the int e rnal or external carotid artery

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7. Di antara rasio-rasio di bawah ini, manakah yang biasanya menurun dengan adanya neoplasma SSP primer pada MR spektroskopi
A. Mionositol : Total kreatin
B. Koline : N-asetil aspartate
C. Koline : total kreatin
D. N -asetil aspartate : total keratin
E. Mionositol : N-Asetil aspartate

D . N-acetyl aspartate (NAA) is a neuronal marker and is generally decreased in most CNS pathologic conditions. Total creatine is generally constant within the brain regardless of the presence of disease. Elevations of choline indicate increased plasma membrane turnover and synthesis . which is commonly observed with neoplasms. Thus, neoplasm ar usually associated with decreases in NA.A and elevations of choline and myoinosirol (and lactate) ; total creatine is largely constant. The ratio of NAA to total creatine is thus decreased. Whereas rhe ratios in A, B, C, and E are all increased with CNS neoplasms

8

8. Seorang anak perempuan dibawa dengan gejala sakit kepala persisten, mual dan muntah selama 1 minggu. Pasien merasa agak lesu dan hasil pemeriksaan menunjukkan tanda hemiparesis kiri ringan. MRI T1 aksial dengan kontras menunjukkan kelainan yang mana?

A. Astrositoma pilositik
B. Subependimoma .
C. Papiloma pleksus koroid
D. Hemangioblastoma
E. Meduloblastoma

E. Medulloblastomas are aggressive, primitive neuroectodermal tumors that occur primarily in the pediatric population. Medulloblastomas are found exclusively in the posterior fossa and usually reside in the midline (vermis) . Occasionally these lesions are found in the lateral cerebellum, but this usually occurs in adults and older children. Medulloblastomas are aggressive tumors that frequently metastasize throughout the CNS via spinal fluid pathways. On MRI, medulloblastomas are generally isointense on T1-weighted images, with variable signal on T2-weighted images and intense enhancement with contrast. The lesions usually occupy most of the fourth ventricle and are often associated with communicating hydrocephalus. The history and MRI findings in this case are most consistent with a medulloblastoma. Choroid plexus papillomas are predominantly supratentorial lesions in the pediatric population, and pilocytic astrocytomas are usually cystic. Subependymomas do not typically enhance, and they are found almost exclusively in adults. Hemangioblastomas are also rare in children and occur most frequently in the brain parenchymas

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9. Ciri manakah yg biasanya TIDAK tampak pada Oligodendroglioma berdasarkan MRI?
A. Pengapuran
B. Hemorase
C. Kistik
D. Sinyal heterogen pada citra T1-tertimbang
E. Penyengatan homogen

E. Oligodendrogliomas generally exhibit mixed signal intensity on T1 -weighted images and hyperintensity on T2-weighted images with m ild heterogenous enhancement . These lesions exhibit calcification 70 to 90% of the time , are often associated with cysts, and frequently have evidence of chronic hemorrhage

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10. Karakteristik berikut yang mana TIDAK tampak pada ‘Tuberous Sclerosis’ (Penyakit
BOURNEVILLE) ?
A. Pola keturunan resesif autosomal
B. Hamartomas kortikal
C. Astrositoma sel besar subependimal
D. Keterbelakangan mental
E. Ramdoniomas jantung

A . Tuberous sclerosis (TS) is an autosomal domi nant neurocutaneous disorder associated with the triad of seizures, mental retardation, and adenoma sebaceum. TS has variable expressivity and very high penetrance. Patients with TS often exhibit cortical tubers, subependymal nodules along the lateral ventricles, and benign foci of dysmyelination in the deep white matter on MRI . Subependymal giant cell astrocytoma develops in 15% of all patients with TS; it frequently occurs near the foramen of Monro and typically presents with obstructive hydrocephalus. TS is also associated with retinal phakomas, subungual fibromas, cardiac rhabdomyomas, and aneurysms

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11. Pengelolaan manakah yang paling tepat untuk lesi yang ditunjukan pada angiogram karotid internal lateral di bawah ini ?

A. Ulangi Angiografi dalam waktu 6 sampai dengan 12 bulan.
B. Antikoagulasi oral
C. Tidak diperlukan perawatan lebih lanjut
D. Perlakuan bedah segera
E. Tindak lanjuti MRA dalam jangka waktu 6 – 12 bulan.

D. This angiogram illustrates a dural arteriovenous fistula (DAVF) with prominent ret rograde conical venous drainage. Most DAVFs originate from the transverse and sigmoid sinuses along the skull base. although cavernous sinus is also frequently involved. The presence of retrograde cortical venous drainage places the ;patient at significam risk for subarachnoid hemorrhage, and mandates treatment. The treatment of DAVF usually consist of preoperative embolization followed by surgical obliteration oi the nidus . Successful treatment entails disconnection oi the cortical venous drainage from the nidus. Follow up angiography may be appropriate with DAVF without retrograde cortical venous drainage but would be inappropriate in this case

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12. Di antara lokasi-lokasi di bawah ini, lokasi manakah yang biasanya TIDAK terlibat dalam cedera aksonal difus (DAI) ?
A. Brainstem
B. Deep white matter
C. Serebelum
D. Corpus callosum
E. Thalamus

C. D iffuse axonal injury most commonly involves the corticomedullary junction of the frontal and temporal lobes or the corpus callosum. DAI can also occur in the deep white matter (usually at gray-white junctions), dorsolateral brainstem, caudate nuclei, thalamus, and internal capsule. DAI rarely involves the cerebellum

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13. Anak, 12 tahun dibawa dengan kejang komplek parsial. Pasien secara neurlogis intak. MRI adanya lesi kistik di mesial kanan lobus temporalis dengan gambaran hipointens pada T1 dan hiperintens pada T-2, dengan mild rim enhancement. Diagnosisnya yang paling mungkin adalah…
A. Ganglioglioma E. Glioblastoma
B. Ksantoastrositoma pleomorfik
C. Astrositoma pilositik
D. Germinoma

A. Gangliogliomas are generally cystic supratentorial tumors that present in pediatric patients with seizures or elevated intracranial pressure. They are most commonly located in the temporal lobes and are hypointense on T1 - weighted images and hyperintense on T2-weighted images, with variable enhancement patterns. Pleomorphic xanthoastrocytoma (PXA) can also present in children with epilepsy, although it is more typically found in a superficial location adjacent to the leptomeninges. PXA is usually cystic with an enhancing mural nodule. Germ cell tumors (including germinomas) are usually found in the pineal or parasellar regions, and pilocytic astrocytomas are usually located in the posterior fossa or third ventricle in children

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14. Methemoglobin ekstraselular
A. Hiper-akut ( sampai dengan 4-6 jam)
B. Akut (7 sampai dengan 72 jam)
C. Sub-akut dini (4 – 7 hari)
D. Akhirnya aub-akut (1 sampai 4 minggu)
E. Sub-kronis dini (mingguan sampai bulanan)
F. Sub-kronis lambat (bulanan sampai tahunan)

D. The appearance of hyperacute hematomas (up to 4 to 6 hours ) on MRI is due to the presence of large amounts of oxyhemoglobin, which is diamagnetic and does not influence T1 and T2 relaxation times . Hyperacute clots have a high concentration of water, which renders them isointense on T1-weighted images and hyperintense on T2-weighted images. Acute hematomas (7 to 72 hours) consist primarily of deoxyhemoglobin, which is paramagnetic and has pronounced effects upon T2 relaxation times but no significant effects on T1 relaxation time. Acute hematomas are therefore isointense on T1-weighted images and hypointense on T2-weighted images. The precise reason for the dramatic T2 effect remains unclear but is believed to result from phase dispersion and subsequent preferential T2 proton relaxation enhancement. During this stage, the red blood cells shrink, lose their spherical shapes, become trapped in blood vessels, and acquire irregular Spiculated projections and form "echinocytes ." Early subacute hematomas (4 to 7 days) consist of intracellular methemoglobin, which is paramagnetic and renders subacute hematomas hyperintense on T 1-weighted images and hypointense on T2- weighted images. With late subacute hematomas (1 to 4 weeks), methemoglobin becomes mostly extracellular (secondary to hemolysis), resulting in a progressively more hyperintense clot on T2-weighted images. Early chronic hematomas (months) generally consist of a pool of dilute-free methemoglobin surrounded by a ferritin- and hemosiderin-containing vascularized wall. At this stage, clots are generally similar in appearance to late subacute clots (hyperintense on both T1- and T2-weighted images), with a thin-rimmed wall of pronounced hypointensity on T2-weighted images (ferritin and hemosiderin deposits) . \Vith time (late chronic hematomas, months to years), ferritin- and hemosiderin-containing substances are further deposited throughout the clot, producing hypointense T1- and T2-weighted images

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15. Oksihemoglobin
A. Hiper-akut ( sampai dengan 4-6 jam)
B. Akut (7 sampai dengan 72 jam)
C. Sub-akut dini (4 – 7 hari)
D. Akhirnya aub-akut (1 sampai 4 minggu)
E. Sub-kronis dini (mingguan sampai bulanan)
F. Sub-kronis lambat (bulanan sampai tahunan)

A. The appearance of hyperacute hematomas (up to 4 to 6 hours ) on MRI is due to the presence of large amounts of oxyhemoglobin, which is diamagnetic and does not influence T1 and T2 relaxation times . Hyperacute clots have a high concentration of water, which renders them isointense on T1-weighted images and hyperintense on T2-weighted images. Acute hematomas (7 to 72 hours) consist primarily of deoxyhemoglobin, which is paramagnetic and has pronounced effects upon T2 relaxation times but no significant effects on T1 relaxation time. Acute hematomas are therefore isointense on T1-weighted images and hypointense on T2-weighted images. The precise reason for the dramatic T2 effect remains unclear but is believed to result from phase dispersion and subsequent preferential T2 proton relaxation enhancement. During this stage, the red blood cells shrink, lose their spherical shapes, become trapped in blood vessels, and acquire irregular Spiculated projections and form "echinocytes ." Early subacute hematomas (4 to 7 days) consist of intracellular methemoglobin, which is paramagnetic and renders subacute hematomas hyperintense on T 1-weighted images and hypointense on T2- weighted images. With late subacute hematomas (1 to 4 weeks), methemoglobin becomes mostly extracellular (secondary to hemolysis), resulting in a progressively more hyperintense clot on T2-weighted images. Early chronic hematomas (months) generally consist of a pool of dilute-free methemoglobin surrounded by a ferritin- and hemosiderin-containing vascularized wall. At this stage, clots are generally similar in appearance to late subacute clots (hyperintense on both T1- and T2-weighted images), with a thin-rimmed wall of pronounced hypointensity on T2-weighted images (ferritin and hemosiderin deposits) . \Vith time (late chronic hematomas, months to years), ferritin- and hemosiderin-containing substances are further deposited throughout the clot, producing hypointense T1- and T2-weighted images

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16. Isointens pada T1, hipointens pada T2
A. Hiper-akut ( sampai dengan 4-6 jam)
B. Akut (7 sampai dengan 72 jam)
C. Sub-akut dini (4 – 7 hari)
D. Akhirnya aub-akut (1 sampai 4 minggu)
E. Sub-kronis dini (mingguan sampai bulanan)
F. Sub-kronis lambat (bulanan sampai tahunan)

B. The appearance of hyperacute hematomas (up to 4 to 6 hours ) on MRI is due to the presence of large amounts of oxyhemoglobin, which is diamagnetic and does not influence T1 and T2 relaxation times . Hyperacute clots have a high concentration of water, which renders them isointense on T1-weighted images and hyperintense on T2-weighted images. Acute hematomas (7 to 72 hours) consist primarily of deoxyhemoglobin, which is paramagnetic and has pronounced effects upon T2 relaxation times but no significant effects on T1 relaxation time. Acute hematomas are therefore isointense on T1-weighted images and hypointense on T2-weighted images. The precise reason for the dramatic T2 effect remains unclear but is believed to result from phase dispersion and subsequent preferential T2 proton relaxation enhancement. During this stage, the red blood cells shrink, lose their spherical shapes, become trapped in blood vessels, and acquire irregular Spiculated projections and form "echinocytes ." Early subacute hematomas (4 to 7 days) consist of intracellular methemoglobin, which is paramagnetic and renders subacute hematomas hyperintense on T 1-weighted images and hypointense on T2- weighted images. With late subacute hematomas (1 to 4 weeks), methemoglobin becomes mostly extracellular (secondary to hemolysis), resulting in a progressively more hyperintense clot on T2-weighted images. Early chronic hematomas (months) generally consist of a pool of dilute-free methemoglobin surrounded by a ferritin- and hemosiderin-containing vascularized wall. At this stage, clots are generally similar in appearance to late subacute clots (hyperintense on both T1- and T2-weighted images), with a thin-rimmed wall of pronounced hypointensity on T2-weighted images (ferritin and hemosiderin deposits) . \Vith time (late chronic hematomas, months to years), ferritin- and hemosiderin-containing substances are further deposited throughout the clot, producing hypointense T1- and T2-weighted images

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17. Deoksihemoglobin, ekinosit
A. Hiper-akut ( sampai dengan 4-6 jam)
B. Akut (7 sampai dengan 72 jam)
C. Sub-akut dini (4 – 7 hari)
D. Akhirnya aub-akut (1 sampai 4 minggu)
E. Sub-kronis dini (mingguan sampai bulanan)
F. Sub-kronis lambat (bulanan sampai tahunan)

B. The appearance of hyperacute hematomas (up to 4 to 6 hours ) on MRI is due to the presence of large amounts of oxyhemoglobin, which is diamagnetic and does not influence T1 and T2 relaxation times . Hyperacute clots have a high concentration of water, which renders them isointense on T1-weighted images and hyperintense on T2-weighted images. Acute hematomas (7 to 72 hours) consist primarily of deoxyhemoglobin, which is paramagnetic and has pronounced effects upon T2 relaxation times but no significant effects on T1 relaxation time. Acute hematomas are therefore isointense on T1-weighted images and hypointense on T2-weighted images. The precise reason for the dramatic T2 effect remains unclear but is believed to result from phase dispersion and subsequent preferential T2 proton relaxation enhancement. During this stage, the red blood cells shrink, lose their spherical shapes, become trapped in blood vessels, and acquire irregular Spiculated projections and form "echinocytes ." Early subacute hematomas (4 to 7 days) consist of intracellular methemoglobin, which is paramagnetic and renders subacute hematomas hyperintense on T 1-weighted images and hypointense on T2- weighted images. With late subacute hematomas (1 to 4 weeks), methemoglobin becomes mostly extracellular (secondary to hemolysis), resulting in a progressively more hyperintense clot on T2-weighted images. Early chronic hematomas (months) generally consist of a pool of dilute-free methemoglobin surrounded by a ferritin- and hemosiderin-containing vascularized wall. At this stage, clots are generally similar in appearance to late subacute clots (hyperintense on both T1- and T2-weighted images), with a thin-rimmed wall of pronounced hypointensity on T2-weighted images (ferritin and hemosiderin deposits) . \Vith time (late chronic hematomas, months to years), ferritin- and hemosiderin-containing substances are further deposited throughout the clot, producing hypointense T1- and T2-weighted images

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18. Hiperintens pada T1, Hipointens pada T2
A. Hiper-akut ( sampai dengan 4-6 jam)
B. Akut (7 sampai dengan 72 jam)
C. Sub-akut dini (4 – 7 hari)
D. Akhirnya aub-akut (1 sampai 4 minggu)
E. Sub-kronis dini (mingguan sampai bulanan)
F. Sub-kronis lambat (bulanan sampai tahunan)

C. The appearance of hyperacute hematomas (up to 4 to 6 hours ) on MRI is due to the presence of large amounts of oxyhemoglobin, which is diamagnetic and does not influence T1 and T2 relaxation times . Hyperacute clots have a high concentration of water, which renders them isointense on T1-weighted images and hyperintense on T2-weighted images. Acute hematomas (7 to 72 hours) consist primarily of deoxyhemoglobin, which is paramagnetic and has pronounced effects upon T2 relaxation times but no significant effects on T1 relaxation time. Acute hematomas are therefore isointense on T1-weighted images and hypointense on T2-weighted images. The precise reason for the dramatic T2 effect remains unclear but is believed to result from phase dispersion and subsequent preferential T2 proton relaxation enhancement. During this stage, the red blood cells shrink, lose their spherical shapes, become trapped in blood vessels, and acquire irregular Spiculated projections and form "echinocytes ." Early subacute hematomas (4 to 7 days) consist of intracellular methemoglobin, which is paramagnetic and renders subacute hematomas hyperintense on T 1-weighted images and hypointense on T2- weighted images. With late subacute hematomas (1 to 4 weeks), methemoglobin becomes mostly extracellular (secondary to hemolysis), resulting in a progressively more hyperintense clot on T2-weighted images. Early chronic hematomas (months) generally consist of a pool of dilute-free methemoglobin surrounded by a ferritin- and hemosiderin-containing vascularized wall. At this stage, clots are generally similar in appearance to late subacute clots (hyperintense on both T1- and T2-weighted images), with a thin-rimmed wall of pronounced hypointensity on T2-weighted images (ferritin and hemosiderin deposits) . \Vith time (late chronic hematomas, months to years), ferritin- and hemosiderin-containing substances are further deposited throughout the clot, producing hypointense T1- and T2-weighted images

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19. Isointens pada T1, hiperintens pada T2
A. Hiper-akut ( sampai dengan 4-6 jam)
B. Akut (7 sampai dengan 72 jam)
C. Sub-akut dini (4 – 7 hari)
D. Akhirnya aub-akut (1 sampai 4 minggu)
E. Sub-kronis dini (mingguan sampai bulanan)
F. Sub-kronis lambat (bulanan sampai tahunan)

A. The appearance of hyperacute hematomas (up to 4 to 6 hours ) on MRI is due to the presence of large amounts of oxyhemoglobin, which is diamagnetic and does not influence T1 and T2 relaxation times . Hyperacute clots have a high concentration of water, which renders them isointense on T1-weighted images and hyperintense on T2-weighted images. Acute hematomas (7 to 72 hours) consist primarily of deoxyhemoglobin, which is paramagnetic and has pronounced effects upon T2 relaxation times but no significant effects on T1 relaxation time. Acute hematomas are therefore isointense on T1-weighted images and hypointense on T2-weighted images. The precise reason for the dramatic T2 effect remains unclear but is believed to result from phase dispersion and subsequent preferential T2 proton relaxation enhancement. During this stage, the red blood cells shrink, lose their spherical shapes, become trapped in blood vessels, and acquire irregular Spiculated projections and form "echinocytes ." Early subacute hematomas (4 to 7 days) consist of intracellular methemoglobin, which is paramagnetic and renders subacute hematomas hyperintense on T 1-weighted images and hypointense on T2- weighted images. With late subacute hematomas (1 to 4 weeks), methemoglobin becomes mostly extracellular (secondary to hemolysis), resulting in a progressively more hyperintense clot on T2-weighted images. Early chronic hematomas (months) generally consist of a pool of dilute-free methemoglobin surrounded by a ferritin- and hemosiderin-containing vascularized wall. At this stage, clots are generally similar in appearance to late subacute clots (hyperintense on both T1- and T2-weighted images), with a thin-rimmed wall of pronounced hypointensity on T2-weighted images (ferritin and hemosiderin deposits) . \Vith time (late chronic hematomas, months to years), ferritin- and hemosiderin-containing substances are further deposited throughout the clot, producing hypointense T1- and T2-weighted images

20

20. Metemoglobin intraseluler
A. Hiper-akut ( sampai dengan 4-6 jam)
B. Akut (7 sampai dengan 72 jam)
C. Sub-akut dini (4 – 7 hari)
D. Akhirnya aub-akut (1 sampai 4 minggu)
E. Sub-kronis dini (mingguan sampai bulanan)
F. Sub-kronis lambat (bulanan sampai tahunan)

C. The appearance of hyperacute hematomas (up to 4 to 6 hours ) on MRI is due to the presence of large amounts of oxyhemoglobin, which is diamagnetic and does not influence T1 and T2 relaxation times . Hyperacute clots have a high concentration of water, which renders them isointense on T1-weighted images and hyperintense on T2-weighted images. Acute hematomas (7 to 72 hours) consist primarily of deoxyhemoglobin, which is paramagnetic and has pronounced effects upon T2 relaxation times but no significant effects on T1 relaxation time. Acute hematomas are therefore isointense on T1-weighted images and hypointense on T2-weighted images. The precise reason for the dramatic T2 effect remains unclear but is believed to result from phase dispersion and subsequent preferential T2 proton relaxation enhancement. During this stage, the red blood cells shrink, lose their spherical shapes, become trapped in blood vessels, and acquire irregular Spiculated projections and form "echinocytes ." Early subacute hematomas (4 to 7 days) consist of intracellular methemoglobin, which is paramagnetic and renders subacute hematomas hyperintense on T 1-weighted images and hypointense on T2- weighted images. With late subacute hematomas (1 to 4 weeks), methemoglobin becomes mostly extracellular (secondary to hemolysis), resulting in a progressively more hyperintense clot on T2-weighted images. Early chronic hematomas (months) generally consist of a pool of dilute-free methemoglobin surrounded by a ferritin- and hemosiderin-containing vascularized wall. At this stage, clots are generally similar in appearance to late subacute clots (hyperintense on both T1- and T2-weighted images), with a thin-rimmed wall of pronounced hypointensity on T2-weighted images (ferritin and hemosiderin deposits) . \Vith time (late chronic hematomas, months to years), ferritin- and hemosiderin-containing substances are further deposited throughout the clot, producing hypointense T1- and T2-weighted images

21

21. 38 th, dg riw 2 hari sakit kepala parah. fotopobia, dan emesis. Hasil pemeriksaan pasien secara neurologis intak. Hasil CT digambarkan di bawah ini. Hal apa yang TIDAK perlu dilakukan pada pengelolaan entitas ini?

A. Angiografi
B. Pemantauan jantung
C. Pemantauan elektrolit
D. Terapi hiperdinamis
E. Pemantauan hidrosepalus

D. This C T scan illustrates perimesencephalic subarachnoid hemorrhage, which usually involves subarachnoid blood within the prepontine, interpeduncular, crural, or ambient cisterns. This is generally a benign entity, thought to result from rupture of a small vein. Angiography is required, however, because ruptured basilar apex aneurysms can exhibit a similar hemorrhage pattern. Patients with perimesencephalic hemorrhage can exhibit cardiac and electrolyte abnormalities. Although this disease is not associated with intraventricular hemorrhage, approximately 1% of cases can eventually develop hydrocephalus. Empiric calcium channel blockers, anticonvulsants, and hyperdynamic therapy is not indicated due to the rarity of vasospasm and seizures with this entity. Repeat angiography is controversial and is generally not indicated if the diagnosis is clear

22


22. Kelainan manakah yang ditunjukkan pada MRI T2 aksial di bawah ini?
A. Oligodendroglioma
B. Relangiestasia kapilaris
C. Malformasi cavernous
D. Angioma venus
E. Koriokarsinoma

C. Cavernous malformations are circumscribed, multilobulated vascular lesions that often exhibit hemorrhage in n1rious stages of evolution. The center of a cavernoma frequently contains a mixed-signal region known as a "reticulated ( popcorn-like) core" The periphery of cavernomas is usually surrounded by a low-signal rim on T2-weighted images that corresponds to a peripheral rim of hemosiderin deposition from remote hemorrhages. Cavernomas can be located anywhere within the brain, although 80% are supratentorial parenchymal lesions, and they are often multiple. Gradient echo sequences are the most sensitive for detecting cavernomas. Capillary telangiectasias are usually small lesions that are hypointense on T2-weighted images and rarely exhibit hemorrhage. Venous angiomas are radial collecting veins that drain normal brain and rarely hemorrhage. venous angiomas are occasionally associated with cavernous malformations. Although oligodendrogliomas and choriocarcinoma can exhibit hemorrhage, the presence of a reticulated core and surrounding hemosiderin rim is more consistent with a cavernoma

23

23. Tn.X, 44 tahun datang dg melanoma kutanus. Setelah reseksi lokal dan terapi radiasi pasien menjalani CT scan pada dada/abdomen/pelvis, bone scan nuklir, dan lumbar puncture untuk systemic staging. Hasilnya menunjukkan tidak ada bukti metastase sistemik dan sitologi CSF negatif. Pasien yang bersangkutan datang kembali 2 minggu kemudian dengan keluhan baru sakit kepala parah di frontal disertai dengan ambulasi. Pasien kemudian menjalani MRI pada otak; di bawah ini kami sajikan citra T1 setelah diperjelas kontrasnya. Langkah berikutnya yang paling tepat dalam mengelola gangguan ini….

A. Biopsi meningeal
B. Ulangi lumbar puncture
C. Patch darah Epidural
D. Angiografi Serebral
E. Jawaban A, B, C dan D semuanya salah

C . This patient's symptoms consist largely of postural headaches that occurred shortly after a lumbar puncture. The patient's MRI shows evidence of diffuse pachymeningeal thickening with enhancement. These features are consistent with primary intracranial hypotension as a consequence of lumbar puncture. Meningeal carcinomatosis can exhibit similar features on MRI; however, this is unlikely in light of the negative cytologic examination of the CSF. Additionally, although melanoma frequently metastasizes to the CNS, this is unlikely in the absence of any other systemic metastases. Therefore an epidural blood patch will likely treat the source of the intracranial hypotension and result in cessation of headaches. The lack of focal neurologic signs and symptoms makes the diagnosis of CNS vasculitis unlikely; thus, cerebral angiography would not be indicated

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24. Dg apakah pembuluh (tanda panah) pada angiogram karotid internal lateral ini lazimnya berasosiasi?

1. Meningioma tentorial
2. Angioma venous
3. Fistula arteriovenus dural
4. Papiloma pleksus koroid

B. The tentorial artery is a branch of the meningohypophyseal artery of the cavernous segment of the internal carotid artery; it is also known as the artery of Bernasconi and Cassinari, or the Italian artery. This artery was classically described in reference to a tentorial meningioma, but it is commonly observed with dural arteriovenous malformations of the tentorium as well

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25. Kelainan apakah yang ditunjukkan pada MR
Scan T2 dibwh ini
A. Fragmen piring herniasi
B. Neurofibrima
C. Kista sinovieal
D. Osteokondroma
E. Kista Neurenteris

C . Juxtafacet (synovial) cysts commonly exhibit hyperintense signal on T2-weighted images with a hypointense capsule. These cysts originate from the facet joint and can present with lumbar radiculopathy secondary to nerve root compression. The signal intensity of the cyst contents is variable on MRI and depends largely upon the protein concentration within the cyst. Synovial cysts occasionally enhance with contrast administration

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26. Ciri manakah yang TIDAK berasosiasi dg gangguan yang ditunjukkan pada MRI T2-sagital dibwh?

A. Prevalensi tertinggi di kalangan penduduk Jepang
B. 70 persen kasus melibatkan sumsum servik
C. Lazim ada bersama-sama Mielopati progresif
D. Redikulopati C5 merupakan komplikasi yang lazim dari pendekatan bedah depan.
E. Lazim diidentifikasikan pada x-ray polos spinal

E. This MRI depicts ossification of the posterior longitudinal ligament (OPLL). OPLL occurs in 0 . 1 2% of all North Americans, and 2.4% of all Japanese and accounts for 27% of all cases of cervical myelopath\' in Japan. OPLL involves the cervical spine •in 70% of cases and the thoracic ( 1 5%) and lumbar ( 15%) regions less frequently OPLL is more common in men and usually presents in the fifth to sixth decade with symptoms of progres!sive myelopathy. OPLL cannot be visualized with plain spinal x-rays; MRI or CT myelography is required to demonstrate the pathology and cord compression. Complications of anterior cervcal decompression for OPLL include worsening myelopathy. durotomy, and radiculopathy. Postoperative CS radiculopathy has been reponed in up to 1 7% of all patients undergoin g anterior decompre. si,procedures for OPLL. Posterior decoii:q!ressions, with up 170 Intensive Neurosurgery Board Review without concomitant fusion, have also been utilized in the treatment of OPLL, with variable success rates

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27. Ny. X, 55 th dg gejala awal hemiparesis kanan ringan akut. Neoplasma manakah yang ditunjukkan pada MRI T1-tertimbang yg telah diperjelas di bawah ini ?
C. Oligodendroglioma
D. Glioblastoma multiforme
E. Melanoma

D. Glioblastoma multiforme (GBM) is usually observed in the fifth to sixth decades of life and is most commonly located in the deep white matter of the frontal or temporal lobes. GBM often exhibits a central hypointense (necrotic) core on T l-weighted images with surrounding "ring enhancement" and prominent peri tumoral edema. GBlvl can be multifocal, as depicted above, in approximately 1 to 5% of all cases. GBM is associated with exposure to hydrocarbons and radiation and often results in progressive neurologic symptoms and signs. Metastases are frequent in the adult population, and they can exhibit variable enhancement patterns on CT and MRI. lvletastases, however, are most commonly located at the gray-white junction. Oligodendrogliomas usually exhibit heterogenous signal patterns on T1-weighted MRI, with patchy enhancement and calcification. CNS lymphoma is also often multiple and is usually found in the periventricular white matter or basal ganglia. CNS lymphoma is usually iso- to hypointense on T1-weighted images with variable enhancement patterns. The ring enhancement, prominent peritumoral edema, demographics, and the acute onset of a focal neurologic deficit are most consistent with a GBM

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28. Ciri manakah yang TIDAK berasosiasi dengan kelainan yang dijelaskan pada CT scan di bawah ini ?
A. Hampir lazim ada bersama-sama dengan sakit kepala
B. Hampir lazim hiperdensi pada CT scan
C. Hampir lazim hiperdensi dengan korteks pada MRI T-1tertimbang
D. Berasal dari ectoderm
E. Tidak menundukkan degenerasi ganas

D. Colloid cysts are cystic, encapsulated lesions that occur at the foramen of Monro in the anterior aspect of the third ventricle. These lesions are usually hyperdense on CT scans ( 66%), hyperintense to cortex on Tl-weighted images, and hypointense to cortex on T2-weighted images, although the MRI characteristics of these cysts are quite variable. Colloid cysts do not exhibit calcification or malignant degeneration; however, they occasionally show mild peripheral enhancement. Colloid cysts are derived from endoderm and usually pres.ent with intermittent or chronic headaches. Vertigo, memory loss, diplopia, and even sudden death can also occur with these lesions

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29. Kelainan manakah yang ditunjukkan pada MRI T1-tertimbang yang telah diperjelas di bawah ini ?

A.Ependymoma
B.Meningioma
C. Astrositoma pilositik
D. Neurositoma sentral
E. Papiloma pleksus koloid

D. Central neurocytoma is a lobulated, intraventricular tumor that usually occurs adjacent to the septum pellucidum or at the foramen of Monro within the lateral ventricle. Central neurocytoma usually presents in the second to third decades and is iso- to slightly hyperdense on CT scans. Central neurocytoma is generally isointense on T1-weighted images and iso- to hyperintense on T2-weigjued images, with minimal to mild heterogenous enhane,ement patterns. Supratentorial ependymomas are generally extraventricular and exhibit prominent enhancement. Additionally, choroid plexus papillomas and intraven tricular meningioma also exhibit prominent enhancement on MRI. lnterventricular pilocytic astrocy.tomas are generally cystic lesions that exhibit heterogeUllllls enhancement. The presence of an intraventricular mass adjacent to the septum pellucidum that is isointense to surrounding brain on T1-weighted MRI without enhancement is most consistent with a central neurocytoma

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30. Laki-laki, 18 tahun dibawa dengan riwayat 6 bulan sakit kepala oksipital progresif dan kulit kepala nyeri dan edema lokal. Kelainan apa yang dijelaskan pada CT scan aksial tdk enhance di bawah ini?

B. Osteoma ostenoid
C. Granuloma eosinopilik
D. Kista tulang aneurismal
E. Osteosarkoma

D. Aneurysmal bone cysts (ABCs) are benign lesions that can occur in all parts of the skeleton and often involve the posterior elements of the cervical and thoracic spine. ABCs usually occur in patients less than 20 years of age, and present with pain, edema, symptoms of neurologic compression, or pathologic fractures. ABCs are osteolytic lesions that often contain multiple lobulations and fluid-fluid levels secondary to hemorrhage at various stages of evolution. Eosinophilic granuloma, osteosarcoma, and osteoid osteoma rarely exhibit fluid-fluid levels and multiple lobulations. Giant cell tumors are also highly vascular, lytic lesions, however, they usually involve the vertebral body and present in patients in the third to fourth decades of life. The CT scan above exhibits prominent fluid-fluid levels within an osteolytic lesion, which is most consistent with an aneurysmal bone cyst