RD 2020

Question 1

9 YO with abdo pain, distant past hx of neuroblastoma (stage 3 at age 3), follow up USS showing multiple hypoechoic liver lesions (1-4cm), was normal USS 3 years ago

a. Mets

b. Adenoma

c. Biliary hamartoma

d. Haemangioma

e. FNH

Answer 1

Mets

Stage 3
- Cannot be surgically removed +/- regional lymph nodes. No distant mets.
- If >1 year of age: 50% 3-year survival

Question 2

Female child with horseshoe kidney, was born with puffy hands and feet. What syndrome?

a. T21

b. Turners

c. Edwards

d. Noonans

Answer 2

Turners syndrome

Note: Horseshoe kidney also associated with other chromosomal abnormalities (T21, T18 aka Edwards, T13 aka Patau) and syndromes (e.g. VACTERL). Not associated with Noonans.

fetal hydrops/anasarca

Question 3

6yo with lateral condyle fracture. What Salter Harris?

a. 1

b. 2

c. 3

d. 4

e. 5

Answer 3

Most are Salter Harris 4

SCS: says this in orthobullets.
Second most common elbow fracture in peds after supracondylar #

Question 4

50ish man presenting with fever and RUQ pain, 6 months post AP resection. Thick walled irregular 6cm hypoechoic liver mass

a. Amoebiasis

b. Hydatid

c. Pyogenic abscess

d. Metastasis

e. Candidiasis

Answer 4

Pyogenic abscess

Question 5

Old lady 6cm cystic pancreatic lesion, contains x2 cystic lesions, 3cm each. No central or peripheral calc

a. Microcystic serous

b. Macrocystic serous

c. IPMN

d. Mucinous

e. SPEN

Answer 5

RY* Favour Mucinous despite age:
Mucinous tends to be ‘Mother lesion’, but can occur in elderly, overall less common than serous, but typical appearance is a encapsulated/thick walled uni or multilocular cyst (2-6 large internal cysts, usually >2cm), sometimes with peripheral calcification +/- enhancing nodule (nodule concerning for carcinoma version).
As per statdx “Macrocystic, oligocystic, and unilocular variants of serous cystadenoma difficult to distinguish from MCN although thick wall and mural nodularity unusual with serous cystadenoma”. They make up approx 20% of all serous tumours.
ESG- with the current info and answer choices I would choose macrocystic SCA, although can look the same as MCN I think the fact it is included as an choice is enough for gamesmanship purposes, compared to not specifying macrocystic and just giving “serous cystadenoma” as a choice.

Question 6

Coronary artery dominance, origin

a. Diagonal

b. Posterior descending

c. Ramus intermedius

d. Conus

e. Obtuse margina

Answer 6

Posterior descending

Question 7

60yo lady ran a marathon. Normal CXR. Left pleuritic chest pain. V/Q scan low probability. Next step?

a. Send home

b. CTPA

c. US scan lower limbs

Answer 7

*RY - With new modified PIOPED 2 criteria, low probability fits into the ‘non-diagnostic’ category, so likely to do CTPA if still concerned.

If the stem said “very low” probability (= normal), then send home

Question 8

Mandibular lesion. Cystic with tooth-like structure. Displacing other roots. Most likely:

a. Dentigerous

b. Ondontoma

c. Ameloblastoma

d. KCOT

Answer 8

Odontoma, based on the wording of “tooth-like structure”, compared to dentigerous cyst which surrounds the tooth crown and tends to displace teeth. Statdx: compound odontoma = Small, tooth-like structures surrounded by radiolucent (low-density) rim.

Additional:
Odontoma: hamartoma, usually scerlotic with lucent rim.
Dentigerous cysts: associated with crown of unerupted tooth, usually unilocular with thin sclerotic border, tends to displace other teeth.
KCOT: Tend to occur at mandibular ramus, daughter cysts classic (but can be unilocular), minimally expansile, can be associated with teeth but not the crown, displacement or re-absorption of teeth.
Ameloblastoma: usually multilocular bubbly, extensive tooth re-absorption typical, expansile, enhancing septa, solid component favours.
(Crack the core, Aids to differential diagnosis)

Question 9

Intrarenal arteries with reduced RI. Most likely cause

a. Hepatorenal syndrome

b. Diabetes

c. ATN

d. Pyelonephritis

e. Ureteric obstruction

Answer 9

**SD - I guess Diabetes then as a causative factor for renal artery stenosis
*RY - Only renal artery stenosis is listed as a cause of decreased RI on radiopaedia (but can also be increased if intrarenal arteriosclerosis).

Combo of google and statdx indicate all of these conditions can cause a raised RI. No clear mention of low RI.

https://www.birpublications.org/doi/10.1259/bjr.20140004

ESG - diabetes -> atherosclerosis -> renal artery stenosis -> reduced RI

Question 10

1cm hepatic lesion. No central scar. Hypervascular. Isointense on hepatobiliary phase.

a. Haemangioma

b. FNH

c. Adenoma

d. Mets

Answer 10

FNH (adenoma does not uptake on hepatobiliary, and FNH is iso- to hyper-intense on hepatobiliary. Central scar is present in <50% as per radiopaedia.)

WJI: agree FNH but flash filling haemangioma could also look like this.

Question 11

35yo recent binge drinking, vomited blood. Next morning complains of pain on swallowing. Normal barium swallow

a. Boerhaaves

b. Mallory Weiss

c. Reflux oesophagitis

d. Barretts oesophagus

Answer 11

Mellory Weiss

Question 12

32 week fetus. EFW <5%. AC 20%. Most correct:

a. IUGR

b. SGA

c. If MCA doppler is <5% should check ductus venosus.

Answer 12

*ESG ??..
Could be symmetric IUGR but would need more info. Not asymmetric IUGR as AC would need to be <10%.
SGA is technically correct as EFW <10%.
As for c, DV is indicated in markedly raised UA PI (»95th ) and reduced MCA PI in preterm SGA, so this may be correct too.
Also as EFW is predominantly based on AC, the rest of the biometry would have to be very small… are they hinting at fetal hydrops with ascites?

**SCS: C. SGA. *WJI agree

Question 13

When assessing MCA PI, most correct

a. Should check the MCA furthest from the probe

b. Use a low PRF (repetitive pulse frequency) to prevent aliasing

c. If less than 5th centile, assess ductus waveform

d. Use a 3mm sample window

e. Sample 2cm from MCA origin

Answer 13

c. If less than 5th centile, assess ductus waveform

*RY - as per NZ obstetric doppler guidelines
- Should check MCA closest to the probe.
- Use a small (0.5-1mm) window, 2mm from MCA origin.
- “Optimise PRF to get a large waveform” (Note: in general PRF too low will result in aliasing)
- Abnormal MCA is <5th centile.

• Indications for ductus venosus PI:
  1) UAPI >95th and reduced MCA PI in preterm SGA
  2) MCDA twins with selective growth restriction or TTS.

Question 14

Regarding SWI, most correct:

a. Diamagnetic and paramagnetic and ….. cause inhomogeneities in the signal

b. Calcium causes positive phase signal (or something similar)

c. ferromagnetic

Answer 14

*RY - SWI is a 3D high-spatial-resolution fully velocity corrected gradient-echo MRI sequence. Compounds that have paramagnetic, diamagnetic, and ferromagnetic properties all interact with the local magnetic field distorting it and thus altering the phase of local tissue which, in turn, results in loss of signal.
- Paramagnetic compounds include deoxyhaemoglobin, ferritin and haemosiderin.
- Diamagnetic compounds include bone minerals and dystrophic calcifications.
- Paramagnetic and diamagnetic substances will be opposite on the phase image.

Diamagnetic substances have negative susceptibilities (χ < 0); paramagnetic, superparamagnetic, and ferromagnetic substances have positive susceptibilities (χ > 0).

the “colors” of blood and calcium on SWI phase images are scanner- dependent. Siemens and Canon use so-called “left-handed” reference schemes where blood products (Paramagnetic) appear bright; GE and Philips use a “right-handed” reference where blood products appear dark.

Question 15

Invasive breast carcinoma most likely presents on mammogram with:

a. Spiculated margins

b. Well-circumscribed mass

c. Architectural distortion

Answer 15

a. Spiculated margins

StatDx:

for IDC:
Spiculated margins: More common in low grade (41% grade 1 vs. 26% grade 3)
Circumscribed margins: More common in high grade (18% grade 1 vs. 36% grade 3)
Architectural distortion: Excellent depiction on tomosynthesis (DBT). More likely to be grade 1 if occult on 2D MMG and US (PPV 50% in one study)

for ILC:
Most common: Spiculated, low/equal-density mass (68%)
More often occult on MMG than IDC: Up to 30%
Architectural distortion (14-25%)

Question 16

Cervical enlargement. Most likely cause:

a. Stromal hyperthecoma

b. PID

c. Endometriosis

d. Ectopic pregnancy

Answer 16

???

ovarian hyperthecosis can have clitoral enlargement due to virilization

Another recall (under Path 2020) had adenomyosis as an option - probably correct - adenomyosis/adenomyoma can involve the cervix

??cervicitis as part of PID

Question 17

ASL

Answer 17

? Arterial spin labelling

*SD: 33/M/CHCH
*CCF 30/M/CHCH , interested in similar, pm pic and stats or no reply

Question 18

Endoleak, sac filling from lumbar artery

a. Type 1

b. Type 2

c. Type 3

d. Type 4

e. Type 5

Answer 18

Type 2

Question 19

MRI contrast,

a. Do not give contrast

b. Use micro

Answer 19

*RY - Presume in regards to poor renal function and risk of nephrogenic systemic fibrosis:
- If eGFR between 15-30 = 0.1% risk (i.e. low) when using high risk gadolinium agent.
- If eGFR <15, on haemodyalysis or peritoneal dialysis = 1% risk when using high risk gadolinium agent. Peritoneal dialysis is the highest risk.

• First consider if alternative test or non-contrast test would provide adequate information.
• If test required, use lowest risk agents (macrocyclic) and lowest dose possible (those with highest relaxivity allow lower doses, limit to 0.1mmol/kg). Do not use high risk agent (linear).
• In high risk settings, haemodyalysis is recommended immediately afterwards (removes approx 75%) +/- repeat at 24hrs (>93% removed) +/- 3rd session. Note: this has not been proven but is still recommended.

Also note: Allergic reactions to gadolinium-based contrast agents are relatively rare, occurring in 0.04-0.3% (radiopaedia).

(https://www.ranzcr.com/college/document-library/gadolinium-containing-mri-contrast-agents-guidelines).

Question 20

Previous history medulloblastoma long time ago, now age 10, high T1 dentate and basal ganglia, non-enhancing

a. Gadolinium deposition

b. Radiation

c. Recurrence

Answer 20

Gadolinium deposition

*SCS: occurs in the dentate nucleus and globus pallidus.

Question 21

60 yo mass in forearm, high T1, partially supressing on STIR, patchy enhancement

a. Melanoma

b. Lipoma

c. Schwannoma

d. Vascular malformation

Answer 21

Vascular malformation

__________

a. Melanoma - F, T1WI MR may be hyperintense signal secondary to paramagnetic effect of melanin, but wouldn’t suppress on STIR

b. Lipoma - F. May have fine peripheral capsular enhancement. Should never have central, nodular, or mass-like enhancement. If present, consider atypical lipoma or liposarcoma

c. Schwannoma - F, may be slightly hyperintense to muscle on T1 but wouldn’t suppress. Can have a thin peripheral rim of fat. Diffuse enhancement (often greater than neurofibroma) is typical, but absent enhancement reported.

d. Vascular malformation - T, (particularly intramuscular haemangioma → blood vessel proliferation within skeletal muscle with associated adipose tissue. Capillary, cavernous, or mixed type. May contain large amount of adipose tissue) Foci of T1 high signal corresponding to adipose tissue or slow-flow blood. Adipose tissue follows subcutaneous fat signal on all imaging sequences. Vascular regions intensely enhance.

Question 22

Young man mass in neck, what differentiates between plunging ranula and low flow vascular malformation

a. Parapharyngeal space

b. Anterior cervical space

c. Posterior cervical space

d. Submandular space

e. Sublingual space

Answer 22

e. Sublingual space

Plunging/diving ranula - body in submandibular space, tail in sublingual space. Tail sign = collapsed sublingual space portion, the “key” to diagnosing plunging ranula. T2 FS MR best delineates subtle tail sign

Oral Cavity Lymphatic Malformation: typically does not involve sublingual space (StatDx)

Question 23

3VV antenatal uss:

a. Normal in TGA

b. Aorta normally bigger than PA

c. In tetralogy of fallot PA significantly smaller than aorta

d. Order from left to right: aorta, PA, SVC

Answer 23

c. In tetralogy of fallot PA significantly smaller than aorta

Question 24

T21, which is most common ASD

a. Sinus venosus ASD

b. Ostium secundum

c. Ostium primum

d. PFO closes permanently at 2 years

Answer 24

c. Ostium primum.
Statdx ASD page “T21 a/w ostium primum and endocardial cushion defects”
However random online article has ostium secundum ASD most common overall, and also most common type of ASD in Down’s syndrome (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5370349/).
However wise radiology elders RY/ESG/SD all agree question is likely getting at the specific associations of T21, and would be an unfair/trick question if wanted secundum as answer.

Question 25

Young man with HTN, no femoral pulses, renal artery stenosis

a. Takayasu
b. Giant cell
c. Coarctation
d. FMD
e. Behcet

Answer 25

a. Takayasu

a. Takayasu - T, a.k.a. “pulseless disease”. Hypertension develops in more than one-half of cases due to narrowing of one or both renal arteries. however, 80-90% female predominance.
b. Giant cell - F, patients > 50 years old, otherwise similar to Takayasu as it is a large vessel arteritis.
c. Coarctation - F, can be hypertensive and pulseless, but no renal artery stenosis.
d. FMD - F, can have HTN and renal artery stenosis, but female-predominant and no limb vessel occlusion.
e. Behcet - F, young males affected, usually small vessel vasculitis and pulmonary artery aneurysms in addition to oral and genital ulcers

Question 26

Left sided IVC drains into:

a. Atrium

b. Ventricle

c. Coronary sinus

d. Brachiocephalic

Answer 26

Left sided IVC (duplicated IVC) drains to the left renal vein.

This question was likely asking about left-sided SVC, which drains to the coronary sinus (in 92%)

Question 27

Venous hepatic disease

a. Sinusoidal veno-occlusive disease occurs in medium and large veins

b. Budd Chiari worst in caudate lobe

c. Hepatic peliosis dilatation sinusoidal spaces, blood filled

d. Cavernous transformation of the portal vein has fistula with hepatic artery

Answer 27

c. Hepatic peliosis dilatation sinusoidal spaces, blood filled

a. Sinusoidal veno-occlusive disease occurs in medium and large veins - F, Hepatic venous outflow obstruction due to occlusion of terminal hepatic venules and sinusoids; presents with acute onset of painful hepatomegaly, jaundice, ascites within 3 weeks following hematopoietic or stem cell transplantation
b. Budd Chiari worst in caudate lobe - F, caudate drains directly to IVC so is spared and hypertrophies
c. Hepatic peliosis dilatation sinusoidal spaces, blood filled - T, a rare benign vascular condition characterised by dilatation of sinusoidal blood-filled spaces within the liver.
d. Cavernous transformation of the portal vein has fistula with hepatic artery - F, Cavernous transformation of the portal vein is most of the times inefficient in guaranteeing adequate portal vein inflow to the liver parenchyma far from the hilum and, therefore, is associated with an increased hepatic arterial flow to those peripheral liver segments

Question 28

Raised ICP

a. Kernohans notch is compression of the ipsilateral midbrain against the falx

b. Basal cistern effacement

c. Subdural haematoma – part of the mass effect is due cerebral oedema

d. Duret haemorrhages are due to tearing of vessels

e. Subfalcine herniation causes compression of pericallosal vessels

f. Ipsilateral compression of the PCA

Answer 28

?

a. Kernohans notch is compression of the ipsilateral midbrain against the falx - F, contralateral midbrain compressed against tentorium, giving ipsilateral neurology (false localising sign)

b. Basal cistern effacement - ?T/F - can be a consequence of a mass lesion causing raised ICP

c. Subdural haematoma – part of the mass effect is due cerebral oedema - ?T/F - “If mass effect, “shift” > aSDH thickness, suspect underlying edema/excitotoxic injury”

d. Duret haemorrhages are due to tearing of vessels - T, Stretching/tearing of basilar artery perforators or draining veins → brainstem Duret haemorrhages

e. Subfalcine herniation causes compression of pericallosal vessels - T, compression of ACA branches, specifically the pericallosal artery

f. Ipsilateral compression of the PCA - T?, seen in ipsilateral descending transtentorial herniation, Posterior cerebral artery (PCA) displaced inferiorly over free edge of tentorium. PCA kinking/occlusion leads to secondary occipital infarct; usually calcarine branch compression

Question 29

PE:

a. Chronic VTE is major cause PAH

b. If PE were to be biopsied, would see necrotic bronchi

c. Wedged shaped haemorrhagic change is strongly suggestive of infarct

d. Multiple stems regard

Answer 29

a. Chronic VTE is major cause PAH - T, a main cause of secondary pulmonary hypertension

b. If PE were to be biopsied, would see necrotic bronchi - T, Robbins: Histologically, the hemorrhagic area shows ischemic necrosis of the alveolar walls, bronchioles, and vessels.

c. Wedged shaped haemorrhagic change is strongly suggestive of infarct - T

Question 30

Haemodialysis line, which is most incorrect:

a. Femoral dialysis line can stay for several months

b. Right IJV line at junction BCV and SVC

c. Tunnelled has more infections than non-tunelled

d. Prefer subclavian access point over IJV

Answer 30

All are incorrect, c. might be the most obviously incorrect?

a. Femoral dialysis line can stay for several months - F, These lines are usually removed after 7-10 days due to the risk of infection.

b. Right IJV line at junction BCV and SVC - F , central tip ideally positioned at the superior cavoatrial junction and should not enter the right atrium

c. Tunnelled has more infections than non-tunelled - F, Subcutaneous tunnel forms natural infection barrier

d. Prefer subclavian access point over IJV - F,
Subclavian vein least preferred upper access route, Much higher risk of pneumothorax, Higher incidence of symptomatic thrombosis/stenosis

Question 31

Interrupted IVC

Answer 31

?

a.k.a. Azygos continuation of the inferior vena cava, the IVC terminates below the hepatic vein and lower limb venous drainage is completed via the azygos and hemiazygos veins into the superior vena cava.

Question 32

50 yo with discharge from umbilicus and mass associated with dome of bladder, most likely

a. Adenocarcinoma

b. TCC

c. SCC

Answer 32

a. Adenocarcinoma

The urachus (the canal that connects the fetal bladder with the allantois) is normally obliterated after birth, but it sometimes remains patent in part or in whole. When totally patent, a fistulous urinary tract connects the bladder with the umbilicus. In other instances, only the central region of the urachus persists, giving rise to urachal cysts, lined by either urothelium or metaplastic glandular epithelium. Carcinomas, mostly glandular tumors, may arise from such cysts (see “Neoplasms”). These account for only a minority of all bladder cancers (0.1% to 0.3%) but 20% to 40% of bladder adenocarcinomas.

Question 33

Child with renal mass and posterior fossa mass.

a. Renal cell carcinoma

b. Rhabdoid

c. Nephroblastoma

d. Nephrogenic rests

e. Wilms.

Answer 33

Rhabdoid - assuming “child” is <2 years old.
Wilms and RCC can met to brain

Question 34

Angiomyolipoma bilateral most common:

a. TS

b. NF1

c. BRCA2

d. VHL

Answer 34

TS

20% of AMLs are associated with tuberous sclerosis
50-60% incidence of AMLs in TS
45-60% incidence of AMLs in sporadic pulmonary LAM (i.e. not TSC), tend to be multiple and bilateral

Although the prevalence of AMLs is low among patients who do not have TSC or LAM, the prevalence of sporadic AML markedly exceeds the estimated birth incidence of TSC or LAM, so among patients who present with AML, the chances are high that the lesion is sporadic AML and not TSC- or LAM-associated AML.

No association with NF1 or VHL (as per StatDx and Uptodate), despite Radiopaedia stating an association

Question 35

Pneumatosis least likely associated with:

a. Acute MI

b. Emphysema

c. CF

d. Diverticulosis

e. Embolus in the major mesenteric vessel with other arteries patent.

Answer 35

d. Diverticulosis

Pneumatosis least likely associated with:

a. Acute MI - T, hypoperfusion, bowel ischaemia (Colonic ischemia more often due to hypoperfusion), seen in elderly

b. Emphysema - T, coughing - barotrauma (alveolar rupture, Gas dissects down mediastinum, into retroperitoneum, out mesentery, into bowel wall)

c. CF - T, coughing, also could be immunosuppressed post-transplant

d. Diverticulosis - F

e. Embolus in the major mesenteric vessel with other arteries patent. - T, bowel necrosis (Small bowel (SB) ischemia is usually due to occlusion of superior mesenteric artery or superior mesenteric vein)

Question 36

Young Asian female RIF pain with pouch-like structure with echogenic structure from the anterior caecal wall, most likely:

a. Appendicitis

b. Diverticulitis

Answer 36

b. Diverticulitis

UpToDate:
A diverticulum is a sac-like protrusion of the colonic wall.
In Asia, the prevalence of diverticulosis is between 13 and 25 percent, and diverticulosis is predominantly right-sided.

Radiopaedia:
diverticula are characterized as bright bowel outpouching (also referred as bowel bright “ears”) showing some degree of acoustic shadowing due to the presence of gas or inspissated feces

Question 37

Bladder, calcification

a. SCC

Answer 37

bladder schistosomiasis = Curvilinear bladder wall calcification in patient from endemic area
Causal relationship between S. haematobium and bladder carcinoma has been shown in animal studies
Tumor usually remains localized for prolonged period because of occlusion of lymphatic channels by fibrotic changes
Squamous cell carcinoma is dominant type (~ 70%)

Question 38

Renal lesion indeterminate on USS, most correct, T1 low, T2 high, well circumscribed, no enhancement:

a. Simple cyst

b. Proteinaceous cyst

c. Haemorrhagic cyst

d. Renal cancer

Answer 38

a. Simple cyst

Question 39

Regarding cerebral aneurysm, most correct:

a. Charcot bouchard at the cortical grey-white junction

b. Amyloid causes BG haemorrhage

c. Commonly associated with renal FMD

d. Atherosclerosis is the most common cause in the basilar artery

Answer 39

d. Atherosclerosis is the most common cause in the basilar artery

Regarding cerebral aneurysm, most correct:

a. Charcot bouchard at the cortical grey-white junction - F, minute aneurysms which develop along perforating arteries as a result of chronic hypertension, most commonly in the basal ganglia and other areas such as the thalamus, pons and cerebellum

b. Amyloid causes BG haemorrhage - F, lobar or cerebellar haemorrhage

c. Commonly associated with renal FMD - F? (Intracranial saccular aneurysms in ~ 10% - StatDx)

d. Atherosclerosis is the most common cause in the basilar artery - T? fusiform type (Radiopaedia - Fusiform aneurysms are most commonly located in the vertebrobasilar circulation
and are most commonly secondary to atherosclerotic disease, but can also be mycotic aneurysms) note -saccular aneurysms are not related to atherosclerosis.

Question 40

Medulloblastoma, most likely

a. In the cerebellar hemispheres in children

b. WNT type is located in the dorsal brainstem

c. (possibly other more correct answer forgotten)

Answer 40

b. WNT type is located in the dorsal brainstem

Medulloblastoma, most likely

a. In the cerebellar hemispheres in children- F, midline 4th ventricular mass arising from roof (dorsal 4th ventricle). Cerebellar hemisphere more frequent location in older children and adults.

b. WNT type is located in the dorsal brainstem - T, Wnt-wingless (least common): Favorable prognosis. Often located in cerebellopontine angle/Cerebellar peduncle

c. (possibly other more correct answer forgotten)

Question 41

Erosive change in the jugular foramen with pulsing

a. Paraganglioma

Answer 41

a. Paraganglioma

“glomus jugulare”
Clinical profile: 50-year-old woman with progressive pulsatile tinnitus & red, pulsatile retrotympanic mass
-Mass in JF with permeative-destructive change of adjacent bone on CT
- Multiple black dots (“pepper”) in tumor mass indicating high-velocity flow voids from feeding arterial branches on MR
- Vector of spread: Superolateral through floor of middle ear (most common)

Question 42

Patent with tinnitus, least correct:

a. Small cerebral aqueduct

b. FMD

c. Dural AV fistula

Answer 42

a. Small cerebral aqueduct

Patent with tinnitus, least correct:

a. Small cerebral aqueduct - F, aqueductal stenosis causes obstructive hydrocephalus (and large vestibular aqueduct causes progressive sensorineural hearing loss in childhood)

b. FMD - T, ICA stenosis, pulsatile tinnitus

c. Dural AV fistula - T (including caroticocavernous fistula), pulsatile tinnitus

Question 43

Nasal dermoid most incorrect:

a. Bifid crista galli

b. Large foramen caecum

c. Nasal cavity location

Answer 43

c. Nasal cavity location

Nasal dermoid most incorrect:

a. Bifid crista galli- T

b. Large foramen caecum - T

c. Nasal cavity location - F, Can be in the nasal septum - does this count as nasal cavity? who knows..

Focal tract (sinus) or mass (dermoid or epidermoid) anywhere from nasal bridge to crista galli.
Fluid-density tract = sinus
Fluid-density mass = epidermoid
Fat-density mass = dermoid
Signs of intracranial extension = Large foramen cecum with bifid or deformed crista galli or cribriform plate

Question 44

Cavernoma

Answer 44

?

Question 45

Pituitary

a. Somatotroph microadenoma is most common cause of Cushings disease

b. Microadenoma typically non-functioning

c. Bilateral adrenalectomy causes pituitary macroadenoma

d. Prolactinoma more readily diagnosed in men because of galactorrhoea

Answer 45

c. Bilateral adrenalectomy causes pituitary macroadenoma

Pituitary

a. Somatotroph microadenoma is most common cause of Cushings disease - F, somatotroph produce GH, leads to gigantism/acromegaly. ACTH-secreting adenoma causes Cushing disease

b. Microadenoma typically non-functioning - F, A pituitary microadenoma is confined to the sella, and as such has no scope to produce symptoms due to mass effect. As such they are most frequently diagnosed as the result of investigating hormonal imbalance (usually excess production of one or more hormones). Rarely they can be incidental findings, however, by their very nature microadenomas are difficult to identify on anything other than dedicated pituitary imaging.

c. Bilateral adrenalectomy causes pituitary macroadenoma - T, Nelson syndrome

**SCS: In the context of Bilateral Adrenalectomy for Cushings. Enlargement of a pre-existing ACTH secreting adenoma. Loss of negative feedback mechanism (no more cortisol production from absent adrenals). Results in Accelerated growth of adenoma.

d. Prolactinoma more readily diagnosed in men because of galactorrhoea, F- The diagnosis of an adenoma is made more readily in women than in men, especially between the ages of 20 and 40 years, presumably because of the sensitivity of menses to disruption by hyperprolactinemia. Lactotroph adenoma underlies almost a quarter of cases of amenorrhea. In contrast, in men and older women, the hormonal manifestations may be subtle, allowing the tumors to reach considerable size (macroadenomas) before being detected clinically.

Question 46

Concerning adrenal glands

a. Conn’s most commonly due to nodular adrenal hyperplasia

b. A cause of Addison’s is fungal infection

Answer 46

b. A cause of Addison’s is fungal infection
*SD: Radiopaedia: Primary hyperaldosteronism is due to bilateral nodular adrenal hyperplasia in about 60% of cases, an autonomous solitary adrenal cortical adenoma in about 35%, with an adrenal carcinoma being a rare cause8.

Concerning adrenal glands

a. Conn’s most commonly due to nodular adrenal hyperplasia - F, Bilateral idiopathic hyperaldosteronism (IHA), characterized by bilateral nodular hyperplasia of the adrenal glands, is the most common underlying cause of primary hyperaldosteronism, accounting for about 60% of cases. Conn syndrome is hyperaldosteronism caused by a solitary adrenal adenoma.

b. A cause of Addison’s is fungal infection - T, Among fungi, disseminated infections caused by Histoplasma capsulatum and Coccidioides immitis may result in chronic adrenocortical insufficiency.

**SCS:
Addisons causes:
Idiopathic (most common
Granulomatous dis: TB, Sarcoid
Fungal as above
Adrenoleukodystrophy
Adrenal haemorrhage (waterhouse- friderichsen= due to sepsis)
Metastases.

Question 47

Least common manifestation of sarcoid

a. Liver and spleen

b. Lymphodenopathy

c. Medullary bone

d. Eyes

e. GIT

Answer 47

e. GIT

UpToDate:

Lung 95%
Lymph nodes 15%
Eye 12%
Liver 11%
Spleen 7%
Bone marrow 4%
GIT 0.1%-0.9%

Question 48

Young person splayed carina, cough, normal exam:

a. Atrial enlargement

b. Bronchogenic cyst

c. Hiatus hernia

d. Oesophageal tumour

e. Neuro enteric cyst

Answer 48

b. Bronchogenic cyst

Young person splayed carina, cough, normal exam:

a. Atrial enlargement - F, would splay carina and could cause cough but usually would have other signs of heart failure. In mitral stenosis from rheumatic heart disease, would occur in middle age. Can get Ortner syndrome - hoarseness due to LA enlargement compressing the L recurrent laryngeal nerve.

b. Bronchogenic cyst - T, usually asymptomatic but classic presentation and location in a young person.
Typically: asymptomatic patient with spherical subcarinal lesion. Can present with chest pain, cough, dyspnea, wheezing

c. Hiatus hernia - F, could cause cough from GORD but wouldn’t splay carina

d. Oesophageal tumour - F, uncommon in young person

e. Neuro enteric cyst - F, wrong location. Cyst along neuraxis (usually intraspinal) ± vertebral anomalies. Most are intradural extramedullary simple unilocular cysts ventral to spinal cord. Can be posterior mediastinal/intraabdominal or both with communication through vertebral body defect

Question 49

Lady with haemorrhage 3 days following a normal vaginal delivery, what is the most likely cause?

a. Placenta previa

b. Bilobed placenta

c. Succenturiate placenta

d. Placenta membraneacia

Answer 49

c. Succenturiate placenta

UpToDate:

The most common causes of secondary PPH are:
●Retained products of conception,
●Subinvolution of the placental bed, and/or
●Infection

Retained products of conception are much more likely after vaginal delivery than cesarean delivery, whereas postpartum endometritis is more likely after cesarean.

Placenta previa is associated with primary post-partum haemorrhage.

Duplex placenta (ie, bilobed or bilobate placenta (picture 25)) refers to complete separation of the placenta into two more or less equal sized lobes with separate umbilical arteries and veins that unite in a single umbilical cord. The umbilical cord of such placentas may insert into a chorionic bridge between lobes. More commonly, membranous vessels extend between lobes or from either lobe to the cord. When the vessels are membranous, vasa previa, compression, and thrombosis are major concerns.

the succenturiate lobe(s) may be retained after the main placental disk has been delivered. This can result in postpartum hemorrhage or infection days or weeks after delivery.

Placenta membranacea refers to a rare type of placenta in which the chorionic sac is covered by functional placental tissue without free membranes. These placentas are very thin and deeply implanted (with occasional placenta accreta), thus requiring manual removal. They are associated with slightly increased risks of second-trimester miscarriage, preterm birth, and antepartum and postpartum bleeding

Question 50

Patient had acute contrast reaction (anaphylactic), most likely:

a. 5% of the general population are expected to have a reaction to contrast

b. Adrenaline IM 1:10,000 is contraindicated

Answer 50

Both false

Patient had acute contrast reaction (anaphylactic), most likely:

a. 5% of the general population are expected to have a reaction to contrast - F, The rate of acute adverse reactions from nonionic low- or iso-osmolar iodinated contrast is approximately 0.15 to 0.7 percent with >98 percent being mild and self-limited

b. Adrenaline IM 1:10,000 is contraindicated - F, this is not ideal as the volume given would be 10x greater than 1:1,000, however better than nothing. The other way around - giving IV adrenaline 1:1,000 - is discouraged as it is associated with dosing errors and cardiovascular complications (arrhythmias) [ probably also venous spasm at the infection site/ tissue injury if extravasates.]

UpToDate:
There are no absolute contraindications to epinephrine use in anaphylaxis [10,12-15,22-26,45]. The risk of death or serious neurologic sequelae from hypoxic-ischemic encephalopathy due to inadequately treated anaphylaxis usually outweighs other concerns

Important points related to treatment of the patient with anaphylaxis include:[46] 1) epinephrine is first, antihistamines and corticosteroids are adjunctive therapies, and 2) epinephrine should be administered intramuscularly, and not intravenously in concentrations of greater than 1:10 000, and then only as a last resort.

Question 51

5yo with cough. CXR shows right heart border obscured, most likely:

a. Cancer

b. RML collapse

c. Pectus carinatum

Answer 51

b. RML collapse

Question 52

Young lady with two uterine cavities and 2 cervices. Most likely diagnosis?

a. Arcuate

b. Didelphys

c. Septate

d. Bicornuate

Answer 52

.b. Didelphys

Question 53

AVN hip

a. More sensitive on MRI than bone scan.

b. Typically affects posterior femoral head

c. Both sides ofarticular surface are affected early (as in acetabular and femoral head)

d. Subchondral lucency in early phase

e. Destroys articular cartilage early

Answer 53

a. More sensitive on MRI than bone scan.

AVN hip

a. More sensitive on MRI than bone scan. , T - May be more sensitive than radiograph (85% sensitivity on SPECT), but significantly less than MR. MR is 97% sensitive, 98% specific for ON

b. Typically affects posterior femoral head, F
location: Early in disease: Anterior weight-bearing femoral head

c. Both sides ofarticular surface are affected early (as in acetabular and femoral head) - F, secondary osteoarthritis is a late finding

d. Subchondral lucency in early phase, F, late
Early radiographs: Patchy sclerosis femoral head
Late radiographs: Irregularity, fragmentation, collapse of femoral head articular surface; secondary osteoarthritis. Crescentic subchondral lucency indicative of fracture, may precede articular surface collapse

e. Destroys articular cartilage early- F, secondary osteoarthritis is a late finding

Question 54

Thoracic aorta CTA in middle-aged male. Focal contrast extending into the media.

a. Longitudinal dissection

b. PAU

c. IMH

Answer 54

b. PAU

Question 55

Typical carcinoid tumour, most correct

a. Low bleeding risk during biopsy

b. Liver metastases typically need to be present for carcinoid syndrome

c. Bronchial carcinoid arises from bronchial metaplasia/dysplasia

d. Something else

e. 90% 5 year survival

Answer 55

Two correct answers.

Typical carcinoid tumour, most correct

a. Low bleeding risk during biopsy - F
Lung NETs are vascular, and there has been concern for bleeding in the past, particularly after flexible bronchoscopy with biopsy. However, in many contemporary series, the incidence of serious bleeding complications during bronchoscopic biopsy is very low

b. Liver metastases typically need to be present for carcinoid syndrome - T
Carcinoid syndrome: Cutaneous flushing, diarrhea, and bronchospasm
- Systemic release of vasoactive substances, such as serotonin and other amines
- Rare with thoracic carcinoid tumors
- Almost all affected patients have hepatic metastases

c. Bronchial carcinoid arises from bronchial metaplasia/dysplasia- F,
Arises from neuroendocrine cells in tracheobronchial epithelium, histologically distinct from atypical carcinoid.

d. Something else

e. 90% 5 year survival - T
StatDx:
5-year survival
90-95% without lymph node involvement
76-88% with lymph node metastases
UpToDate:
Low-grade (typical) lung NETs have an excellent prognosis following surgical resection. Reported five-year survival rates are 87 to 100 percent

Question 56

Ectopic pancreatic tissue in the small bowel is best described as:

a. Hamartoma

b. Choristoma

c. Adenoma

d. Metastatic lesion

Answer 56

b. Choristoma

Choristomas: masses of normal tissues found in abnormal locations

a hamartoma is disorganized overgrowth of tissues in their normal location

Memory aid: you find Chris Fernando hiding in the bushes outside your house. At work he is normal, but he shouldn’t be in the bushes outside your house. “Christoma”

Question 57

Pancreatic islet cell tumour. Most likely association

a. Gastric ulcer

b. Hyperglycaemia

Answer 57

*RY - Gastric Ulcer.
- Insulinoma is the most common - causes whipples triad (fasting HYPOglycaemia, symptoms of hypoglycaemia, relief with glucose)
- Gastrinoma the second most common islet cell tumour - causes Zollinger-Ellison syndrome - which causes hypertrophic gastritis and peptic ulcer disease (jejunal ulcers are most specific).
- Glucagonoma is uncommon - it causes the 5 Ds - diabetes, dermatitis, DVT, depression, death (75% malignant).
So although hyperglycaemia can occur, it would be less common.

Question 58

ZES syndrome, least likely:

a. Mass located in or adjacent to the stomach

b. Lymphadenopathy

Answer 58

*RY - Favour adjacent to the stomach.
90% gastrinomas are usually located within the gastrinoma triangle (points of the triangle: cystic/CBD confluence, 2/3 duodenum junction, panc head/neck junction). Within the stomach is rare. (statdx)

However 60% malignant, 30-50% metastatic (typically to liver).

*ESG agree. Although gastrinoma causes abnormality of the stomach, the mass is located elsewhere.
Most common sites of metastases include liver, local lymph nodes, and bone (sclerotic lesions). Metastases demonstrate similar characteristics to primary tumor: Hypervascular lymph node and liver metastases.
Zollinger-Ellison syndrome (gastrinoma): Avid enhancement and wall thickening of proximal stomach

Question 59

Pagets disease of the bone most likely

a. Low rate of non-union

b. Low rate of heterotopic ossification post surgery

Answer 59

.* RY - difficult to find reliable info. I would favour “low rate of non-union” as most likely, unless another option was better. Both these issues not mentioned on radiopaedia, statdx and orthobullets.
Some papers mentioned:
- ~50% heterotopic ossification post THJR.
- “It is generally accepted that patients with Paget’s disease have normal fracture healing capacity to progress through the process at normal speed”
- “Delayed union and non-union of fractures have been reported in patients with Paget’s disease. Therefore, open reduction and internal fixation of fractures has been recommended to prevent such complications”.

https://asbmr.onlinelibrary.wiley.com/doi/full/10.1359/jbmr.06s214
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5396022/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2881078/#:~:text=Paget’s%20disease%20is%20a%20localized,in%20patients%20with%20Paget’s%20disease.

*ESG - agree no clear answer, but would pick a) because there are rumours about increased heterotopic ossification that have been debunked, but RANZCR wouldn’t be UpToDate:
It has been reported that Paget disease increases risk for postoperative heterotopic bone formation [80,81]. However, a recent large retrospective case control study did not find an increased rate of heterotopic ossification after total hip arthroplasty in patients with Paget disease compared with controls