Get Through Final FRCR 2A - SBAs (2017) PDF

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TRUE PDF  GET THROUGH Final FRCR 2A: SBAs '  GET THROUGH Final FRCR 2A: SBAs Teck Yew Chin, FRCR, MSc, MBChB Susan Cheng Shelmerdine, MBBS, BSc, MRCS, PgCertHBE, FRCR Akash Ganguly, MBBS, DMRD, FRCR Chinedum Anosike, MBBS, MSc, FRCR CRC Press Taylor & Francis Croup Boca Raton London New York CRC Press is an imprint of the Taylor & Francis Group, an informa business V  I ’  PREFACE The examination structure of the Fellowship of Royal College of Radiologists (FRCR) Final Part A examination (CR2 A) in clinical radiology is reverting back from the current modular structure to a single examination. The RCR has approval from the General Medical Council (GMC) and the change will be effective from spring 2018. From spring 2018, the examination will consist of two papers, to be taken on the same day, each consisting of 120 single best answer-type questions per paper. Each paper will be 3 hours long and will cover a broad range of topics from the radiology core curriculum covering all modalities. This book is divided into seven test papers, consisting of 120 mixed SB A-type questions covering all modules (3 hours per paper for practice). The answers are in sequential order, followed by a short explanation and relevant discussion around the topic with appropriate references. vi  ACKNOWLEDGEMENTS Vijay Kesavanarayanan Grant Mair Andrew Baird Matthew Budak Oliver Cram Thomas Hartley Laura Hinksman Menelaos Philippou Jo Powell Calum Nicholson Ewen G. Robertson Nicola Schembri Magdalena Szewczyk-Bieda Richard D. White Stman W.A. Wilkie Nadeem A. Butt Lauren L. Millar Karim Samji Euan G.C. Stubbs Andre Stefan Gatt Asha Neelakantan Bappa Sarkar Mubeen Chaudhry Ramya G. Dhandapani ix '= -  AUTHORS Dr. Teck Yew Chin, MBChB, MSc, FRCR, is a consultant radiologist at Khoo Teck Puat Hospital, Singapore. Dr. Susan Cheng Shelmerdine, MBBS, BSc, MRCS, PgCertHBli, FRCR, is a radiology research fellow at Great Ormond Street Hospital, London, UK. Dr. Akash Ganguly, MBBS, DMRD, FRCR, is a consultant radiologist at Warrington Hospital, Warrington and Halton Hospitals NHS Foundation Trust, Warrington, UK. Dr. Chinedum Anosike, MBBS, MSc, FRCR, is a consultant radiologist at Warrington Hospital, Warrington and Halton Hospitals NHS Foundation Trust, Warrington, UK. xi * «%  ABBREVIATIONS ABC - Aneurysmal Bone Cyst AI3PA - Allergic Bronchopulmonary Aspergillosis AC - Acromio-clavicular ACA - Anterior Cerebral Artery ACE - Angiotensin Converting Enzyme ACL - Anterior Cruciate Ligament ACOM - Anterior Communicating Artery ADC' Apparent Diffusion Coefficient ADEM - Acute Disseminated Encephalomyelitis AED/A&E - Accident and Emergency (department) AFP - Alpha Fetoprotein AICA - Anterior Inferior Cerebellar Artery AIDS - Acquired Immunodeficiency Syndrome ALP - Alkaline Phosphatase ALPS A - Anterior Labroligamcntous Periosteal Sleeve Avulsion ALT - Alanine Aminotransferase AML - Angiomyolipoma AP - Anterior Posterior ARDS - Acute Respiratory Distress Syndrome ASD - Atrial Septal Defect AST - Aspartate Aminotransferase ATN - Acute Tubular Necrosis AVM - Arteriovenous Malformation AVN - Avascular Necrosis BCG - Bacillus Calmette-Guerin BPH - Benign Prostatic Hypertrophy CA - Carbohydrate Antigen CADASIL - Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopa i h y CBD - Common Bile Duct CBF - Cerebral Blood Flow CBV Cerebral Blood Volume CC Coracoclavicular CCAM - Congenital Cystic Adenomatoid Malformation xiii  CDH - Congenital Diaphragmatic Hernia CEA - Carcinoembryonic Antigen CECT - Contrast-Enhanced CT CF - Cystic Fibrosis CFA - Common Femoral Artery CHD - Common Hepatic Duct Cho - Choline CIN - Contrast-Induced Nephropathy CJD - Creutzfeldt-Jakob Disease CMV - Cytomegalo Virus CNS - Central Nervous System COAD - Chronic Obstructive Airway Disease COP - Cryptogenic Organising Pneumonia COPD Chronic Obstructive Pulmonary Disease CPAM Congenital Pulmonary Airway Malformation CPM - Central Pontine Myelinolysis CPPD - Calcium Pyrophosphate Deposition Disease Cr - Creatine CRL - Crown Rump length CRM - Circumferential Resection Margin CSF - Cerebrospinal Fluid CT - Computerised Tomography CTPA - Computed Tomography Pulmonary Angiogram CXR - Chest X-Ray DAD Diffuse Alveolar Damage DAI - Diffuse Axonal Injury DCE - Dynamic Contrast Enhancement DCIS - Ductal Carcinoma In-situ DDH Developmental Dysplasia of Hip DIC - Disseminated Intravascular Coagulation DIP) - Distal Inter-Phalangeal Joint DISH Diffuse Idiopathic Skeletal Hyperostosis DISI - Dorsal Intercalated Segment Instability DJ - Duodenojejunal DNET - Dysembryoplastic Neuroepithelial Tumour DRUJ - Distal Radioulnar Joint DWI - Diffusion-Weighted Imaging ECG - Electrocardiogram ENT - Ear Nose Throat ERCP - Endoscopic Retrograde Chloangio-pancreatography ESR - Erythrocyte Sedimentation Rate xiv ETT - Endotracheal Tube EUS - Endoscopic Eltrasound EVAR - Endovascular (Aortic) Aneurysm Repair FAT - Femoroacetabular Impingement FA PS - Familial Adenomatous Polyposis Syndrome FB - Foreign Body FCD - Fibrous Cortical Defect FCL - Fibular Collateral Ligament FD - Fibrous Dysplasia FDG - F18 Fluorodeoxyglucose FESS - Functional Endoscopic Sinus Surgery FEV Forced Expiratory Volume FLAIR - Fluid Attenuation Inversion Recovery FMD - Fibromuscular dysplasia FNA - Fine Needle Aspiration FNH - Focal Nodular Hyperplasia GCA - Giant Cell Arteritis GCS - Glasgow Coma Score GCT - Giant Cell Tumour GI - Gastrointestinal GIST - Castro Intestinal Stromal Tumour GLAD - Glenolabral Articular Disruption GRE - Gradient-Recalled Echo GVHD - Graft Versus Host Disease HCC - Hepatocellular Carcinoma HCG Hysterosalpingogram HCM - Hypertrophic Cardiomyopathy HELLP syndrome - Haemolysis, Elevated Liver enzyme Levels, and low Platelet syndrome HHV - Human Herpes Virus HIDA - Hepatobiliary Iminodiacetic Acid HIV - Human Immunodeficiency Virus HNPCC - Hereditary Non-Polyposis Colon Cancer Syndrome HOCiM - Hypertrophic Obstructive Cardiomyopathy HRCT - High Resolution Computed Tomography HSV - Herpes Simplex Virus HU - Hounsfield Unit IBD - Inflammatory Bowel Disease ICA - Internal Carotid Artery ICU - Intensive Care Unit IJV - Internal Jugular Vein INR - International Normalised Ratio x\  IPP - Idiopathic Pulmonary Fibrosis IPMN - Intraductal Papillary Mucinous Neoplasm IUCD - Intra-Uterine Contraceptive Device IV - Intravenous IVC - Inferior Vena cava IVU - Intravenous Urogram JVP - Juvenile Pilocytic Astrocytoma KUB - Kidney, Ureters, Bladder LA - Left Atrium LAGBP - Laparoscopic Adjustable Gastric Banding Procedure LAM Lymphangiolciomyomatosis LASA-P - Lipid Associated Aialic Acid P LCH - I/angerhans Cell Histiocytosis LCL - Lateral Collateral Ligament LDII - Lactate Dehydrogenase LFT - Liver Function Tests LIP - Lymphocytic Interstitial Pneumonitis LLL - I-cft Lower I.obe I.UL - Left Upper Lobe LV - Left Ventricle MAC - Mycobacterium Avian Complex MCA - Middle Cerebral Artery MCL - Medial Collateral Ligament MCPJ - Metacarpophalangeal Joint MCUG - Micturating Cysto Urethrogram MDA - Mullerian Duct Anomaly MDT - Multi-disciplinary Team MELAS - Mitochondrial Encephalomyopathy, Lactic Acidosis, and Stroke like episodes MEN Multiple Endocrine Neoplasia MIBG Metaiodobcnzylguanidine MPFL - Medial Patellofemoral Ligament MR - Magnetic Resonance MRA Magnetic Resonance Angiography MRCP - Magnetic Resonance Cholangio-Pancreatography MRE - Magnetic Resonance Enterography MRI Magnetic Resonance Imaging MRS A - Methicillin-Resistant Staphylococcus aureus MRU - Magnetic Resonance Urography MS - Multiple Sclerosis MSSA Methicillin-Sensitive Staphylococcus aureus MTPJ - Metatarsophalangeal Joint xvi MTR - Magnetisation Transfer Ratio MTT - Mean Transit Time NAA - N-Acetylaspartate NAFLD - Non-Alcoholic Fatty Liver Disease NAHI — Non-Accidental Head Injury , NAI - Non-Accidental Injury NASH - Non-Alcoholic Steatohepatitis NF - Neurofibromatosis NG(T) - Nasogastric (Tube) NITL - Non-Hodgkins Lymphoma NICE - National Institute for Health and Care Excellence NOF - Non-Ossifying Fibroma NPH - Normal Pressure Hydrocephalus NSE Neuron-Specific Enolase NSIP - Nonspecific interstitial pneumonitis OA - Osteoarthritis OCD - Osteo-Chondral Defect OCP - Oral Contraceptive Pill OFD - Osteo Fibrous Dysplasia OGD - Oesophago-Gastroduodenoscopy OKC - Odontogenic Keratocyst OM - Occipito-Mental/Osteomyelitis PAN - Polyarteritis Nodosa PCA - Posterior Cerebral Artery PCKD Polycystic Kidney Disease PCL - Posterior Cruciate Ligament PCOM - Posterior Communicating Artery POOS - Polycystic Ovarian Syndrome PCP - Pneumocystis Pneumonia PDA - Patent Ductus Arteriosus PE - Pulmonary Embolism PET Positron Emission Tomography PHACE syndrome - Posterior fossa malformations, Haemangioma Arterial anomalies, Cardiac defects, Eye abnormalities, sternal cleft and supra-umbilical raphe syndrome PICA - Posterior Inferior Cerebellar Artery PIN - Posterior Interosseous Nerve PIPJ - Proximal Inter-Phalangeal Joint PKU - Phenylketonuria PMF - Progressive Massive Fibrosis PML - Progressive Multifocal Leukoencephalopathy PNET - Primitive Neuroectodermal Tumour xvii  POEMS syndrome - Polyneuropathy, Organomegaly, Endocrinopathy, Monoclonal gammopathy, v and Skin changes syndrome PR - Per-Rectal PSA - Prostate-Specific Antigen PSC - Primary Sclerosing Cholangitis PUJ - Pelvi Ureteric Junction PVA - Polyvinyl Alcohol PVL - Periventricular Leukomalacia PVNS - Pigmented Vilonodular Synovitis PWI Perfusion Weighted Imaging RA - Right Atrium RB1LD - Respiratory Bronchiolitis Interstitial Lung Disease RCC - Renal Cell Carcinoma REA - Radio Frequency Ablation RLE - Right Lower Lobe RML - Right Middle Lobe RPF Retroperitoneal Fibrosis RRI - Renal Resistive Index RRMS - Relapsing Remitting Multiple Sclerosis RSV - Respiratory Syncytial Virus RTA - Road Traffic Accident RTC - Road Traffic Collision RUL - Right Upper Lobe RV - Right Ventricle RVOT - Right Ventricular Outflow Tract RYGBT - Roux-en-Y Gastric Bypass Surgery SAH - Sub-Arachnoid Haemorrhage SAPHO - Synovitis, Acne, Palmoplantar Pustulosis, Hyperostosis and Osteitis SBC — Solitary Bone Cyst SBO - Small Bowel Obstruction SCC-A - Squamous Cell Carcinoma Antigen. SCFE - Slipped Capital Femoral Epiphysis SCM - Split Cord Malformation SDH - Sub-dural Hemorrhage SLAC - Scapholunate Advanced Collapse SLAP - Superior Labrum Anterior Posterior SLE — Systemic Lupus Erythematosus SMA - Superior Mesenteric Artery SMV - Superior Mesenteric Vein SSPE - Subacute Sclerosing Panencephalitis STIR - Short-Tau Inversion Recovery sequence xvii SUFE - Slipped Upper Femoral Epiphysis SWI - Susceptibility Weighted Imaging TA - Truncus Arteriosus TACE - Transcatheter Arterial Chemoembolisation TAG-72 - Tumour Associated Glycoprotein ? TAPVR - Total Anomalous Pulmonary Venous Return TB - Tuberculosis TCC - Transitional Cell Carcinoma TFC - Triangular Fibrocartilage TGA - Transposition of Great Arteries THR - Total Hip Replacement TIPS - Transjugular Intrahepatic Portosystemic Shunt TKR - Total Knee Replacement TME - Total Mesorectal Excision TOF - Tetralogy Of Falot/Time-Of-Flight TRUP - Transurethral Resection of Prostate TRUS - Trans Rectal Ultrasound TS - Tuberous Sclerosis TSH - Thyroid Stimulating Hormone TT-TG Tibial Tuberosity-Trochlear Groove TURP - Transurethral Resection of the Prostate TVS - Trans-Vaginal Scan UAC - Umbilical Artery Catheter UAE - Uterine Artery Embolisation UBC - Unicameral Bone Cyst UCL Ulnar Collateral Ligament UFE - Uterine Fibroid Embolisation UIP - Usual Interstitial Pneumonia UPJ - Uretero-Pelvic Junction US - Ultrasound UTI - Urinary Tract Infection UVC - Umbilical Venous Catheter VHL - Von Hippel-Lindau VISI - Volar Intercalated Segment Instability VNA Vanillylmandelic Acid VSD - Ventricular Septal Defect VUJ - Vesico-Ureteric Junction VUR - Vesico-Ureteric Reflux XGP - Xanthogranulomatous Pyelonephritis phCG - beta Human Chorionic Gonadotropin xix  CHAPTER I TEST PAPER I Questions Time: 3 hours 1. A 30-year-old man has been involved in an Road Traffic Accident (RTA). Aortic injury is suspected. CT angiogram shows a fusiform dilatation at the anteromedial aspect of the aortic isthmus with a steep contour superiorly, gently merging with the proximal descending thoracic aorta inferiorly. What is the likely diagnosis? A. Pseudoaneurysm B. Coarctation of the aorta C. Ductus diverticulum D. Aortic nipple E. Avulsed left subclavian artery 2. A 40-year-old man on the third cycle of chemotherapy for non-Hodgkin’s lymphoma presents with dysphagia and odynophagia. A recent blood count revealed neutropenia. He is referred for a barium swallow, which shows several linear ulcers with ‘shaggy’ borders’ in the upper oesophagus. What is the most likely diagnosis? A. Candida oesophagitis B. CMV oesophagitis C. Post radiotherapy stricture D. TB oesophagitis E. Pharyngeal pouch 3. A contras! CT scan shows an incidental renal cyst that is hyperdense with thick septations and a mural nodule. What is the Bosniak classification? A. Type 1 B. Type 2 C. Type 2F D. Type 3 E. Type 4 4. A 33 year old man with short stature and normal intelligence is being investigated for lower back pain. MRI of the thoracolumbar spine shows marked central stenosis with short pedicles. A comment of bullet-shaped vertebra with progressive narrowing of the lumbar interpedicular distance was noted on the report. Which of the following conditions is most likely? A. Hurler’s syndrome B. Congenital pituitary dwarfism C. Achondroplasia D. Thanatophoric dysplasia E. Hunter’s syndrome I  5. A 75-year-old woman is admitted under the physicians with confusion and dementia. She has a history of spontaneous intracranial haemorrhage and has been diagnosed with amyloid angiopathy. The most specific MR sequence for diagnosis of multifocal intracranial cortical subcortical microhaemorrhages in cerebral amyloid angiopathy is: A. T1W spin echo B. STIR C. T2W spin echo D. Gradient echo E. FLAIR 6. Regarding sporting injuries involving the upper limbs, all of the following statements are correct, except: A. Anomalous anconeus epitrochlearis muscle results in Posterior Interosseous Nerve (PIN) entrapment. B. Atrophy of extensor muscles can be seen in chronic PIN neuropathy. C. Partial thickness tears of the biceps can involve either the long or short heads. D. Cubital tunnel syndrome is the most common elbow neuropathy. E. Oedema of flexor carpi ulnaris and ulnar nerve thickening suggests cubital tunnel nerve entrapment. 7. An obese 25-year-old man presents with atypical chest pain. Cardiac MR demonstrates asymmetrical hypertrophy of the interventricular septum, primarily affecting the anteroinferior portion. What is the most likely diagnosis? A. Hypertrophic obstructive cardiomyopathy B. Restrictive cardiomyopathy C. Myocardial infarction D. Dilated cardiomyopathy E. Constrictive pericarditis 8. A 65-year-old diabetic with a history of alcohol excess is referred for a barium swallow following a history of dysphagia. The study shows several small, thin, flask-shaped structures along the cervical oesophagus oriented parallel to the long axis of the oesophagus. What is the most likely diagnosis? A. Feline oesophagus B. Pseudodiverticulosis C. Glycogenic acanthosis D. Traction diverticulum E. Idiopathic eosinophilic oesophagitis 9. A 21-year-old woman with infertility undergoes US that shows a 2-cm right adnexal mass with posterior acoustic enhancement. Another multilocular cyst is seen in the left ovary. Further evaluation with MR shows multiple small lesions in both the ovaries and pouch of Douglas, which were hyperintense on fat-suppressed T1W images with shading sign on T2W images. What is the likely diagnosis? A. Dermoid B. Endometrioid carcinoma of the ovary C. Endometriosis D. PCOS (polycystic ovarian syndrome) E. Pelvic inflammatory disease 10. A young man presents to the ENT clinic with deepening of the voice. Going through his history and clinical notes, the consultant reviews a recent plain radiograph report of his 2  hands, which describes cystic changes in the carpal bones along with enlarged phalangeal tufts and metacarpals. What is the next appropriate imaging investigation? A. CT brain pre- and post-contrast B. MRI brain C. MRI pituitary pre- and post-contrast D. Chest X-ray ? E. Lateral view of the skull 11. A 77-year-old man with gradual onset dementia shows multifocal abnormalities on cranial CT and MRI. He has been recently diagnosed with amyloidosis. All of the following conditions may be present in central nervous system amyloidosis, except: A. Occurrence in elderly patients B. Multifocal subcortical intracranial haemorrhages C Cerebral and cerebellar atrophy D. Non-communicating hydrocephalus E. Typical occurrence in normotensive patients 12. An 11-year-old boy with left shoulder pain has a shoulder X-ray, which shows a lucent lesion in the metaphysis. This has distinct borders and lies in the intramedullary compartment It is orientated along the long axis of the humerus. What is the most likely diagnosis? A. Aneurysmal bone cyst B. GCT C. Simple bone cyst D. Chondroblastoma E. Non-ossifying fibroma 13. A 50-year -old secretary presents with epigastric pain, nausea and weight loss. She also complains of bilateral swollen ankles. She is referred for a barium meal as she is unable to tolerate an oesophago-gastroduodenoscopy (OGD). The examination shows thickened folds in the fundus and body of the stomach; the antrum was not involved. What is the mast likely diagnosis? A. Nephrotic syndrome B. Lymphoma C. Eosinophilic gastroenteritis D. Leiomyoma E. Menetrier's disease 14. A 58-year-old woman undergoes an echocardiogram followed by cardiac MRI for investigation of exertional dyspnoea. The cardiac MRI was reviewed at the X ray meeting, and the radiologist diagnosed concentric hypertrophic cardiomyopathy. Which of the following did the radiologist see? A. Thickening of the interatrial septum at 7 mm B. Thickening of the entire LV wall measuring 17 mm at end diastole C. Nodular high signal in the interventricular septum on T2 D. Thickening of the LV wall measuring 14 mm with normal systolic function E. Thickened LV with delayed hyperenhancement of mid wall 15. A 50-year-old builder is involved in a high speed RTA. CT is performed according to trauma protocol, demonstrating extra-peritoneal rupture of the bladder. Which of the following best describes this? A. Contrast pooling in the paracolic gutters. B. Contrast outlining small bowel loops. C. Flame-shaped contrast seen in the perivesical fat. D. CT cystogram is usually normal. E. Intramural contrast on CT cystogram. 3  16. An elderly patient on long-term dialysis presents to the orthopaedic clinic with right shoulder pain. Plain films show juxta-articular swelling and erosions of the humerus, but the joint space is preserved. MRI shows a small joint effusion and the presence of low- to intermediate-signal soft tissue on all sequences covering the synovial membrane extending into the periarticular tissue. What is the likely diagnosis? A. Amyloid arthropathy B. Gout C. Calcium pyrophosphate deposition disease (CPPD) D. Pigmented villonodular synovitis (PVNS) E. Reticuloendotheliosis 17. A 33-year-old woman with recurrent episodes of optic neuritis with waxing and waning upper limb weakness is referred for an MRI brain with high suspicion of demyelination. All of the following are MR features of acute multiple sclerosis (MS) lesions of the brain, except A. High signal intensity on FLAIR B. ‘Black hole’ appearance C. Incomplete ring-like contrast enhancement D. Increase in size of lesion E. Mass effect 18. A 14-year-old boy complains of left knee pain and limp. He also has medial thigh pain. On examination, he has full range of movement with some discomfort on internal rotation. AP and lateral X-rays of the knee and femur arc normal. What is the next investigation? A. CT B. Bone scan C. MRI D. Frog leg lateral of the hips E. US 19. A 30-year-old woman presents with shortness of breath and fatigue. CT shows enlargement of the right atrium, right ventricle and pulmonary artery and normal appearance of the left atrium. What is the most likely diagnosis? A. VSD - Ventricular Septal Defect B. ASD - Atrial Septal Defect C. Bicuspid aortic valve D. Coarctation of the aorta E. Mitral valve disease 20. A 50-year-old man is referred to a gastroenterologist with a 6 month history of intermittent epigastric pain and nausea. He is referred for a barium meal test due to a failed OGD - oesophago-gastroduodenoscopy. The study shows an ulcer along the lesser curve of the stomach. Which of the following is a malignant feature of a gastric ulcer? A. The margin of the ulcer crater extends beyond the projected luminal surface. B. Carman meniscus sign. C. Hampton’s line. D. Central ulcer within mound of oedema. E. The ulcer depth is greater than the width. 21. Which of the following characteristics is typical of prostate cancer? A. Low on T1 High on T2 B. Low on T1 Low on T2 C. Isointense on T1 High on T2 4  D. High on T1 High on T2 E. Isointense on T1 Isointense on T2 22. An eccentric expansile lesion in the metaphysis of the humerus is noted incidentally following a routine plain radiograph investigation in a young patient following a rugby tackle. MRI performed for further characterisation shows multiple cystic spaces, some with blood fluid level, with an intact low signal periosteal rim. What is the diagnosis? A. Unicameral bone cyst B. Aneurysmal bone cyst C. Eosinophilic granuloma D. Enchondroma E. Fibrous dysplasia 23. A 34-year-old woman with previous history of upper limb weakness that resolved spontaneously and optic neuritis was referred for an MRI brain. MRI confirms the presence of bilateral periventricular hyperintensities on FLAIR with abnormal signal in the corpus callosum and middle cerebellar peduncles. MRI also shows signal abnormality in the right optic nerve. Which portion of the optic nerve does Multiple sclerosis (MS) most commonly affect? A. Intra-orbital. B. Intracanalicular. C. Intracranial. D. Chiasmatic. E. All portions arc equally susceptible. 24. A newborn baby has US of the spine. At which level is the conus expected to be? A. Above L1 B. Above T12 C. L2 to L3 D. L3 to L4 E. S2 25. A middle aged woman presents with cough and haemoptysis. Her chest X ray reveals a large ovoid mass in the right lower lobe. She has a known history of Osler-Weber-Rendu syndrome. What is the most appropriate next imaging investigation that you will organise? A. MRA of the pulmonary artery B. CTPA C. CTPA with portal phase images covering the liver D. Chest HRCT E. Conventional pulmonary angiography 26. A nursing home resident is found to have a lung tumour and undergoes CT staging of the chest and abdomen. This reveals a discrete lesion medial to the second part of the duodenum with a fluid-fluid level. What is the most likely diagnosis? A. Duplication cyst B. Duodenal diverticulum C. Duodenal web D. Annular pancreas E. Adenocarcinoma of the duodenum 27. Which of the following is false? A. Skene cyst Lateral to external urethral meatus B. Nabothian cyst Lateral to the endocervical canal 5  C. Gartner’s dust cyst Posterolateral aspect of the upper vagina D. Bartholin’s cyst Posterolateral aspect of the vagina E. Urethral diverticulum Posterolateral aspect of mid-urethra 28. A 31-year-old man who is known to the gastroenterologist and rheumatologist presents to the ophthalmology department with visual disturbances. A pelvic radiograph done a year ago in the emergency department showed whiskering of the ischial tuberosities and greater trochanters, with symmetrical sclerosis of both sacroiliac joints. What is the most likely diagnosis? A. Reiter syndrome B. Behcet’s syndrome C. Ankylosing spondylitis (AS) I). Rheumatoid arthritis E. Systemic lupus erythematosus (SLE) 29. A 36-year-old woman with resolving limb weakness and previous history of optic neuritis is diagnosed as having relapsing remitting multiple sclerosis (RRMS). Which of the following statements concerning MS imaging is incorrect? A. Black holes correlate well with clinical outcome. B. Brain atrophy is higher in MS than normal ageing. C. The pattern of brain atrophy can mimic Alzheimer’s disease. D. Diffusion tensor imaging demonstrates structural damage to the white matter. E. MS lesions have low MTR (Magnetisation Transfer Ratio) representing myelin loss. 30. A 3 year-old presents as acutely unwell with a maculopapular rash, lymphadenopathy and erythema of her palms. Her white cell count is normal, and a specific cause for her symptoms is not found. She improves on immunoglobulins and supportive treatment. A follow-up echocardiogram shows cardiomegaly and a coronary artery aneurysm. What is the likely diagnosis? A. Takayasu arteritis B. Kawasaki arteritis C. Moyamoya syndrome D. Henoch-Schönlein purpura E. Churg-Strauss syndrome 31. A 76-year-old male patient with chronic inflammatory disease and known history of secondary generalised multisystem amyloidosis showed an abnormal appearance of the heart on echocardiography. Dynamic enhanced cardiac MR imaging was advised for further characterisation. All of the following are imaging findings seen with cardiac amyloidosis, except A. Left ventricular wall hypertrophy B. Subendocardial delayed myocardial hyperenhancement C. Systolic dysfunction D. Granular echogenic myocardium E. Interatrial septal thickening 32. A taxi driver has had recurrent episodes of abdominal pain. On CT, a lesion is seen within the head of the pancreas. Pancreatic duct dilatation is noted with a normal CBD and atrophy of the body and tail of the pancreas. ERCP demonstrates thick mucous material discharging from the bulging papilla. What is the most likely diagnosis? A. Mucinous cystadenocarcinoma B. Serous cystadenocarcinoma 6  C. Main duct IPMN (Intraductal Papillary Mucinous Neoplasm) D. Pancreatic pseudocyst E. Pancreatic adenocarcinoma 33. A 55-year old man with several episodes of epididymo-orchitis in the past has an ultrasound of the scrotum. The radiologist performing the scan notices several hypoechoic structures within the mediastinum testis and incidental epididymal cysts. There was no Doppler flow. What is the most likely diagnosis? A. Lymphoma of the testes B. Cystic dysplasia of the testis C. Seminoma D. Abscess E. Cystic transformation of rete testis 34. An elderly woman presents with progressive atraumatic pain within her right knee over the course of the last month, particularly on the medial aspect, associated with functional impairment. Her clinical history includes a meniscal tear, which was treated arthroscopically 10 years ago with a good outcome. An MRI reveals florid marrow oedema within the medial femoral condyle associated with mild flattening of the weight-bearing surface. What is the diagnosis? A. Perthe’s disease B. Sinding Larsen’s disease C. Blount’s disease D. Spontaneous osteonecrosis of the knee E. Osteochondral defect 35. A known MS patient has presented to the neurologist with clinical features of involvement of the spinal cord. An MRI of the whole spine has been requested with a view towards assessment of the cord for possible multiple sclerosis (MS) plaques. MS lesions in the spinal cord occur most commonly in the A. Cervical segment. B. Thoracic segment. C. Lumbar segment. D. Sacral segment. E. All segments are equally affected. 36. A neonate presents with non-bilious vomiting with a palpable upper abdominal lump. Which of the following US findings would not be in keeping with pyloric stenosis? A. Pyloric muscle thickness 3.5 mm B. Target sign C. Pyloric canal length 14 mm D. Antral nipple sign E. Cervix sign 37. A child with exertional dyspnoea and abnormal chest X-ray showing a boot-shaped heart and oligaemic lungs is diagnosed as suffering from tetralogy of Fallot. The pulmonary oligaemia is secondary to right ventricular outflow tract (RVOT) obstruction. Which of the following is the most common implicated cause for obstruction of RVOT? A. Hypoplastic pulmonary annulus B. Pulmonary valvular stenosis C. Infundibular stenosis D. Combined infundibular and pulmonary valvular stenosis E. Overriding ventricular septum 7  38. A 50-year-old man presents with recurrent episodes of abdominal pain. Blood amylase is normal. Chronic pancreatitis is suspected. All of the following statements regarding MRI imaging in chronic pancreatitis are true, except A. MRI has a poor sensitivity for detecting parenchymal calcification in chronic pancreatitis. B. MRI allows evaluation of the ductal system for strictures and stones, debris within pseudocysts and fistula. C. MRI shows good sensitivity for the differential diagnosis of focal chronic pancreatitis from pancreatic carcinoma. D. Both focal chronic pancreatitis and pancreatic carcinoma demonstrate abnormal post-contrast enhancement on MRI. E. Both focal chronic pancreatitis and pancreatic carcinoma demonstrate low signal intensity of the pancreas on T1W fat-saturated images. 39. A 60-year-old heavy smoker presents with haematuria. US KUB shows a midline fluid-filled cavity with mixed echogenicity and calcification adjacent to the bladder wall. CT shows a focal low-attenuation enhancing mass along a cord-like structure extending from the bladder to the umbilicus. What is the most likely diagnosis? A. Complex urachal cyst B. Vescico urachal diverticulum C. Urachal adenocarcinoma D. Transitional cell carcinoma E. Urachal rhabdomyosarcoma 40. A 10 x 7 mm dense ossified focal lesion is noted in the neck of the right femur of a young man incidentally on a pelvic radiograph performed for an unrelated reason. The lesion has benign features and is consistent with a bone island (enostosis). No follow-up is suggested. All of the following are true of bone islands, except A. If more than 2 cm, they are classified as a giant’ bone island. B. They have a sclerotic appearance on imaging. C. They show a characteristic brush border on plain films. D. They can be positive on a bone scan. E. Giant bone islands can be locally aggressive. 41. A patient recently diagnosed with MS has been sent for an MRI of the whole spine to detect possible spinal plaques. All of the following are MR features of spinal cord lesions in MS, except A. The sole site of involvement (in some cases). B. Imaging features similar to those of MS lesions in the brain. C. Most lesions are centrally located. D. The length rarely exceeds two vertebral segments. E. Dorsal column involvement. 42. Barium enema of a neonate shows an inverted cone shape at the rectosigmoid colon. There is marked retention of the barium on delayed post-evacuation films after 24 hours. The cause for this is A. Meconium ileus B. Meconium plug syndrome C. Hirschsprung's disease D. Imperforate anus E. Hyperplastic polyp of colon 8 43. A 3-year-old child with shortness of breath is diagnosed with tetralogy of Fallot. All of the following abnormalities may be associated with this condition, except A. Transposition of great vessels (TGA) B. Patent ductus arteriosus (PDA) C. Anomalous origin of coronary arteries D. DiGeorge syndrome E. Right-sided aortic arch 44. A 40-year old woman presents to her GP with right upper quadrant pain and is referred for an ultrasound of the abdomen. The scan demonstrates a thickened gall bladder wall with several intramural small echogenic foci showing ‘comet tail artefacts’. A few gallstones are also noted. What is the most common diagnosis? A. Xanthogranulomatous cholecystitis B. Strawberry gallbladder C. Porcelain gallbladder D. Gallbladder adenomyomatosis H. Acute cholecystitis 45. A woman presents with infertility and undergoes a hysterosalpingogram. This demonstrates a uterus with two converging horns. A wide angle is seen at the roof of the uterus. Which uterine anomaly does the patient have? A. Uterine didelphys B. Septate uterus C. Arcuate uterus D. Bicornuate uterus E. Unicornuate uterus 46. A 53-year old woman presents to the A&E department with acute knee pain. She has had two previous similar episodes in the past, which settled with analgesics and anti-inflammatory medications. Plain films show extensive degenerative change, which is worst at the patellofemoral joint with large subchondral cystic change and chondrocalcinosis of the knee menisci. She informs the attending doctor that she is under review with the endocrinologist. What is the likely diagnosis? A. Calcium pyrophosphate deposition disease (CPPD) B. Gout C. Rheumatoid arthritis D. Ochronosis E. Psoriasis 47. A 54-year-old man who developed brain metastases almost 9 years after resection of an acral lentiginous melanoma of the distal thumb shows two peripheral nodules in the right frontal lobe. All of the following are features of CNS metastatic melanoma, except A. Moderate to intense enhancement post-contrast administration B. Cystic components C. Subependymal nodules D. Multiple lesions at the gray white matter junction E. Miliary pattern 48. A child presents with vomiting and sudden onset abdominal pain. Plain X-rays show a target sign in the right upper quadrant. US shows a pseudo kidney sign in keeping with intussusception. Which of the following is false regarding hydrostatic reduction? A. Free intraperitoneal air is a contraindication. B. A maximum of two attempts can be made. 9  C. Air is preferred to Gastrografin water solution in some institutions. D. The perforation rate is 0.4%-3%. E. Air enema is associated with a higher perforation rate. 49. Plain X-ray of a newborn shows a large tubular air shadow behind the trachea. The lungs are clear. The bowels are grossly distended with air. What is the likely type of tracheo-oesophagcal fistula? A. Type A B. Type B C. Type C D. Type D E. Type E 50. A 46-year-old American man who has come to the UK on a holiday trip arrives at the AED with worsening shortness of breath. Chest X-ray shows bilateral asymmetrical calcified mediastinal and hilar nodes, and chronic pulmonary histoplasmosis is provisionally diagnosed. The worsening symptoms are attributed to fibrosing mediastinitis. All the following conditions can occur as complications of fibrosing mediastinitis, except A. SVC syndrome B. Pulmonary arterial hypertension C. Pulmonary venous stenosis D. Tracheal stenosis E. Aortic stenosis 51. A 70-year-old pensioner has been referred for an abdominal ultrasound as part of a routine medical examination. He is fit and well with no significant past medical history. The scan demonstrates a small focal well-defined hyperechoic area in the right lobe of the liver showing posterior acoustic enhancement. The most likely differential diagnosis is A. Metastasis B. Fatty infiltration C. Liver cyst D. FNH (Focal nodular hyperplasia) E. Capillary haemangioma 52. The causes of medullary nephrocalcinosis include all, except A. Hyperparathyroidism B. Renal tubular acidosis C. Medullary sponge kidney D. Hypervitaminosis D E. Alport’s syndrome 53. A 56 year-old woman known to the endocrinologist has been going to her family doctor with a funny sensation in her right hand and fingers for the last few months. An MRI was organised along with nerve conduction studies by her family doctor. MRI revealed fusiform swelling of the median nerve in the distal forearm just before the entrance into the carpal tunnel with increased signal on T2. What is the likely diagnosis? A. Cervical spondylosis B. Ulnar tunnel syndrome C. Carpal tunnel syndrome D. Cervical rib with brachial plexus impingement E. Neurofibroma of the median nerve 10 54. A 7-year-old boy with a history of a penetrating injury from a tree branch was sent for CT orbits for further assessment. Which of the following statements regarding the CT detection of intra-orbital foreign bodies is false? A. Size, type and location of glass foreign body (FB) affects detection. B. Wooden FB is hyperattenuating. C. Old wood can be mistaken for air. D. Attenuation of wood changes with water content. E. CT can demonstrate metal FB less than a millimetre. 55. A 56-year-old woman with an increase in shortness of breath comes to the A&E department and is assessed by the physicians. The ECG is low in voltage and a chest X-ray is organised. The chest X-ray shows a very large heart with sharply defined borders and a narrow pedicle, suggesting pericardial effusion. All of the following are associated, except A. Tuberculosis pericarditis B. Blunt trauma to the sternum C. Hyperthyroidism D. Radiation pericarditis E. Pericardial lymphoma 56. A 66-year-old joiner presents to his GP with jaundice and abdominal discomfort. He was subsequently referred to a gastroenterologist who requests a liver biopsy due to deranged liver function tests. Which of the following options is not a contraindication for percutaneous liver biopsy? A. INR above 1.6 B. Platelets less than 60,000/mm3 C. Tense ascites D. Extra-hepatic biliary obstruction E. Suspected haemangioma 57. A 40-year-old man who is a known hypothyroid patient, presents with weight loss and dull pain in the flank and back. He undergoes an abdominal CT. Regarding retroperitoneal fibrosis, all of the following is seen on imaging, except A. Medial deviation of the ureters in the middle third, typically bilateral. B. CT shows soft-tissue mass displacing the aorta anteriorly. C. T2W MRI shows variable signal. D. PET CT has high sensitivity. E. Hydronephrosis is evident on CT urogram. 58. A 17-year-old teenager is under investigation for vague pain in the knee associated with a limp. A plain film radiograph shows an oval lucent lesion in the epiphysis of the distal femur. The pain was noticed following an injury sustained during a football match. What would be the next investigation of choice? A. CT B. MRI C. Bone biopsy D. Tc-99m bone scan E. No imaging necessary since it looks benign 59. Abnormal high density is noted in the vitreous on CT orbits, suggesting the presence of blood in the posterior chamber. All of the following conditions are potential causes of vitreous haemorrhage, except A. Intra ocular tumour B. Abnormal vascularisation of the retina C. Terson syndrome II  D. Corneal abrasion E. Trauma 60. A 1-month-old baby presents with difficulty in feeding and shortness of breath. Chest X-ray shows cardiomegaly. She has an episode of seizure and undergoes cranial US, which shows a median tubular cystic space with high-velocity turbulent flow on Doppler. The ventricles are also mildly dilated. These findings are consistent with A. Pineal tumour B. Arachnoid cyst C. Colloid cyst D. Vein of Galen aneurysm E. Ventriculitis 61. A 66 year-old man with progressive shortness of breath and low-volume ECG shows an enlarged heart on chest X-ray. Echocardiogram confirms the presence of a moderately large pericardial effusion. The pericardial fluid is aspirated for symptomatic relief and sent off for cytology and culture. Cytology comes back as positive for malignant cells. Which of the following is the most common type of primary pericardial malignancy? A. Fibrosarcoma B. Pericardial angiosarcoma C. Fibromyxoid sarcoma D. Mesothelioma E. Epithelioid endothelioma 62. A 40-year-old man undergoes a CT KUB for renal colic, which shows an incidental finding of an 8-mm lesion in Segment VIII of the liver. Further characterisation of this lesion with MRI shows it to be low signal on T1W and high signal on T2W. On the dynamic phase, it shows peripheral nodular enhancement with centripetal filling. What is the most likely diagnosis? A. FNH B. Adenoma C. Haemangioma D. Early appearance of Hepatocellular Carcinoma (HCC) E. Cholangiocarcinoma 63. Of the normal uterus signal on MR, which is correct? Endometrium Myometrium Junctional zone A. High on T2 Intermediate on T2 High on T2 B. High on T2 Intermediate on T2 Low on T2 C. Isointense on Tl Isointense on T1 High on T1 D. Isointense on Tl High on Tl Low on Tl E. Low on Tl Low on T2 High on T2 64. A plain lumbar spine radiograph of a 45-year-old woman shows marked posterior scalloping of the vertebral bodies extending over several vertebral lengths. All of the following are diseases associated with this finding, except A. Marfan B. Neurofibromatosis C. Ependymoma D. Achondroplasia E. Hypothyroidism 12 65. A 58-year-old man with facial fractures shows deformity of the globe on unenhanced axial CT, but it is unclear if there is an open-globe injury. All of the following CT findings suggest an open-globe injury, except A. Intra-ocular air B. Lens dislocation C. Scleral discontinuity D. Flat tire sign E. Deep anterior chamber 66. An 18-month-old child is brought in by her mother with complaints of visual problems; on examination, the left eye is of normal size with a whitish mass behind the lens. US shows a heterogeneous hyperechoic solid intra-ocular mass with retinal detachment. There are fine focal calcifications with acoustic shadowing. The appearances suggest A. Persistent hyperplastic primary vitreous B. Coats disease C. Retinoblastoma D. Toxocara endophthalmitis E. Retrolental fibroplasia 67. A 35-year-old woman undergoes an X-ray in the A&E department with suspicion of chest infection. The X-ray reveals an abnormal mediastinal opacity but no evidence of chest infection. Review of two old films done 2 and 6 years ago shows the same abnormal mediastinal opacities with no significant interval change in size, shape, appearance or location. Judging by its location, the radiologist reports it as a simple pericardial cyst or spring water cyst. Which of the following statements concerning congenital simple pericardial cysts is false? A. They are homogenous and well defined on frontal chest X-ray. B. They are most commonly left-sided. C. On MRI, they are low' on T1W and high on T2W images. D. Pericardial cysts can contain proteinaceous material. E. Pericardial cysts can occasionally calcify. 68. A 90-year-old man is admitted following intermittent episodes of bright red rectal bleeding. He is haemodynamically stable on initial assessment. OGD and flexible colonoscopy are normal. He subsequently has another bleed on the surgical ward and is then referred for a CT mesenteric angiogram. Which of the following statements is false regarding CT mesenteric angiography? A. Severe bleeding episodes, such as those manifesting with hemodynamic instability, decrease the pretest probability of a positive result for active bleeding at CT angiography. B. Active bleeding must be present during the time contrast is injected into the vascular system in order to demonstrate the site of bleeding. C. Portal venous phase imaging depicts extravascular blushes with higher sensitivity than arterial phase imaging does. D. Retention of previously administered barium in colonic diverticula may be mistaken for, or may obscure, acute extravasation of contrast material. E. Hyperattenuating material within the bowel lumen on the unenhanced scan without additional findings in the contrast-enhanced phases indicates recent haemorrhage. 69. A 25-year-old man undergoing abdominal CT shows the presence of bridging renal tissue across the midline at the level of the lower poles, consistent with a horseshoe kidney. All the following are recognised associations, except A. Bicornuate uterus B. Cardiac anomaly 13  C. Undescended testis D. Tracheo-oesophageal fistula E. Anorectal malformation 70. A young patient is followed up for a fractured tibia at the outpatient clinic. A repeat radiograph is acquired, which shows abnormal healing and callus formation at the fracture site. All the following are possible causes, except A. Cushing's syndrome B. Osteogenesis imperfecta C. Osteopoikilosis D. Paralytic state li. Asthmatic on steroids 71. A 67 year-old man has been rushed to the stroke unit with features of acute stroke. All of the following are true about acute stroke imaging, except A. CT source images correlate with infarct volume. B. Matched CBV (Cerebral blood volume) and CBF (Cerebral blood flow) represent salvageable brain. C. Diffusion-weighted MR imaging assesses the infarct core. D. Mismatch between PWI (Perfusion weighted imaging) and DWI (Diffusion weighted imaging) volumes represents salvageable brain. E. T2 shine through is seen as bright on DWI. 72. Neck US of a previously well 2-year old girl shows a 3-cm thin-walled cystic structure with multiple septae of variable thickness in the left posterior triangle with extension into the mediastinum. The diagnosis is: A. Third branchial cleft cyst B. Cervical meningocoele C. Cystic teratoma I). Lymphangioma E. Second branchial cleft cyst 73. A.34-year-old woman with chest pain, shortness of breath and collapse is brought to the A&E department. Initial chest X-ray is abnormal. Subject to the abnormal appearance of the cardiac contour, an MRI is obtained in the local cardiac centre on the following day, which confirms a large congenital pericardial defect. All of the following are imaging features, except: A. Abnormal cardiac contour on plain chest X-ray. B. Failure to identify pericardium on CT or MR is diagnostic. C. Most commonly, a left-sided location. D. Shift of cardiac axis to the left. E. Association with ASD. 74. A 5-year-old boy involved in an RTA is referred for a trauma CT scan. The reporting radiologist does not find any acute abnormality. However, there are other incidental findings on the scan suggestive of malrotation. Which of the following options is the most specific feature of gut malrotation on CT? A. SMV (superior mesenteric vein) anterior to the SMA (superior mesenteric artery) B. SMV to the right of the SMA C. Whirl sign around the SMA D. DJ (duodenojejunal) flexure to the right of the midline E. SMV to the left of the SMA 14 75. A 17-year-old girl is brought to the emergency department with sudden onset abdominal pain. She is known to have a cardiac tumour. On examination, she is hypotensive, peritonitic, and undergoes an urgent CT abdomen and pelvis. This shows bilateral large renal masses; the largest on the right measures 12 cm with multiple low-attenuation areas of -20 HU with large tortuous vessels and contrast extravasation into the retroperitoneum. These features arc associated with A. Von Hippel-Lindau B. Neurofibromatosis type 1 C. Sturge-Weber syndrome D. Tuberous sclerosis E. Amyloidosis 76. A young woman presents to the AED following a scuffle on a night out. On examination, there is a suspected fifth metacarpal fracture of her right hand. A plain radiograph is subsequently organised. This does not demonstrate a fracture, but it is noted that the patient has relatively short fourth metacarpal bones. Old chest films show bilateral inferior rib notching involving the third to sixth ribs bilaterally. What is the likely diagnosis? A. Noonan syndrome B. Turner syndrome C. Pseudohypoparathyroidism D. Marfan syndrome E. Achondroplasia 77. A 66-year-old man with acute onset of right upper limb weakness was brought to A&E within an hour of the onset of symptoms. All of the following arc recognised features of early ischaemic change, except A. Insular ribbon sign B. Dense MCA sign C. Sulcal effacement D. Obscuration of the lentiform nucleus E. Dilatation of ventricle 78. In order of frequency, the most common location of congenital lobar emphysema is as follows: A. LUL, LLL, RUL B. LUL, RML, RUL C. RUL, RML, LLL D. LUL, RUL, RLL E. LUL, RML, RLL (LLL - left lower lobe, LUL left upper lobe, RLL right lower lobe, RML right middle lobe, RUL - right upper lobe) 79. A 66-year-old woman with progressive shortness of breath, reduced exercise tolerance and occasional chest pain shows engorged neck veins and hepatomegaly on clinical examination. She is clinically thought to have constrictive pericarditis. All of the following are imaging features of constrictive pericarditis, except A. Pericardial thickness of more than 4 mm. B. Pericardial thickening may be limited to the right side of the heart. C. MR is better at demonstrating pericardial calcification. D. Sigmoid-shaped ventricular septum. E. Increased diameter of the IVC. 15  80. A 60-year-old woman presents with abdominal cramps and watery diarrhoea associated with flushing of the face. A CT colonography study is performed, as the patient is unable to tolerate optical colonoscopy. The colon and rectum are normal, but there is ileal thickening and a 2-cm partly calcified mass in the small bowel mesentery with surrounding desmoplasia. Carcinoid is suspected. Which of the following statements is true about small bowel carcinoid tumours? A. Carcinoid syndrome has higher morbidity and mortality than the tumour itself. B. Over 60% have carcinoid syndrome. C. Carcinoid tumours are associated with neurofibromatosis type II. D. They most commonly occur in the colon. E. They commonly cause osteolytic metastasis to bone. 81. The following are signs of a normal gestational sac, except A. Intradecidual sign. B. Cardiac activity seen with a CRL (crown-rump length) of 6 mm. C. Double decidual sign. D. Mean sac diameter increases by 1 mm/day. E. Embryo seen with a mean sac diameter of 10 mm. 82. A 17-year-old girl presents with a history of acute-on-chronic burning neck pain radiating into the right shoulder and arm. There is associated palmar paraesthesia, easy fatigability and loss of power, exacerbated by elevating the arm to the shoulder level. Sagittal T1W MRI obtained with the arm in the neutral position shows ample fat surrounding the subclavian vessels and brachial plexus. With the arm in abduction, there is compression of the subclavian vessels. What is the diagnosis? A. Subclavian artery stenosis B. Parsonage-Turner syndrome C. Median nerve entrapment D. Thoracic outlet syndrome E. Subclavian steal syndrome 83. A 67-year-old woman is imaged 3 hours after a witnessed sudden onset of a right hemiparesis. Transverse DWI ( b = 1,000 sec/mm2) demonstrates signal change in the subcortical region, including in the lenticular nucleus and corona radiate. Which of the following statements concerning diffusion-weighted MR imaging in cerebral infarction is false? A. It measures redistribution of water to intracellular space. B. DWI can remain positive for up to 3 weeks post-infarction. C. DWT is positive as early as 30 minutes post-infarction. D. Acute infarcts show hyperintense signal on ADC. E. Acute infarcts show hyperintense signal on DWI. 84. The most common structure to herniate in Bochdalek hernia is A. Stomach B. Spleen C. Omentum D. Left lobe of liver E. Pancreas 85. Which of the following statements regarding the normal pericardium is false? A. It consists of two inner serous layers of tissue and one outer fibrous layer. B. It is visualised on lateral chest X-ray as a fat pad sign. C. It is 1- 2 mm thick on CT and may contain up to 30 ml of fluid. D. It is low in signal on TlW MRI. E. On frontal chest X-ray, it is visualised as a 2-mm stripe outlined by fat. 16 86. A 50-year-old woman with long-standing abdominal pain, weight loss and poor appetite undergoes a CT abdomen and pelvis. This shows mesenteric thickening with a fine stellate pattern extending to the bowel border. The mesenteric mass does not displace the mesenteric vessels masses and shows a fat ring sign. The most likely diagnosis is A. Retroperitoneal fibrosis B. Carcinoid C. Sclerosing mesenteritis D. Epiploic appendagitis E. Lymphoma 87. A 56-year-old man undergoing CT urogram displays an incidental lesion in his right adrenal gland. He is asymptomatic apart from pain in the left loin, which is currently being investigated. All these features suggest that adrenal carcinoma is more likely than a benign adenoma, except A. Size more than 5 cm B. Delayed washout C. HU value of 60. C. If serum creatinine is above normal range, metformin should be withheld for 24 hours. D. If eGFR is 30° and the scapholunate angle is >80°. What is your diagnosis? A. Volar intercalated segment instability (VISI) B. Dorsal intercalated segment instability (DISI) C. Refracture of scaphoid D. Perilunate dislocation E. Scapholunate advanced collapse (SLAC) deformity 113. A 49-year-old woman with right lower extremity weakness and rigidity undergoes MRI with DWI, ADC map, FLAIR, T2W and T1W pre- and post gadolinium images. Early hyperacute stroke is diagnosed. All of the following are true about the timing of stroke and MRI, except A. Low ADC signal suggests that the stroke is less than a week old. B. FLAIR hyperintensities are seen in 6-12 hours. 21  C. High signal on T2W MRI is seen >8 hours. D. Low signal on T1W MRI is seen >8 hours. E. Parenchymal enhancement generally doesn’t persist beyond 8-12 weeks. 114. A neonate has an umbilical venous catheter inserted. On an abdominal X-ray, it has advanced up to the level of T10 at the midline. In which structure is the tip of the catheter? A. Left portal vein B. Right portal vein C. Ductus venosus D. Superior mesenteric vein E. Splenic vein 115. Which ot the following statements concerning malignant cardiac masses is false? A. Cardiac metastasis outnumbers primary cardiac malignancy. B. Angiosarcomas have a high T1 signal due to methaemoglobin. C. Undifferentiated sarcomas mostly affect the left atrium. D. Primary cardiac lymphomas mostly affect the left side of the heart. E. Rhabdomyosarcoma commonly affects the valve. 116. A 30-year-old cab driver presents to his GP with malaise, jaundice and abdominal distension. Blood tests performed show deranged liver function tests. A provisional diagnosis of Budd-Chiari syndrome was made. All of the following are imaging features of Budd-Chiari syndrome, except A. Ultrasound demonstrates portal vein enlargement and change in flow dynamics. B. In acute Budd Chiari, the liver is globally enlarged, with lower attenuation on CT. C. There is caudate lobe atrophy in chronic Budd-Chiari. D. CT shows non homogenous liver enhancement with a predominantly central area of enhancement and delayed enhancement of the periphery. E. On MRI, the liver is low signal on unenhanced T1 and T2 and delayed enhancement post-contrast. 117. All of the following are major indications for ultrasound of the breast except A. Delineation of cystic from solid breast masses B. Evaluation of a palpable breast mass in a mammographically dense breast C. Evaluation of nipple discharge in a mammographically dense breast D. Evaluation of breast lesions not well seen on mammography E. Routine breast screening 118. A 19 year-old man is reviewed at a clinic for a persistent ache in his lower back that has not improved for over 3 months. He is an avid mountain biker, but there is no history of significant trauma and there are no neurological deficits. The patient is found to have mild increase in thoracic kyphosis with mild wedging of the T4, T5 and T6 vertebrae. MRI reveals the presence of small scattered vertebral end plate lesions with signal characteristics identical to the adjacent intervertebral discs in several thoracic and lumbar vertebrae. What is the diagnosis? A. Spondylodiscitis with developing vertebral collapse B. Congenital kyphosis C. Metastatic deposits with early vertebral collapse D. Vertebral insufficiency fractures E. Scheuermann’s disease 119. A 76-year-old man with known cerebral atrophy and dementia has been unsteady on his feet for the last 2-3 weeks following a fall down a flight of three steps. There is a small external cut 22  in the parietal region of the scalp, but he was never brought to the A&E department A CT brain has been performed to investigate his unsteady gait. It shows a large isodense subdural haemorrhage. All of the following are expected Endings on the CT, except A. Fourth ventricle enlargement B. Lateral ventricle compression C. Effacement of the cortical sulci D. Midline shift E. White matter buckling 120. A 1-year-old boy is brought to the A&E department by his parents with head injury after falling off a sofa. The on-call paediatrician strongly suspects non-accidental injury. Which of the following features on unenhanced CT is most consistent with this? A. Bilateral occipital extradural haemorrhage B. Bilateral occipital subdural haemorrhage C. Subarachnoid haemorrhage D. Parietal skull fracture E. Bilateral frontal subdural haemorrhage 23  CHAPTER 2 TEST PAPER I Answers 1. C. Ductus diverticulum Ductus diverticulum is a focal bulge at the anteromedial aspect of the aortic isthmus, visualised in 9% of adults. It is critical to identify this normal variant and distinguish it from a post traumatic false aneurysm, which also occurs most commonly at the aortic isthmus (88%). The classic ductus diverticulum has smooth, uninterrupted margins and gently sloping symmetric shoulders; in contrast, false aneurysms have a variety of shapes and sizes with sharp margins and often contain linear defects. Compared with the classic ductus diverticulum, the atypical ductus diverticulum has a shorter and steeper slope superiorly and a more classic gentle slope inferiorly. However, both shoulders have smooth, uninterrupted margins, an important feature that distinguishes this variant from true injury. Other normal variants that can mimic injury include aortic spindle, which is a smooth circumferential bulge immediately distal to the aortic isthmus; infundibulum at the origin of aortic branches like the brachiocephalic and intercostal arteries, which are spherical or conical in shape but have a vessel at its apex, thereby differentiating them from false aneurysms. Fisher RG, ct al. ‘Lumps’ and ‘bumps’ that mimic acute aortic and brachiocephalic vessel injury. Radiographics. 1997;17(4):825—34. 2. A. Candida oesophagitis Candida oesophagitis occurs in patients whose normal flora is altered by broad spectrum antibiotic therapy and in patients whose immune systems are suppressed by malignancy, immunosuppressive agents like chemotherapy and radiotherapy, and immunodeficiency states such as AIDS. When the disease is superficial, the oesophageal mucosa may appear normal radiographically. Early in the course of Candida oesophagitis, mucosal plaques are the most frequent finding. Later erosions and ulcerations may develop, which together with intramural haemorrhage and necrosis result in the ‘shaggy’ margin seen on esophagograms. Roberts L Jr, et al. Adult oesophageal candidiasis: A radiographic spectrum. Radiographics. 1987;7(2):289-307. 3. D. Type 3 Type 3 cysts have thickened irregular/smooth walls or septa in which measurable enhancement is present. These need surgery in most cases, as neoplasm cannot be excluded. They include complicated haemorrhagic/infected cysts, multilocular cystic nephroma and cystic neoplasms. Type 2F (F denotes follow-up) cysts may contain multiple hairline-thin septa. Perceived (not measurable) enhancement of a hairline smooth septum or wall can be identified, and there may be minimal thickening of the wall or septa, which may contain calcification that may be thick 25  and nodular. There are no enhancing soft-tissue components; totally intrarenal non enhancing high-attenuation renal lesions (>3 cm) are also included in this category. These lesions are generally well marginated and are thought to be benign but need follow-up. Type 1 is a benign simple water attenuation cyst with a hairline-thin wall that does not contain septa, calcifications, or solid components and does not enhance. Type 2 is a benign cystic lesion that may contain a few hairline septa in which perceived (not measurable) enhancement might be appreciated; fine calcification or a short segment of slightly thickened calcification may be present in the wall or septa. Uniformly high-attenuation lesions (95%) and syringohydromyelia. Supratentorial abnormalities arc common: dysgenesis of corpus callosum (>80%), obstructive hydrocephalus following closure of meningocoele, absent septum pellucidum, to name a few. CT and MRI show colpocephaly (enlarged occipital horn and atria), ‘batwing' configuration of frontal horns on coronal view (pointing inferiorly secondary to enlarged caudate nucleus), ‘hourglass ventricle', excessive cortical gyration (stenogyria), interdigitation of medial cortical gyri, cerebellar peg sign’, thin elongated fourth ventricle exiting below the foramen magnum, dysplastic tentorium, towering cerebellum, tethered cord and cervico medullary kink among multiple other cranial and spinal anomalies. It is not associated with basilar impression/Cl assimilation/Klippel Feil deformity. Dähnert W. Radiology Review Manual, 7th edn. Philadelphia, PA: Lippincott Williams & Wilkins, 2011. 103. I). Infective endocarditis Extracardiac Complications of Infective Endocarditis Central nervous Embolic stroke, intracranial haemorrhage, intracranial mycotic aneurysm, system brain abscess, meningitis Thoracic Septic pulmonary emboli, pulmonary oedema, pulmonary abscess, pleural effusion/empyema, pneumothorax 54 Abdominal Renal infarction, renal failure, splenomegaly, splenic infarction, hepatic infarction, mesenteric ischaemia Musculoskeletal Spondylodiscitis, osteomyelitis, septic arthritis, peripheral soft-tissue abscess Vascular Major arterial emboli, mycotic aneurysm (including aortic aneurysm), vasculitis (including aortits) Colen TW, et al. Radiologic manifestations of extra-cardiac complications of infective endocarditis. F.ur Radiol. 2008;18:2433-45. 104. A. Focal nodular hyperplasia Focal nodular hyperplasia (FNil) is the second most common benign liver tumour after haemangioma. FNH is classified into two types: classic (80% of cases) and non-classic (20%). Distinction between FNli and other hypervascular liver lesions such as hepatocellular adenoma, hepatocellular carcinoma and hypervascular metastases is critical to ensure proper treatment. An asymptomatic patient with FNH does not require biopsy or surgery. MRI has higher sensitivity and specificity for FNH than does US or CT. Typically, FNH is iso- or hypointense on T1-weighted images, is slightly hyper- or isointense on T2-weighted images, and has a hyperintense central scar on T2-weighted images. FNH demonstrates intense homogeneous enhancement during the arterial phase of gadolinium-enhanced imaging and enhancement of the central scar during later phases. Hussain SM, et al. Focal nodular hyperplasia: Findings at state-of-the-art MR imaging, US, CT, and pathologic analysis. RadioGraphics. 2004;24:3-19. 105. A. Feeding central vessel on Doppler imaging. US features characteristic of benign lesions have been described. These include hyperechogenicity compared to fat, an oval or well-defined, lobulated, gently curving shape and the presence of a thin echogenic pseudocapsule. Doppler examination of benign lesions shows displacement of normal vessels around the edge of the lesion. In contrast, malignant lesions show abnormal vessels that are irregular and centrally penetrating. Adam A, et al Grainger & Allison's Diagnostic Radiology: A Textbook of Medical Imaging, 5th edn. New York: Churchill Livingstone, 2008:1180. 106. B. Ewings sarcoma The main differential in such findings would be between infection and a primary bone tumour. Because infection has not been given as an option, the choices would be between osteosarcoma and Ewings sarcoma. Ewing’s sarcoma tends to occur in both the appendicular and axial skeleton equally, whereas osteosarcoma mostly occurs in the appendicular skeleton. Ewings sarcoma usually begins in the diaphysis of the long bones, whereas osteosarcoma tends to occur in the metaphysis. Ewing’s sarcoma may also have a large extra osseous component. The two are often differentials of each other, as each can have a large overlap of imaging findings, but the above traits can help one sway towards the other. Dähnert W. Radiology Review Manual, 6th edn. Philadelphia, PA: Lippincott Williams & Wilkins, 2007:75. Kan JH, Klienman PK. Pediatric and Adolescent Musculoskeletal MRI - A Case Based Approach. Secaucus, NJ: Springer-Verlag, 2007: 23-4. 107. A. Microbleeds have a worse prognosis than haematoma. Haemorrhagic transformation demonstrates a spectrum of findings ranging from small microbleeds to large parenchymal haematoma. Several studies have reported that microbleeds are present in one-half to the majority of patients with ischaemic stroke and are seen around 48 hours after onset of symptoms. Studies have shown that these areas of microbleeding are not associated with a worse outcome, and guidelines state that the presence of fewer than five areas of microbleeding on initial MRIs does not contraindicate thrombolysis. 55  Parenchymal haematoma is a rarer type of haemorrhagic transformation that results from vessel wall rupture caused by high reperfusion pressure. It is more common with cardio-embolic events, is associated with hyperglycaemia, most commonly occurs in the basal ganglia, and confers a much worse prognosis. Haemorrhagic transformation is rare in the first 12 hours after stroke onset (the hyperacute stage), particularly within the first 6 hours. When it occurs, it is usually within the first 24-48 hours and, in almost all cases, is present 4-5 days after stroke. Studies have reported that the presence of early parenchymal enhancement within 6 hours of stroke is associated with a higher risk for clinically significant haemorrhagic transformation. Allen LM, et al. Sequence-specific MR imaging findings that are useful in dating ischemic stroke. Radiographics. 2012;32(5):1285-97. 108. A. Pulmonary' interstitial emphysema MRFs excellent tissue contrast resolution allows easy differentiation between organs, allowing prenatal diagnosis of congenital diaphragmatic hernia. MRI is also useful in the evaluation of foetal lung maturation through volume and signal intensity. Congenital cystic adenomatoid malformation (CCAM) is the most commonly diagnosed lung malformation. In CCAM, abnormal branching of the immature bronchioles and lack of normal alveolar development results in a solid/cystic intrapulmonary mass. Most pulmonary sequestrations detected prenatally are extralobar, with an anomalous vein that drains into the systemic circulation. On T2-weighted images, they are seen as well-defined hyperintense masses with or without hypointense septa. Intralobar sequestration may be difficult to differentiate from CCAM. MRI is also useful for evaluating other pulmonary and thoracic anomalies. Bronchogenic cysts are identified as hyperintense lesions on T2-wcightcd sequences; they are usually single lesions, located in the lung or mediastinum. Oesophageal duplication cysts are also identified as hyperintense mediastinal lesions. Congenital lobar emphysema can be difficult to distinguish from intralobar sequestration and from CCAM. Pulmonary interstitial emphysema refers to the abnormal location of air within the pulmonary interstitium, resulting from rupture of over-distended alveoli following barotrauma in infants who have surfactant deficiency lung disease. Martin C, et al. Fetal MR in the evaluation of pulmonary' and digestive system pathology. Insights Imaging. 2012;3(3):277—93. 109. E. Sarcoidosis Cardiac thrombus tends to occur in older adults with a history of atrial fibrillation or ventricular aneurysm due to prior myocardial infarction. Right ventricular thrombus has been reported in patients with deep venous thrombosis, Behcet’s syndrome, Löffler syndrome, endocarditis, Churg-Strauss syndrome and right atrial aneurysms. Cardiac thrombus appears as a lobular, intracavitary mass. The density and signal intensity depend on the age of the thrombus. Cardiac thrombus does not enhance. Patients with cardiac thrombus are treated with anticoagulation. Francois CJ, et al. CT and MR imaging of primary, metastatic, and nonneoplastic cardiac masses. Contemp Diagn Radiol. 2006:29(24): 1-6. 110. C. Scleroderma Systemic sclerosis, or scleroderma, is characterised by excessive collagen production, autoimmune disease-induced inflammation, and microvascular injury. It is divided into two subtypes: limited cutaneous systemic sclerosis and diffuse cutaneous systemic sclerosis. Limited cutaneous systemic sclerosis typically manifests as CREST syndrome, which stands for calcinosis 56 cutis, Raynaud phenomenon, oesophageal dysmotility, sclerodactyly and telangiectasia and is generally anticentromere-antibody positive. The systemic manifestations of systemic sclerosis are diverse. Abnormalities of the circulatory system (most notably Raynaud phenomenon) and involvement of multiple organ systems - such as the musculoskeletal, renal, pulmonary, cardiac and gastrointestinal systems - with fibrotic or vascular complications are most common. Nearly 90% of patients with systemic sclerosis have evidence of gastrointestinal involvement, which is, ultimately, a substantial cause of morbidity. The underlying pathologic change consists of smooth muscle atrophy and fibrosis caused by collagen deposition primarily in the tunica muscularis. Oesophageal involvement typically affects the distal two thirds of the oesophagus because of the lack of striated muscle in the upper one-third. Findings of oesophageal involvement include decreased or absent oesophageal peristalsis combined with prominent gastroesophageal reflux from an incompetent lower oesophageal sphincter. Oesophagitis is frequently present, and associated complications such as oesophageal stricture or Barrett metaplasia are fairly common. Small bowel findings include hypomotility from smooth muscle atrophy and fibrosis, which leads to stasis, dilatation and pseudo obstruction. The ‘hide-bound’ sign of valvular packing is a fairly specific finding and may be seen in as many as 60% of patients with scleroderma. Bhavsar AS. Abdominal manifestations of neurologic disorders. RadioGraphics. 2013;33:135-53. 111. B. Anechoic mass Carcinomas are irregular in outline, ill-defined and hypoechoic compared to the surrounding fat. They are taller than wide (AP dimension more than transverse dimension). There may be an ill-defined echogenic halo around the lesion, particularly the lateral margins, and distortion of the adjacent breast tissue, akin to spiculations, may be evident. Posterior acoustic shadowing is frequently observed, due to attenuation of the US beam by dense tissue. Doppler examinations of malignant lesions show abnormal vessels that are irregular and centrally penetrating. Adam A, ct al. Grainger & Allison's Diagnostic Radiology: A Textbook of Medical Imaging, 5th edn. New York: Churchill Livingstone, 2008:1184. 112. B. Dorsal intercalated segment instability (D1SI) D1SI and VISI injuries refer to malalignment of the carpal rows with emphasis of the relation of the lunate to the capitate. In DISI (associated with tear of scapholunate ligament), the lunate is tilted dorsally with an increased scapholunate angle (>60 degrees) and capitolunate angle (>30 degrees). In VISI (associated with tear of the luno triquetral ligament), there is a volar tilt of the lunate with decreased scapholunate angle (30 degrees). Manaster BJ, et al. Musculoskeletal Imaging: The Requisites, 4th edition. Philadelphia, PA: Mosby Elsevier, 2013:130. 113. D. Low signal on T1W MRI is seen >8 hours. A good rule of thumb is that if the signal intensity on ADC maps is low, the stroke is less than 1 week old. Most literature indicate that in patients with ischaemic stroke, findings on FLAIR images are positive 6 12 hours after onset of symptoms. Sometimes the presence of restricted diffusion with negative findings at FLAIR imaging alone has been enough to initiate treatment. High signal intensity is not usually seen at T2-weighted imaging until at least 8 hours after the initial ischaemic insult and continues into the chronic phase. Low signal intensity is not usually seen at T1 weighted imaging until 1 6 hours after the onset of stroke and persists into the chronic phase. The pattern of contrast enhancement may help determine the age of the stroke. In ischaemic stroke, enhancement may be arterial, meningeal, or parenchymal. Arterial enhancement, dubbed the ‘intravascular enhancement’ sign, usually occurs first and may be seen as early as 0-2 hours after the onset of stroke. Meningeal enhancement is the rarest type of enhancement. 57  It occurs within the first week after onset of stroke. If parenchymal enhancement persists longer than 8 12 weeks, a diagnosis other than ischaemic stroke should be sought. Allen LM, et al. Sequence-specific MR imaging findings that are useful in dating ischemic stroke. Radiographics. 2012;32(5): 1285-97. 114. C. Ductus venosus The single umbilical vein extends from the umbilicus to the left portal vein. When blood from the umbilical vein reaches the left portal vein, it is directed to the ductus venosus, which originates from the left portal vein immediately opposite the insertion site of the umbilical vein and courses cephalad to the inferior vena cava. The preferred location of the tip of the umbilical venous catheter is typically in the cephalad portion of the inferior vena cava or at the inferior vena caval-right atrial junction. An umbilical venous catheter can be distinguished from an umbilical arterial catheter as the UVC travels cranially in the umbilical vein while the UAC travels caudally in an umbilical artery to reach a common iliac artery. Schlesinger AE, et al. Neonates and umbilical venous catheters: Normal appearance, anomalous positions, complications, and potential aid to diagnosis. AJR Am J Roentgenol. 2003; 180(4): 1147-53. 115. D. Primary cardiac lymphomas mostly affect the left side of the heart. Secondary malignancies involving the heart are 20-40 times more frequent than primary cardiac neoplasms. Angiosarcoma is the most common primary cardiac malignancy of adulthood. The tumour typically involves the right atrium, and so presenting symptoms are related to obstruction to right cardiac filling and pericardial tamponade. They are heterogeneously high signal on Tl and T2-weighted images with heterogeneous enhancement. Undifferentiated sarcoma mostly arises in the left atrium, although they can also involve the cardiac valve. It appears as an isointense irregular mass infiltrating the myocardium. Primary cardiac lymphomas are exceedingly rare, are typically of the non-Hodgkin B-cell type and are confined to the heart or pericardium. They most commonly involve the right side of the heart, in particular the right atrium, with frequent involvement of more than one chamber and invasion of the pericardium. At MRI, they are isointense on T1-weighted images and heterogeneously hyperintense on T2-weighted images; they demonstrate heterogeneous enhancement after administration of gadolinium contrast material. Rhabdomyosarcomas do not arise from any specific chamber, but they are more likely than any other primary cardiac sarcomas to involve the valves. Sparrow PJ, et al. MR imaging of cardiac tumors. Radiographics. 2005^5(5): 1255-76. 116. C. There is caudate lobe atrophy in chronic Budd-Chiari. Budd-Chiari syndrome is a heterogeneous group of disorders characterised by hepatic venous outflow obstruction at the level of the hepatic veins, the IVC, or the right atrium. Budd-Chiari syndrome has variable imaging features. Hepatic vein or IVC thrombosis, with resultant changes in liver morphology and enhancement patterns, venous collaterals, varices, and ascites may be directly observed. Duplex Doppler US is a useful method for detecting Budd-Chiari syndrome because it allows easy assessment of hepatic venous flow and detection of hepatic parenchymal heterogeneity. CT and MR imaging also can depict hepatic venous flow or thrombosis and IVC compression or occlusion. In the presence of acute disease, the imaging features correspond with histologic findings of liver congestion and oedema. The liver is globally enlarged, with lower attenuation on CT images, decreased signal intensity on Tl - weighted MRIs, and heterogeneously increased signal intensity on 58 T2 weighted MRIs, predominantly in the periphery. Differential contrast enhancement between the central and peripheral areas of liver parenchyma is a feature of acute Budd-Chiari syndrome. The more oedematous and congested peripheral regions demonstrate decreased contrast enhancement, whereas stronger enhancement is seen in the central parenchyma. After the administration of contrast material, increased enhancement is seen in areas of venous drainage that are less affected, such as the caudate lobe. The development of intra- and extrahepatic collateral veins in subacute Budd-Chiari syndrome permits the egress of venous flow, producing a more homogeneous enhancement pattern with persistent signs of oedema. In chronic Budd-Chiari syndrome, there is atrophy of the affected portions of the liver, and the parenchymal oedema is replaced by fibrosis, which results in decreased Tl- and T2-weighted signal intensity at unenhanced MRI and in delayed enhancement in contrast-enhanced studies. Hypertrophy of the caudate lobe, irregularities of the liver contour, and regenerative nodules are prominent features of chronic Budd-Chiari syndrome. Cura M. Diagnostic and interventional radiology for Budd-Chiai syndrome. RadioGraphics. 2009;29:669-81. 117. E. Routine breast screening Ultrasound is not a screening tool. It is used for assessment of a palpable lump, particularly in young patients (below 30 years) and mammographically dense breasts, and in characterisation of a mammographic or palpable mass as solid or cystic. It is used for evaluation of mammographically uncertain lesion or for confirmation of lesion seen on a single projection. It is used for assessing breast discharge, suspected silicone leaks, follow-up of lesions seen on US and for guiding cyst aspiration, biopsy or wire localisation. Dähnert W. Radiology Review Manual, 7th cdn. Philadelphia, PA: lippincott Williams & Wilkins, 2011:573-5. 118. E. Scheuermann disease Scheuermann disease is a spinal disorder named after Dr Holger Scheuermann, who, in 1921, first described a structural thoracic kyphosis mainly affecting adolescents. Its best-known manifestations are multiple wedged vertebrae and thoracic kyphosis known as Scheuermann kyphosis. Its classic diagnostic criterion was '3 or more consecutive wedged thoracic vertebrae'. However, the pathological changes also include disc and end plate lesions, primarily Schmorl node and irregular vertebral end plate. Therefore, the diagnosis of ‘atypical Scheuermann disease' was proposed for patients with only one or two wedged vertebrae and no notable kyphosis but characteristic disc/end plate lesions. Because atypical Scheuermann disease tends to affect the lumbar or thoracolumbar junction region instead of the thoracic spine, it is also called lumbar Scheuermann disease. Liu N, et al. Radiological signs of Scheuermann disease and low back pain. Retrospective categorization of 188 hospital staff members with 6-year follow up. Spine. 2014;39(20): 1666-75. 119. A. Fourth ventricle enlargement Isodense subdural haematoma are a recognised pitfall on CT, which is often difficult to recognise. Indirect signs are hence critical, midline shift; compression of the ipsilateral lateral ventricle; effacement of cerebral sulci; medial displacement of junction of grey and white matter (white matter buckling); and dilatation of contralateral lateral ventricle, which is a bad prognostic sign. In case of bilateral collections, the frontal horns lie closer than normal, giving ‘rabbit ear' appearance. Adam A, et aL Grainger & Allison's Diagnostic Radiology: A Textbook of Medical Imaging, 5th edn. New York: Churchill Livingstone, 2008:1343-4. 59  120. B. Bilateral occipital subdural haemorrhage Subdural haemorrhage (SDH) and subarachnoid haemorrhage (SAH) are common abusive injuries. Epidural haematoma is much more often accidental. Probably the most common location of inflicted SAH, and SDH diagnosed radiologically is a layer of hyperattenuating material adjacent to the falx; bleeding at this site represents an interhemispheric extra-axial haemorrhage. In this location, it is often difficult, radiologically, to distinguish SAH from SDH, and SDH and SAH may coexist. Lonergan GJ, et al. From the archives of the AFIP. Child abuse: Radiologic-pathologic correlation. Radiographics. 2003;23(4):811-45. 60  CHAPTER 3 TEST PAPER 2 Questions Time: 3 hours 1. An intracardiac mass was incidentally detected during echocardiography in a patient undergoing preoperative assessment. Chest X-ray was non specific, showing an enlarged heart. Which one of the following statements regarding primary benign cardiac tumours is false? A. Cardiac fibromas are homogenously low on T2W MRI. B. Cardiac lipomas are high on T1W MRI. C. Cardiac rhabdomyomas are associated with tuberous sclerosis. D. Cardiac fibroelastomas usually arise from the pericardium. E. Cardiac myxomas show heterogeneous signal on MRI. 2. A 40-year-old man undergoes a CT scan of the abdomen for recurrent abdominal pain. The precontrast scan showed bilateral renal calculi. A post-contrast scan showed several pancreatic lesions, measuring between 1 and 2 cm. What is the likely unifying diagnosis? A. MEN I B. MEN IIA C. Insulinoma D. Glucagonoma E. NF1 3. A 45-year old woman presents with a rapidly enlarging mildly painful breast mass over a period of few months. An urgent ultrasound is performed. The ultrasound shows that the mass measures 7 cm, filling up almost the entire breast with fluid-filled clefts in the tumour. What is the diagnosis? A. Inflammatory carcinoma B. Cystosarcoma phylloides C. Complex breast cyst D. Invasive lobular carcinoma E. Breast lymphoma 4. Osteoid osteomas: A. Are aggressive bone lesions with malignant potential B. Are referred to as osteoblastomas when larger than 3 cm C. Are typically cortical rather than subcortical based lesions D. Typically require surgical curettage and resection E. Are more common in women 5. A 67-year-old known alcoholic man with acute onset neurological symptoms has been referred for an urgent CT brain to exclude haemorrhage. CT shows an isodense subdural on the right, but the history' of trauma was 24 hours earlier with no previous history of head 61  injury or fall. All of the following are causes of isodense subdural hacmatoma on CT following head trauma, except A. A 2-week-old head injury with subdural haemorrhage B. Acute subdural haematoma in a patient with Hb 7.5 g/dL C. Chronic haematoma in a patient with coagulopathy D. Patient with an associated arachnoid tear E. Patient with leptomeningeal metastasis 6. A child presents with intermittent abdominal pain, vomiting, and a right upper-quadrant mass. On clinical examination, blood is noted on rectal examination. A clinical diagnosis of intussusception is made. Where is the most common site of intussusception in this population group? A. Ileoileal B. Ileocolic C. Ileoileocolic D. Colocolic E. Jejunoileal 7. A 29 year-old woman with fever, malaise, fatigue, intermittent pain and numbness in both hands and feet, and normal chest radiograph is referred for MRI thorax. MRI shows wall thickening of the origin of the right subclavian artery and both carotid arteries. What is the diagnosis? A. Moyamoya disease B. Takayasu arteritis C. Churg-Strauss disease D. PAN E. Wegener’s granulomatosis 8. A slimly built 60-year-old woman presents with anorexia, diarrhoea, and weight loss. Barium meal shows multiple filling defects in the stomach with thickened gastric rugae. Colonoscopy shows multiple colonic polyps. The top differential is A. Peutz-Jeghers syndrome B. Familial adenomatous polyposis C. Cronkhite-Canada syndrome D. Cowden syndrome E. Turcot's syndrome 9. A middle-aged woman presents to the breast clinic with a few weeks’ history of vague breast pain and lumpiness. On further direct questioning, she reveals a history of trauma to the breast a few months ago. Mammogram show's a well-defined circular mass with central translucency and eggshell calcification. What is the most likely diagnosis? A. Cystosarcoma phylloides B. Complex breast cyst C. Invasive lobular carcinoma D. Fat necrosis E. Fibroadenoma 10. A 60-year-old patient is admitted for progressive thoracic back pain with a low-grade fever, which has been going on for several weeks. Routine chest radiograph reveals no abnormality. An M RI of the spine reveals minimal intervertebral disc space reduction at T4/5 with hyperin tensity of the disc. There is adjacent vertebral end plate oedema and irregularity. A well-defined and 62  predominantly high T2W signal collection is noted, extending beneath the anterior longitudinal ligament and cranially to reach the level of T2. What is the most likely diagnosis? A. Pyogenic discitis 13. Insufficiency fracture with ongoing collapse, complicated by chronic vertebral osteomyelitis C. Degenerative disc disease with Modic Type II end plate changes D. Pott disease E. Vertebral lymphoma 11. A 16 year old boy with progressive extra-pyramidal symptoms, dementia and positive family history was sent for an MRI brain by his neurologist. MRI showed bilaterally symmetric hyperintense signal changes in the anterior medial globus pallidus with surrounding hypointensity in the globus pallidus on T2W images, commonly described as ‘eye of the tiger sign. Caudate was normal and no other areas of signal change was demonstrated. What is the diagnosis? A. Wilson disease B. Huntington disease C. MELAS I). Hallervorden-Spatz disease E. CADASIL 12. A 2-year-old boy presents with a large abdominal mass and there is suspicion of an underlying neuroblastoma. Which feature would be supportive of this diagnosis with the highest confidence? A. Calcification is uncommon. B. Well circumscribed. C. Displaces major vessels rather than encasing them. D. Encases major vessels but does not invade them. E. Claw of renal tissue extends partially around the mass. 13. A 73-year-old woman with previous history of myocardial infarction was referred for a chest radiograph by her GP to exclude chest infection. No infective focus was identified but a focal bulge was noticed in the left heart border, with curvilinear calcification along the edge. What is the diagnosis? A. Myocardial calcification B. Right atrial calcification C. Mitral annulus calcification D. Calcified vegetations E. Left ventricular aneurysm calcification 14. A 70-year-old man presents with rectal bleeding. Flexible sigmoidoscopy shows a circumferential tumour in the upper third of the anal canal. An MRI performed for staging shows locoregional lymphadenopathy. The lymph node group most likely to be involved is A. Superficial inguinal B. Common iliac C. Pudendal D. External iliac E. Paraortic 15. A fit and healthy 25-year-old woman presents to the breast clinic with a small mobile non-tender breast lump that she noticed incidentally. An ultrasound is deemed as the first-line 63  investigation; it reveals an extremely well-defined homogenous, hypoechoic oval mass with posterior acoustic shadowing. What is the most likely diagnosis? A. Cystosarcoma phylloides B. Fibroadenoma C. Complex breast cyst D. Invasive lobular carcinoma E. Fat necrosis 16. A 35-year-old weightlifter presents to the orthopaedic clinic with pain in the right shoulder. An initial radiograph is normal and no abnormality is identified on US. An MRI is suggested for further evaluation; it reveals increased T2W signal changes with fatty atrophy of the teres minor muscle. What is the likely diagnosis? A. Parsonage Turner syndrome B. Spinoglenoid notch paralabral cyst C. Duchenne's muscular dystrophy D. Quadrilateral space syndrome E. Acute rotator cuff tear 17. A 45-year-old male patient with low back pain, rectal bleeding and faecal incontinence is investigated with CT and MRI. CT shows an enhancing soft-tissue mass replacing the sacrum with areas of amorphous calcifications. On MRI, the lesion shows low to intermediate signal on T1W and high signal on T2W images. What is your diagnosis? A. Sacral meningocoele B. Sacral chordoma C. Central dural ectasia D. Rhabdomyosarcoma E. Sacrococcygeal teratoma 18. A 3-ye