VIQ - Final

Question 1

@#e2 31. Which of the following are correct regarding benign and malignant adrenal masses: (T/F)

(a) Chemical shift MR utilises T1 weighted sequences.

(b) Approximately one third of benign adenomas have HU of >10 on unenhanced CT.

(c) Adenomas tend to show delayed enhancement with IV contrast.

(d) Adenomas tend to show delayed clearance of IV contrast.

(e) Lesions >4cm tend to be malignant.

Answer 1

Answers:

(a) Correct
(b) Correct
(c) Not correct
(d) Not correct
(e) Correct

Explanation:

Adenomas (benign) show rapid enhancement and rapid washout of contrast media on post contrast study.

Question 2

@#e2 A 60-year-old nulliparous woman presents with postmenopausal bleeding. On transvaginal ultrasound, her endometrium is 8 mm thick and the endomyometrial junction appeared indistinct. The radiologist suspects invasive endometrial cancer and refers her for an MRI examination. What are the likely findings on MRI?

A On unenhanced Tlw images the endometrial cancer appears of high signal intensity compared to the surrounding myometrium.

B On contrast-enhanced Tlw images, endometrial cancer shows avid enhancement compared with surrounding myometrium.

C On T2w images the normally high signal junctional zone is disrupted.

D Tlw fat-saturated sequences are best used to assess the junctional zone.

E The endometrial cancer demonstrates delayed/little enhancement compared to the normal surrounding myometrium on postcontrast Tlw images

Answer 2

E The endometrial cancer demonstrates delayed/little enhancement compared to the normal surrounding myometrium on postcontrast Tlw images

Question 3

@#e2 QUESTION 79
A 28-year-old woman has a strong family history of breast cancer and is referred for an MRI examination of the breasts. Regarding MRI of the breast, which one of the following statements is correct?

A Breast MRI should be performed during the middle of the menstrual cycle to improve sensitivity.

B Malignant lesions tend to show poor enhancement following intravenous contrast, compared with surrounding breast tissue.

C MRI has a high sensitivity and specificity for the detection of invasive breast cancer.

D Post radiotherapy, abnormal enhancement patterns return to normal within 3—6 months.

E The patient is imaged in a supine position with the breasts placed in adedicated breast coil to improve signal to noise ratio.

Answer 3

D Post radiotherapy, abnormal enhancement patterns return to normal within 3—6 months.

Malignant breast lesions enhance postcontrast; however, normal hormonally active breast tissue can also enhance, particularly during the middle of the menstrual cycle (6th—17th days). In younger patients it may be helpful to repeat the scan earlier or later in the menstrual cycle to improve specificity

Question 4

@#e2 28. Which of the following are correct regarding ovarian cancer: (T/F)

(a) It is the commonest gynaecological malignancy.

(b) It is associated with colorectal cancer.

(c) CA-125 is specific for ovarian cancer.

(d) CT only has a pre-operative staging accuracy of 50%.

(e) Doppler ultrasound may help with differentiating benign from malignant disease.

Answer 4

Answers:

(a) Not correct

(b) Correct

(c) Not correct

(d) Not correct

(e) Correct

Explanation:

Endometrial cancer is the most common gynaecological malignancy. CA-125 is not specific for ovarian cancer, it is increased in benign conditions like fibroids, endometriosis and inflammatory pelvic disease. CT only has a pre-operative staging accuracy of 70% - 90%.

Question 5

@#e2 Cauda equina end level:

A) Above T12

B) Below L1

C) L2/3

D) L3/4

Answer 5

B) Below L1

Question 6

@#e2 28. A follow-up of a young man under the care of the neurooncologists reveals a drop in metastases. Which statement is most true?

A. Drop metastases tend to be in the upper spine

B. Metastases within the spinal canal are usually ventral

C. Glioblastoma is the commonest cause of drop metastases

D. Are associated with positive CSF cytology in approximately 10% of cases

E. Usually demonstrates homogenous enhancement with contrast

Answer 6

E. Usually demonstrates homogenous enhancement with contrast

Drop metastases are usually dorsal in location in the spinal canal.

Medulloblastomas are the most common cause of drop metastases.

A higher percentage of CSF cytology is positive.

Question 7

@#e2 42. Which is a cause of solitary dense pedicle rather than erosion/absence?

A. Osteoblastoma

B. Metastatic carcinoma

C. Neurofibroma

D. Tuberculosis with paravertebral abscess

E. Aneurysmal bone cyst

Answer 7

42. A Osteoblastoma is a cause of a solitary dense pedicle

Question 8

@#e2 32 An MR of the spine in a neonate reveals two separate hemichords in two separate dural tubes. Which type of split cord malformation does this represent?

(a) Type I

(b) Type II

(c) Type Ill

(d) Type IV

(e) Type V

Answer 8

(a) Type I

This is a type I malformation, also known as diastematomyelia. A type II of malformation comprises two hemicords within a single dural tube, also known as diplomyelia. There is no type III, IV or V malformations.

Question 9

@#e2 49. A 52-year-old woman presents with gradually increasing gait disturbance and lower limb sensory symptoms. An MRI of her spine is performed and this shows an anteriorly placed intradural, but extramedullary spinal mass.It is fairly markedly low signal on T1WI and T2WI, and shows only miminal patchy enhancement post administration of intravenous gadolinium. What isthe most likely diagnosis?

A. Neurofibroma.

B. Schwannoma.

C. Lymphoma.

D. Metastasis.

E. Meningioma.

Answer 9

49. E. Meningioma.

Spinal meningiomas are typically iso- to hypointense on T1WI and slightly hyperintense onT2WI. There is usually strong and homogeneous enhancement with gadolinium. However, some meningiomas may contain calcification and are typically the only intradural extramedullarytumours to do so.

Some meningiomas can be heavily calcified and such a meningioma is being described in the question. These will remain dark on all MRI sequences and demonstrate onlylittle contrast uptake (in the non-calcified areas).

Schwannomas, neurofibromas, and metastases would not typically be hypointense on T2WI.

Meningeal lymphomas are very rare and usually manifest as diffuse thickening of nerve roots and/or multiple enhancing nodules.

Question 10

@#e2 50. You are asked to protocol an MRI scan that is specifically being performed to look for vertebral metastatic disease. The radiographer complains that you have asked for too many sequences. Which of the following sagittal sequences is likely to be least helpful for the purposes of your examination?

A. STIR.

B. T2 fast SE with fat saturation.

C. T2 fast SE.

D. T1 fast SE.

E. T1 GE out of phase.

Answer 10

50. C. T2 fast SE.

T2 fast SE is probably the least useful sequence when specifically looking for vertebral marrow deposits because the metastases are less conspicuous, typically being high signal on a background of high-signal fatty marrow.

On STIR and T2 fast SE with fat saturation, the metastases typically stand out as being of increased signal on a background of dark marrow because of the fat saturation techniques.

On T1 fast SE sequences, the metastases typically stand out as being lowsignal on a background of high-signal fatty marrow.

Finally, T1 GE out-of-phase imaging is also good for looking for vertebral metastatic disease. This is a sequence with a specific echo time corresponding to the time it takes for water and fat protons to move exactly 180° out of phase. In the normal adult human, the medullary bone of the vertebral bodies contains approximately equal amounts of water and fat protons. In out-ofphase conditions, the signal of both will cancel out, leaving the vertebrae completely black. In the case of vertebral pathology, however, the signal will increase and, as such, vertebral metastases (or other lesions) will clearly stand out.

Question 11

@#e2 (MSK) 41 A 19-year-old female presented with lower back pain and a lumbosacral X-ray showed an expansile lyric lesion in the right sacrum. The margins were well defined and there was no softtissue mass visible. No other lesions were suspected. What is the most likely diagnosis?

a Multiple myeloma

b Osteoid osteoma

C Chordoma

d Giant cell tumour

e Aneurysmal bone cyst

Answer 11

41 Answer D: Giant cell tumour (GCT)

GCTs are characteristically well defined with a non-sclerotic margin and are most frequently seen in young adults aged between 20 and 40 years. Most GCTs occur in the long bones, but a number do occur in the spine where they tend to affect younger patients and to be three to four times more common in the sacrum than rest of spine.

Question 12

@#e2 (MSK) 60 A 29-year-old male presented with difficulty walking and was found to have a complex sensory deficit. After investigation he was found to have an astrocytoma of the spinal cord. Which area is most likely to be involved?

a Brainstem

b Cervical spine

C Thoracic spine

d Lumbar spine

e Sacrum

Answer 12

60 Answer C: Thoracic spine

Almost two-thirds occur in the thoracic spinal cord, although half involve the cervical cord as they usually extend over a long region of cord (approximately seven segments on average).

Question 13

@#e2 68 An 18-year-old boy was involved in a road traffic accident. He had multiple injuries and one month after his accident he still had a right Ti nerve root palsy. MRI of the brachial plexus was normal. A further MRI study of his cervicothoracic spine was performed which showed an absent right Ti nerve root. No conjoint roots were seen at C7 or T2. There was a small, well-defined area of CSF signal at the right Ti neural exit foramina. What is the most likely diagnosis?

a Lateral myelomeningocele

b Traumatic nerve root avulsion

C Tarlov cyst

d Neurogenic cyst

e Synovial cyst from the facet joint

Answer 13

68 Answer B: Traumatic nerve root avulsion

The right Ti nerve root has been avulsed. This most commonly occurs in the cervical region following severe acute traction on the upper limb such as a fall from a motorbike. Imaging typically demonstrates an absent nerve root within the neural foramina and a pseudomeningocele. If patients are not able to have an MRI, a CT myelogram could be performed.

Question 14

@#e2 (ped) 2 The paediatric team sees a neonate with respiratory distress, bradycardia and poor swallowing. Following imaging investigation the child was found to have a small posterior fossa and dysgenesis of the hindbrain. The fourth ventricle and hindbrain are displaced caudally and the tonsils and vermis are herniating through the foramen magnum. What further CNS abnormalities may be present?

a A funnel-shaped posterior fossa

b Klippel-Feil deformity

C Basilar impression

d Herniation of the cerebellar tonsils

e Lumbar myelomeningocele

Answer 14

2 Answer E: Lumbar myelomeningocele

The child has Arnold Chiari malformation (Chiari II malformation), which has the above characteristic features. It is associated with lumbar myelomeningocele in >95% of cases and syringohydromyelia. In addition it is associated with the following supratentorial anomalies:
* dysgenesis of corpus callosum (80-85%)
* obstructive hydrocephalus secondary to closure of myelomeningocele (50-98%)
* absence of septum pellucidum (40%)
* excessive cortical gyration.
It is notably not associated with basilar impression, Cl assimilation and KlippelFeil deformity

Question 15

@#e2 60 A 20-year-old man had progressive upper and lower limb weakness, worse in the lower limbs. On MR there was widening of the spinal canal with posterior vertebral scalloping between D3 and D7. On Ti- and T2-weighted imaging a well-defined high-intensity mass was present anterior to the spinal cord with atrophy of the cord at this level. The CSF space was slightly expanded immediately superior to the mass. No high signal was present in the cord on T2. What is the most likely diagnosis?

a Epidural abscess

b Epidural haematoma

C Neuroma

d Neurogenic cyst

e Meningioma

Answer 15

60 Answer D: Neurogenic cyst

The description above describes a chronic process resulting in bone remodelling and atrophy of the cord. Thus an epidural abscess and haematoma are unlikely. This mass is extramedullary but intradural. Although meningiomas and neuromas are intradural they are isointense on Ti hence the best answer is a neurogenic cyst. Neurogenic cyst is an intradural mass, which is commonly seen within the cervical and thoracic region. They are associated with other spinal abnormalities such as diastematomyelia and Klippel-Feil syndrome.

Question 16

@#e2 62 Following surgery for a herniated L4/L5 disc a 66-year-old obese patient had little symptomatic relief. An MRI scan performed in the second postoperative week revealed extradural soft-tissue material within the spinal canal, which demonstrated little enhancement following contrast. Nerve root enhancement was striking. What is the most likely diagnosis?

a Arachnoiditis

b Epidural haematoma

c Residual disc material

d Epidural fibrosis

e Neuritis

Answer 16

62 Answer C: Residual disc material

Appearances of the post-operative spine can be challenging.

In the early postoperative period, persistent symptoms are usually due to epidural haematoma, retained fragment or recurrent disc.

In the subacute and chronic stage the differential is mainly between a disc and epidural fibrosis.

Osseous abnormalities depend on the specific surgical procedure.

Epidural fibrosis occurs commonly, enhances with contrast administration and the degree of enhancement varies with time since the operation, enhancing most strongly within a year following surgery.

Neuritis, identified as intrathecal enhancement of nerve roots, is seen in approximately 20% of symptomatic patients.

Early postoperative root enhancement is common in asymptomatic patients and is considered significant only if it persists beyond at least six to eight months.

Question 17

@#e2 18 An elderly, hypertensive man is found collapsed. CT imaging demonstrates a large intracerebral haematoma. The mean CT attenuation is 70 HU, and there are fluid/ fluid levels. How old is the haematoma likely to be?

(a) 0-2 hours

(b) 3-48 hours

(c) 3-7 days

(d) 2-4 weeks

(e) 2 months

Answer 17

(b) 3-48 hours

Question 18

@#e2 35 An elderly, hypertensive man is found collapsed. MR imaging demonstrates a large intracerebral haematoma, with intermediate. signal intensity on T1W and high signal intensity on T2W. How old is the haematoma likely to be?

(a) 0-12 hours·· ·

(b) 12-72 hours

(c) 4-7 days

(d) 8-30 days c

(e) More than 1 month

Answer 18

(a) 0-12 hours

Question 19

@#e2 1 A young man presents with a thunderclap headache. A CT examination is performed. Sub-arachnoid blood is seen with a localised clot which has a maximum thickness of 2 mm. No intraventricular nor parenchymal blood is seen. What is the Fisher Grade?

(a) Grade 0

(b) Grade I

(c) Grade II

(d) Grade Ill

(e) Grade IV

Answer 19

(d) Grade Ill

The Fisher scale is useful in communicating the description of SAH.

Grade 1: no haemorrhage evident,

grade 2: SAH < 1 mm,

grade 3: SAH > 1 mm,

grade 4: associated intra-ventricular haemorrhage or parenchymal extension.

Question 20

@#e2 9. Which brain tumour has the greatest incidence across all age groups?

A. Meningioma

B. Metastases

C. Pituitary adenoma

D. Haemangioblastoma

E. Glioma

Answer 20

E. Glioma

Gliomas consist of astrocytomas, oligodendrogliomas, paragangliomas, ganglogliomas and medulloblastomas

Question 21

@#e2 26 An elderly man is admitted for assessment of focal neurological symptoms. An incidental supratentorial cystic lesion is demonstrated. Which of the following features would make the diagnosis of subdural hygroma, rather than arachnoid cyst, more likely?

(a) Isointense to CSF on T1W MR imaging

(b) Mass effect

(c) Isointense to CSF on T2W MR imaging

(d) Flattened sulci

(e) Bony remodeling

Answer 21

(e) Bony remodeling

Scalloping of the adjacent bone, possibly through transmitted pulsations, is often seen in arachnoid cysts. This is never seen in subdural hygromas, but can be seen with epidermoid cysts or porencephaly.?

Question 22

@#e2 47 A 40 year old man presents with a seizure and a CT head reveals an intracranial lesion. An oligodendroglioma is suspected. Which feature would be least expected with this diagnosis?

(a) Ill-defined enhancement

(b) Cystic degeneration

(c) Absence of oedema

(d) Calcification

(e) Hyperdense on unenhanced imaging

Answer 22

(e) Hyperdense on unenhanced imaging

Oligodendrogliomas are slowly growing gliomas, most commonly located in the frontal lobes.

Large nodular calcification is present in approximately 90% of cases.

Cystic degeneration, ill-defined enhancement and a lack of oedema are all common.

Over 80% are either hypo- or iso- dense on unenhanced CT imaging.

Question 23

@#e2 47 A seven-year-old boy presented with sudden onset gait problems and subtle uncoordination on the finger nose test. CT demonstrated a low density cystic solid lesion with subtle calcification centred on the vermis. Thick heterogeneous enhancement was seen within the solid area along with obstructive hydrocephalus. What is diagnosis?

a Pilocytic astrocytoma

b Medulloblastoma

c Haemangioblastoma

d Ependymoma

e Brainstem glioma

Answer 23

47 Answer A: Pilocytic astrocytoma

Pilocytic astrocytoma is the most likely diagnosis as it is low density on CT with calcification and nodular enhancement. They are commonly located in the vermis (50%) and are complicated by hydrocephalus.

They commonly occur before the age of nine and are characteristically a cyst with an enhancing nodule.

Haemangioblastoma is a serious consideration, but more commonly occurs in the paravermian position; the nodule is hyperdense on non-contrast CT and they virtually never calcify.

Both lesions can be cystic with a solid enhancing nodule.

Haemangioblastomas occur more commonly in adults and as part of VHL syndrome.

Question 24

@#e2 (Ped) 58 A three-year-old boy is taken to an optician following problems reading. The optician finds the child has a loss of visual acuity and visual fields; he also did not think the boy looked well. He referred the child to the hospital. The paediatrician found the boy to be thin, hyperactive and unusually alert for his age. A CT brain was performed, which showed a mass in the suprasellar region that appeared to be extending into the optic chiasm. This had mixed enhancement with some cystic areas and calcifications. What is the most likely diagnosis?

a Hypothalamic glioma

b Hypothalamic hamartoma

C Craniopharyngioma

d Astrocytoma

e Pituitary adenoma

Answer 24

58 Answer A: Hypothalamic glioma

These are the most common hypothalamic masses accounting for 10-15% of supratentorial tumours in children and present between the ages of two and four years old.

This child is showing visual deficits and diencephalic syndrome, which is present in up to 20% of cases.

The inhomogeneous enhancement is caused by tumour necrosis.

Craniopharyngioma and astrocytomas are uncommon in these sites.

Hypothalamic hamartomas are rare and usually present before the age of two years old. They are round isodense lesions that do not enhance on CT.

Question 25

@#e2 2.A 38-year-old male with Human Immunodeficiency Virus (HIV) stopped taking his retrovirals 6 months ago and now presents with confusion. CT brain shows non-enhancing hypodensities, with apparent dilated perivascular spaces, although these were not present on a CT brain from 2 years ago. What is the most likely cause? A. Cryptococcus B. Progressive multifocal leukoencephelopathy C. Tuberculosis D. CMV encephalitis E. Toxoplasmosis

Answer 25

A. Cryptococcus More commonly cryptococcus meningitis but Cryptococcus or gelatinous pseudocysts reside in dilated perivascular spaces

Question 26

@#e2 57. A four month old male undergoes investigation for microcephaly and hearing loss. Unenhanced CT brain shows several periventricular subependymal cysts and multiple coarse periventricular and parenchymal white matter calcifications. There is diffuse hypoplasia of the cerebellum. What is the most likely diagnosis? a. Tuberous sclerosis b. Sturge–Weber syndrome c. Cytomegalovirus infection d. Venous sinus thrombosis e. Congenital rubella

Answer 26

57. c. Cytomegalovirus infection This is the most common intrauterine infection and the leading cause of brain disease and hearing loss in children. Typical imaging findings include periventricular subependymal cysts representing focal areas of necrosis and glial reaction, periventricular postinflammatory calcifications, scattered calcifications in basal ganglia and brain parenchyma, microcephaly due to disturbance of cell proliferation and hypoplasia of the cerebellum. There may also be lissencephaly, cortical dysplasia, polymicrogyria and schizencephaly due to disturbed neuronal migration.

Question 27

@#e2 (Ped) 25 You are asked to perform a cranial ultrasound scan on a neonate who was born with poor APGAR scores and made a poor inspiratory effort. On the ultrasound you find multiple irregular foci of calcification throughout the periventricular region, the thalamus and basal ganglia. What is the most likely diagnosis? a Congenital Cytornegalovirus infection b Tuberous sclerosis c Congenital toxoplasmosis infection d Grade IV acute haemorrhage e Periventricular leukomalacia due to hypoxic injury

Answer 27

25 Answer C. Congenital toxoplasmosis infection The presentation of congenital toxoplasmosis infection is very non-specific, as with most of the congenital infections. The ultrasound characteristics are different from congenital Cytornegalovirus in that the calcifications are in the basal ganglia and thalamus as well as the periventricular region. The calcifications can be lobulated or curvilinear and can be present in the choroid plexus. The location also differentiates the findings from tuberous sclerosis. Periventricular leukomalacia findings are a broad zone of periventricular echogenicity.

Question 28

@#e2 46 A 2 7-year-old HIV positive man was admitted with increasing confusion and lethargy. He had a CD4 count of 150 but had no history of an AIDS-defining illness. Cross-sectional imaging of the head was performed. What features make a diagnosis of toxoplasmosis more likely than lymphoma? a Corpus callosum involved b Haemorrhage on CT C Basal ganglia lesions d Single lesion e Subependymal spread

Answer 28

46 Answer B: Haemorrhage on CT Differentiating toxoplasmosis and cerebral lymphoma can be difficult as both can present as multiple ring enhancing lesions. Features that are more likely to represent lymphoma are a single lesions, subependymal spread and lesions within the corpus callosum. Features that are more likely to represent toxoplasmosis are haemorrhage on CT and high signal on T2 W imaging. Toxoplasmosis has a predilection for the basal ganglia but lymphoma can also be found in this region.

Question 29

@#e2 70 A 27-year-old female with AIDS presented with a fit and following further investigations, including CT and MRI scans, her symptoms were felt to be attributable to HIV encephalitis. Which region of her brain is most likely to be abnormal on the MRI scan? a Anteroinferior aspects of the temporal lobes b White matter of the centrum semiovale C Corpus striatum (putamen and caudate nuclei) d Superior cerebellar peduncles e Hypothalamus

Answer 29

70 Answer B: White matter of the centrum semiovale Human immunodeficiency virus causes encephalitis in 60% of patients with AIDS. It predominately affects the white matter, particularly the **centrum semiovale** and results in gliosis and demyelinating plaques. These plaques are not dissimilar to plaques in multiple sclerosis as they are in a periventricular position and high signal on T2-weighted images. Unlike plaques in MS they tend not to enhance with contrast. (Acute plaques in MS can enhance for up to six weeks after they first appear.) Generalised diffuse parenchymal atrophy is a feature.

Question 30

@#e2 12. Which is the cause of low attenuation in the basal ganglia? A. Hypoparathyroidism B. Pseudohypoparathyroidism C. Hypothyroidism D. Wilson’s disease E. Radiation therapy

Answer 30

D. Wilson’s disease Other causes increase CO poisoning, barbiturate intoxication, hypoxia, hypoglycaemia and lacunar infarcts.

Question 31

@#e2 31. A 58-year-old patient is found at home with a reduced GCS. CT brain reveals atrophy only. MRI brain reveals hyperintensity in the tegmentum (except for the red nucleus) and hypointensity of the superior colliculus on T2WI, as well as hyperintensity in the basal ganglia. What is the most likely cause? A. Cocaine abuse. B. Methanol poisoning. C. Primary basal ganglia haemorrhage. D. Wilson’s disease. E. Carbon monoxide poisoning.

Answer 31

31. D. Wilson’s disease. Hyperintensity in the tegmentum (except for the red nucleus) and hypointensity of the superior colliculus are described as the ‘face of the giant panda sign’ and are seen in axial T2WI sections of the midbrain in Wilson’s disease. A ‘double panda sign’ has also been described, with a second ‘panda cub face’ in the pons. Abnormal signal can also be seen in the basal ganglia and thalamus in Wilson’s disease (putamen most commonly). The signal abnormalities are due to copper deposition. Signal is generally reduced on T1WI sequences, although it may be increased due to the paramagnetic effects of copper and also due to the hepatic component of Wilson’s disease (a portocaval shunt can produce this latter finding). Signal is generally increased on T2WI sequences, but it can be of mixed or reduced intensity. Similarly carbon monoxide poisoning and methanol poisoning can cause increased or reduced signal on T1WI. Methanol poisoning typically causes abnormal signal in the putamen, with haemorrhagic necrosis being more typical, whereas carbon monoxide poisoning typically affects the globus pallidus. The latter would be expected to cause low attenuation in the basal ganglia on CT. The findings on CT exclude basal ganglia haemorrhage. Amphetamine and cocaine abuse can cause high T2WI signal in the basal ganglia due to small areas of infarction, but are not associated with the midbrain changes.

Question 32

@#e2 34. A 34-year-old liver transplant recipient presents to hospital with confusion and seizures. A CT brain reveals low attenuation in the deep and subcortical white matter of the occipital and parietal lobes bilaterally. There is no abnormal enhancement post IV contrast administration. As the reporting radiologist, you advise that the clinical team first: A. measure blood glucose B. measure serum alpha-feta protein C. measure blood pressure D. send coagulation screen E. measure d-dimer.

Answer 32

34. C. Measure blood pressure The CT findings are consistent with PRES. This is a usually reversible neurological syndrome with a variety of presenting symptoms ranging from altered mental status to seizures, headache, and loss of vision. Common causes include hypertension, eclampsia and preeclampsia, immunosuppressive medications such as cyclosporine, various antineoplastic agents (including interferon), SLE, and various causes of renal failure. Hypertension is common in PRES, but may be mild and is not universally present, especially in the setting of immunosuppression. However, in the vignette given, hypertension is a possible cause and should be sought. Cyclosporin or tacrolimus might be causes; the former is thought to result in PRES both via a direct neurotoxic effect and by causing hypertension. The condition is not always reversible and may result in haemorrhagic infarcts. The classic MRI finding is of hyperintensity on FLAIR in the parieto-occipital and posterior frontal cortical and subcortical white matter. Less commonly the brainstem, basal ganglia, and cerebellum are involved. Atypical imaging appearances include contrast enhancement, haemorrhage, and restricted diffusion on MRI. Abnormalities can often be seen on CT, as described in the vignette.

Question 33

@#e2 37. A 73-year-old has been referred for assessment of cognitive decline. A CT brain reveals cerebral atrophy and a dementia specialist refers her for PET-CT brain. Which of the following findings is most consistent with early Alzheimer’s disease? A. Diffuse reduced activity. B. Reduced activity in the precuneus and posterior cingulate gyrus. C. Reduced activity in the frontotemporal regions. D. Reduced activity in the caudate and lentiform nuclei. E. Reduced activity bilaterally in the occipital cortex.

Answer 33

37. B. Reduced activity in the precuneus and posterior cingulate gyrus. FDG-PET-CT has been shown to have a sensitivity and specificity of 93% for mild to moderate Alzheimer’s disease. The technique has been shown to provide important prognostic information so that a negative PET-CT scan is indicative of unlikely progression of cognitive impairment for a mean follow-up of 3 years in those patients who initially present with cognitive symptoms of dementia. The more specific findings on PET-CT in Alzheimer’s disease are early reduced activity in the precuneus/posterior cingulate gyrus and the superior, middle, and inferior temporal lobe gyrus, with relative sparing of the primary sensorimotor and visual cortex, and sparing of the striatum, thalamus, and cerebellum. Diffuse reduced activity of the cortical/subcortical regions and cerebellum is more typical of multiinfarct dementia. Reduced activity in the fronto-temporal regions is more consistent with fronto-temporal dementia. Reduced activity in the occipital cortex reflects the visual problems encountered in lewy body dementia. Reduced activity in the caudate and lentiform nuclei is more typical of Huntingdon’s chorea.

Question 34

@#e2 (CNS) 9 A plain radiograph is performed on a male child. Unilateral, premature fusion of both the coronal and lambdoid sutures is evident. What is the most appropriate description? (a) Scaphocephaly (b) Brachycephaly (c) Plagiocephaly (d) Trigonocophaly (e) Oxycephaly

Answer 34

(c) Plagiocephaly The common craniosynostoses include:

Question 35

@#e2 11 A cranial US is performed in a pre-term neonate. There is hyperechoic material within the ventricles consistent with recent haemorrhage, but the ventricles are not dilated. How would you grade this germinal matrix bleed? (a) Grade I (b) Grade II (c) Grade Ill (d) Grade IV (e) Grade V

Answer 35

(b) Grade II Grade I: subependymal haemorrhage, Grade II: intraventricular haemorrhage, no ventricular dilation (10% mortality), Grade Ill: intraventricular hemorrhage with ventricular dilation (20% mortality), Grade ·IV: intraparenchymal haemorrhage (>50% mortality). There is no Grade V.

Question 36

@#e2 21 Which of the following is not a cause of secondary craniosynostosis? (a) Crouzon's syndrome (b) Hypothyroidism (c) Previous shunt procedures (d) Rickets (e) Thalassaemia

Answer 36

(b) Hypothyroidism Craniosynostosis is the premature closure of the sutures, which may be primary (idiopathic) or secondary. Secondary causes include: metabolic (rickets, hypercalcaemia, hyperthyroidism, hypervitaminosis D), haematological (thalassaemia, SCD), and bone dysplasias (achondroplasia, metaphyseal dysplasia). It is also associated with syndromes (Crouzon, Apert, Treacher-Collins), and can occur following shunt surgery for hydrocephalus.

Question 37

@#e2 49 A 4 week old ex-premature baby has a witnessed seizure. A cranial US is performed which shows cystic structures bilaterally, adjacent to the trigone of the lateral ventricles. Which of the following favours a diagnosis of chronic periventricular leukomalacia over porencephaly? (a) Anechoic cysts (b) Persistenae of cysts on follow-up US (c) Septated cysts (d) Symmetrical distribution (e) Watershed territory distribution

Answer 37

(d) Symmetrical distribution PVL is more common in preterm children, is secondary to ischaemia and usually occurs in the watershed areas. Initially there will be hyperechoic changes which gradually become cystic (>2 wks); the cysts are never septated and usually resolve over time. Porencephaly can be developmental or due to a vascular or infectious process which destroys brain tissue; it is almost always asymmetrical, rarely disappears over time and is often seen as an extension of the ventricle or sub-arachnoid space. If secondary to ischaemia it can also be in a watershed distribution.

Question 38

@#e2 53. Regarding rhabdomyosarcoma in the paediatric population. What is the most likely site of origin? (a) Extremities (b) Genito-urinary system (c) Head and neck (d) Orbits (e) Retroperitoneal

Answer 38

(c) Head and neck Rhabdomyosarcoma represents 4-8% of cancers in children and is the 4th commonest after CNS tumours, neuroblastoma and Willl)'s and is the commonest soft tissue sarcoma in children. The sites affected are: head and neck (28%), extremities (24%), genitourinary system, trunk (11%), orbits (7%), and retroperitoneum (6%); other sites in <3%.

Question 39

@#e2 (MSK) 58 A 30 year old patient presents with multiple bilateral renal angiomyolipomas, one of which has bled. She is also found to have a giant cell astrocytoma in her brain and bilateral interstitial lower lobe fibrosis on CXR. Which of the following bone lesions is most commonly associated with this condition? (a) Bone cysts (b) Osteochondroma (c) Giant cell tumour (d) Fibrous dysplasia (e) Adamantinoma

Answer 39

(a) Bone cysts The underlying condition described is tuberous sclerosis. The associated bone cysts most commonly affect the small bones of the hand. Other skeletal features include sclerotic bone islands which most commonly affect the calvarium (in 45% of cases) and also the pelvis and long bones.

Question 40

@#e2 37 A 64-year-old lady is being consented for a diagnostic cerebral angiogram for a suspected MCA aneurysm. She asks about the risk of stroke. What is the risk due to the angiogram? a 4.7% b 0.2% c 1.3% d 10% e 3.5%

Answer 40

37 Answer C: 1.3% The risk of stroke due to an angiogram is approximately 1.3 %.

Question 41

@#e2 22 You are considering the utility of CT in detecting acoustic neuromas and read a study evaluating its use in 200 people of whom 10 actually had the condition. The study reports that CT was reported as abnormal in seven patients and there were 188 true negatives. What is the sensitivity of CT for detection of acoustic neuroma in this study? a 2.5% b 29% c 50% d 70% e 99%

Answer 41

22 Answer C: 50% Sensitivity is a measure of how well the test picks up the disease if it is present; that is, true positives/(true positives and false negatives). Specificity is a measure of how often the test is negative when the disease is not present; that is, true negatives/(true negatives + false positives).

Question 42

@#e2 17 A 55-year-old woman is being treated for hyperthyroidism using I131. How soon after it is ingested should imaging be performed? a Within 30 minutes b 1-2 hours c 6 hours d 24 hours e One week

Answer 42

17 Answer D: 24 hours I131 has a half-life of eight days and is usually taken as an oral preparation for the treatment of hyperthyroidism. Patients are typically imaged 24 hours after ingesting the I131. Antithyroid drugs are stopped six weeks before treatment to ensure maximum uptake of I131. Patients can remain on symptomatic management, such as beta-blocker type drugs, to reduce symptoms. The peak energy of 1131 is 364keV and the absorbed dose is 50-100cGy (rad). 1123 has a half-life of 13 hours and is ingested orally; imaging is typically performed after six hours. The peak energy is 159 keV and the absorbed dose is 2-5 cGy (rad).

Question 43

@#e2 2. The following skull foramina transmit the named cranial nerves: (T/F) (a) Superior orbital fissure –VIth cranial nerve. (b) Foramen ovale – orbital division of Vth cranial nerve (c) Inferior orbital fissure – IIIrd cranial nerve. (d) Internal auditory meatus – VIIth cranial nerve. (e) Foramen rotundum – maxillary division of Vth cranial nerve.

Answer 43

Answers: (a) Correct (b) Not correct (c) Not correct (d) Correct (e) Correct Explanation: The inferior orbital fissure transmits the infraorbital nerve (i.e. continuation of the second division of the fifth cranial nerve) and emissary veins that drain the inferior ophthalmic vein to the pterygoid plexus. The foramen ovale transmits the mandibular division of fifth cranial nerve and the accessory meningeal artery. The internal auditory meatus contains the seventh and eighth cranial nerves as well as the internal auditory artery.

Question 44

@#e2 33. A 65 year old woman is investigated for enophthalmos and headache. She is cachetic, anaemic and you suspect a metastatic process. CT head demonstrates an infiltrative retrobulbar mass. What is the most likely site of primary disease? a. Breast b. Lung c. Renal d. Melanoma e. Ovarian

Answer 44

33. a. Breast Most retrobulbar metastases are extraconal (outside the muscle cone). Neuroblastoma and Ewing’s sarcoma are the most common in children and produce smooth extraconal masses related to the posterior lateral wall of the orbit. In adults, an infiltrative retrobulbar mass and enophthalmos is characteristic of scirrhous carcinoma of the breast (invasive ductal carcinoma). Enophthalmia is also considered to be one of the earliest signs of metastatic breast cancer.

Question 45

@#e2 59 A patient presents with pulsatile tinnitus. CT reveals a mass in the left temporal bone and there is focal uptake with 111 1n octreotide imaging. Which of the following is least likely? (a) Glomus tympanicum (b) Meningioma (c) Carcinoid metastasis (d) Small cell cancer metastasis (e) Metastasis of papillary carcinoma of the thyroid

Answer 45

(e) Metastasis of papillary carcinoma of the thyroid Octreotide is a somatostatin analogue, and uptake is seen where somatostain receptors are expressed, such as neuroendrocine tumours (e.g., glomus tympanicum), and other malignancies (e.g., small cell lung cancer, lymphoma, and breast cancer). There is also uptake in a few tumours that do not express the receptor (e.g., meningioma, astrocytoma).

Question 46

@#e2 (Ped) 82) A 13-year-old male presents with recurrent epistaxis. CT shows a highly vascular mass in the nasopharynx, with widening of the pterygopalatine fossa and invasion of the sphenoid sinus. Which arterial branch is the feeding vessel likely to be arising from? a. ascending pharyngeal b. facial artery c. superficial temporal artery d. internal maxillary artery e. internal carotid artery

Answer 46

d. internal maxillary artery Juvenile angiofibromas are the commonest benign tumour of the nasopharynx and can grow to enormous sizes. They tend to present in teenagers with recurrent and severe epistaxis, as well as nasal obstruction. They are highly vascular and biopsy is contraindicated. In most cases, they are supplied primarily by the internal maxillary artery

Question 47

@#e2 (Ped) 82) A 13-year-old male presents with recurrent epistaxis. CT shows a highly vascular mass in the nasopharynx, with widening of the pterygopalatine fossa and invasion of the sphenoid sinus. Which arterial branch is the feeding vessel likely to be arising from? a. ascending pharyngeal b. facial artery c. superficial temporal artery d. internal maxillary artery e. internal carotid artery

Answer 47

d. internal maxillary artery Juvenile angiofibromas are the commonest benign tumour of the nasopharynx and can grow to enormous sizes. They tend to present in teenagers with recurrent and severe epistaxis, as well as nasal obstruction. They are highly vascular and biopsy is contraindicated. In most cases, they are supplied primarily by the internal maxillary artery

Question 48

@#e2 48 Which of the following is not involved in a Le Fort type II fracture? (a) Pterygoid plates (b) Orbital floor (c) Anterior wall of the maxillary sinus (d) Postero-lateral wall of the maxillary sinus (e) Medial wall of the maxillary sinus

Answer 48

(e) Medial wall of the maxillary sinus The medial wall of the maxillary sinus is spared in a type II fracture. The pterygoid plates are involved in all Le Fort fractures.

Question 49

@#e2 QUESTION 45 A 24-year-old woman presents to her GP with jaw stiffness and headaches. Her partner complains that she grinds her teeth during the night. She attends for an MRI scan to visualise the temporomandibular joints. Sequences are performed with the mouth open and closed. Which of the following radiological findings are most likely? A Anterolateral displacement of the biconcave articular disc on mouth closing B Anteromedial displacement of the biconcave articular disc on mouth opening C Anteromedial displacement of the biconvex articular disc on mouth opening D Posterior displacement of the biconcave articular disc on mouth opening E Posterior displacement of the biconvex articular disc on mouth opening

Answer 49

B Anteromedial displacement of the biconcave articular disc on mouth opening

Question 50

@#e2 8 A neck lump is found on clinical examination. Axial MR images of the neck demonstrate a mass displacing the parapharyngeal space posteromedially and the styloid musculature posteriorly. In which fascial space is the mass most likely to be located? (a) Masticator space (b) Carotid space (c) Pharyngeal mucosal space (d) Parotid space (e) Retropharyngeal space

Answer 50

(a) Masticator space The displacement of the parapharyngeal space and styloid musculature can help localise neck lesions:

Question 51

@#e2 42. You are reporting a CT scan of neck in a patient with a head and neck cancer. You see an enlarged necrotic jugulo-digastric lymph node on the right side and wish to describe the appropriate level of this lymph node in your report. What is the correct level? A. I. B. II. C. III. D. IV. E. V. F. VI. G. VII.

Answer 51

42. B. II. Lymph nodes in the neck have been divided into seven levels, generally for the purpose of squamous cell carcinoma staging. This is, however, not all inclusive, as the parotid nodes and retropharyngeal space nodes are not included in this system. Level I: Below mylohyoid to hyoid bone anteriorly Level Ia: Submental Level Ib: Submandibular Level II: Jugulodigastric (base of skull to hyoid) Level III: Deep cervical (hyoid to cricoid) Level IV: Virchow (cricoid to clavicle) Level V: Posterior triangle groups Level Va: Accessory spinal (posterior triangle), superior half Level Vb: Accessory spinal (posterior triangle), inferior half Level VI: Prelaryngeal/pretracheal/Delphian node Level VII: Superior mediastinal (between common carotid arteries (CCAs), below top of manubrium) Lymph node levels of the neck.

Question 52

@#e2 49. On a thyroid radioisotope study, which is a cause of a hot thyroid nodule? A. Involutional nodule B. Focal thyroiditis C. Adenomatous hyperplasia D. Granuloma E. Abscess

Answer 52

C. Adenomatous hyperplasia Other causes include autonomous adenoma and, very rarely, thyroid cancer. Any hot nodule on Tc-99m should be imaged with I-123 to differentiate between autonomous and cancerous lesions.

Question 53

@#e2 30. Regarding radionuclide imaging of thyroid cancers, which radiological finding best fits the diagnosis? a. Usually concentrates radioiodine – follicular carcinoma b. Usually concentrates pertechnetate – papillary carcinoma c. Usually concentrates pertechnetate and radioiodine – papillary carcinoma d. No radioiodine or pertechnetate uptake but frequently concentrates thallium-201 – medullary carcinoma e. No radioiodine or pertechnetate uptake but frequently concentrates thallium-201 – anaplastic carcinoma

Answer 53

30. d. No radioiodine or pertechnetate uptake but frequently concentrates thallium-201 – medullary carcinoma Types of thyroid carcinoma in order of worsening prognosis are papillary, follicular, medullary and anaplastic. Papillary tumours usually concentrate radioiodine, follicular tumours concentrate pertechnetate but fail to accumulate radioiodine, and anaplastic tumours show no radioiodine uptake.

Question 54

@#e2 Ped) 27 A father of a two-month-old boy is concerned that his son has been getting progressively blue, which becomes more apparent when he cries. On examination he is cyanosed with a pansystolic murmur. A CXR reveals a moderately enlarged heart. What is the likely diagnosis? a Tetralogy of Fallot b Corrected transposition of great arteries C Pulmonary atresia d Tricuspid atresia e Patent ductus arteriosus

Answer 54

27 Answer D: Tricuspid atresia Tricuspid atresia is the second most common cause of neonatal cyanosis after transposition of the great arteries. It is characterised by an absent tricuspid valve, ASD, and a small VSD. Most occur in the absence of transposition (80%), but it may also occur in the setting of transposition. The heart may be normal in size or moderately enlarged with enlargement and hypertrophy of the left ventricle and enlargement of the right atrium.

Question 55

@#e2 49. Which of the following are correct regarding transposition of the great arteries (TGA)? (T/F) (a) Pulmonary stenosis is an associated feature. (b) In the D loop of TGA the atria and ventricles have a normal morphological relationship. (c) Dextrocardia is associated with L loop of TGA. (d) Chest radiograph shows pulmonary plethora in D loop of TGA. (e) In the L loop (corrected) transposition there is physiologically corrected circulation.

Answer 55

Answers: (a) Correct (b) Correct (c) Correct (d) Correct (e) Correct Explanation: In the D loop of TGA the aorta arises from the right ventricle and the pulmonary artery from the left ventricle. A normal relationship exists between the atria and the ventricles. In the L loop of TGA, there is transposition of the aorta and pulmonary arteries in addition to inversion of the left and right ventricles. The atria and coronary arteries are associated with their corresponding ventricles.

Question 56

@#e2 28. A 55-year-old man with a recent diagnosis of multifocal hepatocellular carcinoma is referred for transarterial chemoembolisation. Which of the following statements regarding hepatic arterial anatomy is true? A. The classic hepatic arterial anatomy, with the proper and hepatic artery dividing into the right and left hepatic arteries, is seen in approximately 80% of the population. B. Accessory left hepatic artery from left gastric artery is seen in 25% of cases. C. Replaced right hepatic artery commonly arises from the gastroduodenal artery. D. Replaced left hepatic artery commonly arises from the left gastric artery. E. The common hepatic artery is a branch of the superior mesenteric artery.

Answer 56

28. D. Replaced left hepatic artery commonly arises from the left gastric artery. The classic hepatic arterial anatomy, with the proper and hepatic artery dividing into the right and left hepatic arteries, is seen in approximately 55% of the population. Variations in hepatic arterial anatomy are common. A replaced right hepatic artery from the superior mesenteric artery is seen in 11%. A replaced left hepatic artery arising from the left gastric artery is seen in 10%. The entire hepatic trunk may be replaced, which may arise from the superior mesenteric artery (4.5%) or left gastric artery (0.5%). The common hepatic artery is a branch of the coeliac axis.

Question 57

@#e2 13 A 46-year-old Russian sailor presented with malaise and chest pain. In the course of the investigations he underwent CT scanning of his chest and abdomen. His VDRL and MHA-TP (for Treponerna pallidurn) tests are positive. What is the most likely finding on his CT? a Saccular aneurysm of the ascending aorta with thin, dystrophic wall calcification b Saccular aneurysm of the ascending aorta with interrupted calcification, para-aortic gas collection and adjacent reactive lymph node enlargement C Fusiform aneurysm of the descending aorta with cresenteric mural thrombus. There is ectasia of the remainder of the aorta with heavy atherosclerosis d Fusiform aneurysm of the abdominal aorta demonstrating mural thickening and extensive surrounding fibrosis e Fusiform aneurysm of the descending aorta with an irregular wall and active extravasations of intravenous contrast

Answer 57

13 Answer A: Saccular aneurysm of the ascending aorta with thin, dystrophic wall calcification This is the typical description of a syphilitic aneurysm. Options B, C, D and E are typical of a mycotic aneurysm, an atherosclerotic aneurysm, an inflammatory aneurysm and an actively leaking aneurysm respectively.

Question 58

@#e2 20. Which of the following are correct regarding fibromuscular dysplasia (FMD): (T/F) (a) Is more common in males. (b) Usually affects the intimal layer. (c) Renal artery FMD is bilateral in 5% of cases. (d) Can occur in veins. (e) May present with a transient ischaemic attack.

Answer 58

Answers: (a) Not correct (b) Not correct (c) Not correct (d) Correct (e) Correct Explanation: FMD is more common in females and presents between 15 to 50 yrs. Medial fibroplasia is more common form of FMD with characteristic ‘strings of beads’ appearance. Intimal fibroplasia occurs in 10% of cases and adventitial hyperplasia is the rarest form. Renal artery FMD is bilateral in approximately 30% of cases.

Question 59

@#e2 22. Vascular anatomy of the liver: (T/F) (a) The middle hepatic vein divides the liver into anatomical right and left lobes (Couinard classification). (b) At microscopic level, centrilobular veins drain into the portal circulation. (c) The portal vein bifurcation is intrahepatic in 90% of cases. (d) The right hepatic artery arises solely from the superior mesenteric artery in 10-15% of individuals. (e) In the fetus, the ducutus venosus joins the right portal vein to the inferior vena cava.

Answer 59

Answers: (a) Correct (b) Not correct (c) Not correct (d) Correct (e) Not correct Explanation: The hepatic lobule is the basic histological unit. The triads of hepatic arterioles, portal venules and bile duct branches run at the edge of the lobule. Blood flows from periphery inwards via hepatic sinusoids and is drained bycentrilobular veins which in turn drain into hepatic veins. The portal bifurcation is extrahepatic in 40% - 80% cases. Left portal vein is critical to fetal circulation as it receives blood from the placenta via the left umbilical vein and delivers it across the liver to the IVC via ductus venosus.

Question 60

@#e2 26- A 66-year-old man presents with right thigh claudication on walking 20 yards. He is referred for an angiogram with a view to possible angioplasty. The angiogram demonstrates a 3-cm focal stenosis of the right extremal iliac artery with no other significant disease seen. What sized balloon would be appropriate for attempted angioplasty? (a) 3 mm (b) 5 mm (c) 7 mm (d) 10 mm (e) 13 mm

Answer 60

(c) 7 mm The more distal the occlusion, the smaller the balloon required for angioplasty, if the balloon is too big there is an increased risk of arterial rupture; if it's too small there is a reduced probability of success. Appropriate balloon sizes include: popliteal artery 3-4 mm, SFA or renal artery 4-6 mm, ElA 6-8 mm, and common iliac 8—10 mm.

Question 61

@#e2 38 Regarding catheters used for interventional angiography. Which of the following catheters is inappropriate for imaging the respective artery? (a) Bernstein - superior mesenteric artery (b) Cobra - renal artery (c) Pigtail - abdominal aorta (d) Sidewinder (Simmons) - coeliac axis (e) Straight catheter - iliac artery

Answer 61

(a) Bernstein - superior mesenteric artery Catheters are sized using the French system: the circumference in mm (diameter is roughly this measurement divided by 3, i.e. 6 Fr has approximately 2 mm diameter). Sheaths are sized in French measurement of their internal diameter (i.e. a 4Fr sheath can hold a 4 Fr catheter). Bernstein catheters are upwards pointed, thus they are ideal for accessing branches of the aortic arch. Access to the downwardly orientated mesenteric vessels would be technically very challenging with a Bernstein catheter - the downward facing sidewinder, or even the sidefacing cobra catheters can be used.

Question 62

@#e2 41- Which of the following CT features indicates post-primary rather than primary pulmonary tuberculosis? (a) Miliary nodules (b) Bronchiectasis (c) Cavitation (d) Tree-in—bud opacification (e) Lymphadenopathy

Answer 62

(a) Miliary nodules The difference between primary and post—primary (reactivated) TB is in the degree Of previous exposure the patient has had to T B. Most features are seen in both to some degree with the exception of miliary nodules.

Question 63

@#e2 47. A 45-year-old woman had allogenic bone marrow transplant for treatment of leukaemia. Two weeks later she developed cough and shortness of breath. CT demonstrates bilateral ground-glass shadowing, thickened interstitial lines and bilateral pleural effusion. What is the most likely diagnosis? (a) Bronchiolitis obliterans (b) Drug toxicity (c) Pulmonary oedema (d) Diffuse alveolar haemorrhage (e) Bronchiolitis obliterans organising pneumonia

Answer 63

47. (c) Pulmonary oedema This is usually secondary to fluid overload and associated renal dysfunction. Bronchiolitis obliterans and bronchiolitis obliterans organising pneumonia are late complications seen after 3 months. Drug toxicity and alveolar haemorrhages may present with ground-glass shadowing but do not show pleural effusions or interstitial involvement.

Question 64

@#e2 73 In the assessment of a thoracic CT, which of the following features is least supportive of a diagnosis of nonspecific interstitial pneumonitis? (a) Traction bronchiectasis (b) Volume loss (c) Ground glass opacifrcation (d) Thin-walled cysts (e) Reticular abnormality

Answer 64

(d) Thin-walled cysts Thin-walled cysts are not a feature of NSIP but should raise the possibility of LIP. The remaining features are typical. Consolidation, honeycombing and nodules are variably reported in the literature as being present or absent.

Question 65

@#e2 9. A 48-year-old female non-smoker presents to the Accident & Emergency Department with acute dyspnoea and chest pain. The chest radiograph shows bilateral basal airspace shadowing. Chest CT shows disuse basal consolidation and air-bronchograms within a background of ground-glass opacity. There is septal thickening and bilateral pleural effusions. The most likely diagnosis is? (a) Desquamative interstitial pneumonitis (b) Lymphocytic interstitial pneumonitis (c) Acute interstitial pneumonia (d) Usual interstitial pneumonitis (e) Cryptogenic organising pneumonia

Answer 65

9. (c) Acute interstitial pneumonia This clinically presents as adult respiratory distress syndrome and has high mortality. It has a fulminant course leading to respiratory failure and requiring mechanical ventilation with a mortality of > 50%. CT findings are non-specific but include bilateral, diffuse ground-glass opacity with consolidation and air bronchograms. Honeycombing and traction bronchiectasis may be seen in advanced cases after recovery.

Question 66

@#e2 9 A 45 year old man is referred from chest clinic with a cough and intermittent breathlessness. A CT of his thorax demonstrates ill-defined centrilobular nodules and a mosaic attenuation pattern, exacerbated on expiratory phase imaging. What is the most likely diagnosis? (a) Respiratory bronchilitis-interstitial lung disease (b) Chronic pulmonary thrombo-embolism (c) Sarcoidosis (d) Extrinsic allergic alveolitis (e) Lymphocytic interstitial pneumonitis

Answer 66

(d) Extrinsic allergic alveolitis The clinical features are non-specific, but many patients with EAA (also known as hypersensitivity pneumonitis) have exacerbati,on of symptoms on exposure to the antigen, e.g. returning to the workplace. EAA has acute, sub acute and chronic phases which may progress to widespread pulmonary fibrosis. The mosaic attenuation with gas trapping described here is a characteristic finding.

Question 67

@#e2 QUESTION 29 You are asked to review the CT scan of an elderly female patient who has evidence of left upper lobe collapse on a CXR. On CT, in which one of the following directions will the left upper lobe have collapsed? A Anteriorly and laterally B Anteriorly and medially C Inferiorly and medially D Posteriorly and medially E Superiorly and medially

Answer 67

B Anteriorly and medially Left upper lobe collapse results in volume loss in an anterior and medial direction, as opposed to superior and medial collapse of the right upper lobe collapse.

Question 68

@#e2 50 A 40-year-old schoolteacher presented with a non-productive cough, dyspnoea and low-grade pyrexia. She has never smoked. The CXR demonstrated several bilateral areas of patchy consolidation which were confirmed on HRCT and shown to be in a mainly sub-pleural distribution. In addition there is also patchy ground-glass change and small (<5 mm) centrilobular nodules). What is the most likely diagnosis? a Bronchoalveolar cell carcinoma b Histoplasmosis C Sarcoidosis d Cryptogenic organising pneumonia e Multifocal streptococcal pneumonia

Answer 68

50 Answer D: Cryptogenic organising pneumonia These imaging findings are classical of COP. Effusions and adenopathy are also present in up to one third of patients. Bronchoalveolar cell carcinoma is an important differential, but is most commonly solitary and centrilobular nodules are not a feature, and there is a strong smoking association.

Question 69

@#e2 32 Plain radiographic signs seen more commonly in patients with acute pulmonary embolism include all but which of the following? (a) Cardiomegaly (b) Decreased vascularity (c) Pulmonary oedema (d) Pleural opacity (e) Atelectasis

Answer 69

(c) Pulmonary oedema Pulmonary oedema is seen in patients with PE rarely (4% vs 13% in patients without PE). Other signs include pleural effusion.

Question 70

@#e2 33 A patient with a known malignancy presented with acute shortness of breath. The attending physician requested CT pulmonary angiogram to exclude a pulmonary embolus. A filling defect was seen in the left lower pulmonary artery with a wedge-shaped collapse distal to it. Which primary tumour is most frequently associated with pulmonary embolism? a Lung carcinoma b Hepatocellular carcinoma C Gastric carcinoma d Ovarian cystadenoma e Prostate carcinoma

Answer 70

33 Answer C: Gastric carcinoma Ovarian carcinoma and extra hepatic bile duct carcinomas also demonstrate a high rate of pulmonary emboli.

Question 71

@#e2 38- A 40-year-old Woman presents hemoptysis- CXR shows multiple cavitating lesions in both lungs- Needle biopsy confirms the lesions are metastatic. Which of the following is the least likely cause? (a) Squamous cell carcinoma of the larynx (b) Adenocarcinoma of the cervix (c) Transitional cell carcinoma of the bladder (d) Adenocarcinoma of the colon (e) Giant cell tumor of the distal femur

Answer 71

(e) Giant cell tumor of the distal femur The differential diagnosis for cavitating metastases also includes melanoma. Giant cell tumor metastases may calcify.

Question 72

@#e2 17. The staging chest CT of a 40 year old man with a known primary malignancy demonstrates cavitating pulmonary metastases. The least likely type of primary lesion would be: a. Squamous cell carcinoma b. Malignant melanoma c. Renal cell cancer d. Sarcomas e. Colonic carcinoma

Answer 72

17. c. Renal cell cancer

Question 73

@#e2 QUESTION 32 A middle-aged man has recently had a CT abdomen performed for chronic lower left abdominal pain. Whilst mild sigmoid diverticular disease was present, it was also noted that there was significant para-aortic lymphadenopathy. Lymphoma was the suspected diagnosis and a chest CT was performed, prior to biopsy. "Which additional CT finding is most likely to suggest a diagnosis of non-Hodgkin’s lymphoma rather than Hodgkin's disease? A Isolated pulmonary consolidation B Paramediastinal interstitial fibrosis C Peripheral subpleural masses with a pleural effusion D Peripheral subpleural masses without a pleural effusion E Pulmonary consolidation with mediastinal lymphadenopathy

Answer 73

A Isolated pulmonary consolidation At presentation, Hodgkin's disease most commonly has lung parenchymal disease accompanied by intrathoracic adenopathy, whereas isolated lung involvement is not uncommon in non-Hodgkin's lymphoma. Pleural effusions (unilateral) are common in both types of lymphoma, as are peripheral subpleural masses. Consolidation with air bronchograms can also be seen in both diseases.

Question 74

@#e2 31 A 32-year-old man developed a low-grade fever and weight loss and was found to have Hodgkin's lymphoma with lymphadenopathy in both thorax and abdomen. Involvement of which extra-nodal site is associated with the worst prognosis? a Pleural effusion b Spleen c Thymus d Bone e Small intestine

Answer 74

31 Answer E: Small intestine.

Question 75

@#e2 36 A 55-year-old man presented with a persistent cough and wheeze. CT of his thorax showed a solitary 2-cm endobronchial polypoidal mass that enhanced vividly in the late arterial phase. There were no other positive findings and a PET scan showed no uptake in this lesion. From which artery is the blood supply to this lesion most likely to be derived? a Pulmonary artery b Bronchial artery c Adjacent intercostal artery d Internal mammary artery e Inferior thyroid artery

Answer 75

36 Answer B: Bronchial artery Pulmonary carcinoid is a slow-growing low-grade malignant vascular tumour supplied by the bronchial circulation.

Question 76

@#e2 43 An 18-year-old male was investigated for lethargy and haemoptysis. A chest radiograph revealed multiple lung nodules, which contained small irregular calcifications. Assuming these lesions to be metastases, what it the most likely underlying primary tumour? a Pancreas b Renal C Prostate d Testis e Lung

Answer 76

43 Answer D: Testis Other primary malignancies causing calcification within metastases include breast, colon (mucinous adenocarcinoma), osteosarcoma and ovarian.

Question 77

@#e2 2. With regards to imaging of primary extranodal lymphomas, in which of the following sites does extranodal Hodgkin’s disease most commonly occur? A. Spleen B. Thymus C. Thyroid D. Small bowel E. Lung

Answer 77

B. Thymus When the main bulk of disease at an extranodal site, a lymphoma should be classified as the extranodal type, as these have distinctive pathological, radiological and clinical features from nodal lymphomas. The thymus is the only extranodal site where Hodgkin’s lymphoma commonly occurs, and almost all cases are of the nodular sclerosing subtype.

Question 78

@#e2 29. Plain radiographs of a previously well 60-year-old man with lower limb pain show lamellar periosteal reaction in the diametaphyseal regions. Bone scintigraphy demonstrates symmetrical increased uptake along the cortical margins in the diametaphyseal regions. What is the most likely underlying thoracic cause? A. Pulmonary haemangioma B. Pleural fibroma C. TB D. Blastomycosis E. Malignant mesothelioma

Answer 78

B. Pleural fibroma Hypertrophic osteoarthropathy is commonly associated with primary bronchogenic carcinoma, typically non-small-cell lung cancer (NSCLC). HOA is also seen in patients with pulmonary metastases from extrathoracic malignancies such as breast carcinoma, nasopharyngeal tumours, renal cell carcinoma, melanoma and osteosarcoma. Benign associations include pleural fibroma and bronchiectasis.

Question 79

@#e2 17) A 65-year-old man presents with painful wrists and ankles. There is no digital clubbing. A chest radiograph shows a well-defined pleural mass, forming an obtuse angle with the chest wall. CT confirms an ovoid, plurally based, enhancing mass with no bone destruction, effusion or volume loss. Radiographs of the wrists and ankles show symmetrical periosteal reaction. What is the most likely diagnosis? a. hypertrophic osteoarthropathy with bronchogenic carcinoma b. hypertrophic osteoarthropathy with malignant mesothelioma c. hypertrophic osteoarthropathy with pleural fibroma d. rheumatoid arthritis e. tuberculosis

Answer 79

c. hypertrophic osteoarthropathy with pleural fibroma The periosteal reaction is typical of hypertrophic osteoarthropathy (HOA), which has many causes, both intra- and extra thoracic. It is associated with bronchogenic carcinoma and malignant mesothelioma, but features of the described lesion are not typical of either of these, and are more in keeping with pleural fibroma. These are associated with HOA in 20–35% of cases and rarely with clubbing. They may arise in pleura adjacent to the chest wall or in a fissure, and can vary in size from 2 cm to 30cm in diameter. Tuberculosis is a rare cause of HOA. Rheumatoid arthritis is associated with bilateral periosteal reactions, but not HOA.

Question 80

@#e2 14) A 3-day-old boy presents with respiratory distress without cyanosis. Clinically, there is reduced air entry in the right hemithorax with dull percussion note. A chest radiograph shows an opaque right hemithorax with mediastinal shift to the left. Ultrasound scan shows a large effusion, which aspiration demonstrates to be milky. What is the most likely cause? a. idiopathic b. birth trauma c. lymphangioleiomyomatosis d. thoracic duct atresia e. lymphangiectasia

Answer 80

a. idiopathic Chylothoraces in neonates are usually right sided, and in most cases no obvious cause is found. Treatment is conservative with special formula and intermittent aspiration. All of the listed conditions are causes of chylothorax, but lymphangioleiomyomatosis presents in adult females and not in the neonatal period.

Question 81

@#e2 41. A seven year old girl with repeated chest infections and chronic cough presents with another episode of acute exacerbation. She is known to have raised sodium and chloride in her sweat. Which of the following features is least likely on an HRCT of her chest? a. Cylindrical bronchiectasis b. Centrilobular emphysema c. Segmental/subsegmental atelectasis d. Branching intrabronchial soft tissue e. Hilar lymphadenopathy

Answer 81

41. b. Centrilobular emphysema All the features described are of cystic fibrosis except centrilobular emphysema. They usually develop paraseptal emphysema.

Question 82

@#e2 59 A neonate has a CXR for respiratory distress following a precipitous normal vaginal delivery at term. This shows mild cardiomegaly and mild hyperexpansion but no focal lung abnormality. Which of the following is the most likely underlying diagnosis? a Respiratory distress syndrome b Transient tachypnoea of the newborn C Meconium aspiration d Group B Streptococcal pneumonia e Pulmonary haemorrhage

Answer 82

59 Answer B: Transient tachypnoea of the newborn Cardiomegaly in neonates has multiple causes including hypoglycaemia, congenital heart disease, asphyxia and infants of diabetic mothers.

Question 83

@#e2 52 A 62-year-old patient with ongoing dyspnoea underwent CT of the chest. Among other findings it demonstrated two ill-defined foci of consolidation within the posterior and apical segments of the right upper lobe. In addition, within the remainder of the right lung, and to a lesser extent the left lung, there was a more diffuse abnormality characterised by small (<4 mm) centrilobular, well-defined nodules within 1 cm of the pleural surface. These nodules were connected by linear, branching opacities. What is the most likely cause for these findings? a Obliterative bronchiolitis b Primary pulmonary lymphoma C Respiratory syncytial virus infection d Reactivation tuberculosis e Renal cell carcinoma metastases

Answer 83

52 Answer D: Reactivation tuberculosis The description of interconnected subpleural nodules is that of `tree-in-bud'. This represents bronchiolar luminal impaction with mucus, pus or fluid. The causes are myriad (in fact all the options are potential causes). Infection is the commonest cause, and tuberculosis (via endobronchial spread) is the commonest infection accounting for this appearance.

Question 84

@#e2 45 A 45-year-old man presented to the Emergency Department with severe dyspnoea, pleuritic chest pain, malaise and diarrhoea. Blood tests showed hyponatraemia and a chest radiograph showed a moderate-sized pleural effusion, unilateral pulmonary infiltrates and prominent lymphadenopathy. In view of a recent local outbreak of Legionnaires' disease at a local conference centre this diagnosis was considered. What finding in the work-up would make a different diagnosis more likely? a Prominent lymphadenopathy b A moderate pleural effusion C Unilateral pulmonary infiltrates d Hyponatraemia e Pleuritic chest pain

Answer 84

45 Answer A: Prominent lymphadenopathy Lymphadenopathy is a rare finding.

Question 85

@#e2 1. A 70-year-old male presents to his GP with cough. The chest radiograph shows bilateral egg shell calcifications in the hilar regions. Which of the following is the least likely diagnosis? (a) Silicosis (b) Asbestosis (c) Coal workers pneumoconiosis (d) Sarcoidosis (e) Histoplasmosis

Answer 85

1. (b) Asbestosis All the other given options are known to cause egg shell calcification of the hilar lymph nodes.

Question 86

@#e2 69 A 70-year-old man with chronic obstructive airways disease underwent a CT scan and a tracheal diverticulum was identified. What is the most likely site of this abnormality? a just below the larynx on the left anterolateral wall b In the distal trachea on the anterior wall c just above the carina on the posterior wall d At the level of the thoracic inlet on the right posterolateral wall e At a variable level on the anterior wall

Answer 86

69 Answer D: At the level of the thoracic inlet on the right posterolateral wall Usually they occur between the cartilaginous and muscular portion of the wall and tend to be asymptomatic.

Question 87

@#e2 17 A 25 year old woman has a CXR for insurance purposes. There is a 2 cm well-circumscribed lesion in the periphery of the RLL. The subsequent CT demonstrates fat and calcification within the lesion; no other lesions are identified. What two further conditions, if present, would make the diagnosis part of Carney's triad? (a) Atrial myxoma and extra-adrenal paraganglioma (b) Atrial myxoma and pituitary adenoma (c) Breast fibroadenoma and pituitary adenoma (d) Gastric leiomyosarcoma and breast fibroadenoma (e) Gastric leiomyosarcoma and extra-adrenal paraganglioma

Answer 87

(e) Gastric leiomyosarcoma and extra-adrenal paraganglioma Pulmonary hamartomas, gastric leiomyosarcomas (GISTs) and functioning extra-adrenal paragangliomas make up this rare triad. Almost all patients are female (80%) aged 10-30 years. Pituitary adenomas, cardiac myxomas, along with myxoid fibroadenomas of the breast and testicular tumours are associated with the autosomal dominant Carney complex.

Question 88

@#e2 37 A 78-year-old female patient had a chest radiograph that showed multiple pulmonary nodules of varying sizes in both lungs, without zonal predilection which were thought to be metastases. What is the most likely site of an underlying primary tumour? a Breast b Colon c Bone d Pancreas e Ovary

Answer 88

37 Answer A: Breast

Question 89

@#e2 48. The following statements regarding lymphangitis carcinomatosis are correct: (T/F) (a) Chest X-Ray appearances are of multiple reticulonodular opacities. (b) It is associated with gastric cancer. (c) Kerley A and B lines are seen. (d) Radiological changes usually precede symptom onset. (e) Hilar adenopathy is seen in 80-90%

Answer 89

Answers: (a) Correct (b) Correct (c) Correct (d) Not correct (e) Not correct Explanation: Lymphangitis carcinomatosis presents with shortness of breath before radiological changes. Hilar adenopathy is seen in 20% - 50%.

Question 90

@#e2 32 A 3 year old presents with a persistent cough that has not responded to antibiotics. CXR demonstrates a triangular shaped-mass medially at the left lung base. CT is arranged for further investigation. What feature favours a diagnosis of intra- over extrapulmonary sequestration? (a) Air seen within lesion (b) Communication with the bronchial tree (c) Multiple associated anomalies (d) Systemic venous drainage (e) Systemic arterial supply

Answer 90

(a) Air seen within lesion Intralobar type is within the lung, sharing its pleura; it may be of airless, or air-containing, cystic type, and presents late in childhood / adulthood with recurrent infections or haemoptysis. Arterial supply is systemic, drainage is to the pulmonary vein in 95% and there is a low association with other anomalies. Extrapulmonary sequestration presents in neonates, is located outside the lung with its own pleura, has a systemic arterial supply, and drainage is to the systemic circulation. In 65% there are associated anomalies and it is 'always' airless (unless there is a communication with the GI tract).

Question 91

@#e2 QUESTION 12 A 4-year-old child presents with upper back pain. General examination reveals hepatomegaly and blood tests demonstrate an iron deficiency anaemia. The child's chest radiograph demonstrates an abnormal mediastinal contour and subsequent CT confirms an 8-cm posterior mediastinal mass which contains calcification. The lungs are clear. Which one of the following is most likely the diagnosis? A Extramedullary haemopoiesis B Lymphoma C Neuroblastoma D Neurofibroma E Teratoma

Answer 91

C Neuroblastoma If a paediatric posterior mediastinal mass contains calcification, it is most likely to be a sympathetic chain tumour.

Question 92

@#e2 50. A CT chest has been requested for a neonate in the neonatal ICU. This infant was born at 27 weeks gestation and developed right-sided PIE during the first week of life. The neonatologists practiced selective left bronchial intubation and no further air leak sequelae occurred. Also present on the CXR is a hyperlucent lesion in the right lower lobe. This is not clearly seen on the initial radiographs due to the generalized haziness present due to the surfactant deficiency. This lesion is not increasing in size and is not causing any significant respiratory embarrassment, but requires further assessment to define treatment. On CT a focal lesion is present confined to the right lower lobe, which consists of multiple cystic structures with central linear densities. This area demonstrates mild expansion. What is the diagnosis? A. Congenital cystic adenomatoid malformation. B. Persistent PIE. C. Congenital diaphragmatic hernia. D. Congenital lobar emphysema. E. Bronchogenic cyst.

Answer 92

50. B. Persistent PIE. Although alluded to in the clinical scenario, this should not be assumed to be the most likely diagnosis in the absence of the CT findings, as this is an extremely uncommon condition. The CT findings provide the diagnosis due to the linear densities within the cystic cavities representing the bronchopulmonary bundle surrounded by air within the interstitial space. This appearance is seen in over 80% of cases. The abnormality is often confined to a single lobe, but can be more widespread. Current optimal management is debated. Lesions increasing in size are thought to be best treated with surgical resection, with stable lesions often resolving over time with conservative management.

Question 93

@#e2 4. Childhood rhabdomyosarcoma: (T/F) a) Is the most common soft tissue sarcoma in children b) Is the most common pelvic malignant neoplasm in children c) Genitourinary tumours account for 25% of cases d) Orbital tumours are highly malignant e) T2 weighted MRI is ideal for assessing tumours of prostatic origin

Answer 93

4. a) True b) True c) True d) False - non-invasive, with a good prognosis e) False - tumours are hyperintense on T2 sequences, and may be obscured by adjacent high signal urine

Question 94

@#e2 7. Medullary calcification of the kidneys occurs in: (T/F) a) Hyperparathyroidism b) Renal tubular acidosis c) Pseudohyperparathyroidism d) Medullary sponge kidney e) Chronic glomerulonephritis

Answer 94

7. a) True b) True c) False d) True e) False - cortical nephrocalcinosis

Question 95

@#e2 9. Slipped upper femoral epiphysis: (T/F) a) Is seen typically between 4-8 years of age b) is bilateral in one third of cases c) The Line of Klein should intersect the normal femoral head d) The epiphysis slips posteromedially e) Subchondral lucency is an early sign

Answer 95

a) False - typically 8-17 years of age b) True c) True d) True e) False - an early sign of Perthes’ disease

Question 96

@#e2 22. Concerning congenital diaphragmatic hernias: (T/F) a) Most congenital hernias are of the Morgagni type b) Bochdalek hernias are usually left-sided c) Defective closure of the pleuroperitoneal membranes leads to a Bochdalek hernia d) Right-sided hernias may have a delayed presentation e) Congenital cystic adenomatoid malformation is a differential diagnosis

Answer 96

22. a) False - 85-90% are Bochdalek hernias b) True c) True d) True e) True

Question 97

@#e2 41. Medulloblastoma: (T/F) a) Is the most common paediatric CNS malignancy b) Typically has a brief history (< 3 months) c) Typically arises within the cerebellar hemispheres d) Is usually hypodense on pre-contrast CT e) Post-contrast shows heterogenous enhancement

Answer 97

41. a) True b) True c) False - cerebellar vermis d) False - 89% show some degree of hyperattenuation pre-contrast e) True

Question 98

@#e2 46. Features of dysostosis multiplex include: (T/F) a) Calvarial thickening b) J shaped sella c) Narrow anterior rib ends d) Odontoid hypoplasia e) Dysplastic femoral heads

Answer 98

46. a) True b) True c) False - narrow posterior ribs, with wide anterior rib ends d) True e) True

Question 99

@#e2 1. Ewing's sarcoma: (T/F) a) Most commonly affects children and adolescents b) Readily metastasises to bone c) Is usually medullary in origin d) Is of low signal on T1 weighted MRI e) Is iso-intense to skeletal muscle on T2 weighted MRI

Answer 99

1. a) True - 75% are <20 years of age, with most being 5-15 b) True c) True - mostly diaphyseal in origin (25% metaphyseal) d) True - allows the extent of marrow involvement to be assessed e) False - hyperintense to skeletal muscle on T2 sequences

Question 100

@#e2 8. Regarding imaging of the adrenal glands: (T/F) a) At birth, the adrenal glands are around one third the size of the adjacent kidney b) The limb of a mature adrenal gland should not measure more than 5 mm c) In renal agenesis, the adrenal gland assumes a discoid shape d) Childhood adrenocortical neoplasms are hyperintense on T2 weighted MRI e) Ectopic adrenal tissue is typically sited around the superior mesenteric artery

Answer 100

8. a) True b) True c) True d) True e) False - around the adrenal bed, or the coeliac axis

Question 101

@#e2 25. Regarding paediatric ependymomas: (T/F) a) Tumours usually arise from the cerebellar hemispheres b) Tumours are more frequently supratentorial c) Tumours commonly extend through the foramen of Magendie d) MR signal is characteristic e) Calcification is seen in up to 50%

Answer 101

25. a) False - the 4th ventricle b) False - infratentorial in 70% c) True d) False e) True