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MNJ05-001
Identify the anatomical structures labeled A to K in the neuroanatomy and brain imaging sections below:

MNJ-P-OSCE 05. Neuroimaging_page_3_Picture_3.jpeg
MNJ-P-OSCE 05. Neuroimaging_page_3_Picture_5.jpeg
MNJ-P-OSCE 05. Neuroimaging_page_3_Picture_7.jpeg
MNJ-P-OSCE 05. Neuroimaging_page_3_Picture_8.jpeg
MNJ-P-OSCE 05. Neuroimaging_page_4_Picture_2.jpeg

  1. Identify the anatomical landmarks and structures labeled on the CT/MRI brain sections.

Answer

MNJ05-002
Review the neonatal cranial ultrasound images showing Periventricular Leukomalacia (PVL):

  1. Identify the imaging planes and grade of PVL shown in the sagittal views.
  2. State the de Vries ultrasound grading system for PVL.

Answer

  1. Parasagittal and coronal cranial ultrasound views showing Periventricular Leukomalacia (PVL): Grade 1 (prolonged periventricular flares) and Grade 3 (extensive cystic changes in periventricular white matter).
  2. de Vries Ultrasound Classification of PVL:
    • Grade I: Prolonged periventricular echogenicity / flaring persisting for ≥ 7 days.
    • Grade II: Localized periventricular cysts developing in the frontoparietal white matter.
    • Grade III: Extensive periventricular cystic lesions extending to frontoparietal and occipital white matter.
    • Grade IV: Extensive subcortical white matter cystic lesions involving deep and peripheral parenchyma.

MNJ05-003
Review the cranial ultrasound images of a preterm newborn below:

MNJ-P-OSCE 05. Neuroimaging_page_4_Picture_9.jpeg

  1. What are the major risk factors for intraventricular / germinal matrix hemorrhage (IVH/GMH)?
  2. State the Papile (CT) and Volpe (Ultrasound) grading criteria.
  3. What are the key preventive strategies?
  4. What are the possible long-term neurological complications in a preterm infant?
  5. Grade the IVH seen in these ultrasound images.

Answer

  1. Risk factors:
    • Extreme prematurity (<32 weeks) and very low birth weight (<1500 g)
    • Fluctuating cerebral blood flow (hypotension, rapid volume expansion/boluses, rapid sodium bicarbonate infusion)
    • Severe respiratory distress syndrome, pneumothorax, hypoxia, hypercapnia
    • Sepsis, acidosis, coagulopathy
  2. Grading Systems:
    • Papile Grading (CT):
      • Grade I: Subependymal / Germinal matrix hemorrhage alone.
      • Grade II: Intraventricular hemorrhage without ventricular dilatation (fills <50% of lateral ventricle).
      • Grade III: Intraventricular hemorrhage with ventricular dilatation (fills ≥50% of lateral ventricle).
      • Grade IV: Intraventricular hemorrhage with parenchymal hemorrhage / hemorrhagic infarction.
    • Volpe Grading (Cranial USG):
      • Grade 1: Germinal matrix hemorrhage with minimal/no IVH (<10% ventricular area).
      • Grade 2: IVH occupying 10–50% of ventricular area.
      • Grade 3: IVH occupying >50% of ventricular area with acute ventricular distension.
      • Periventricular Hemorrhagic Infarction (PVHI / IPE): Concomitant venous intraparenchymal echodensity.
  3. Preventive strategies:
    • Antenatal corticosteroids in threatened preterm labor
    • Gentle resuscitation and avoid rapid volume/bicarbonate boluses
    • Synchronized gentle ventilation to avoid fluctuating cerebral venous pressures
    • Minimal handling and neutral head positioning in the first 72 hours of life
  4. Complications: Post-hemorrhagic ventricular dilatation (PHVD), obstructive hydrocephalus, cerebral palsy (spastic diplegia/quadriplegia), developmental delay, epilepsy.
  5. Grading of Images:
    • Grade I: Echogenic clot localized to the caudothalamic groove.
    • Grade II: Clot in the dependent portion of the lateral ventricle without dilatation.
    • Grade III: Large distending echogenic cast filling and ballooning the entire lateral ventricle.

MNJ05-004
Diagnose the two conditions shown on brain MRI (Image A and Image B) and outline their specific medical management:

MNJ-P-OSCE 05. Neuroimaging_page_4_Picture_11.jpeg

  1. Identify the condition in Image A and state the treatment.
  2. Identify the condition in Image B and state the treatment.

Answer

  1. Image A: Japanese Encephalitis (JE)
    • Imaging: Characteristic bilateral symmetrical hyperintensity in the thalamus, basal ganglia, and midbrain/brainstem on T2/FLAIR.
    • Treatment: Supportive care (airway protection, control of raised intracranial pressure with mannitol/hypertonic saline, seizure management, fluid and electrolyte maintenance; no specific antiviral therapy).
  2. Image B: Herpes Simplex Encephalitis (HSE)
    • Imaging: Asymmetric hyperintensity and edema involving the temporal lobes, inferior frontal lobes, and insular cortex on T2/FLAIR with gyral enhancement.
    • Treatment: Intravenous Acyclovir (10–15 mg/kg/dose or 500 mg/m²/dose IV every 8 hours) for 14–21 days.

MNJ05-005
An 8-year-old child presents with acute onset of seizures, multiple cranial nerve palsies, dysarthria, and dysphagia following a febrile viral illness 2 weeks prior:

MNJ-P-OSCE 05. Neuroimaging_page_5_Picture_5.jpeg

  1. Identify the condition from the clinical presentation and brain MRI.
  2. What is the treatment and expected prognosis?

Answer

  1. Diagnosis: Acute Disseminated Encephalomyelitis (ADEM) (showing widespread, asymmetric, poorly demarcated T2/FLAIR hyperintense demyelinating lesions involving the deep white matter, subcortical white matter, brainstem, and basal ganglia).
  2. Treatment & Prognosis:
    • Treatment: High-dose intravenous Methylprednisolone (30 mg/kg/day, max 1000 mg/day) for 3–5 days, followed by oral prednisolone taper over 2–4 weeks. Refractory cases: IVIG (2 g/kg over 2 days) or plasmapheresis (plasma exchange).
    • Prognosis: Generally good; complete neurological recovery in 70–80% of children following a monophasic course.

MNJ05-006
Review the cerebral angiogram / MRI below:

MNJ-P-OSCE 05. Neuroimaging_page_5_Picture_10.jpeg

  1. Diagnose the condition shown in the image.
  2. List 4 predisposing / associated risk factors.
  3. Describe the typical clinical presentation.
  4. What is the definitive surgical treatment?

Answer

  1. Diagnosis: Moyamoya Disease / Moyamoya Syndrome (progressive stenosis of the terminal internal carotid arteries and circle of Willis with characteristic "puff of smoke" collateral vessel network).
  2. Associated conditions:
    • Down syndrome (Trisomy 21)
    • Neurofibromatosis type 1 (NF-1)
    • Sickle cell disease
    • Post-radiation vasculopathy
    • Asian descent (familial RNF213 gene mutation)
  3. Clinical presentation: Recurrent transient ischemic attacks (TIAs) or ischemic strokes triggered by crying, hyperventilation, dehydration, or coughing; alternating hemiparesis, headaches, seizures, chorea, cognitive decline.
  4. Surgical management: Cerebral revascularization procedures:
    • Direct bypass: Superficial Temporal Artery to Middle Cerebral Artery (STA-MCA) anastomosis.
    • Indirect bypass: Encephaloduroarteriosynangiosis (EDAS) or Encephalomyosynangiosis (EMS).

MNJ05-007
CT scan of an 8-year-old child:

MNJ-P-OSCE 05. Neuroimaging_page_6_Picture_5.jpeg

  1. Diagnose the abnormality seen on this non-contrast CT scan.
  2. Give 4 differential diagnoses / etiologies of this condition in children.

Answer

  1. Diagnosis: Bilateral symmetrical Basal Ganglia Calcification (hyperdense calcification involving globus pallidus, putamen, and caudate nuclei).
  2. Differential diagnoses / Causes:
    • Idiopathic basal ganglia calcification (Fahr disease)
    • Hypoparathyroidism and Pseudohypoparathyroidism
    • Congenital TORCH infections (Toxoplasmosis, CMV, Congenital HIV)
    • Mitochondrial disorders (MELAS, Leigh syndrome, Kearns-Sayre syndrome)
    • Post-infectious / post-inflammatory (Tuberculous meningitis, Neurocysticercosis)
    • Carbon monoxide or lead poisoning

MNJ05-008
Review the two brain MRI scans below:

MNJ-P-OSCE 05. Neuroimaging_page_6_Picture_9.jpeg
MNJ-P-OSCE 05. Neuroimaging_page_7_Picture_2.jpeg

  1. What is this imaging modality / sequence?
  2. Identify the lesions in Image A and Image B, and explain how to differentiate them on MRI.

Answer

  1. Modality: T2-weighted / FLAIR and Contrast-Enhanced T1-weighted Magnetic Resonance Imaging (MRI).
  2. Differentiation:
    • Image A (Tuberculoma): Solid granulatous lesions with central hypointensity on T2-weighted MRI, thick nodular or ring enhancement on T1+contrast, and marked perilesional edema.
    • Image B (Neurocysticercosis - NCC): Cystic lesions with thin smooth ring enhancement; T2W hyperintense cyst fluid with an eccentric hypointense mural nodule representing the scolex ("hole-with-dot" sign).

MNJ05-009
Diagnose the four leukodystrophies shown in A, B, C, and D based on their characteristic white matter involvement:

MNJ-P-OSCE 05. Neuroimaging_page_7_Picture_4.jpeg

  1. Identify leukodystrophy A.
  2. Identify leukodystrophy B.
  3. Identify leukodystrophy C.
  4. Identify leukodystrophy D.

Answer

  1. A: X-linked Adrenoleukodystrophy (X-ALD): Confluent, symmetric demyelination in the parieto-occipital white matter and splenium of the corpus callosum with leading-edge intermediate rim enhancement.
  2. B: Metachromatic Leukodystrophy (MLD): Symmetrical confluent periventricular white matter demyelination with sparing of subcortical U-fibers, showing a characteristic tigroid / leopard-skin pattern.
  3. C: Canavan Disease: Diffuse, bilateral, symmetrical white matter involvement with prominent early involvement of subcortical U-fibers and macrocephaly (markedly elevated NAA peak on MR spectroscopy).
  4. D: Alexander Disease: Symmetrical white matter demyelination with frontal lobe predominance, frontal cystic degeneration, basal ganglia involvement, and macrocephaly (GFAP mutation).

MNJ05-010
Review the contrast-enhanced CT brain scans of a 6-year-old child with cyanotic congenital heart disease:

MNJ-P-OSCE 05. Neuroimaging_page_7_Picture_9.jpeg
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  1. Interpret the CT brain findings.
  2. What are the predisposing factors for this condition in pediatric patients (mention at least 5)?
  3. What long-term neurological sequelae can occur in this child?

Answer

  1. CT findings: Multiple well-defined, thin ring-enhancing lesions with surrounding vasogenic perilesional edema and mass effect, consistent with Multiple Brain Abscesses.
  2. Predisposing factors:
    • Cyanotic congenital heart disease with right-to-left shunt (e.g., Tetralogy of Fallot - loss of pulmonary capillary filtering)
    • Contiguous focus of infection: Chronic suppurative otitis media (CSOM), mastoiditis, paranasal sinusitis, orbital cellulitis, dental infection
    • Penetrating head trauma or neurosurgical procedures (VP shunt infection)
    • Immunodeficiency (HIV, severe combined immunodeficiency, post-chemotherapy neutropenia)
    • Infective endocarditis with septic emboli
  3. Long-term sequelae: Focal neurological deficits (hemiparesis, cranial nerve palsies), secondary epilepsy / seizure disorder, hydrocephalus, cognitive impairment, learning disabilities.

MNJ05-011
Review the T2-weighted brain MRI scan below:

MNJ-P-OSCE 05. Neuroimaging_page_8_Picture_6.jpeg

  1. Identify the imaging sequence and anatomical level.
  2. Give the diagnosis based on the distribution of white matter hyperintensity.
  3. Mention two other peroxisomal / metabolic disorders from the same group.

Answer

  1. Sequence & Level: Axial T2-weighted MRI at the level of the basal ganglia, internal capsules, and lateral ventricles.
  2. Diagnosis: X-linked Adrenoleukodystrophy (X-ALD) (showing confluent, symmetric T2 hyperintensity predominantly in the parieto-occipital periventricular white matter and splenium of the corpus callosum).
  3. Other peroxisomal disorders:
    • Zellweger syndrome spectrum (Zellweger syndrome, Neonatal Adrenoleukodystrophy, Infantile Refsum disease)
    • Refsum disease (phytanic acid storage disease)
    • Rhizomelic chondrodysplasia punctata (RCDP)

MNJ05-012
A 10-month-old infant is brought with complaints of rapidly increasing head size, developmental delay, and a prominent occiput:

MNJ-P-OSCE 05. Neuroimaging_page_8_Picture_11.jpeg
MNJ-P-OSCE 05. Neuroimaging_page_9_Picture_1.jpeg

  1. Mention the abnormalities noted on these neuroimaging studies.
  2. Give your diagnosis.
  3. Mention associated anomalies.

Answer

  1. Abnormalities:
    • Massive cystic dilatation of the fourth ventricle ballooning into the posterior fossa.
    • Complete or partial agenesis/hypoplasia of the cerebellar vermis.
    • Upward displacement of the tentorium cerebelli and torcula (high torcular Herophili).
    • Enlarged posterior fossa with secondary non-communicating hydrocephalus (dilated third and lateral ventricles).
  2. Diagnosis: Dandy-Walker Malformation.
  3. Associated anomalies: Agenesis of corpus callosum, polymicrogyria, schizencephaly, holoprosencephaly, congenital heart disease, cleft palate, polycystic kidneys.

MNJ05-013
Identify the cortical and developmental brain malformations shown in Image A and Image B:

MNJ-P-OSCE 05. Neuroimaging_page_9_Picture_3.jpeg

  1. Identify malformation in Image A.
  2. Identify malformation in Image B.

Answer

  1. Image A: Grey Matter Heterotopia (nodular or band-like collections of normal neurons arrested along the periventricular ependymal lining or in subcortical white matter, isointense to cortex on all MRI sequences).
  2. Image B: Schizencephaly (full-thickness CSF-filled cleft extending from the ependymal wall of the lateral ventricle to the pial surface of the cerebral cortex, lined by dysplastic/polymicrogyric grey matter; open-lip or closed-lip type).

MNJ05-014
A 10-year-old male child presents with recurrent falls during walking, gait ataxia, and worsening early morning headache with vomiting for 3 months:

MNJ-P-OSCE 05. Neuroimaging_page_9_Picture_7.jpeg

  1. Diagnose the condition given in the MRI.
  2. Outline the treatment plan.

Answer

  1. Diagnosis: Medulloblastoma (high-grade embryonal tumor presenting as a contrast-enhancing mass arising from the cerebellar vermis in the roof of the 4th ventricle, causing obstructive hydrocephalus).
  2. Treatment:
    • Emergency management of raised intracranial pressure / hydrocephalus (corticosteroids, temporary EVD or VP shunt).
    • Maximal safe surgical resection / craniotomy.
    • Craniospinal radiation therapy (in children >3 years of age) plus adjuvant combination chemotherapy (e.g., cisplatin, vincristine, cyclophosphamide).

MNJ05-015
Review the neuroimaging studies showing brain malformations below:

MNJ-P-OSCE 05. Neuroimaging_page_9_Picture_11.jpeg
MNJ-P-OSCE 05. Neuroimaging_page_10_Picture_2.jpeg

  1. Identify the brain abnormalities in Image A and Image B.
  2. Name one genetic syndrome associated with Image A and state its key clinical features.

Answer

  1. Identifications:
    • Image A: Lissencephaly (Smooth brain / Agyria-Pachygyria): Loss of normal cerebral sulcation and gyration with thickened cortex and a "figure-of-8" / hourglass appearance of the brain.
    • Image B: Porencephalic Cyst: A focal, fluid-filled cavity within the cerebral parenchyma that communicates with the ventricular system, typically secondary to perinatal vascular occlusion, hemorrhage, or trauma.
  2. Syndrome for Image A: Miller-Dieker Syndrome (17p13.3 microdeletion involving LIS1 gene).
    • Features: Severe lissencephaly (Grade 1), distinctive facial dysmorphism (prominent forehead, bitemporal hollowing, upturned nose with anteverted nares, micrognathia, thin vermilion of upper lip), severe infantile spasms/epilepsy, profound developmental delay, and early mortality.

MNJ05-016
A 9-year-old child presents with new-onset focal seizures with secondary generalization. Brain CT/MRI is shown below:

MNJ-P-OSCE 05. Neuroimaging_page_10_Picture_7.jpeg

  1. What is the diagnosis?
  2. Describe the stepwise management protocol and mandatory preliminary investigations.
  3. How long should antiepileptic drug therapy be continued?
  4. What preventive advice should you provide to the family?

Answer

  1. Diagnosis: Neurocysticercosis (NCC) (multiple parenchymal cysticerci in various stages: colloidal vesicular and granular nodular stages with perilesional edema).
  2. Stepwise Management:
    • Assess and manage acute seizures and raised intracranial pressure.
    • Initiate antiepileptic drugs (e.g., Levetiracetam, Carbamazepine, or Valproate).
    • Mandatory Preliminary Investigation: Fundoscopic / ophthalmologic examination to rule out ocular/intraretinal cysticercosis (cysticidal therapy can cause severe intraocular inflammation and blindness) and CT/MRI spine if indicated.
    • Steroid Coverage: Start systemic corticosteroids (Prednisolone 1–2 mg/kg/day or Dexamethasone) for 2 days prior to cysticidal therapy and continue throughout the course to suppress the host inflammatory response to dying parasites.
    • Cysticidal Therapy: Start Albendazole (15 mg/kg/day in two divided doses for 10–14 days) ± Praziquantel (50 mg/kg/day for dual therapy in multiple viable lesions).
  3. Duration of AED Therapy: Continue antiepileptic therapy until complete CT/MRI resolution of active cystic lesions and edema, plus at least 6–12 months of seizure-free period (or up to 2 years if calcified residues remain).
  4. Preventive Advice:
    • Strict personal hygiene and handwashing with soap before eating and after using the toilet.
    • Thorough washing of all raw vegetables, salads, and fruits.
    • Safe drinking water (boiled/filtered).
    • Proper cooking of pork and meat to ensure larvae are destroyed.
    • Screen household contacts for intestinal Taenia solium carriage (tapeworm carrier).