Neuroimaging Flashcards

Question

An 8-year-old boy has headaches and an MRI is performed. The lesion pictured below is associated with a syndrome caused by which chromosomal abnormality? A. 17 B. 22 C. 9 D. 3

Answer 1

A. 17 B. 22 **C. 9** D. 3 ## Footnote This MRI demonstrates a homogenously enhancing mass at the level of the foramen of Monro most consistent with a subependymal giant cell astrocytoma. These tumors are found in tuberous sclerosis, which can be caused by a mutation in tuberous sclerosis 1 (TSC1) on chromosome 9. Further Reading: Bernstein, Berger. Neuro-Oncology: The Essentials, 3rd edition, 2015, familial tumor syndromes.

Answer 2

A. Septum pellucidum B. Basal vein of Rosenthal C. Choroid plexus **D. Internal cerebral veins** ## Footnote In this coronal MRI, the white arrowheads are pointing to the paired internal cerebral veins within the third ventricle. Further Reading: Bernstein, Berger. Neuro-Oncology: The Essentials, 3rd edition, 2015, cranial venous anatomy.

Answer 3

A. Limen insulae B. Amygdala C. Diagonal band of Broca **D. Hippocampus** ## Footnote This coronal MRI is T2 weighted, and number 18 demonstrates the hippocampal formation. It is important to identify the hippocampus, especially in patients in whom there is concern for mesial temporal sclerosis and seizures. Further Reading: Cataltepe, Jallo. Pediatric Epilepsy Surgery, 2010, resective surgical techniques in temporal lobe epilepsy: transsylvian selective amygdalohippocampectomy.

Answer 4

A. Aneurysmal subarachnoid hemorrhage B. Metastatic tumor **C. Posterior reversible encephalopathy syndrome** D. Multiple system atrophy ## Footnote This MRI demonstrates T2 hyperintensities within the parieto-occipital lobes bilaterally. This, associated with seizures on presentation, is classic for posterior reversible encephalopathy syndrome (PRES). Further Reading: Harbaugh, Shaffrey, Couldwell, Berger. Neurosurgery Knowledge Update, 2015, posterior reversible encephalopathy syndrome.

Answer 5

**A. Start acyclovir** B. Start barbiturates C. Check blood sugar D. Arrange for needle biopsy ## Footnote This MRI demonstrates hyperintensities within the anterior temporal lobes bilaterally. In the setting of a rapidly declining patient with seizures, herpes encephalitis should be strongly considered and acyclovir should be initiated. Further Reading: Hall, Kim. Neurosurgical Infectious Disease, 2014, radiology of central nervous system infections.

Answer 6

A. Metastases **B. Neurocysticercosis** C. Familial cavernomatosis D. Gliomatosis cerebri ## Footnote This MRI demonstrates multiple lesions within the cerebrum. Each lesion demonstrates T2 hyperintensities within the central core as well as a hypointense region within the cyst, the classic “cyst with a dot sign.” This MRI is consistent with neurocysticercosis. Further Reading: Hall, Kim. Neurosurgical Infectious Disease, 2014, radiology of central nervous system infections.

Answer 7

A. Aqueductal stenosis **B. Cytomegalovirus (CMV) encephalitis** C. Germinal matrix hemorrhage D. Vein of Galen malformation ## Footnote This CT scan demonstrates diffuse periventricular calcifications and hydrocephalus, findings associated with CMV encephalitis in the pediatric population. Further Reading: Hall, Kim. Neurosurgical Infectious Disease, 2014, microbiological diagnosis of central nervous system infections.

Answer 8

**A. Multiple sclerosis** B. CNS lymphoma C. Metastases D. Gliomatosis cerebri ## Footnote This MRI demonstrates the classic periventricular hyperintensities, “Dawnson’s fingers” associated with multiple sclerosis. The intermittent nature of the deficits helps point toward the diagnosis of MS. Further Reading: Forsting, Jansen. MR Neuroimaging: Brain, Spine, Peripheral Nerves, 2017, multiple sclerosis and related diseases.

Answer 9

A. Balo’s concentric sclerosis B. CNS lymphoma **C. Tumefactive multiple sclerosis** D. Glioblastoma ## Footnote This MRI demonstrates an acute, fulminant demyelinating process causing severe mass effect consistent with tumefactive MS. There is incomplete ring enhancement and decreased perfusion to the region, making GBM less likely. Further Reading: Forsting, Jansen. MR Neuroimaging: Brain, Spine, Peripheral Nerves, 2017, multiple sclerosis and related diseases.

Answer 10

**A. Very long chain fatty acid synthesis** B. Glucocerebrosidase deficiency C. Isocitrate dehydrogenase deficiency D. Glycogen storage ## Footnote This MRI demonstrates white matter edema that appears to spare the subcortical U-fibers. This can be seen in X-linked adrenoleukodystrophy, which is caused by an abnormality in very long chain fatty acid synthesis. Further Reading: Forsting, Jansen. MR Neuroimaging: Brain, Spine, Peripheral Nerves, 2017, metabolic disorders.

Answer 11

A. Metastasis **B. Cerebral abscess** C. Glioblastoma D. Meningioma ## Footnote This CT demonstrates a cortical ring enhancing mass with significant surrounding edema. Given the clinical history, cerebral abscess should be high on the differential. Metastatic lesions can cause this much edema, but GBM often does not present with this much perilesional edema. Further Reading: Forsting, Jansen. MR Neuroimaging: Brain, Spine, Peripheral Nerves, 2017, infections.

Answer 12

**A. Streptococcus milleri** B. Listeria monocytogenes C. Staphylococcus aureus D. Klebsiella pneumoniae ## Footnote This MRI demonstrates a cortical ring enhancing mass with significant surrounding edema. Given the clinical history, cerebral abscess should be high on the differential. The most common isolate from primary cerebral abscesses listed here is Streptococcus milleri. Further Reading: Forsting, Jansen. MR Neuroimaging: Brain, Spine, Peripheral Nerves, 2017, infections.

Answer 13

A. Pituitary macroadenoma B. Craniopharyngioma C. Pituitary apoplexy **D. Lymphocytic hypophysitis** ## Footnote This sagittal MRI demonstrates an enlarged pituitary gland as well as an enlarged infundibular stalk, both of which enhance with contrast. Given the female gender and history of recent pregnancy, lymphocytic hypophysitis should be strongly considered. This condition is often self-limited. Further Reading: Forsting, Jansen. MR Neuroimaging: Brain, Spine, Peripheral Nerves, 2017, brain tumors.

Answer 14

A. Emergent pituitary decompression B. Obtain MRI C. Check sodium **D. Give hydrocortisone** ## Footnote This MRI demonstrates pituitary hemorrhage, and in this patient, consistent with Sheehan’s syndrome, a pituitary infarction caused by largevolume blood loss during delivery. After necrosis of the pituitary gland, hemorrhage can occur. These patients can decompensate quickly due to further hypotension given a complete lack of cortisol. Hydrocortisone should be given immediately and, next, consideration of pituitary decompression should be considered to save vision. Further Reading: Forsting, Jansen. MR Neuroimaging: Brain, Spine, Peripheral Nerves, 2017, brain tumors.

Answer 15

A. CNS lymphoma B. Leptomeningeal carcinomatosis **C. Neurosarcoidosis** D. Acute disseminated encephalomyelitis ## Footnote This skull base MRI demonstrates diffuse, homogenous enhancement of cranial nerves, and the leptomeninges. This finding, with cranial neuropathies, can be consistent with neurosarcoidosis. Further Reading: Forsting, Jansen. MR Neuroimaging: Brain, Spine, Peripheral Nerves, 2017, brain tumors.

Answer 16

A. Acetylcholine **B. Dopamine** C. Norepinephrine D. Serotonin ## Footnote This MRI demonstrates the substantia nigra, which uses dopamine as its primary neurotransmitter. Further Reading: Forsting, Jansen. MR Neuroimaging: Brain, Spine, Peripheral Nerves, 2017, anatomy.

Answer 17

A. Corticobasal degeneration **B. Parkinson’s disease** C. Frontotemporal dementia D. Alzheimer’s disease ## Footnote This MRI demonstrates atrophy of the frontal lobe with sparing of the parietal lobes. These findings, along with socially disruptive behavior and personality changes, are consistent with frontotemporal dementia. This term is becoming antiquated, and behavioral variant FTLD (frontotemporal lobe degeneration) is being used. It has also been termed Pick’s disease, but this should refer only to patients with histologically proven Pick’s bodies. Further Reading: Forsting, Jansen. MR Neuroimaging: Brain, Spine, Peripheral Nerves, 2017, degenerative diseases.

Answer 18

**A. Isointense** B. Hyperintense C. Hypointense D. Hyperdense ## Footnote Blood products on MRI are highly testable and annoying to memorize. Several mnemonics exist, but consider the classic mnemonic I Be, iDDy, BiDy, BaBy, DooDoo. Hyperacute (< 24 hours) = I B (T1/T2) or T1 isointense and T2 hyperintense. Acute (1–3 days) = DD (T1 dark, T2 dark), early subacute (3–7 days) = BD (T1 bright, T2 dark), late subacute (7–14 days) = BB (T1 bright, T2 bright), chronic (> 14 days) = DD (T1 dark, T2 dark). Further Reading: Forsting, Jansen. MR Neuroimaging: Brain, Spine, Peripheral Nerves, 2017, vascular diseases.

Answer 19

A. Isointense **B. Hyperintense** C. Hypointense D. Hyperdense ## Footnote Blood products on MRI are highly testable and annoying to memorize. Several mnemonics exist, but consider the classic mnemonic I Be, iDDy, BiDy, BaBy, DooDoo. Hyperacute (< 24 hours) = I B (T1/T2) or T1 isointense and T2 hyperintense. Acute (1–3 days) = DD (T1 dark, T2 dark), early subacute (3–7 days) = BD (T1 bright, T2 dark), late subacute (7–14 days) = BB (T1 bright, T2 bright), chronic (> 14 days) = DD (T1 dark, T2 dark). Further Reading: Forsting, Jansen. MR Neuroimaging: Brain, Spine, Peripheral Nerves, 2017, vascular diseases.

Answer 20

A. Isointense B. Hyperintense **C. Hypointense** D. Hyperdense ## Footnote Blood products on MRI are highly testable and annoying to memorize. Several mnemonics exist, but consider the classic mnemonic I Be, iDDy, BiDy, BaBy, DooDoo. Hyperacute (< 24 hours) = I B (T1/T2) or T1 isointense and T2 hyperintense. Acute (1–3 days) = DD (T1 dark, T2 dark), early subacute (3–7 days) = BD (T1 bright, T2 dark), late subacute (7–14 days) = BB (T1 bright, T2 bright), chronic (> 14 days) = DD (T1 dark, T2 dark). Further Reading: Forsting, Jansen. MR Neuroimaging: Brain, Spine, Peripheral Nerves, 2017, vascular diseases.

Answer 21

A. Isointense B. Hyperintense **C. Hypointense** D. Hyperdense ## Footnote Blood products on MRI are highly testable and annoying to memorize. Several mnemonics exist, but consider the classic mnemonic I Be, iDDy, BiDy, BaBy, DooDoo. Hyperacute (< 24 hours) = I B (T1/T2) or T1 isointense and T2 hyperintense. Acute (1–3 days) = DD (T1 dark, T2 dark), early subacute (3–7 days) = BD (T1 bright, T2 dark), late subacute (7–14 days) = BB (T1 bright, T2 bright), chronic (> 14 days) = DD (T1 dark, T2 dark). Further Reading: Forsting, Jansen. MR Neuroimaging: Brain, Spine, Peripheral Nerves, 2017, vascular diseases.

Answer 22

A. Isointense **B. Hyperintense** C. Hypointense D. Hyperdense ## Footnote Blood products on MRI are highly testable and annoying to memorize. Several mnemonics exist, but consider the classic mnemonic I Be, iDDy, BiDy, BaBy, DooDoo. Hyperacute (< 24 hours) = I B (T1/T2) or T1 isointense and T2 hyperintense. Acute (1–3 days) = DD (T1 dark, T2 dark), early subacute (3–7 days) = BD (T1 bright, T2 dark), late subacute (7–14 days) = BB (T1 bright, T2 bright), chronic (> 14 days) = DD (T1 dark, T2 dark). Further Reading: Forsting, Jansen. MR Neuroimaging: Brain, Spine, Peripheral Nerves, 2017, vascular diseases.

Answer 23

A. Isointense B. Hyperintense **C. Hypointense** D. Hyperdense ## Footnote Blood products on MRI are highly testable and annoying to memorize. Several mnemonics exist, but consider the classic mnemonic I Be, iDDy, BiDy, BaBy, DooDoo. Hyperacute (< 24 hours) = I B (T1/T2) or T1 isointense and T2 hyperintense. Acute (1–3 days) = DD (T1 dark, T2 dark), early subacute (3–7 days) = BD (T1 bright, T2 dark), late subacute (7–14 days) = BB (T1 bright, T2 bright), chronic (> 14 days) = DD (T1 dark, T2 dark). Further Reading: Forsting, Jansen. MR Neuroimaging: Brain, Spine, Peripheral Nerves, 2017, vascular diseases.

Answer 24

A. Isointense **B. Hyperintense** C. Hypointense D. Hyperdense ## Footnote Blood products on MRI are highly testable and annoying to memorize. Several mnemonics exist, but consider the classic mnemonic I Be, iDDy, BiDy, BaBy, DooDoo. Hyperacute (< 24 hours) = I B (T1/T2) or T1 isointense and T2 hyperintense. Acute (1–3 days) = DD (T1 dark, T2 dark), early subacute (3–7 days) = BD (T1 bright, T2 dark), late subacute (7–14 days) = BB (T1 bright, T2 bright), chronic (> 14 days) = DD (T1 dark, T2 dark). Further Reading: Forsting, Jansen. MR Neuroimaging: Brain, Spine, Peripheral Nerves, 2017, vascular diseases.

Answer 25

A. Isointense **B. Hyperintense** C. Hypointense D. Hyperdense ## Footnote Blood products on MRI are highly testable and annoying to memorize. Several mnemonics exist, but consider the classic mnemonic I Be, iDDy, BiDy, BaBy, DooDoo. Hyperacute (< 24 hours) = I B (T1/T2) or T1 isointense and T2 hyperintense. Acute (1–3 days) = DD (T1 dark, T2 dark), early subacute (3–7 days) = BD (T1 bright, T2 dark), late subacute (7–14 days) = BB (T1 bright, T2 bright), chronic (> 14 days) = DD (T1 dark, T2 dark). Further Reading: Forsting, Jansen. MR Neuroimaging: Brain, Spine, Peripheral Nerves, 2017, vascular diseases.

Answer 26

A. Isointense B. Hyperintense **C. Hypointense** D. Hyperdense ## Footnote Blood products on MRI are highly testable and annoying to memorize. Several mnemonics exist, but consider the classic mnemonic I Be, iDDy, BiDy, BaBy, DooDoo. Hyperacute (< 24 hours) = I B (T1/T2) or T1 isointense and T2 hyperintense. Acute (1–3 days) = DD (T1 dark, T2 dark), early subacute (3–7 days) = BD (T1 bright, T2 dark), late subacute (7–14 days) = BB (T1 bright, T2 bright), chronic (> 14 days) = DD (T1 dark, T2 dark). Further Reading: Forsting, Jansen. MR Neuroimaging: Brain, Spine, Peripheral Nerves, 2017, vascular diseases.

Answer 27

A. Isointense B. Hyperintense **C. Hypointense** D. Hyperdense ## Footnote Blood products on MRI are highly testable and annoying to memorize. Several mnemonics exist, but consider the classic mnemonic I Be, iDDy, BiDy, BaBy, DooDoo. Hyperacute (< 24 hours) = I B (T1/T2) or T1 isointense and T2 hyperintense. Acute (1–3 days) = DD (T1 dark, T2 dark), early subacute (3–7 days) = BD (T1 bright, T2 dark), late subacute (7–14 days) = BB (T1 bright, T2 bright), chronic (> 14 days) = DD (T1 dark, T2 dark). Further Reading: Forsting, Jansen. MR Neuroimaging: Brain, Spine, Peripheral Nerves, 2017, vascular diseases.

Answer 28

A. Ipsilateral hemiparesis and 2-point discrimination loss, contralateral pain/temperature loss **B. Circumferential weakness** C. Bowel/bladder incontinence D. Bilateral lower extremity paresthesias ## Footnote This MRI demonstrates a foramen magnum meningioma. Classically, these tumors present with circumferential weakness starting, for example, with right upper extreme (RUE) weakness followed by right lower extreme (RLE) weakness, followed by left lower extreme (LLE) weakness, and finally left upper extreme (LUE) weakness. Further Reading: Al-Mefty, DeMonte, McDermott. Al-Mefty’s Meningiomas, 2nd edition, 2011, foramen magnum meningiomas.

Answer 29

A. Ependymoma B. Spinal cord astrocytoma **C. Meningioma** D. Hemangioblastoma ## Footnote This MRI demonstrates a thoracic meningioma. A dural tail is noticeable and homogenous enhancement is seen. The other options listed are all intramedullary lesions. Further Reading: Al-Mefty, DeMonte, McDermott. Al-Mefty’s Meningiomas, 2nd edition, 2011, current surgical techniques in the treatment of spinal meningiomas.

Answer 30

**A. Ependymoma** B. Spinal cord astrocytoma C. Meningioma D. Hemangioblastoma ## Footnote Ependymomas of the spinal cord are the most common intramedullary spinal cord tumors. They make up 60% of adult glial spinal cord tumors. Further Reading: Dickman, Fehlings, Gokaslan. Spinal Cord and Spinal Column Tumors, 2006, radiologic imaging of tumors of the spine, spinal cord, and peripheral nerves.

Answer 31

A. NF1 **B. NF2** C. Tuberous sclerosis D. Li–Fraumeni syndrome ## Footnote This MRI demonstrates a spinal cord ependymoma. These tumors are associated with neurofibromatosis type 2. Further Reading: Dickman, Fehlings, Gokaslan. Spinal Cord and Spinal Column Tumors, 2006, radiologic imaging of tumors of the spine, spinal cord, and peripheral nerves.

Answer 32

A. Spinal cord astrocytoma B. Meningioma **C. Myxopapillary ependymoma** D. Hemangioblastoma ## Footnote This sagittal MRI demonstrates classic findings for myxopapillary ependymoma. A uniform, enhancing mass in close approximation to the conus medullaris is most often consistent with myxopapillary ependymoma. Further Reading: Dickman, Fehlings, Gokaslan. Spinal Cord and Spinal Column Tumors, 2006, intradural extramedullar spinal tumors.

Answer 33

**A. NF1** B. NF2 C. Tuberous sclerosis D. Li–Fraumeni syndrome ## Footnote This MRI demonstrates a spinal cord astrocytoma. There is diffuse T2 signal throughout the cord and patchy enhancement within the spinal cord itself. Spinal cord astrocytomas can be associated with neurofibromatosis type 1. Further Reading: Dickman, Fehlings, Gokaslan. Spinal Cord and Spinal Column Tumors, 2006, intramedullary spinal cord tumors.

Answer 34

A. Ependymoma **B. Astrocytoma** C. Metastasis D. Meningioma ## Footnote This MRI demonstrates expansion of the thoracic spinal cord with T2 hyperintensity. This is most consistent with spinal cord astrocytoma. Astrocytomas of the spine are the second most common intramedullary tumor behind ependymomas; however, ependymomas are usually more circumscribed and homogenously enhancing. Further Reading: Dickman, Fehlings, Gokaslan. Spinal Cord and Spinal Column Tumors, 2006, intramedullary spinal cord tumors.

Answer 35

A. Hemangioma B. Aneurysmal bone cyst C. Metastatic lesion **D. Osteoid osteoma** ## Footnote This CT scan demonstrates the hyperdense lesion with hypodense halo consistent with osteoid osteoma. Oftentimes, these masses cause pain that is more severe at night and relieved by aspirin. Further Reading: Dickman, Fehlings, Gokaslan. Spinal Cord and Spinal Column Tumors, 2006, oncologic classification of vertebral neoplasms.

Answer 36

**A. Hemangioma** B. Burst fracture C. Metastatic lesion D. Osteoid osteoma ## Footnote This CT scan demonstrates the classic honeycomb appearance of a vertebral hemangioma. This is the most common benign vertebral column neoplasm. Further Reading: Dickman, Fehlings, Gokaslan. Spinal Cord and Spinal Column Tumors, 2006, primary vertebral column tumors.

Answer 37

A. Hemangioma B**. Aneurysmal bone cyst** C. Metastatic lesion D. Osteoid osteoma ## Footnote This MRI demonstrates a lytic appearing mass within the vertebral body and extending into the posterior elements. It is consistent with an aneurysmal bone cyst (ABC). In some cases, fluid–fluid levels can be seen within the ABC owing to blood products within the cyst itself. Further Reading: Dickman, Fehlings, Gokaslan. Spinal Cord and Spinal Column Tumors, 2006, primary vertebral column tumors.

Answer 38

**A. Chordoma** B. Aneurysmal bone cyst C. Lipomyelomeningocele D. Metastasis ## Footnote This MRI demonstrates a large sacral mass that is homogeneously enhancing. It is most consistent with a sacral chordoma based on the honeycomb appearance of the enhancement and origination from the sacrum. Further Reading: Dickman, Fehlings, Gokaslan. Spinal Cord and Spinal Column Tumors, 2006, primary vertebral column tumors.

Answer 39

A. Rosenthal fibers B**. Physaliphorous cells** C. Eosinophilic intranuclear inclusion bodies D. Homer Wright rosettes ## Footnote This MRI demonstrates a large sacral mass that is homogeneously enhancing. It is most consistent with a sacral chordoma based on the honeycomb appearance of the enhancement and origination from the sacrum. Histologically, these tumors are found to contain physaliphorous cells (vacuolated cells) that are characteristic of chordoma. Further Reading: Dickman, Fehlings, Gokaslan. Spinal Cord and Spinal Column Tumors, 2006, primary vertebral column tumors.

Answer 40

A. Posterior longitudinal ligament B. Anterior longitudinal ligament **C. Ligamentum flavum** D. Spinous process ## Footnote This MRI demonstrates lumbar stenosis, consistent with the patient presentation as well. The level with the yellow arrow demonstrates a disk bulge as well as ligamentum flavum hypertrophy, common in lumbar spinal stenosis. Further Reading: Harbaugh, Shaffrey, Couldwell, Berger. Neurosurgery Knowledge Update, 2015, stenosis/spondylolisthesis/spondylolysis.

Answer 41

A. Type I collagen B. Type II collagen **C. Elastin** D. Laminin ## Footnote This MRI demonstrates lumbar stenosis, consistent with the patient presentation as well. The level with the yellow arrow demonstrates a disk bulge as well as ligamentum flavum hypertrophy, common in lumbar spinal stenosis. The ligamentum flavum is comprised of 80% elastin, which allows it to stretch in flexion and not buckle in extension. As patients age, the elastin is replaced with collagen and the yellow ligament loses its elasticity, causing it to buckle in extension and compress the neural elements. Further Reading: Harbaugh, Shaffrey, Couldwell, Berger. Neurosurgery Knowledge Update, 2015, stenosis/spondylolisthesis/spondylolysis.

Answer 42

A. Right L4 B. Left L4 **C. Right L5** D. Left L5 ## Footnote This MRI demonstrates disk-herniation at L4L5 on the right side. Given that it is a paracentral disk herniation, this patient would most likely experience symptoms from compression of the right L5 nerve root as it is traversing at this level. The right L4 nerve root has already exited the foramen. Further Reading: Harbaugh, Shaffrey, Couldwell, Berger. Neurosurgery Knowledge Update, 2015, disk herniations.

Answer 43

A. Right quadriceps weakness B. Right hip adduction weakness **C. Right extensor hallucis longus weakness** D. Right gastrocnemius weakness ## Footnote This MRI demonstrates disk herniation at L4–L5 on the right side. Given that it is a paracentral disk herniation, this patient would most likely experience symptoms from compression of the right L5 nerve root as it is traversing at this level. The right L4 nerve root has already exited the foramen. The L5 nerve is easily assessed by examining the extensor hallucis longus on the ipsilateral side. Further Reading: Harbaugh, Shaffrey, Couldwell, Berger. Neurosurgery Knowledge Update, 2015, disk herniations.

Answer 44

A. Right iliopsoas weakness **B. Right quadriceps weakness** C. Right extensor hallucis longus weakness D. Right gastrocnemius weakness ## Footnote This MRI demonstrates disk herniation at L3–L4 on the right side, but it demonstrates a far lateral/ foraminal disk herniation. This is different from a paracentral herniation in that foraminal/far lateral disk herniations affect the exiting root at that level rather than the traversing root. In this case, the right L3 root would be compressed, causing quadriceps weakness. Further Reading: Harbaugh, Shaffrey, Couldwell, Berger. Neurosurgery Knowledge Update, 2015, disk herniations.

Answer 45

**A. Right L3** B. Left L4 C. Right L5 D. Left L5 ## Footnote This MRI demonstrates disk herniation at L3–L4 on the right side, but it demonstrates a far lateral/ foraminal disk herniation. This is different from a paracentral herniation in that foraminal/far lateral disk herniations affect the exiting root at that level rather than the traversing root. In this case, the right L3 root would be compressed, causing quadriceps weakness. Further Reading: Harbaugh, Shaffrey, Couldwell, Berger. Neurosurgery Knowledge Update, 2015, disk herniations.

Answer 46

A. Lumbar spondyloptosis **B. Lumbar spondylolisthesis** C. Lumbar burst fracture D. Chance fracture ## Footnote This X-ray demonstrates L4–L5 spondylolisthesis of the lumbar spine, resulting in likely spinal stenosis. Further Reading: Harbaugh, Shaffrey, Couldwell, Berger. Neurosurgery Knowledge Update, 2015, stenosis/spondylolisthesis/spondylolysis.

Answer 47

A. 36-inch-long cassette X-rays **B. Lumbar spine MRI** C. Lumbar CT scan D. CT myelogram ## Footnote The flexion/extension X-rays demonstrate spondylolisthesis at L4-L5. The patient has pain that may correlate with these findings. A lumbar spine MRI should be performed to better determine any areas of spinal stenosis and help with treatment planning. Long-cassette X-rays could be considered if there is concern for saggital imbalance. Further Reading: Harbaugh, Shaffrey, Couldwell, Berger. Neurosurgery Knowledge Update, 2015, stenosis/spondylolisthesis/spondylolysis.

Answer 48

A. Noncontrast lumbar spine MRI **B. Contrast-enhanced lumbar spine MRI** C. Standing AP/lateral lumbar spine X-rays D. Lumbar spine CT ## Footnote A contrast-enhanced MRI scan of the lumbar spine should be ordered as this is the best way to demonstrate the difference between scar tissue and recurrent disk. Recurrent disks tend to have some peripheral enhancement with central hypointensity, whereas scar tissue is generally homogenously enhancing. Further Reading: Harbaugh, Shaffrey, Couldwell, Berger. Neurosurgery Knowledge Update, 2015, disk herniations.

Answer 49

A. Burst fracture B. Grade I spondylolisthesis **C. Spondyloptosis** D. Spondylolysis ## Footnote This CT scan demonstrates complete anterolisthesis of the lumbar spine from the sacrum, known as spondyloptosis. Further Reading: Harbaugh, Shaffrey, Couldwell, Berger. Neurosurgery Knowledge Update, 2015, stenosis/spondylolisthesis/spondylolysis.

Answer 50

A. Spondylosis B. Spondylolisthesis C. Spondyloptosis **D. Spondylolysis** ## Footnote This CT scan demonstrates a disruption of the pars interarticularis, which is termed spondylolysis. Further Reading: Harbaugh, Shaffrey, Couldwell, Berger. Neurosurgery Knowledge Update, 2015, stenosis/spondylolisthesis/spondylolysis.

Answer 51

A. Anterior longitudinal ligament **B. Transverse ligament** C. Apical ligament D. Ligamentum nuchae ## Footnote This MRI demonstrates a periodontoid pannus formation in a patient with rheumatoid arthritis. There is also associated laxity of the transverse ligament. Abnormal motion can increase the mass formation and even lead to significant stenosis causing compression of the cord. In some cases, decompression and fusion of the atlantoaxial joint can decrease or completely eliminate this pannus without direct decompression. Further Reading: Goel, Cacciola. The Craniovertebral Junction: Diagnosis, Pathology, Surgical Techniques, 2011, radiological investigations.

Answer 52

A. Anterior cervical diskectomy and fusion **B. CT scan of the cervical spine** C. EMG D. Physical therapy ## Footnote This MRI demonstrates multilevel narrowing of the cervical spine by very hypointense, contiguous soft-tissue posterior to the vertebral bodies. This should concern you for the presence of ossification of the posterior longitudinal ligament (OPLL), and a CT scan to confirm this is warranted. OPLL can cause erosion of the dura, and without knowing a patient has OPLL, a simple anterior procedure could cause disastrous CSF leak complications. Further Reading: Baaj, Mummaneni, Uribe, Vaccaro, Greenberg. Handbook of Spine Surgery, 2016, spondyloarthropathies.

Answer 53

**A. Ossification of the posterior longitudinal ** ligament B. Diffuse idiopathic skeletal hyperostosis C. Ankylosing spondylitis D. Klippel–Feil syndrome ## Footnote This X-ray and CT scan demonstrate contiguous bone formation posterior to the vertebral body consistent with OPLL. Further Reading: Baaj, Mummaneni, Uribe, Vaccaro, Greenberg. Handbook of Spine Surgery, 2016, spondyloarthropathies.

Answer 54

**A. Right C6** B. Left C6 C. Right C7 D. Left C7 ## Footnote This MRI demonstrates a cervical disk herniation likely causing this patient’s radiculopathy. In the cervical spine, nerve roots exit above their corresponding level, meaning that the right C6 nerve root would be compressed in this patient at this level. Further Reading: Baaj, Mummaneni, Uribe, Vaccaro, Greenberg. Handbook of Spine Surgery, 2016, cervical and thoracic spine degenerative disease.

Answer 55

A. Right shoulder **B. Right thumb** C. Right middle finger D. Right fifth digit ## Footnote This MRI scan demonstrates a cervical disk herniation at C5/C6, meaning that C6 will be compressed. This would lead to a sensory radiculopathy affecting the right thumb. Further Reading: Baaj, Mummaneni, Uribe, Vaccaro, Greenberg. Handbook of Spine Surgery, 2016, cervical and thoracic spine degenerative disease.

Answer 56

A. Myxopapillary ependymoma B. Synovial cyst **C. Epidural lipomatosis** D. Spinal stenosis ## Footnote This MRI exaggerated fat within the epidural space notable on this T1 image. This is consistent with epidural lipomatosis. Further Reading: Forsting, Jansen. MR Neuroimaging: Brain, Spine, Peripheral Nerves, 2017, degenerative spinal and foraminal stenoses.

Answer 57

A. Herniated disk **B. Synovial cyst** C. Epidural lipomatosis D. Spinal stenosis ## Footnote This MRI demonstrates a T2-hyperintense mass emanating from the left synovial joint impinging on the traversing nerve root. This is most consistent with a synovial cyst. Further Reading: Wolfla, Resnick. Neurosurgical Operative Atlas: Spine and Peripheral Nerves, 2017, minimally invasive resection of lumbar synovial cysts and foraminal disks.

Answer 58

A. Ependymoma B. Spinal dural arteriovenous fistula **C. Spinal arteriovenous malformation** D. Spinal astrocytoma ## Footnote This MRI demonstrates evidence of T2 signal changes within the cervical cord as well as the presence of multiple flow voids dorsal to the cord. This is most consistent with a spinal cord arteriovenous malformation (AVM). While spinal dural arteriovenous fistulas (AVFs) can also have multiple flow voids, it is rare for there to be an intramedullary component. This is more often seen in spinal cord AVMs. Further Reading: Spetzler, Kalani, Nakaji. Neurovascular Surgery, 2nd edition, 2015, radiosurgery for spinal arteriovenous malformations.

Answer 59

A. Flexion/extension X-rays B. Cervical spine CT **C. Conventional angiogram** D. Gadolinium-enhanced MRI ## Footnote This MRI demonstrates evidence of T2 signal changes within the cervical cord as well as the presence of multiple flow voids dorsal to the cord. This is most consistent with a spinal cord AVM. A conventional spinal angiogram should be performed next to better characterize the AVM. Further Reading: Spetzler, Kalani, Nakaji. Neurovascular Surgery, 2nd edition, 2015, radiosurgery for spinal arteriovenous malformations.

Answer 60

A. Flexion/extension X-rays B. Lumbar spine CT **C. Conventional angiogram** D. Gadolinium-enhanced MRI ## Footnote This MRI demonstrates evidence of T2 signal changes within the spine as well as the presence of multiple flow voids dorsal to the cord. Since there is no appreciable intramedullary component with mass effect, this MRI is most consistent with a spinal dural AVF (dAVF). A conventional angiogram should be performed to determine the abnormal connection location. Further Reading: Spetzler, Kalani, Nakaji. Neurovascular Surgery, 2nd edition, 2015, surgical management of spinal vascular malformations.

Answer 61

A. Spinal cavernous malformation **B. Spinal dural arteriovenous fistula** C. Spinal cord infarction D. Spinal hemangioblastoma ## Footnote This angiogram demonstrates congestion of the spinal cord veins and evidence of a direct fistula arising from the left L4 root. This would be consistent with a type I spinal AVM (dAVF). Further Reading: Spetzler, Kalani, Nakaji. Neurovascular Surgery, 2nd edition, 2015, surgical management of spinal vascular malformations.

Answer 62

A. Flexion/extension X-rays B. Lumbar CT scan **C. CT myelogram** D. Lumbar MRI ## Footnote In patients who are pacemaker dependent or cannot undergo MRI for other reasons, a CT myelogram of the lumbar spine can be used to determine the level of compression. Further Reading: Anderson, Vaccaro, Gebauer. Decision Making in Spinal Care, 2nd edition, 2013, thoracic disk herniation.

Answer 63

A. CSF leak **B. Hardware failure** C. Junctional kyphosis D. Adjacent segment disease ## Footnote This X-ray demonstrates fusion hardware failure of the pedicle screw at the inferior aspect of the construct. Hardware failure can be a cause for pseudoarthrosis and return of significant pain. Further Reading: Abdulhak, Marzouk. Challenging Cases in Spine Surgery, 2006, hardware failure.

Answer 64

A. Improved NDI score **B. Pseudoarthrosis** C. Complete bony fusion D. Deltoid weakness E. Triceps weakness ## Footnote This patient has screw pullout and plate dislodgement after an attempted anterior cervical diskectomy and fusion (ACDF). The hardware failure in this case would very likely lead to pseudoarthrosis and worsened pain. Further Reading: Abdulhak, Marzouk. Challenging Cases in Spine Surgery, 2006, hardware failure.

Answer 65

A. Ankylosing spondylitis **B. Diffuse idiopathic hyperostosis** C. Osteochondroma D. Chordoma ## Footnote This MRI and CT scan demonstrate flowing bony osteophytes anterior to the cervical spine. This is consistent with a diagnosis of diffuse idiopathic skeletal hyperostosis (DISH). Further Reading: Anderson, Vaccaro, Gebauer. Decision Making in Spinal Care, 2nd edition, 2013, diffuse idiopathic skeletal hyperostosis.

Answer 66

A. HLA-DR2 B. HLA-DR3 **C. HLA-B27** D. HLA-B47 ## Footnote This MRI/CT scan demonstrates flowing bony osteophytes anterior to the cervical spine. This is consistent with a diagnosis of DISH, which is associated with HLA-B27. Further Reading: Anderson, Vaccaro, Gebauer. Decision Making in Spinal Care, 2nd edition, 2013, diffuse idiopathic skeletal hyperostosis.

Answer 67

A. HLA-DR2 B. HLA-DR3 **C. HLA-B27** D. HLA-B47 ## Footnote This CT scan demonstrates the classic ankylosed “bamboo spine.” This is consistent with a diagnosis of ankylosing spondylitis, which is associated with HLA-B27. Further Reading: Anderson, Vaccaro, Gebauer. Decision Making in Spinal Care, 2nd edition, 2013, ankylosing spondylitis.

Answer 68

**A. Ankylosing spondylitis** B. Diffuse idiopathic skeletal hyperostosis C. Osteochondroma D. In situ surgical fusion ## Footnote This CT scan demonstrates the classic ankylosed “bamboo spine.” This is consistent with a diagnosis of ankylosing spondylitis. Further Reading: Anderson, Vaccaro, Gebauer. Decision Making in Spinal Care, 2nd edition, 2013, ankylosing spondylitis.

Answer 69

**A. Ankylosing spondylitis** B. Diffuse idiopathic skeletal hyperostosis C. Osteochondroma D. In situ surgical fusion ## Footnote This X-ray demonstrates the classic ankylosed “bamboo spine.” This is consistent with a diagnosis of ankylosing spondylitis. Patients can also experience fusion of the sacroiliac (SI) joints. Further Reading: Anderson, Vaccaro, Gebauer. Decision Making in Spinal Care, 2nd edition, 2013, ankylosing spondylitis.

Answer 70

A. Spinal cord astrocytoma B. Cauda equine syndrome C. Congenital cervical stenosis **D. Transverse myelitis** ## Footnote This MRI scan demonstrates T2 signal change within the spinal cord in the setting of an otherwise patent spinal canal. The sudden onset nature of her symptoms are suggestive of transverse myelitis rather than tumor. Further Reading: DeWald, Arlet, Carl, O’Brien. Spinal Deformities, 2003, anterior horn cell disease: poliomyelitis, spinal muscular atrophy, acute transverse myelitis.

Answer 71

A. Osteochondroma B. Spinal hemangioma **C. Diskitis/osteomyelitis** D. Vertebral metastasis ## Footnote This MRI scan demonstrates increased T2 signal within the disk space as well as endplate destruction at the bordering vertebral bodies. These findings, in the setting of a patient with history of IV drug use, are most consistent with diskitis/osteomyelitis. Further Reading: Khanna. MRI Essentials for the Spine Specialist, 2014, the lumbar and thoracic spine.

Answer 72

A. Streptococcus milleri **B. Staphylococcus aureus** C. Staphylococcus epidermidis D. Enterococcus ## Footnote This MRI scan demonstrates increased T2 signal within the disk space as well as endplate destruction at the bordering vertebral bodies. These findings, in the setting of a patient with history of IV drug use, are most consistent with diskitis/osteomyelitis. The most common pathogen is Staphylococcus aureus. Further Reading: Kraemer. Intervertebral Disk Diseases, 3rd edition, 2009, Nondegenerative disk diseases.

Answer 73

A. Ankylosing spondylitis **B. Paget’s disease of bone** C. Diffuse idiopathic skeletal hyperostosis D. Osteoporosis ## Footnote This X-ray demonstrates classic “picture-frame vertebral bodies” consistent with Paget’s disease of bone. There is also an associated fracture. The CT scan demonstrates central cavities within the bone. Patients can also present with hearing loss and have a higher risk of developing bony tumors. Further Reading: Kraemer. Intervertebral Disk Diseases, 3rd edition, 2009, lumbar syndrome.

Answer 74

**A. Serum alkaline phosphatase** B. Serum calcium C. Serum phosphorous D. Vitamin B12 ## Footnote This X-ray demonstrates classic “picture-frame vertebral bodies” consistent with Paget’s disease of bone. There is also an associated fracture. The CT scan demonstrates central cavities within the bone. Patients can also present with hearing loss and have a higher risk of developing bony tumors. Serum alkaline phosphatase is elevated in this condition, while calcium and phosphorous levels are normal. Further Reading: Bambakidis, Dickman, Spetzler, Sonntag. Surgery of the Craniovertebral Junction, 2nd edition, 2013, bone softening diseases and disorders of bone metabolism.

Answer 75

A. Scheuermann’s nodes **B. Schmorl’s nodes** C. Spinal stenosis D. Synovial cyst ## Footnote This X-ray and MRI demonstrate disk herniation through the endplate, which are termed Schmorl’s nodes. Unless they form acutely, they are generally not associated with back pain. They are part of the diagnosis of Scheuermann’s disease, but they are found in up to 75% of autopsies as well. Further Reading: Meyers. Differential Diagnosis in Neuroimaging: Spine, 2017, solitary osseous lesions involving the spine.

Answer 76

**A. Scheuermann’s disease** B. Schmorl’s nodes C. Junctional kyphosis D. Dystonia ## Footnote This X-ray demonstrates kyphosis and wedging of multiple thoracic vertebral bodies. This is consistent with Scheuermann’s kyphosis, often seen in pediatrics (~ 5% incidence), and is diagnosed based on the Sorensen classification (thoracic kyphosis > 40 degrees; thoracolumbar kyphosis > 25 degrees). Or multiple thoracic vertebral bodies wedged > 5 degrees. Further Reading: Anderson, Vaccaro, Gebauer. Decision Making in Spinal Care, 2nd edition, 2013, Scheuermann disease.

Neuroimaging Flashcards

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