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  • QUESTION
     
    Regarding intracranial hemorrhage in premature infants, which ONE of the following is TRUE?
    A)     90% of hemorrhages occur by day 1
    B)     The most common site of hemorrhage is intraventricular
    C)     50% of patients with intraventricular hemorrhage require ventriculoperitoneal shunts
    D)     Subependymal cyst is a sequela  [85 %]  
    E)     Acute parenchymal blood is hypoechoic to the choroid plexus

       

    Approximately 50% of affected infants have onset of hemorrhage on the first postnatal day, an additional 25% on the second day, and an additional 15% on the third day (Option A is false). By 72 to 96 hours, 80% to 90% of ICH has occurred.The most common site of hemorrhage in premature infants is the subependymal germinal matrix that lies in the floor of the lateral ventricle above the caudate nucleus (Option B is false).  The ventricular dilatation arrests or resolves in 50% to 75% of infants with posthemorrhagic hydrocephalus. Progressive ventricular dilatation with increased intracranial pressure develops in the remaining patients. Fewer than 10% of infants with posthemorrhagic ventricular dilatation require a shunt (Option C is false).  

    As the subependymal clot retracts, it undergoes central liquefaction. The cavitary areas can involute completely or evolve into true cysts (Option D is true). Post-hemorrhagic subependymal cysts are relatively small, measuring between 3 and 5 mm in diameter. These cysts appear to be of little clinical significance and most disappear within a year.  

    Acute parenchymal blood usually is hyperechoic to choroid plexus (Option E is false). The increased echogenicity associated with hemorrhage, especially when involving the posterior periventricular area, must be differentiated from the periventricular echoes seen in normal neonates. In general, the echogenicity of the normal periventricular area is less than that of the choroid plexus. The normal periventricular echoes also have a homogeneous, brush-like appearance, whereas hemorrhage is more irregular or lobulated.  

    Suggested Readings:  

    Siegel MJ. Brain. In: Siegel MJ, ed. Pediatric Sonography, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2001; 41-121.  


      
    QUESTION
     
    Which ONE of the following features is more commonly associated with intracranial hemorrhage in premature infants than in term infants?
    A)     Birth trauma
    B)     Subdural hemorrhage
    C)     Cerebellar hemorrhage  [50 %]  
    D)     Choroid plexus hemorrhage

       

    Intracranial hemorrhage occurs in approximately 2 to 4% of term infants and by comparison, in approximately 40% of premature infants at less than 32 weeks of gestation or weighing less than 1,500 g. The causes of intracranial hemorrhage differ in the two groups. In term infants, hemorrhage is usually related to birth trauma (Option A is false). Other predisposing factors include asphyxia, vascular malformations, coagulation defects and cyanotic heart disease. Bleeding can also occur without these risk factors. In premature infants, hemorrhage is the result of ischemia.Subdural hemorrhage is more common in term infants than in premature infants (Option B is false) and is usually related to birth trauma. Supratentorial subdural hemorrhage results when there is laceration of the falx or tearing of bridging veins. Posterior fossa subdural bleeds are a result of tentorial lacerations and occipital osteodiastasis.  Intracerebellar hemorrhage is more frequent in premature infants than in term infants (Option C is true). In premature infants, the causes include primary hemorrhage, venous infarction, and extension of intraventricular or subarachnoid hemorrhage into the cerebellum. In term infants, the cause of bleeding is thought to be a traumatic delivery which results in laceration of the cerebellum or rupture of major posterior fossa veins or the occipital sinuses.  

    Choroid plexus hemorrhage is more common in term infants than in premature infants (Option D is false). The cause of this hemorrhage is not known precisely.  

    Suggested Readings:  

    1. Siegel MJ. Brain. In: Siegel MJ, ed. Pediatric Sonography , 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2001; 41-121.
    2. Bellah RD. Intracranial hemorrhage and ischemia in the premature infant. In: Bluth EI, Arger PH, Benson CB, Ralls PW, Siegel MJ. Ultrasound: A Practical Approach to Clinical Problems . Thieme. New York. 2000; 503-520.

       


      
    QUESTION
     
    Regarding periventricular leukomalacia in premature infants, which ONE of the following is TRUE? 
    A)     The regions of the corona radiata and trigone are the most common sites of involvement  [89 %]  
    B)     It is a sequela of intraventricular hemorrhage
    C)     Sonography reliably distinguishes the hemorrhagic and nonhemorrhagic forms
    D)     Periventricular cysts are the earliest finding

       

    In the premature infant, hypoxic-ischemic injury results in periventricular leukomalacia (PVL). The frequency of PVL ranges from 7 to 22% in autopsy series. The watershed area of the premature brain is in the area of the corona radiata and also adjacent to the trigones of the lateral ventricles and to the foramina of Monro (Option A is true).Histopathologically, the earliest finding of PVL is coagulation necrosis. Phagocytosis of the necrotic area follows within 5 to 7 days, resulting in cavitation. The cavitary areas can involute, leading to gliosis and loss of white matter volume, or in about 15% of cases, they can evolve into larger cysts. The earliest sonographic finding of PVL, occurring in the first 2 weeks of life, is increased periventricular hyperechogenicity (Option D is false). The hyperechogenic zone can disappear within 2 to 3 weeks or it can evolve into periventricular cysts. Long term sequelae of PVL are ventriculomegaly and prominent sulci, resulting from brain atrophy.  Subependymal and intraventricular hemorrhages can occur in association with PVL, but they are incidental findings. They are not causes of PVL (Option B is false).  

    Parenchymal hemorrhage into areas of PVL has been described in about 25% of cases. The hemorrhage is thought to be a result of reperfusion of ischemic tissue. The hemorrhagic and nonhemorrhagic forms of PVL cannot be differentiated by sonography because the degree of echogenicity is similar in both forms (Options C is false).  

    Suggested Readings:  

    1. Siegel MJ. Brain. In: Siegel MJ, ed. Pediatric Sonography, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2001; 41-121.
    2. Vannucci RC. Mechanisms of perinatal hypoxic-ischemic brain damage. Semin Perinatol 1993; 17:330-337

       


      
    QUESTION
     
    Regarding the Chiari II malformation, which ONE of the following is true?
    A)     It is nearly always associated with failure of neural tube closure  [77 %]  
    B)     The tentorial attachment is usually normal
    C)     Supratentorial abnormalities are uncommon
    D)     The severity of hydrocephalus nearly always improves after repair of the meningocele

       

    The type II malformation is the most common of the Chiari anomalies. It is seen in neonates and infants and is nearly always associated with a clinically obvious myelomeningocele (Option A is true).The type II Chiari malformation is characterized by caudal displacement of the 4 th ventricle, cerebellum, and medulla through the foramen magnum into the upper spinal canal, which results in elongation and thinning of the medulla, pons and cervical cord. Thus, patients with this malformation have a small posterior fossa and abnormally low attachment of the tentorium (Option B is false).  Supratentorial anomalies are common (Option C is false). These anomalies include: an enlarged massa intermedia partially or totally filling the third ventricle, disproportionately large occipital horns compared with the frontal horns (colpocephaly), and anterior and inferior angulation of the frontal horns, referred to as a “bat-wing” appearance. Anomalies of the corpus callosum are also common and consist of dysplasia or dysgenesis.  

    Ventricular enlargement is variable prior to surgical repair of the neural tube defect. After closure of the meningocele, hydrocephalus is present in the majority of patients and not uncommonly worsens or first becomes apparent at this time (Option D is false). The explanation for this is thought to be the closure of the spinal defect, which prior to repair, allowed an outlet for cerebrospinal fluid drainage.  

    Suggested Readings:  

    1. Siegel MJ. Brain. In: Siegel MJ, ed. Pediatric Sonography, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2001; 41-121

       


      
    QUESTION
     
    Concering vein of Galen malformation in neonates, which ONE of the following is TRUE?
    A)     Seizure is the most common clinical manifestation
    B)     Most are fed by multiple arteries rather than a single artery  [47 %]  
    C)     A nidus is typical of this malformation
    D)     It drains into the superior sagittal sinus
    E)     Spectral tracings show decreased flow velocities in the arterial supply  

     Classically, neonates with the vein of Galen malformation present soon after birth with high output congestive heart failure due to shunting through a large arteriovenous fistula. Older infants and children are more likely to present with headaches or seizures due to intracranial hemorrhage or an enlarging head due to obstructive hydrocephalus (Option A is false)

    The vein of Galen malformation is a congenital vascular malformation resulting from failure of embryonic arteriovenous shunts to be replaced by capillaries. Two anatomic types of Galenic malformations have been described: choroidal and mural. The choroidal type is more common and is characterized by multiple arterial feeders arising in the midbrain. The mural type is characterized by one or a few arterial feeders (Option B is true)

    Venous drainage is into an aneurysmally dilated vein in the area of the vein of Galen. The draining vein is not the vein of Galen but is the midline prosencephalic vein. The dilated vein drains into the straight sinus and then into the torcula (Option D is false)

    In neonates, this malformation is a direct arteriovenous fistula without an interconnecting nidus or tangle of abnormal vessels. In older children, there may be a true arteriovenous malformation which has a nidus (Option C is false)

    On coronal sonograms, the Galenic malformation appears as a well-circumscribed hypoechoic mass in the midline, posterior to the third ventricle. On sagittal views, the straight sinus and torcula can also be noted. Spectral tracings typically show elevated flow velocities in the arterial feeders, dampened pulsatility of the feeders, and arterialization of venous flow (Option E is false)

    Suggested Readings: 

    1. Brunelle F. Arteriovenous malformation of the vein of Galen in children. Pediatr Radiol 1997; 27:501-513
    2. Horowitz MB, Jungreis CA, Quisling RG, Pollack I. Vein of galen aneurysms: a review and current perspective. AJNR 1994; 15:1486-1496

      

    QUESTION
     
    The earliest sonographic finding seen in a normal pregnancy is:
    A)     The intradecidual sac sign  [89 %]  
    B)     The double decidual sac sign
    C)     The yolk sac
    D)     The embryo
    E)     Fluid in endometrial cavity

       

    The intradecidual sac sign refers to the gestational sac which implants within the endometrium. It is visible by 4 to 4.5 weeks gestational age (answer a is correct). The double decidual sac sign is composed of three distinct layers (decidua basalis, capsularis and parietalis) and is seen when the gestational sac enlarges. It occurs after the intradecidual sac sign (answer b is incorrect). The yolk sac is seen by 5 to 5.5 weeks gestational age, and the embryo is seen by 6 to 6.5 weeks gestational age, both later than the intradecidual sac sign (answers c and d are incorrect). Fluid in the endometrial cavity is characteristic of pseudosac seen in ectopic pregnancy.References:
    Chiang G, Levine D, Swire M, McNamara A, Mehta T. The intradecidual sign: IS it reliable for diagnosis of early uterine pregnancy? AJR 2004;183:725-731.Levine D. Ectopic Pregnancy. Radiology 2007;245(2):385-397.Lyons EA, Levi CS. The First Trimester. In Diagnostic Ultrasound 3rd edition (ed Rumack) 2005;1069-1125.  


      
    QUESTION
     
    Which of the following is true regarding dichorionic, diamniotic twins?
    A)     They are always dizygotic
    B)     They are at risk for twin-twin transfusion syndrome
    C)     This is the most common twinning presentation  [83 %]  
    D)     They separated by a thin membrane
    E)     The diagnosis is easiest to make in the 2nd trimester

       

    Dizygotic twins represent approximately 70% of all twins (answer c is correct). All dizygotic twins are by definition dichorionic/diamniotic. Additionally 30% of monozygotic twins are dichorionic/diamniotic, which occurs if there has been cleavage of the embryo early in gestation (answer a is incorrect). Since dichorionic, diamniotic twins do not share a placenta, there is no sharing of circulation and thus no risk of twin-twin transfusion syndrome (answer b is incorrect). The membrane separating dichorionic, diamniotic twins is thick, especially in the first trimester (answer d is incorrect). The diagnosis is easiest to make in the 1st trimester (answer e is incorrect).References:
    Hertzberg BS, Kurtz AB, Choi HY, et al. Significance of membrane thickness in the sonographic evaluation of twin gestations. AJR 1987;148:151-153.Levi CS, Lyons EA, Martel MJ. Sonsgraphy of Multifetal Pregnancy. In Diagnostic Ultrasound 3rd edition (ed Rumack) 2005;1185-1214.Kennedy AM. Multiple Gestations. In Diagnostic Imaging:Obstetrics. 1st edition (ed Woodward) 2005; Section 13 p 2-13.  


      
    QUESTION
     
    Which of the following would be considered abnormal in a first trimester pregnancy?
    A)     A gestational sac > 10 mm without a fetal pole
    B)     A 3 mm embryo without a heartbeat
    C)     An embryo with a heart rate of 70 bpm  [85 %]  
    D)     A 4 mm yolk sac
    E)     Not seeing an embryo at 5.0 weeks

       

    A gestational sac > 18 mm must have a demonstrable fetal pole, but a fetal pole may not be visible between 10 and 18 mm (answer a is incorrect). A fetal heartbeat is not seen until the embryo measures 5 mm (answer b is incorrect). Embryonic bradycardia is defined as a heartbeat < 100 beats per minute; anything less is very concerning and requires short term follow-up (answer c is correct). A yolk sac is not considered abnormal until it reaches 6 mm; a 4 mm yolk sac is normal (answer d is incorrect). The embryo is usually seen at 6-6-5 weeks (answer e is incorrect).References:
    Levine D. Ectopic Pregnancy. Radiology 2007;245(2):385-397.Lyons EA, Levi CS. The First Trimester. In Diagnostic Ultrasound 3rd edition (ed Rumack) 2005;1069-1125.Kennedy AM. Normal Early Pregnancy and Imaging. In Diagnostic Imaging: Obstetrics. 1st edition (ed Woodward) 2005; Section 1 p 1-6.  


      
    QUESTION
     
    The amniotic fluid index is defined as:
    A)     The sum of the deepest pocket of amniotic fluid in four quadrants of the uterus  [93 %]  
    B)     The greatest pocket of amniotic fluid that can be measured
    C)     The average of four pockets of amniotic fluid measured in four quadrants of the uterus
    D)     The largest pocket of amniotic fluid multiplied by 4
    E)     The subjective assessment of amniotic fluid based on prior examinations

       

    The amniotic fluid index as originally defined is the sum of four measurements of the deepest pocket of amniotic fluid in each quadrant of the uterus. An arbitrary division of the uterus into quadrants is made at the time of examination and the largest pocket of fluid is chosen. It is important that no fetal extremities or cord be included in the measurement. Literature supports the average AFI to range from 8-16 cm. with values of less than 5 cm. as definite oligohydramnios and more than 20 cm as polyhydramnios. These determinations are usually compared with the subjective or “eyeball” determination of the overall amniotic fluid volume and any discrepancy is an indication for follow-up studies.Gramellini D, Fieni S, Verrotti C, et al. Ultrasound evaluation of amniotic fluid volume: methods and clinical accuracy. Acta Biomed 2004;75 Suppl1:40-44.Magann EF, Sanderson M, Martin JN, Chauhan S. The amniotic fluid index, single deepest pocket, and two-diameter pocket in normal human pregnancy. Am J Obstet Gynecol 2000;182:1581-1588.  


      
    QUESTION
     
    Which one of the following combination of measurements are routinely obtained to determine gestational age?
    A)     Biparietal diameter, head circumference, estimated fetal weight and femur length
    B)     Biparietal diameter, head circumference, abdominal circumference and femur length  [92 %]  
    C)     Biparietal diameter, head circumference, femur length and abdominal diameter
    D)     Biparietal diameter, occipitofrontal diameter, estimated fetal weight and femur length
    E)     Biparietal diameter, head circumference, estimated fetal weight and thigh circumference

       

    The four measurements routinely performed for the estimation of gestational age are the biparietal diameter, bead circumference, abdominal circumference, and femur length (answer b is correct). While the estimated fetal weight is an important part of the assessment of fetal growth, it is a value derived from the four measurements and is not an independent measure of gestational age.References:
    AIUM accreditation: http://www.aium.org/publications/clinical/obstetric.pdf


     
    QUESTION
     
    The three minimum structures required in imaging the fetal brain are:
    A)     Cavum septi pellucidi, cisterna magna and ventricular atrium  [88 %]  
    B)     Cavum septi pellucidi, cerebellar vermis and ventricular atrium
    C)     Cavum septi pellucidi, cisterna magna and choroid plexus
    D)     Corpus callosum, cisterna magna and ventricular atrium
    E)     Corpus callosum, third ventricle and ventricular atrium

       

    While evaluation of fetal intracranial structures can sometimes be difficult, most inctracranial abnormalities can be excluded by documenting a normal cavum septi pellucidi, cisterna magna, and ventricular atrium. A normal cavum septi pellucidi ensures that the fetal brain has undergone normal cerebral separation and that there is no holoprosencencephalic spectrum malformation. Documentation of a normal cisterna magna indicates that there is no Dandy-Walker malformation or spinal dysraphism. Ventriculomegaly is a non-specific finding, but commonly accompanies fetal brain malformations. The ACR requires only documentation of the ventricular atria and cisterna magna, whereas the AIUM also requires documentation of the cavum septi pellucidi.References:
    AIUM accreditation: http://www.aium.org/publications/clinical/obstetric.pdf


     
    QUESTION
     
    In the fetal chest, documentation of the following is required for AIUM and ACR accreditation:
    A)     Cardiothoracic ratio
    B)     Four-chamber view of the heart  [98 %]  
    C)     Outflow tracts
    D)     Ductus arteriosus
    E)     Color Doppler image of the ventricular septum

       

    For both AIUM and ACR accreditation, a four-chamber view of the heart is required answer b is correct). The AIUM guideline recommends, but does not require, obtaining views of the outflow tracts as part of cardiac screening (answer c is incorrect). Similarly, while evaluation of the cardiothoracic ratio, the ductus arteriosus, and the ventricular septum are important in fetal echocardiography, they are beyond the images required for basic standard obstetrical sonographic accreditation (answers a, d, and e are incorrect).References:
    AIUM accreditation: http://www.aium.org/publications/clinical/obstetric.pdf


     
    QUESTION
     
    Documentation of the following normal structures in the fetal abdomen are required for AIUM and ACR accreditation:
    A)     Kidneys, stomach, urinary bladder and liver
    B)     Stomach, spleen, urinary bladder and liver
    C)     Liver, kidneys, urinary bladder and cord insertion
    D)     Stomach, kidneys, urinary bladder and cord insertion  [93 %]  
    E)     Cord insertion, kidneys, urinary bladder and liverBoth the AIUM and ACR require documentation of the stomach, kidneys, urinary bladder, and umbilical cord insertion site (answer d is correct). In addition, the AIUM guideline requires documentation of umbilical cord vessel number. Specific evaluation of the liver and spleen is not part of the standard obstetrical sonographic examination (answers a, b, c, and e are incorrect).References:
    AIUM accreditation: http://www.aium.org/publications/clinical/obstetric.pdf  

       

    QUESTION
     
    When performing CT urography, when is it best to administer IV Furosemide in addition to IV contrast material?
    A)     When also giving IV saline
    B)     When there is likely to be difficulty visualizing the ureters
    C)     In all patients as long as there is no history of allergy to sulfa drugs  [84 %]  
    D)     In all patients

       

    Answer: CFurosemide is recommended as a means to improve the opacification and distension of the collecting systems and ureters. Furosemide can be used to improve the opacification and distension of the collecting system, and ureters, in all patients, unless contraindicated. Furosemide is a sulfa derivative and should be withheld in patients with sulfa allergy. It is not possible to predict which patients’ collecting systems will not be opacified and distended in advance of the examination. IV saline is a suitable alternative but does not add significantly to the benefits of furosemide in improving opacification and distension of the urinary tract.Reference: Silverman SG, Akbar SA, Mortele KJ, Tuncali K, Bhagwat JG, Seifter JL. Multidetector-row CT urography: comparison of furosemide and saline as adjuncts to contrast medium for depicting the normal urinary collecting system. Radiology 2006;240:749-755.
    QUESTION
     
    In which of the following patients is CT urography (including scans before and after IV contrast material) indicated?
    A)     32 year-old man with flank pain
    B)     45 year-old woman with a suspicious renal mass
    C)     50 year-old with a suspected urinary leak after radical prostatectomy
    D)     70 year-old woman with gross hematuria  [82 %]  

       

    Answer: DCT urography provides a comprehensive examination of the entire urinary tract and is, therefore, used in patients with hematuria, particularly those with a risk factor such as gross hematuria. CT urography could be used in patients with flank pain, suspicious renal masses, and suspected post-operative complications; however, other protocols are likely to be as effective and require less scans (and less radiation exposure). Flank pain in young patients is likely to be due to urolithiasis that can be diagnosed with an unenhanced CT scan alone. A suspicious renal mass is best evaluated with a renal mass protocol and does not require detailed images of the urothelium or IV furosemide. A post-operative complication in which a urinary leak is suspected can be diagnosed with excretory phase CT scans alone and does not require unenhanced CT or detailed images of the kidneys.Reference: Grossfeld GD, Wolf JS, Litwin MS, et al. Asymptomatic microscopic hematuria in adults: summary of the AUA best practice policy recommendations. Am Fam Physician 2001; 63:1145-54.
    QUESTION
     
    Which of the following is true about upper tract transitional cell carcinoma on CT urography?
    A)     It is most commonly a polypoid mass
    B)     It is most commonly noted as collecting system wall thickening  [84 %]  
    C)     It can only be detected when larger than 2 cm
    D)     It cannot be detected at CT urography

       

    Answer: BTransitional cell carcinoma is most commonly manifest at CT urography as wall thickening.Reference: Caoili EM, Cohan RH, Inampudi P, Ellis JH, Shah RB, Faerber GJ, Montie JM. MDCT urography of upper tract urothelial neoplasms. AJR 2005;184:1873-1881.
    QUESTION
     
    Which of the following is also administered in addition to IV gadolinium when performing excretory MR urography?
    A)     IV saline
    B)     IV furosemide
    C)     IV saline and furosemide  [68 %]  
    D)     Oral water

       

    Answer: CIV saline and furosemide are used to optimize gadolinium-enhanced excretory MR urography.IV saline and furosemide are recommended for gadolinium enhanced excretory MR urography when the upper tracts are not dilated. They help improve upper tract distention, increase homogeneity of opacification, and minimize artifacts. Saline alone is not sufficient. Furosemide should be withheld if there are contraindications.Reference: Ergen FB, Hussain HK, Carlos, RC, et al. 3D excretory MR urography: improved image quality with intravenous saline and diuretic administration. J Magn Reson Imaging 2007;25:783-789.  
    QUESTION
     
    Which of the following is true about using gadolinium-enhanced MR urography for the detection of upper tract transitional cell carcinoma?
    A)     It cannot be used for this purpose
    B)     It should be performed as the first line imaging test instead of CT urography
    C)     It can be performed instead of CT urography in patients with compromised renal function
    D)     It is a potential alternative to CT urography but the value of MR urography for the detection of small upper tract transitional cell carcinoma is not established  [89 %]  

       

    Answer: DA potential alternative to CT urography, but the value of MR urography for the detection of small upper tract transitional cell carcinoma is not established.CT urography has been shown to be excellent for the detection of upper tract transitional cell carcinoma and is often used as the first line imaging test for this purpose. MR urography is a potential alternative to CT urography, but its value for the detection of small upper tract transitional cell carcinoma is not established. Transitional cell carcinoma manifests as wall thickening or an intraluminal filling defect. Gadolinium contrast agent should be avoided in patients with compromised renal function due to the risk of Nephrogenic Systemic Fibrosis (NSF).Reference: Nolte-Ernsting CCA, Adam GB, Gunther RW. MR Urography: examination, techniques and clinical applications. Eur Radiol 2001; 11:355-372.  
    QUESTION
     
    Which of the following is true about T2-weighted MR urography?
    A)     It provides functional information about the upper tract (pelvocaliceal system)
    B)     It is used to evaluate dilated upper tracts (pelvocaliceal systems)  [87 %]  
    C)     It is used to evaluate non dilated upper tracts (pelvocaliceal systems)
    D)     It requires IV gadoliniumAnswer: BT2-weighted MR urography is used to evaluate the upper tract.T2-weighted MR urography generates static water images of the urinary tract and does not require gadolinium. It does not yield functional information about the urinary tract. This technique is used to evaluate the dilated upper tract and can be performed even in patients with non-excreting kidneys, but is of limited value for the evaluation of the non-dilated upper tract. T2-weighted MR urography is usually performed using thin-slice and thick slab T2-weighted single shot fast spin-echo (SSFSE or HASTE) sequences.  Reference: Nolte-Ernsting CCA, Adam GB, Gunther RW. MR Urography: examination, techniques and clinical applications. Eur Radiol 2001; 11:355-372.  

       

    QUESTION
     
    All of the following are changes of cirrhosis that may be seen in the liver on imaging except:
    A)     Nodular contour of the liver
    B)     Atrophy of the anterior segment of the right lobe and medial segment of the left followed by hypertrophy of the left lateral segment and caudate
    C)     Periportal space hypertrophy with fat deposition
    D)     Dilatation and beading of the biliary tree  [88 %]  

       

    Answer: DDilatation and beading of the biliary tree. This may be seen in association with underlying liver diseases, which may lead to cirrhosis such as primary sclerosing cholangitis. However, it is not a finding of cirrhotic changes in the liver parenchyma.Reference: Dodd GD et al, Spectrum of Imaging Findings of the Liver in End-Stage Cirrhosis: Part II, Focal Abnormalities. AJR 1999:173(4)1031-1036
    QUESTION
     
    A 1.5 cm nodule in a cirrhotic liver that demonstrates hyperintensity on T1-W imaging, isointensity on T2-W imaging, but without increased enhancement in the arterial phase of imaging relative to the surrounding liver parenchyma is likely to represent:
    A)     Regenerative nodule
    B)     Dysplastic nodule  [65 %]  
    C)     Hepatocellular carcinoma
    D)     Hemangioma

       

    Answer: BDysplastic nodule. The lack of arterial enhancement is suggestive of a benign nodule; either regenerative or dysplastic. The precontrast T1-weighted hyperintensity may cause difficulty in identifying enhancement in the arterial phase. By subtracting the precontrast image from the arterial-phase image, the presence of enhancement can be visualized as increased signal intensity on the subtracted image.Both dysplastic and regenerative nodules have been reported to have variable appearance on T1 –W imaging. However, the T1-W hyperintensity is more commonly seen in dysplastic nodules than in regenerative nodules.Hemangioma would be less likely given the T2-W isointensity rather then hyperintensity.Reference: Krinsky GA, Lee VS MR imaging of cirrhotic nodules. Abdom Imaging. 2000 Sep-Oct;25(5):471-82.  
    QUESTION
     
    In regard to hepatic fibrosis, which of the following is true:
    A)     Fibrosis tends to be hypointense on T1 and T2 weighted imaging.
    B)     Fibrosis is usually associated with volume loss and a retraction of the liver capsule rather then bulging and mass effect.  [88 %]  
    C)     Conventional T1-W, T2-W and post contrast MR imaging is highly sensitive in detection of early stages of fibrosis.
    D)     Fibrosis tends to have increased enhancement on arterial phase rather then delayed phases of imaging post IVgadolinium.

       

    Answer: BFibrosis is usually associated with volume loss, which can help differentiate focal confluent fibrosis from HCC.Fibrosis tends to be hypointense on T1-W imaging, but hyperintense on T2-W imaging.Conventional MRI is not sensitive to early stages of fibrosis with signal changes usually only being apparent in later stages. Functional MR techniques such as DWI and PWI are currently being investigated for evaluation of fibrosis. Fibrosis tends to have increased signal intensity on delayed rather then arterial phase imaging relative to surrounding liver parenchyma, although occasionally fibrosis can show arterial enhancement. If arterial enhancement is associated with focal confluent fibrosis, it can be difficult to differentiate from HCC and biopsy may be required.Reference: Dodd GD et al, Spectrum of Imaging Findings of the Liver in End-Stage Cirrhosis: Part II, Focal Abnormalities. AJR 1999:173(4)1031-1036.  
    QUESTION
     
    In pseudocirrhosis associated with metastatic breast cancer, the liver may demonstrate the following patterns of liver contour abnormality:
    A)     Absent
    B)     Limited retraction of capsule
    C)     Widespread retraction of the capsule
    D)     Diffuse nodularity
    E)     All of the above  [88 %]  

       

    Answer: EAll of the above mentioned patterns of contour abnormality can be seen with metastatic breast cancer with limited areas of capsular retraction being the most common.Reference: Qayyum et al, Clinical Imaging 2007;31(1):6-10.
    QUESTION
     
    Considering current deaths from chronic liver disease, which condition is most prevalent as the underlying cause of liver disease:
    A)     Alcoholic liver disease
    B)     Nonalchoholic fatty liver disease (NAFLD)
    C)     Hepatitis C  [82 %]  
    D)     Hepatitis B
    E)     Cryptogenic cirrhosis

       

    Answer: CHepatitis C accounts for 35%, Alcoholic liver disease 25%, Hepatitis B 20% NAFLD 15% and 5% other.Reference: Sirlin CB The epidemic of cirrhosis and HCC. webcast 2009. ARRS.
    QUESTION
     
    Which of the following statements is not true?
    A)     90-95 % of Hepatocellular carcinoma occurs in patients with liver cirhhosis.
    B)     Chronic liver disease is one of the top 10 causes of death in the United States with peak age group shifting to older patients.  [63 %]  
    C)     In the future, NAFLD may account for a larger number of patients with chronic liver disease due to increasing rates of obesity in the USA.
    D)     Early stage fibrosis in the liver is associated with increased risk of HCC, but less than that associated with cirrhosis.

       

    Answer: BCirhhosis is currently the eighth leading cause of death in the USA; however, the peak age group is shifting to younger patients.Reference: El-Serag HB, Rudolph KL, Hepatocellular carcinoma: epidemiology and molecular carcinogenesis. Gastroenterology. 2007 Jun;132(7):2557-76.
    QUESTION
     
    Which of the following statements is false regarding perfusion weighted imaging (PWI) of the liver:
    A)     PWI involves the use of high spatial resolution imaging following the administration of IV contrast.  [73 %]  
    B)     The proportion of arterial to portal venous blood supply to the liver increases in fibrosis and cirrhosis.
    C)     An advantage of using PWI techniques in detection of fibrosis and cirrhosis is its noninvasive nature without risks associated with biopsy.
    D)     Current disadvantages to use of PWI include long processing time on computer workstation, misregistration due to patient motion during acquisition, limited accuracy in patients with early fibrosis, and cannot be used in patients with decreased renal function.Answer: APWI involves the use of high temporal not spatial resolution imaging following the administration of IV contrast.Reference: Taouli B,. Perfusion MRI applications in chronic liver disease. webcast 2009. ARRS.Annet L, Materne R, Danse E, Jamart J, Horsmans Y, Van Beers BE. Hepatic flow parameters measured with MR imaging and Doppler US: correlations with degree of cirrhosis and portal hypertension. Radiology. 2003 Nov;229(2):409-14.  Hagiwara m et al Advanced liver fibrosis: diagnosis with 3D whole-liver perfusion MR imaging–initial experience. Radiology. 2008 Mar;246(3):926-34.  

       

    QUESTION
     
    At baseline evaluation, PET/CT is clinically indicated for which one of the following circumstances:
    A)     In all patients with esophageal cancer
    B)     Evaluation of local tumor extension (the T descriptor in TNM staging)
    C)     Localization of nodal metastases in the gastrohepatic ligament
    D)     Detection of clinically unsuspected metastases  [69 %]  

       

    At baseline evaluation, PET/CT is clinically indicated for which one of the following circumstances:(a) In all patients with esophageal cancer
    Unfortunately, most patients with esophageal cancer present with late stage or metastatic carcinoma (1), for which PET-CT is unlikely to provide additional useful information.(b) Evaluation of local tumor extension (the T descriptor in TNM staging)
    Assessment of local tumor invasion is not well performed by PET-CT due to its limited spatial resolution and the variable FDG uptake of early-stage carcinomas (4).(c) Localization of nodal metastases in the gastrohepatic ligament
    Localization of nodal metastases in the gastohepatic ligament is difficult by any technique and usually requires correlation of CT, EUS and PET-CT images (8).(d) Detection of clinically unsuspected metastases
    PET/CT can detect clinically unsuspected metastases in up to 29% of patients at baseline evaluation (5).
    QUESTION
     
    For esophageal cancer following neoadjuvant therapy, FDG PET/CT
    A)     has no role
    B)     is inferior to endoscopic ultrasonography for assessment of local tumor response
    C)     is useful for detection of new interval metastases not present at baseline imaging  [100 %]  
    D)     always indicates residual viable tumor with persistent hypermetabolic primary tumor activity

       

    For esophageal cancer following neoadjuvant therapy, FDG PET/CT(a) has no role
    FDG PET/CT can detect new interval metastases in up to 8% of patients following completion of neoadjuvant therapy and prior to planned esophagectomy (15) and is therefore a useful test (11).(b) is inferior to endoscopic ultrasonography for assessment of local tumor response
    A meta-analysis comparing the diagnostic accuracy of CT, EUS and PET-CT after neoadjuvant therapy found that PET-CT and EUS were of comparable accuracy in predicting the presence or absence of residual viable tumor (6).(c) is useful for detection of new interval metastases not present at baseline imaging
    FDG PET/CT can detect new interval metastases in up to 8% of patients following completion of neoadjuvant therapy and prior to planned esophagectomy (15) and is therefore a useful test (11).(d) always indicates residual viable tumor with persistent hypermetabolic primary tumor activity
    A meta-analysis comparing the diagnostic accuracy of CT, EUS and PET-CT after neoadjuvant therapy found that PET-CT and EUS were of comparable accuracy in predicting the presence or absence of residual viable tumor (6). However, residual FDG activity may be seen secondary to esophageal ulceration following radiotherapy or biopsy (14).
    QUESTION
     
    According to the recommendations of the Harmonization Project in Lymphoma, for which type of lymphoma is a pretreatment FDG-PET scan recommended, but not necessary?
    A)     MALT lymphoma
    B)     Cutaneous T-cell lymphoma
    C)     Diffuse large B-cell lymphoma  [77 %]  
    D)     Marginal zone lymphoma
    E)     Small lymphocytic lymphoma

       

    According to the recommendations of the Harmonization Project in Lymphoma, for which type of lymphoma is a pretreatment FDG-PET scan recommended, but not necessary?(a) MALT lymphoma
    Malt lymphoma has variable uptake on FDG-PET/CT, and a baseline scan should be performed (Cheson BD, Pfistner B, Juweid ME, et. al. Revised response criteria for malignant lymphoma. 2007. J Clin Oncol 25: 579-86.)(b) Cutaneous T-cell lymphoma
    Cutaneous T-cell lymphoma has variable uptake on FDG-PET/CT, and a baseline scan should be performed (Cheson BD, Pfistner B, Juweid ME, et. al. Revised response criteria for malignant lymphoma. 2007. J Clin Oncol 25: 579-86.)(c) Diffuse large B-cell lymphoma
    Diffuse large B-cell lymphoma is typically intensely hypermetabolic on FDG-PET/CT, and a baseline scan, although preferred, is not necessary (Cheson BD, Pfistner B, Juweid ME, et. al. Revised response criteria for malignant lymphoma. 2007. J Clin Oncol 25: 579-86.)(d) Marginal zone lymphoma
    Marginal zone lymphoma has variable uptake on FDG-PET/CT, and a baseline scan should be performed (Cheson BD, Pfistner B, Juweid ME, et. al. Revised response criteria for malignant lymphoma. 2007. J Clin Oncol 25: 579-86.)(e) Small lymphocytic lymphoma
    Small lymphocytic lymphoma has variable uptake on FDG-PET/CT, and a baseline scan should be performed (Cheson BD, Pfistner B, Juweid ME, et. al. Revised response criteria for malignant lymphoma. 2007. J Clin Oncol 25: 579-86.)
    QUESTION
     
    In post-therapy FDG-PET imaging, which one of the following is most concerning for residual tumor?
    A)     Large residual mass without FDG uptake
    B)     Diffuse marrow activity
    C)     Low-grade (blood pool) activity in a large mass
    D)     Residual splenic mass with uptake similar to normal spleen
    E)     Persistent focal marrow uptake  [92 %]  

       

    In post-therapy FDG-PET imaging, which one of the following is most concerning for residual tumor?(a) Large residual mass without FDG uptake
    Residual masses without FDG uptake are consistent with treated tumor (Juweid ME, Stoobants S, Hoekstra OS, et. al. Use of positron emission tomography for response assessment of lymphoma: consensus of the imaging subcommittee of international harmonization project in lymphoma. 2007. J Clin Oncol 25:571-8.)(b) Diffuse marrow activity
    Diffuse marrow activity in the post-treatment setting should be attributed to marrow hyperplasia (Juweid ME, Stoobants S, Hoekstra OS, et. al. Use of positron emission tomography for response assessment of lymphoma: consensus of the imaging subcommittee of international harmonization project in lymphoma. 2007. J Clin Oncol 25:571-8.)(c) Low-grade (blood pool) activity in a large mass
    Large masses may sometimes demonstrate low-grade radiotracer activity equivalent to blood pool, and such activity should not be misinterpreted as a sign of residual lymphoma (Juweid ME, Stoobants S, Hoekstra OS, et. al. Use of positron emission tomography for response assessment of lymphoma: consensus of the imaging subcommittee of international harmonization project in lymphoma. 2007. J Clin Oncol 25:571-8.)(d) Residual splenic mass with uptake similar to normal spleen
    A residual splenic mass equivalent to background spleen in intensity is consistent with treated tumor (Juweid ME, Stoobants S, Hoekstra OS, et. al. Use of positron emission tomography for response assessment of lymphoma: consensus of the imaging subcommittee of international harmonization project in lymphoma. 2007. J Clin Oncol 25:571-8.)(e) Persistent focal marrow uptake
    Focal marrow uptake in the post-treatment setting should be considered suspicious for residual lymphoma (Juweid ME, Stoobants S, Hoekstra OS, et. al. Use of positron emission tomography for response assessment of lymphoma: consensus of the imaging subcommittee of international harmonization project in lymphoma. 2007. J Clin Oncol 25:571-8.)
    QUESTION
     
    In transformed lymphoma, which one of the following statements is true?
    A)     Chronic Lymphocytic Leukemia (CLL) commonly converts to high-grade lymphoma
    B)     In Richter Transformation, the pathology is usually Mantle Cell Lymphoma
    C)     The largest nodal masses in transformed CLL are always involved with high-grade lymphoma
    D)     PET can differentiate between sites of low and high-grade tumor in transformed CLL  [77 %]  
    E)     Patients with Richter Transformation have an excellent prognosis

       

    In transformed lymphoma, which one of the following statements is true?(a) Chronic Lymphocytic Leukemia (CLL) commonly converts to high-grade lymphoma
    Transformation is an uncommon occurrence, with a rate of approximately 4% (Bruzzi JF, Macapinlac H, Tsimberidou AM, et. al. Detection of Richter’s transformation of chronic lymphocytic leukemia by PET/CT. 2006. J Nucl Med 47:1267-73.)(b) In Richter Transformation, the pathology is usually Mantle Cell Lymphoma
    When transformation occurs, the histopathology is typically diffuse large B-cell lymphoma (Bruzzi JF, Macapinlac H, Tsimberidou AM, et. al. Detection of Richter’s transformation of chronic lymphocytic leukemia by PET/CT. 2006. J Nucl Med 47:1267-73.)(c) The largest nodal masses in transformed CLL are always involved with high-grade lymphoma
    Transformation can occur in any size node; one of the strengths of FDG-PET/CT in patients with suspected transformation is its ability to differentiate nodes based on metabolic activity rather than size (Bruzzi JF, Macapinlac H, Tsimberidou AM, et. al. Detection of Richter’s transformation of chronic lymphocytic leukemia by PET/CT. 2006. J Nucl Med 47:1267-73.)(d) PET can differentiate between sites of low and high-grade tumor in transformed CLL
    Areas of high-grade tumor show more intense tracer uptake on FDG-PET/CT than areas of indolent disease, and PET has been shown to differentiate these two processes (Bruzzi JF, Macapinlac H, Tsimberidou AM, et. al. Detection of Richter’s transformation of chronic lymphocytic leukemia by PET/CT. 2006. J Nucl Med 47:1267-73.)(e) Patients with Richter Transformation have an excellent prognosis
    The prognosis of Richter Transformation is poor (Bruzzi JF, Macapinlac H, Tsimberidou AM, et. al. Detection of Richter’s transformation of chronic lymphocytic leukemia by PET/CT. 2006. J Nucl Med 47:1267-73.)
    QUESTION
     
    In lung cancer staging, which one of the following statements is true regarding PET/CT?
    A)     It is more useful than CT in determining the extent of the primary tumor (T stage).
    B)     It improves detection of distant metastasis compared to conventional imaging (i.e., CT, MRI).  [85 %]  
    C)     It has reduced futile (unnecessary) lung cancer surgeries by 5%.
    D)     All lung cancers greater than 2 cm exhibit FDG activity.
    E)     Its lymph node specificity for malignancy is 59-89%.

       

    In lung cancer staging, which one of the following statements is true regarding PET/CT?(a) It is more useful than CT in determining the extent of the primary tumor (T stage).
    It has limited value because the tumor margins are not clearly defined by the FDG activity secondary to blooming artifacts, and therefore the extent and invasion by the tumor (T) is not as good as CT.(b) It improves detection of distant metastasis compared to conventional imaging (i.e., CT, MRI).
    Correct Answer(c) It has reduced futile (unnecessary) lung cancer surgeries by 5%.
    Futile surgery is reported to be reduced by 21 – 41%.(d) All lung cancers greater than 2 cm exhibit FDG activity.
    FDG can be negative in some tumors, such as bronchioloalveolar cell carcinoma, regardless of size.(e) Its lymph node specificity for malignancy is 59-89%.
    Lymph node specificity is reported to be 94 – 100%. CT alone is 59 – 89%.Reference:  van Tinteren H, Hoekstra OS, Smit EF, et al. Effectiveness of positron emission tomography in the preoperative assessment of patients with suspected non-small-cell lung cancer: the PLUS multicentre randomised trial. Lancet 2002;359(9315):1388-93.  
    QUESTION
     
    In regards to re-assessing lung cancer patients, which one of the following is true?
    A)     PET/CT cannot differentiate radiation fibrosis from recurrent tumor within the radiation field.
    B)     Conventional CT is not useful in assessing tumor response using RECIST criteria.
    C)     PET/CT has a low utility in detecting second primary tumors or distant metastasis.
    D)     PET/CT has no value in assessing tumor response to therapy.
    E)     4D PET/CT is a method to correct for motion artifacts in calculating SUV in PET/CT imaging.  [77 %]In regards to re-assessing lung cancer patients, which one of the following is true?(a) PET/CT cannot differentiate radiation fibrosis from recurrent tumor within the radiation field.
    FDG activity is high in recurrent tumor and there is no or very little activity in fibrosis.(b) Conventional CT is not useful in assessing tumor response using RECIST criteria.
    RECIST criteria are based on conventional CT imaging(c) PET/CT has a low utility in detecting second primary tumors or distant metastasis.
    Second primary tumors are detected in approximately 5% of lung cancer patients(d) PET/CT has no value in assessing tumor response to therapy.
    PET/CT is proving to be very useful in assessing tumor response and new guidelines are under development for RECIST applications.(e) 4D PET/CT is a method to correct for motion artifacts in calculating SUV in PET/CT imaging.
    Correct Answer  Reference:  

    Munden RF, Swisher SG, Stevens CW, Stewart DJ. Imaging of the patient with non-small cell lung cancer. Radiology 237:803-818, 2005   

       

    QUESTION

    Which is a potential cause of acetabular labral tear?
    A)     Trauma
    B)     Femoral-acetabular impingement
    C)     Hip dysplasia
    D)     All of the above  [94 %]  

       

    Answer: DTears of the acetabular labrum can result from a variety of causes. They can result from acute trauma such as a hip subluxation injury, or repetitive trauma as occurs in femoral-acetabular impingement. Degenerative tears can occur from excess stress on the labrum as seen in patients with a shallow acetabulum from development dysplasia of the hip.References:1. Petersilge CA, Haque MA, Petersilge WJ, Lewin JS, Lieberman JM, Buly R. Acetabular labral tears: evaluation with MR arthrography. Radiology. 1996 Jul;200(1):231-235.
    2. Kassarjian A, Belzile E. Femoroacetabular impingement: presentation, diagnosis, and management. Semin Musculoskelet Radiol. 2008 Jun;12(2):136-145.
    QUESTION
     
    A possible sign of femoral-acetabular impingement includes:
    A)     An osseous prominance (‘bump’) at the femoral head-neck junction  [93 %]  
    B)     Upturn of the lateral acetabular roof
    C)     A shallow acetabular socket
    D)     Acetabular anteversion

       

    Answer: AOne of the two main types of femoral-acetabular impingement (FAI) is cam FAI, which results from an osseous bump at the head-neck junction. An upturned lateral acetabular roof would allow more free range of motion of the femoral head and make FAI less likely, as would a shallow acetabular socket. Acetabular retroversion is associated with the 2nd type of FAI, pincer-type. Anteversion however is not associated with FAI.Reference:Tannast M, Siebenrock KA, Anderson SE. Femoroacetabular impingement: radiographic diagnosis–what the radiologist should know. AJR Am J Roentgenol. 2007 Jun;188(6):1540-52.
    QUESTION
     
    The best imaging exam for acetabular labral tear is:
    A)     Ultrasound
    B)     MRI
    C)     CT
    D)     MR arthrogram  [89 %]  

       

    Answer: DMR arthrography is the most sensitive and accurate imaging exam for identifying labral tears, with an accuracy of 90-95%. Conventional MR is much less accurate as is CT. Ultrasound has not been proven to be better than MR arthrography for labral tears.Reference:Toomayan GA, Holman WR, Major NM, Kozlowicz SM, Vail TP. Sensitivity of MR arthrography in the evaluation of acetabular labral tears. AJR Am J Roentgenol 2006;186:449–453.
    QUESTION
     
    Which of the following is true in regard to MR arthrography of the hip?
    A)     Joint distention is achieved by injection of more than 20 ml of a dilute solution of gadolinium.
    B)     Posterior acetabular labral tears are the most commonly encountered labral tear.
    C)     MR arthrography has a high sensitivity and accuracy of at least 90% for labral tears.  [93 %]  
    D)     Labral tears are recognized by interposition of contrast material between the acetabulum and labrum in the posteroinferior quadrant of the acetabulum.
    E)     In asymptomatic individuals, the labrum is typically rounded or blunted.

       

    Correct answer: Ca. Adequate hip joint distension for MR arthrography can be achieved with a volume of 12-15 cc. False
    b. In several studies, around 90% of acetabular labral tears occur in the anterior superior labrum. False
    c. A study by Czerny et al. reported a sensitivity of 90% and a specificity of 91% for MR arthrography of labral tears. True
    d. Labral tears appear on MR arthrography as either increased signal that extends to the surface of the labrum, or abnormal interposition of contrast between the labrum and acetabulum. Interposition of contrast material at the acetabular labral junction can also be seen normally posteroinferiorly where it represents a normal recess. Some authors believe that a shallow smooth sulcus can occur at other regions involving the acetabular labral junction, including the anterior superior acetabulum. False
    e. In asymptomatic individuals the most common appearance of the labrum is triangular, seen in 66%-80% of people at MR arthrography. A minority of asymptomatic individuals may have a blunted or rounded shape to the labrum, and this is more common as people get older.References:1. Byrd JW, Jones KS. Diagnostic accuracy of clinical assessment, magnetic resonance imaging, magnetic resonance arthrography, and intra-articular injection in hip arthroscopy patients. Am J Sports Med. 2004 Oct-Nov;32(7):1668-74.
    QUESTION
     
    The most common cause of an internal snapping hip is due to:
    A)     Labral tear
    B)     Intraarticular loose body
    C)     Iliopsoas tendon  [79 %]  
    D)     Iliofemoral ligament
    E)     Iliotibial band

       

    Correct answer: Ca. There are three main types of causes of painful snapping hip syndrome: external, internal and intra-articular. Labral tears and loose bodies are categorized as the intra-articular type when they cause a painful snapping hip. False
    b. Loose bodies are categorized as the intra-articular type when they cause a painful snapping hip. False
    c. The main cause of the internal type of the snapping hip syndrome is due to the iliopsoas tendon passing over the iliopectineal eminence at the anterior acetabular rim. True
    d. The iliofemoral ligaments are an uncommon cause of internal snapping hip syndrome.
    e. The iliotibial band snapping as it passes over the greater trochanter is considered an external type of snapping hip syndrome. FalseReferences:1. Schaberg JE, Harper MC, Allen WC. The snapping hip syndrome. Am J Sports Med 1984; 12:361-365.
    2. Cardinal E, Buckwalter KA, Capello WN, Duval N. US of the snapping iliopsoas tendon. Radiology. 1996 Feb;198(2):521-2.
    3. Pelsser V, Cardinal E, Hobden R, Aubin B, Lafortune M. Extraarticular snapping hip: sonographic findings. AJR Am J Roentgenol. 2001 Jan;176(1):67-73.
    QUESTION
     
    By MRI, osteitis pubis manifests as?
    A)     Unilateral or grossly asymmetric pubic ramus bone marrow edema
    B)     A ‘secondary cleft’ sign on T2 weighted coronal images
    C)     Subchondral marrow edema spanning the anterior – posterior symphysis with or without osseous productive change  [89 %]  
    D)     A joint effusion extending from the pubic symphysis into the inguinal canal

       

    Correct answer: COsteitis pubis appears as marrow edema of the pubic bones on both sides of the symphysis. Osteitis pubis shows MRI characteristics similar to osteoarthritis, with reciprocal bone marrow edema in a subchondral location. A secondary cleft sign indicates a disruption of the rectus abdominis/abductor aponeurosis or an abductor tendon avulsion, and is a more severe injury. Joint effusion extending into the inguinal canal is not seen with osteitis pubis.Reference:Athletic pubalgia and the “sports hernia”: MR imaging findings. Zoga AC, Kavanagh EC, Omar IM, Morrison WB, Koulouris G, Lopez H, Chaabra A, Domesek J, Meyers WC. Radiology. 2008 Jun;247(3):797-807.
    QUESTION
     
    Optimization of MRI in the setting of clinical athletic pubalgia includes?
    A)     The use of dynamic imaging with and without valsalva
    B)     Pre and post intravenous contrast T1 weighted fast field echo/gradient echo acquisitions
    C)     Positioning the patient prone for reduction of respiratory motion artifact
    D)     A dedicated surface receiver coil positioned over the pubic symphysis  [90 %]  

       

    Correct answer: DThe optimal protocol includes both high resolution, small field of view sequences with the surface coil turned on for symphysis pathology as well as large field of view sequences of the pelvis using the built in body coil for remote, confounding lesions. Dynamic imaging is used to image inguinal hernias, which are different than ‘sports hernias.’ Intravenous contrast and prone positioning are not necessary to image athletic pubalgia.Reference:Athletic pubalgia and “sports hernia”: optimal MR imaging technique and findings. Omar IM, Zoga AC, Kavanagh EC, Koulouris G, Bergin D, Gopez AG, Morrison WB, Meyers WC. Radiographics. 2008 Sep-Oct;28(5):1415-38.
    QUESTION
     
    The lesion most likely to be identified clinically as a “sports hernia” is a(n)?
    A)     Rectus abdominis / adductor aponeurosis tear or detachment.  [96 %]  
    B)     Tear of the posterior wall of the inguinal canal
    C)     Breech of the external oblique aponeurosis
    D)     Adductor longus tendon avulsion

       

    Correct answer: ARectus abdominis / adductor aponeurosis tear or detachment is the usual etiology of athletic pubalgia. The lateral edge of the caudal rectus abdominis tendon is positioned just deep to the posterior wall of the superficial inguinal ring. Tear of the posterior wall of the inguinal canal or tears of the external oblique aponeurosis are uncommon causes of groin pain in athletes. Adductor longus tendon avulsion can be seen in athletes with groin pain, but may present more with more distal symptoms.Reference:Experience with “sports hernia” spanning two decades. Meyers WC, McKechnie A, Philippon MJ, Horner MA, Zoga AC, Devon ON. Ann Surg. 2008 Oct;248(4):656-65.
    QUESTION
     
    A rectus abdominis / adductor aponeurotic plate disruption will manifest on MRI as?
    A)     Unilateral detachment of the rectus abdominis / adductor aponeurosis causing enlargement of the superficial inguinal ring
    B)     A confluent detachment of bilateral rectus abdominis tendons from their caudal pubic insertions  [48 %]  
    C)     Displacement of the interpubic disk at the pubic symphysis
    D)     Fatty atrophy of the rectus abdominis muscle, unilateral or bilateral

       

    Correct answer: BThis bilateral lesion can lead to instability at the pubic symphysis causing rapid evolution of osteitis pubis, and is unlikely to respond long term to conservative therapies. Unilateral detachment is less common. Displacement of the pubic symphysis disc is uncommon, while fatty atrophy of the rectus abdominis in athletes is generally related to a unilateral aponeurosis lesion.Reference:Anatomy, pathology, and MRI findings in the sports hernia. Shortt CP, Zoga AC, Kavanagh EC, Meyers WC. Semin Musculoskelet Radiol. 2008 Mar;12(1):54-61.
    QUESTION
     
    The most frequently encountered confounding lesion for pubic symphysis osseous or tendinous injury in the setting of groin pain is?
    A)     Inguinal hernia
    B)     Obturator internus or iliopsoas bursitis
    C)     Internal derangement of the hip/labral tear  [76 %]  
    D)     Adnexal lesions

       

    Correct answer: C  

    There are many confounders about the pelvis that may manifest as activity-induced groin pain, but labral tear or hip chondral lesions are the most common.  

    Reference:  

    Spectrum of MRI findings in clinical athletic pubalgia. Zajick DC, Zoga AC, Omar IM, Meyers WC. Semin Musculoskelet Radiol. 2008 Mar;12(1):3-12.  

    QUESTION
     
    In a postmenopausal woman with abnormal vaginal bleeding who is not receiving hormone replacement therapy, which of the following endometrial thickness cutoff criteria is used to optimize accuracy for detecting cancer?
    A)     ≥ 4 mm.
    B)     5 mm.  [96 %]  
    C)     ≥ 6 mm.
    D)     ≥ 7 mm.
    E)     ≥ 8 mm.

       

    Meta-analysis of the diagnostic performance of endovaginal sonography in detecting endometrial cancer [1] has shown that a cutoff criterion of ≥ 5 mm results in 96% sensitivity and 92% specificity and shows optimum overall accuracy. Option B is the best response. Higher thickness cutoff criteria result in decreased sensitivity, whereas lower thickness cutoff criteria decrease specificity without significant increases in sensitivity. Options A, C, D, and E are not the best responses.
    QUESTION
     
    In a postmenopausal woman with abnormal vaginal bleeding who is undergoing hormone replacement therapy, which of the following endometrial thickness cutoff criteria is used to optimize accuracy for detecting cancer?
    A)     ≥ 4 mm.
    B)     5 mm.  [85 %]  
    C)     ≥ 6 mm.
    D)     ≥ 7 mm.
    E)     ≥ 8 mm.

       

    Endovaginal sonography is the first-line screening technique for endometrial cancer in the workup of postmenopausal women receiving hormone replacement therapy. A thickness of 8 mm is considered the upper limit of normal if the patient is asymptomatic. However, if the patient reports postmenopausal bleeding, a thickness cutoff of ≥ 5 mm is used. Option B is the best response. Meta-analysis of the diagnostic performance of endovaginal sonography in detecting endometrial cancer [1] has shown that a cutoff criterion of ≥ 5 mm results in 96% sensitivity and 77% specificity and shows optimum overall accuracy. Higherthickness cutoff criteria result in improved specificity but significant decreases in sensitivity, whereas lower-thickness cutoff criteria do not significantly increase sensitivity. Options A, C, D, and E are not the best responses.
    QUESTION
     
    All of the following increase a woman’s risk for endometrial hyperplasia and cancer EXCEPT which one?
    A)     Multiparity.  [96 %]  
    B)     Obesity.
    C)     Diabetes.
    D)     Hypertension.
    E)     Tamoxifen exposure.

       

    Endometrial hyperplasia and cancer are caused by unopposed estrogen stimulation. Risk factors include endogenous or exogenous exposure to estrogen, tamoxifen use, nulliparity, obesity, hypertension, and diabetes [2]. Options B, C, D, and E are not the best responses. Multiparity is not a risk factor for endometrial hyperplasia and cancer. Option A is the best response.
    QUESTION
     
    Which of the following statements regarding women receiving tamoxifen is FALSE?
    A)     Tamoxifen causes an increase in the prevalence of endometrial polyps, hyperplasia, and carcinoma.
    B)     Postmenopausal women taking tamoxifen usually show endometria that are thicker than in control subjects.
    C)     Endovaginal sonography is an accurate tool for diagnosing endometrial abnormalities in this patient population.  [95 %]  
    D)     Subendometrial cystic changes can often simulate endometrial thickening on transvaginal sonography.
    E)     What should be considered normal endometrial thickness in asymptomatic women on tamoxifen is controversial.

       

    Tamoxifen has a weak estrogenic effect in the uterus and causes an increased prevalence of endometrial polyps, hyperplasia, and carcinoma. Option A is not the best response. Subendometrial cysts, a finding associated with tamoxifen exposure, can often simulate endometrial thickening on transvaginal sonography, decreasing its diagnostic accuracy. Option D is not the best response. Furthermore, several disorders, such as polyps and carcinoma, may coexist, limiting the usefulness of endovaginal sonography in the diagnosis of specific abnormality [3]. Option C, which is not true, is the best response. Sonohysterography may help differentiate subendometrial from endometrial abnormalities and guide proper diagnostic workup. Postmenopausal women taking tamoxifen often have endometria that are thicker than those of control subjects [4], and most of them are asymptomatic. Option B is not the best response. What constitutes the normal endometrial thickness for this group of patients is controversial, with 5–8 mm having been proposed [5–7]. Option E is not the best response.
    QUESTION
     
    The differential diagnosis of focal endometrial abnormality seen on sonohysterography includes which of the following?
    A)     Polyp.
    B)     Hyperplasia.
    C)     Carcinoma.
    D)     Subendometrial fibroid.
    E)     All of the above.  [97 %]  

       

    Polyps are a common cause of focal endometrial thickening. On sonohysterography, polyps appear as echogenic, smooth, intracavitary masses outlined by fluid. The point of attachment does not disrupt the endometrial lining. Cystic spaces corresponding to dilated glands filled with proteinaceous fluid, or heterogeneous echotexture as a result of hemorrhage, infarction, or inflammation, can be seen. Although diffuse thickening is the most common appearance of endometrial hyperplasia and cancer, both can be focal on occasion. Subendometrial fibroids can usually but not always be distinguished from endometrial disorders by the appearance on sonohysterography. Subendometrial fibroids are typically hypoechoic, well-defined solid masses that show acoustic attenuation. Most important, they show an overlying layer of echogenic endometrium [8]. Options A–D are all correct, so option E is the best response.
    QUESTION
     
    In differentiating focal endometrial disorders (e.g., polyp) from a subendometrial disorder (e.g., fibroid) on sonohysterography, which of the following statements is FALSE?
    A)     Polyps are frequently multifocal, whereas fibroids are usually solitary.  [94 %]  
    B)     Polyps usually show a narrow base, whereas fibroids have a broad base of attachment to the uterine wall.
    C)     Polyps are typically echogenic like normal endometrium, whereas fibroids are typically hypoechoic like normal myometrium.
    D)     The normal endometrial lining underlies the base of a polyp, whereas it overlies the surface of a fibroid.
    E)     On color Doppler imaging, polyps show a single feeding vessel, whereas fibroids show a diffuse network of vessels.

       

    On sonohysterography, endometrial polyps are typically echogenic, like normal endometrium, and show a narrow attachment to the normal endometrial lining at its base [9]. Option B is not the best response. A single feeding vessel is sometimes seen on color Doppler sonography. In contrast, subendometrial fibroids are typically hypoechoic, like normal myometrium, and show a broad base of attachment to the myometrial wall with the normal endometrial lining overlying its surface [8]. Option C is not the best response. Fibroids show a hypervascular network of vessels on color Doppler sonography [10]. Option E is not the best response. The key to differentiating the two entities is ascertaining the location of the endometrial lining with regard to the lesion. The normal endometrial lining underlies the base of a polyp, whereas it overlies the surface of a fibroid. Option D is not the best response. Whether a focal lesion is solitary or multiple on sonohysterography does not distinguish between an endometrial or subendometrial process. Option A, which is not true, is the best response.
    QUESTION
     
    An endovaginal sonography examination depicts the endometrium of a postmenopausal woman with vaginal bleeding , abnormally thick, measuring 2.1 cm, and contains multiple cysts . There is a history of several years of tamoxifen exposure. Which of the following is the LEAST LIKELY diagnosis? 
    A)     Polyp.
    B)     Hyperplasia.
    C)     Carcinoma.
    D)     Subendometrial fibroid.  [93 %]  
    E)     Subendometrial cysts.

       

    The endometrium is abnormally thick, measuring 2.1 cm, and contains multiple cysts. Chronic exposure to tamoxifen results in an increased likelihood of endometrial disorders such as polyps, hyperplasia, and carcinoma [4]. Options A, B, and C are not the best responses. These disorders are often detected as abnormal endometrial thickening, sometimes with cystic changes. In addition, patients taking tamoxifen can show subendometrial cysts that mimic endometrial thickening on transvaginal sonography [11]. Option E is not the best response. The appearance of this endometrium is least consistent with an underlying submucosal fibroid that typically appears hyhypoechoic, homogeneously solid, and well circumscribed. Option D is the best response.
    QUESTION
     
    A sonohysterography examination depicts a a hypoechoic, well-defined solid mass focal lesion. Which of the following is the MOST LIKELY diagnosis? 
    A)     Polyp.
    B)     Hyperplasia.
    C)     Carcinoma.
    D)     Subendometrial fibroid.  [97 %]  

       

    The lesion is a hypoechoic, well-defined solid mass with a broad base of attachment. Most important, it shows an overlying layer of echogenic endometrium, indicating that this lesion is subendometrial in location. This appearance is most consistent with a subendometrial fibroid. Option D is the best response. Polyp, hyperplasia, and carcinoma are endometrial disorders. Options A, B, and C are not the best responses.
    QUESTION
     
    Which of the following statements regarding diagnostic tools for endometrial disorders is TRUE?
    A)     Nonfocal biopsy to detect cancer should be performed after a negative workup for a focal abnormality.
    B)     Sonohysterography is more accurate than hysteroscopy for detecting focal endometrial disorders.
    C)     Endovaginal sonography is the most sensitive test for endometrial cancer detection in postmenopausal women.  [84 %]  
    D)     Endovaginal sonography is highly sensitive in detecting endometrial disorders in the premenopausal woman.
    E)     MRI is replacing sonohysterography as a diagnostic tool for endometrial disorders.

       

    Because endometrial cancer and hyperplasia, which are nonfocal abnormalities, constitute the only potentially lifethreatening endometrial disorders, endovaginal sonography, followed by nonfocal endometrial biopsy when indicated, should be performed early in the diagnostic workup of abnormal bleeding to evaluate for these disorders. Only after these prove negative should focal, more likely benign causes be sought to explain the bleeding. Option A is not the best response. Sonohysterography and hysteroscopy are two methods for detecting focal lesions and are similar in sensitivity and specificity [12, 13]. Option B is not the best response. Endovaginal sonography is highly effective in screening for cancer in the postmenopausal population using a thickness cutoff of ≥ 5 mm. Option C is the best response. In the premenopausal population, endovaginal sonography is a useful tool for identifying mural abnormalities such as fibroids and adenomyosis. However, its performance in detecting endometrial disorders is suboptimal, with a sensitivity of 67% and a specificity of 75% [14]. Option D is not the best response. The role of MRI in the workup of abnormal vaginal bleeding is limited. Option E is not the best response.
    QUESTION
     
    Sonohysterography can be appropriately used in evaluating women with abnormal bleeding for all of the following purposes EXCEPT which one?
    A)     Evaluate endometrium not visualized or poorly visualized on endovaginal sonography.
    B)     Evaluate women with abnormal vaginal bleeding and normal findings on endovaginal sonography for underlying endometrial disorders.
    C)     Distinguish abnormality seen on endovaginal sonography as endometrial versus subendometrial.
    D)     Determine the size and location of focal lesions to plan hysteroscopic resection.
    E)     Characterize an endometrial lesion as benign or malignant.  [97 %]Sonohysterography distinguishes endometrial from subendometrial abnormalities. Options C is not the best response. Once a lesion has been characterized as endometrial, imaging cannot reliably exclude malignancy. Focal endometrial hyperplasia or carcinoma can mimic a sessile polyp, and foci of atypical hyperplasia are sometimes found in polyps. Thus, endometrial lesions should undergo histologic evaluation. Option E, which is not true, is the best response. Sonohysterography is useful for detecting, localizing, and sizing focal endometrial disorders before hysteroscopic resection. Option D is not the best response. It is more sensitive than endovaginal sonography for detecting focal endometrial disorders, especially in premenopausal women or those who have undergone long-term tamoxifen therapy [15]. Option B is not the best response. Sonohysterography can be used to evaluate the endometrium when endovaginal sonography fails to adequately visualize it, often because of distortion by fibroids. Option A is not the best response. 

       

    QUESTION
     
    When a bone tumor is suspected, what role does conventional radiography play in the workup?
    A)     Conventional radiography is the first choice for initial imaging.  [100 %]  
    B)     Conventional radiography is limited because of poor lesion characterization.
    C)     Conventional radiography is limited because of poor lesion detection.
    D)     Conventional radiography is rarely useful.

       

    Conventional radiographs are the mainstay for initial evaluation of bone lesions [1, 2]. Radiographs provide important information regarding the underlying pathology of bone tumors. Particularly, the location in the skeleton, location in the bone, rate of tumor growth (aggressiveness), and lesion characterization, including mineralization, are key factors leading to a diagnostic conclusion. Option A is the best response. Conventional radiographs are very useful to characterize lesions, especially with regard to aggressiveness of the lesion and associated lesion matrix. Option B is not the best response. Conventional radiographs are useful for lesion detection. Metastatic bone surveys are commonly used in clinical practice. Option C is not the best response. Conventional radiographs are commonly used when working up suspected bone tumors. Their specificity is excellent because of their ability to characterize lesion location, lesion rate of growth, and associated tissue, which significantly narrows the differential diagnosis in many cases. Option D is not the best response.
    QUESTION
     
    Advantages of CT over MRI for bone tumor characterization include evaluation of all of the following features EXCEPT:
    A)     Cortical integrity.
    B)     Neurovascular invasion.  [92 %]  
    C)     Matrix mineralization.
    D)     Periosteal reaction.

       

    CT for characterization of tumors is superior to MRI when assessing certain tumor characteristics. However, MRI is better than CT for evaluation of the soft tissues [1]. This includes the presence or absence of neurovascular invasion [2]. Option B, which is false, is the best response. CT is superior to MRI for assessing bone and other mineralized structures [2] and for assessing cortical integrity, matrix mineralization, and periosteal reaction. Options A, C, and D are correct and are not the best responses.
    QUESTION
     
    Limb-sparing surgical techniques are used for all of the following reasons EXCEPT:
    A)     Improved or equal long-term survival rates compared with conventional surgical techniques.
    B)     Improved functional results.
    C)     Proven efficacy of metastasectomy.
    D)     Ease of surgical procedure.  [92 %]  

       

    Limb-sparing surgical techniques are used for many reasons. These surgical techniques are complicated and were designed for optimum patient outcome, not for the ease of the surgical procedure [1]. Option D, which is false, is the best response. Outcomes for limb-sparing surgical techniques show improved or equal long-term survival rates when compared with conventional surgical techniques. Option A, which is true, is not the best response. Limb-sparing surgical techniques are most valuable because of the improved functional results for patients [3]. Option B, which is true, is not the best response. Limb-sparing surgical techniques are also valuable because surgical resection of distant metastases has been proven to be effective. Option C, which is true, is not the best response.
    QUESTION
     
    For the imaging of bone tumors, MRI has the advantage over CT for all of the following reasons EXCEPT:
    A)     Superior soft-tissue contrast resolution.
    B)     Improved assessment of skip lesions.
    C)     Need to use IV contrast material.  [92 %]  
    D)     Lack of exposure to ionizing radiation.

       

    MRI has some advantages over CT when evaluating bone tumors. However, the need to use IV contrast material is not one of these advantages [1]. Most bone lesions can be accurately characterized on CT without the use of IV contrast material. Option C, which is false, is the best response. MRI is superior to CT with respect to soft-tissue contrast resolution [2]. Option A, which is true, is not the best response. MRI also well evaluates the marrow space within the bone, providing a more sensitive method for the detection of skip metastases. This is also an advantage. Option B, which is true, is not the best response. The lack of exposure to ionizing radiation in MRI is also an advantage, especially when evaluating children. Option D, which is true, is not the best response.
    QUESTION
     
    In a patient with an intramedullary bone lesion, a primary sarcoma can be excluded in the presence of:
    A)     Homogeneous density of –20 HU on CT.  [100 %]  
    B)     History of previously resected breast cancer.
    C)     Similar signal on in-phase and opposed-phase MR images.
    D)     Patient age > 65 years.

       

    If a bone “lesion” has internal fat density and a uniform appearance, it is likely a focal area of trabecular scarcity related to osteoporosis or an intraosseous lipoma [6]. Tumors generally replace the marrow fat from the intramedullary space rather than filter throughout the marrow. A liposarcoma may have some internal fat but would not appear homogeneous or be within a bone unless it is metastatic. Option A is the best response. Even if a patient has a history of a primary malignancy, one cannot assume that a new bone lesion is a metastasis without a biopsy. If a treatment regimen is begun for the wrong type of tumor, the disease may progress to a more advanced stage before the correct diagnosis is made and the correct treatment is begun. Option B is not the best response. Similar low signal on inphase and opposed-phase gradient-echo MR images is a sign that a water-containing lesion has replaced all marrow fat, which can be seen with both malignant and benign tumors. When a lesion loses signal on the opposed-phase image compared with the in-phase image, it is most likely benign, representing either hematopoietic marrow or marrow edema [7, 8]. Option C is not the best response. Although it is true that a bone or soft-tissue tumor in a patient older than 65 years is more likely to be a metastasis or myeloma, many primary sarcomas of bone and soft tissues occur in elderly patients. Option D is not the best response.
    QUESTION
     
    Reasons for a nondiagnostic or false-negative bone biopsy include sampling all of the following EXCEPT:
    A)     Areas of adjacent reactive periosteal new bone formation.
    B)     Foci of tumor necrosis shown on enhanced imaging.
    C)     Areas with tumor vascularity seen on Doppler ultrasound.  [92 %]  
    D)     Areas of hemorrhage in or adjacent to the tumor.

       

    The finding of blood-flow Doppler signal in a portion of a mass is useful for identifying a target for biopsy that contains viable tissue [6]. Option C, which is false, is the best response. In sclerotic bone lesions, some of the density is due to reactive bone formation and does not contain tumor cells. A needle biopsy of a reactive portion of a lesion can have a nondiagnostic result. Diagnostic yield can be increased with larger needles and more biopsy passes [9]. Option A, which is true, is not the best response. If a biopsy of a necrotic lesion is attempted, the solid and viable portions should be sought as a target. Necrotic areas may not contain enough tumor cells for a successful diagnosis [10]. Option B, which is true, is not the best response. Regions of masses that appear hemorrhagic on MRI or CT often have less diagnostic yield than solid viable areas of abnormal tissue. Option D, which is true, is not the best response.
    QUESTION
     
    Which of the following statements is TRUE regarding tumor cryoablation versus radiofrequency ablation?
    A)     Cryoablation is more painful than radiofrequency ablation.
    B)     Cryoablation is easier to monitor than radiofrequency ablation.  [96 %]  
    C)     Cryoablation is more harmful to fibrous structures than radiofrequency ablation.
    D)     Cryoablation will not damage the skin immediately overlying a treated lesion.Cryoablation freezes and destroys only water-containing cells (tumor and nerve cells). A cryoablation lesion can be visualized in real time with CT because the ice ball created around the cryoprobe is of lower density than water and surrounding nonfrozen soft tissues. A radiofrequency ablation (RFA) lesion is not clearly visible on CT. The leading edge of the ice ball causes shadowing on ultrasound [6, 11, 12]. Option B is the best response. Compared with RFA, cryoablation is less painful for the patient [13]. Option A is not the best response. Collagenous or fibrous structures, including pleura, peritoneum, bowel walls, bladder walls, and urothelium, are better preserved with cryoablation. Option C is not the best response. Cryoablation can cause frostbite to nearby skin, whereas RFA can burn overlying skin. Option D is not the best response.

       

    Which arthropathy is LEAST likely to be associated with erosive disease in the distal interphalangeal joints?
    A)     Psoriatic arthritis
    B)     Erosive osteoarthritis
    C)     Gout
    D)     Rheumatoid arthritis  [86 %]  
    Rheumatoid arthritis usually does not cause erosive disease in the distal interphalangeal joint. Exceptions to this rule are rare and but can be seen in patients with long standing disease and a diagnosis on rheumatoid arthritis has been well established. Erosions can also be seen in the distal interphalangeal joints of patients with rheumatoid arthritis that also have erosive osteoarthritis (EOA). The erosions of EOA however will be central rather than marginal and will be associated with osteophyte formation.Reference:
    Resnick, D. Rheumatoid arthritis. In: Diagnosis of Bone and Joint Disorders, 4rth ed. Philadelphia, PA: WB Saunders, 2002; 891-987.
    QUESTION
     
    Soft tissue swelling of an entire digit (sausage digit) is a relatively specific finding for which arthropathy?
    A)     Psoriatic arthropathy  [99 %]  
    B)     Osteoarthritis
    C)     Gout
    D)     Rheumatoid arthritis
    Soft tissue swelling of entire digit, also known as dactylitis, is a finding seen in spondyloarthopathies such as psoriatic and reactive arthritis. It is not seen in rheumatoid arthritis, gout or osteoarthritis. Dactylitis is seen in 16-24% of patients with psoriatic arthritis and the reason for diffuse soft tissue swelling in these patients is unclear. Some authors consider dactylitis to be a manifestation of enthesitis and other, a presentation of flexor tenosynovitis. Regardless of the etiology, dactylitis is a relatively specific finding for spondyloarthropathy such as psoriatic arthritis.Reference:
    Resnick, D. Rheumatoid arthritis. In: Diagnosis of Bone and Joint Disorders, 4rth ed. Philadelphia, PA: WB Saunders, 2002; 1082-1109.
    QUESTION
    State-of-the-art ultrasound evaluation of patients with Rheumatoid Arthritis requires:
    A)     Specialized ultrasound equipment
    B)     Dedicated image analysis software
    C)     Use of injectable sonographic contrast media
    D)     All of the Above
    E)     None of the above  [68 %]  
    State-of-the-art ultrasound evaluation of patients can be performed with conventional and commercially-available equipment. Postprocessing image quantification, which is usually done with dedicated image analysis software, is not part of the routine clinical examination, nor is the use of injectable sonographic contrast media.Reference:
    Bruno, M.A., Gold, G.E., Mosher, T.J. “Arthritis In Color: Advanced Imaging In Arthritis,” with 5 Contributors. Philadelphia: Saunders-Elsevier Scientific Press. © 2009. ISBN: 978-14160-4722-3. Chapter 5: Ultrasound In Arthritis.
    QUESTION
     
    Advantages of Ultrasound over MRI for evaluation of patients with RA include:
    A)     US has lower cost than MRI.
    B)     US has higher spatial resolution than MRI.
    C)     US is easier for patient to tolerate/cooperate with examination.
    D)     All of the above.  [73 %]  
    E)     A and C only.
    Many radiologists do not realize that ultrasound actually has higher spatial resolution than MRI, a point which is made in the lecture. Ultrasound examinations do not require difficult positioning or require the patient to remain still for an extended period of time. Their cost is usually much less than MRI as well.Reference:
    Bruno, M.A., Gold, G.E., Mosher, T.J. “Arthritis In Color: Advanced Imaging In Arthritis,” with 5 Contributors. Philadelphia: Saunders-Elsevier Scientific Press. © 2009. ISBN: 978-14160-4722-3 Chapter 5: Ultrasound in Arthritis.
    QUESTION
     
    Molecular / Nuclear imaging of patients with RA
    A)     Is entirely experimental at this time—with no role in the clinical management of patients with RA
    B)     Primarily consists of “physiological” or “functional” imaging, rather than “anatomic” or “structural” imaging methods  [84 %]  
    C)     Primarily involves use of highly specific, experimental “activatable” targeted molecular probes
    D)     Currently limited to animal models and clinical trials
    Although PET/CT, SPECT/CT and PET/MRI combine both anatomic and physiologic/functional imaging, the main advantage of molecular techniques is to enable the visualization of physiological, metabolic and cellular processes.Reference:
    Biswal, S. Chapter 9: “Molecular Imaging in Arthritis” in Bruno, M.A., Gold, G.E., Mosher, T.J. “Arthritis In Color: Advanced Imaging In Arthritis,” with 5 Contributors. Philadelphia: Saunders-Elsevier Scientific Press. © 2009. ISBN: 978-14160-4722-3.
    QUESTION
     
    All of the following can simulate MRI findings of Ankylosing Spondylitis EXCEPT:
    A)     Ulcerative Colitis
    B)     Crohn’s Disease
    C)     Splenectomy  [93 %]  
    D)     Salmonella, Shigella, Yersinia infections
    E)     Intestinal bypass surgery
    A multitude of disease processes can lead to enteropathic arthropathy, which has similar imaging features as Ankylosing Spondylitis. These etiologies include ulcerative colitis, Crohn’s disease, gastrointestinal infections (such as Salmonella, Shigella and Yersinia) as well as intestinal bypass surgery. Splenectomy has not been reported to be associated with enteropathic spondyloarthropathy.Reference:
    Mester AR, Mako EK, Karlinger K, et al. Enteropathic arthritis in the sacroiliac joint. Imaging and differential diagnosis. Eur J Radiol 2000; 35:199-208.
    QUESTION
     
    Is synovial chondromatosis considered a metaplastic process of the synovium?
    A)     True
    B)     False  [62 %]  
    Although primary synovial chondromatosis historically has been deemed a metaplastic process of the synovium, it is now widely considered an uncommon benign neoplastic process in which hyaline cartilage nodules are present in the subsynovial tissues of joints, tendon sheaths or bursae. The cartilaginous nodules are most often found in the knee and hip, may enlarge and detach from the synovium. Rarely, there may be malignant transformation of synovial chondromatosis into chondrosarcoma.Reference:
    Murphey MD, Vidal JA, Fanburg-Smith JC, Gajewski DA. Imaging of synovial chondromatosis with radiologic and pathologic correlation. RadioGraphics 2007; 27:1465-88.
    QUESTION
     
    Which of the following is NOT associated with osteoarthrosis:
    A)     Osteophytes
    B)     Articular cartilage loss
    C)     Osteopenia  [85 %]  
    D)     Synovitis
    E)     Effusions

    Osteoarthrosis is a degenerative process in which there is loss of articular cartilage, resulting in increased stresses across a joint. The abnormal mechanical forces can lead to reactive changes along the joint and increased (not decreased) osseous density related to marginal osteophytes and subchondral sclerosis. There is an increased incidence of synovitis and joint effusions in patients with osteoarthrosis, although theses are nonspecific findings and can be found in multiple other arthropathies.  

    Reference:
    Brower AC and Flemming DJ. Osteoarthritis in Arthritis: In Black and White. 2nd ed. Brower AC and Flemming DJ, ed. 1996. Elsevier Health Sciences.  

    Neonatal Medical and Surgical Chest Diseases

        

    A newborn chest shows diffuse opacification with “ground-glass” appearance. Which one question is most helpful in making a correct diagnosis?
    A)     What is the oxygen saturation?
    B)     Were there fetal decelerations?
    C)     Is there a fever?
    D)     What is the gestational age?  [85 %]  
    E)     Is there a murmur?
    Correct Answer: DExplanation: The ground-glass pattern is seen with Respiratory Distress Syndrome (RDS) or Surfactant Deficient Disease (SDD) and Group B Streptococcal infection. RDS is most common with prematurity. Therefore, the most helpful information is gestational age. Option A is incorrect because: in both cases of RDS and Group B Streptococcal infection there may be oxygen desaturation Option B is incorrect because: RDS and Group B Streptococcal infection do not present in the fetal period Option C is incorrect because: Fever is not a good indicator for infection in the neonatal period as the newborn may not mount a response Option E is incorrect because: Murmur is not a feature of either RDS or Group B Streptococcal infection References: 

    1. Agrons GA et al. Lung Disease in Premature Neonates: Radiologic-Pathologic Correlation. Radiographics 2005;25:1047-1073.
    2. Donnelly L (ed). Diagnostic Imaging: Pediatrics. Surfactant Deficient Disease. 2:30-33. Amirsys, Salt Lake City, Utah 2005.
    QUESTION
    With ground glass, what one is the most helpful ancillary finding?
    A)     Pneumothorax
    B)     Pleural effusion  [77 %]  
    C)     Pneumomediastinum
    D)     Cardiomegaly
    E)     Lymphadenopathy
    Correct Answer: BExplanation: The two most common reasons for ground-glass pattern in the newborn are RDS and Group B Streptococcal infection. Pleural effusion is unusual in RDS and common in infection. Option A is incorrect because: Pneumothorax may be seen as a later complication of RDS or Group B Streptococcal infection and is not a good discriminator between the two. Option C is incorrect because: Pneumomediastinum may be seen as a later complication of RDS or Group B Streptococcal infection and is not a good discriminator between the two. Option D is incorrect because: Cardiomegaly is not a common feature of RDS or Group B Streptococcal infection. Option E is incorrect because: Lymphadenopathy is not a feature of RDS or Group B Streptococcal infection and would be extremely difficult to see on newborn chest radiography as would be obscured by thymus. References: 

    1. Donnelly L (ed). Diagnostic Imaging: Pediatrics. Surfactant Deficient Disease and Neonatal Pneumonia. 2:30-37. Amirsys, Salt Lake City, Utah 2005.
    2. Cleveland RH. A radiologic update on medical diseases of the newborn chest. Pediatric Radiology 1995; 25(8): 631-7
    QUESTION
     
    A newborn has aspirated thick meconium and has respiratory distress. What pattern do you expect to see on CXR?
    A)     Ground-glass
    B)     Fine Reticular
    C)     Coarse Reticular  [100 %]  
    D)     Mass
    E)     Multiple Lucencies
    Correct Answer: CExplanation: Meconium aspiration results in chemical pneumonitis and inspissated secretions, which will lead to areas of atelectasis and interstitial inflammation seen as coarse interstitial disease. In fact some of the opacity lies within the airspaces but the pattern is most strikingly interstitial Option A is incorrect because: Ground glass pattern occurs in RDS or Group B Streptococcal infection Option B is incorrect because: Fine reticular pattern is seen with edema, retained fetal lung liquid and some cases of infection. Option D is incorrect because: Meconium aspiration does not produce masses. Option E is incorrect because: Meconium aspiration may cause pneumothorax in up to 25% of cases but this rarely presents as multiple lucencies (suggesting interstitial emphysema). References: 

    1. Cleveland RH. A radiologic update on medical diseases of the newborn chest. Pediatric Radiology 1995; 25(8): 631-7

    Donnelly L (ed). Diagnostic Imaging: Pediatrics. Meconium Aspiration. 2:38-41. Amirsys, Salt Lake City, Utah 2005..   

    QUESTION
     
    All of the following are diagnosed prenatally by ultrasound (US) or MRI except:
    A)     Pulmonary interstitial emphysema  [85 %]  
    B)     Pulmonary sequestration
    C)     Congenital diaphragmatic hernia
    D)     Congenital pulmonary airway malformation
    E)     Bronchial atresia
    Correct Answer: AExplanation: All but pulmonary interstitial emphysema develop in the prenatal period and can be diagnosed by imaging. Pulmonary interstitial emphysema is part of the air block sequence and is seen once the child starts breathing. Option B is incorrect because: Pulmonary sequestration can be readily diagnosed and characterized by prenatal US and MRI Option C is incorrect because: Congenital diaphragmatic hernia can be readily diagnosed and characterized by prenatal US and MRI Option D is incorrect because: Congenital cystic adenomatoid malformation can be readily diagnosed and characterized by prenatal US and MRI Option E is incorrect because: Bronchial atresia can be suspected and characterized by prenatal US and MRI References: 

    1. Agrons GA et al. Lung Disease in Premature Neonates: Radiologic-Pathologic Correlation. Radiographics 2005;25:1047-1073.
    2. Barnes NA, Pilling DW. Bronchopulmoary foregut malformations: embryology, radiology and quandary. Eur Radiol. 2003 Dec;13(12):2659-73.
    QUESTION
     
    The pattern of apparent cardiomegaly with increased pulmonary blood flow is seen with all but:
    A)     Ventricular Septal Defect (VSD)
    B)     Patent ductus arteriosus (PDA)
    C)     Hypoplastic left heart syndrome (HLHS)
    D)     Transient tachypnea of the newborn (TTN)
    E)     Respiratory distress syndrome (RDS)  [62 %]  
    Correct Answer: AExplanation: All but pulmonary interstitial emphysema develop in the prenatal period and can be diagnosed by imaging. Pulmonary interstitial emphysema is part of the air block sequence and is seen once the child starts breathing. Option B is incorrect because: Pulmonary sequestration can be readily diagnosed and characterized by prenatal US and MRI Option C is incorrect because: Congenital diaphragmatic hernia can be readily diagnosed and characterized by prenatal US and MRI Option D is incorrect because: Congenital cystic adenomatoid malformation can be readily diagnosed and characterized by prenatal US and MRI Option E is incorrect because: Bronchial atresia can be suspected and characterized by prenatal US and MRI References: 

    1. Agrons GA et al. Lung Disease in Premature Neonates: Radiologic-Pathologic Correlation. Radiographics 2005;25:1047-1073.
    2. Barnes NA, Pilling DW. Bronchopulmoary foregut malformations: embryology, radiology and quandary. Eur Radiol. 2003 Dec;13(12):2659-73.
    QUESTION
     
    All of the following are possible complications for bacterial infection in children except:
    A)     Necrotizing pneumonia
    B)     Pleuropulmonary blastoma  [85 %]  
    C)     Lung abscess
    D)     Pneumatocele
    Correct Answer: EExplanation: Cardiomegaly is uncommon in uncomplicated RDS. Once the child begins to improve, a patent ductus arteriosus may declare itself as the pulmonary arterial pressures decrease and then there may be a big heart and increased pulmonary blood flow. Option A is incorrect because: VSD has cardiomegaly and increased pulmonary arterial blood flow Option B is incorrect because: PDA has cardiomegaly and increased pulmonary arterial blood flow Option C is incorrect because: HLHS has cardiomegaly and increased pulmonary venous blood flow with edema Option D is incorrect because: TTN has cardiomegaly and increased interstitial markings, which leads to apparent increased venous blood flow References: 

    1. Agrons GA et al. Lung Disease in Premature Neonates: Radiologic-Pathologic Correlation. Radiographics 2005;25:1047-1073.
    2. Donnelly L (ed). Diagnostic Imaging: Pediatrics. Surfactant Deficient Disease. 2:30-33. Amirsys, Salt Lake City, Utah 2005.
    QUESTION          
     

     

       

      

     

    Recurrent infection in the left lower lobe in children is most likely due to which one of the following diagnoses?
    A)     Viral bronchiolitis
    B)     Primary tuberculosis infection
    C)     Histoplasmosis infection
    D)     Pulmonary sequestration  [92 %]  
    Correct Answer: DExplanation: Underlying congenital lung anomalies such as pulmonary sequestration often cause recurrent infection in children. When recurrent infection repeatedly occurs, particularly within the lower lobes (left lower lobe > right lower lobe) which is a common location for pulmonary sequestration, pulmonary sequestration should be considered as the cause of recurrent infection in children. Option A is incorrect because: viral bronchiolitis does not typically present as recurrent infection in the lower lobe. Bilateral perihilar interstitial opacities associated with peribronchial cuffing and hyperinflation in infants or young children are typical radiological findings. Option B is incorrect because: a primary tuberculosis infection typically manifests as mediastinal lymphadenopathy with or without parenchymal lung disease, which is not localized within the left lower lobe. Option C is incorrect because: a histoplasmosis infection usually presents as bilateral lung nodules and mediastinal / hilar lymphadenopathy which can be often calcified. Isolated histoplasmosis infection within the left lower lobe is unlikely. References: 

    1. Yikilmaz A, Lee EY. CT imaging of mass-like nonvascular pulmonary lesions in children. Pediatr Radiol. 2007; 37(12): 1253 – 1263.
    2. Lee EY, Boiselle PM, Cleveland RH. Multidetector CT evaluation of congenital lung anomalies. Radiology. 2008; 247(3): 632 – 648.
    QUESTION
     
    All of the following are underlying risk factors for invasive pulmonary aspergillosis infection in children except:
    A)     Neutropenia
    B)     Corticosteroid therapy
    C)     History of prior prematurity  [92 %]  
    D)     AIDS

    Correct Answer: C Explanation: Invasive pulmonary aspergillosis infection typically occurs in immunocompromised or immunosuppressed children. History of prior prematurity by itself will not cause immunocompromise or immunosuppression in children. Option A is incorrect because: children with neutropenia, characterized by an abnormally low number of neutrophils, a type of white blood cell, are prone to infectious processes including fungal infection such as aspergillosis infection. Option B is incorrect because: children receiving corticosteroid therapy are often under the immunosupressed state. Option D is incorrect because: children with AIDS infection caused by human immunodeficiency virus (HIV) have decreased effectiveness of the immune system, resulting in susceptibility to various infectious processes including fungal infection. Reference:   

    1. Yikilmaz A, Lee EY. CT imaging of mass-like nonvascular pulmonary lesions in children. Pediatr Radiol. 2007; 37(12): 1253 – 1263.

     

    What is the most definitive test for diagnosing CNS vasculitis?
    A)     CT angiography with 3D volume rendering.
    B)     Cerebral angiography.
    C)     Biopsy.  [91 %]
    D)     MR angiography.
    E)     Transcranial Doppler sonography.

    Because many cases of vasculitis affect small to mediumsized blood vessels, MR angiography is relatively insensitive for the diagnosis of CNS vasculitis. CT angiography is less accurate than cerebral angiography. Cerebral angiography is used as the gold standard for diagnosis at many institutions. When characteristic angiographic findings such as alternating areas of stenosis and dilatation or a beading appearance are observed in multiple vessels and multiple vascular beds, cerebral angiography is diagnostic. However, angiography can be normal in up to 40% of biopsy-proven cases. Thus, negative cerebral angiography does not completely exclude the diagnosis. Moreover, its specificity is not perfect. Intracranial atherosclerotic disease may show irregularity of multiple vessels, mimicking CNS vasculitis.
    Transcranial Doppler sonography is used to characterize the morphology of the superficial temporal artery as a screening tool for temporal arteritis. However, transcranial Doppler sonography is not suitable to evaluate arteries fully to diagnose CNS vasculitis. Options A, B, D, and E are not the best responses.
    Biopsy of CNS tissue would logically be considered the ultimate gold standard of diagnosis, but clearly the procedure is limited by several factors. It is highly invasive and carries certain risks. Successful biopsy requires a willing and experienced neurosurgeon, who may not be readily available. Sampling error could result in limited sensitivity. The site of biopsy should be tailored to the individual patient [2]. The biopsy of the superficial temporal artery is often performed in patients suspected of having giant cell vasculitis. The false-negative rate of biopsy for a diagnosis of vasculitis has been reported to be 16%, yielding a sensitivity of 84% [2]. Therefore, the most definitive test is biopsy of the blood vessels. Option C is the best response.        

    Which one of the following is NOT associated with vasculitis?
    A)     Polyarteritis nodosa.
    B)     Tuberculosis.
    C)     Systemic lupus erythematosus.
    D)     Drugs (amphetamine, cocaine).
    E)     Marfan syndrome.  [97 %]

    The causes of vasculitis are often divided into infectious and noninfectious. Infectious causes include tuberculosis, fungal infection, bacterial vasculitis, and HIV vasculitis. The frequent causes of noninfectious vasculitis are immune-mediated vasculitis such as rheumatoid arthritis and systemic lupus erythematosus, and granulomatous disease, such as Wegener’s granulomatosis and sarcoid, as well as giant cell arteritis (also called temporal arteritis). Drugs, particularly amphetamines and cocaine, are frequent causes of noninfectious vasculitis. An amphetamine causes inflammatory vasculitis with vascular wall necrosis and subsequent hemorrhage. The pathologic features of amphetamine-related vasculitis are similar to those of polyarteritis nodosa. This patient had taken amphetamines for several years. Cocaine, on the other hand, induces cerebral infarction or ischemia as well as hemorrhage by vasoconstrictive effect and increased platelet aggregation, rather than a vasculitis-type inflammation of the vessels [1]. Options A, B, C, and D are not the best responses.
    Marfan syndrome is an autosomal dominant disorder of the connective tissue characterized by disproportionally long limbs and tall stature. It affects the heart and aorta and causes aortic root dilatation, aortic regurgitation, and dissection. However, involvement of CNS vessels is unusual. Option E is the best response.       

    Which one of the following techniques is LEAST appropriate to confirm a diagnosis of venous sinus thrombosis?
    A)     Rapid contrast-enhanced gradient-echo MRI with contrast-enhanced multiplanar imaging.
    B)     MDCT angiography or venography.
    C)     Brain MRI and phase-contrast MR venography.
    D)     Cerebral angiography.  [96 %]
    E)     Brain MRI with time-of-flight MR venography.

    The next diagnostic test to confirm venous sinus thrombosis is brain MRI with MR venography. On conventional MRI, venous sinus thrombosis may be suspected from lack of a flow void or high-signal thrombus in the dural sinuses. Lack of flow void is best appreciated on FLAIR or T2- weighted spin-echo images. Parenchymal changes, such as venous infarction or hemorrhage, along with lack of a flow void on conventional MRI raises the suspicion of venous sinus thrombosis. Superacute thrombus is relatively isointense on T1- and hypointense on T2-weighted images because of deoxyhemoglobin potentially mimicking slow venous flow on conventional MR images and thus requiring MR venography to confirm the diagnosis of venous sinus thrombosis [3]. A subacute blood clot in the venous sinus is often seen as hyperintense on T1-weighted images as a result of methemoglobin mimicking flowing blood on time-offlight (TOF) MR venography. Phase-contrast MR venography is a fairly reliable test for the diagnosis of subacute venous sinus thrombosis.
    Recently, rapid contrast-enhanced gradient-echo imaging has been reported to yield a higher diagnostic accuracy than 2D TOF MR venography [4, 5]. With advances in MDCT technology, CT angiography and venography have been increasingly used to diagnose venous sinus thrombosis and are considered a quick and reliable alternative to MR venography. Options A, B, C, and E, the appropriate next tests to confirm venous sinus thrombosis, are not the best responses.
    Cerebral angiography also shows lack of flow in the dural venous sinuses. However, cerebral angiography is an invasive test that is associated with complication rates of 1–2%. Noninvasive imaging should be considered first to confirm the diagnosis of venous sinus thrombosis. Option D, which is the least appropriate technique, is the best response.       

    Which one of the following is NOT associated with venous sinus thrombosis?
    A)     Sickle cell disease.
    B)     Oral contraceptives.
    C)     Cancer.
    D)     Disseminated intravascular coagulation.  [97 %]
    E)     Dehydration.

    Common medical conditions associated with venous sinus thrombosis are pregnancy,a postpartum state, and hypercoagulable states such as sickle cell disease, oral contraceptives use, and cancer. Dehydration often seen in neonates and elderly patients is associated with venous sinus thrombosis as a result of low-flow circulatory states. Extrinsic compression (tumor) or adjacent infection (mastoiditis) is also a risk factor. Options A, B, C, and E are not the best responses.
    Disseminated intravascular coagulation, however, is a hypocoagulable state and is not associated with venous sinus thrombosis. Option D is the best response.
    Venous sinus thrombosis is an underdiagnosed condition and can be a life-threatening disease if left untreated. Delay in diagnosis often leads to rapid deterioration and poor clinical outcomes. Intracranial hemorrhage is associated with 20–50% of cases of venous sinus thrombosis. Treatment for venous sinus thrombosis is immediate IV anticoagulation with low-molecular-weight heparin, despite the risk of hemorrhagic complications [6].

     
    What is the 30-day mortality rate of subarachnoid hemorrhage secondary to aneurysm?
    A)     15%.
    B)     30%.
    C)     45%.  [95 %]
    D)     65%.
    E)     80%.

    Aneurysmal subarachnoid hemorrhage (SAH) has a 30-day mortality rate of 45%,with approximately half of the survivors sustaining irreversible brain damage [7]. Option C is the best response.The annual incidence of aneurysmal SAH is six per 100,000 in the United States.Approximately 5–10% of stroke cases are secondary to ruptured saccular aneurysms [8].Recurrent hemorrhage remains a serious consequence, with a 70% fatality rate in patients who rebleed.

     
    Which of the following factors does NOT influence management decisions for a ruptured aneurysm?
    A)     Age.
    B)     Sex.  [99 %]
    C)     Aneurysm size.
    D)     Aneurysm location.
    E)     History of hypertension.

    Treatment options for a ruptured aneurysm are surgical resection or endovascular coil embolization. Endovascular occlusion of aneurysms using electrolytically detachable Guglielmi detachable coil system (GDC, Target Therapeutics [now Boston Scientific]) has been used to treat ruptured or unruptured aneurysms in a large number of patients worldwide. Published reports suggest that the endovascular technique is associated with fewer treatment-related complications than open surgery [7]. However, the long-term efficacy in the prevention of rupture or recurrence of aneurysm remains indeterminate. The recent International Subarachnoid Aneurysm Trial (ISAT) showed that retreatment was performed in 17.4% of patients treated with endovascular coiling and in 3.8% of patients after surgical clipping [9]. Younger age and larger aneurysm size were risk factors for retreatment. A higher rate of recurrence is seen in posterior communicating artery aneurysms after endovascular coiling and anterior communicating artery aneurysms after surgical clipping, which might reflect the technical difficulty. Hypertension is also associated with an increasing rate of rupture in patients with an unruptured aneurysm. Thus age, medical history such as hypertension, aneurysm location, and size are all relevant factors in treatment decisions and, therefore, options A, C, D, and E, all relevant factors in treatment decisions, are not the best responses. Although aneurysms are more common in women than in men, sex is not a factor affecting management decisions or predicting outcomes. Option B is the best response.

     
    Despite CT angiography showing an aneurysm causing subarachnoid hemorrhage, cerebral angiography is still performed at some institutions. Which one of the following is NOT a rationale for performing cerebral angiography in this setting?
    A)     Searching for an additional incidental aneurysm that could be treated at the same time.
    B)     Better assessing the degree of incorporation of the aneurysm wall into the parent vessel.
    C)     Assessing flow dynamics—that is, the side of the internal carotid artery feeding anterior communicating aneurysm.
    D)     Measuring the aneurysm neck–dome ratio.  [94 %]
    E)     Suspecting mycotic aneurysm in patients with IV drug use.

    CT angiography is a noninvasive vascular imaging technique that has replaced catheter angiography in some institutions. CT angiography may show aneurysms larger than 3 mm with a sensitivity of 77–97% and specificity of 87–100% [10]. CT angiography also has been used as a screening tool in populations at high risk for cerebral aneurysms. Cerebral angiography, however, still remains the gold standard in the diagnostic evaluation of cerebral aneurysms. In particular, 3D rotational angiography shows the most information about small perforating vessels, the relationship of the aneurysm to the parent vessels (how much of the aneurysm wall is incorporated into the parent vessel), and the flow dynamics of aneurysms that affect surgical planning. Multiple aneurysms can be seen in patients with subarachnoid hemorrhage. These incidental aneurysms are often smaller than 3 mm, which CT angiography has a limited ability to detect. Small unruptured aneurysms are associated with a risk of future SAHs. If they are in a surgically or endovascularly accessible location, these incidental aneurysms can be treated at the same time as the ruptured primary aneurysm. Mycotic aneurysms often involve peripheral vessels and may present with subarachnoid or parenchymal hemorrhage or septic emboli. Because mycotic aneurysms involve distal vessels, cerebral angiography is a more definitive test than CT angiography. Options A, B, C, and E are not the best responses. The aneurysm neck–dome ratio can be calculated on the basis of CT angiography. Option D is the best response.   

     
  •  

      What percentage of patients with acute ischemic stroke are treated with IV tPA?  

  • A)     Less than 6%.  [96 %]
    B)     8–15%.
    C)     20–25%.
    D)     25–50%.
    E)     50–60%.
    Which of the following is NOT associated with poor neurologic outcomes in patients with acute ischemic infarction?
    A)     Hypoventilation.
    B)     Extensive area of low attenuation and mass effect on initial head CT.
    C)     Hyperglycemia.
    D)     Hypothermia.  [97 %]
    E)     Arrhythmia.

    Maintaining adequate tissue oxygenation is critical in the setting of acute stroke to prevent hypoxia and potential worsening of brain damage. Patients with decreased consciousness or brain stem dysfunction have the greatest risk of airway compromise. The prognosis of a patient who requires endotracheal intubation is generally poor; approximately 50% of these patients die within 30 days of their stroke. Option A is not best response.
    An extensive area of low attenuation on initial head CT indicates widespread damage to the brain tissue. An “early infarct sign” on unenhanced CT involving more than one third of the territory of the middle cerebral infarction indicates a poor outcome. The presence of mass effect or edema is also associated with an eightfold increase in the risk of symptomatic hemorrhage [11]. Option B is not the best response.
    Hyperglycemia is associated with poor clinical outcomes, presumably due to increased tissue acidosis secondary to anaerobic glycolysis and lactic acidosis. Hyperglycemia may affect the blood–brain barrier and lead to brain edema. Hypoglycemia may cause focal neurologic signs and symptoms that mimic acute ischemic stroke. Hypoglycemia itself may aggravate neuronal ischemia. The prompt assessment of the serum glucose level and correction of the glucose level are important. Option C is not the best response.
    Fever in the setting of acute ischemic stroke is associated with a poor neurologic outcome secondary to increased metabolic demands and enhanced release of neurotransmitters. Hypothermia is not associated with poor clinical outcomes. In fact, hypothermia has been reported to be neuroprotective in experimental models and small clinical trials. Hypothermia may delay depletion of the energy reserve, slow tissue acidosis, and slow calcium iron influx into cells. Option D is the best response.
    Patients with acute ischemic stroke have an increased risk of developing myocardial infarction and cardiac arrhythmia. Patients with infarctions of the right hemisphere, particularly those involving the insula, may have an increased risk of cardiac complications, presumably secondary to disturbances in autonomic nervous system function. The most common arrhythmia associated with acute stroke is atrial fibrillation, which may be either the cause of stroke or a complication. Life-threatening arrhythmia is relatively uncommon, but sudden death may occur. Cardiac monitoring is often required for at least first 24 hours after the onset of stroke symptoms. Option E is not the best response.      

    Which of the following in a patient’s medical history is LEAST likely to be associated with septic emboli in the brain?
    A)     Organ transplantation with pulmonary infection.
    B)     Cancer and presently receiving systemic chemotherapy.
    C)     IV drug abuse.
    D)     Recent travel to Southeast Asia.  [97 %]
    E)     Aortic valve replacement and endocarditis.

    Septic emboli are often seen in immunocompromised patients such as those who have undergone organ transplantation, those who have AIDS, and patients who have undergone chemotherapy. In these cases, organisms may include tuberculosis or fungal infections. Among immunocompetent patients, infection with Staphylococcus organisms is most often seen in IV drug abusers or in patients with endocarditis. Options A, B, C, and E are not the best responses. A history of recent travel to Southeast Asia can be seen in other infections such as tuberculosis, brucellosis, West Nile virus, hepatitis, and malaria. This is not the expected history in this patient. Option D is the best response.
    This patient had a history of heart transplantation and pulmonary aspergillosis. Pulmonary aspergillosis in severely immunocompromised patients is highly invasive and has a dismal prognosis (near 100% mortality). It quickly gains access to the systemic circulation and is disseminated throughout the body, including the brain. This patient died 4 days after MRI was performed.

     
    What are the characteristic MRI findings of disseminated cerebral aspergillosis in immunocompromised patients?
    A)     Numerous foci of restricted diffusion in the corticomedullary junction, basal ganglia, and thalami, with minimum or no enhancement.  [97 %]
    B)     Markedly bright signal on diffusion-weighted images.
    C)     Involvement of the middle cerebellar peduncle.
    D)     Leptomeningeal invasion.
    E)     Infection in the paranasal sinuses.

    Disseminated cerebral aspergillosis infection in immunocompromised patients is most often caused by hematogenous spread from pulmonary infection. Hematogenous, or angioinvasive, Aspergillus organisms characteristically lodge inside medium-sized blood vessels, resulting in multifocal infarction, and then invade through the vascular walls, causing hemorrhagic transformation or direct extension into the parenchyma. This vasculopathy-mediated septic infarction has regional vulnerability to basal ganglia or thalami, in addition to the corticomedullary junction. The predilection to basal ganglia and thalami indicates involvement of the lenticulostriate and thalamoperforating arteries. Aspergillosis often destroys the internal elastic lamina of the cerebral arteries. Perforating vessels are the first ones to lose their patency because of their narrow diameter.
    MRI characteristics of disseminated aspergillosis involvement of the brain in 18 patients was reported by De- Lone et al. [16] and others [17, 18]. Those authors reported that the typical MRI appearance is a predilection to basal ganglia or thalami. Enhancement was minimal or absent.
    Lack of enhancement is most likely related to the host’s immune capacity. Severely immunocompromised patients have no or little immune capacity to react to an infectious organism to form capsule or inflammatory response; thus, lack of enhancement may indicate poor prognosis and rapid dissemination of angioinvasive aspergillosis. Option A is the best response.
    Marked bright signal on diffusion-weighted images in this patient likely reflects infarction and cytotoxic edema. Numerous foci of restricted diffusion can be seen in patients with embolic infarction, brain abscesses, and metastases from highly cellular tumors [19]. Option B is not the best response.
    Neither involvement of the middle cerebellar peduncle nor leptomeningeal involvement is a typical finding for disseminated aspergillosis. Options C and D are not the best responses.
    Involvement of the paranasal sinuses is often seen in diabetic patients who have angioinvasive mucormycosis. Mucormycosis is a rare opportunistic infection caused by ubiquitous fungi typically found in soil or dust. The route of infection is usually rhinocerebral and is commonly seen in patients with uncontrolled diabetes, which is often associated with metabolic acidosis or ketoacidosis [20]. Mucormycosis can spread from the paranasal sinuses to the brain in a few days. Treatment should include aggressive débridement and IV amphotericin B. Option E is not the best response.

     
    Which of the followings is LEAST likely to be a risk factor for Wernicke’s encephalopathy?
    A)     Chronic alcoholism.
    B)     Prolonged parenteral nutrition without a vitamin supplement.
    C)     Hyperemesis gravidarum.
    D)     Gastrectomy.  [96 %]
    E)     Anorexia nervosa.

    The triad of encephalopathy, ataxic gait, and oculomotor dysfunction is seen in only one third of patients with Wernicke’s encephalopathy. Ocular abnormalities are the hallmarks of Wernicke’s encephalopathy. The oculomotor signs are nystagmus, bilateral lateral rectus palsies, and conjugate gaze palsies reflecting involvement of the oculomotor and abducens nerves. Option D is the best response. Gait ataxia is believed to be due to focal midline degeneration of the superior vermis, as opposed to global ataxia, a sign of cerebellar dysfunction. Option E is not the best response. Cerebellar testing with the finger-to-nose or heel-to-shin test may not elicit any notable deficit. Vestibular dysfunction without hearing loss is also a common finding.
    Rigidity and tremor as well as bradykinesia and postural instability are common symptoms seen in patients with Parkinson’s disease, not in patients with Wernicke’s encephalopathy. Visual hallucination is associated with psychiatric disorders and drugs, particularly alcohol. Patients with schizophrenia often have visual and, more often, auditory hallucinations. Learning disability refers to a group of disorders affecting academic and functional skills, including the abilities to listen, speak, write, read, and organize information. It is not specific for Wernicke’s encephalopathy. Thus, options A, B, and C are not the correct responses.    

     
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