Neuroimaging Flashcards
A 45-year-old man has an abnormality discovered on MRI. From the MR spectroscopy study shown in the following image, what is the most likely diagnosis?
A. Abscess
B. Infarction
C. Glioma
D. Hemorrhage
A. Abscess
B. Infarction
C. Glioma
D. Hemorrhage
This MR spectroscopy (MRS) image demonstrates an area of abnormality in the left insula. On MRS, the choline peak is much higher than the N-acetylaspartate (NAA) or creatine peak. This is suggestive of glioma.
Further Reading: Jain, Essig. Brain Tumor Imaging, 2015, metabolic imaging: MR spectroscopy.
A 73-year-old man has an abnormality discovered on MRI. The MR spectroscopy study indicates an elevated lactate. What is the most likely diagnosis?
A. Abscess
B. Infarction
C. Glioma
D. Hemorrhage
A. Abscess
B. Infarction
C. Glioma
D. Hemorrhage
MRS can be used to determine what an abnormality may be when seen on MRI. The classic choline peak is suggestive of glioma. When the lactate peak is elevated, ischemic stroke is suggested, given that the brain has switched over to anaerobic metabolism.
Further Reading: Jain, Essig. Brain Tumor Imaging, 2015, metabolic imaging: MR spectroscopy.
A 55-year-old man undergoes resection of a right frontal glioblastoma. He undergoes a standard temozolomide and radiation regimen postoperatively. Nine months later, enhancement is seen within the resection cavity. MR spectroscopy demonstrates the NAA peak to be double the choline peak. What is the most likely diagnosis?
A. Abscess
B. Infarction
C. Recurrent glioma
D. Radiation necrosis
A. Abscess
B. Infarction
C. Recurrent glioma
D. Radiation necrosis
MRS can be difficult to determine the difference between radiation necrosis and recurrent glioma. However, in recurrent glioma, a choline peak would be suggested, while in radiation necrosis, a significant NAA peak can be seen.
Further Reading: Jain, Essig. Brain Tumor Imaging, 2015, metabolic imaging: MR spectroscopy.
This MRI is from a 50-year-old woman who was having headaches. What mutation listed below would suggest that this lesion is primary and not due to malignant transformation?
A. PTEN mutant
B. PTEN wild type
C. IDH-1 mutant
D. IDH-1 wild type
A. PTEN mutant
B. PTEN wild type
C. IDH-1 mutant
D. IDH-1 wild type
This MRI is suggestive of a glioblastoma (GBM), based on ring enhancement of a “butterfly” lesion. Most primary GBMs are IDH-1 wild type and, when found to be IDH-1 mutant, may be suggestive of a malignant transformation from a lower grade glioma.
Further Reading: Bernstein, Berger. Neuro-Oncology: The Essentials, 3rd edition, 2015, malignant gliomas.
What is the most likely diagnosis?
A. Glioblastoma
B. Infarction
C. Hemorrhage
D. Huntington’s disease
A. Glioblastoma
B. Infarction
C. Hemorrhage
D. Huntington’s disease
This MRI demonstrates evidence of a malignant GBM.
Further Reading: Bernstein, Oncology: The Essentials, 3rd malignant gliomas.
What is the most likely diagnosis?
A. Glioblastoma
B. Meningioma
C. Metastasis
D. Low-grade glioma
A. Glioblastoma
B. Meningioma
C. Metastasis
D. Low-grade glioma
This MRI demonstrates a classic appearance of a meningioma with associated dural tails.
Further Reading: Bernstein, Oncology: The Essentials, 3rd meningiomas.
If final pathology of the image below comes back as chordoid type, what WHO grade is the lesion?
A. WHO grade I
B. WHO grade II
C. WHO grade III
D. WHO grade IV
A. WHO grade I
B. WHO grade II
C. WHO grade III
D. WHO grade IV
This MRI demonstrates a classic appearance of a meningioma with associated dural tails. If pathology determined this to be chordoid type, it would make it an atypical, or WHO grade II lesion.
Further Reading: Bernstein, Oncology: The Essentials, 3rd meningiomas.
What is the most likely diagnosis?
A. Glioblastoma
B. Metastasis
C. Hemangiopericytoma
D. Fibrous dysplasia
A. Glioblastoma
B. Metastasis
C.Hemangiopericytoma
D. Fibrous dysplasia
Hemangiopericytoma This MRI demonstrates an invasive lesion that appears to be associated with the meninges. It has a look of a meningioma, but in this case was a hemangiopericytoma. When these tumors are based in the meninges, they can closely resemble meningiomas, but may appear much more vascular and may have more associated cerebral edema.
Further Reading: Bernstein, Berger. NeuroOncology: The Essentials, 3rd edition, 2015, intraventricular tumors.
Where are the lesions pictured below most often located within the brain?
A. Cortical surface
B. Gray–white matter junction
C. White matter
D. Ependymal lining
A. Cortical surface
B. Gray–white matter junction
C. White matter
D. Ependymal lining
This MRI demonstrates evidence of multiple metastatic lesions. These lesions most often are located at the gray–white matter junction as this is the level of the small capillaries that tend to filter out cells as they metastasize.
Further Reading: Bernstein, Berger. NeuroOncology: The Essentials, 3rd edition, 2015, metastatic brain tumors.
This MRI demonstrates a metastatic lesion with edema. What is the most likely primary source?
A. Skin
B. Lung
C. Breast
D. Colon
A. Skin
B. Lung
C. Breast
D. Colon
This MRI demonstrates a cerebral metastasis with significant edema and a fluid–fluid level within the mass suggestive of hemorrhage. The hemorrhagic nature of this mass makes it most likely to be melanoma out of the choices listed above. Renal cell metastases are also known to hemorrhage.
Further Reading: Bernstein, Berger. NeuroOncology: The Essentials, 3rd edition, 2015, metastatic brain tumors.
What chromosomal abnormality does the patient with the MRI findings below most likely have?
A. 3
B. 7
C. 17
D. 22
A. 3
B. 7
C. 17
D. 22
This MRI demonstrates bilateral vestibular schwannomas. This is very common in patients with NF2, caused by a chromosomal abnormality on chromosome 22.
Further Reading: Bernstein, Berger. NeuroOncology: The Essentials, 3rd edition, 2015, vestibular schwannomas.
What is the most likely diagnosis?
A. Vestibular schwannoma
B. Epidermoid cyst
C. Petrous meningioma
D. Ependymoma
A. Vestibular schwannoma
B. Epidermoid cyst
C. Petrous meningioma
D. Ependymoma
This diffusion-weighted MRI demonstrates a cerebellopontine (CP) angle mass that is bright on diffusion images. This finding is consistent with an epidermoid cyst of the CP angle. The diffusion scans are important to evaluate with CP angle masses to rule out epidermoid cysts, as they are the mass in this region that are bright on diffusion.
Further Reading: Bernstein, Berger. NeuroOncology: The Essentials, 3rd edition, 2015, skull base meningiomas and other tumors.
A 45-year-old man presents with headaches and persistent nausea prompting an MRI pictured below. What is the most likely diagnosis?
A. Vestibular schwannoma
B. Epidermoid cyst
C. Subependymoma
D. Ependymoma
A. Vestibular schwannoma
B. Epidermoid cyst
C. Subependymoma
D. Ependymoma
This gadolinium-enhanced MRI demonstrates an expansile mass with heterogenous enhancement within the fourth ventricle. It also extends laterally through the foramen of Luschka. This, along with the history of nausea at presentation, makes ependymoma the most likely diagnosis. Ependymomas are known to extend laterally, enhance, and cause nausea at presentation. There is also an association between these tumors and NF2.
Further Reading: Bernstein, Berger. NeuroOncology: The Essentials, 3rd edition, 2015, pediatric posterior fossa tumors.
A 45-year-old man presents with headaches and persistent nausea prompting an MRI pictured below. What foramen is this tumor extending through?
A. Magendie
B. Luschka
C. Magnum
D. Lacerum
A. Magendie
B. Luschka
C. Magnum
D. Lacerum
This gadolinium-enhanced MRI demonstrates an expansile mass with heterogenous enhancement within the fourth ventricle. It also extends laterally through the foramen of Luschka. This, along with the history of nausea at presentation, makes ependymoma the most likely diagnosis. Ependymomas are known to extend laterally, enhance, and cause nausea at presentation. There is also an association between these tumors and NF2.
Further Reading: Bernstein, Berger. NeuroOncology: The Essentials, 3rd edition, 2015, pediatric posterior fossa tumors.
A 52-year-old woman presents with persistent headaches prompting an MRI pictured below. What is the most likely diagnosis?
A. Ependymoma
B. Subependymoma
C. Vestibular schwannoma
D. Medulloblastoma
A. Ependymoma
B. Subependymoma
C. Vestibular schwannoma
D. Medulloblastoma
This gadolinium-enhanced MRI demonstrates a mass within the fourth ventricle that does not enhance. This is a classic picture for a subependymoma. While ependymomas can also present in the fourth ventricle, they generally have a heterogenous enhancement pattern.
Further Reading: Bernstein, Berger. NeuroOncology: The Essentials, 3rd edition, 2015, intraventricular tumors.
A 52-year-old woman presents with a severe headache that resolves. An MRI is obtained and is shown below. What is the most likely diagnosis?
A. Ependymoma
B. Subependymoma
C. Vestibular schwannoma
D. PICA aneurysm
A. Ependymoma
B. Subependymoma
C. Vestibular schwannoma
D. PICA aneurysm
This T2 sequence axial MRI demonstrates a large mass in the posterior fossa. There is T2 hypointensity within the mass in a somewhat layered form. Given the location and the appearance on T2, this should be concerning for a posterior fossa aneurysm.
Further Reading: Spetzler, Kalani, Nakaji. Neurovascular Surgery, 2nd edition, 2015, surgical therapies for vertebral artery and posterior inferior cerebellar artery aneurysms.
A 28-year-old man has sudden onset of dysarthria and a left sixth nerve palsy. MRI is shown below. What is the most likely diagnosis?
A. Dural arteriovenous fistula
B. Arteriovenous malformation
C. Cavernous malformation
D. Aneurysm
A. Dural arteriovenous fistula
B. Arteriovenous malformation
C. Cavernous malformation
D. Aneurysm
These MRI sequences demonstrate a mass within the brainstem consistent with a cavernous malformation. Cavernomas often appear very dark on gradient-echo (GRE) sequences owing to bleeding events.
Further Reading: Spetzler, Kalani, Nakaji. Neurovascular Surgery, 2nd edition, 2015, cavernous malformations: natural history, epidemiology, presentation, and treatment options.
A patient is set to undergo a Wada test to determine language dominance. Before the procedure commences, a standard angiogram is performed. In this lateral DSA of the internal carotid artery, what is demonstrated?
A. PICA aneurysm
B. Dural arteriovenous malformation
C. Fetal posterior cerebral artery
D. Persistent trigeminal artery
A. PICA aneurysm
B. Dural arteriovenous malformation
C. Fetal posterior cerebral artery
**D. Persistent trigeminal artery
**
This lateral DSA of the ICA demonstrates filling of both the ICA and posterior circulation simultaneously. There is a persistent trigeminal artery connecting the ICA to the basilar artery. It is the most common persistent connection between the ICA and basilar systems. A fetal PCA would be an enlarged posterior communicating artery with an absent ipsilateral P1 segment.
Further Reading: Spetzler, Kalani, Nakaji. Neurovascular Surgery, 2nd edition, 2015, cranial vascular anatomy of the posterior circulation.
A 54-year-old woman has an abnormality discovered on routine MRI and undergoes a formal cerebral angiogram, which is pictured below. What type of aneurysm is this?
A. Posterior communicating artery aneurysm
B. Carotid-ophthalmic aneurysm
C. Superior hypophyseal aneurysm
D. Cavernous sinus aneurysm
A. Posterior communicating artery aneurysm
B. Carotid-ophthalmic aneurysm
C. Superior hypophyseal aneurysm
D. Cavernous sinus aneurysm
This DSA of the ICA demonstrates an aneurysm of the ophthalmic segment of the ICA. It is superiorly projecting, which makes it most likely a carotid ophthalmic aneurysm. Superior hypophyseal aneurysms can arise in the same location, but tend to project inferomedially rather than superolaterally.
Further Reading: Spetzler, Kalani, Nakaji. Neurovascular Surgery, 2nd edition, 2015, endovascular treatment of carotid-ophthalmic aneurysms.
Where is this aneurysm located?
A. Intracranial/intradural
B. Intracranial/extradural
C. Extracranial/intradural
D. Extracranial/extradural
A. Intracranial/intradural
B. Intracranial/extradural
C. Extracranial/intradural
D. Extracranial/extradural
This angiogram of the ICA demonstrates a petrous/cavernous segment fusiform aneurysm, making it intracranial, but extradural. This makes these aneurysms much more stable and in some cases, they do not require treatment (mainly for stable cavernous segment aneurysms). When they rupture, a direct/indirect CC fistula can occur and patients can present with paralysis of the eye, as well as chemosis, proptosis, and venous congestion on the ipsilateral eye.
Further Reading: Spetzler, Kalani, Nakaji. Neurovascular Surgery, 2nd edition, 2015, endovascular therapies for aneurysms of the internal carotid artery.
What structure is demonstrated (arrows, not arrowheads) in this angiogram in a patient with a sagittal sinus thrombosis?
A. Anastomotic vein of Trolard
B. Anastomotic vein of Labb
C. Vein of Galen
D. Petrosal sinus
A. Anastomotic vein of Trolard
B. Anastomotic vein of Labbé
C. Vein of Galen
D. Petrosal sinus
The arrows in this magnetic resonance venography (MRV) are demonstrating the inferior anastomotic vein (of Labbé). It is an important structure as damage the vein of Labbé can lead to venous infarction of the temporal lobe.
Further Reading: Spetzler, Kalani, Nakaji. Neurovascular Surgery, 2nd edition, 2015, cranial venous anatomy.
What characteristic macroadenoma?
A. Encirclement of the carotid
B. Optic nerve compression
C. Size greater than 1 cm
D. Size greater than 2.0 cm
A. Encirclement of the carotid
B. Optic nerve compression
C. Size greater than 10 cm
D. Size greater than 2.0 cm
This coronal MRI demonstrates a pituitary macroadenoma given that the size of the adenoma is greater than 1.0 cm.
Further Reading: Schwartz, Anand. Endoscopic Pituitary Surgery, 2012, radiographic evaluation of pituitary tumors.
What is the most likely diagnosis?
A. Pituitary macroadenoma
B. Craniopharyngioma
C. Tuberculum meningioma
D. Chordoma
A. Pituitary macroadenoma
B. Craniopharyngioma
C. Tuberculum meningioma
D. Chordoma
This enhanced MRI demonstrates a suprasellar mass. It is most consistent with a tuberculum meningioma due to the dural tail.
Further Reading: Di Ieva, Lee, Cusimano. Handbook of Skull Base Surgery, 2016, endoscopic transsphenoidal approaches.
An 8-year-old boy is developing slowly progressive visual loss prompting an MRI shown below. What condition is this mass associated with?
A. NF1
B. NF2
C. Tuberous sclerosis
D. Cowden’s syndrome
A. NF1
B. NF2
C. Tuberous sclerosis
D. Cowden’s syndrome
This MRI demonstrates enlargement of the optic nerve in a pediatric patient consistent with an optic pathway glioma. These tumors are highly associated with neurofibromatosis type 1 (NF1).
Further Reading: Bernstein, Berger. Neuro-Oncology: The Essentials, 3rd edition, 2015, pediatric supratentorial tumors.
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
A. 17
B. 22
C. 9
D. 3
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.
What structure does number demonstrate?
A. Septum pellucidum
B. Basal vein of Rosenthal
C. Choroid plexus
D. Internal cerebral veins
A. Septum pellucidum
B. Basal vein of Rosenthal
C. Choroid plexus
D. Internal cerebral veins
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.
What structure does number 18 in this coronal, T2-weighted MRI demonstrate?
A. Limen insulae
B. Amygdala
C. Diagonal band of Broca
D. Hippocampus
A. Limen insulae
B. Amygdala
C. Diagonal band of Broca
D. Hippocampus
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.
A 65-year-old man has sudden onset of headache and starts having difficulty controlling generalized tonic–clonic seizures in the emergency department. Ultimately, he requires intubation for seizure control. MRI is shown below; what is the most likely diagnosis?
A. Aneurysmal subarachnoid hemorrhage
B. Metastatic tumor
C. Posterior reversible encephalopathy syndrome
D. Multiple system atrophy
A. Aneurysmal subarachnoid hemorrhage
B. Metastatic tumor
C. Posterior reversible encephalopathy syndrome
D. Multiple system atrophy
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.
A 62-year-old man has sudden onset of headache and starts having difficulty controlling generalized tonic–clonic seizures in the emergency department. Ultimately, he requires intubation for seizure control. MRI is shown below; what is the next best step?
A. Start acyclovir
B. Start barbiturates
C. Check blood sugar
D. Arrange for needle biopsy
A. Start acyclovir
B. Start barbiturates
C. Check blood sugar
D. Arrange for needle biopsy
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.
You are seeing a 35-year-old man with difficulty controlling seizures. The MRI scan is demonstrated below. What is the most likely diagnosis?
A. Metastases
B. Neurocysticercosis
C. Familial cavernomatosis
D. Gliomatosis cerebri
A. Metastases
B. Neurocysticercosis
C. Familial cavernomatosis
D. Gliomatosis cerebri
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.
You are asked to evaluate a 2-month-old infant who has been found to have hydrocephalus and altered mental status. Head CT is demonstrated below. What is the most likely diagnosis?
A. Aqueductal stenosis
B. Cytomegalovirus (CMV) encephalitis
C. Germinal matrix hemorrhage
D. Vein of Galen malformation
A. Aqueductal stenosis
B. Cytomegalovirus (CMV) encephalitis
C. Germinal matrix hemorrhage
D. Vein of Galen malformation
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.
You are evaluating a 46-year-old woman with a history of headaches and intermittent clumsiness of the left hand that resolves completely several weeks after onset. MRI is
demonstrated below. What is the most likely diagnosis?
A. Multiple sclerosis
B. CNS lymphoma
C. Metastases
D. Gliomatosis cerebri
A. Multiple sclerosis
B. CNS lymphoma
C. Metastases
D. Gliomatosis cerebri
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.
You are evaluating a 37-year-old woman with a history of headaches and intermittent neurologic deficits that seem to resolve completely over time. Now she is in the emergency department with a GCS of 12 (E3, V4, M5). MRI is demonstrated below. What is the most likely diagnosis?
A. Balo’s concentric sclerosis
B. CNS lymphoma
C. Tumefactive multiple sclerosis
D. Glioblastoma
A. Balo’s concentric sclerosis
B. CNS lymphoma
C. Tumefactive multiple sclerosis
D. Glioblastoma
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.
The syndrome that causes the findings on this MRI is due to abnormality in what cellular process?
A. Very long chain fatty acid synthesis
B. Glucocerebrosidase deficiency
C. Isocitrate dehydrogenase deficiency
D. Glycogen storage
A. Very long chain fatty acid synthesis
B. Glucocerebrosidase deficiency
C. Isocitrate dehydrogenase deficiency
D. Glycogen storage
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.
You are evaluating a 35-year-old homeless man who reports intravenous (IV) drug use who has developed persistent headaches. An abnormality is seen on CT; findings are shown below. What is the most likely diagnosis?
A. Metastasis
B. Cerebral abscess
C. Glioblastoma
D. Meningioma
A. Metastasis
B. Cerebral abscess
C. Glioblastoma
D. Meningioma
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.
You are evaluating a 35-year-old homeless man who has developed persistent headaches. An abnormality is seen on CT scan prompting an MRI; findings are shown below. If the diagnosis of a cerebral abscess is confirmed, what would be the most likely isolate?
A. Streptococcus milleri
B. Listeria monocytogenes
C. Staphylococcus aureus
D. Klebsiella pneumoniae
A. Streptococcus milleri
B. Listeria monocytogenes
C. Staphylococcus aureus
D. Klebsiella pneumoniae
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.
A 26-year-old woman is 6 months postpartum and is found to be in diabetes insipidus by her primary care provider. An MRI is obtained and is demonstrated below. What is the most likely diagnosis?
A. Pituitary macroadenoma
B. Craniopharyngioma
C. Pituitary apoplexy
D. Lymphocytic hypophysitis
A. Pituitary macroadenoma
B. Craniopharyngioma
C. Pituitary apoplexy
D. Lymphocytic hypophysitis
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.
A 26-year-old woman is 3 days post vaginal delivery that was complicated by uterine hemorrhage resulting in approximately 2 L of blood loss. On postpartum day 3, her blood pressure suddenly increases due to pain while walking and she experiences onset of headaches and visual disturbances. An MRI is demonstrated below. What should be your next step?
A. Emergent pituitary decompression
B. Obtain MRI
C. Check sodium
D. Give hydrocortisone
A. Emergent pituitary decompression
B. Obtain MRI
C. Check sodium
D. Give hydrocortisone
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.
A 67-year-old man has onset of right facial droop, tongue deviation to the left, and some dysmetria on finger–nose–finger testing. Postcontrast MRI is demonstrated below. What is the most likely diagnosis?
A. CNS lymphoma
B. Leptomeningeal carcinomatosis
C. Neurosarcoidosis
D. Acute disseminated encephalomyelitis
A. CNS lymphoma
B. Leptomeningeal carcinomatosis
C. Neurosarcoidosis
D. Acute disseminated encephalomyelitis
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.
Which neurotransmitter does the structure identified by number 2 in this coronal MRI use?
A. Acetylcholine
B. Dopamine
C. Norepinephrine
D. Serotonin
A. Acetylcholine
B. Dopamine
C. Norepinephrine
D. Serotonin
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.
An 80-year-old man has started to develop changes in personality and socially disruptive behavior. More recently, his language has been affected. MRI is demonstrated below. What is the most likely diagnosis?
A. Corticobasal degeneration
B. Parkinson’s disease
C. Frontotemporal dementia
D. Alzheimer’s disease
A. Corticobasal degeneration
B. Parkinson’s disease
C. Frontotemporal dementia
D. Alzheimer’s disease
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.
A 42-year-old woman has the MRI shown below. What is the most likely presentation?
A. Ipsilateral hemiparesis and 2-point discrimination loss, contralateral pain/temperature loss
B. Circumferential weakness
C. Bowel/bladder incontinence
D. Bilateral lower extremity paresthesias
A. Ipsilateral hemiparesis and 2-point discrimination loss, contralateral pain/temperature loss
B. Circumferential weakness
C. Bowel/bladder incontinence
D. Bilateral lower extremity paresthesias
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.
A 56-year-old man has noticed the onset of bilateral lower extremity weakness that has been slowly progressive. MRI is shown below. What is the most likely diagnosis?
A. Ependymoma
B. Spinal cord astrocytoma
C. Meningioma
D. Hemangioblastoma
A. Ependymoma
B. Spinal cord astrocytoma
C. Meningioma
D. Hemangioblastoma
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.
A 23-year-old man has been developing proximal lower extremity weakness and sensory loss in bilateral upper extremities in a capelike distribution. MRI findings are below. What condition is this mass associated with?
A. NF1
B. NF2
C. Tuberous sclerosis
D. Li–Fraumeni syndrome
A. NF1
B. NF2
C. Tuberous sclerosis
D. Li–Fraumeni syndrome
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.
What is the most likely diagnosis based on the MRI shown?
A. Spinal cord astrocytoma
B. Meningioma
C. Myxopapillary ependymoma
D. Hemangioblastoma
A. Spinal cord astrocytoma
B. Meningioma
C. Myxopapillary ependymoma
D. Hemangioblastoma
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.
A 23-year-old man has been developing proximal lower extremity weakness and sensory loss in bilateral upper extremities in a capelike distribution. MRI findings are below. What condition is this mass is associated with?
A. NF1
B. NF2
C. Tuberous sclerosis
D. Li–Fraumeni syndrome
A. NF1
B. NF2
C. Tuberous sclerosis
D. Li–Fraumeni syndrome
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.
What is the most likely diagnosis based on the MRI demonstrated below?
A. Ependymoma
B. Astrocytoma
C. Metastasis
D. Meningioma
A. Ependymoma
B. Astrocytoma
C. Metastasis
D. Meningioma
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.
A 14-year-old adolescent girl has severe low back pain that is most severe at night. CT scan of L5 is below. What is the most likely diagnosis?
A. Hemangioma
B. Aneurysmal bone cyst
C. Metastatic lesion
D. Osteoid osteoma
A. Hemangioma
B. Aneurysmal bone cyst
C. Metastatic lesion
D. Osteoid osteoma
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.
A 33-year-old woman has a trauma spine CT after she was involved in a motor vehicle accident. The axial slice through T10 is shown below. What is the most likely diagnosis?
A. Hemangioma
B. Burst fracture
C. Metastatic lesion
D. Osteoid osteoma
A. Hemangioma
B. Burst fracture
C. Metastatic lesion
D. Osteoid osteoma
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.
A 16-year-old adolescent girl has the onset of persistent back pain. MRI is demonstrated below. What is the most likely diagnosis?
A. Hemangioma
B. Aneurysmal bone cyst
C. Metastatic lesion
D. Osteoid osteoma
A. Hemangioma
B. Aneurysmal bone cyst
C. Metastatic lesion
D. Osteoid osteoma
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.
A 33-year-old woman has had the onset of urinary and fecal incontinence. Imaging is demonstrated below. What is the most likely diagnosis?
A. Chordoma
B. Aneurysmal bone cyst
C. Lipomyelomeningocele
D. Metastasis
A. Chordoma
B. Aneurysmal bone cyst
C. Lipomyelomeningocele
D. Metastasis
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.
A 33-year-old woman has had the onset of urinary and fecal incontinence. Imaging is demonstrated below. What is the most likely finding on hisc specimen?
A. Rosenthal fibers
B. Physaliphorous cells
C. Eosinophilic intranuclear inclusion bodies
D. Homer Wright rosettes
A. Rosenthal fibers
B. Physaliphorous cells
C. Eosinophilic intranuclear inclusion bodies
D. Homer Wright rosettes
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.
An 82-year-old man notices the onset of severe, aching back and leg pain when he is upright and walking, relieved by leaning forward on a counter. MRI is shown below. The stenosis at the level with the yellow arrow is caused by a bulging disc and what structure?Use the following figure to answer questions 64 and 65:
A. Posterior longitudinal ligament
B. Anterior longitudinal ligament
C. Ligamentum flavum
D. Spinous process
A. Posterior longitudinal ligament
B. Anterior longitudinal ligament
C. Ligamentum flavum
D. Spinous process
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.
An 82-year-old man notices the onset of severe, aching back and leg pain when he is upright and walking, relieved by leaning forward on a counter. MRI is shown in Question 64. What extracellular structure is the posterior element causing compression mainly comprised of?
A. Type I collagen
B. Type II collagen
C. Elastin
D. Laminin
A. Type I collagen
B. Type II collagen
C. Elastin
D. Laminin
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.
A 54-year-old woman has the onset of right leg pain that has been persistent despite physical therapy. MRI is shown below. What nerve root is most likely involved?Use the following figure to answer questions 66 and 67:
A. Right L4
B. Left L4
C. Right L5
D. Left L5
A. Right L4
B. Left L4
C. Right L5
D. Left L5
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.
A 54-year-old woman has the onset of right leg pain that has been persistent despite physical therapy. MRI is shown in Question 66. If she were to develop weakness, what would you expect to see on examination?
A. Right quadriceps weakness
B. Right hip adduction weakness
C. Right extensor hallucis longus weakness
D. Right gastrocnemius weakness
A. Right quadriceps weakness
B. Right hip adduction weakness
C. Right extensor hallucis longus weakness
D. Right gastrocnemius weakness
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.
A 54-year-old man has the onset of right leg pain that has been persistent despite physical therapy. Imaging of the L3-4 region is demonstrated. If he were to have weakness on presentation, what would you expect to see?Use the following figure to answer questions 68 and 69:
A. Right iliopsoas weakness
B. Right quadriceps weakness
C. Right extensor hallucis longus weakness
D. Right gastrocnemius weakness
A. Right iliopsoas weakness
B. Right quadriceps weakness
C. Right extensor hallucis longus weakness
D. Right gastrocnemius weakness
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.
A 54-year-old man has the onset of right leg pain that has been persistent despite physical therapy. Imaging of the L3-4 space is shown in Question 68. What nerve root is compressed?
A. Right L3
B. Left L4
C. Right L5
D. Left L5
A. Right L3
B. Left L4
C. Right L5
D. Left L5
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.
A 68-year-old man has the onset of severe, bilateral lower extremity pain that is persistent despite physical therapy. MRI is shown below. What is the most likely diagnosis?
A. Lumbar spondyloptosis
B. Lumbar spondylolisthesis
C. Lumbar burst fracture
D. Chance fracture
A. Lumbar spondyloptosis
B. Lumbar spondylolisthesis
C. Lumbar burst fracture
D. Chance fracture
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.
An 88-year-old man has the onset of severe, bilateral lower extremity pain that is persistent despite physical therapy. X-ray is shown below. What other imaging modality should be considered prior to offering a procedure?
A. 36-inch-long cassette X-rays
B. Lumbar spine MRI
C. Lumbar CT scan
D. CT myelogram
A. 36-inch-long cassette X-rays
B. Lumbar spine MRI
C. Lumbar CT scan
D. CT myelogram
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.
What is the diagnosis?
A. Spondylosis
B. Spondylolisthesis
C. Spondyloptosis
D. Spondylolysis
A. Spondylosis
B. Spondylolisthesis
C. Spondyloptosis
D. Spondylolysis
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.
A 44-year-old woman had been experiencing the onset of transient tetraparesis, and imaging demonstrated a mass. Ultimately she underwent decompression and fusion with resolution of the mass pictured below. Laxity of what may be contributing to her transient weakness?
A. Anterior longitudinal ligament
B. Transverse ligament
C. Apical ligament
D. Ligamentum nuchae
A. Anterior longitudinal ligament
B. Transverse ligament
C. Apical ligament
D. Ligamentum nuchae
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.
You are evaluating a 65-year-old man from Japan who has symptoms of cervical myelopathy. MRI is demonstrated below. What would be the next best step?
A. Anterior cervical diskectomy and fusion
B. CT scan of the cervical spine
C. EMG
D. Physical therapy
A. Anterior cervical diskectomy and fusion
B. CT scan of the cervical spine
C. EMG
D. Physical therapy
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.
What is the diagnosis?
A. Ossification of the posterior longitudinal ligament
B. Diffuse idiopathic skeletal hyperostosis
C. Ankylosing spondylitis
D. Klippel–Feil syndrome
**A. Ossification of the posterior longitudinal **
ligament
B. Diffuse idiopathic skeletal hyperostosis
C. Ankylosing spondylitis
D. Klippel–Feil syndrome
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.
You are evaluating a 45-year-old woman with the onset of neck and right arm pain. Axial MRI scan is demonstrated below. What nerve root is compressed?
A. Right C6
B. Left C6
C. Right C7
D. Left C7
A. Right C6
B. Left C6
C. Right C7
D. Left C7
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.
You are evaluating a 45-year-old woman with the onset of neck and right arm pain. MRI scan is demonstrated in Question 78. Where would you expect the patient to have sensory symptoms?
A. Right shoulder
B. Right thumb
C. Right middle finger
D. Right fifth digit
A. Right shoulder
B. Right thumb
C. Right middle finger
D. Right fifth digit
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.
You are evaluating a 55-year-old woman with the onset of back pain worsened by being upright and walking. MRI is shown below. What is the most likely diagnosis?
A. Myxopapillary ependymoma
B. Synovial cyst
C. Epidural lipomatosis
D. Spinal stenosis
A. Myxopapillary ependymoma
B. Synovial cyst
C. Epidural lipomatosis
D. Spinal stenosis
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.
You are evaluating a 55-year-old woman with the onset of left leg pain worsened by being upright and walking. MRI is shown below. What is the most likely diagnosis?
A. Herniated disk
B. Synovial cyst
C. Epidural lipomatosis
D. Spinal stenosis
A. Herniated disk
B. Synovial cyst
C. Epidural lipomatosis
D. Spinal stenosis
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.
A 42-year-old woman has the onset of progressive proximal leg weakness, hand incoordination, and urinary incontinence. MRI is shown below. What is the most likely diagnosis?
A. Ependymoma
B. Spinal dural arteriovenous fistula
C. Spinal arteriovenous malformation
D. Spinal astrocytoma
A. Ependymoma
B. Spinal dural arteriovenous fistula
C. Spinal arteriovenous malformation
D. Spinal astrocytoma
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.
A 42-year-old woman has the onset of progressive proximal leg weakness, hand incoordination, and urinary incontinence. MRI is shown below. What is the next best step?
A. Flexion/extension X-rays
B. Cervical spine CT
C. Conventional angiogram
D. Gadolinium-enhanced MRI
A. Flexion/extension X-rays
B. Cervical spine CT
C. Conventional angiogram
D. Gadolinium-enhanced MRI
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.
A 42-year-old woman has the onset of progressive lower extremity weakness and urinary incontinence. MRI is shown below. What is the next best step?
A. Flexion/extension X-rays
B. Cervical spine CT
C. Conventional angiogram
D. Gadolinium-enhanced MRI
A. Flexion/extension X-rays
B. Lumbar spine CT
C. Conventional angiogram
D. Gadolinium-enhanced MRI
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.
A 42-year-old woman has the onset of progressive lower extremity weakness and urinary incontinence. MRI is shown below. What is the most likely diagnosis?
A. Spinal cavernous malformation
B. Spinal dural arteriovenous fistula
C. Spinal cord infarction
D. Spinal hemangioblastoma
A. Spinal cavernous malformation
B. Spinal dural arteriovenous fistula
C. Spinal cord infarction
D. Spinal hemangioblastoma
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.
A 75-year-old man underwent a complex spinal fusion procedure 3 months ago. He initially had improvement in his back pain, but over the last 24 hours his pain has returned. X-rays are demonstrated below. What is the most likely diagnosis?
A. CSF leak
B. Hardware failure
C. Junctional kyphosis
D. Adjacent segment disease
A. CSF leak
B. Hardware failure
C. Junctional kyphosis
D. Adjacent segment disease
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.
What is likely to be present in this patient?
A. Improved NDI score
B. Pseudoarthrosis
C. Complete bony fusion
D. Deltoid weakness
E. Triceps weakness
A. Improved NDI score
B. Pseudoarthrosis
C. Complete bony fusion
D. Deltoid weakness
E. Triceps weakness
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.
A 75-year-old man sustains a fall and a head injury. You are covering spine call and are asked to comment on his cervical spine imaging. What is the most likely diagnosis?
A. Ankylosing spondylitis
B. Diffuse idiopathic hyperostosis
C. Osteochondroma
D. Chordoma
A. Ankylosing spondylitis
B. Diffuse idiopathic hyperostosis
C. Osteochondroma
D. Chordoma
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.
A 75-year-old man sustains a fall and a head injury. You are covering spine call and are asked to comment on his cervical spine CT. With what human leukocyte antigen is this condition associated?
A. HLA-DR2
B. HLA-DR3
C. HLA-B27
D. HLA-B47
A. HLA-DR2
B. HLA-DR3
C. HLA-B27
D. HLA-B47
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.
An 88-year-old man is involved in a motor vehicle accident and undergoes a trauma evaluation of his spine. The CT scan is below. With what human leukocyte antigen is this condition associated?
A. HLA-DR2
B. HLA-DR3
C. HLA-B27
D. HLA-B47
A. HLA-DR2
B. HLA-DR3
C. HLA-B27
D. HLA-B47
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.
An 88-year-old man is involved in a motor vehicle accident and undergoes a trauma evaluation of his spine. The CT scan is shown in Question 91. What is the most likely diagnosis?
A. Ankylosing spondylitis
B. Diffuse idiopathic skeletal hyperostosis
C. Osteochondroma
D. In situ surgical fusion
A. Ankylosing spondylitis
B. Diffuse idiopathic skeletal hyperostosis
C. Osteochondroma
D. In situ surgical fusion
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.
What is the most likely diagnosis based on this lateral spine X-ray?
A. Ankylosing spondylitis
B. Diffuse idiopathic skeletal hyperostosis
C. Osteochondroma
D. In situ surgical fusion
A. Ankylosing spondylitis
B. Diffuse idiopathic skeletal hyperostosis
C. Osteochondroma
D. In situ surgical fusion
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.
A 54-year-old woman with no history of neurologic disease has the sudden onset of paraplegia and urinary incontinence over the last 24 hours. MRI is demonstrated below. What is the most likely diagnosis?
A. Spinal cord astrocytoma
B. Cauda equine syndrome
C. Congenital cervical stenosis
D. Transverse myelitis
A. Spinal cord astrocytoma
B. Cauda equine syndrome
C. Congenital cervical stenosis
D. Transverse myelitis
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.
A 28-year-old man with a history of intravenous drug use develops the onset of back pain that is unremitting. MRI scan is demonstrated below. What is the most likely diagnosis?
A. Osteochondroma
B. Spinal hemangioma
C. Diskitis/osteomyelitis
D. Vertebral metastasis
A. Osteochondroma
B. Spinal hemangioma
C. Diskitis/osteomyelitis
D. Vertebral metastasis
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.
A 28-year-old man with a history of intravenous drug use develops the onset of back pain that is unremitting. MRI scan is demonstrated in Question 95. What is the most likely pathogen?
A. Streptococcus milleri
B. Staphylococcus aureus
C. Staphylococcus epidermidis
D. Enterococcus
A. Streptococcus milleri
B. Staphylococcus aureus
C. Staphylococcus epidermidis
D. Enterococcus
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.
A 44-year-old man presents with back pain. X-ray and CT are demonstrated below. What is the most likely diagnosis?
A. Ankylosing spondylitis
B. Paget’s disease of bone
C. Diffuse idiopathic skeletal hyperostosis
D. Osteoporosis
A. Ankylosing spondylitis
B. Paget’s disease of bone
C. Diffuse idiopathic skeletal hyperostosis
D. Osteoporosis
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.
A 44-year-old man presents with back pain. X-ray is demonstrated in Question 97. What blood test should you order?
A. Serum alkaline phosphatase
B. Serum calcium
C. Serum phosphorous
D. Vitamin B12
A. Serum alkaline phosphatase
B. Serum calcium
C. Serum phosphorous
D. Vitamin B12
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.
What is the most likely diagnosis?
A. Scheuermann’s nodes
B. Schmorl’s nodes
C. Spinal stenosis
D. Synovial cyst
A. Scheuermann’s nodes
B. Schmorl’s nodes
C. Spinal stenosis
D. Synovial cyst
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.
This X-ray is performed on a 15-year-old adolescent girl with a deformity discovered during school screening. What is the most likely diagnosis?
A. Scheuermann’s disease
B. Schmorl’s nodes
C. Junctional kyphosis
D. Dystonia
A. Scheuermann’s disease
B. Schmorl’s nodes
C. Junctional kyphosis
D. Dystonia
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.
