The Final FRCR Self-Assessment
The Final FRCR Self-Assessment
The Final FRCR Self-Assessment
Benedict Thomson
Nicky Dineen
Vincent Helyar
Aidan Shaw
@ CRC Press
Taylor Si Francis Group
0
masterpass^
THE FINAL FRCR
THE FINAL FRCR
Self-Assessment
Trademark notice: Product or corporate names may be trademarks or registered trademarks and
are used only for identification and explanation without intent to infringe.
ISBN: 9780367637187 (hbk)
ISBN: 9781482259742 (pbk)
ISBN: 9780429195327 (ebk)
Typeset in Palatino
by MPS Limited, Dehradun
I dedicate this book to all my family; my parents, Richard and Gill, to whom I owe
so much. My husband Bruce and our son Magnus. Thank you for the love, support and happiness
that you ceaselessly provide. And finally, to Melanie – never forgotten.
Amanda Rabone
I would like to dedicate this book to my family for their love and support.
Benedict Thomson
To my wonderful family who have been a constant source of joy, love and support.
Nicky Dineen
To my family, my wife Sinéad and my daughters Clara, Elizabeth and Frances for
their love and support. I am very grateful to my parents for giving me my love of words and to my
mother for the inspiration to write.
Vincent Helyar
I would like to dedicate this book to my incredible wife Juliette and my two wonderful boys,
Edward and George, and for their continuing love and support throughout
my career. I am also ever grateful to my amazing parents, Bryn and Ozden, who have always been
there for me and my family, and without whom I would not be where I am today.
Aidan Shaw
Contents
Foreword....................................................................................................................................................... ix
Acknowledgement................................................................................................................................... xi
Authors ........................................................................................................................................................ xiii
Introduction................................................................................................................................................ xv
1. Paper ........................................................................................................................................................... 1
Answers ................................................................................................................................................... 27
2. Paper ......................................................................................................................................................... 59
Answers ................................................................................................................................................... 84
3. Paper ....................................................................................................................................................... 115
Answers ................................................................................................................................................. 140
4. Paper ....................................................................................................................................................... 171
Answers ................................................................................................................................................. 197
vii
Foreword
This book provides four papers, each containing 120 FRCR Part 2A examination mock single best
answer questions, with answers in a separate section. The questions are well constructed and
comprehensive, and closely simulate the style, standard and content of the current FRCR Part 2A
questions which cover all body systems in a single examination.
A very valuable feature of the book is the extremely helpful, clear and pertinent explanations of
why the best answer is the correct answer, and why the other possible answers are less likely or
incorrect. The subject matter of each question is referenced (where relevant) for further revision and
reading to the previously published companion book The Final FRCR: Complete Revision Notes.
There is no doubt that this book will appeal greatly to radiology candidates preparing for their
FRCR examinations, making their personal revision programme much more interesting, focused,
and also fun. I only wish I had had the benefit of this book myself when preparing for the
examination! Nevertheless, I have hugely enjoyed reading the book and testing myself on the
questions. Post-FRCR radiologists will also find this book invaluable as a quick and stimulating
way of bringing them ‘up to speed’ with radiological knowledge across the whole spectrum of
modern imaging.
I congratulate the authors on compiling such an excellent revision text, and I have no hesitation
in highly recommending this book (and its companion Revision Notes book) to all radiologists.
ix
Acknowledgement
We would like to acknowledge all the teachers, supervisors and mentors over the years who have
guided and encouraged us throughout our medical and radiology training.
xi
Authors
Dr Amanda Rabone, FRCR is a recently appointed Consultant Radiologist at Maidstone and
Tunbridge Wells NHS Trust. Dr Rabone graduated with Distinctions from Guy’s, King’s and
St Thomas’ School of Medicine in London. Following 2 years of Foundation training in the South
East of England, she completed speciality training at Kent, Surrey and Sussex School of Radiology
working in a variety of Kent district general hospitals and tertiary London centres.
Dr Rabone has subspecialist interests in breast and gynaecology imaging, whilst maintaining a
broad interest in general radiology. She has won a number of prizes, published in peer-reviewed
journals and has presented both nationally and internationally.
Dr Benedict Thomson, MRCP FRCR is a speciality Registrar in clinical radiology at Guy’s and
St Thomas’ NHS Foundation Trust. He undertook his medical and radiological training in London
and the South East. He is currently completing a sub-speciality fellowship in interventional
radiology. Dr Thomson has a keen interest in teaching and has published research in international
peer-reviewed journals and presented at national and international conferences in the field of
diagnostic and interventional radiology. He is a member of the Royal College of Radiologists,
British Society of Interventional Radiology, Cardiovascular and Interventional Radiology Society of
Europe, European Society of Radiology and Radiological Society of North America.
Dr Nicky Dineen, FRCR qualified from Leicester University Medical School in 2011 and completed
specialist radiology training in Kent, Surrey and Sussex School of Radiology, rotating across
hospitals in Kent and London. She was appointed as a radiology Consultant Radiologist at
Maidstone and Tunbridge Wells NHS Trust in 2018. Dr Dineen has particular interest in breast and
thoracic imaging. She is a member of the Royal College of Radiologists and the British Society of
Breast Radiology.
xiii
Introduction
This book was created with the aim of helping candidates to prepare for the new format of the Final
Fellowship of the Royal College of Radiologists (FRCR) Part A examinations. It is the perfect
accompaniment to the first book from this series, The Final FRCR: Complete Revision Notes.
The old style of the Final FRCR Part A examination consisted of six separate papers spread over
the initial years of radiology subspecialist training − one for each curriculum module. Candidates
now sit one large exam later in their training, consisting of two papers comprising 120 single best
answer questions, encompassing all six modules. This is challenging to prepare for, both in terms of
the vast amount of knowledge required and the stamina for sitting both papers on the same day.
This book comprises four full length papers, followed by detailed answer explanations. It aims to
help candidates improve their radiology knowledge and their examination technique. Both of these
attributes are vital for acquiring the Fellowship of the Royal College of Radiologists, not only for all
of the written examinations but also for the Final FRCR Part B examination.
We hope you find this book helpful. Unlike the majority of question books available, which
follow the old modular examination style, this book provides papers which are comparable to the
new format of the Final FRCR Part A. We want candidates to be able to put their knowledge and
timing to the test. Each paper has a selection of questions, of varying difficulty, from each
curriculum module. Each answer has a page reference for The Final FRCR: Complete Revision Notes,
so you can easily access extra reading on a topic if required.
The key to passing the Final FRCR is preparation. The volume and depth of knowledge required
is quite overwhelming at the start of your revision journey so start reading early.
The more thoroughly you can prepare for the Final FRCR Part A examination, the easier you will
find the preparation for the Final FRCR Part B, because you will already have acquired a strong
foundation of radiology knowledge to build upon. We wish you the best of luck!
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PAPER 1
1. A 57 year old man had an abdominal aortic aneurysm endovascular repair 6 months ago.
The stent graft extends from the infrarenal region to hyperintense and enhance the common
iliac arteries bilaterally. A recent CT abdomen and pelvis demonstrates that the aneurysm sac
has enlarged following the repair with a blush of contrast within the sac at the origin of the
inferior mesenteric artery from the abdominal aorta.
What is the most likely diagnosis?
a. Type 1a endoleak
b. Type 1b endoleak
c. Type 2 endoleak
d. Type 3 endoleak
e. Type 5 endoleak
2. A 46 year old man has an MRI head for persistent headache which demonstrates a 5-mm
area in the pituitary with reduced enhancement compared to the rest of the gland. This is
isointense on T1 weighted sequences and mildly hyperintense on T2 weighted sequences.
Other recent plain films requested by the GP for joint pain demonstrate generalised
osteopenia, chondrocalcinosis at the knees and joint space widening at the ankle.
What other radiological finding would support the diagnosis?
a. Eleven pairs of ribs
b. Heel pad thickness of 30 mm
c. Increased interpedicular distance
d. Madelung deformity
e. Sclerosis of the vertebral end plates
3. A 36 year old female patient originally presented to her GP with difficulty swallowing solids
and liquids, associated chest discomfort and occasional episodes of regurgitation. Barium
swallow helps to obtain the diagnosis. There is smooth distal oesophageal tapering with
proximal oesophageal dilatation and tertiary contractions. This is successfully treated at the
time but 19 years later the same patient presents with dysphagia again. The barium swallow
now demonstrates an irregular, shouldered narrowing with proximal oesophageal dilatation.
Endoscopy confirms malignancy.
Where is the new narrowing most likely to be sited?
a. Cervical oesophagus
b. Distal oesophagus
c. Mid-oesophagus
d. Mid and distal oesophagus
e. Proximal stomach
4. A 42 year old female patient, undergoing long-term peritoneal dialysis, has an abdominal
ultrasound for left-sided flank pain with haematuria. The kidneys measure up to 5.5 cm in
bipolar length with cortical thinning. There is no hydronephrosis or renal calculi. There are
several bilateral renal lesions. These are small, exophytic, anechoic and well defined. One
lesion on the left side has internal echoes and dependent debris. There is a moderate amount
of free fluid in the abdomen and pelvis.
What is the most likely underlying diagnosis causing the renal lesions?
a. Acquired cystic kidney disease
b. Autosomal dominant polycystic kidney disease
c. Autosomal recessive polycystic kidney disease
d. Idiopathic bilateral renal cysts
e. Tuberous sclerosis
5. A CT head is performed on a toddler who has tripped at home, hitting his head. The
paediatric team are concerned about a possible seizure following the event and a couple of
episodes of vomiting. The scan shows no intracranial haemorrhage. However, there is a
hypodense posterior fossa lesion. An MRI more clearly demonstrates that this is in the
posterior midline of the posterior fossa displacing the cerebellum anteriorly. The tentorium
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cerebelli and cerebellar vermis appear intact and have normal appearances. There is no
hydrocephalus and the fourth ventricle is within normal limits. There is no significant
enhancement following contrast administration. There is no restricted diffusion. On a FLAIR
sequence the lesion is isointense to cerebrospinal fluid.
Which diagnosis is most likely?
a. Dermoid cyst
b. Epidermoid cyst
c. Ependymal cyst
d. Pilocytic astrocytoma
e. Mega cisterna magna
6. An MRI of the spine is performed in a 43 year old patient with no significant medical history
complaining of cervical pain. This reveals a solitary, oval, intradural extramedullary lesion
extending from C5 to C6. It is sited anteriorly within the spinal canal and is isointense to the
cord on T1, hyperintense on T2 sequences with heterogenous enhancement following contrast.
It is displacing the spinal cord and right C5 nerve root and mildly widening the neural foramen.
What is the most likely underlying cause?
a. Epidermoid
b. Meningioma
c. Metastasis
d. Paraganglioma
e. Schwannoma
7. A 44 year old male presents to the emergency department with left side renal colic; he has an
unenhanced CT urinary tract to investigate. There is no renal calculus and no other significant
finding in the abdomen or pelvis. There is an incidental finding of a partially visualised 2-cm
subpleural nodule in the right lower lobe. He is discharged back to the care of the GP, with
advice to further investigate the nodule. An unenhanced outpatient CT chest demonstrates
that the nodule is solitary and slightly lobulated with punctate calcification. There are low
density foci within the nodule that have a density of negative Hounsfield units. No other
abnormality is seen on the CT chest.
What is the most appropriate next course of action?
a. Staging CT scan to look for a primary malignancy
b. Investigation of the nodule with CT angiogram
c. FDG PET scan to assess whether the nodule is avid
d. Discharge the patient
e. Investigation with a Gallium 68 PET scan
8. A 53 year old diabetic patient presents with right shoulder pain and reduced range of
movement which does not improve despite community physiotherapy. The patient is
reviewed in the orthopaedic outpatient clinic and an MRI shoulder arthrogram is requested.
Which of the options below is most consistent with adhesive capsulitis?
Table 1.1:
Joint Subscapularis Coracohumeral Lymphatic
Capsule Bursa Ligament Filling
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9. A 56 year old male presents with gradual onset right upper quadrant pain. An ultrasound
examination is performed which demonstrates absence of Doppler flow in the hepatic veins.
Budd-Chiari syndrome is suspected.
Which of the following imaging features differentiates chronic from acute Budd-Chiari?
a. Hepatomegaly
b. Hypertrophied caudate lobe
c. Heterogeneous hepatic echotexture
d. Splenomegaly
e. Ascites
10. A 5 year old girl has an obvious deformity affecting the right side of her upper back and
shoulder with a visible ‘bump’. She has spinal imaging which detects fusion of the C2-C4
vertebrae. The patient has also had an MRI brain and spine.
Given the other findings, which of the following is most likely to be found on the MRI brain?
a. Chiari I malformation
b. Haemangioblastoma
c. Holoprosencephaly
d. Optic glioma
e. Polymicrogyria
11. An oncology patient has an MRI spine due to increasing back pain. Apart from mild
generalised motor weakness he has no significant neurology. The MRI identifies multiple
areas of abnormal T1 and T2 signal which are hypointense compared to the adjacent disc.
There is heterogenous high STIR signal in these regions and restricted diffusion. There is no
significant narrowing of the canal or neural foramina. The cord returns normal signal.
What is the most likely underlying primary site of malignancy?
a. Colorectal carcinoma
b. Melanoma
c. Non-small cell lung carcinoma
d. Prostate carcinoma
e. Renal cell carcinoma
12. A 47 year old man complains of progressive discomfort and swelling of his right knee over a
couple of years which is now causing difficulty walking. An MRI shows no significant
degenerative change but there is synovial proliferation. There is some erosion of the bones on
both sides of the joint and multiple small, lobulated intra-articular foci which are intermediate
signal on T1 and T2 hyperintense. An earlier radiograph confirms some of these intra-articular
bodies are calcified.
What is the most likely diagnosis?
a. Pigmented villonodular synovitis
b. Primary osteochondromatosis
c. Secondary osteochondromatosis
d. Synovial chondrosarcoma
e. Synovial haemangioma
13. A 36 year old man is referred by his GP following a diagnosis of hypertension and has a chest
radiograph. The lungs and pleural spaces are clear. The mediastinum is abnormal and the
aorta has a ‘reverse 3’ sign with bilateral inferior rib notching.
What other finding is magnetic resonance angiography most likely to reveal?
a. Aortic root dilatation
b. Pulmonary arterial aneurysm
c. Scoliosis
d. Truncus arteriosus
e. Ventricular septal defect
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14. A 35 year old male patient presents to the emergency department with atraumatic right hip
pain for 10 days; he is otherwise systemically well. A radiograph shows mild osteopenia in
the right femoral head. A previous abdominal radiograph from 2 years ago included the right
hip, which looked normal at that time, but you notice foci of calcification projected over
the upper abdominal quadrants bilaterally and generalised osteosclerosis.
What MRI finding in the proximal femur would be most specific for the correct diagnosis?
a. Adjacent subchondral hypo and hyperintense T2 linear signal
b. Low T1 signal at the medial aspect of the femoral neck
c. Low T1 signal line parallel to the subarticular cortex
d. Synovial enhancement with gadolinium
e. Subchondral high STIR signal
15. You report an outpatient portal venous phase CT abdomen pelvis which has been performed
3 days earlier for a 67 year old male GP patient with a 1-month history of abdominal pain,
weight loss and anaemia. There is no discernible abnormality of the solid abdominal viscera.
You notice a small amount of pelvic free fluid. There is evidence of previous endovascular
repair of an abdominal aortic aneurysm with a fenestrated suprarenal graft. There are a couple
of small gas locules adjacent to the proximal aortic graft and the aortic wall appears thickened,
with a loop of small bowel in contact with the aorta.
What is the most appropriate course of action?
a. Ask radiology secretaries to email report to GP for their attention
b. Arrange triple phase CT abdomen and pelvis
c. Inform on-call vascular specialist registrar of findings
d. No further action required and suggest endoscopy to exclude gastrointestinal malignancy
e. Suggest 18F-FDG PET/CT to further evaluate
16. A 28 year old female patient is admitted with right flank pain and a temperature of 37.8 °C.
Urine dip is positive for blood and leukocytes. The patient is haemodynamically stable.
Inflammatory markers are elevated but liver and renal function tests are normal.
What would be the most appropriate immediate course of action?
a. Antibiotics followed by blood culture
b. Antibiotics followed by blood culture and urinary tract ultrasound
c. Antibiotics followed by blood culture and CT urinary tract
d. Blood culture followed by antibiotics
e. Blood culture followed by antibiotics and urinary tract ultrasound
17. A 6 week old baby is undergoing investigation for ongoing jaundice associated with
dark urine and pale stools. An ultrasound abdomen demonstrates an enlarged liver with a
normal contour. There is an echogenic region just anterior to the portal vein in the region
of the porta hepatis. There is no intrahepatic duct dilatation. The spleen and kidneys
have normal appearances. The gallbladder is not visualised. The head and body of the
pancreas have normal appearances but the tail is obscured by overlying bowel gas. There
is no free fluid.
What is the most appropriate next investigation to aid diagnosis?
a. CT abdomen
b. Hepatic iminodiacetic acid (HIDA) scan
c. Hepatic ultrasound with contrast
d. MRCP
e. Ultrasound guided liver biopsy
18. You have an ultrasound list with a thyroid ultrasound booked for a middle-aged male patient
referred by the GP for possible thyroid goitre. You complete the scan and are writing the
report.
Which nodule characteristic is most concerning for malignancy?
a. Hyperechoic echotexture
b. Greater than 1.5 cm in size
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c. Hypoechoic halo
d. Internal vascularity
e. Microcalcification
19. A 22 year old male medical student reports to his GP with recurrent spontaneous epistaxis as
well as fatigue and increasing dyspnoea. The patient is found to be tachycardic and
tachypnoeic. The GP is concerned and in view of the patient’s significant family history refers
him to be seen by the on-call medical team at hospital. The medical team organise an urgent
chest radiograph and perform an arterial blood gas which demonstrates hypoxia. They refer
the patient to you for a CT pulmonary angiogram to exclude a pulmonary embolus.
On review of the plain film, you confirm the presence of multiple pulmonary nodules and the
heart appears large. There is no other significant abnormality.
What is the most likely underlying diagnosis?
a. Caplan syndrome
b. Goodpasture's syndrome
c. Granulomatosis with polyangiitis
d. Multiple metastases
e. Osler-Weber-Rendu syndrome
20. A 55 year old female patient has a lateral cervical spine radiograph requested by the rheumatology
clinic. On the lateral view, the tip of the odontoid process of C2 sits at the basion-opisthion line.
Which of the conditions below is NOT associated with this appearance?
a. Achondroplasia
b. Fibrous dysplasia
c. Osteopetrosis
d. Paget disease
e. Rheumatoid arthritis
21. An 18 year old girl with a previous history of intussusception as a child presents with
abdominal pain. She is noted to have peri-oral pigmentation. A barium meal and follow-
through examination demonstrate multiple polyps within the stomach and small bowel.
The patient is known to have a congenital syndrome.
What is the most likely underlying diagnosis?
a. Cronkhite-Canada syndrome
b. Cowden syndrome
c. Peutz-Jegher syndrome
d. Familial adenomatous polyposis syndrome
e. Juvenile polyposis syndrome
22. A GP registrar calls for advice regarding an 11 month old girl following the diagnosis of her
first urinary tract infection. This has been confirmed on urine culture as positive for Escherichia
coli which is sensitive to trimethroprim. The patient has had 2 days of oral antibiotics at home
and on review again today at the surgery she is improving. The GP registrar asks for your
advice regarding further management.
What is the most appropriate advice?
a. Paediatric referral
b. Ultrasound within 6 weeks
c. Ultrasound and DMSA within 6 weeks
d. Ultrasound and DMSA if recurrent infection
e. Urgent ultrasound
23. An MRI lumbar spine performed for back pain is described as having abnormal signal
consistent with Modic type I end plate changes at the L1/2 level.
Which of the following signal characteristics would be most consistent with this?
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Table 1.2:
Endplate T1 Endplate T2 Endplate Disc T2
Signal Signal Enhancement Signal
24. A 43 year old male patient has a barium swallow and meal study. You are asked to review the
images by a junior colleague. There is swift passage of contrast to the stomach with normal
oesophageal outline and no gastro-oesophageal reflux. The stomach distends well. Gastric
folds at the fundus measure 15 mm in thickness and 6 mm in the prepyloric region of the
stomach. No gastric wall irregularity is identified and there is evidence of rapid gastric
emptying.
What is the most likely cause of the thickened gastric folds?
a. Atrophic gastritis
b. Alcoholic gastritis
c. Crohn’s disease
d. Lymphoma
e. Zollinger-Ellison syndrome
25. A 45 year old motorcyclist involved in a high speed road traffic collision is brought into the
emergency department intubated and ventilated and has a portable chest radiograph in the
resus bay. This demonstrates the endotracheal tube tip projected over the right main
bronchus, multiple right rib fractures, large right pneumothorax, right lung consolidation, a
left apical cap and bilateral pleural effusions.
Which finding most urgently needs to be conveyed to the trauma team?
a. Bilateral pleural effusions
b. Endotracheal tube tip position
c. Left apical cap
d. Right lung consolidation
e. Right pneumothorax
26. A 60 year old male patient is referred from his GP with 6 weeks of increased right knee
pain. The GP palpated a mass at the posterior aspect of the knee. Radiograph of the
right knee demonstrates spiking of the intercondylar eminence and reduction in
patellofemoral and medial tibiofemoral joint space. There has been no significant interval
change since a radiograph 2 years previously. The patient has an MRI knee which reveals
a well-defined high T2 and low T1 signal lesion at the posterior aspect
of the knee arising, and extending, from the joint space into the soft tissues posteriorly.
This is separate to the neurovascular bundle. There is no associated increased STIR signal
in the marrow or soft tissues.
Which anatomical structures would this lesion arise between?
a. Biceps femoris muscle and medial head of gastrocnemius
b. Gracilis tendon and semimembranosus tendon
c. Iliotibial tract and biceps femoris muscle
d. Semimembranosus tendon and medial head of gastrocnemius
e. Semitendinosus tendon and medial head of gastrocnemius
27. A 23 year old male presents with fever, loose stools and watery diarrhoea for the last 2 weeks.
He has recently returned from a trip to southeast Asia. Blood tests show raised inflammatory
markers. An abdominal radiograph is performed which shows mucosal oedema and thumb
printing affecting the ascending colon. Stool cultures are sent.
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Given the distribution of the abnormality, what is the most likely organism responsible for the
appearances?
a. Salmonella
b. Shigella
c. Cytomegalovirus
d. Herpes simplex virus
e. Clostridioides difficile
28. A 54 year old female patient has an abdominal ultrasound for right upper quadrant pain. This
demonstrates a homogenous, echogenic lesion in the upper pole of the left kidney. It is well
defined, exophytic and measures 46 mm with posterior acoustic shadowing. There is no
hydronephrosis and the kidney otherwise has normal appearances. Appearances of the right
kidney are within normal limits.
What would be the next most appropriate step?
a. CT chest, abdomen and pelvis
b. CT abdomen as next available outpatient appointment
c. CT abdomen in 3–6 months
d. Discussion at the urology multidisciplinary team meeting
e. Repeat ultrasound in 3–6 months
29. The urology team request an urgent testicular ultrasound on a teenager with left sided scrotal
pain and swelling. The ultrasound demonstrates scrotal wall thickening with associated increased
Doppler flow. The testicles have a homogenous echotexture with symmetrical vascularity. The left
testicle is marginally bigger than the right testicle. There is a trace amount of fluid around the left
testicle. There is a 3-mm thin-walled, avascular, anechoic structure with posterior acoustic
enhancement at the left epididymal head adjacent to the upper pole of the testicle. The left
epididymal tail is swollen with a heterogenous echotexture and diffusely increased vascularity
compared to the right side. The right epididymis has a homogenous echotexture. There is no
evidence of varicocele. The urology registrar comes to discuss the findings after the scan.
What is the most appropriate report conclusion?
a. Epididymitis
b. Epididymo-orchitis
c. Orchitis
d. Testicular torsion
e. Torsion of the appendix testis
30. You are the radiology registrar in a major trauma centre. An intubated and ventilated 35 year
old motorcyclist has an MRI whole spine following a road traffic collision earlier the same
day. The initial trauma CT identified intracranial haemorrhage and fractures of the T4, T5
and L1 vertebrae. The MRI reveals a thoracic epidural collection which is isointense on T1
sequences and mildly hyperintense on T2 sequences. The radiology consultant agrees with
your observations.
What is the most appropriate next step in management?
a. Inform neurosurgical team
b. Request immediate T2* MRI sequence
c. Request immediate additional contrast enhanced MRI sequences
d. Repeat MRI in 24 hours
e. Urgent discussion with microbiology
31. A 59 year old male patient is referred to radiology from the GP for investigation of a chronic
cough. No other history is provided. He has a chest radiograph. The performing radiographer
notices an abnormality and asks you to review the image before the patient is sent away.
There are scattered tiny nodules seen in both lungs; there is also eggshell calcification of the
nodes in the hilar regions bilaterally and the mediastinum. No other finding is seen on
the plain film. You reassure the radiographer that the patient can go home. You report the
imaging, suggesting further investigation with non-contrast CT chest.
Which diagnosis is LEAST likely?
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a. Amyloidosis
b. Histoplasmosis
c. Sarcoidosis
d. Silicosis
e. Treated lymphoma
32. A 67 year old diabetic male patient presents to hospital with a 4-day history of erythema and
swelling of his left elbow which has not improved despite 2 days of antibiotics from his GP.
There is no history of preceding trauma. Inflammatory markers are raised and he has a
temperature of 38.5 °C. A blood culture is negative. A radiograph of the left elbow demonstrates
soft tissue swelling but the bones are normal in appearance. The MRI scanner is undergoing
maintenance; therefore a nuclear medicine triple phase bone scan is performed.
Which of the below patterns of tracer uptake would be most consistent with osteomyelitis?
Table 1.3:
Angiographic Phase Tissue Phase Osseous Phase
33. A 58 year old male patient has a barium swallow and meal study for heartburn and symptoms
of gastritis which have not responded to treatment. This demonstrates a malignant appearing
gastric ulcer and the patient subsequently has an endoscopy that confirms malignancy.
CT chest, abdomen and pelvis confirms no distant spread of the disease.
With regard to the ulcer, what imaging finding on barium meal best correlates with this
diagnosis?
a. Carmen meniscus
b. Hampton’s line
c. Location on the lesser curve
d. Extending beyond the gastric wall
e. Gastric folds reach the edge of the ulcer
34. A 2 month old boy has an abdominal ultrasound scan which identifies small kidneys bilaterally
with bilateral hydronephrosis and hydroureter. The urinary bladder is thickened and trabeculated.
On micturating cystourethrogram there is bilateral vesicoureteral reflux and dilatation of the
posterior urethra. Contrast also fills a small diverticulum, continuous with the bladder dome, at the
bladder’s anterosuperior aspect. Assessment of the scrotum finds that the testicles are undescended.
Which one of the following conditions is most consistent with these radiological findings?
a. Bladder exstrophy
b. Eagle-Barrett syndrome
c. Edwards syndrome
d. Patau syndrome
e. Posterior urethral valve
35. A 70 year woman falls on the pavement whilst walking, hits her head and loses consciousness.
She is assessed in the emergency department.
Which of the following findings is an indication to perform an immediate CT according to
NICE guidelines?
a. 30 minutes of antegrade amnesia
b. High energy trauma
c. Age >65
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c. Extradural haematoma
d. Intraparenchymal haematoma
e. Subarachnoid haemorrhage
49. A 31 year old football player with a family history of heart disease has a cardiac MRI
following syncopal episodes during exertion. This demonstrates an overall ejection fraction of
60% (normal 50–70%), segmental right ventricular dilatation and wall motion abnormality
with T1 hyperintensity in the right free wall basally and apically. There is normal left wall
motion.
What is the most likely diagnosis?
a. Arrhythmogenic right ventricular dysplasia
b. Dilated cardiomyopathy
c. Established myocardial infarct
d. Hypertrophic cardiomyopathy
e. Restrictive cardiomyopathy
50. A 52 year old female patient presents to hospital feeling unwell with fever, fatigue and
generalised aches and pains causing difficulty mobilising. There is a rash on her back and upper
arms. The emergency department team request blood tests and chest and abdominal radiographs.
The chest radiograph shows some air space opacification and bibasal atelectasis. The abdominal
radiograph demonstrates a normal bowel gas pattern with subcutaneous calcification in a linear
distribution projected over the soft tissues of the pelvis and upper thigh.
What is the most appropriate next investigation?
a. Barium swallow
b. CT chest
c. Oesophageal endoscopy
d. Nuclear medicine cardiac perfusion study
e. Ultrasound Doppler lower limbs
51. A 30 year old female is referred to the gastroenterologists by her GP with intermittent
abdominal pain. She has recently undergone significant weight loss through intense
dieting and exercise. She describes an intermittent cramping abdominal pain that is
relieved by lying prone in bed. The gastroenterology team request a CT abdomen and
pelvis. This shows a paucity of intrabdominal fat. The proximal duodenum is noted to be
dilated and there is an abrupt transition point as the D3 segment passes between the
duodenum and aorta.
What is the most likely diagnosis?
a. Nutcracker syndrome
b. Mesenteric ischaemia
c. Irritable bowel syndrome
d. Superior mesenteric artery syndrome
e. Duodenal ulcer
52. A 31 year old male patient falls off a horse and is brought into the emergency department with
generalised abdominopelvic pain and haematuria upon catheterisation. Following initial
review the team request a CT abdomen and pelvis. A portal venous phase scan is performed.
This demonstrates a fracture of the L2–4 left transverse processes and comminuted, displaced
fractures of the left superior and inferior pubic rami. The solid organs appear intact. The
urinary catheter is appropriately sited. There is a moderate volume of free fluid in the pelvis
with a density of approximately 5HU but no free gas. No focal bowel wall thickening or
mesenteric fat stranding is evident.
What would be the most appropriate next step?
a. CT cystogram
b. Cystoscopy
c. Repeat CT abdomen and pelvis in 20 minutes
d. Repeat CT in 24 hours
e. Immediate triple phase CT abdomen and pelvis
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53. An abdominal radiograph is performed for a 51 year old patient with abdominal pain
presenting to hospital. Bilateral renal calcification is evident in a medullary distribution.
Which of the following is unlikely to be a cause for this appearance?
a. Hyperparathyroidism
b. Hypothyroidism
c. Multiple myeloma
d. Sarcoidosis
e. Tuberculosis
54. A 20 year old man is assaulted sustaining several heavy blows to the face. Facial bone
radiographs are performed in the emergency department followed by CT facial bones. There
are bilateral complex facial bone fractures.
Which structure needs to be involved to classify the injury as a Le Fort fracture?
a. Zygomatic arch
b. Inferior orbital rim
c. Pterygoid plates
d. Nasal septum
e. Lateral walls of maxillary sinuses
55. A 68 year old female with known HIV infection presents to the emergency department with
insidious onset exertional dyspnoea. Her CD4 count is 120 cells/mm3 (500–1400 cells/mm3) and
her chest radiograph demonstrates bilateral perihilar ground glass opacification. Pneumocystis
jiroveci is suspected and the clinical team refer her for a CT chest prior to bronchoscopy.
Which of the following imaging features are LEAST likely to be seen on CT chest?
a. Perihilar ground glass opacification
b. Pleural effusion
c. Pneumatoceles
d. Pneumothorax
e. Septal thickening
56. A 69 year old male patient has a radiograph of the spine following a fall from standing which
shows an incidental finding of diffuse idiopathic skeletal hyperostosis.
Which feature is NOT associated with this condition?
a. Calcaneal spur
b. Dysphagia
c. Facet joint ankylosis
d. Ossification of the patella tendon
e. Posterior longitudinal ligament calcification
57. A CT abdomen pelvis is performed for a 51 year old female patient with abdominal discomfort,
change in bowel habit and generalised fatigue. This demonstrates a small, hyper-enhancing
polypoid lesion in the distal small bowel measuring 15 mm with adjacent mural thickening.
The small bowel loops proximal to this are prominent with faecalisation of small bowel contents.
There is a 2-mm focus within the lesion with a density of 956HU and there are a couple of
adjacent 10-mm short axis low density mesenteric lymph nodes.
What is the most appropriate next step in the management of this patient to aid diagnosis and
treatment planning?
a. Arterial phase CT chest and abdomen
b. MIBG scan
c. 5-HIAA serum levels
d. 111In-octreotide study
e. 18F-FDG PET/CT
58. An athletic 45 year old man is seen in a follow-up orthopaedic clinic following surgery for a
prolapsed L3/4 disc 12 months ago as an emergency case for cauda equina. He recovered well
immediately postoperatively but is concerned because he has been suffering from increasing
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back pain for 3 months radiating down his left leg. The patient has no neurological symptoms
on examination. The orthopaedic team request an MRI of the lumbar spine. At the L3/4 disc
space there is moderate low T1 signal narrowing the left subarticular zone.
Which finding in the left subarticular zone is most in keeping with post-surgical fibrosis
versus recurrent disc prolapse?
a. Early enhancement following gadolinium
b. High T2 signal
c. Smooth border
d. Late enhancement following gadolinium
e. Restricted diffusion
59. A 7 year old girl with urinary incontinence is referred for a micturating cystourethrogram. The
patient has an ultrasound followed by an intravenous urogram. Both kidneys have a normal
position and size. The left kidney has two ureters draining it and one of the ureters drains into
the vagina with the other ureter draining into the urinary bladder.
Which of the following is the most accurate statement?
a. The anatomy in this case represents a bifid ureter
b. The lower pole moiety is frequently obstructed by a ureterocoele
c. The upper pole moiety can have a ‘drooping lily’ appearance
d. The ureter draining into the vagina is associated with the upper pole moiety
e. Vesicoureteral reflux is associated with the ureter draining into the vagina
60. A 60 year old woman presents following a traumatic head injury. She is noted to have
haemotympanum. A CT head is performed which shows a transverse fracture extending
through the left petrous temporal bone.
What likely complication is most associated with this type of fracture?
a. Tympanic membrane disruption
b. Sensorineural hearing loss
c. Conductive hearing loss
d. Carotid artery dissection
e. Sigmoid sinus injury
61. A 37 year old male presents to his GP with a long-standing cough. A plain film demonstrates a
large, smoothly marginated opacity in the right lower zone abutting the right heart border. A
second similar density is seen in the periphery of the left lower zone. A contrast-enhanced CT
helps investigate further. This confirms the presence of two well circumscribed, rounded,
slightly lobulated densities with thin walls and low density contents (10HU). Within left lower
zone lesion there is the presence of a serpiginous structure; the surrounding lung is normal.
What is the most likely diagnosis?
a. Bronchogenic cysts
b. Diaphragmatic hernias
c. Hydatid cysts
d. Pericardial cysts
e. Pulmonary abscesses
62. A 31 year old patient comes to the emergency department with worsening lower lumbar back
pain over the past 7 weeks. The patient has no fixed abode and has a recent history of
intravenous drug use. Inflammatory markers are raised and the patient has a temperature of
37.5 °C. Chest radiograph is normal and urine dip is negative. Blood cultures are sent to the
laboratory. Radiograph of the spine shows reduction in disc space at L3/4. MRI reveals high
T2 signal and post contrast enhancement in the L3/4 disc with low T1 and high T2 signal in
the adjacent vertebral bodies. There is also an enhancing paravertebral collection which is
inseparable from the left psoas muscle.
What is the most likely causative organism?
a. Burkholderia pseudomallei
b. Candida
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c. Mycobacterium tuberculosis
d. Salmonella
e. Streptococcus viridans
63. A 75 year old male patient is admitted with fever, reduced appetite, shortness of breath and
chest pain. Contrast enhanced CT chest, abdomen and pelvis identifies no consolidation or
intrabdominal collections however there are multiple low attenuation hepatic lesions
consistent with metastases and subsegmental bilateral lower lobe pulmonary emboli. An
echocardiogram reveals tricuspid valve vegetations. Blood cultures obtained upon
presentation to hospital have grown Streptococcus bovis.
Which is the most likely primary site of malignancy?
a. Biliary tree
b. Colon
c. Oesophagus
d. Pancreas
e. Prostate
64. A 57 year old woman has a breast assessment following a positive CT pulmonary angiogram
which reported a small, enhancing, solid mass in the right breast and two similar lesions in the
left breast. The lesions are assessed in the clinic and biopsied. The pathology reports they are
metastatic lesions rather than primary breast carcinoma.
Which of the following is the most likely underlying malignancy?
a. Colonic carcinoma
b. Lung carcinoma
c. Lymphoma
d. Ovarian carcinoma
e. Renal cell carcinoma
65. You are telephoned to review a paediatric emergency department chest radiograph for a
3 year old boy brought in by his parents with a short history of a cough and wheeze.
An inspiratory chest film demonstrates a mildly lucent right lung with increased right rib
spacing. The lungs are clear with no consolidation and no pleural effusion. The mediastinum,
imaged skeleton and soft tissues have normal appearances.
What is the most appropriate next step to help obtain the diagnosis?
a. Arterial phase low dose CT chest
b. Expiratory chest radiograph
c. Spirometry
d. Sputum sample
e. Ventilation-perfusion nuclear medicine study
66. An 80 year old women is admitted from a nursing home with acute onset right hemiparesis. A
CT is performed which shows an acute intraparenchymal haemorrhage in the subcortical
white matter of the left frontal lobe. There is a small amount of surrounding oedema. Small
foci of blooming artefact are evident on gradient echo sequences at the grey−white matter
junction in both cerebral hemispheres and in the cerebellum. Generalised parenchymal
volume loss and moderate small vessel ischaemia are also present.
What is the most likely diagnosis?
a. Hypertensive bleed
b. Arteriovenous malformation
c. Haemorrhagic metastases
d. Amyloid angiopathy
e. Herpes encephalitis
67. A 44 year old female patient presents with a couple of months’ history of feeling generally
unwell and more recently with headaches. On admission the patient is hypertensive with a
blood pressure of 180/110. Following further workup the patient has an arterial and portal
venous phase CT chest and abdomen. On the arterial phase there is bilateral renal artery
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stenosis with wall thickening but no associated vascular calcification. The appearance of the
kidneys on the portal venous phase imaging are symmetrical with no focal abnormality
identified. The renal artery walls mildly enhance. Similar stenosis, arterial wall thickening and
enhancement is also noted at the proximal left subclavian artery and descending thoracic aorta.
Which other investigation would be most appropriate in this patient?
a. Carotid Doppler ultrasound
b. Circle of Willis CT
c. CT pelvis with contrast
d. Lower limb Doppler ultrasound
e. MRA renal arteries
68. A 67 year old female patient has a chest radiograph following presentation to hospital with
chest pain. The lungs and pleural spaces are clear and appearances of the mediastinum are
within normal limits; however, there are multiple osseous lytic lesions. The patient is
investigated further with a CT chest, abdomen and pelvis and a nuclear medicine bone scan.
The CT scanner is currently undergoing maintenance awaiting a new part and therefore the
nuclear medicine bone scan occurs first and is reported as normal osseous uptake.
What is the next best available test to confirm the diagnosis?
a. Breast clinic triple assessment
b. Bone marrow biopsy
c. Blood culture
d. Serum alkaline phosphatase levels
e. Serum parathyroid hormone levels
69. A 40 year old man with known HIV presents with night sweats, abdominal pain and weight
loss. His CD4 count is <200 cells/mm3 (500–1400 cells/mm3). He is noted to have multiple
purple, painless plaques on both legs. A CT abdomen and pelvis demonstrates multiple
enlarged and enhancing periportal lymph nodes around the liver. Multiple submucosal
duodenal nodules are also seen.
What is the most likely diagnosis?
a. Lymphoma
b. Mycobacterial disease
c. Histoplasmosis
d. Kaposi sarcoma
e. Candidiasis
70. An abdominal ultrasound in a 5 year old girl finds hepatomegaly with increased periportal
echogenicity and reversal of hepatic venous flow. There are dilated intrahepatic bile
ducts. The gallbladder and pancreas have normal appearances. The spleen is enlarged. The
kidneys are enlarged bilaterally and echogenic with reduction in corticomedullary
differentiation.
Which inheritance pattern does the condition associated with this constellation of
radiological findings have?
a. Autosomal dominant
b. Autosomal recessive
c. Spontaneous mutation
d. X-linked dominant
e. X-linked recessive
71. A 23 year old gastroenterology clinic patient is being investigated for iron deficiency anaemia
and abdominal pain. A small bowel meal and follow-through are performed.
Regarding the findings of coeliac disease on fluoroscopic imaging, which feature is the most
likely to be associated with the diagnosis?
a. Crowding of the valvulae conniventes
b. Jejunoileal fold pattern reversal
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c. Luminal dilatation
d. Reduced peristalsis
e. Small bowel sacculation
72. A 22 year old student develops cognitive decline and then worsening ataxia and spasticity
over a period of a few weeks. Following admission she has an MRI head which demonstrates
subcortical and deep white matter T2 hyperintensity affecting the majority of the right parietal
lobe, the left temporoparietal region and minimal signal changes in the left putamen and
globus pallidus. There is evidence of adjacent oedema and patchy white matter enhancement.
There is also mild volume loss in the frontotemporal region.
Past medical history is unremarkable apart from appendicectomy as a child. Upon further
questioning she recalls an episode of feeling unwell about 6 months ago with fever and flu-
like symptoms before developing white spots on the inside of her cheeks and then a more
generalised rash.
What is the most likely diagnosis?
a. Acute demyelinating encephalomyelitis
b. Acute haemorrhagic leukoencephalopathy
c. Herpes simplex encephalitis
d. Japanese encephalitis
e. Subacute sclerosing panencephalitis
73. A 34 year old male is under investigation for a newly diagnosed malignancy. Lymph node
biopsy demonstrates Reed-Sternberg cells.
Where is the most likely site of thoracic lymph node enlargement on the CT chest?
a. Hilar
b. Internal mammary
c. Paratracheal
d. Peri-oesophageal
e. Subcarinal
74. A 37 year old semi-professional footballer attends the orthopaedic clinic due to left hip pain
which is causing him difficulty when playing. Following clinical review, radiographs and
subsequent MRI, a diagnosis of cam femoroacetabular impingement is made.
Which radiological findings are most consistent with this diagnosis?
Table 1.4:
Radiographic Feature α Angle MRI Feature
75. A 52 year old male patient with anaemia has a CT staging study following a colonoscopic
biopsy confirming colorectal malignancy. The CT demonstrates some mild bowel wall
thickening correlating with the area biopsied. There are a couple of small low attenuation
areas in the liver which are unchanged from a CT study following trauma 2 years ago.
However, there are multiple new bilateral sub-centimetre lung nodules.
In which venous drainage distribution is the primary tumour likely located?
a. Inferior mesenteric vein
b. Middle rectal vein
c. Sigmoid vein
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Table 1.5:
ICA PSV (cm/sec) ICA/CCA PSV ratio ICA EDV (cm/sec)
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80. A 6 year old patient has a chest radiograph for cough which is not responding to antibiotics.
There is hyperinflation of the lungs and mild bronchial wall thickening suggestive of asthma.
Incidental note is made of complete collapse of the T8 vertebral body.
What other finding would best correlate with the most common paediatric cause of this
vertebral appearance?
a. Abdominal mass on ultrasound abdomen arising adjacent to aorta
b. Enlarged rounded lymph nodes on ultrasound neck and axilla
c. Multiple lytic skull lesions
d. Permeative lytic lesion with laminated periosteal reaction in the right femur
e. Raised inflammatory markers
81. A 24 year old motorcyclist is admitted following a road traffic collision. He has sustained
significant blunt force trauma, falling off his motorbike at around 20 mph and hitting a tree. On
arrival at hospital he is cardiovascularly compromised. Following stabilisation he is brought for
a trauma CT. Internal haemorrhage is suspected and his abdomen is acutely tender.
Which of the following organs is he most likely to have injured?
a. Kidney
b. Liver
c. Pancreas
d. Spleen
e. Small bowel and mesentery
82. A 6 year old boy has a chest radiograph requested by his GP following a week of fever and
productive cough. There is a small region of air space opacification in the right lower zone.
Asymmetry is noted between both sides of the chest; the left hemithorax is smaller and more
lucent compared to the right with reduced vascular markings. There is no significant
mediastinal shift. The heart size is normal.
What is the most likely cause?
a. Congenital lobar over inflation
b. MacLeod syndrome
c. Poland syndrome
d. Pulmonary agenesis
e. Scimitar syndrome
83. A 40 year old male had an incidental finding of a low density sella mass on a CT head which
was performed for trauma. The report states that a Rathke cleft cyst is the most likely
differential and an MRI brain is recommended.
Which of the following statements regarding Rathke cleft cysts is correct?
a. They commonly calcify
b. They frequently show diffusion restriction
c. They sometimes contain an intracystic nodule
d. They often extend beyond the boundaries of the sella
e. Uniform enhancement is typical
84. A neonate has an abdominal ultrasound for a right sided abdominal mass. The patient is
3 days old and was born by emergency caesarean section following an unsuccessful induction
of labour. The pregnancy was uncomplicated and antenatal scans unremarkable.
The ultrasound finds there is a hypoechoic mass in the right upper quadrant containing
internal echoes without Doppler vascularity. This is posterior to the liver and the right kidney
is seen inferiorly.
What is the most appropriate next step in management?
a. MIBG study
b. MRI abdomen
c. No further management required
d. Repeat ultrasound in 3 weeks
e. Ultrasound-guided biopsy
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85. A 56 year old male presents with increasing shortness of breath and persistent cough. He has
never smoked and has a medical history of rheumatoid arthritis. His GP requests a plain film
of the chest which is abnormal. Therefore, a non-contrast CT chest is suggested to assess
further. The CT chest reveals volume loss in the lower zones. There is diffuse ground glass
opacification seen in the mid and lower zones which demonstrates immediate subpleural
sparing with fine subpleural reticulation and traction dilatation of the small airways.
What is the most likely diagnosis?
a. Cryptogenic organising pneumonia
b. Hypersensitivity pneumonitis
c. Lymphocytic interstitial pneumonitis
d. Non-specific interstitial pneumonia
e. Usual interstitial pneumonia pattern of disease
86. A 25 year old male patient has a CT head and sinuses after review in the Ear, Nose and Throat
clinic for symptoms of recurrent sinusitis. The CT shows the paranasal sinuses are lacking
normal aeration and obliterated due to medullary expansion of the adjacent bones. An
abdominal ultrasound from the previous year described the spleen as measuring 17 cm in
craniocaudal extent and the inferior border of the liver extending to 6 cm below the lower pole
of the right kidney. A recent radiograph of the left shoulder demonstrates normal bone
density with metaphyseal flaring at the proximal humerus.
What is the most likely diagnosis?
a. Gaucher disease
b. Osteopetrosis
c. Sarcoidosis
d. Thalassaemia
e. Granulomatosis with polyangiitis (previously known as Wegener granulomatosis)
87. One of the gastroenterology consultants discusses a case with you of a patient with weight
loss and suspicious gastric findings on a recent CT abdomen pelvis. The patient has declined
endoscopy. Based on imaging findings, the differential lies between gastric lymphoma and
primary gastric carcinoma.
Which of the following is more consistent with gastric lymphoma than carcinoma?
a. Associated with a history of atrophic gastritis
b. Duodenal involvement
c. Large polypoid mass
d. Gastric outlet obstruction
e. Perigastric fat invasion
88. A 49 year old woman has an MRI of her pelvis to assess her uterus. The patient has been having
heavy, painful periods. A pelvic ultrasound identified a heterogenous area of uterine wall
thickening. This area is evident on the MRI as a focal but ill-defined, thickened area of the posterior
uterine wall with T2 hyperintensities. Enhancement is similar to the adjacent uterus. The endome-
trium measures up to 7 mm. The junctional zone measures 15 mm. There is a right ovarian corpus
luteum. The left ovary has normal appearances. There are a couple of cervical Nabothian cysts.
What is the most likely diagnosis?
a. Adenomyosis
b. Endometrial carcinoma
c. Endometriosis
d. Leiomyoma
e. Leiomyosarcoma
89. The radiology department performs a skeletal survey for a 4 month old child with injuries
suspicious for non-accidental injury (NAI).
Which of the following injuries is most specific for NAI?
a. Diaphyseal metacarpal fracture
b. Fractures of different ages
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c. Joint aspiration
d. 18F-FDG PET/CT
e. Serum parathyroid hormone levels
99. The colorectal nurse specialist calls for advice regarding a 48 year old male patient who
underwent total mesorectal excision 23 months ago for T3 N1b M0 rectal carcinoma. More
recently he has had a stoma reversal and anastomosis. The patient’s serum carcinoembryonic
antigen (CEA) level has increased over the past 3 months.
What would be the most appropriate course of action?
a. CT cologram and CT chest
b. Ultrasound abdomen
c. FDG-PET/CT study
d. MRI liver with liver specific contrast agent
e. Re-check serum CEA in 3 months
100. A 43 year old male patient is brought in as a trauma call following a fight where he was stabbed
multiple times in the posterior chest and abdomen. Arterial and portal venous phase CT chest
abdomen pelvis are performed which demonstrate a couple of subcutaneous gas bubbles and a
skin defect in the posterior left abdomen. There is adjacent subcutaneous fat stranding and left
perinephric fat stranding with a thin rim of fluid with a density of 2HU around the left kidney.
There is a 16-mm laceration of the right kidney extending to the renal pelvis. There is no
evidence of contrast extravasation on the arterial or portal venous phase sequence.
Using the American Association for the Surgery of Trauma (AAST) guidelines, what grade of
renal trauma would this be?
a. Grade I
b. Grade II
c. Grade III
d. Grade IV
e. Grade V
101. A chest radiograph is performed for a neonate followed repeated episodes of aspiration. The
paediatric team feel tracheo-oesophageal fistula ± oesophageal atresia is likely due to cardiac
abnormalities detected on antenatal scans. The chest radiograph demonstrates right lower
zone air space opacification. The gastric air bubble is visible under the left hemidiaphragm.
Which of the following is most likely?
a. Double fistula with intervening oesophageal atresia
b. Isolated fistula without oesophageal atresia
c. Isolated oesophageal atresia
d. Proximal fistula with distal oesophageal atresia
e. Proximal oesophageal atresia with distal fistula
102. A 43 year old man with a three day history of headache, fever and vomiting is admitted.
Neurological assessment finds he has a GCS of 12. The right eyelid is drooping and the eye is
deviated outwards and downwards. A non-contrast CT head is normal. The scan acquired
following contrast injection shows evidence of leptomeningeal enhancement with thickening and
enhancement of the basal meninges extending into the sylvian fissures. The brain parenchyma
returns normal signal. The leptomeninges overlying the cerebral convexities are not thickened or
enhancing. There is mild dilatation of the temporal horns of the lateral ventricles.
What is the most likely underlying cause for these changes?
a. Enterovirus
b. Group B streptococcus
c. Mycobacterium tuberculosis
d. Neurosarcoidosis
e. Streptococcus pneumoniae
103. An active 48 year old man presents with a history of fatigue, weight loss and fever with right
sided loin pain. The patient is tachycardic, hypotensive and has a low haemoglobin. Urine dip
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demonstrates a small amount of blood and protein. Triple phase CT abdomen and pelvis
reveals a right perinephric haematoma with a blush of contrast at the right lower pole on
arterial phase imaging with pooling on the portal venous phase sequence. The patient
undergoes urgent interventional radiology procedure. During the procedure the radiologist
reports abnormality of the interlobar and arcuate arteries, with segments of short stenoses and
aneurysmal dilatation.
What is the most likely underlying diagnosis?
a. Behçet disease
b. Fibromuscular dysplasia
c. Goodpasture syndrome
d. Polyarteritis nodosa
e. Takayasu disease
104. A young patient has a diagnosis of cleidocranial dysostosis; he is reviewed regularly in the
paediatric outpatient clinic. The clinical team are concerned as he has a 1-week history of
productive cough and increased shortness of breath. The paediatric junior doctor asks you to
review his chest radiograph. There is consolidation in the left mid-lower zone which obscures
the left heart border. The clavicles are absent.
What other feature would correlate with the patient’s underlying congenital skeletal abnormality?
a. Decreasing interpedicular distance
b. Incompletely ossified sternum
c. Pectus excavatum
d. Platyspondyly
e. Shortened horizontally orientated ribs
105. A 52 year old woman under surveillance following previous colorectal carcinoma resection
has a CT chest abdomen and pelvis. This shows a splenic artery aneurysm measuring 2 cm in
maximal diameter.
Which of the following statements is most accurate regarding splenic artery aneurysms?
a. Aneurysms below 15 mm do not require follow-up
b. Increased rupture risk is associated with cirrhosis
c. Peripheral calcification is uncommon
d. Splenic artery aneurysms in pregnancy should be treated conservatively
e. The majority represent pseudoaneurysms
106. A 45 year old female patient has been referred to the orthopaedic service with anterior right
knee pain, exacerbated by climbing stairs. A radiograph is unremarkable. Chondromalacia
patellae is suspected clinically. The patient is mildly claustrophobic and the radiographer
from the MRI scanner asks you which sequences you would like to prioritise in case the
patient cannot tolerate the whole scan.
What sequence would be most helpful in assessing the cartilage?
a. Axial T1 weighted
b. Axial proton density fat saturation
c. Coronal short tau inversion recovery (STIR)
d. Sagittal T1 post gadolinium
e. Sagittal T1 weighted
107. A baby is born with radial dysplasia and anal atresia. Following further investigation two
hemivertebrae are noted. The child has further investigations and is found to have a cardiac
anomaly.
What is the most likely cardiac anomaly?
a. Atrial septal defect
b. Coarctation of the aorta
c. Patient ductus arteriosus
d. Tetralogy of Fallot
e. Ventricular septal defect
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108. A 25 year old woman has a simple, partial seizure and goes on to have a CT head. This shows a
focal, 9-mm hyperdense mass in the left centrum semiovale. There is speckled calcification
within the lesion. The patient is suspected to have a cerebral cavernoma and a MRI brain is
requested.
What is the best MRI sequence to diagnose cerebral cavernomas?
a. T2*
b. T2
c. T1 post contrast
d. Diffusion weighted imaging
e. FLAIR
109. You are asked to review a plain film by a junior doctor working in the emergency department
who is concerned about the appearance of the mediastinum. The case is that of a 25 year old
male who has presented with a productive cough and a fever. You review the chest radiograph;
there is consolidation in the left lower zone which obscures the left hemidiaphragm, the airways
appear dilated and abnormally thick walled and there is evidence of dextrocardia. You look
back at the patient’s previous imaging and see the patient had a CT for investigation of sinusitis.
What is the most likely unifying diagnosis?
a. Cystic fibrosis
b. Hypogammaglobulinaemia
c. Post-infective bronchiectasis
d. Primary ciliary dyskinesia
e. Recurrent aspiration
110. A 12 year old girl presents to the emergency department with pain weight bearing on her
right leg after a school hockey tournament. Pelvic radiograph demonstrates a small linear
flake of bone adjacent to the right ischial tuberosity.
Which tendinous avulsion is most likely to cause this appearance?
a. Adductor magnus
b. Gracilis
c. Iliopsoas
d. Rectus femoris
e. Tensor fascia lata
111. An 84 year old care home resident is brought into hospital with fever, abdominal pain,
distension and vomiting. The patient is referred to the surgeons, made nil by mouth and an
attempted nasogastric tube insertion is unsuccessful. Chest radiograph demonstrates right
lower lobe consolidation and an air-fluid level projected over the heart extending just to the
right of the midline. A chest radiograph taken 1 year previously demonstrates a smaller
retrocardiac air-fluid level. A current abdominal radiograph demonstrates no gas-filled
dilated small or large bowel loops. Inflammatory markers, lactate and renal function tests are
raised. Liver function tests are normal.
Which is the most likely diagnosis?
a. Epiphrenic diverticulum
b. Hiatus hernia with aspiration pneumonia
c. Lung abscess
d. Mesentero-axial gastric volvulus
e. Organo-axial gastric volvulus
112. A 59 year old male patient has an MRI spine for back pain which incidentally identifies an
exophytic right sided renal mass. This measures up to 35 mm and is homogenously low signal
on both T1 and T2 weighted images. A subsequent unenhanced CT followed by a contrast
enhanced scan visualises the renal mass. This has a density of 35HU which increases to 40HU
following contrast. Additional MRI sequences are performed which confirm restricted
diffusion of the mass and similar enhancement characteristics to the CT.
Based on the imaging characteristics, what is the most likely diagnosis?
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ANSWERS 1
Source: Reprinted with permission from V Helyar and A Shaw, The Final FRCR: Complete Revision Notes.
CRC Press, Taylor & Francis Group, 2018, p. 3.
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is suggestive of mega cisterna magna. This appearance can be detected antenatally and in
these cases can be associated with infections such as cytomegalovirus or chromosomal
abnormalities.
An epidermoid cyst has similar appearances to an arachnoid cyst on imaging apart from
on DWI and FLAIR sequences where there will be restricted diffusion and FLAIR
hyperintensity compared to CSF.
Dermoid cysts are usually in the midline but they characteristically contain fat and will
therefore have high T1 signal. If they rupture they may cause a chemical meningitis.
Ependymal cysts also have similar imaging features to arachnoid cysts but are usually
deep within the parenchyma or associated with the ventricles, being either peri or
intraventricular.
Pilocytic astrocytoma is an important differential for midline paediatric posterior fossa
lesions. They usually have a large cystic component with an enhancing solid nodule.
(The Final FRCR Complete Revision Notes Page 294)
6. (e) Schwannoma
The intradural, extramedullary location raises the possibility of a variety of lesions. One
mnemonic to aid memory is ‘MNM’: Meningioma, Nerve sheath tumours, Metastases. The
lesion described in the case has typical imaging features of a schwannoma. They are most
commonly found in the cervical and lumbar spine and cause neural displacement, bone
remodelling and can have a dumbbell appearance.
Spinal meningiomas are most commonly found in the thoracic spine. They have a
characteristic dural tail and broad based dural attachment. They are usually T1 iso to
hypointense, T2 iso to hyperintense and enhance homogenously following contrast. They are
unusual in that they can calcify, but less commonly than intracranial meningiomas.
Metastases in the spinal canal can arise from a primary within the brain or via
haematogenous seeding from primaries such as breast, lung or melanoma. They can manifest
as diffuse dural thickening and nodularity.
Spinal paragangliomas are extramedullary and intradural however they usually involve the
cauda equina region and so the location does not fit with this diagnosis. Their imaging
characteristics are the same as for paragangliomas elsewhere in the body; they enhance avidly,
can have flow voids and are T2 hyperintense. Additionally, they frequently show evidence of
haemorrhage.
Epidermoid cysts have a similar appearance to cerebrospinal fluid and would exhibit low T1
signal, high T2 signal and would not demonstrate the enhancement pattern described in this
case. DWI and FLAIR imaging is important in the diagnosis of epidermoid cysts.
(The Final FRCR Complete Revision Notes Page 454)
7. (d) Discharge the patient
The presence of fat and description of ‘punctate calcification’ is typical for a hamartoma,
which is a benign entity. Hamartomas are usually asymptomatic and most are detected
incidentally. Typically they are peripheral; a minority (10%) are endobronchial. Malignant
transformation is very rare. According to the most recent 2015 British Thoracic Society
guidelines, nodules with clear benign features can be discharged without further imaging.
Hamartomas can demonstrate avidity on FDG PET in 20% of cases but this investigation is not
warranted and likely to cause confusion rather than aid diagnosis.
CT angiogram is not an appropriate next investigation; calcification is rare in arteriovenous
malformations and there is no description provided of a feeding vessel. A Gallium 68 PET-CT
scan can aid diagnosis of carcinoid tumour, however the description provided in the main stem
is not suggestive of a carcinoid owing to the presence of fat. Although carcinoid tumours can be
peripherally located (atypical 10%), more commonly they are central (typical 90%).
(The Final FRCR Complete Revision Notes Page 32)
8. (a)
Adhesive capsulitis is also known as frozen shoulder and classically presents with restriction
in shoulder elevation and external rotation. It is most common in middle-aged women,
particularly diabetic patients, and can also be associated with previous trauma. Classical
radiological features are a thickened joint capsule and coracohumeral ligament. The
subscapularis bursa is small, and lymphatic filling is a feature. The subcoracoid fat triangle
between the coracohumeral ligament and coracoid process can be obliterated. The joint volume
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is reduced and therefore there is limited filling capacity during arthrogram injection.
(The Final FRCR Complete Revision Notes Page 62)
9. (b) Hypertrophied caudate lobe
In the chronic phase of Budd-Chiari there is compensatory enlargement of the caudate lobe
as it drains directly into the inferior vena cava. There is associated atrophy of the peripheral
segments, and regenerative nodules may be a feature.
In the acute presentation there is classically hepatosplenomegaly and ascites. CT can
demonstrate a ‘flip-flop’ pattern of enhancement due to hyperenhancement of the central liver
segments on early-phase images, with peripheral hypoenhancement. This appearance is
reversed on delayed phase images.
(The Final FRCR Complete Revision Notes Page 198)
10. (a) Chiari I malformation
The patient has characteristic features of Klippel-Feil syndrome with Sprengel deformity of the
shoulder and cervical vertebral fusion. Chiari I malformation is associated with Klippel-Feil
syndrome and is when the cerebellar tonsils descend ≥5 mm below the level of the foramen magnum.
It is often asymptomatic and found incidentally in adults. As well as being associated with Klippel-
Feil syndrome, it is also associated with craniosynostosis, hydrocephalus, syrinx and a tethered cord.
Haemangioblastomas are a cause of predominantly posterior fossa cystic lesions and are
associated with von Hippel-Lindau. They often have an enhancing solid nodule and flow voids.
Optic gliomas are associated with neurofibromatosis type I, along with pilocytic astrocytoma,
sphenoid wing dysplasia and focal areas of parenchymal T2 signal hyperintensity.
Holoprosencephaly is a cleavage failure and appearances range from severe (alobar) to less
severe (lobar).
Polymicrogyria is associated with a number of infections during pregnancy including
toxoplasmosis, rubella and cytomegalovirus.
(The Final FRCR Complete Revision Notes Page 289)
11. (d) Prostate carcinoma
Vertebral metastases, when diffuse, can be difficult to appreciate. It is always important to
compare the vertebral body signal to the adjacent disc. The signal of metastases depends on
whether they are sclerotic or lytic. STIR signal is usually high and they demonstrate restricted
diffusion. Lytic metastases would be low on T1 and high on T2 compared to the disc. However,
sclerotic metastases would be low on both sequences.
The metastases in this case are consistent with sclerotic lesions and therefore the most likely
primary site is prostate cancer. The other cancers are more commonly associated with lytic
metastases. Melanoma is unusual in that it can demonstrate high T1 signal due to melanin.
(The Final FRCR Complete Revision Notes Page 453)
12. (b) Primary osteochondromatosis
The question describes multiple, intra-articular, cartilaginous nodules, with some early
calcification. This is in keeping with osteochondromatosis and the relatively young age of the
patient and lack of degenerative change is suggestive of the primary, rather than the secondary
form of the condition. Radiographic appearances can be variable depending on the degree of
ossification of the nodules but the typical calcification is described and ‘ring and arc’ which fits
with a chondral pattern. Erosion on both sides of the joint can occur due to the synovial
proliferation and mass effect.
Calcification is rare in pigmented villonodular synovitis and when diffuse it can be more
mass-like in appearance. Haemosiderin deposition within the synovial proliferation will
demonstrate blooming artefact on gradient echo sequences.
Synovial chondrosarcoma is rare but tends to have much more aggressive appearances extending
beyond the joint with cortical erosion, marrow infiltration and potentially metastatic spread.
Synovial haemangioma present as a soft tissue mass which will demonstrate linear areas of flow
void on MRI and marked enhancement of the mass.
(The Final FRCR Complete Revision Notes Page 98)
13. (a) Aortic root dilatation
The patient has typical radiographic features of aortic coarctation. The most common
association (75–80%) is with a bicuspid aortic valve. A bicuspid aortic valve is predisposed to
stenosis and over time can cause aortic root dilatation due to the high pressure jet of blood
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through the stenotic valve. A congenital bicuspid aortic valve is one of the most common
causes of aortic valve disease in young adults.
Other conditions associated with aortic coarctation include ventricular septal defect,
hypoplastic aortic arch, truncus arteriosus, scoliosis and Turner syndrome. Congenital truncus
arteriosus and ventricular septal defect would become symptomatic much earlier in the
patient’s life. Pulmonary artery aneurysms are not associated with aortic coarctation.
(The Final FRCR Complete Revision Notes Page 3)
14. (a) Adjacent subchondral hypo- and hyperintense T2 linear signal
The patient has features of sickle cell disease on abdominal radiograph with osteosclerosis,
likely calcified gallstones in his right upper quadrant and a calcified spleen in the left upper
quadrant. Therefore, the most likely diagnosis is avascular necrosis of the hip.
Radiographic features are often not visible, or subtle in the early stages, and osteopenia may
be present. It is only later in the disease process that sclerosis, lucency, irregularity and
flattening of the femoral heads develop.
MRI is the most sensitive test for diagnosis and the most specific sign is the ‘double line’ sign
which is paired high and low T2 linear signal. The low T1 signal parallels the subarticular
cortex, also known as the ‘crescent’ sign − representing a subchrondral fracture. This would
likely be associated with subchrondral high STIR signal in the acute phase.
Low signal at the medial aspect of the femoral neck can be seen in stress fractures, which
typically affect young patients; however the clinical findings are more in keeping with sickle
cell anaemia and subsequent avascular necrosis.
Synovial enhancement with gadolinium is not typical for avascular necrosis but would be
seen in septic arthritis, which patients with sickle cell disease are at higher risk of; however you
would also expect systemic illness.
(The Final FRCR Complete Revision Notes Pages 65, 348)
15. (c) Inform on-call vascular specialist registrar of findings
The finding of gas locules adjacent to an aortic graft >3 months following surgery, a loop of
small bowel in contact with the aorta, and thickening of the aortic wall are all concerning for a
possible aorto-enteric fistula. These most commonly occur between the duodenum and aorta.
This patient’s graft is suprarenal and therefore the position potentially places the patient at risk.
Other radiological signs include pseudoaneurysm formation and disruption of the aortic wall.
In acute cases there may be extravasation of contrast into the bowel lumen. Often patients
present with a herald bleed which can then be followed by massive haemorrhage. This patient
is anaemic, which, given the radiological findings, is concerning. Urgent action is required and
the most appropriate step is to inform the vascular specialist registrar on-call; their team can
review the patient and decide regarding further management.
Another differential diagnosis would be graft infection, also a serious complication. Recent
studies have suggested 18F-FDG PET/CT studies can help differentiate cases of infection from
non-infected grafts; however, a more appropriate initial step would be to correlate with
inflammatory markers and blood cultures.
(The Final FRCR Complete Revision Notes Page 152)
16. (d) Blood culture followed by antibiotics
The patient has typical signs and symptoms of pyelonephritis. If the patient is septic then
antibiotics need to be given within an hour as per sepsis protocol; however, from the
description there is no indication of sepsis and the patient is haemodynamically stable. Blood
cultures should be obtained prior to antibiotics where possible. Urinary tract ultrasound is
insensitive for pyelonephritis and the diagnosis should be clinical. Radiology can be helpful if
there is concern regarding other diagnoses, such as urinary tract calculi; however, these are
uncommon, particularly in young women. In an uncomplicated case of pyelonephritis no
imaging may be required. Radiology can be incorporated if there is concern regarding abscess
formation, infarction or obstruction. Ultrasound would be preferable over CT in the first
instance to reduce radiation exposure in a relatively young patient.
(The Final FRCR Complete Revision Notes Page 246)
17. (b) Hepatic iminodiacetic acid (HIDA) scan
The baby has typical radiological features of biliary atresia with hepatomegaly and the
‘triangular cord’ sign which is caused by fibrous echogenic tissue anterior to the portal vein.
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Intrahepatic biliary duct dilatation may or may not be present. The inability to see the
gallbladder is suspicious and the common bile duct may also not be visible. Biliary atresia
most commonly presents within the first couple of months of life with jaundice, pale stools
and dark urine. Prompt diagnosis and surgical treatment is important to avoid cirrhosis and
liver transplant.
A HIDA scan will demonstrate hepatic tracer uptake but absent bowel tracer excretion at 24 hours.
In contrast to this, neonatal hepatitis will cause reduced hepatic uptake and maintained excretion.
(The Final FRCR Complete Revision Notes Page 334)
18. (e) Microcalcification
Concerning features in thyroid nodules include microcalcification, irregular margins, a
nodule being taller than it is wide, invasion into adjacent structures, an incomplete hypoechoic
halo and enlarged or abnormal appearing cervical lymph nodes. A hyperechoic echotexture is
reassuring compared to hypoechoic nodules, which are more frequently associated with
malignancy. However, some benign nodules can be hypoechoic. No one characteristic is
completely diagnostic for malignancy but there are various guidelines to help guide
management. Ultrasound follow-up can be undertaken and depending on the level of
suspicion if a nodule reaches 1–1.5 cm then fine needle aspiration would be indicated.
(The Final FRCR Complete Revision Notes Page 435)
19. (e) Osler-Weber-Rendu syndrome
The most likely diagnosis is Osler-Weber-Rendu syndrome, or hereditary haemorrhagic
telangiectasia. It is characterised by multiple arteriovenous malformations (AVMs) with a triad
of telangiectasia, epistaxis (due to nasal telangiectasia) and a positive family history (autosomal
dominant). The pulmonary nodules seen on plain film are multiple AVMs. The AVMs cause
cyanosis and can cause high output heart failure.
Although multiple pulmonary nodules are seen in granulomatosis with polyangiitis
(previously known as Wegener granulomatosis), the associated upper respiratory tract
symptom is sinusitis rather than epistaxis, and cyanosis is not usually a feature.
Caplan syndrome is a combination of rheumatoid arthritis and pneumoconiosis. Although
lung nodules are seen in this condition, there is no relevant history provided in the main stem,
and there is no evidence of interstitial abnormality provided on plain film.
Goodpasture syndrome may present with haemoptysis; however, pulmonary nodules are
not a typical feature.
Multiple metastases is a possible answer; however it is not the most likely from the
information provided, especially given the patient’s age.
(The Final FRCR Complete Revision Notes Page 32)
20. (c) Osteopetrosis
Basilar invagination is where the odontoid process of C2 sits at or above the level of the basion-
opthision line which is also known as the McRae line. It should sit >5 mm below this line and it can
lead to compression of the brainstem and subsequent hydrocephalus, syringomyelia and
neurological symptoms.
Causes can be acquired or congenital, and a common mnemonic is PF ROACH:
Paget disease
Fibrous dysplasia
Rheumatoid arthritis, rickets
Osteogenesis imperfecta, osteomalacia
Achondroplaisa
Chiari I/II, cleidocranial dysostosis
Hyperparathyroidism
Osteopetrosis is not associated with basilar invagination.
(The Final FRCR Complete Revision Notes Page 67)
21. (c) Peutz-Jegher syndrome
The vignette alludes to a history of Peutz-Jegher syndrome. This is an autosomal dominant
syndrome that causes multiple, benign, hamartomatous polyps; more common in the
stomach and small bowel. It is the most common polyposis syndrome to involve the small
intestine but these have no malignant potential. Intussusception is a common presentation. It
can also affect the large bowel where there is a risk of malignant transformation. The risk of
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extraintestinal malignancy is increased, for example in the ovary, thyroid, testis, pancreas
and breast.
Cronkhite-Canada syndrome, a type of non-hereditary syndrome, and Cowden syndrome
can also affect the entire GI tract with hamartomatous polyps. Familial adenomatous
polyposis syndrome (FAPS) is a hereditary condition characterised by hundreds of
adenomatous polyps of the large bowel. Juvenile polyposis syndrome also causes hundreds
of juvenile hamartomatous polyps affecting the entire GI tract.
(The Final FRCR Complete Revision Notes Page 181)
22. (d) Ultrasound and DMSA if recurrent infection
NICE guidelines on paediatric urinary tract infections (UTI) are intermittently updated and
the current guidelines are listed for review in December 2024. In both the previous and current
guidance for a typical Escherichia coli infection, in a child of 11 months who is responding to
treatment, the guidance suggests no imaging is required. US and DMSA only becomes
necessary if the UTI is recurrent.
If the infection is atypical (non-E. coli) or there are other concerning features such as sepsis,
abdominal mass, unresponsiveness to treatment, raised creatinine or poor urine flow, then
urgent US is indicated.
Similarly, if a child is less than 3 months old and has a UTI, then paediatric referral and
imaging would be indicated.
(The Final FRCR Complete Revision Notes Page 358)
National Institute for Health and Care Excellence (NICE). 2007 (updated 2018). NICE Clinical
Guideline 54. Urinary Tract Infection in Under 16s: Diagnosis and Management.
23. (a) Endplate: Low T1, High T2, enhancement present, Disc: T2 low
Modic endplate changes are subdivided into three types, ranging from acute to chronic
appearances. In the early phases, (Type I) there is inflammation causing low T1 and high T2
endplate signal. Endplate enhancement can be present. In contrast to discitis, the disc will
demonstrate low T2 signal.
Modic Type II endplate changes are related to fat deposition and therefore T1 signal is high
and T2 signal is intermediate to high.
Following this, the endplates become hypointense on both T1 and T2 sequences due
to sclerosis (Type III). As with Modic Type I changes, the disc should stay low signal on
T2 sequences.
(The Final FRCR Complete Revision Notes Pages 83, 444)
24. (b) Alcoholic gastritis
The stomach can be challenging to assess on imaging, particularly if not well-distended.
Abnormally thickened gastric folds are described as above 3–5 mm at the prepyloric region and
>5–10 mm at the fundus. The most common cause of thickened gastric folds is alcoholic gastritis.
In contrast to this, atrophic gastritis causes inflammation and atrophy of the gastric glands
causing loss of rugae and a smooth, featureless stomach.
Another cause of thickened folds is lymphoma, which is the most common malignant
cause. Other findings would include diffuse stomach wall thickening and ulceration causing
wall irregularity.
Crohn’s disease and Zollinger-Ellison syndrome can also cause thickened folds, along
with multiple ulcers and a cobblestone appearance in the former. Zollinger-Ellison causes
hypersecretion of gastric acid so there can be high volumes of fluid in the stomach which
dilute the contrast.
(The Final FRCR Complete Revision Notes Page 153)
25. (b) Endotracheal tube tip position
Always remember lines and tubes on a plain film and always remember ABC (airway,
breathing, circulation). Although a left apical cap is suspicious for aortic transection
and is a very urgent finding, the airway is potentially compromised due to the
incorrect placement of the endotracheal tube, especially with a concomitant large right
pneumothorax.
Bilateral pleural effusions in the context of trauma should be considered to
represent haemothoraces, and right lung consolidation is presumed to represent lung contusion.
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Radiographic findings associated with aortic transection include left apical pleural
cap, mediastinal widening (over 8 cm above the level of the carina and more than 25%
the width of the chest), indistinct aortic arch contours, filling in of the aortopulmonary
window, tracheal deviation towards the right and depression of the left main bronchus.
(The Final FRCR Complete Revision Notes Page 5)
26. (d) Semimembranosus tendon and medial head of gastrocnemius
Baker’s cysts are associated with osteoarthritis of the knee and extend from the joint space,
often with a beaked appearance, between the medial head of gastrocnemius and the
semimembranosus tendon. They can present as a mass or with pain. A ruptured Baker’s cyst
can cause acute presentations, and ruptured popliteal aneurysms and deep vein thrombosis
would be the main differentials.
Radiographic appearances can include increased soft tissue density at the posterior aspect of
the knee on the lateral view.
On ultrasound these lesions can be discriminated from a popliteal artery aneurysm by their
anatomical location but also due to lack of vascularity. Baker’s cysts will be anechoic with
posterior acoustic enhancement. They can contain loose bodies.
MRI reveals a fluid signal lesion at the posterior aspect of the knee extending from the joint
between the medial head of gastrocnemius and the semimembranosus tendon – remember the
‘m’s of medial head and semimembranosus go together.
(The Final FRCR Complete Revision Notes Page 67)
27. (a) Salmonella
The underlying organism in infectious colitis may be predicted by the segment of the bowel
affected.
The typical inpatient and antibiotic history associated with Clostridioides difficile (previously
known as Clostridium difficile) colitis does not fit with the history in this case. Furthermore, it
tends to cause a diffuse colitis with gross mural thickening.
(The Final FRCR Complete Revision Notes Page 182)
Source: Reprinted with permission from V Helyar and A Shaw, The Final FRCR: Complete Revision Notes,
CRC Press, Taylor & Francis Group, 2018, p. 182.
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In this case, MRI abdomen would be the best modality to assess local disease extent and
particularly neuroforaminal involvement.
(The Final FRCR Complete Revision Notes Page 354)
37. (c) Myxoma
This is a typical description of a cardiac myxoma, which is the most frequent primary cardiac
tumour in adults. It is typically attached to the interatrial septum within the atria, on the left
(75–80%) more than right. Rarely it can be sited in the ventricles. Myxomas can be part of
Carney’s complex which is a multiple endocrine neoplasia syndrome comprising multiple,
often cardiac, myxomas and skin pigmentation.
Both fibroma and rhabdomyoma are more typically in the ventricles with rhabdomyoma the
most common cardiac tumour in childhood, and can be associated with tuberous sclerosis.
Metastases are 20–40 times more common than primary cardiac tumours but with the typical
description of the atrial myxoma, this is less likely. The most common primary tumours to
metastasise to the heart include melanoma, lung and breast.
Thrombus is a possibility, especially on a CT pulmonary angiogram study; however the
description, particularly the enhancement on the MRI, makes this unlikely.
(The Final FRCR Complete Revision Notes Page 8)
38. (a) Abrupt change in median nerve diameter
Carpal tunnel syndrome can be associated with conditions such as acromegaly,
hypothyroidism, pregnancy, rheumatoid arthritis and diabetes. It presents with pain and
paraesthesia in the hand in the distribution of the median nerve. Tinel test (tapping the median
nerve) and Phalen test (paraesthesia exacerbated by wrist flexion) are used to aid diagnosis.
The most specific sign on MRI is enlargement of the nerve. Other findings include bowing of
the flexor retinaculum, flattening and/or enhancement of the nerve and oedema within the
nerve or carpal tunnel and loss of fat within the carpal tunnel.
Ultrasound can be used and can also show bowing of the flexor retinaculum and nerve
compression causing flattening distally and enlargement of the nerve just proximal to the flexor
retinaculum.
(The Final FRCR Complete Revision Notes Page 69)
39. (b) Small bowel tuberculosis
Differentiating tuberculosis (TB) from Crohn’s disease can sometimes be challenging on imaging;
however, Table 1.8 summarises the main differentiating features. Hypoattenuating lymph nodes
can be seen in TB and small bowel lymphoma. Lymphoma of the small bowel most classically
affects the ileum. In this case, the presence of dense ascites and predominant caecal involvement
points towards a diagnosis of TB. Yersiniosis and actinomycosis classically affect the appendix,
mimicking appendicitis.
(The Final FRCR Complete Revision Notes Pages 183, 162)
Source: Reprinted with permission from V Helyar and A Shaw, The Final FRCR: Complete Revision Notes.
CRC Press, Taylor & Francis Group, 2018, p. 184.
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The site of a Charcot joint can help point towards an underlying diagnosis, and involvement
of shoulder or other upper limb joint is most likely to be caused by syringomyelia. The ankle
and foot is most commonly affected in diabetic-related Charcot arthropathy, and traumatic
spinal cord injury can cause similar appearances of the spine. Neurosyphilis is a less common
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cause now, but most commonly affects the knee joint. Chronic alcohol excess tends to be
associated with changes in the foot.
(The Final FRCR Complete Revision Notes Page 70)
45. (a) Adenomyomatosis
The patient has symptoms and sonographic signs of cholecystitis with gallbladder wall
thickening (>3 mm) and pericholecystic fluid. Adenomyomatosis is associated with gallstones
and causes both diffuse or focal thickening of the gallbladder wall. On ultrasound, bright
echoes may be seen in the wall with ‘comet tail’ ring down artefact from Rokitanky-Aschoff
sinuses. The main differential for wall thickening, particularly when focal, is gallbladder
carcinoma. MRI can be helpful in differentiating the two diagnoses, with the finding of
multiple curvilinear foci of T2 hyperintensities (string of beads sign) in the wall being highly
specific and the hallmark for adenomyomatosis.
Gangrenous cholecystitis can develop secondary to ischaemia and necrosis of the gallbladder
wall and is more likely in diabetic patients; however these MRI appearances are typical for
adenomyomatosis. Mural gas on T2 weighted imaging would appear hypointense rather than
the hyperintensities described in this patient.
Gallbladder polyps are frequently incidental findings and are polypoid ingrowths into the
lumen rather than an area of thickening.
The finding of a Phrygian cap is an incidental anatomic variant where there is folding at the
fundus which can produce a thickened or septated appearance on ultrasound. Cross-sectional
imaging usually helps to confirm the diagnosis in challenging cases.
(The Final FRCR Complete Revision Notes Page 195)
46. (a) Disc material extending >90° circumference and >3 mm beyond the vertebral body margin
impinging the left L2 nerve
A broad based protrusion is when the disc material extends >3 mm beyond the vertebral
body margin over an area extending >90° but <180° over the circumference of the vertebral
body.
This is in contrast to a focal protrusion which is <90° and a broad based bulge which is >180°.
In the lumbar spine the nerve roots exit below the matching pedicle, so at L2/3, the L2 nerve exits.
In the cervical spine there is a mismatch so at C2/3 the C3 nerve root exits below the C2 pedicle.
(The Final FRCR Complete Revision Notes Page 443)
47. (d) Multicystic dysplastic kidney
Multicystic dysplastic kidney is an obstructed non-functioning kidney which manifests as an
enlarged multicystic kidney lacking normal renal parenchyma. The cysts may have rim
calcification. If it is bilateral it is incompatible with survival. When unilateral, the contralateral
side is commonly associated with vesicoureteral reflux.
The appearance may be difficult to differentiate from a hydronephrotic kidney; however, the
absence of tracer uptake on the MAG3 study indicates there is no functioning renal tissue and
therefore helps to differentiate the two.
Congenital mesoblastic nephroma are most commonly predominantly solid lesions.
Autosomal recessive polycystic kidney disease is associated with bilateral enlarged kidneys
and multiple tiny cysts. Hepatic fibrosis is also a feature.
Multilocular cystic nephromas typically have a thick fibrous capsule and multiple septations
which may demonstrate vascularity. The lesion may compress surrounding normal renal
parenchyma. A typical characteristic is herniation into the renal pelvis, although with large
lesions this may be difficult to appreciate.
(The Final FRCR Complete Revision Notes Page 353)
48. (c) Extradural haematoma
Extradural haematomas are usually lentiform in shape, secondary to skull fractures and
characteristically do not cross sutures. The blood is located between the skull and the dura. They
can be arterial; for example secondary to middle meningeal artery injury, or venous, and the
history is commonly of a head injury followed by a lucid interval prior to reduced consciousness.
In contrast, subdural haematomas are sited between the dura and the arachnoid mater. They
are usually venous bleeds, crescenteric in shape and due to their subdural location can cross
sutures but not dural attachments. The superior sagittal sinus is bounded by a dural lining and the
observation in this case that the haematoma crosses the midline and displaces the superior sagittal
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concern regarding acute haemorrhage clinically then triple phase CT could be considered; however,
in this case there has already been contrast administered which will confuse the findings, as a true
non-contrast scan could not be obtained.
Confirmation and characterisation of any urinary bladder injury is important as it will impact
further management. Extraperitoneal rupture, characterised by contrast extravasation into the
extraperitoneal space, which can extend into the thighs, anterior abdominal wall and scrotum, is
treated conservatively. However, intraperitoneal rupture, when contrast extravasates around
bowel loops, would require surgical intervention. Subserosal bladder rupture is less common but
suggested when there is elliptical contrast extravasation adjacent to the bladder.
Sometimes a delayed phase CT can be helpful to obtain an excretory phase of contrast and
helps exclude urine leak, for example from the ureters; however, the urinary bladder will be
more uniformly opacified and better distended on a CT cystoscopy.
(The Final FRCR Complete Revision Notes Page 249)
53. (e) Tuberculosis
Chronic end-stage renal tuberculosis tends to manifest as amorphous foci of calcification
forming throughout the kidney sometimes associated with the process of autonephrectomy.
The kidney often appears shrunken with a thinned cortex. The other available answers −
hyperparathyroidism, hypothyroidism, sarcoidosis and multiple myeloma − are all associated
with medullary calcification, which is the most common form of nephrocalcinosis. The most
common causes of medullary nephrocalcinosis are hyperparathyroidism, renal tubular acidosis
and medullary sponge kidney.
(The Final FRCR Complete Revision Notes Page 352)
54. (c) Pterygoid plates
Le Fort fractures are midface fractures involving the pterygoid plates. The fractures are
categorised as Type I–III.
Type I is known as a floating palate, Type II a floating maxilla and Type III is the most severe
and is separation of the base of skull and midface, otherwise known as ‘floating face’ or
‘craniofacial disjunction’. When facial fractures are bilateral there may be asymmetry in the Le
Fort fracture types.
(The Final FRCR Complete Revision Notes Page 364)
55. (b) Pleural effusion
The underlying diagnosis is Pneumocystis jiroveci, a fungal infection seen in immunocom-
promised patients. In the context of HIV, patients have CD4 count <200 cells/mm3. The most
common imaging abnormality is perihilar ground glass opacification and foci of consolidation,
features which may or may not be accompanied by fine reticulation. Pneumatocoeles and
subpleural blebs are also a common feature, usually in the upper zones. Occasionally the rupture
of these cysts or blebs cause pneumothorax, which would be considered pathognomonic of
P. jiroveci in the case described. Pleural effusions are rarely seen in this infection, and lymph node
enlargement is also uncommon and so should prompt alternative differential diagnosis.
(The Final FRCR Complete Revision Notes Page 34)
56. (c) Facet joint ankylosis
Diffuse idiopathic skeletal hyperostosis (DISH) is often an incidental finding on radiographs
but reports suggest it can be associated with stiffness and decreased mobility. The classic
appearance is flowing osteophytes affecting ≥4 contiguous vertebrae, commonly in the thoracic
spine tending to occur on the right side of the vertebral bodies as aortic pulsation inhibits
ossification on the left.
In contrast to degenerative change of the spine, intervertebral disc spaces are preserved. If
DISH affects the cervical spine it can cause dysphagia. There can be calcification of the anterior
and posterior longitudinal ligaments but the facet joints are spared, as are the sacroiliac joints
(unlike ankylosing spondylitis). Calcification can occur elsewhere, for example along tendons
and ligaments such as the calcaneus, patella, iliac crest and around the elbow. Patients with
spinal fusion are at increased risk of fracture following trauma.
(The Final FRCR Complete Revision Notes Page 72)
57. (d) 111In Octreotide study
The top differential for a distal small bowel tumour containing calcification with low density
lymph node involvement is a carcinoid. These are most common in the gastrointestinal tract,
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particularly the terminal ileum, followed by the rectum and colon. They can be plaquelike or
polypoidal and tend to hyper enhance. Similarly, any liver metastases hyper enhance on an
arterial phase study compared to the portal venous phase, when they may become difficult to
appreciate. Up to 70% of the primary tumours contain calcification. Carcinoids can affect the
mesentery causing the typical ‘spoke wheel’ appearance of desmoplastic reaction. The
symptoms are often non-specific.
The most appropriate answer is 111In-Octreotide study which aids diagnosis, detects occult
tumours and helps to assess disease extent enabling appropriate treatment planning. An
arterial phase CT chest and abdomen may aid diagnosis of distant metastases, including
arterially enhancing liver lesions, but a 111In-Octreotide study is recommended at baseline for
all patients with these tumours. 5-HIAA serum levels can be raised in functioning tumours but
this serum marker will not aid treatment planning in terms of disease extent. 18F-FDG PET/CT
is not routinely used in carcinoid tumours as uptake can be low, particularly in low grade
lesions, due to relatively low metabolic rate. MIBG scans are used in the investigation of
phaeochromocytomas and not for carcinoid tumours.
(The Final FRCR Complete Revision Notes Page 158)
58. (a) Early enhancement following gadolinium
Patients who have previously had back surgery, for example discectomy or laminectomy,
and develop back pain often require repeat MRI to distinguish between recurrent disc prolapse
and postoperative epidural fibrosis. This is an important distinction to make as recurrent
prolapse would be treated surgically whereas surgeons would be reluctant to intervene for
postoperative fibrosis. It can be difficult to distinguish between the two entities on non-contrast
imaging as both have low T1 signal, although fibrosis tends to have irregular borders and
evidence of thecal retraction towards the area of interest. In contrast to this, a disc would
typically have a smoother border. Following gadolinium administration, scarring enhances
early whereas a disc will either not enhance or enhance late. Enhancement of the fibrosis
diminishes after a few years. DWI and ADC imaging are not routinely performed for spinal
imaging. High T2 signal in a disc is associated with discitis.
(The Final FRCR Complete Revision Notes Page 72)
59. (d) The ureter draining into the vagina is associated with the upper pole moiety
The anatomy in this case represents a double collecting system. A bifid ureter is two ureters
that unite before the urinary bladder. A duplicated system is associated with a normally
inserting ureter which arises from a lower pole moiety and an ectopic ureter which arises from
an upper pole moiety. The ectopic ureter can insert elsewhere in the urinary bladder, usually
more inferiorly and medially, or as in this case into nearby structures such as the vagina, which
can lead to incontinence. The upper pole moiety can be obstructed due to the presence of a
ureterocoele. This can inferiorly displace the lower pole moiety, leading to the ‘drooping lily’
appearance. The lower pole ureter is frequently affected by vesicoureteral reflux.
(The Final FRCR Complete Revision Notes Page 351)
60. (b) Sensorineural hearing loss
Temporal bone fractures are split into longitudinal, transverse and mixed fractures.
Transverse fractures are less common but more likely to lead to vertigo and sensorineural
hearing loss secondary to CN VIII injury. CN VII can also be affected causing facial paralysis.
Longitudinal fractures are more likely to lead to conductive hearing loss with involvement of
the ossicles and tympanic membrane.
(The Final FRCR Complete Revision Notes Page 365)
61. (c) Hydatid cysts
The description is that of hydatid cysts. The described serpiginous structure is known as the
‘water lily sign’, which represents a floating membrane within the cyst fluid. Whilst the liver is
the most common site for cyst formation, the lungs are the second most common. The lower
lobes are more commonly affected. Unlike in the liver, pulmonary hydatid cysts rarely calcify.
There may occasionally be an air-fluid level due to communication with the bronchial tree.
Bronchogenic cysts are solitary and found within the mediastinum adjacent to the main
airways. Pericardial cysts are also usually solitary and found adjacent to the pericardium,
within the cardiophrenic angle. Surrounding inflammatory change would be expected in the
case of pulmonary abscess with a thicker wall and less smoothly marginated than a cyst.
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• Stage IV is when extra-nodal disease sites become affected, such as the liver, bone marrow
or cerebrospinal fluid.
• Other letters may be used including ‘A’ when a patient is asymptomatic and ‘B’ when they
have symptoms such as fevers, weight loss and night sweats.
• E is used when there is extra-nodal extension adjacent to a known nodal site.
• S indicates splenic involvement.
• X is used when there is a nodal mass >10 cm.
(The Final FRCR Complete Revision Notes Page 35)
74. (d) Lateral osseous bump, 65°, Labral tear
There are two subtypes of femoroacetabular impingement (FAI); cam FAI is more
common in young men versus pincer FAI which is associated more with middle-aged
females. Cam FAI is caused by a non-spherical femoral head impacting against the
acetabulum; typically there is a flattening at the junction between the femoral head and
neck with an osseous bump just lateral to the physeal scar. This is associated with
subsequent degenerative change and labral tears. Cartilage and labral injuries tend to be
positioned anterior-superiorly. The alpha angle is frequently cited and an angle >55–60°
(depending on the article) is considered abnormal.
Pincer FAI is due to a deep acetabulum; therefore the coverage of the femoral head is
increased and leads to abnormal contact between the femoral head/neck junction and the
overhanging acetabulum. Chondral injury is more typically circumferential versus the
anterior-superior position in cam FAI. It is also possible to have a combined type of FAI.
(The Final FRCR Complete Revision Notes Page 74)
75. (b) Middle rectal vein
The most frequent location for colorectal cancer is the rectosigmoid colon followed by
descending, transverse and then ascending colon and caecum. Left sided tumours may present
with fresh red rectal blood; however, bleeding from right sided tumours is often occult and
therefore patients may present with anaemia.
In this question the low attenuation liver lesions are longstanding and of unlikely clinical
significance. In contrast, the multiple bilateral lung nodules are concerning. The presence of
lung metastases in the absence of convincing liver lesions makes a rectal primary site most
likely as the drainage of the rectum is via the pelvic veins directly into the inferior vena cava.
Consequently, metastatic spread can bypass the portal venous system and the liver, causing
lung metastases. The superior rectal vein drains into the portal venous system but the middle
and inferior rectal veins drain directly into the inferior vena cava.
(The Final FRCR Complete Revision Notes Page 160)
76. (e) Unenhanced CT abdomen
The patient has bilateral renal lesions. The lesion on the right kidney is consistent with a
Bosniak 2F cyst with thin septae and nodular calcification; this will require CT follow-up. Once
septae or walls become thickened and nodular with measurable enhancement then the cyst falls
into the Bosniak 3 category and many patients will undergo invasive management, either
surgery or radiofrequency ablation.
The lesion associated with the left kidney is hyperdense. This CT is enhanced, likely portal
venous phase imaging for this clinical indication, so we need to establish whether this
hyperdensity is enhancement or due to the inherent density of the lesion. A hyperdense renal
cyst should not significantly change density between the unenhanced and the enhanced
sequences. A soft tissue mass would demonstrate a significant difference being lower density
on the unenhanced and then increasing following contrast administration.
The patient should be fully worked up prior to being discussed at the multidisciplinary team
meeting and therefore although the patient will require follow-up for the right Bosniak 2F
lesion, the unenhanced CT should be performed in the first instance to complete the imaging
and complete characterisation of the lesion.
(The Final FRCR Complete Revision Notes Page 250)
77. (c) Langerhans cell histiocytosis
The constellation of clinical signs and symptoms are consistent with Hand-Schüller-Christian
disease which is the chronic systemic form of Langerhans cell histiocytosis. It can manifest with
bone lesions, hepatosplenomegaly, diabetes insipidus, proptosis and dermatitis. The majority
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of bone lesions in Langerhans cell histiocytosis have variable appearances, with both lucency
and sclerosis depending on the stage of the disease. However, skull lesions typically have a
bevelled ‘hole within a hole’ appearance and vertebral involvement leads to vertebra plana,
which is the most common cause of vertebra plana in children.
Sarcoidosis and tuberculosis can cause diabetes insipidus with other systemic signs and
symptoms, including musculoskeletal manifestations. Sarcoidosis can affect the eyes too but
usually affects the lacrimal glands rather than causing proptosis.
Graves disease can cause exophthalmos and skeletal changes, such as thyroid acropachy, but
it is not associated with the other clinical signs in this case.
Diabetes mellitus is a cause of increased thirst in children but does not account for the other
changes.
(The Final FRCR Complete Revision Notes Page 324)
78. (d) T1 sagittal and coronal, T1 post contrast sagittal and coronal, T1 coronal with dynamic
contrast
The coronal and sagittal planes give the most information. Coronal dynamic post-contrast T1
sequences are also crucial for imaging potential microadenomas. Post-contrast imaging is
always acquired on T1 sequences rather than with T2. Using a small field of view can also be
helpful.
The normal pituitary gland has anterior and posterior components. The anterior pituitary is
T1 and T2 isointense. The posterior pituitary is T1 hyperintense and T2 hypointense. Post-
contrast imaging helps to detect microadenomas which are usually hypo enhancing compared
to the rest of the gland.
(The Final FRCR Complete Revision Notes Page 404)
79. (a) Recommendations for the categorisation of carotid artery stenosis is as follows:
(The Final FRCR Complete Revision Notes Page 10)
Source: Data from Grant EG, Benson CB, Moneta GL et al. Carotid artery stenosis: Grayscale and Doppler
Ultrasound Diagnosis-Society of Radiologists in Ultrasound Consensus Conference. Ultrasound Quarterly.
2003;19(4):190−198.
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aorta on abdomen ultrasound. Raised inflammatory markers are non-specific but would be
associated with infection, including osteomyelitis and tuberculosis.
Multiple abnormal lymph nodes would be suspicious for lymphoma; however in lymphoma
there may be multi-level spine involvement.
(The Final FRCR Complete Revision Notes Pages 101, 324)
81 (d) Spleen
Splenic injury is most common following a blunt force trauma causing abdominal injury.
Hepatic injury is more common following penetrating trauma. The history in this case also
indicates the potential for significant haemorrhage which would fit with splenic injury. Regardless,
careful scrutiny of all the abdominal viscera is required. If splenic injury is identified then
consideration of injuries in other adjacent structures is important, for example the left kidney,
pancreatic tail and left hemidiaphragm. Splenic (and other abdominal visceral) injury is graded
with the American Association for the Surgery of Trauma (AAST) grading system.
(The Final FRCR Complete Revision Notes Page 240)
82 (b) MacLeod syndrome
MacLeod syndrome, also known as Sywer-James syndrome, is thought to occur secondary
to childhood infectious bronchiolitis. Previous infections with mycoplasma pneumoniae and
viral infections are thought to play a role. It causes a unilateral, often small, lucent lung with
reduced vascularity and expiratory air trapping. It can be an incidental finding in adulthood.
The history in this case is not typical for congenital lobar over inflation (CLO), which was
previously known as congenital lobar emphysema. CLO usually presents in neonates with
respiratory distress. It most commonly affects the left upper lobe, followed by the right middle
and upper lobes. It tends to cause marked mediastinal shift.
Pulmonary agenesis causes an absent lung on one side with no vasculature. Therefore, this
usually causes a dense hemithorax with mediastinal shift towards the affected side due to
cross-herniation from the contralateral side.
Poland syndrome is a congenital unilateral absence of the pectoralis muscles. It would not
cause a small unilateral hemithorax and would also not impact the vasculature.
Scimitar syndrome does not typically cause a lucent lung; however, the lung is commonly small,
with associated ipsilateral mediastinal shift and anomalous venous drainage. This is most
commonly into the inferior vena cava which causes a ‘scimitar’ appearance in the right lower zone.
(The Final FRCR Complete Revision Notes Page 325)
83 (c) They sometimes contain an intracystic nodule
Rathke cleft cysts are benign, incidental, midline lesions associated with the pituitary gland.
Intracystic nodules are pathognomic for these lesions and are typically non-enhancing and
small. Rathke cleft cysts neither calcify nor demonstrate restricted diffusion. There may be
minimal peripheral rim enhancement. They rarely extend beyond the sella.
(The Final FRCR Complete Revision Notes Page 405)
84 (d) Repeat ultrasound in 3 weeks
The radiological findings are suggestive of adrenal haemorrhage. This often presents as an
asymptomatic abdominal mass, and depending on the age of the haemorrhage it can have
variable sonographic appearances. Acutely they may appear more solid with internal echoes
but over time blood products liquify and they become more heterogenous with cystic
components. Chronically they may calcify. The main differential is neuroblastoma which can
have similar appearances of a solid appearing mass. One distinguishing feature is the history,
and in this case there is a history of a traumatic birth. Secondly, the lack of vascularity is
indicative of adrenal haemorrhage rather than neuroblastoma. On follow-up ultrasound,
adrenal haemorrhage will decrease in size over time, whereas neuroblastoma will increase in
size. Therefore prompt follow-up ultrasound is important. Ultrasound guided biopsy would
not be indicated and MRI is usually reserved for challenging cases. MIBG is often used in the
staging of neuroblastoma.
(The Final FRCR Complete Revision Notes Page 349)
85 (d) Non-specific interstitial pneumonia (NSIP)
Rheumatoid arthritis can be associated with both usual interstitial pneumonia (UIP) pattern
of disease as well as NSIP. The features described on the CT are more typical for NSIP.
Radiological overlap between the two diseases can occur; however the UIP pattern is
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Osteopetrosis can cause medullary hyperexpansion and hepatosplenomegaly but the bones
are typically sclerotic and fracture easily. Similarly, Niemann-Pick disease can cause
hepatosplenomegaly; however, Gaucher disease is more common than Niemann-Pick.
Granulomatosis with polyangiitis (previously known as Wegener granulomatosis) is a cause of
paranasal sinus obliteration and sarcoidosis is a cause of hepatosplenomegaly but neither cause
Erlenmeyer flask deformities.
(The Final FRCR Complete Revision Notes Page 76)
87 (b) Duodenal involvement
The appearances of gastric lymphoma can be varied; however, wall thickening tends to be
more diffuse and thicker than with gastric carcinoma. Extensive wall thickening and
submucosal infiltration can extend into the duodenum. There is less likely to be perigastric fat
invasion and gastric outlet obstruction than with gastric carcinoma.
Atrophic gastritis is a risk factor for gastric carcinoma, along with pernicious anaemia.
Helicobacter pylori infection is associated with both gastric carcinoma and lymphoma.
Both gastric carcinoma and lymphoma tend to metastasise to the liver first. Regional
adenopathy is common in both malignancies but the lymph nodes in gastric lymphoma are
usually larger and more extensive than with gastric carcinoma, potentially extending below
the level of the renal vein.
(The Final FRCR Complete Revision Notes Pages 168–169)
88 (a) Adenomyosis
Adenomyosis tends to affect perimenopausal women and is a cause of heavy periods. It is
caused by ectopic endometrial tissue within the myometrium. The whole uterus can be
affected, appearing bulky and thickened, or it can be more focal, as in this case. There is
thickening of the junctional zone >12 mm (the region between the endometrium and
myometrium) and there are frequently cystic T2 hyperintensities in this region. There may also
be areas of T1 hyperintensity with recent haemorrhage.
Endometrial cancer can be a cause of abnormal uterine bleeding. The endometrium in this
case is 7 mm. Normal endometrial thickness pre-menopause is up to 16 mm, depending on the
stage of the menstrual cycle, and post menopause it can measure up to 3–4 mm.
Imaging features are not typical for a leiomyoma (fibroid), which are usually T2 hypointense
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following the injury, suspected open or depressed skull injury, suspected basal skull
fracture or focal neurological deficit. Based on the provided information the patient does not
fulfil these criteria.
The NICE indications for CT cervical spine in paediatric patients include initial GCS < 13,
other areas being scanned, for example for head injury, focal neurological signs and/or
paraesthesia and if there was an urgent definitive diagnosis of cervical spine injury
required, for example prior to surgery. In this case, the answer is no to all of these and
therefore due to the neck pain and mechanism of injury the patient would be suitable for
three-view cervical spine radiographs in the first instance. If there is still a strong suspicion
of injury or if the films are suboptimal, then CT should be considered.
The ALARA principal is important when considering imaging in paediatric trauma
patients and the Royal College of Radiologists have published useful guidance based on the
NICE algorithms.
The Royal College of Radiologists. 2014. Paediatric trauma protocols.
https://www.rcr.ac.uk/publication/paediatric-trauma-protocols
National Institute for Health and Care Excellence (NICE). 2014 (updated 2019). NICE Clinical Guideline
176. Head injury: assessment and early management.
https://www.nice.org.uk/guidance/cg176
93 (b) Typhlitis
Typhlitis (or neutropenic enterocolitis) is a serious, potentially life threatening, acute
inflammation of the bowel that typically involves the caecum, appendix and terminal ileum. It
is usually seen in children who are neutropenic secondary to immunosuppression following
treatment of lymphoma or leukaemia. Classically there is concentric bowel wall thickening
with surrounding mesenteric inflammatory fat stranding. Pneumatosis can also be present.
The history in this case is particularly suggestive of typhlitis. Although the appendix is
affected, the more extensive involvement of the caecum and terminal ileum makes acute
appendicitis less likely. Similarly, although Crohn’s disease favours the terminal ileum it is
frequently multifocal with skip lesions, stricturing and extraintestinal manifestations. Bowel
lymphoma is usually non-Hodgkin and small bowel involvement is more likely than large
bowel involvement; it also usually affects an older age group. Necrotising enterocolitis is a
condition affecting preterm neonates.
(The Final FRCR Complete Revision Notes Page 187)
94 (b) Dentigerous cyst
The mandibular cyst in this case is unilocular and related to the dentition. This narrows the
differentials to a radicular cyst or a dentigerous cyst. A radicular cyst, also known as a
periapical cyst, is related to the root of the tooth whereas a dentigerous cyst is related to an
unerupted or impacted tooth and is in a pericoronal position.
Unilocular cysts which are not related to the teeth have differentials depending on the age of
a patient. Generally if the patient is >40 years old, consider diagnoses such ameloblastoma,
myeloma or metastases. Ameloblastoma typically has a ‘bubbly’ appearance and can cause
root resorption. If the patient is younger (<30 years), consider odontogenic keratocysts and
simple bone cysts. The appearance of a multilocular cyst raises the possibility of an
aneurysmal bone cyst or odontogenic keratocyst. In the case of multiple odontogenic
keratocysts consider Gorlin-Goltz syndrome.
(The Final FRCR Complete Revision Notes Page 442)
95 (a) Catheter passes inferiorly from umbilicus into pelvis, turning cephalad with the tip at the
level of T9
Umbilical arterial catheters should pass from the umbilicus inferiorly into the pelvis before
turning cephalad and going into the aorta. The aim is for the tip to be sited within the aorta in
either a high or low position, but not between the levels of T10-L3 which is where the main
aortic branches arise.
In contrast to this, umbilical venous catheters should pass superiorly from the umbilicus into
the umbilical vein, portal vein, ductus venosus and then into the hepatic vein and inferior vena
cava. The tip should ideally lie at the junction of the inferior vena cava and right atrium, which
is usually around the level of the diaphragm at T8/9.
(The Final FRCR Complete Revision Notes Page 332)
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appearance with central enhancement. On T2 weighted imaging they show peripheral low
signal intensity due to haemosiderin deposition.
(The Final FRCR Complete Revision Notes Page 367)
109 (d) Primary ciliary dyskinesia
Kartagener syndrome is a type of primary ciliary dyskinesia, typically consisting of a triad of
dextrocardia, bronchiectasis and sinusitis. It has an autosomal recessive mode of inheritance. It
is also associated with infertility in males, reduced fertility in females, transposition of the
great vessels, pyloric stenosis, post-cricoid web and epispadias. The patient has presented with
pneumonia which is caused by ciliary dysfunction and can be a recurrent problem in patients
with this condition.
Post infective bronchiectasis is the most common acquired cause of bronchiectasis, including
allergic bronchopulmonary aspergillosis (ABPA).
Recurrent aspiration and immunodeficiency such as hypogammaglobulinaemia also cause
bronchiectasis, but are not associated with dextrocardia.
Cystic fibrosis is the most common congenital cause of bronchiectasis.
(The Final FRCR Complete Revision Notes Page 39)
110 (a) Adductor magnus
The ischial tuberosity is the origin of the hamstring muscles. These include biceps femoris,
semimembranosus and semitendinosus. The ‘hamstring portion’ of the adductor magnus
muscle also arises from this site.
Avulsion fractures are more common in children due to their immature skeleton, and
appearances may be subtle with just small bone flakes visible on close inspection.
Avulsion fracture sites of the other tendons around the pelvis and proximal femora are listed
below.
Gracilis – inferior pubic ramus
Iliopsoas – lesser trochanter of the femur
Rectus femoris – anterior inferior iliac spine
Tensor fascia lata – anterior superior iliac spine
Sartorius – anterior superior iliac spine
(The Final FRCR Complete Revision Notes Page 104)
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for example in psoriatic and reactive arthritis, or marginal and symmetrical; for example in
ankylosing spondylitis and inflammatory bowel disease.
Therefore, the likely answers for this question would either be ankylosing spondylitis or
inflammatory bowel disease. Ankylosing spondylitis is more common in males and you would
expect other associated changes on radiographs of the spine. Therefore, inflammatory bowel
disease is most likely to be the underlying diagnosis. Faecal calprotectin levels are commonly used
in the diagnosis of inflammatory bowel disease.
Anti-CCP levels are more sensitive and specific than rheumatoid factor (RF) in the diagnosis of
rheumatoid arthritis. HLA B27 is associated with the RF seronegative arthropathies including
ankylosing spondylitis and psoriatic arthritis. Parathyroid hormone levels could be investigated
in suspected hyperparathyroidism, and punch skin biopsy is sometimes used to help diagnose
psoriasis.
(The Final FRCR Complete Revision Notes Pages 63 and 91–93)
117 (d) Long axis of the distended loops arises from the right lower quadrant
Differentiating sigmoid from caecal volvulus on plain abdominal radiograph can be
challenging. However, it is important to distinguish between the two as the management can
differ greatly. Typically caecal volvulus occurs in younger patients (30–60 years) than sigmoid
volvulus. Radiographs shows marked caecal distension, preservation of haustral markings and
the distended loop arises from the right lower quadrant and usually extends towards the left
upper quadrant. Sometimes the caecum can twist axially and remain in the right lower
quadrant.
In contrast to this, the bowel wall in sigmoid volvulus is ahaustral and the bowel loop has a
different position; it arises from the pelvis extending cranially towards the left
hemidiaphragm. The apex of the loop can sometimes reach the level of the thoracic spine and
overlaps the hepatic border. It has been described as a ‘coffee bean’ appearance.
(The Final FRCR Complete Revision Notes Page 188)
118 (b) Maximum pressure generated of 120 mmHg within the colon
Pneumatic reduction of intussusception is attempted to try and avoid the need for surgery;
however, recurrence and procedural failure is possible. Most cases of recurrence reoccur
within 72 hours. Contraindications include peritonitis, pneumoperitoneum and
hypovolaemic shock. Children should be fluid resuscitated prior to attempting the procedure
and a member of the surgical team should be present. The risks, as mentioned previously, are
failure and recurrence as well as perforation. Pneumatic reduction is more likely to be
successful if there is a shorter duration of symptoms (<24 hours) but longer than this is not a
contraindication.
Three attempts can be made, with three minutes between each attempt. The maximum
pressure within the colon should not exceed 120 mmHg.
(The Final FRCR Complete Revision Notes Pages 341, 342)
119 (e) Posterior midline diverticulum proximal to cricopharyngeus
A pharyngeal pouch, otherwise known as a Zenker’s diverticulum, originates from the
midline posteriorly above the level of cricopharyngeus. This is more common and more
likely to be symptomatic than a Killian-Jamieson diverticulum which arises more laterally,
often on the left side, and below cricopharyngeus. These are both examples of ‘false’
diverticula because the outpouching does not contain all layers of the oesophageal wall but is
mucosa protruding through a muscular defect.
A pulsion diverticulum is most commonly seen in the distal oesophagus and is associated
with high pressures, for example in diffuse oesophageal spasm. The diverticulum may be
present along with a ‘corkscrew oesophagus’ appearance.
(The Final FRCR Complete Revision Notes Page 164)
120 (d) Contrast enhancement extending into the sulci
Both lepto and pachymeningeal metastases are possible in breast cancer. Pachymeningeal
disease is durally based and may be secondary to adjacent skull lesions or via lymphatic or
haematogenous spread. The dura appears thickened around the brain in a curvilinear
distribution and enhances following contrast.
Leptomeningeal disease is characterised by fine nodular post contrast enhancement of the
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surface of the brain which, unlike pachymeningeal disease, extends into the sulci. Signal
abnormality may also be evident on FLAIR and DWI/ADC sequences. It is sometimes
described as having a ‘sugar coated’ ‘sugar-coated’ appearance. It can be secondary to primary
intracranial malignancies or secondary to haematogenous spread from primary cancers such
as breast or lung. Parenchymal brain lesions are not a feature of either pachymeningeal or
leptomeningeal diseasedisease; however, there may be associated adjacent cerebral oedema.
(The Final FRCR Complete Revision Notes Page 394)
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PAPER 2
1. An athletic 28 year old man presents with intermittent claudication affecting the right leg
particularly when running or playing sports. Examination is normal with present lower limb
pulses. The vascular team query popliteal artery entrapment syndrome and request further
imaging to evaluate further and help plan surgical management.
What would be the most appropriate test?
a. Angiography
b. AP and lateral right knee radiographs
c. Arterial phase CT
d. MRI
e. Ultrasound
2. A 49 year old dialysis patient is referred to the rheumatology clinic with back and joint pain
involving bilateral shoulders and hips. Radiographs of the hips and shoulders demonstrate erosions
and subchondral cyst formation. Joint space is well preserved. An MRI spine reveals normal
alignment. There is a low T1 and T2 signal lesion at the inferior endplate of the L3 vertebral body
adjacent to the L3/4 disc. This lesion enhances following contrast. The L3/4 disc returns normal
MRI signal. Similar low signal intra-articular nodules are seen on MRI of the right shoulder.
Which finding would indicate the most appropriate diagnosis?
a. Congo red staining of synovial fluid
b. Cartilage pigmentation on arthroscopy
c. Growth of Staphylococcus aureus on blood culture
d. Serum parathyroid hormone levels
e. Weakly positive birefringent crystals on polarised light microscopy of synovial fluid
3. A 60 year old female with a recent diagnosis of scleroderma presents with dysphagia to both
solids and liquids. A barium swallow is performed.
What is the most likely radiological finding?
a. Improvement of the flow of barium following the ingestion of warm fluid
b. Narrowing of the distal oesophagus
c. Aperistalsis of the lower oesophagus
d. Oesophageal diverticulum
e. Mucosal ulceration
4. A 23 year old cyclist is on the Intensive Care Unit following a road traffic collision. Thirty-six
hours previously he was knocked off his bike by a car at approximately 20 mph. Initial
admission CT demonstrated a right subcapsular renal haematoma.
The team call you for an ultrasound urinary tract, including Doppler assessment, due to
uncontrollable hypertension and increasing right flank pain which has developed over the
past 4 hours. Ultrasound shows an unobstructed right kidney with a substantial right
subcapsular collection. There is vascularity within the kidney and the arterial trace shows
forward flow in diastole with a resistive index of 0.9. Appearances of the left kidney and
bladder are within normal limits.
What is the most likely diagnosis?
a. Page kidney
b. Pseudoaneurysm
c. Renal artery stenosis
d. Renal vein thrombosis
e. Ureteric obstruction
5. A 3 year old child is seen with a painless right upper quadrant mass which can be balloted. An
ultrasound confirms a heterogenous right upper quadrant lesion with cystic and solid
components measuring up to 10 cm centred on the right kidney.
What is the most likely diagnosis?
a. Mesoblastic nephroma
b. Multilocular cystic nephroma
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c. Nephroblastoma
d. Neuroblastoma
e. Rhabdoid tumour
6. A 35 year old man was assaulted several months previously, experiencing head trauma. He
now presents with reduced visual acuity in his left eye and also describes pulsatile
exophthalmos. An MRI of the orbits is performed.
What is the most likely finding?
a. Orbital mass
b. Dilated superior ophthalmic vein
c. Thrombosis of the cavernous sinus
d. Optic nerve enlargement
e. Aneurysm of the ophthalmic artery
7. A 55 year old man reviewed in the Infection and Immunity clinic has marked cachexia and is
generally unwell. He is known to have HIV and has poor compliance with antiretrovirals; his
CD4 count is 154 cells/mm3 (500–1400 cells/mm3). A chest radiograph is abnormal, and the
patient is referred for a CT chest abdomen pelvis to investigate further. CT reveals multiple
perihilar and peribronchovascular ill-defined nodular opacities with surrounding ground glass
opacification and marked bilateral enhancing hilar lymph node enlargement. The abdomen and
pelvis are normal. He is considered too unwell for a bronchoscopy and so you suggest a gallium
scan to aid diagnosis. The thoracic abnormalities are not tracer avid.
Which diagnosis is most consistent with the above clinical information?
a. Cytomegalovirus
b. Kaposi sarcoma
c. Lymphoma
d. Mycobacterium avium
e. Pneumocystis pneumonia
8. A 55 year old female rheumatology clinic patient is sent for hand radiographs. These show
distal phalangeal cortical irregularity and widening of the joint spaces with marginal erosions
at the middle and distal interphalangeal joints. Adjacent soft tissue swelling is also
demonstrated and there is periosteal reaction along the diaphyses of some of the middle
phalanges. The metacarpal phalangeal joints have normal appearances. Bone density is well
preserved. You also note the patient is awaiting radiographs of the right shoulder and left
knee due to pain and swelling.
What is the most likely diagnosis?
a. Erosive osteoarthritis
b. Gout
c. Psoriatic arthritis
d. Reactive arthritis
e. Rheumatoid arthritis
9. A 28 year old female patient with frequent abdominal discomfort, diarrhoea and weight loss
has a positive faecal calprotectin test. Following a recent exacerbation of symptoms, an MRI
abdomen is performed which demonstrates multiple radiological features of Crohn’s disease.
Which MRI sequence is most helpful in identifying fistulae?
a. T1 weighted sequence
b. T2 weighted sequence
c. Fat supressed T1 weighted sequence
d. Fat supressed T2 weighted sequence
e. Diffusion weighted imaging
10. A 44 year old female patient with hereditary spastic paraplegia is unable to tolerate a
transvaginal ultrasound and has an MRI pelvis for intermenstrual bleeding. On the most
inferior slices a lesion is seen adjacent to the proximal right femur. The patient denies any pain
in this area. The duty radiologist suggests extending the MRI imaging to include the entire
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area of abnormality. The mass is approximately 50 mm, with very low peripheral T1 and T2
signal. Centrally the T1 signal is isointense to muscle and T2 signal is heterogenous. On STIR
sequences there is marked peripheral hyperintensity in the surrounding muscle.
Which test is most likely to confirm benignity?
a. CT angiogram of the lower limb
b. Nuclear medicine bone scan
c. Radiograph of the proximal femur
d. Ultrasound guided biopsy
e. Post contrast MRI sequence
11. A neonate with dyspnoea has a chest radiograph which demonstrates a large lower zone
opacity. An MRI scan helps confirm a congenital diaphragmatic hernia containing abdominal
fat and viscera.
Where is the diaphragmatic defect most likely to be?
a. Left posterolateral
b. Left posteromedial
c. Right anterolateral
d. Right anteromedial
e. Right posterolateral
12. A day 2 postpartum woman in Intensive Care has a CT brain followed by an MRI brain after
she was neurologically inappropriate during a sedation hold. The patient experienced a
period of hypertension secondary to pre-eclampsia which has now resolved. Clinically the
differential lies between posterior reversible encephalopathy syndrome (PRES) and a
posterior circulation infarct.
Which of the following would be most consistent with the finding of an acute posterior
cerebral artery territory infarct rather than PRES?
a. Low density on CT
b. Microhaemorrhage
c. Occipital lobe distribution
d. Restricted diffusion
e. T2 hyperintensity
13. A 55 year old male patient of average weight with a 15 year pack year smoking history has an
incidental finding of a nodule on a chest radiograph. CT confirms a 17-mm right middle lobe
lung nodule and MDT discussion suggests CT guided lung biopsy. On the day the patient is
positioned, the skin is cleaned and 10 mL 1% lidocaine is injected into the skin and soft tissues;
however the patient continues to experience discomfort and requests more local anaesthetic.
What is the maximum additional volume of 1% lidocaine you can safely administer to this
patient?
a. 0 mL
b. 5 mL
c. 10 mL
d. 15 mL
e. 25 mL
14. A 10 year old boy’s spinal radiograph demonstrates posterior vertebral body scalloping,
beaking of the vertebral bodies at the anteroinferior corners and shortened pedicles with a
decreased interpedicular distance.
Which of the following underlying congenital skeletal anomalies is consistent with these
findings?
a. Achondroplasia
b. Asphyxiating thoracic dysplasia
c. Hurler syndrome
d. Morquio syndrome
e. Thanatophoric dysplasia
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15. A 33 year old woman has an abdominal ultrasound for investigation of non-specific
abdominal pain. The spleen is normal in size but there is a hyperechoic 3-cm nodule within it.
The patient goes on to have a MRI abdomen. The nodule shows low T1 and high T2 signal.
Following contrast administration there is peripheral enhancement on arterial phase imaging.
Delayed images show progressive central enhancement of the nodule.
What is the most likely diagnosis?
a. Metastasis
b. Lymphoma
c. Abscess
d. Sarcoidosis
e. Haemangioma
16. A CT aorta in an emergency department patient with hypertension and abdominal pain
describes an indeterminate adrenal lesion. An MRI adrenals is requested and the lesion
demonstrates characteristic features of a phaechromocytoma.
Which of the following radiological features fits with this diagnosis?
Table 2.1:
T1 Signal T2 Signal Enhancement Out-of-Phase Sequence
17. A neonate is diagnosed with pyloric stenosis following presentation with vomiting. This is
confirmed following an upper gastrointestinal (GI) fluoroscopic study and ultrasound scan.
Which of the following radiological findings correlates with this diagnosis?
a. Corkscrew appearance on upper GI contrast study
b. Muscle wall thickness of 2 mm on ultrasound
c. Pyloric canal length of 15 mm on ultrasound
d. Pyloric transverse diameter of 10 mm on ultrasound
e. Pyloric volume of 1.6 cm3 on ultrasound
18. A 36 year old woman presents with sudden onset headache and visual disturbance. On
examination she is found to have bilateral homonymous hemianopia and left third cranial
nerve palsy. A diagnosis of pituitary apoplexy is suspected.
Regarding imaging in suspected pituitary apoplexy, which of the following statements is most
accurate?
a. CT is sensitive for the diagnosis
b. High T1 signal helps differentiate it from other pituitary masses
c. Macroscopic haemorrhage is uncommon
d. The pituitary gland rarely demonstrates restricted diffusion on MRI
e. The pituitary gland usually shows peripheral enhancement
19. A 45 year old male is under investigation for haematuria and proteinuria. He also has
episodes of chest pain, shortness of breath and new haemoptysis. The renal team perform a
renal biopsy which shows focal glomerulonephritis and a serologic cytoplasmic ANCA test is
positive. A CT chest has features supportive of the diagnosis.
Which of the following findings is most commonly seen on CT chest in this condition?
a. Airway wall thickening
b. Increased mediastinal or hilar lymph node enlargement
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Table 2.2:
Position of Defect Peritoneal Covering Herniated Liver Associated Bowel
Complications
23. A 62 year old woman, with known gallstones, presents to the emergency department with
abdominal pain and vomiting. An abdominal radiograph is performed which shows bowel
obstruction, pneumobilia and a densely calcified abdominal mass. The doctors suspect the
patient has gallstone ileus.
What is the most likely site of bowel obstruction?
a. D2
b. Proximal ileum
c. Caecum
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d. Terminal ileum
e. Sigmoid colon
24. An MRI is performed for an Ear, Nose and Throat clinic patient with right haemotypanum
and conductive hearing loss. There is a well-defined mass in the right middle ear without
evidence of adjacent bone involvement. This is predominantly high signal on T1 and T2
weighted sequences with a rim of peripheral low signal. Hyperintensity is maintained on a fat
supressed sequence. There is mild peripheral enhancement but no restricted diffusion.
What is the most likely underlying cause?
a. Cholesterol granuloma
b. Cholesteatoma
c. Chondrosarcoma
d. Glomus tympanicum
e. Mucocoele
25. A 28 year old female non-smoker presents to the emergency department with acute onset
shortness of breath and left sided chest pain. She had a chest radiograph which demonstrates a
left sided pneumothorax. The acute medical team site a chest drain and she undergoes a high
resolution CT chest. The CT shows the drain sited appropriately with almost complete resolution
of the pneumothorax. Within the lungs there are multiple, bilateral thin-walled cysts. These are
uniform in size, distributed in all zones and have normal intervening lung parenchyma.
What is the most likely underlying diagnosis?
a. Birt-Hogg-Dubé syndrome
b. Lymphocytic interstitial pneumonia
c. Pneumocystis jiroveciinfection
d. Pulmonary Langerhans cell histiocytosis
e. Tuberous sclerosis
26. A 42 year old female patient without significant past medical history presents to her GP with a
3 week history of feeling increasingly tired and feverish with generalised aches and pains. On
examination, the chest is clear and the abdomen is soft and non-tender. The GP notes
characteristic tender swollen red patches on both her lower limbs. A chest radiograph is
requested and reports bilateral prominent hila but the lungs are clear.
Which diagnosis is most appropriate?
a. Chronic lymphocytic leukaemia
b. Löffler syndrome
c. Löfgren syndrome
d. Sapho syndrome
e. Sever disease
27. A contrast enhanced CT abdomen and pelvis is performed for a 49 year old female patient with
abdominal pain. Previous medical history includes smoking, hypertension, type 2 diabetes and
a community acquired pneumonia which was treated by the GP 2 weeks previously. The CT
identifies bowel wall thickening and hyperenhancement along with pericolic fat stranding and a
small amount of free fluid. These changes affect the entire colon and rectum.
Which radiological feature is more suggestive of inflammatory bowel disease rather than
pseudomembranous colitis?
a. Bowel wall thickening
b. Free fluid
c. Mucosal hyperenhancement
d. Pericolic fat stranding
e. Rectal involvement
28. A 53 year old female patient has a contrast enhanced CT abdomen pelvis for non-specific
abdominal pain. This identifies multiple small, ill-defined, bilateral renal lesions which are
hyperdense to the adjacent renal parenchyma. The kidneys are unobstructed. You also report
an ill-defined 16 mm splenic lesion and 12 mm short axis retrocrural and retroperitoneal
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lymph node enlargement. The other solid abdominal viscera are within normal limits. The
imaged lung bases demonstrate multiple pulmonary nodules.
What is the most likely primary malignancy?
a. Breast
b. Lung
c. Lymphoma
d. Melanoma
e. Gastrointestinal tract
29. The neonatal intensive care unit request a written report for a radiograph of a baby who has
just undergone endotracheal intubation.
When reviewing the position of the endotracheal tube, which of the following statements is
correct?
a. The tube tip should be projected approximately 1.5 cm distal to the carina
b. The tube tip should be projected approximately 1.5 cm proximal to the carina
c. The tube tip should be projected approximately 3 cm proximal to the carina
d. The tube tip should be projected around the level of T4
e. The tube tip should be projected at the level of the superior clavicular line
30. A 10 year old boy presents with a sudden reduction in GCS following a week-long history of
headaches, nausea and vomiting. A CT head shows hydrocephalus and a large cystic mass in
the posterior fossa. An MRI brain is performed. This demonstrates a well-defined cystic mass
arising from the cerebellum. There is also a small solid component which is isointense on T1
weighted imaging and hyperintense to the adjacent cerebellum on T2 weighted imaging. It
shows avid contrast enhancement on T1 post contrast.
Which diagnosis is most consistent with this description?
a. Cerebellar abscess
b. Ependymoma
c. Medulloblastoma
d. Pilocytic astrocytoma
e. Pleomorphic xanthoastrocytoma
31. A 52 year old male patient presents with symptoms of shortness of breath and pedal oedema.
Echocardiogram shows reduced contractility and ejection fraction. The only previous imaging
is a radiograph of the left hand 2 years previously. This was performed for trauma and did not
show a fracture but did report osteopenia and chondrocalcinosis, as well as osteophytes. The
cardiac MRI demonstrates reduced myocardial signal intensity. You notice on the MRI scout
images that the liver has an irregular contour.
What is the most likely diagnosis?
a. Amyloidosis
b. Alcohol related dilated cardiomyopathy
c. Haemochromatosis
d. Haemosiderosis
e. Sarcoidosis
32. A 56 year old male patient has 6 months of increasing thoracic back pain. A lumbar spine
radiograph performed at first presentation was normal. A more recent MRI lumbar spine shows
vertebral body collapse at T12. Marrow signal at T12 is hypointense to the intervertebral disc on
T1 and T2 weighted images with no hyperintensity on the STIR sequence.
Which other feature would most appropriately correlate with these findings?
a. Convex margin of the posterior vertebral body
b. Post-contrast enhancement in the vertebral body
c. Multiple further fractures
d. Retropulsion of bone fragments
e. Vacuum phenomenon of the intervertebral disc
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33. A 56 year old man with a background of hepatitis C undergoes a routine surveillance liver
ultrasound. There is a 3-cm hyperechoic lesion in segment VI of the liver. A CT liver is
performed. The lesion is arterially enhancing with rapid contrast washout. The case is
discussed at the regional hepatocellular carcinoma MDT meeting.
Which of the following statements are true regarding the management of hepatocellular
carcinoma?
a. Transarterial chemoembolisation (TACE) is a curative treatment option
b. TACE and thermal ablation cannot be used together
c. TACE is indicated in Child-Pugh score C and D patients
d. TACE may be used for large, unresectable tumours
e. Thermal ablation is a curative treatment option
34. Antenatal scans for a 3 day old baby demonstrated polyhydramnios. A chest radiograph
following a difficult insertion of a nasogastric tube depicts a coiled tube projected over the
mediastinum. The patient has surgical management for oesophageal atresia. A subsequent
upper gastrointestinal water soluble contrast study demonstrates a good result but reveals a
short narrowing of the duodenum at D2. There are normal calibre gas-filled distal small and
large bowel loops. A couple of hemivertebrae are noted.
What is the most likely cause?
a. Annular pancreas
b. Duodenal atresia
c. Duodenal diverticulum
d. Duodenal web
e. Pancreas divisum
35. An MRI brain has been performed for a 32 year old neurology outpatient with worsening
parkinsonism and ataxia. A recent CT brain found no focal abnormality. The MRI
demonstrates T2 hyperintensity in the caudate nuclei, lateral thalami, putamina and
tegmentum with sparing of the red nuclei and substantia nigra.
What is the most likely diagnosis?
a. Haemochromatosis
b. Menke’s disease
c. Pantothenate kinase-associated neurodegeneration
d. Creutzfeldt-Jakob disease
e. Wilson disease
36. A chest radiograph for a febrile 6 year old child with a cough demonstrates left lower lobe air
space opacification with air bronchograms. There is no evidence of cavitation or significant
volume loss and no pleural effusion. The right lung is clear. Heart size is normal.
What is the most likely causative organism?
a. Group B streptococcus
b. Haemophilus influenzae
c. Klebsiella
d. Listeria
e. Pneumococcus
37. A 42 year old male patient presents to the urgent care centre with a 2 month history
of increasing shortness of breath on exertion. His past medical history includes scoliosis
and an episode of spontaneous pneumothorax 20 years previously. Chest radiograph is
in keeping with pectus excavatum but is otherwise normal with no pneumothorax.
An echocardiogram reports reduced ejection fraction and an aortic root diameter of
57 mm.
What is the most likely unifying diagnosis?
a. Beals syndrome
b. Homocystinuria
c. Loeys-Dietz syndrome
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d. Marfan syndrome
e. Multiple endocrine neoplasia
38. A 72 year old male patient presents to the emergency department with facial bruising and
swelling. Radiographs of his facial bones reveal a fracture of the nasal bone and soft tissue
swelling. You also notice a couple of lucent areas in the partially imaged skull which are well-
defined without surrounding sclerosis. In his right proximal ulna there is bony expansion and
a lytic lesion extending along the cortex. Subsequent nuclear medicine bone scan reveals tracer
uptake in all these regions, particularly peripherally in the skull lesions. There is also diffuse
uptake throughout the L3 vertebral body.
What is the most likely underlying diagnosis?
a. Fibrous dysplasia
b. Langerhans cell histiocytosis
c. Myeloma
d. Metastatic disease
e. Paget’s disease
39. A 32 year old woman complains of right upper quadrant pain. Ultrasound demonstrates a
well-defined solitary lesion in the right lobe of the liver.
What further imaging features would favour a diagnosis of focal nodular hyperplasia rather
than hepatic adenoma?
a. No uptake of hepatobiliary contrast agent on MRI
b. T1 hyperintensity on MRI
c. Lesion size greater than 10 cm
d. Central T2 hyperintense scar on MRI
e. Reduced tracer uptake on Tc99m sulphur colloid scan
40. A 35 year old male patient with no fixed abode is admitted with bilateral flank pain and
haematuria. The flank pain is worse on the right side. An abdominal radiograph reveals no
urinary tract calcification; however, there is coarse calcification in the left upper quadrant. The
left femoral head is noted to be flattened and sclerotic.
Renal ultrasound identifies mild right hydronephrosis but no calcified calculi. There are
similar findings following an unenhanced CT urinary tract. A contrast enhanced CT urogram
is then performed which identifies a few small filling defects in the right renal pelvis.
Which of the following conditions accounts for the findings in this case?
a. Acute tubular necrosis
b. Indinavir calculi
c. Papillary necrosis
d. Pyelouretitis cystica
e. Pyonephrosis
41. A trauma CT scan is completed for a child following a road traffic collision. There are multiple
pelvic fractures and evidence of haemorrhage within the pelvis. The CT has features of
hypoperfusion complex.
Which of the following is NOT consistent with hypoperfusion?
a. Hyper enhancing kidneys
b. Increased adrenal gland enhancement
c. Increased splenic enhancement
d. Small calibre aorta
e. Thickened jejunal wall with hyperdense mucosa
42. A 53 year old presents with a 2 day history of seizures, reduced conscious level and fever.
There is no history of trauma or significant medical history. An admission CT head 2 days
previously was normal. An MRI reveals signal abnormality in the cingulate gyrus and
asymmetrical signal in the insula cortices and posterior temporal lobe white matter and
cortex with predominantly T2 and FLAIR hyperintensity. There is restricted diffusion in the
areas of FLAIR hyperintensity and subtle gyral enhancement. There are small punctate foci
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of T2 hypointensity which are high signal on T1 sequences. The basal ganglia have normal
appearances.
What is the most likely underlying cause?
a. Autoimmune encephalitis
b. Epstein-Barr virus encephalitis
c. Gliomatosis cerebri
d. Herpes simplex encephalitis
e. Middle cerebral artery territory infarct
43. A patient is referred to the respiratory team for follow-up of an incidental lung nodule seen in
the visualised lung bases on an unenhanced CT urinary tract performed for renal colic. They
have a past medical history of rheumatoid arthritis.
What is the most common finding in the thorax in rheumatoid arthritis?
a. Bronchiectasis
b. Lung nodule
c. Pleural effusion
d. Pulmonary artery hypertension
e. Pulmonary fibrosis
44. A 40 year old female patient has lumbar spine and pelvic radiographs following a
trampolining accident. The emergency department junior doctor asks you to review it as he is
unsure if there is abnormality of the sacrum. There are no acute fractures. There is dense
subchondral sclerosis at the inferior aspects of the bilateral medial iliac bones. Sacroiliac and
hip joint spaces are well preserved. There is no cortical irregularity.
What recommendation is the most appropriate?
a. MRI sacrum with T1, T2 and STIR sequences
b. No further action required
c. Nuclear medicine bone study
d. Review other previous plains films to assess for other skeletal manifestations
e. Suggest clinical correlation and consideration of rheumatology referral
45. The ultrasound of a 71 year old female patient with weight loss and abdominal bloating
demonstrates large volume ascites. Past medical history includes hyperlipidaemia. A CT chest
abdomen pelvis reveals bibasal atelectasis in the lungs with a couple of 3 mm lung nodules
unchanged from a CT pulmonary angiogram 3 years previously.
In the abdomen and pelvis there is large volume of septated fluid with a density ranging
from 0 to 12HU. Scalloping of the hepatic and splenic contours is evident; however no
parenchymal splenic or hepatic lesions are identified. There are several calcified peritoneal
foci and multiple small lymph nodes.
What is the most likely diagnosis?
a. Peritoneal lymphomatosis
b. Peritoneal mesothelioma
c. Sclerosing peritonitis
d. Pseudomyxoma peritonei
e. Tuberculosis
46. A 54 year old male undergoes a follow-up MRI brain with spectroscopy. He has a left
frontal lobe glioblastoma diagnosed 6 months previously that was treated with
chemoradiotherapy. The scan shows a substantial increase in size of the peripherally
enhancing component of the tumour. There is surrounding vasogenic oedema causing
mass effect.
Which of the following features indicate tumour progression as opposed to pseudo progression?
a. Elevated ADC values
b. Elevated Cho/NAA ratio
c. Increased lactate peak
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51. A 45 year old male presents with acute, severe abdominal pain. This is localised to the right
lower abdomen. A CT abdomen pelvis demonstrates a well-defined 3.5-cm area of
homogenous, high attenuation fat with stranding within the mesentery adjacent to the
ascending colon. The adjacent colon and small bowel are normal.
What is the most likely diagnosis?
a. Desmoid tumour
b. Diverticulitis
c. Epiploic appendagitis
d. Omental infarction
e. Mesenteric vein thrombosis
52. A 24 year old patient has an MRI pelvis following an abnormal cervical smear and subsequent
examination under anaesthetic and biopsy reveals squamous cell carcinoma. The patient tests
positive for human papilloma virus. The patient is going to be discussed at the gynaecology
MDT meeting.
Which initial staging imaging is most appropriate?
a. CT chest/abdomen and MRI pelvis
b. CT chest and MRI abdomen/pelvis
c. CT chest/abdomen/pelvis and US pelvis
d. 18F-FDG PET/CT and CT chest/abdomen/pelvis
e. 18F-FDG PET/CT and MRI pelvis
53. A 15 month old with abdominal distension has an abdominal ultrasound. This identifies a
large right upper quadrant mass, inseparable from the liver. The lesion contains multiple
anechoic, septated cysts. The septae demonstrate vascularity. The kidneys, pancreas and
spleen have normal appearances. There is no free fluid. The aorta is normal calibre. Serum
alpha-fetoprotein is normal.
What is the most likely diagnosis?
a. Hepatic adenoma
b. Hepatoblastoma
c. Infantile haemangioendothelioma
d. Mesenchymal hamartoma
e. Metastatic Wilms tumour
54. A 30 year old male is referred by the neurologists with a several month history of headache.
He was found to have papilloedema. An MRI brain shows a well-defined intraventricular
mass. This appears to arise from the septum pellucidum. It is T1 isointense and T2
hyperintense with multiple cystic regions. There is blooming artefact on susceptibility
weighted imaging. It shows mild, heterogenous T1 enhancement.
What is the most likely diagnosis?
a. Central neurocytoma
b. Choroid plexus papilloma
c. Ependymoma
d. Intraventricular meningioma
e. Subependymal giant cell astrocytoma
55. A 21 year old male student has a chest radiograph prior to going travelling which reveals an
incidental smooth, rounded mediastinal mass at the level of the hila. Subsequent CT chest
shows that this is a well-defined, thin walled lesion in the middle mediastinum just caudal to
the carina and anterior to the oesophagus with a density of 11HU. It does not enhance
following contrast administration.
What is the most likely diagnosis?
a. Bronchogenic cyst
b. Enlarged subcarinal lymph node
c. Enteric cyst
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d. Neurenteric cyst
e. Pericardial cyst
56. A 27 year old male presents to the emergency department with right wrist pain. There is no
history of trauma, there is point tenderness on examination. A plain film of the wrist is
performed which demonstrates increased sclerosis of the lunate bone. The ulnar is also noted
to be approximately 5 mm shorter than the radius.
What is the most likely diagnosis?
a. Blount disease
b. Freiberg disease
c. Kienböck disease
d. Köhler disease
e. Preiser disease
57. A CT abdomen pelvis is performed for a 76 year old GP patient who is feeling well in himself
but has deranged liver function tests. It has been reported as having a liver with an increased
attenuation of around 100HU. A recent ultrasound abdomen showed no gross abnormality.
There is no previous CT imaging for comparison.
Which of the following conditions would NOT be associated with this radiological finding?
a. Amiodarone hepatotoxicity
b. Thalassaemia
c. Hepatic amyloidosis
d. Previous Thorotrast use
e. Wilson disease
58. A 45 year old female has a staging CT scan of the chest, abdomen and pelvis following a recent
diagnosis of breast cancer. Within the visualised proximal left femur there is a low density lesion
seen in the subtrochanteric region. It has a thin sclerotic margin and there is the impression of a
central calcified nidus, although the lesion is not completely imaged. Further assessment with
MRI is performed; the lesion demonstrates high T1 signal, and there is a low signal intensity rim.
What is the most likely diagnosis?
a. Chondromyxoid fibroma
b. Fibrous dysplasia
c. Intraosseous ganglion cyst
d. Intraosseous lipoma
e. Metastasis
59. An 8 year old girl has had a couple of small volume episodes of rectal bleeding following an
upper respiratory tract infection 1 week prior to this. An abdominal ultrasound identifies a
pseudo kidney appearance in the right upper quadrant. During the scan both kidneys are also
noted to be enlarged and mildly hyperechoic with reduced corticomedullary differentiation.
The liver and spleen have normal appearances. The child reports arthralgia and has a rash on
the back of her legs.
Which of the following is the most likely diagnosis?
a. Eosinophilic granulomatosis with polyangiitis (Churg-Strauss)
b. Granulomatosis with polyangiitis (Wegener granulomatosis)
c. IgA vasculitis (Henoch-Schönlein purpura)
d. Intussusception
e. Systemic lupus erythematosus
60. An MRI brain is performed for a stroke patient confirming a right middle cerebral artery
territory infarct. Whilst reviewing the acquired images you note a well-defined midline
nasopharyngeal mass, just deep to and elevating the mucosa of the posterior nasopharynx
between the heads of the longus colli muscles. The mass is homogenous, T1 isointense and T2
hypointense. There is no restricted diffusion. Looking at a previous MRI from 1 year earlier,
this was present at that time and has not changed.
What is the most likely underlying cause?
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patient with an ABCDE approach and diagnose anaphylaxis. You follow the anaphylaxis
treatment algorithm.
What is the most appropriate next step?
a. High flow oxygen via a non rebreathe mask
b. 500 µg of 1:1000 intramuscular adrenaline
c. 1 mg of 1:10,0000 adrenaline via intravenous injection
d. 10 mg slow intravenous injection of chlorphenamine
e. 200 mg hydrocortisone via intravenous injection
71. A 55 year old man has an MRCP as an investigation for recurrent pancreatitis. A previous CT
demonstrates generalised pancreatic atrophy. At MRCP the main pancreatic duct measures
7 mm and there is a enhancing solid nodule with low signal on T2 weighted imaging in the
pancreatic head. No calcification is associated with this when reviewed alongside the
previous CT.
What is the most likely diagnosis?
a. Branch duct intraductal papillary mucinous papillary neoplasm
b. Main duct intraductal papillary mucinous neoplasm
c. Insulinoma
d. Serous cystadenoma
e. Mucinous cystadenoma
72. A 36 year old woman with neurofibromatosis type 1 has an MRI brain and whole spine as part
of her annual follow-up.
Which of the following findings would NOT be expected in her condition?
a. Diffusely thickened, enhancing optic nerve
b. Enhancing bilateral cerebellopontine angle masses
c. Expanded spinal dura causing posterior vertebral scalloping
d. Kyphoscoliosis
e. Multiple, bilateral cerebral white matter high T2/FLAIR signal lesions
73. A 25 year old asymptomatic male doctor requires a chest radiograph to apply for a visa to
work in Australia. The chest radiograph is performed which is of good quality, although
slightly rotated to the left side. It demonstrates increased transradiancy of the whole right
hemithorax. Lung markings are present; however there is paucity of the vascular markings on
the right when compared to the left side. The hilum of the right side is thought to be
marginally smaller than on the left; however this is difficult to determine accurately due to the
rotation.
What is the most likely aetiology?
a. Large pulmonary embolus
b. MacLeod syndrome
c. Poland syndrome
d. Pneumothorax
e. Rotated chest radiograph
74. A 50 year old male is under investigation by the endocrinology team for a hormonal disorder.
A chest radiograph is performed. There is a well-defined lucent and expansile lesion in the
lateral aspect of a left sided rib. CT chest demonstrates the lesion well. There is no associated
periosteal reaction. Further scrutiny of the distal clavicle demonstrates subperiosteal bone
resorption. Following a period of treatment, the lucent lesion resolves.
What is the most likely diagnosis?
a. Brown tumour
b. Fibrous dysplasia
c. Haemangioma
d. Metastasis
e. Myeloma
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75. A 31 year old male is referred for an abdominal ultrasound by the gastroenterologists. He
presented with pruritis and was noted to have elevated alkaline phosphatase (ALP) and
gamma glutamyl transferase (GGT). Ultrasound shows multiple dilated intra- and
extrahepatic ducts. There is increased echogenicity of the portal triads. An MRCP shows
irregular stricturing of both the intra- and extra hepatic ducts with dilatation between
strictures.
What is the most likely diagnosis?
a. Primary biliary cirrhosis
b. Choledochal cyst
c. Primary sclerosing cholangitis
d. Ischaemic cholangiopathy
e. Cholangiocarcinoma
76. A 50 year old male is involved in a road traffic collision. He was driving a car at approximately
50 mph and collided with an oncoming vehicle. A trauma CT shows multiple rib fractures, a right
lower lobe lung contusion, a grade III liver laceration and free fluid in the pelvis. In addition, there
is a nodular focus of hyperdensity seen in the body of the right adrenal gland which has density
of 70HU, and there is peri-adrenal fat stranding. The left adrenal gland is normal.
Which of the following has caused these appearances in the right adrenal gland?
a. Adrenal calcification
b. Adrenal haemorrhage
c. Adrenal hyperplasia
d. Adrenal laceration
e. Myelolipoma
77. A 4 year old girl is referred to the paediatric neurologists for investigation of recurrent
seizures and global developmental delay. An MRI brain shows a thick band of abnormal T1
hyperintense, T2 hypointense signal intensity deep to the cerebral cortex. It parallels the cortex
in contour and signal intensity. There is diminished overlying gyral sulcation and many of the
cortical sulci are shallow.
Which of the following conditions correlates best with these features?
a. Band heterotopia
b. Polymicrogyria
c. Schizencephaly
d. Subependymal heterotopia
e. Subcortical heterotopia
78. An 82 year old, unkempt woman who lives alone is admitted with acute confusion. On clinical
examination she is noted to be ataxic. A CT head is unremarkable. MRI brain demonstrates
bilateral high T2 and FLAIR signal within the mammillary bodies and medial thalami. Further
high signal is seen within the pons. Following gadolinium administration there is
enhancement of the mammillary bodies bilaterally.
What is the most likely diagnosis?
a. Cerebral lymphoma
b. Leigh syndrome
c. Osmotic demyelination syndrome
d. Pontine glioma
e. Wernicke encephalopathy
79. A 45 year old male smoker has a high resolution CT to investigate chronic cough. The only
finding is a mixed ground glass nodule in the right upper lobe measuring 9 mm in diameter.
Which of the following parameters is the most powerful in predicting invasive
adenocarcinoma over adenocarcinoma in situ or minimally invasive adenocarcinoma?
a. Nodule diameter
b. Nodule location
c. Nodule mass
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d. Nodule multiplicity
e. Nodule volume
80. A 27 year old male presents with a firm lump arising around the left elbow. Elbow
radiographs demonstrate a pedunculated bony outgrowth from the humerus consisting of the
cortex and medulla. MRI confirms the presence of a cartilage cap. The most likely diagnosis is
considered to be a benign osteochondroma.
Which of the following is most likely to be true?
a. The bony protrusion is directed away from the joint
b. The humerus is most commonly affected
c. The cartilage cap is 2.2 cm in thickness
d. There are likely to be multiple osteochondromas
e. The stem is prone to fracture
81. A 55 year old male with a background of type 2 diabetes has an abdominal ultrasound due
to deranged serum liver function tests. This shows a diffusely echogenic liver. There is
attenuation of the ultrasound beam with poor visualisation of the portal venous
architecture.
Which of the following features is most likely given the likely underlying condition?
a. Liver density of 10HU more than the spleen on unenhanced CT
b. Increased tracer uptake on Tc99m sulphur colloid scan
c. Liver reflectivity less than that of the renal cortex on ultrasound
d. Hypoenhancement of the liver relative to the spleen on contrast CT
e. Signal dropout of the liver on out-of-phase MRI sequence
82. A 6 month old girl is referred for investigation for suspected congenital cytomegalovirus
(CMV) infection due to delayed neurological development.
Which of the following features is more typically associated with congenital rubella infection
than with congenital CMV infection?
a. Hepatomegaly
b. Hydrocephalus
c. Cardiac anomaly
d. Microcephaly
e. Ultrasound showing hyperechoic foci in a periventricular distribution
83. The MRI brain of a 47 year old female neurology inpatient is reviewed. The patient is
cardiovascularly stable and immunocompetent. The MRI has features of multiple sclerosis.
However, there is also a left temporal lobe lesion. It is T2 hyperintense but the central signal is
T1 hypointense. There is surrounding white matter oedema, mass effect and a complete rim of
peripheral enhancement. Restricted diffusion is present peripherally, but not centrally. MRI
perfusion finds that relative cerebral blood flow is markedly increased both in and
surrounding the lesion.
What is the most likely diagnosis of the left temporal lobe lesion?
a. Abscess
b. Glioblastoma
c. Lymphoma
d. Metastases
e. Tumefactive multiple sclerosis
84. An 18 month old girl, born by elective caesarean section at term, is referred to the
ophthalmologists due to leukocoria. A CT orbits shows a large, calcified retrolental mass in
the left globe. An MRI of the orbits is performed, and the mass is T1 isointense and T2
hypointense. Following gadolinium administration there is heterogenous enhancement.
What is the most likely diagnosis?
a. Capillary haemangioma
b. Cavernous haemangioma
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c. Retinoblastoma
d. Retrolental fibroplasia
e. Rhabdomyosarcoma
85. An emergency department doctor asks you to review the chest radiograph of a 22 year old
woman presenting with shortness of breath and green sputum. There is patchy consolidation with
relatively symmetrical perihilar and upper lobe tubular opacities. There is elevation of the oblique
fissures and hila bilaterally. The film demonstrates a right sided tunnelled central venous catheter.
What is the most likely diagnosis?
a. Allergic bronchopulmonary aspergillosis
b. Drug induced lung disease
c. Invasive aspergillosis
d. Tracheobronchopathia osteochrondroplastica
e. Granulomatosis with polyangiitis (Wegener granulomatosis)
86. A 56 year old with left wrist pain has radiographs taken. The report suggests the presence of a
periosteal reaction at the distal radius and recommends further assessment with an MRI scan.
Which of the following features is most likely to be associated with a benign periosteal reaction?
a. Codman’s triangle (elevated periosteum)
b. Lamellated
c. Onion skin
d. Soap bubble
e. Sunray
87. An 18 month old boy presents to the emergency department with his parents following two
episodes of bright red blood in his nappy. He is cardiovascularly stable. There is no significant
medical history and he was born at term by an uncomplicated vaginal delivery. The paediatric
team suspect Meckel’s diverticulum and ask for your advice regarding imaging.
Which is the most appropriate test to confirm the diagnosis?
a. Angiography
b. CT angiography
c. Small bowel fluoroscopy
d. 99mTc-Na-pertechnetate scintigraphy
e. Ultrasound
88. A 31 year old female patient has an MRI pelvis following a completed miscarriage. The
sonographer in the early pregnancy assessment unit was concerned about a uterine anomaly
and so an MRI was arranged. The uterine cavity is bisected by soft tissue extending to the
internal cervical os. The external fundal uterine contour is convex. There is one cervix, one
vagina and two ovaries and fallopian tubes.
Which Müllerian duct anomaly does this patient have?
a. Arcuate uterus
b. Bicornuate uterus
c. Septate uterus
d. Unicornuate uterus
e. Uterus didelphys
89. A 4 year old girl presents with fever, rash, conjunctivitis and bilateral cervical lymph node
enlargement. Chest radiograph demonstrates bilateral atelectasis and a small right pleural
effusion. A diagnosis of Kawasaki disease is made.
Which of the following radiological findings would be consistent with this diagnosis?
a. Abdominal aortic wall thickening
b. Calcified splenic artery aneurysm
c. Enlarged kidneys with loss of corticomedullary differentiation
d. Renal artery microaneurysms
e. Thin-walled dilated gallbladder
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90. A 25 year old man with a background of Cowden syndrome presents to the neurologist with
left sided dysarthria and ataxia. An MRI brain is arranged. This shows a mass-like appearance
of the left cerebellum with widened left cerebellar folia and a striated appearance. The
affected area is T1 hypointense and T2 hyperintense and demonstrates high signal on both
DWI and ADC. The lesion does not enhance. Supratentorial appearances are within normal
limits.
What is the most likely diagnosis?
a. Cerebellitis
b. Cerebellar infarction
c. Cerebral lymphoma
d. Demyelination
e. Lhermitte-Duclos disease
91. A 56 year old female is under investigation for increasing shortness of breath. She has a CT
chest which shows symmetrical honeycomb destruction of the parenchyma in the lower lobes
with scattered ground glass opacification and basal volume loss. The oesophagus is markedly
patulous.
What is the most likely diagnosis?
a. Achalasia
b. Non-specific interstitial pneumonitis
c. Recurrent aspiration
d. Scleroderma
e. Usual interstitial pneumonitis
92. A 67 year old male presents with a 1 year history of pain and new bladder dysfunction.
On plain film there is a large lytic, expansile lesion within the sacrum with internal
calcification. A CT neck chest abdomen pelvis is performed − the lesion is confirmed to be
solitary and there is no evidence of visceral disease. The lesion demonstrates a narrow zone of
transition, a mixed density, with areas of low attenuation and calcification, and it enhances.
MRI pelvis shows a lobulated sacral mass, which is high signal on T2 with multiple foci of T1
high signal.
What is the most likely primary bone tumour?
a. Chondrosarcoma
b. Chordoma
c. Metastasis
d. Osteosarcoma
e. Sacrococcygeal teratoma
93. A 70 year old female has a CT abdomen and pelvis due to right upper quadrant pain and
leucocytosis. This demonstrates gallbladder wall thickening.
Which of the following features favours a diagnosis of xanthogranulomatous cholecystitis
over gallbladder carcinoma?
a. Pericholecystic infiltration into the liver
b. Biliary obstruction
c. Regional lymphadenopathy
d. Multiple, hypodense intramural nodules
e. Cholelithiasis
94. A 45 year old woman attends the neurology clinic with right-sided hearing loss and facial
paraesthesia. She also complains of intermittent dizziness. An MRI brain shows a large mass
at the right cerebellopontine angle which is high signal on T2 weighted imaging. Differentials
include vestibular schwannoma, epidermoid cyst and meningioma.
Which of the following sequences would be most helpful in deciding if the mass is an
epidermoid cyst?
a. DWI
b. FLAIR
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c. STIR
d. SWI
e. T2
95. A neonate who was diagnosed with truncus arteriosus in the antenatal period has a chest
radiograph.
Which of the following radiographic features is most likely to be observed in this child?
Table 2.3:
Heart Size Lungs Aortic Arch
96. A 7 year old boy is referred to a paediatric neurologist with lower than normal IQ and
recurrent seizures. He is noted to have a facial rash. A diagnosis of tuberous sclerosis is
suspected and an MRI brain is performed which confirms the diagnosis.
Which of the following imaging findings is most likely to be present in this child?
a. Focal areas of signal intensity in the deep white matter
b. Subcortical calcification
c. Optic nerve gliomas
d. Subependymal giant cell astrocytoma
e. Prominent leptomeningeal enhancement
97. A 23 year old motorcyclist is brought into hospital following a road traffic collision at 50 mph with
a car. The patient requires stabilising before being brought to the CT scanner for a trauma scan.
The paramedics report an open fracture to the left femur and suspect thoracoabdominal injuries.
The emergency department team ask you to review a portable chest radiograph; this demonstrates
an appropriately sited endotracheal tube and a nasogastric tube with the tip projected over the left
lower hemithorax. There are several left sided rib fractures and increased density in the left lower
zone obscuring the contour of the left hemidiaphragm. The mediastinal width is 6 cm.
Which of the following injuries would you suspect from the radiographic appearances?
a. Aortic rupture
b. Diaphragmatic rupture
c. Fat embolism
d. Tracheobronchial rupture
e. Oesophageal rupture
98. A 4 year old patient is currently under the paediatric team for investigation of severe iron
deficiency anaemia, thought to be secondary to poor nutritional state. In view of safeguarding
concerns, a skeletal survey and CT head are performed.
Which of the following findings is LEAST likely to be seen?
a. Hair-on-end appearance of the skull
b. Osteoporosis of the long bones
c. Rodent facies
d. Sparing of the occiput
e. Widening of the diploe and thinning of the inner and outer tables
99. A 34 year old woman presents to the emergency department with right upper quadrant pain.
Blood tests show she has elevated inflammatory markers and deranged liver function tests.
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An abdominal ultrasound finds that the gallbladder is distended, thick walled and
oedematous. The common bile duct measures 12 mm in diameter, extending down to the level
of the cystic duct. A 3-mm echogenic mass is seen in the cystic duct. It demonstrates posterior
acoustic shadowing. MRCP is performed which confirms the ultrasound findings and the
absence of any common bile duct stones.
What is the most accurate diagnosis?
a. Acute cholecystitis
b. Mirizzi syndrome
c. Gallbladder polyp
d. Adenomyomatosis
e. Choledochocele
100. You are asked to review the first screening mammogram for an asymptomatic patient. They
have had no previous breast imaging previously. There is calcification in the breasts.
Which of the following types of calcification is most concerning for malignancy?
a. Bilateral scattered coarse calcification
b. Branching linear calcification extending from the right upper outer quadrant towards the
nipple areolar complex
c. Calcification with a layered appearance, dependent on the MLO view in the right upper
outer quadrant
d. Coarse dystrophic calcification in right upper inner quadrant
e. Tram-like serpiginous calcification in the left upper outer quadrant extending towards the
nipple areolar complex
101. A neonate is born at term with respiratory distress. The initial radiograph shows a hazy, mass-
like opacity in the left upper zone. Follow-up radiographs show a hyperlucent left upper zone
with mass effect and contralateral mediastinal shift.
What is the most likely diagnosis?
a. Bronchial atresia
b. Bronchogenic cyst
c. Congenital lobar over inflation
d. Congenital pulmonary airway malformation
e. Mucous impaction
102. A middle-aged male patient with a low CD4 count, secondary to poorly controlled HIV
infection, is admitted as an inpatient due to deteriorating neurological function. An MRI
brain reveals normal cerebral volume and no evidence of hydrocephalus. There are
multifocal white matter abnormalities with high T2 signal and low T1 signal. This is
primarily affecting the right parieto-occipital region, and to a lesser degree the left parietal
lobe and subcortical right frontal lobe. There is no associated mass effect, no enhancement
and minor peripheral restricted diffusion.
What is the most likely diagnosis?
a. Cerebral toxoplasmosis
b. Cytomegalovirus encephalitis
c. HIV encephalopathy
d. Posterior reversible encephalopathy syndrome
e. Progressive multifocal leukoencephalopathy
103. A 56 year old male who retired from the mining industry 10 years ago has investigations for
worsening shortness of breath. The CT chest shows tiny calcified nodules predominantly in
the upper lobes. In the right mid-zone the nodules coalesce and there is upper lobe fibrosis
with volume loss and elevation of the hila bilaterally. The hila lymph nodes demonstrate
eggshell calcification.
What is the most likely diagnosis?
a. Caplan syndrome
b. Coal workers’ pneumoconiosis
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c. Hypersensitivity pneumonitis
d. Pulmonary alveolar proteinosis
e. Silicosis
104. A baby is stillborn with obvious skeletal abnormalities including shortening and bowing of
the femora and humeri with metaphyseal flaring. The child is short in length and plain films
also reveal platyspondyly, trident acetabula and squared iliac wings.
The features are considered to be in keeping with thanatophoric dysplasia. What type of
dwarfism are these imaging appearances consistent with?
a. Acromelic
b. Mesomelic
c. Metatrophic
d. Micromelic
e. Rhizomelic
105. A Meckel diverticulum is diagnosed incidentally on an MRI small bowel performed for a
patient with Crohn’s disease.
Where is the diverticulum most likely to have been visualised?
a. Antimesenteric border of the distal jejunum
b. Antimesenteric border of the distal ileum
c. Antimesenteric border of the proximal ileum
d. Mesenteric border of the distal ileum
e. Mesenteric border of the proximal jejunum
106. A 15 year old female with physical features of a short neck and low posterior hairline has restricted
neck movement. She has an MRI of the spine, which demonstrates scoliosis, spinal stenosis within
the cervical spine, partial fusion of C2 and C3 as well as the presence of hemivertebrae.
What is the most likely diagnosis?
a. Ankylosing spondylitis
b. Homocysteinuria
c. Juvenile idiopathic arthritis
d. Klippel-Feil syndrome
e. Turner syndrome
107. A 12 year old boy is referred to the paediatric cardiologists with shortness of breath and
palpitations. On examination he is found to have an ejection systolic murmur heard loudest at
the left upper sternal border. He is suspected of having an atrial septal defect.
Which of the following radiological signs would be indicative of an atrial septal defect?
a. Enlarged left atrium
b. Enlarged aortic arch
c. Enlarged right atrium
d. Enlarged left ventricle
e. Lower zone vascular prominence
108. A 62 year old presents with worsening headaches, dysarthria and confusion. A CT brain
shows an ill-defined, hypoattenuating mass arising from the midline with a large amount of
surrounding vasogenic oedema. The patient then has an MRI brain. Again, there is a large,
solitary central mass which involves the corpus callosum and crosses the midline. The mass
shows ring-like post contrast T1 enhancement. There is minimal restricted diffusion.
What is the most likely diagnosis?
a. Cerebral lymphoma
b. Cerebral metastasis
c. Demyelination
d. Glioblastoma multiforme
e. Toxoplasmosis
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109. A 72 year old female patient with right lower limb intermittent claudication has a CT
angiogram of her lower limbs which identifies widespread vascular calcification with a short
tight stenosis of her right common iliac artery. The patient is prepared for an interventional
radiology procedure to stent the stenotic segment. Endovascular access is straightforward and
the stenosis is confirmed with digital subtraction angiography. Following positioning of the
stent and dilatation of the stenosis, the patient’s blood pressure suddenly drops and the
patient becomes tachycardic.
What is the most appropriate immediate management?
a. CT angiogram of the lower limbs
b. Deploy embolisation coils at the site of the stenosis
c. Re-inflate the balloon at the site of stenosis
d. Re-inflate the balloon proximal to the stenosis
e. Remove the vascular access sheath, wire and balloon
110. A 12 year old male attends the GP with his mother. He complains of knee pain and swelling.
He plays football regularly but doesn’t recall any specific trauma. The GP refers him for a
plain film, which shows increased radiolucency of the infrapatellar fat pad, fragmentation of
the tibial tubercle, loss of the sharp margin of the patellar tendon and anterior soft tissue
swelling.
Which of the following is LEAST likely to be seen on the subsequent MRI?
a. Anterior cruciate ligament tear
b. Bone marrow oedema on STIR sequence
c. Distension and fluid in the deep infrapatellar bursa
d. Oedema in the soft tissues and the Hoffa fat pad
e. Thickening of the distal patellar tendon
111. A 67 year old female presents with a palpable abdominal mass. A CT abdomen pelvis demonstrates
a large retroperitoneal soft tissue mass containing fat density as well as soft tissue density.
Which of the following is most accurate?
a. Distant metastases are a rare finding in leiomyosarcoma
b. The myxoid type subtype of liposarcoma typically shows low T2 signal
c. Liposarcoma are the most common retroperitoneal sarcoma
d. Calcification is rare in malignant fibrous histiocytoma.
e. Retroperitoneal angiosarcoma has rarely metastasised at presentation
112. A 32 year old female patient had a living donor renal transplant 3 years previously in France
and has now relocated to the UK. Her GP refers her for transplant follow-up and the patient
has an outpatient renal ultrasound. This identifies the transplant kidney in the right iliac fossa.
There is a 10-mm upper pole simple renal cyst and no hydronephrosis. There is good global
perfusion of the kidney with an arterial resistive index of 0.6 and forward flow in diastole.
Normal colour Doppler flow is evident in the renal vein. There is a 50-mm avascular, thin-
walled, anechoic structure which appears separate from, but adjacent to, the kidney.
Based on the imaging characteristics, what is the most likely diagnosis?
a. Abscess
b. Haematoma
c. Lymphocele
d. Seroma
e. Urinoma
113. A 14 year old boy is referred to the paediatricians for recurrent chest infections. A chest
radiograph shows a wedge-shaped opacity within the medial right lower zone.
Bronchopulmonary sequestration is suspected, and a CT thorax is arranged.
Which of the following features favour a diagnosis of intralobar sequestration over extralobar
sequestration?
a. Associated diaphragmatic hernia
b. Venous drainage to pulmonary veins
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e. Severe cerebellar hypoplasia without displacement of the cerebellum through the foramen
magnum
119. A 57 year old male oncology patient with T3c N1 M1 renal cell carcinoma is suspected to have
acute Budd-Chiari syndrome following an admission with abdominal pain, abnormal liver
function tests and rapid onset ascites. A contrast enhanced CT chest, abdomen and pelvis is
performed. This confirms thrombus partially obstructing the suprahepatic inferior vena cava
and there is a large volume of ascites.
What CT finding would NOT be consistent with acute Budd-Chiari syndrome?
a. Absent hepatic veins
b. Caudate lobe hypertrophy
c. Hepatosplenomegaly
d. Hyperenhancing early phase central liver enhancement
e. Increased portal vein diameter
120. A 42 year old man without significant past medical history has returned to the UK after 5 years
teaching in Asia. He presents with headache and seizures. His MRI brain identifies hydrocephalus
and there are multiple small bilateral parenchymal cysts. These are predominantly at the
grey−white matter junction and some of them have a small amount of surrounding oedema and
rim enhancement. There is also a cyst in the fourth ventricle, which appears as a small nodular
focus of increased T1 signal compared to the cerebrospinal fluid. This enhances following
contrast.
What is the most likely diagnosis?
a. Cryptococcus
b. Hydatid cysts
c. Neurocysticercosis
d. Toxoplasmosis
e. Tuberculosis
ANSWERS 2
1. (d) MRI
Popliteal artery entrapment syndrome is caused by symptomatic compression or occlusion of
the popliteal artery by adjacent structures. It commonly presents in athletic males and is most
frequently caused by the medial head of gastrocnemius or occasionally popliteus. It presents as
intermittent claudication, which may be exacerbated by plantar flexion, or with thrombosis and
can be bilateral in two-thirds. MRI is the favoured imaging modality because it demonstrates
the underlying anatomy and aids surgical planning. Arterial phase CT and angiography would
help to delineate the popliteal artery but the underlying soft tissue definition is better on MRI
than CT. Similarly, ultrasound can help to demonstrate the artery and plantar flexion whilst
scanning may reveal arterial compression, but MRI would still be favoured for surgical
planning. A knee radiograph would not provide much benefit in this scenario.
(The Final FRCR Complete Revision Notes Page 14)
2. (a) Congo red stain following biopsy
The case describes amyloid arthropathy caused by amyloid deposition in the joints. This can be
primary, or secondary to dialysis-dependent renal failure or multiple myeloma. It often presents as
a large joint, bilateral, symmetrical arthropathy. Shoulder pain and carpal tunnel syndrome are
common. Radiographic findings include preservation of joint space with subchondral cyst
formation and well circumscribed erosions. MRI can reveal low T1 and T2 intra-articular nodules
and bone lesions which enhance following contrast. Amyloid protein stains with Congo red.
Cartilage pigmentation is seen in ochronosis, otherwise known as alkaptonuria. Homogentisic
acid accumulates within cartilage leading to dark pigmentation and premature degeneration.
Synovial pigmentation is a feature of pigmented villonodular synovitis due to haemosiderin
staining.
Staphylococcus aureus is associated with spondylodiscitis. Amyloid lesions in the spine can
resemble discitis; however, the disc would be expected to have high T2 signal rather than the low
signal described in the question.
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Secondary hyperparathyroidism is associated with chronic renal failure too but features
include metastatic calcification and osteosclerosis with the ‘rugger jersey’ spine appearance.
Weakly positive birefringent crystals are associated with calcium pyrophosphate deposition
disease (CPPD), also known as pseudogout. This can be commonly misdiagnosed as
osteoarthritis due to overlapping features but the distribution is more unusual and
chondrocalcinosis is frequently present.
(The Final FRCR Complete Revision Notes Page 62)
3. (c) Aperistalsis of the lower oesophagus
The oesophagus is the most commonly affected part of the gastrointestinal tract in
scleroderma. There is fibrosis of the smooth muscle, resulting in a dilated oesophagus with
absent or reduced peristalsis in the distal two-thirds. A mediastinal air-fluid level may be
apparent on frontal imaging due to poor oesophageal emptying. The upper oesophagus is
composed of skeletal muscle and is therefore unaffected. Aspiration, reflux, Barrett oesophagus
and distal strictures are all potential complications. Warm fluids may help the passage of
contrast in achalasia but this is not a feature of scleroderma.
(The Final FRCR Complete Revision Notes Page 180)
4. (a) Page kidney
Arterial resistive index can be raised above normal limits (0.70 is the upper limit of normal)
for several reasons in native kidneys, including renal artery stenosis, ureteric obstruction,
hypotension and a perinephric fluid collection.
In transplant kidneys problems such as transplant rejection, renal vein thrombosis, drug
toxicity and acute tubular necrosis are also within the differential.
Page kidney is a condition caused by a subcapsular collection compressing the kidney and
typically presenting with flank pain and hypertension. Compression of the renal vasculature
leads to activation of the renin angiotensin system.
The history and clinical presentation in this case is key. On ultrasound there is often a distorted
appearance to the kidney due to the subcapsular haematoma and an elevated resistive index. CT
may show reduced enhancement of the kidney along with the perinephric collection.
Pseudoaneurysm is possible following trauma; however, these would be more common follow
a laceration. Renal artery stenosis would be unlikely to acutely develop in this clinical setting.
Renal vein thrombosis is more common in transplant kidneys than native kidneys and the
forward flow in diastole on the arterial trace is reassuring. The lack of hydronephrosis and the
clinical history makes ureteric obstruction unlikely.
(The Final FRCR Complete Revision Notes Page 261)
5. (c) Nephroblastoma
Nephroblastoma (also known as a Wilms tumour) is the most common renal mass in
childhood. This is usually heterogenous in appearance due to necrosis, haemorrhage and less
commonly, calcification. It typically displaces adjacent structures compared to neuroblastoma
which encases them. Neuroblastoma also tends to affect a slightly younger age group.
Assessment of the adjacent vascular structures such as the renal vein and inferior vena cava is
important. It typically metastasises to adjacent para-aortic nodes, lungs and liver.
Mesoblastic nephroma is the commonest neonatal renal mass and usually presents before
3 months of age so does not fit with the patient in this case. It also can have a heterogenous
appearance. It does not typically invade the vasculature.
(The Final FRCR Complete Revision Notes Page 359)
6. (b) Dilated superior ophthalmic vein
The history is suggestive of a caroticocavernous fistula; a fistula between the carotid artery and
cavernous sinus. Signs include pulsatile exophthalmos, chemosis, reduced visual acuity and cranial
nerve palsies (commonly III and VI). MRI findings include enlarged, oedematous extraocular
muscles, a dilated superior ophthalmic vein with flow void and enlargement of the cavernous
sinus. There can be enlargement of the superior orbital fissure and sella erosion when chronic.
(The Final FRCR Complete Revision Notes Pages 369–370, 376)
7. (b) Kaposi sarcoma
The perihilar and peribronchovascular nodular opacities describe the ‘flame-shaped’ nodular
opacities seen in Kaposi sarcoma, accompanied by the lymph node enlargement. This condition
is seen in patients with HIV and CD4 count <200 cells/mm3.
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The main differential diagnosis in this patient is lymphoma; however lymphoma associated
with HIV (mostly non-Hodgkin) is usually associated with disseminated extra-nodal disease
involving the CNS, GI tract and bone marrow. Lack of avidity on gallium scan is more in
favour of Kaposi sarcoma. Lymphoma is gallium avid.
Pneumocystis pneumonia can occur in patients with CD4 count <200 cells/mm3. The
imaging appearances are of diffuse ground glass opacification but enhancing lymph node
enlargement is not a feature.
Cytomegalovirus (CMV) can be seen in patients with CD4 >200cells/mm3. The predominant
imaging features of pulmonary CMV are multiple ground glass pulmonary nodules and
consolidation. Mycobacterium avium is seen in patients with CD4 count <50 cells/mm3.
(The Final FRCR Complete Revision Notes Page 33)
8. (c) Psoriatic arthritis
Psoriatic arthritis is one of the seronegative spondyloarthropathies. It most commonly affects
the hands and feet and can manifest as a symmetric polyarthropathy or asymmetric
oligoarthropathy at these sites. When affecting larger joints it is typically asymmetrical. The
spine and sacroiliac joints are also commonly involved.
Findings in the hands and feet include a predominance for the distal joints, marginal
erosions, periostitis, joint space widening and preserved bone density. As the disease
progresses, changes such as terminal tuft resorption and pencil-in-cup deformity can also
be seen.
Rheumatoid arthritis tends to be symmetrical with a predilection for the metacarpal
phalangeal joints causing periarticular osteopenia and erosions.
Reactive arthritis (previously known as Reiter syndrome) preferentially affects young men
and the feet. It can also cause periosteal reaction but has a predilection for the first metatarsal
phalangeal joint and calcaneus.
Erosive osteoarthritis also typically affects the distal interphalangeal joints but causes more
central erosions and marginal osteophytes leading to the ‘gull-wing’ appearance.
Gout is more likely to be monoarticular affecting the first metatarsal phalangeal joint. It also
does not commonly cause periarticular osteopenia. The erosions are more peripherally sited
than in psoriatic or rheumatoid arthritis and are well-defined with sharp overhanging edges.
(The Final FRCR Complete Revision Notes Page 91)
9. (d) Fat supressed T2 weighted sequence
MRI is helpful in Crohn’s disease for monitoring disease activity and has the added benefit of
no radiation, particularly for younger patients with the condition. Fistulae are possible in
Crohn’s disease due to transmural bowel inflammation. Bowel wall ulceration can progress to
full thickness fistulae which can communicate between bowel loops as well as between bowel
and bladder, perineum or sometimes the vagina.
Although all the sequences in the question may be employed for an MRI looking for
manifestations of Crohn’s disease, fistulae can be visualised particularly well with fat
supressed T2 weighted imaging, where they appear as a high signal tract. Following contrast
administration the fistulae will enhance and post contrast enhancement can also highlight other
areas of disease activity within the abdomen and pelvis.
(The Final FRCR Complete Revision Notes Page 162)
10. (c) Radiograph of the proximal femur
The question describes typical MRI findings of myositis ossificans. This condition causes
heterotopic bone formation, most commonly following trauma but it occurs in paraplegic
patients, sometimes with no history of preceding trauma. Typical radiographic appearances
include a lesion adjacent to the knee or hip with peripheral calcification. Calcification will be
low signal on T1 MRI sequences and sometimes the early features can include quite marked
increased STIR signal extending into the muscle.
The main imaging differential is paraosteal osteosarcoma but these tend to calcify centrally
rather than peripherally and on MRI they are often low signal on both T1 and T2 sequences.
Radiographs can therefore help to confirm benignity. Myositis ossificans is a ‘don’t touch’ lesion,
meaning the radiological features are characteristic and they should not be biopsied. Histology
from myositis ossificans can be difficult to differentiate from a soft tissue osteosarcoma.
Nuclear medicine bone scan may show uptake in both myositis ossificans and malignant
lesions and will therefore not help to differentiate. Similarly, early myositis ossificans will likely
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ear, mastoid or petrous apex. Due to their cholesterol content they are T1 and T2 hyperintense
but their predisposition to haemorrhage means they may have a low signal haemosiderin rim.
There may be thinning of the adjacent bone. They may enhance peripherally but do not
demonstrate restricted diffusion.
Cholesteatoma are an important differential for a middle ear mass but they have different
signal characteristics with low T1, high T2 signal and restricted diffusion. Depending on
location they may displace and erode the ossicles.
A mucocoele may exhibit similar T1 and T2 hyperintensity as a cholesterol granuloma but
they would not have the low signal rim and enhancement described in this case.
Glomus tympanicum are highly vascular and demonstrate intense enhancement. Similar to
paragangliomas elsewhere in the body, they can have a ‘salt-and-pepper’ appearance due to
the presence of flow voids.
A chondrosarcoma affecting the skull base would be centred on the bone rather than on the
middle ear, although these masses may erode into the middle ear. Signal would classically be
T1 hypointense and T2 hyperintense with heterogenous enhancement.
(The Final FRCR Complete Revision Notes Page 431)
25. (e) Tuberous sclerosis
The imaging features are that of lymphangioleiomyomatosis (LAM), which is a rare interstitial
lung disease, more common in women of childbearing age. It manifests as thin-walled cysts of
uniform size with normal intervening lung parenchyma. Patients with the condition can present
with a pneumothorax and sometimes they develop chylous pleural effusion. It is associated with
tuberous sclerosis (approximately 40% of patients with tuberous sclerosis have LAM).
Pulmonary Langerhans cell histiocytosis occurs most commonly in smokers. Early in the disease
it is seen as 3- to 10-mm nodules in the mid-upper zones; later in the process the nodules undergo
cystic degeneration. The cysts are typically irregularly shaped and can coalesce to form ‘bizarre’-
shaped cysts. The lung parenchyma between cysts may demonstrate emphysematous change.
Birt-Hogg-Dubé syndrome is a genetic multisystem disease which is characterised by multiple
lung cysts; these are predominantly in the lower zones with variable morphology and internal
septation.
Lymphocytic interstitial pneumonia is associated with HIV and other connective tissue disorders
such as Sjögren syndrome. Interstitial infiltrate causes findings of ground glass opacification,
consolidation, centrilobular nodules and scattered pulmonary cysts.
Pneumocystis jiroveciiis an infection of immunocompromised patients. The imaging finding in this
fungal infection are typically of bilateral ground glass densities. Cysts can occur within the ground
glass density, usually in the upper zones.
(The Final FRCR Complete Revision Notes Page 42)
26. (c) Löfgren syndrome
Löfgren syndrome is an acute form of sarcoidosis characterised by fevers, malaise, arthritis,
lymph node enlargement and erythema nodosum.
Leukaemia can also cause similar symptoms along with erythema nodosum; however
chronic lymphocytic leukaemia usually affects an older age group.
Löffler syndrome is another term for simple pulmonary eosinophilia and although sounding
similar to Löfgren syndrome should not be confused with it. Patients are not usually
particularly unwell, and chest radiograph should show transient infiltrates rather than being
completely clear. Hilar lymph node enlargement is also not a feature.
Sapho syndrome is relatively rare and is a condition causing synovitis, acne, pustolosis,
hyperostosis and osteitis. Skeletally, the sternoclavicular joint is most commonly involved.
Sever disease causes pain in the posterior foot due to calcaneal apophysitis.
(The Final FRCR Complete Revision Notes Page 95)
27. (d) Pericolic fat stranding
Pseudomembranous colitis, also called Clostridioides difficile extradural soft tissue extension and
extension colitis, is commonly seen in patients following a course of antibiotics. It causes significant
bowel wall thickening which may cause a ‘thumbprint’ appearance. Approximately 40% of cases
can have ascites. It most commonly involves the entire colon including the rectum. Many
radiological features of pseudomembranous colitis overlap with inflammatory bowel disease, and
differentiation can be challenging. Wall thickening is typically more severe in
pseudomembranous colitis and any hyperenhancement is centred on the mucosa due to the
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patient, the most common causes are Mycoplasma pneumoniae, influenza A and Streptococcus
pneumoniae, also known as pneumococcus.
Pneumococcus causes a lobar pneumonia and is also a common cause of community-
acquired pneumonia in adults. It can cause lower lobe opacification and air bronchograms.
Cavitation and empyema is unusual. In children it is associated with round pneumonia.
Listeria and group B streptococcus are more common in neonates, along with Escherichia coli
and cytomegalovirus. Group B streptococcus causes bilateral opacification and reduced lung
volumes. Pleural effusions may be present.
Pre-school age children are more prone to infections with respiratory syncytial virus (RSV),
Haemophilus, pneumococcus and chlamydia.
(The Final FRCR Complete Revision Notes Page 326)
37. (d) Marfan syndrome
Marfan syndrome is an autosomal dominant connective tissue disorder which can lead to
cardiac failure. Other cardiovascular associations include a dilated aortic root, aortic aneurysm,
coarctation and dissection. Patients also have an increased risk of spontaneous pneumothorax
as well as emphysema and bullae formation. The condition is associated with both pectus
excavatum and carinatum and scoliosis. Ocular complications include myopia, cataracts,
glaucoma and lens dislocation.
Beals syndrome is also a connective tissue disorder which can have similar appearances to
Marfan syndrome but without the cardiac or ocular manifestations.
Patients with homocystinuria can also experience lens dislocation, pectus excavatum and
scoliosis. The condition also typically affects the central nervous system and patients have
prothrombotic tendencies
Loeys-Dietz syndrome is a rare autosomal dominant connective tissue disorder presenting,
amongst other features, with a triad of bifid uvula or cleft palate, hypertelorism and arterial
tortuosity and aneurysm formation.
Multiple endocrine neoplasia type IIb can cause marfanoid appearances; however it is also
associated with phaeochromocytomas, medullary thyroid cancer and mucosal neuromas.
(The Final FRCR Complete Revision Notes Pages 1, 114)
38. (e) Paget’s disease
Paget’s disease has various phases. The initial lytic phase leads to bone resorption followed
by laying down of abnormal bone with coarsened trabeculae and then later sclerosis
predominates. Paget’s disease typically affects the skull, pelvis, spine and long bones. The skull
lesions described in the question are in keeping with osteoporosis circumscripta and are
usually well-defined without a sclerotic margin. The humeral lesion which is extending along
the cortex is consistent with the ‘blade of grass’ sign which describes a lucent leading edge
when Paget’s affects long bones. During the lucent phase of Paget’s disease there is often
increased tracer uptake on nuclear medicine bone scan due to the osteoblastic activity.
Fibrous dysplasia typically causes a ‘ground glass’ appearance within the bones rather than
lysis. With myeloma there would usually be more diffuse skull and skeletal lytic lesions
causing a ‘raindrop’ appearance when affecting the skull. Metastatic disease is possible,
although again, more diffuse lesions may be expected; the distal long bones are also not
typically affected initially. When there is malignant vertebral body marrow infiltration the
uptake on nuclear medicine bone scan would usually be focal rather than the diffuse uptake
described. Similarly, the peripheral uptake in the skull lesions is typical for osteoporosis
circumscripta. Langerhans cell histiocytosis can cause lytic skull lesions but is not typical in this
age group and lesions also tend to have bevelled, sclerotic margins.
(The Final FRCR Complete Revision Notes Page 88)
39. (d) Central T2 hyperintense scar on MRI
Focal nodular hyperplasia (FNH) is a benign, hamartomatous malformation that is most
common in young women. In 50% of cases there is a central scar which is T2 hyperintense
and shows delayed enhancement. Unlike adenoma, FNH is composed of normal liver
tissue containing Kupffer cells. Therefore, they will show increased uptake of Tc99 m and
hepatobiliary specific contrast agents in sulphur colloid and MRI scans respectively. FNH
is also typically smaller (<5 cm) than an adenoma; the latter can be very large at
presentation. Adenomas are lipid rich and therefore often demonstrate T1 hyperintensity,
similarly if it has been complicated by acute haemorrhage there will be foci of high T1
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be present. Patients are usually asymptomatic. Pulmonary (rheumatoid) nodules are usually well
circumscribed; they may cavitate and can be multiple. Rheumatoid disease is also associated with
pulmonary fibrosis, most commonly usual interstitial pneumonia but also non-specific interstitial
pneumonia. Bronchiectasis and bronchiolitis obliterans are seen in a third of patients.
(The Final FRCR Complete Revision Notes Pages 52−53)
44. (b) No further action required
The features described are of osteitis condensans ilii, a benign appearance described typically
in women who have had children but also seen in nulliparous females and males. Appearances
affect the iliac side of the sacroiliac joint with subchondral sclerosis which is often triangular in
shape. The sacroiliac joint space is preserved and normal in appearance. It is usually an
incidental finding, although there are reports of it causing lower back pain.
In a case such as this where it is an incidental finding, no further action is required.
If there were features of sacroiliitis with changes affecting both sides of the sacroiliac joints
and the joint itself, then review of other skeletal films and/or rheumatology referral may be
indicated. An MRI or nuclear medicine bone scan would not be appropriate for this indication
but can be helpful in detecting insufficiency fractures of the sacrum; however this would
normally affect an older age group.
(The Final FRCR Complete Revision Notes Page 86)
45. (d) Pseudomyxoma peritonei
Pseudomyxoma peritonei is characterised by large volume of low attenuation, often
loculated fluid. There may be peritoneal calcifications present and the fluid typically causes a
scalloped appearance of the liver contour. The cause is thought to be secondary to a ruptured
benign or malignant appendiceal or ovarian mucinous tumour.
Calcifications may be associated with tuberculosis; however, the ascites associated with
tuberculosis tends to have a higher density.
The patient does not have any past medical history, such as previous peritoneal dialysis or a
ventriculoperitoneal shunt, to suggest sclerosing peritonitis is likely, and the calcification
associated with this tends to be extensive.
Peritoneal mesothelioma is rare and is not associated with large volume ascites. There is
frequently evidence of pleural calcification as peritoneal calcification can be variable.
Enlarged lymph nodes would be expected with peritoneal lymphomatosis. There are also
frequently splenic deposits and nodular peritoneal soft tissue thickening. Involvement may
also extend both above and below the diaphragm.
(The Final FRCR Complete Revision Notes Page 191)
46. (b) Elevated Cho/NAA ratio
Table 2.4 displays some of the key factors that can be used to aid differentiation between
tumour recurrence and chemoradiotherapy damage (pseudo progression).
In pseudo progression, ADC values usually increase as cell destruction occurs. ADC values
are variable in progressing tumours and this is dependent on the tumour grade. This is
therefore not a reliable way to differentiate between the two conditions. Lactate and lipid peaks
are increased in both tumour progression and pseudo progression.
(The Final FRCR Complete Revision Notes Page 386)
Source: Modified from and reprinted with permission from V Helyar and A Shaw, The Final FRCR: Complete
Revision Notes. CRC Press, Taylor & Francis Group, 2018, p. 386.
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A lymph node does not have a wall. Usually there is cortex surrounding a fatty hilum,
although abnormal nodes can become more rounded, necrotic and lose normal architecture.
Unless necrotic, the density would usually be closer to soft tissue density and there may be
enhancement following contrast administration.
Enteric cysts are uncommon, and compared to bronchogenic cysts have thick walls lined with
gastrointestinal epithelium and are intimately related to the oesophagus. They can become
symptomatic due to peptic ulceration, infection and haemorrhage.
Neurenteric cysts occur in the posterior rather than the middle mediastinum, between
the oesophagus and spine, and are typically closely related to the spine. Similar to enteric
cysts, they can be symptomatic, causing pain, and can be associated with vertebral
anomalies.
Pericardial cysts are often asymptomatic lesions at the cardiophrenic angles (R > L)
inseparable from the pericardium.
(The Final FRCR Complete Revision Notes Page 24)
56. (c) Kienböck disease
The description is that of avascular necrosis of the lunate bone. The usual age of onset in this
condition is 20–40 years. The condition is associated with negative ulnar variance. Blount disease
is avascular necrosis of the medial tibial condyle, usually affecting patients over 6 years age.
Freiberg disease typically affects the head of the second metatarsal. Sometimes the third or fourth
metatarsal may be affected. Köhler disease is avascular necrosis of the navicular in patients 3–10
years old, more common in boys. Preiser disease is non-traumatic osteonecrosis of the scaphoid.
(The Final FRCR Complete Revision Notes Page 82)
57. (c) Hepatic amyloidosis
Causes of increased liver attenuation include haemochromatosis, amiodarone use,
thorotrastosis, iron overload, Wilson disease and haemosiderosis. The latter can occur due to
haemolytic conditions such as thalassaemia or in conditions necessitating multiple blood
transfusions. In contrast to this, causes of decreased liver attenuation include diffuse fatty
infiltration, amyloidosis, hepatic venous congestion and steroid use. Glycogen storage disease
can cause either increased or reduced attenuation.
Haemochromatosis and haemosiderosis have similar imaging appearances on CT and MRI
but the distribution of changes varies slightly. MRI will demonstrate low signal with both
conditions; however in haemochromatosis the hyperattenuation on CT and reduced signal
intensity on MRI will be in the liver, pancreas and heart. In contrast to this, haemosiderosis
causes hyperattenuation and reduced signal intensity in the liver and spleen.
(The Final FRCR Complete Revision Notes Page 197)
58. (d) Intraosseous lipoma
The features described are consistent with an intraosseous lipoma. This is a rare lesion,
usually present in the metadiaphysis of long bones, particularly the intertrochanteric/
subtrochanteric femur. Features on plain film are a lucent lesion with a thin sclerotic margin
and a central calcified nidus. CT features are low density (−60 to −100HU). On MRI the lesion is
high T1 with a low signal rim.
Chondromyxoid fibroma is a rare cartilaginous tumour which is a well-defined lucent lesion
with a sclerotic rim. On MRI the lesions have a low signal on T1.
Although fibrous dysplasia can look like anything, the description of T1 high signal is more
typical of a lipoma.
Intraosseous ganglion cyst has low T1 and high T2 signal on MRI.
Metastases would not be expected to have a sclerotic rim and would be low signal on T1.
(The Final FRCR Complete Revision Notes Pages 132–133, 143–144)
59. (c) IgA vasculitis (Henoch-Schönlein purpura)
IgA vasculitis often follows an upper respiratory tract infection. The condition is characterised
by findings such as a rash on the extensor surfaces, arthralgia, glomerulonephritis, gastrointestinal
bleeding and intussusception.
Granulomatosis with polyangiitis (formerly known as Wegener granulomatosis) can cause
glomerulonephritis and haemoptysis but less commonly causes cutaneous or musculoskeletal
manifestations.
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Source: Reprinted with permission from V Helyar and A Shaw, The Final FRCR: Complete
Revision Notes. CRC Press, Taylor & Francis Group, 2018, p. 200.
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nervous, musculoskeletal and renal systems are most commonly affected. Common central
nervous system findings include optic nerve gliomas, sphenoid wing dysplasia, kyphoscoliosis
and dural ectasia causing vertebral body scalloping. Focal areas of signal intensity (FASIs) are
also a feature, and manifest as multiple cerebral and cerebellar high T2 and FLAIR foci.
Bilateral acoustic neuromas are seen in NF2.
(The Final FRCR Complete Revision Notes Page 381)
73. (b) MacLeod syndrome
The finding is most likely due to MacLeod syndrome, also known as Swyer-James syndrome.
It is often an incidental finding and is due to previous childhood infectious bronchiolitis.
Radiographic findings are that of a hyperlucent lung with reduced lung markings and normal
or small volume lung and hilum on the affected side. On HRCT there is also bronchiectasis and
bronchial wall thickening.
Poland syndrome is a congenital unilateral absence of the pectoralis major and minor
muscles which causes increased transradiancy of the hemithorax. There may also be associated
chest wall deformity. This is within the differentials for this case; however, it is a comparatively
rare condition and not associated with the paucity of vascular markings and small hilum.
Large pulmonary embolus may cause the imaging features of reduced lung markings. The
‘Westermark’ sign is a radiographic sign of focal increased lucency of the lung, thought to be
secondary to occlusion of the pulmonary artery or due to vasoconstriction distal to the
embolus. This sign is not commonly seen and the patient in the main stem is asymptomatic.
Hyperlucency due to rotation occurs in the same hemithorax as the direction of rotation and
so this cannot account for the findings in this stem.
Pneumothorax is also an important consideration; however absent lung markings would be
expected as well as presence of a lung edge.
(The Final FRCR Complete Revision Notes Pages 43, 49)
74. (a) Brown tumour
Brown tumours can be seen in primary or secondary hyperparathyroidism. They can mimic
metastases and myeloma. Brown tumours are well-defined, lucent and expansile lesions
commonly found in the jaw, rib or pelvis. There is no periosteal reaction. Following treatment
they may become sclerotic or disappear. Subperiosteal bone resorption is pathognomonic for
hyperparathyroidism and the distal clavicle is a common site.
Fibrous dysplasia can look like anything; however it would not be expected to resolve.
Haemangiomas are usually seen in the vertebrae and would have coarsened trabeculae.
Myeloma and metastases are important considerations; however the hormonal disorder and
subperiosteal bone resorption favours a brown tumour.
(The Final FRCR Complete Revision Notes Page 132)
75. (c) Primary sclerosing cholangitis (PSC)
The description is typical for PSC. This condition typically affects males aged 20–40 years. It
is an idiopathic, progressive, fibrosing inflammatory disorder of the biliary tree. Associated
with ulcerative colitis (UC), Riedel thyroiditis, Sjögren syndrome, cystic fibrosis (CF) and
retroperitoneal fibrosis. Imaging features include both intra- and extrahepatic duct strictures
with alternating segments of dilatation and stenosis (the ‘string of beads’ appearance on
MRCP). On ultrasound there is increased echogenicity of the portal triads. MRCP can
demonstrate a ‘pruned tree’ appearance with obliteration of the peripheral ducts.
Primary biliary cirrhosis is the inflammatory destruction of peripheral bile ducts leading to
cirrhosis. The majority of patients are female. It is associated with autoimmune disorders
including rheumatoid arthritis, Sjögren syndrome, scleroderma and Hashimoto thyroiditis. The
disease is limited to the intrahepatic bile ducts.
(The Final FRCR Complete Revision Notes Page 219)
76. (b) Adrenal haemorrhage
The appearances of the adrenal gland are most likely in keeping with haemorrhage, which
can be seen following trauma. It can also be seen in association with shock or secondary to an
underlying tumour. In the cases of shock, the haemorrhage is more likely to be bilateral.
Bilateral haemorrhage can cause adrenal insufficiency, a life-threatening condition unless
steroids are given. Haemorrhage can mature to a cystic lesion and become calcified.
Adrenal laceration occurs less commonly than adrenal haemorrhage, when it occurs the right
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adrenal gland is most commonly affected, due to compression of the gland between the liver
and the spine.
Adrenal hyperplasia is diffuse thickening of the adrenal limbs, although it may be normal at
the time of physiological stress.
Adrenal myelolipoma is a rare, benign adrenal tumour associated with punctate calcification.
Low attenuation due to fat is diagnostic of this lesion.
(The Final FRCR Complete Revision Notes Page 268)
77. (a) Band heterotopia
Band heterotropia is a diffuse form of grey matter heterotopia almost exclusively affecting
females. It is associated with seizures and developmental delay. On imaging, this condition is
characterised by a band of grey matter located deep to and roughly paralleling the cortex.
Polymicrogyria is another form of cortical maldevelopment where there are numerous small
gyri.
Schizencephaly is a rare cortical malformation that manifests as a grey matter−lined cleft
extending from the ependyma to the pia matter.
Subependymal and subcortical heterotopia are more nodular types of heterotopia rather than the
diffuse types (band and lissencephaly).
(The Final FRCR Complete Revision Notes Page 291)
78. (e) Wernicke encephalopathy
Wernicke encephalopathy is caused by thiamine (vitamin B1) deficiency and is typically seen
in alcoholics or those who self-neglect. It presents with the classic triad of confusion, ataxia and
ophthalmoplegia. Korsakoff psychosis is the chronic form of the condition and is characterised
by confabulation and memory loss. MRI findings include symmetrical high signal on T2 and
FLAIR sequences with post-contrast enhancement in the mammillary bodies, basal ganglia,
paraventricular/medial thalamic regions, brain stem and periaqueductal grey matter.
Korsakoff syndrome is associated with mammillary body atrophy and dilatation of the third
ventricle.
Leigh syndrome can have similar imaging appearances but occurs in young children and the
mammillary bodies are spared. Pontine glioma are also more common in children.
Furthermore, the supra- and infratentorial abnormalities in this case are not consistent with this
diagnosis. Osmotic demyelination is possible in patients with chronic alcohol misuse due to
rapid correction of hyponatraemia; however, the radiological features are more consistent with
Wernicke encephalopathy.
(The Final FRCR Complete Revision Notes Page 385)
79. (c) Nodule mass
Lung nodules are a common finding on CT chest imaging. The mixed ground glass nodule is
a significant finding due to the high malignancy rate associated with them. A study published
in the June 2018 Clinical Radiology journal by X-W Wang et al. considered features which may be
useful in predicting invasive adenocarcinoma (ICA) compared to adenocarcinoma in-situ (AIS)
and minimally invasive adenocarcinoma (MIA). There is emerging evidence to suggest that AIS
and MIA may be able to undergo sublobar resection instead of lobectomy (an important
consideration in the elderly or those with bilateral ground glass nodules), whereas IAC
requires lobectomy. Thus presurgical assessment of the nodule is required. This study reports
that the most powerful predictor of IAC over AIS or MIA is nodule mass. Mass can be
calculated using computer-aided measurement, which considers nodule volume as well as CT
attenuation value. Nodule volume and diameter were also found to be statistically significant
predictor of IAC; however less powerful than mass, as they do not consider internal
attenuation. Nodule location and multiplicity were not found to be significant predictors of
IACs.
Wang XW, Chen WF, He WJ et al. CT features differentiating pre- and minimally invasive from
invasive adenocarcinoma appearing as mixed ground glass nodule: mass is a potential imaging
biomarker. Clinical Radiology. 2018;73(3) 549–554.
80. (a) The bony protrusion is directed away from the joint
An osteochondroma is a cartilage capped exostosis, classically directed away from the joint
space. It most frequently affects the lower limbs. It is the most common benign bone tumour,
seen between the ages of 2 and 60 years. Cartilage cap thickness of >2 cm on CT and >1 cm on
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MRI is indicative of chondrosarcomatous change. This occurs in less than 1% of cases. Fracture
of the stem is rare; the lesion is usually identified incidentally or with an enlarging painless
lesion. Rarely they may be multiple, such as in diaphyseal aclasis, which is also known as
hereditary multiple osteochondromatosis.
(The Final FRCR Complete Revision Notes Page 145)
81. (e) Signal dropout of the liver on out-of-phase MRI sequence.
Fatty liver disease is caused by accumulation of fat into hepatocytes. On ultrasound the renal
cortex is hyporeflective compared to the adjacent liver. On CT a liver density of <40HU is
specific but not sensitive. Density of >10HU less than the spleen on unenhanced CT is
diagnostic. The spleen enhances earlier than the liver, so comparing densities in the arterial or
early portal venous phases is unhelpful. Fatty liver shows reduced tracer uptake on Tc99m
sulphur colloid scan. In- and out-of-phase imaging is best for diagnosis: there is loss of signal
on out-of-phase imaging compared to in-phase imaging.
(The Final FRCR Complete Revision Notes Page 205)
Hamer OW, Aguirre DA, Casola G et al. Fatty liver: imaging patterns and pitfalls. RadioGraphics.
2006;26(6):1637–1653.
82. (c) Cardiac anomaly
Cytomegalovirus (CMV) is the most common intrauterine infection and intracranially can cause
hydrocephalus, microcephaly, delayed myelination and cerebral calcification. The calcification
tends to be periventricular and will be hyperechoic on a cranial ultrasound. More generally, it can
cause intrauterine growth restriction and in the abdomen can cause hepatomegaly. There is
overlap between many of the features in the congenital TORCH infections; however, CMV is not
usually associated with congenital cardiac anomalies, whereas rubella frequently is.
(The Final FRCR Complete Revision Notes Page 290)
83. (b) Glioblastoma
The key features that make glioblastoma more likely are the central fluid signal suggesting
necrosis, the complete rim of enhancement, mild restricted diffusion and markedly increased
relative cerebral blood flow both in and around the lesion.
The patient has radiological features of multiple sclerosis (MS). The left temporal lobe lesion
is different and the central fluid signal is concerning for necrosis and raises the possibility of a
malignant lesion, infective process or tumefactive multiple sclerosis.
Lymphoma usually enhances homogenously (the exception is in patients with AIDS where
there may be central necrosis and rim enhancement). The relative cerebral blood flow (rCBF)
may be slightly raised with lymphoma but not to the same degree as a glioblastoma.
Differentiating ring enhancing lesions is important on an MRI brain. Tumefactive multiple
sclerosis is an important differential in a patient with other signs of MS; however, unlike in this
case, the rim of enhancement is usually incomplete and rCBF is usually reduced.
Intracranial abscesses would usually have restricted diffusion centrally and this is a useful
differentiating factor between them and other pathologies. rCBF is also usually reduced
compared to glioblastoma.
Metastases can have a similar appearance to glioblastoma; however the rCBF in the oedema
surrounding the lesion is usually reduced.
(The Final FRCR Complete Revision Notes Pages 391, 419)
84. (c) Retinoblastoma
The location and MRI signal are characteristic of retinoblastoma. A calcified intraocular mass
in a young child (<3 years) is a retinoblastoma until proven otherwise. Rhabdomyosarcoma,
capillary and cavernous haemangiomas are extraocular tumours. Cavernous haemangiomas do
not usually present until later adulthood. Furthermore, capillary and cavernous haemangiomas
tend to show avid homogenous enhancement. Retrolental fibroplasia, also known as
retinopathy of prematurity, is an ocular condition seen in the infant population which usually
affects both eyes and can cause the globes to be small, calcification can also occur.
(The Final FRCR Complete Revision Notes Page 309)
85. (a) Allergic bronchopulmonary aspergillosis (ABPA)
This patient has typical features of ABPA. The ‘finger-in-glove’ appearance is caused by gross
perihilar bronchiectatic airways filled with mucous. Late disease also has upper lobe fibrosis
indicated by the elevated fissures and hila. ABPA is associated with asthma and cystic fibrosis. This
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is a young patient with a central venous catheter indicating long-term drug therapy. In a cystic
fibrosis patient this typically will be antibiotics. The upper lobe fibrosis is also typical of cystic
fibrosis.
Drug-induced lung disease does not typically have these features and can be non-specific, varying
depending on the drug therapy.
Invasive aspergillosis is associated with immunocompromised patients and CT features include
poorly defined nodules with a ground glass halo representing haemorrhage.
Tracheobronchopathia osteochrondroplastica is a rare condition affecting the trachea and
proximal airways where there are submucosal cartilaginous and osseous nodules which spare the
posterior tracheal wall due to the lack of cartilage here.
Pulmonary manifestations of granulomatosis with polyangiitis (previously known as Wegener
granulomatosis) include consolidation, ground glass opacification and pulmonary nodules. Larger
nodules tend to cavitate and there is a lower lobe predominance.
(The Final FRCR Complete Revision Notes Pages 20, 23)
86. (d) Soap bubble
In aggressive disease, there is no time for the periosteum to consolidate. In benign processes
there is time form new periosteum and so the periosteum is thickened and dense.
(The Final FRCR Complete Revision Notes Page 148)
Source: Reprinted with permission from V Helyar and A Shaw, The Final FRCR: Complete Revision Notes. CRC
Press, Taylor & Francis Group, 2018, p. 148.
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Mucous impaction could explain the initial radiograph but not the follow-up one.
(The Final FRCR Complete Revision Notes Page 321)
102. (e) Progressive multifocal leukoencephalopathy
Progressive multifocal leukoencephalopathy is associated with immunocompromised states
due to reactivation of the JC virus. The key distribution is in the white matter; it is
asymmetrical and typically parieto-occipital and subcortical. There is T2 hyperintensity and
T1 hypointensity, minimal, if any enhancement and no mass effect. There may be restricted
diffusion at the leading edge of the changes.
In contrast to this, HIV encephalopathy is symmetrical and more typically frontal and
focused on the periventricular white matter and centrum semi ovale. Cerebral atrophy is also
a feature. Although there is similar T2 hyperintensity and no enhancement or mass effect,
there are not usually the same T1 signal changes.
Cytomegalovirus encephalopathy causes T2 hyperintense brainstem and periventricular
white matter abnormalities. These do not cause mass effect or enhancement unless there is
ventriculitis, in which case there will be ependymal enhancement.
Posterior reversible encephalopathy syndrome classically also affects the parieto-occipital
regions with minimal, if any enhancement or diffusion restriction; however, the history is the
key factor and does not fit in this case.
Toxoplasmosis typically causes ring-enhancing lesions in the basal ganglia, thalamus and
corticomedullary junction with mass effect.
(The Final FRCR Complete Revision Notes Page 416)
103. (e) Silicosis
The correct underlying diagnosis is silicosis. This is a pneumoconiosis found in those in
sandblasting or mining industries, secondary to inhaled silica. The features of tiny calcified
pulmonary nodules and calcified hila lymph nodes is indicative of this condition, complicated
by progressive massive fibrosis (PMF). PMF occurs when the nodules coalesce and form large
opacities in the upper zones with upper zone fibrosis.
Coal workers’ pneumoconiosis (CWP) is secondary to inhalation of coal dust and can also
produce calcified pulmonary nodules and hilar/mediastinal lymph node calcification;
however eggshell calcification is more typical in silicosis. Silicosis is more likely than CWP to
be complicated by PMF.
Caplan syndrome is CWP with features of rheumatoid arthritis.
Pulmonary alveolar microlithiasis is a rare idiopathic condition, in which diffuse, dense,
miliary calcification is seen in both lungs, more conspicuous in the mid-lower zones.
Hypersensitivity pneumonitis, also known as extrinsic allergic alveolitis, is a response to
inhaled antigen. In chronic cases it can cause fibrosis, typically in the upper zones.
Centrilobular nodules seen in this condition are not typically calcified.
(The Final FRCR Complete Revision Notes Pages 45−47)
104. (e) Rhizomelic
Thanatophoric dysplasia is one of the lethal dwarfisms. Rhizomelia involves shortening of a
proximal segment relative to a distal segment, for example the humerus or femur, as
described in this case. Achondroplasia, thanatophoric dysplasia and chondrodysplasia
punctata can be examples of this.
Mesomelia is the shortening of an intermediate segment (e.g. ulna and radius). This type of
dwarfism is rare. Dyschondrosteosis is one example.
Acromelia is shortening of a distal segment (e.g. the hand). These conditions are also rare,
and Jeune syndrome (also known as asphyxiating thoracic dysplasia) is one cause.
Micromelia is the shortening of an entire limb (e.g. humerus, radius, ulna and hand) and
can be seen in some types of thanatophoric dysplasia and diastrophic dysplasia.
In metatropic dwarfism, there is a change of proportion of the trunk to the limbs over time
secondary to developing kyphoscoliosis in childhood.
(The Final FRCR Complete Revision Notes Pages 110, 128−129)
105. (b) Antimesenteric border of the distal ileum
Meckel’s diverticulum are most common in the terminal ileum on the antimesenteric
border. The ‘rule of 2s’ suggests that they present in 2% of the population, 20% have
ectopic gastric mucosa, they are 2 feet from the ileocaecal valve and usually around 2
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cruciate ligament tear is the most common knee ligamentous injury; however, it is not a
feature of Osgood-Schlatter disease. It usually follows an episode of trauma and can be
associated with injury to other ligamentous structures. It may be associated with avulsion
of the tibial attachment.
(The Final FRCR Complete Revision Notes Page 117)
111. (c) Liposarcoma are the most common retroperitoneal sarcoma
Differentiating liposarcoma from a benign lipoma is not always possible; however,
septations >2 mm thick or soft tissue components suggest sarcoma. Retroperitoneal
leiomyosarcoma commonly metastasise to the liver and lung, particularly the intravascular
subtype. Myxoid type liposarcoma is T2 hyperintense and shows delayed enhancement post
contrast. Calcification occurs in approximately 25% of malignant fibrous histiocytomas. It is a
relatively specific finding and rare in other types of retroperitoneal masses. Angiosarcoma are
a very aggressive sarcoma and metastasises early.
(The Final FRCR Complete Revision Notes Page 192)
112. (c) Lymphocele
The lesion has features of a simple cystic structure which, along with the history of a well
patient, would make abscess unlikely. A haematoma would typically have more complex
features, possibly with internal echoes, septations and layering of debris.
Haematomas are also more likely in the immediate postoperative period and resolution
would be expected after 3 years. A seroma could have similar appearances to the collection
described in this case; however, this should also have regressed over a period of 3 years.
The main differential lies between urinoma and lymphocele. Lymphocele fits the
description and they are the most common cause of a perirenal post-transplant collection.
They can persist for a long time following renal transplant and may be asymptomatic or cause
compression of surrounding structures. A urinoma is frequently secondary to anastomotic
failure or ischaemia. They have fewer septations than haematomas and they frequently
contour the renal outline due to the intimate relationship with the urinary tract.
(The Final FRCR Complete Revision Notes Pages 259−261)
113. (b) Venous drainage to pulmonary veins
Pulmonary sequestration tends to present in childhood and is more common in males. The
extralobar subtype usually presents earlier than intralobar sequestration. The anomaly is a
segment of lung with no communication to the pulmonary arteries or bronchial tree.
The most common type is intralobar. This is supplied from the descending thoracic aorta
and drains via the pulmonary venous system. Intralobar sequestration is enclosed in visceral
pleura. It does not have any associated conditions.
In contrast to this, extralobar sequestration is associated with other conditions such as
duplication cysts and cardiac anomalies. The segment has its own pleura. The arterial supply
is from the aorta or sometimes the splenic, intercostal or gastric arteries. The venous drainage
is systemic and not via the pulmonary veins.
(The Final FRCR Complete Revision Notes Page 320)
114. (c) Diffuse, smooth dural enhancement
Intracranial hypotension is associated with postural headache, nausea, vertigo and
vomiting. It can be spontaneous or secondary to procedures such as lumbar puncture or
surgery. Radiological features can include acquired tonsillar ectopia, subdural effusions, a
sagging brainstem, distension of the venous structures and pachymeningeal enhancement
which is commonly diffuse and smooth.
(The Final FRCR Complete Revision Notes Page 388)
115. (a) Lymphoma
Although the imaging findings could be in keeping with sarcoidosis, the features of hilar
and mediastinal lymph node enlargement, as well as the parenchymal infiltration would be in
keeping with stage 3 sarcoidosis (according to the Siltzbach classification), which has not been
given as an option.
Lymphoma is the most likely correct answer in this case. Hodgkin’s lymphoma is more
commonly a cause for enlarged lymph nodes than non-Hodgkin’s lymphoma. The posterior
mediastinum is not frequently involved; however it is an important site for recurrence of
disease, as it may not be included in the radiotherapy field. The presence of nodular
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4. Parenchymal infiltration
5. Parenchymal volume loss as a result of pulmonary fibrosis – 20% get to stage 4 with
irreversible fibrosis
Source: Reprinted with permission from V Helyar and A Shaw, The Final FRCR: Complete Revision Notes. CRC
Press, Taylor & Francis Group, 2018, p. 53.
Table 2.9: Ossification Centres of the Elbow and Age of their Appearance
Ossification Centre Age of Appearance
Capitellum 1 year
Radial head 3 years
Internal epicondyle 5 years
Trochlea 7 years
Olecranon 9 years
External epicondyle 11 years
Source: Reprinted with permission from V Helyar and A Shaw, The Final FRCR: Complete Revision Notes. CRC
Press, Taylor & Francis Group, 2018, p. 119.
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Fungal abscesses typically occur in the immunosuppressed and are usually due to candidiasis.
They have a classical ‘wheel within wheel’ appearance in the early stages due to a centrally
necrotic nidus.
(The Final FRCR Complete Revision Notes Page 214)
118. (c) Displacement of the medulla and cerebellar vermis through the foramen magnum.
Chiari II malformations can have varying degrees of severity. There is a small posterior fossa
with descent of structures through the foramen magnum along with a spinal
myelomeningocele. It has various other associations including absence of the septum
pellucidum, abnormality of the corpus callosum and polymicrogyria. The posterior fossa is
small with inferior displacement of the cerebellar tonsils and vermis. There may be
hydrocephalus and the fourth ventricle may be low lying.
Chiari I is when just the cerebellar tonsils are inferiorly displaced, and is commonly
incidentally discovered on brain imaging.
Chiari III malformations are more unusual and are associated with encephaloceles.
(The Final FRCR Complete Revision Notes Page 289)
119. (b) Caudate lobe hypertrophy
Acute Budd-Chiari syndrome typically presents with abdominal pain, hepatomegaly and
ascites. It is often secondary to thrombus in the suprahepatic vena cava or hepatic veins. The
finding of hyperenhancement in the central liver on early phase post-contrast imaging with
peripheral hyperenhancement on delayed images is called the ‘flip-flop’ pattern.
Splenomegaly, absent hepatic veins and increased portal vein diameter are also features.
Hypertrophy of the caudate lobe is associated with the chronic form of the condition. It
drains directly into the inferior vena cava and is therefore spared. It hypertrophies to
compensate for the atrophy which can manifest in the other liver lobes. Gallbladder wall
thickening is also commonly seen with chronic Budd-Chiari syndrome.
(The Final FRCR Complete Revision Notes Page 198)
120. (c) Neurocysticercosis
Neurocysticerosis is characterised by cysts at the grey−white matter junction and in the
subarachnoid and intraventricular spaces. When intraventricular, they can affect the fourth
ventricle and lead to hydrocephalus. The appearances of the cysts can vary depending on the
life cycle of the larvae, and as they die can enhance. Breakdown of the cyst membrane leads to
surrounding oedema. Calcification is seen in chronic cases.
Intracranial toxoplasmosis and cryptococcus infection are not common unless a patient is
immunocompromised, and there is no history to suggest this. Toxoplasmosis does also cause
ring-enhancing lesions and they can have a similar distribution, affecting the corticomedullary
junction as well as the basal ganglia. Cryptococcus has non-specific imaging features, although
one described feature is prominent perivascular spaces and ring-enhancing cryptococcomas.
Cerebral hydatid cysts often lie in the territory of the middle cerebral artery and are usually
solitary. Enhancement and surrounding oedema is not typical unless there is superadded
infection.
Another differential for these appearances is intracranial tuberculosis infection causing
tuberculomas at the corticomedullary junction. These may also enhance peripherally and cause
surrounding oedema. The other features of an intraventricular lesion and hydrocephalus are
more consistent with neurocysticercosis.
(The Final FRCR Complete Revision Notes Page 415)
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PAPER 3
1. A 64 year old female patient presents with shortness of breath on exertion. She smokes five
cigarettes per day and her past medical history includes rheumatoid arthritis, hypertension,
hypercholesterolaemia and atrial fibrillation. Initial bloods are normal apart from the arterial
blood gas, which reveals a PaO2 of 9.5 kPa (normal range 10.5–13.5 kPa) with a restrictive
pattern on spirometry. High resolution CT chest demonstrates bilateral hyperdense
consolidation which is predominantly peripheral, affecting the bases more than the apices
with patchy ground glass opacification and reticulation.
What is the most likely diagnosis?
a. Amiodarone lung disease
b. Eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome)
c. Simple pulmonary eosinophilia
d. Non-specific interstitial pneumonia
e. Gold induced lung toxicity
2. A 26 year old male presents to the GP with ongoing wrist pain that has not resolved with anti-
inflammatory medications or physiotherapy. The GP requests a plain film. Amongst other
findings, the report mentions positive ulnar variance and suggests further investigation with
MRI to assess for complications.
What is a likely complication of the condition described, which will be seen on the MRI?
a. Avascular necrosis of the lunate bone
b. Radioulnar convergence
c. Scalloping of the distal radius by the ulna
d. Tear of the triangular fibrocartilage complex
e. Ulnar impingement syndrome
3. A 64 year old woman is referred by her GP for a CT abdomen pelvis indicated for weight loss
and non-specific abdominal pain. The CT shows widening of the presacral space.
Which of the following would NOT be within the differential for widening of the presacral
space?
a. Pelvic lipomatosis
b. Chordoma
c. Neurofibroma
d. Dermoid cyst
e. Mesenteric carcinomatosis
4. A 50 year old female has a CT abdomen and pelvis for unexplained abdominal pain following
a normal ultrasound scan. This identifies a large cystic mass in the pancreatic tail with
peripheral calcification. There are a couple of thin enhancing septations. There are no enlarged
regional lymph nodes and no evidence of metastatic disease. An MRCP does not demonstrate
a connection to the main pancreatic duct.
What is the most likely diagnosis?
a. Ductal adenocarcinoma
b. Intraductal papillary mucinous neoplasm
c. Mucinous cystic neoplasm
d. Neuroendocrine tumour
e. Serous microcystic adenoma
5. A 12 year old boy is referred for a chest radiograph. He has recurrent pulmonary
infections and shortness of breath on exertion. The radiograph shows a small right lung
with ipsilateral mediastinal shift. There is a curvilinear tubular opacity adjacent to the
heart border.
What is the most likely diagnosis?
a. Partial anomalous pulmonary venous return
b. Pulmonary sequestration
c. Right middle lobe atelectasis
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d. Tetralogy of Fallot
e. Unilateral absence of the pulmonary artery
6. An MRI whole spine of a 53 year old man reveals a solitary thoracic spinal cord lesion. It is
intradural and has both an intramedullary and extramedullary component which is extending
posteriorly. It extends inferiorly over 1–2 segments. It is well defined, low T1 signal and
predominantly high T2 signal apart from very low T2 signal at its caudal margin. It has a
small, rounded, enhancing soft tissue component and flow voids. There is high STIR signal in
the surrounding cord.
What is the most likely diagnosis?
a. Arteriovenous malformation
b. Astrocytoma
c. Ependymoma
d. Haemangioblastoma
e. Meningioma
7. A 59 year old female presents with increasing shortness of breath and persistent cough. She
has a 20 pack year smoking history. The GP requests a CT chest for further investigation.
The CT shows volume loss in the lower lung zones. There is extensive honeycomb
destruction of the lungs, predominantly in the dependent aspect of the lower zones but also
at the lateral and anterior aspect of the mid and lower zones. The airways within the
abnormal looking lung demonstrate traction dilatation. There is minimal ground glass
opacification in both lungs. The upper and mid zones of the lung demonstrate mild
background emphysematous change.
What is the most likely diagnosis?
a. Cryptogenic organising pneumonia
b. Hypersensitivity pneumonitis
c. Non-specific interstitial pneumonia
d. Respiratory bronchiolitis-associated interstitial lung disease
e. Usual interstitial pneumonia
8. A 56 year old male presents with neck pain following a fall. A CT cervical spine demonstrates
a destructive lytic lesion in the right lamina of C4 which appears to encroach into the canal.
A smaller lytic lesion is seen in the anterior aspect of the C7 vertebral body. The appearances
are considered most likely in keeping with metastases.
What is the most likely primary site of disease?
a. Breast
b. Bronchus
c. Colon
d. Kidney
e. Prostate
9. A barium swallow study is performed on a 42 year old female patient on her third cycle of
neoadjuvant chemotherapy for breast cancer with a plan to proceed to surgery and
radiotherapy. The patient has been experiencing increasing odynophagia but no dysphagia,
reflux or regurgitation.
What appearances on the barium swallow study would be most likely in this clinical setting?
a. Flask-shaped mucosal outpouchings
b. Large areas of oesophageal ulceration
c. Long, linear oesophageal filling defects
d. Multiple, small, nodular oesophageal filling defects
e. Smooth stricture in the mid-oesophagus
10. A 15 year old female presents the emergency department with a fall onto an outstretched
hand. The referring clinician asks you to review the plain film wrist, which demonstrates
bullet-shaped metacarpals, a wide radius and ulna and metacarpal irregularity but no
fracture. The referrer explains there are features of dwarfism but no other history is provided.
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You review previous imaging and see a plain film of the spine, which shows posterior
vertebral body scalloping, platyspondyly and anterior central beaking of the vertebral bodies.
What is the most likely underlying aetiology?
a. Achondroplasia
b. Down syndrome
c. Hurler syndrome
d. Morquio syndrome
e. Pseudoachondroplasia
11. A 15 year old boy is under investigation for hypertension and polycythaemia. Renal
ultrasound showed multiple bilateral renal cysts but nil else of note. He develops
headaches and signs of cerebellar dysfunction and is referred for an MRI. This shows a large,
T1 hypointense, T2 hyperintense lesion within the cerebellum. There is a centrally, avidly
enhancing nodule. Multiple flow voids are seen within the periphery of the mass.
What is the most likely diagnosis?
a. Ependymoma
b. Haemangioblastoma
c. Medulloblastoma
d. Meningioma
e. Pilocytic astrocytoma
12. An adult passenger suffers a sudden acceleration-deceleration injury in a high-speed road
traffic collision. He develops severe left-sided neck pain occipital headache, nausea and
vertigo. He is suspected of having a left vertebral artery dissection.
What is the most likely location for this to occur?
a. At its origin from the subclavian artery
b. C2
c. C6
d. C7
e. Intracranial segment
13. A 24 year old female patient presents with a 2 day history of right flank pain and haematuria.
The emergency department team are querying renal calculus. She has an abdominal ultrasound
that incidentally finds at least three separate splenic structures in the left upper quadrant.
Which is most commonly associated with polysplenia?
a. Dextrocardia
b. Gallbladder agenesis
c. Bilateral bilobed lungs
d. Bilateral eparterial bronchi
e. Bilateral right atria
14. An 8 year old male has plain films to investigate acute right leg pain. In the proximal tibial
diaphysis/metaphysis there is a well-defined central lucency with a thin sclerotic rim; the
lesion is orientated along the long axis of the tibia and there is no periosteal reaction. In view
of the patient’s pain a CT is performed. This demonstrates the same features as the plain films
as well as a cortical break which is considered in keeping with a fracture. A small bone
fragment is also seen at the dependant aspect of the lesion.
What is the most likely diagnosis?
a. Chondroblastoma
b. Eosinophilic granuloma
c. Ewing sarcoma
d. Brodie abscess
e. Unicameral bone cyst
15. A 40 year old woman presents to her GP with right upper quadrant pain. An outpatient
abdominal ultrasound is arranged. She is noted to have a 3-mm gallstone. The gallbladder
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wall is thickened and there are multiple echogenic foci within the wall which demonstrate
posterior acoustic shadowing.
What is the most likely differential?
a. Porcelain gallbladder
b. Emphysematous cholecystitis
c. Gallbladder carcinoma
d. Adenomyomatosis
e. Gallbladder polyp
16. A 32 year old female patient with no significant past medical history is brought into hospital
with at least three abdominal stab wounds for which she has an arterial and portal venous
phase CT abdomen pelvis. This demonstrates three sites of skin breach without evidence of
deep extension or peritoneal breach. Incidental note is made of alternating dilatation and
stenoses of the distal renal arteries bilaterally. The kidneys both enhance symmetrically and
uniformly. There is no vascular calcification. Appearances elsewhere on the CT are normal.
The patient continues to have normal observations on the ward. Following discharge she
attends the renal outpatient clinic for follow-up and has normal serum renal function tests.
What is the most appropriate management for this condition?
a. Angioplasty
b. Angioplasty plus stenting
c. Continued follow-up
d. No further management required
e. Steroid treatment
17. A 13 year old boy with an underlying congenital syndrome undergoes an MRI brain. This
demonstrates a lesion within the left cerebellar hemisphere with widened folia and a striated/
tigroid appearance. The lesion is T1 hypointense and T2 hyperintense and does not enhance
following contrast administration. No other lesions are identified. The child has a thyroid
ultrasound recently which demonstrates a thyroid goitre.
What underlying syndrome does the child likely have?
a. Ataxia telangiectasia
b. Cowden syndrome
c. Neurofibromatosis type 1
d. Sturge-Weber syndrome
e. Tuberous sclerosis
18. You are asked to review an unenhanced CT head for a newly admitted 56 year old inpatient
under the care of neurology. There is a 30-mm lesion in the right temporal lobe with
significant surrounding oedema and effacement of the temporal horn of the right lateral
ventricle. There is a similar, slightly smaller lesion in the left frontal lobe abutting the frontal
horn of the left lateral ventricle. The team feel that cerebral abscess is more likely clinically
than metastases; however, the patient suffers with claustrophobia and may only be able to
tolerate a short time in the MRI scanner.
Which of the below would you prioritise to help confirm the diagnosis of abscess?
a. DWI + ADC map
b. FLAIR
c. MR perfusion
d. Susceptibility weighted imaging
e. T1 + gadolinium
19. A 64 year old inpatient with a history of atrial fibrillation is admitted with an acute
exacerbation of shortness of breath. A chest radiograph is consistent with cardiac failure.
What is the earliest radiographic feature of cardiac failure?
a. Cardiomegaly
b. Consolidation
c. Interlobular septal thickening
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d. Pleural effusion
e. Upper lobe diversion
20. A 77 year old female presents to the GP with right-sided hip pain. She has a plain film of the pelvis
and right hip. There is cortical thickening of the proximal right femur and coarsening of the
trabeculations. The visualised right femur itself appears mildly enlarged when compared to the left
side, with evidence of bowing. There is the impression of ill-defined mixed lucent and sclerotic
density at the greater trochanter and an aggressive periostitis with a hair-on-end periosteal reaction.
What is the most likely primary bone tumour?
a. Bizarre parosteal osteochondromatous proliferation
b. Haemangioma
c. Multiple myeloma
d. Osteoblastoma
e. Osteosarcoma
21. A 30 year old female with a background of medullary sponge kidney presents with right
upper quadrant pain. On examination blood tests show elevated bilirubin levels. A liver
ultrasound demonstrates multiple, dilated cystic structures converging towards the porta
hepatis. The cysts communicate with the bile ducts. No peripheral biliary duct dilatation is
identified. MRCP shows ectatic intrahepatic ducts extending into the periphery. The common
bile duct is dilated but no strictures are seen.
What is the most likely diagnosis?
a. Primary sclerosing cholangitis
b. Polycystic liver disease
c. Choledochocele
d. Primary biliary cirrhosis
e. Caroli disease
22. A patient has a micturating cystogram following a renal ultrasound which diagnosed mild,
bilateral hydronephrosis. Following contrast administration via a urinary catheter, there is
reflux of contrast from the urinary bladder into both ureters, bilateral ureteric and renal pelvis
dilatation and calyceal clubbing.
What vesicoureteral reflux grading would this patient have?
a. Grade I
b. Grade II
c. Grade III
d. Grade IV
e. Grade V
23. A CT abdomen pelvis for a 59 year old female patient with vomiting, abdominal pain and
guarding is reported as small bowel obstruction secondary to an obstructed right obturator
hernia.
Which anatomical landmarks are obturator hernias associated with?
a. Obturator externus and iliacus
b. Obturator externus and iliopsoas tendon
c. Obturator externus and pectineus
d. Obturator externus and piriformis
e. Obturator externus and pyramidalis
24. A 40 year old woman with known HIV presents with worsening confusion. Her partner
reports she has been noncompliant with her antiretroviral medication. Her CD4 count is
found to be <200 cells/mm3 (500–1500 cells/mm3). An MRI brain reveals bilateral basal
ganglia lesions.
Which of these other imaging features also favours a diagnosis of toxoplasmosis over
lymphoma?
a. Increased uptake on thallium SPECT
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b. Intralesional haemorrhage
c. Solitary lesion
d. Subependymal distribution
e. Uniform enhancement
25. A 69 year old male patient with increasing shortness of breath is reviewed in the respiratory
outpatient clinic following a GP referral. CT chest prior to the appointment demonstrates
increased bilateral, predominantly lower lobe subpleural reticulation, interlobular septal
thickening with associated bronchiectasis.
Which is the most likely underlying diagnosis?
a. Ankylosing spondylitis
b. Asbestosis
c. Chronic hypersensitivity pneumonitis
d. Silicosis
e. Sarcoidosis
26. A 6 year old male with a limp and left sided hip pain has plain films of the pelvis. AP and frog
legged views are performed, and these are considered unremarkable. An ultrasound shows a
joint effusion in the anterior recess with capsular distention of 3 mm. The synovium is not
thickened. He had a viral illness for a week preceding the hip pain.
What is the most likely diagnosis?
a. Developmental dysplasia of the hip
b. Juvenile idiopathic arthritis
c. Septic arthritis
d. Slipped upper femoral epiphysis
e. Transient synovitis of the hip
27. A 60 year old female presents with weight loss and early satiety. She is found to have
deranged serum liver function tests. A CT abdomen pelvis with contrast is performed. No
pancreatic mass is identified but the ‘double duct sign’ is identified.
What is the most likely diagnosis?
a. Duplication cyst
b. Annular pancreas
c. Periampullary tumour
d. Pancreas divisum
e. Duodenal atresia
28. A 5 year old girl with recurrent urinary tract infection is investigated as an outpatient by the
paediatric team with a urinary tract ultrasound. The appearances are highly suggestive of a
right duplex kidney. There are normal appearances of the left kidney. There is no
hydronephrosis. Appearances of the urinary bladder suggest a right sided ureterocoele. The
patient has an excretory phase CT further investigate.
What is the most likely CT appearance?
a. Two right ureters converging just proximal to the urinary bladder
b. Two right ureters with upper moiety ureter inserting superolateral to lower moiety ureter
c. Two right ureters with upper moiety ureter inserting inferomedial to lower moiety ureter
d. Two right ureters with lower moiety ureter inserting superolateral to upper pole moiety
e. Two right ureters with lower moiety ureter inserting inferomedial to upper pole moiety
29. Following the delivery of a neonate who had an abnormal third trimester antenatal
ultrasound scan, the neonatal intensive care team request a neonatal cranial ultrasound.
There is evidence of hydrocephalus. In the region of the third ventricle there is an anechoic
midline intracranial lesion with prominent flow on Doppler examination.
Which of the following imaging findings is most likely to be associated with this abnormality?
a. Absence of the corpus callosum
b. Cardiomegaly
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34. The paediatric team ask you to review a radiograph of a patient who is currently being kept as
an inpatient due to concerns about non-accidental injury (NAI).
Which of these is the commonest skeletal injury in NAI?
a. Fracture of the distal clavicle
b. Linear skull fracture
c. Metaphyseal tibial fracture
d. Posterior rib fracture
e. Transverse humeral fracture
35. A 55 year old man is admitted with cognitive disturbance, ataxia and seizures. A CT head
reveals anterior cerebellar vermian atrophy as well as more generalised cerebral volume loss
which is excessive for the age of the patient. There is also subtle hypodensity in the corpus
callosum. An MRI the following day finds that this area is T2 hyperintense with low signal on
T1 sequences and primarily affecting the body and genu of the corpus callosum.
What is the most likely diagnosis?
a. Marchiafava-Bignami disease
b. Methanol intoxication
c. Multiple sclerosis
d. Susac syndrome
e. Wernicke’s encephalopathy
36. A 1 day old preterm neonate is referred for a cranial ultrasound due to low Apgar scores
following delivery and abnormal posturing. Hypoxic ischaemic injury is suspected.
Which of the following sonographic findings is most likely?
a. Cerebellar involvement
b. Globally reduced Doppler signal
c. Hypoechoic basal ganglia
d. Normal study
e. Widened Sylvian fissures
37. A 67 year old retired decorator presents to his GP following multiple episodes of chest pain
during the past 2 weeks brought on by exertion. Past medical history includes hypertension and
gallstones. The GP refers him to the rapid access chest pain clinic. As part of the investigations
the patient has a cardiac MRI which demonstrates increased T2 weighted signal intensity in the
mid anterior and septal walls, with delayed subendocardial hyperenhancement.
What is the most likely diagnosis?
a. Acute myocarditis
b. Hibernating myocardium
c. Myocardial infarct involving the left anterior descending artery
d. Myocardial infarct involving the right coronary artery
e. Myocardial stunning
38. A 7 year old female falls from a trampoline and develops wrist swelling. The parents take her
to the emergency department and a plain film is performed. The imaging demonstrates
buckling of the cortex; the cortex remains intact.
What type of fracture is this?
a. Greenstick fracture
b. Lead pipe
c. Plastic bowing
d. Salter-Harris fracture
e. Torus fracture
39. A 50 year old man has arthralgia, hyperpigmentation and new onset diabetes. His maternal
grandfather had haemochromatosis.
Which of the following liver MRI findings would help differentiate primary haemochromatosis
from haemosiderosis?
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a. Multiple tumours
b. The lesion abuts the physis
c. Non-sclerotic margin
d. Matrix calcification
e. The tumour is centred on the medullary cavity
45. Following a road traffic collision a 12 year old cyclist is brought into hospital by ambulance
intubated and ventilated. A trauma CT is performed. Thoracic imaging reveals a right sided
pneumothorax, bilateral rib fractures and a fractured right proximal humerus. The
abdominopelvic imaging demonstrates abdominal free fluid with retroperitoneal free gas.
There is a short segment of duodenal mural thickening with disruption of the wall and
adjacent free gas locules.
Where in the duodenum is the rupture most likely to be sited?
a. At the level of the ampulla of Vater
b. At the level of the ligament of Treitz
c. D1–2
d. D2–3
e. D3–4
46. A 15 year old boy with epistaxis is reviewed by the ear nose and throat (ENT) team. There is a
red/blue mass visible on nasoendoscopy and an MRI head confirms a diagnosis of juvenile
angiofibroma. The ENT team request radiological guided embolisation prior to surgical
management.
Which artery is the most likely feeding vessel?
a. Ascending pharyngeal
b. Facial
c. Internal maxillary
d. Lingual
e. Superficial temporal
47. A 16 year old boy is referred for a MR angiogram for suspected aortic coarctation. He has a left
sided aortic arch. The coarctation lies distal to the brachiocephalic trunk but proximal to the
origin of the left subclavian artery.
What rib notching pattern would be most likely?
a. Bilateral first and second ribs
b. Bilateral third to ninth ribs
c. Left third to ninth ribs
d. Right first and second ribs
e. Right third to ninth ribs
48. A 7 year old girl presents with ataxia, diplopia and facial droop. On clinical examination she is
found to have cranial nerve VI and VII palsies. A CT brain shows a mass enlarging the pons
and flattening the floor of the fourth ventricle. There is resultant mild hydrocephalus. MRI
brain reveals the lesion has low T1 and heterogeneously high T2 signal relative to cortical grey
matter. There is minimal enhancement and the affected area does not restrict on diffusion
weighted imaging.
What is the most likely diagnosis?
a. Acute demyelinating encephalomyelitis
b. Diffuse brainstem glioma
c. Medulloblastoma
d. Osmotic demyelination
e. Rhombencephalitis
49. The respiratory team request a CT chest for a 64 year old female patient presenting with
increased shortness of breath on exertion. The patient has a 20 pack-year history and has
previously been exposed to asbestos. Past medical history includes hypertension and
pancreatitis, for which she has had two intensive care admissions. Previous imaging requests
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state that on one of these admissions she developed acute respiratory distress syndrome
(ARDS).
Where would you be most likely to see the long term pulmonary changes associated with her
previous ARDS?
a. Anteriorly
b. Apical regions
c. At the lung bases
d. Perihilar region
e. Posteriorly
50. A 60 year old male patient has an unenhanced CT urinary tract for left sided renal colic. There
is a 3-mm left renal calculus. Incidentally, a bone lesion is identified within the T12 vertebral
body; the lesion is lucent with coarse vertical trabeculations and a ‘polka-dot’ appearance on
axial slices. There is no soft tissue component, the cortex is intact and there is no periosteal
reaction.
What is the most appropriate next investigation for the bone lesion?
a. FDG PET-CT scan
b. Follow-up CT scan in 6 months
c. Further assessment with whole spine MRI
d. No further investigation required
e. SPECT study
51. A 16 year old female patient has a urinary tract ultrasound following several urinary tract
infections. This shows the right kidney is atrophic and the left kidney is normal in appearance.
Previous ultrasound from when the patient was younger demonstrated a large right kidney.
There is no hydronephrosis and the renal hilum is normal; however, there are multiple
anechoic right renal lesions varying in size. These are separated by hyperechoic linear tissue
without increased vascularity.
What is the most likely underlying diagnosis?
a. Autosomal recessive polycystic kidney disease
b. Juvenile nephronophthisis
c. Mesoblastic nephroma
d. Multicystic dysplastic kidney
e. Cystic nephroma
52. A 32 year old male with a background of multiple endocrine neoplasia type 1 undergoes
surveillance imaging. He has been previously diagnosed with a parathyroid adenoma and
pancreatic gastrinoma.
Which of these radiological findings is most likely to be present in this patient?
a. Hypoechoic thyroid nodule with tiny hyperechoic foci on ultrasound
b. A markedly T2 hyperintense right adrenal nodule
c. Polypoid caecal lesion on CT colonoscopy
d. Minimally enhancing pituitary lesion on MRI brain
e. An avidly enhancing right hilar mass
53. Twins are born by caesarean section at 34 weeks’ gestation. They are treated with surfactant
replacement therapy at birth and require treatment on the neonatal intensive care unit. One of
the twins develops signs of respiratory distress syndrome, and a chest radiograph at day 5
post birth reveals small lung volumes and multiple bilateral lucencies. The thymic lobes are
displaced laterally and surrounded by air. The trachea and mediastinum are central.
The endotracheal tube and vascular catheters are positioned appropriately, with the tip of the
umbilical artery catheter at the level of T8.
Which of the following statements is most accurate?
a. An umbilical artery catheter tip should be sited between T10 and L3
b. Bronchopulmonary dysplasia is associated with meconium aspiration
c. Surfactant deficiency is associated with increased lung volumes
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58. A 12 year old boy has a plain film of the pelvis for investigation of 8 weeks’ history of left sided
hip pain. Radiographs demonstrate joint space widening on the left when compared to the
right. On ultrasound there is bulging of the anterior joint capsule and >3 mm distance between
the bony femoral neck and joint capsule. He is thought to have juvenile idiopathic arthritis.
Which of the following statement is most accurate in this condition?
a. Bone changes occur early
b. Most are seronegative
c. Periostitis is considered atypical
d. The hip joint is the most common site for the monoarticular variant
e. There is often late closure of the growth plates
59. A baby is admitted to the neonatal intensive care unit with respiratory distress. Following an
abnormal chest radiograph, an arterial phase CT is performed. There is a right lower lobe
mass. This contains multiple air-fluid levels. There is a clear connection between the mass and
the right bronchial tree. The mass does not have a systemic vascular supply.
What does this mass most likely represent
a. Bronchogenic cyst
b. Congenital lobar over inflation
c. Congenital pulmonary airway malformation
d. Diaphragmatic hernia
e. Intralobar pulmonary sequestration
60. A 60 year old man is found unconscious at home. Following ambulance transfer to hospital, a
CT head is requested. This shows bilateral hypodensity affecting the globus pallidi bilaterally.
On MRI the same area shows high signal on T2 weighted imaging and restricted diffusion.
Which of the following is the cause of his findings?
a. Asphyxiation
b. Carbon monoxide poisoning
c. Hypoglycaemia
d. Lead poisoning
e. Methanol poisoning
61. A 49 year old male patient with no fixed abode is admitted with a 3 day history of increasing
abdominal pain. CT abdomen and pelvis demonstrates an infrarenal saccular dilatation of the
abdominal aorta measuring up to 45 mm in maximum diameter with para-aortic soft tissue
stranding. Adjacent para-aortic and aortocaval lymph nodes measure up to 11 mm in short axis.
What is the most likely causative organism?
a. Actinomycosis
b. Cryptococcosis
c. Histoplasmosis
d. Salmonella
e. Treponema pallidum
62. A 19 year old male who is usually fit and active has plain films of the right knee for ongoing
knee pain. The radiograph demonstrates subtle flattening of the lateral surface of the medial
femoral condyle with a loose osteochondral fragment. He has an MRI for investigation of
suspected osteochondritis dissecans.
Which finding is most likely to be seen on MRI?
a. Blooming artefact on gradient echo sequence
b. Cartilaginous defect on T1
c. Fat-fluid level within joint effusion
d. Low signal material within the defect on T2
e. Synovial proliferation
63. A 56 year old male presents with acute epigastric pain. He is found to have a grossly elevated
amylase level and leucocytosis. He is admitted under the general surgeons for conservative
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management. However, after several days he becomes febrile and septic and a CT abdomen
pelvis confirms severe pancreatitis with associated complications. The radiology report gives
a severity score based on the CT severity index incorporating the Balthazar score.
Which of the following imaging features would be included in the Balthazar score?
a. Associated intestinal ileus
b. Background features of liver cirrhosis
c. Peripancreatic inflammation
d. Splenic vein thrombosis
e. The underlying cause of pancreatitis
64. A renal transplant patient is 4 days post-surgery and the transplant team request an
ultrasound Doppler due to increased tenderness in the right iliac fossa, decreased urine
output and haematuria. It is a single artery, vein and ureter organ from an adult cadaveric
donor. The unobstructed transplant measures 15 cm in bipolar length and there is a trace of
perinephric fluid. Corticomedullary differentiation appears normal. There is generalised
Doppler vascularity evident within the kidney. The arcuate arterial traces at the upper, lower
and middle poles demonstrate a sharp upstroke and a resistive index of 0.71. The renal artery
and vein are difficult to visualise but the main renal artery demonstrates reverse flow in
diastole. The urinary bladder has normal appearances.
What is the most likely diagnosis?
a. Pseudoaneurysm
b. Rejection
c. Renal artery stenosis
d. Renal artery thrombosis
e. Renal vein thrombosis
65. A neonate fails to pass meconium. A water-soluble contrast enema identifies dilated loops of
proximal colon with a transition point at the splenic flexure. Contrast outlines retained
meconium in a normal calibre descending colon. The rectum is normal calibre.
Given the above findings, which of the following conditions is most likely?
a. Hirschsprung disease
b. Ileal atresia
c. Meconium ileus
d. Meconium plug syndrome
e. Zuelzer-Wilson syndrome
66. You are reporting an MRI brain for a neurology outpatient with a history of epilepsy. There is
unilateral partial opacification of the left maxillary sinus by a rounded lesion. The opacity
demonstrates high T2 signal and intermediate T1 signal without restricted diffusion or
enhancement. The maxillary ostia are symmetrical. On a CT brain from 2 months previously
there is a similar appearance with a hypodense lesion in a partially aerated left maxillary sinus.
What does this mass most likely represent?
a. Allergic fungal sinusitis
b. Antrochoanal polyp
c. Mucocele
d. Mucous retention cyst
e. Papilloma
67. A 33 year old female presents with left sided chest pain and shortness of breath. She has a
chest radiograph in the emergency department which shows a left sided pleural effusion. She
is under outpatient follow-up with the rheumatology team for systemic lupus erythematosus
(SLE). She has a CT pulmonary angiogram as the team are concerned that she is at increased
risk of pulmonary embolus. This shows no evidence of pulmonary embolus; however, there
are radiological features consistent with her underlying diagnosis.
What is the most common radiological chest finding associated with SLE?
a. Interstitial lung disease
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b. Pericardial thickening
c. Pleural effusion
d. Pneumonia
e. Pulmonary haemorrhage
68. A 3 year old girl is brought to the emergency department following a fall. The consultant
looking after the child requests a CT head. The patient, who is known to have an autosomal-
dominant inherited abnormality, has blue tinting of the sclera and suffers with recurrent
fractures. Previous plain films of the lower limbs demonstrate poor bone density, evidence of
previous fractures with callus formation, and a ‘shepherd’s crook’ deformity of the femur.
What are the most likely findings on CT head?
a. Greater than 10 wormian bones
b. Ground-glass appearance of the sphenoid wing
c. Optic nerve atrophy
d. Subdural haematoma
e. Widening of the diploic space
69. A patient is discussed at the upper gastrointestinal multidisciplinary team meeting. They
presented with dysphagia and weight loss. A barium swallow revealed mid-oesophageal
mucosal irregularity and endoscopic biopsies confirm moderately differentiated oesophageal
squamous cell carcinoma. Staging imaging is required to aid management.
What is the most appropriate staging imaging?
a. Contrast enhanced CT chest abdomen and pelvis
b. Endoscopic ultrasound
c. Endoscopic ultrasound and 18F-FDG PET/CT
d. Endoscopic ultrasound and contrast enhanced CT chest, abdomen and pelvis
e. Thoracic MRI and contrast enhanced CT chest, abdomen and pelvis
70. A 6 year old boy with developmental delay is referred to the paediatric neurologists for an
MRI brain due to recurrent seizures. This reveals multiple subependymal nodules which
return high T1 and intermediate T2 signal. Previous ultrasound of the abdomen demonstrated
bilateral echogenic renal masses.
Based on the above findings, what other feature is most likely on the MRI head?
a. Cystic lesion in right cerebellum containing an enhancing solid nodule
b. Homogenous intermediate signal durally based lesion adjacent to the right frontal lobe
c. Intraventricular markedly enhancing lobulated mass
d. Multiple foci of FLAIR hyperintensity in the cortical and subcortical regions
e. Several foci of T2 hyperintensity in the deep white matter bilaterally
71. A 54 year old man presents with nausea, weight loss and abdominal pain. The surgeons refer him
for a contrast-enhanced CT abdomen and pelvis. This demonstrates a well-defined, heterogenous
mass at the mesenteric root. The mass envelops the vessels, but the terminal ileum and large bowel
are unaffected. The vessels are surrounded by a circumferential low-attenuation area of adipose.
What is the most likely diagnosis?
a. Radiation enteritis
b. Mesenteric panniculitis
c. Tuberculosis
d. Carcinoid
e. Mesenteric lipoma
72. A 42 year old man is referred for a CT head due to partial complex seizures. The CT shows a
large, well defined mass involving the left frontal cortex and white matter. It erodes the inner
table of the skull. The mass shows diffuse, amorphous calcification. There is little mass effect.
Following contrast administration there is heterogenous enhancement.
What is the most likely diagnosis?
a. Astrocytoma
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b. Ependymoma
c. Glioblastoma multiforme
d. Meningioma
e. Oligodendroglioma
73. A 49 year old female patient is admitted under the gynaecologists with pain, fever and nausea
3 days following uterine artery embolisation performed for menorrhagia caused by multiple
uterine fibroids. A CT abdomen and pelvis scan is requested which demonstrates density
of −1000HU in a couple of fibroids with a small amount of pelvic free fluid. On transvaginal
ultrasound scan multiple intramural and submucosal fibroids are again demonstrated and the
uterus appears bulky. There is small volume free fluid in the pouch of Douglas; the
endometrium is partially effaced by the fibroids but the thickness is approximately 8 mm at
the fundus and the ovaries have functional appearances.
What is the most likely diagnosis?
a. Endometritis
b. Fibroid torsion
c. Infection within the fibroids
d. Post-embolisation syndrome
e. Uterine necrosis
74. A 44 year old female patient attends the orthopaedic outpatient clinic with a fracture of her right
distal radius following a fall onto an outstretched hand. The orthopaedic registrar asks you to
review the plain films. There is a well-defined, expansile, lytic lesion at the site of the fracture
which has thinned the cortex. Other findings include generalised sclerosis and subperiosteal
resorption along the radial aspect of the middle phalanges. MRI of the wrist confirms a cystic
and solid lesion with fluid-fluid levels and enhancement of the solid components.
What other imaging finding would most likely correlate with these appearances?
a. A focus of tracer uptake in the region of the thyroid on a Tc-99m pertechnetate scan
b. Diffusely increased thyroid tracer uptake on a Tc-99m pertechnetate scan
c. Multiple low attenuation liver lesions on CT abdomen pelvis
d. Renal cortical thickness of 5 mm on abdominal ultrasound
e. Cortical irregularity with adjacent sclerosis at the medial aspect of the proximal femur
75. A 28 year old male patient, under the care of the gastroenterology team, has been admitted
with an exacerbation of ulcerative colitis. After 48 hours in hospital he is stable but has some
increased abdominal discomfort. You are asked to review his contrast-enhanced CT abdomen
and pelvis. This demonstrates mural thickening and pericolic fat stranding affecting the entire
colon and rectum. There is a rim of lower attenuation in the wall of the colon with a
Hounsfield unit of −95 and minimal faecal residue in the colon. There is a tiny amount of
peritoneal free fluid but no free gas. The colon measures up to 50 mm in diameter. Mesenteric
lymph nodes measure up to 11 mm in short axis.
What is the most appropriate recommendation to the clinical team?
a. Abdominal radiograph in 24 hours
b. Barium enema in 24 hours
c. Colonoscopy within 48–72 hours
d. Repeat CT abdomen pelvis in 48 hours
e. Urgent surgical referral
76. A 23 year old builder is seen in the emergency department following a fall from scaffolding.
CT chest abdomen pelvis demonstrates several right rib fractures and a small amount of free
fluid in the pelvis. The patient has haematuria and blood at the urethral meatus. The urology
team request retrograde urethrography. This demonstrates extravasation of contrast into the
retropubic space, but continuity of the urethra is maintained.
Where is the urethral injury most likely to be sited?
a. Above the urogenital diaphragm
b. Below the urogenital diaphragm
c. Bladder dome
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d. Bulbous urethra
e. Penile urethra
77. A 5 year old child undergoes a barium swallow for dysphagia. This shows an anterior
indentation over the oesophagus just above the level of the carina.
What is the most likely cause for this appearance?
a. Aberrant left pulmonary artery
b. Aberrant right subclavian artery
c. Double aortic arch
d. Enlarged left atrium
e. Right sided aortic arch
78. A 53 year old female patient with metastatic breast cancer has a CT head to assess for
intracranial metastases. This demonstrates no evidence of intracranial disease; however, there
is a solitary enhancing right parotid lesion within the deep lobe. It is not amenable to
ultrasound-guided biopsy. An MRI head is suggested.
Which MRI sequence would be most helpful in confirming that this is a pleomorphic
adenoma?
a. Fat supressed T1
b. Gradient echo
c. Post contrast T1
d. T1
e. T2
79. An emergency department junior doctor requests a CT pulmonary angiogram to look for a
pulmonary embolus in a 52 year old patient who is complaining of acute onset pleuritic chest
pain and shortness of breath. The patient is tachycardic with heart rate of 120 bpm; the Wells
score is 4.5. They have had a normal chest radiograph. You agree to a CTPA; however the
pulmonary artery opacification achieved is inadequate. The main pulmonary artery is noted
to be wider than the ascending aorta and the proximal arteries are also dilated; the peripheral
vessels are reduced in calibre. There is a mosaic appearance to the lung parenchyma.
What is the most appropriate next step?
a. Advise further investigation with CT abdomen pelvis to look for underlying malignancy
b. Advise further investigation with myocardial perfusion study
c. Advise referral to the respiratory team
d. Perform expiratory phase CT chest
e. Perform a ventilation-perfusion (VQ) scan
80. A 45 year old male has a plain film of the knee for investigation of ongoing knee pain. This
shows evidence of degenerative change and genu varus. There is also cortical hyperostosis
affecting the diaphysis of the lateral aspect of the tibia, which is described as dripping candle
wax in appearance.
What is the most likely diagnosis?
a. Caffey disease
b. Focal scleroderma
c. Melorheostosis
d. Osteopoikilosis
e. Pyknodysostosis
81. A 65 year old male who has a background of chronic alcohol abuse presents to the emergency
department with an upper gastrointestinal bleed. He undergoes endoscopy which confirms
oesophageal varices. These are injected and the patient improves. An abdominal ultrasound is
subsequently arranged.
Which of the following ultrasound findings is UNLIKELY to be identified in this patient?
a. Ascites
b. Gallbladder wall thickening
c. Hepatopetal portal venous flow
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a. Haemophilia
b. Homocysteinuria
c. Juvenile rheumatoid arthritis
d. Pigmented villonodular synovitis
e. Primary synovial chondromatosis
87. The clinical team ask your opinion on the best form of imaging for a 49 year old male with a
family history of multiple endocrine neoplasia. He has symptoms of diarrhoea, abdominal
pain and reflux. The patient has also presented twice during the past year to his GP with
episodes of haematemesis.
What test would you recommend to the team?
a. Barium meal
b. CT chest, abdomen pelvis with arterial and portal venous phase contrast
c. 18F-FDG PET/CT
d. MRI brain
e. MRI small bowel
88. A 57 year old male patient is investigated for painless haematuria. Past medical history
includes hypertension and type 2 diabetes, for which he is on oral medication. On ultrasound
the kidneys are unobstructed but eccentrically positioned lower than normal with poor
visualisation of the lower poles. There are normal appearances of the urinary bladder. CT
urogram is completed and confirms a horseshoe kidney. There are several small filling defects
in the renal pelvises and proximal ureters; these have a density of 10HU on the non-contrast
sequence and then 15HU following contrast administration.
What is the most likely diagnosis?
a. Leukoplakia
b. Multiple calculi
c. Pyeloureteritis cystica
d. Transitional cell carcinoma
e. Tuberculous urethritis
89. You are asked to review imaging for a 2 month old child with bilious vomiting. An ultrasound
and then an upper gastrointestinal contrast study have been completed. Both sets of imaging
confirm malrotation.
Which of the following findings is NOT consistent with this conclusion?
a. Cephalad positioning of the caecum
b. Duodenojejunal flexure is at the level of the duodenal bulb
c. Duodenojejunal junction lies to the right of the right vertebral body pedicle
d. Superior mesenteric vein lies to the left of the superior mesenteric artery
e. Whirlpool appearance of the mesenteric vessels
90. An 18F-FDG PET/CT for a 71 year old patient seen in outpatients with decline in memory and
cognitive function reveals changes suggestive of Alzheimer disease. The clinician feels that is
in keeping with the clinical findings.
Which of these patterns of reduced tracer uptake is consistent with this conclusion?
a. Anterior and medial temporal lobes
b. Basal ganglia and posterior frontoparietal lobes
c. Corpus striatum
d. Occipital cortex and cerebellum
e. Precuneus, posterior cingulate cortex, posterior temporoparietal lobes
91. A 60 year old female presents to her GP with a cough and fever. She has a chest radiograph
which reports consolidation in the left lower zone. A follow-up plain film following treatment
is suggested. She returns to the department with ongoing symptoms for a repeat radiograph
6 weeks later. The left lower zone consolidation has resolved; however, there is new
opacification in the left mid zone. The GP organises an unenhanced CT chest which is
performed a couple of months after initial presentation. There is ground glass opacification at
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the periphery of the left mid zone which is surrounded by dense crescentic opacification.
Further patchy consolidation is seen in the periphery of the right lower lobe.
What is the most likely diagnosis?
a. Adenocarcinoma in situ
b. Cryptogenic organising pneumonia
c. Invasive fungal infection
d. Pulmonary haemorrhage
e. Pulmonary infarct
92. A 6 year old female suffers an inversion injury of her ankle on a trampoline. She is taken to the
emergency department and plain films are performed. There is subtle slip of the distal fibula
epiphysis.
What type of Salter-Harris fracture is this?
a. Type I
b. Type II
c. Type III
d. Type IV
e. Type V
93. A 42 year old woman undergoes a liver transplant for primary biliary cirrhosis. She is reviewed
in the transplant clinic 2 weeks after discharge and undergoes a routine surveillance ultrasound.
Which of the following statements regarding this patient’s liver transplant ultrasound is correct?
a. A perihepatic haematoma is an unexpected finding
b. A tardus parvus Doppler waveform is normal in the early post-transplant period
c. Biliary strictures are an uncommon early complication
d. Hepatic vein thrombosis is the most common vascular complication
e. The gallbladder may be mildly oedematous
94. A 23 year old female with no past medical history except taking the oral contraceptive pill
presents with headache and a tonic clonic seizure. An unenhanced CT head shows a small
parenchymal haemorrhage in the subcortical region of the right temporal lobe which does not
conform to a vascular territory. There is associated sulcal effacement.
What is the next best investigation?
a. CT intracranial angiogram
b. Catheter angiogram
c. MR venogram
d. Intracranial Doppler
e. Lumbar puncture
95. A neonate is noted to be cyanotic from birth. A frontal chest radiograph is performed which
shows a grossly dilated heart and right atrium with elevated apex. The lungs are oligaemic.
What is the most likely diagnosis?
a. Aortic coarctation
b. Ebstein anomaly
c. Tetralogy of Fallot
d. Total anomalous pulmonary venous return (TAPVR)
e. Transposition of the great arteries
96. A 49 year old male patient has had his care transferred to the local ear, nose and throat team
after relocating to the area. He has a history of thyroid cancer for which he has undergone
total thyroidectomy 18 months previously. At the time of the ultrasound the patient is not sure
about the type of thyroid cancer he had and the referral letter is not available. The scan
demonstrates a 9-mm left level III lymph node with microcalcification. Early pathological
assessment confirms malignant cells.
Which underlying malignancy is most likely?
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d. Scaphocephaly
e. Trigonocephaly
102. A 10 year old boy presents with a reduced GCS. An urgent CT brain reveals a large mixed
solid and cystic suprasellar lesion causing hydrocephalus. The mass contains calcification. A
subsequent MRI demonstrates that the lesion has heterogeneously high T2 signal. The solid
components of the mass enhance avidly on T1 post contrast imaging.
What is the most likely diagnosis?
a. Craniopharyngioma
b. Intracranial teratoma
c. Meningioma
d. Pituitary macroadenoma
e. Rathke cleft cyst
103. A 53 year old male has ongoing cough and shortness of breath following a lung transplant
18 months earlier. He has a CT chest as part of his workup to look for complications. He has
suffered intermittent infective episodes since the transplant, which have required treatment
with antiviral therapy. He is increasingly symptomatic and the clinicians are concerned about
chronic rejection. The CT scan shows hyperinflated lungs, bronchiectasis and airway wall
thickening with mosaicism, worse in the lower zones.
What is the most likely diagnosis?
a. Acute transplant rejection
b. Bronchiolitis obliterans
c. Cytomegalovirus infection
d. Post-transplant lymphoproliferative disease
e. Reperfusion syndrome
104. A 15 year old male with back pain, who has a diagnosis of Scheuermann’s disease, has an MRI
of the whole spine.
When reviewing the imaging, which of the following is most accurate?
a. The kyphosis is <35°
b. Less than three vertebral bodies are affected
c. The lumbar spine is most likely affected
d. There is preservation of the disc spaces
e. Schmorl nodes are one of the most common features
105. A 54 year old patient with chronic hepatitis B infection and a high body mass index has an
abdominal ultrasound to monitor her liver. Her previous scan was 12 months previously. The
most recent ultrasound shows no sonographic evidence of cirrhosis; however, there is an
indeterminate hypoechoic area in the left lobe. Further liver imaging is advised.
With regard to liver MRI, which of the below is correct regarding normal liver appearances?
Table 3.1:
MRI T1 Signal MRI T2 Signal MRI In- and Out-of-Phase Sequences
106. A 12 year old male with repeated fractures attends the emergency department following a fall.
He has a plain film of the left femur which demonstrates increased bone density of the
medulla, a ‘bone-in-bone’ appearance, Erlenmeyer flask deformity and evidence of previous
healed fracture but no acute fracture seen.
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Table 3.2:
Enhancement MRI Spectroscopy Choline Level Relative Cerebral Blood Flow (rCBF)
109. A 42 year old female patient is referred to the respiratory team for persistent cough and recurrent
chest infections. A chest radiograph that the GP requested 6 weeks ago reveals right lower lobe
atelectasis. The patient attends for CT chest which identifies a well-defined 15-mm soft tissue
lesion containing calcification. This is centred on the right hilar region with associated right
lower lobe consolidation. There are a couple of 10-mm right hilar lymph nodes and a subcarinal
lymph node. The patient is referred for lung multidisciplinary team (MDT) meeting discussion.
What further imaging would be appropriate to recommend to the MDT prior to surgery?
a. 18F FDG PET/CT
b. 18F DOPA PET/CT
c. Gallium 68 PET/CT
d. Liver MRI
e. Repeat CT chest in 6 months
110. A 21 year old female with a known chromosomal abnormality has a fall onto an outstretched
hand and attends the emergency department, where a plain film is performed to assess for
scaphoid fracture. She has had previous investigations which described a Madelung deformity.
Which of the following is most likely to be seen on plain film?
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Table 3.3:
T1 T2
a Low Low
b High High
c High Low
d Isointense Low
e Isointense High
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115. A 29 year old female has a CT scan of the chest. This shows an incidental finding of lobulated
soft tissue within the anterior mediastinum which is thought to represent a thymic
abnormality. She undergoes an MRI scan to further characterise this lesion.
Which of the following sequences is most useful to assess for thymic hyperplasia?
a. Diffusion weighted imaging
b. In- and out-of-phase imaging
c. Post-contrast fat saturated T1 imaging
d. T1 weighted imaging
e. T2 weighted imaging
116. A 36 year old woman is referred for an MRI brain due to tinnitus and vertigo. This
demonstrates a mass at the left cerebellopontine angle.
Which of the following radiological features is most suggestive of a vestibular schwannoma
compared to a meningioma?
a. Blooming artefact due to calcification on gradient echo sequence
b. Expansion of the internal acoustic canal
c. Hypointensity on T2 weighted imaging
d. Obtuse angle with the dura
e. Restricted diffusion
117. A 36 year old cyclist is involved in a collision with a car. In the emergency department he is
hypotensive. On examination there is guarding in the left upper quadrant. A split bolus, trauma
protocol CT chest abdomen and pelvis is performed. This demonstrates left-sided rib fractures.
There is hyperdense (50HU) free fluid in the splenic bed. Within the upper pole of the spleen there
is a linear area of hypoenhancement that measures 4 cm. No contrast extravasation or blush is
identified.
According to The American Association for the Surgery of Trauma (AAST) grading scale, what is
the grade of splenic injury?
a. Grade I
b. Grade II
c. Grade III
d. Grade IV
e. Grade V
118. A cranial ultrasound is performed on a premature neonate. Germinal matrix haemorrhage is
identified.
Which of the following radiological findings indicates the worst prognosis?
a. Hyperechoic foci in the peritrigonal area
b. Intraparenchymal haemorrhage
c. Intraventricular haemorrhage
d. Intraventricular haemorrhage with ventricular dilatation
e. Subependymal haemorrhage
119. A 42 year old woman with a history of Sjögren syndrome presents with acute abdominal pain.
On examination she is tender with guarding in the epigastric region. Blood tests show highly
elevated serum amylase level. She undergoes a CT abdomen pelvis with contrast. This shows
a diffusely enlarged pancreas with a surrounding hypoattenuating rim. There is minimal
peripancreatic stranding and no pseudocyst formation or necrosis. An autoimmune
pancreatitis is considered to be most likely clinically.
Which of the following biochemical test results are most likely to be associated with these
imaging features?
a. Elevated serum IgG4
b. Elevated serum Ca 19-9
c. Elevated serum chromogranin A
d. Elevated chromogranin B
e. Elevated serum alpha-fetoprotein
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120. You are asked to review the MRI brain protocol for cases of suspected multiple sclerosis at
your institution.
Which of the following sequences is best for assessing for posterior fossa involvement?
a. DWI and ADC map
b. FLAIR
c. Gradient echo
d. T1 post gadolinium
e. T2 spin echo
ANSWERS 3
Source: Hain KS, Pickhardt PJ, Lubner MG et al. Presacral masses: multimodality imaging of a multidisciplinary
space. RadioGraphics. 2013;33(4):1145–1167.
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in the thoracic spine. In contrast to the lesion in this case, they are usually ill-defined and
more infiltrative. They also usually extend over more than four segments.
Meningiomas are solid lesions which are usually extramedullary, unlike the lesion in
this case. They can sometimes be low on T1 and T2 if they are calcified.
(The Final FRCR Complete Revision Notes Page 450)
7. (e) Usual interstitial pneumonia (UIP)
The CT description provided is that of a fibrotic lung process and is typical of a UIP pattern
of disease. A UIP pattern of disease is associated with predominantly honeycomb destruction
of the lung which has an apicobasal gradient and tends to be peripheral.
Ground glass opacification is the predominant finding in non-specific interstitial pneumonia.
The imaging findings of chronic hypersensitivity pneumonitis can overlap significantly with
UIP pattern. However, the fibrosis distribution is more typically basal and peripheral in UIP,
whereas in hypersensitivity pneumonitis the fibrotic change is less likely to be peripheral and is
typically upper zones, although all zones can be affected. Hypersensitivity pneumonitis may
also be associated with mosaicism secondary to air trapping.
The predominant imaging finding in cryptogenic organising pneumonia is ground glass
change and dense consolidation. Respiratory bronchiolitis−associated interstitial lung disease
represents a spectrum of disease associated with smokers. The findings on CT chest are more
typically centred on the airways with airway wall thickening and evidence of air trapping.
There may be small centrilobular nodules which represent occlusion of the small airways.
(The Final FRCR Complete Revision Notes Page 37)
8. (b) Bronchus
Bone metastases favour the axial skeleton rather than the appendicular skeleton due to the
presence of red marrow. The most common malignancy associated with bone metastases is
carcinoma of the bronchus. Colon cancer is another cause of lytic bone metastasis. Renal and
thyroid malignancies may be associated with lytic, expansile lesions. Breast cancer is a common
cause of lytic, mixed lytic/sclerotic and sclerotic bone metastases; however this is much less
common in male patients.
(The Final FRCR Complete Revision Notes Page 143)
9. (c) Long, linear oesophageal filling defects
The patient is likely immunocompromised due to the chemotherapy regimen and therefore
opportunistic infections such as candida, herpes simplex and cytomegalovirus (CMV) should be
considered. Candida oesophagitis is the most common infectious cause, and findings include
long linear plaque-like lesions, ulceration and pseudomembrane formation. CMV (and HIV)
cause massive ulcers, whereas herpes simplex oesophagitis tends to lead to multiple small ulcers.
Flask-shaped mucosal outpouchings are typical for pseudo diverticulosis of the oesophagus
caused by the mucous glands filling with contrast. It is associated with reflux, strictures and
oesophagitis.
Multiple small nodular oesophageal filling defects are seen in glycogenic acanthosis, a
condition associated with the elderly due to glycogen deposition.
Smooth oesophageal strictures infer benign causes such as previous caustic ingestion,
radiation, Barrett oesophagus and skin diseases with oesophageal manifestations, such as
epidermolysis bullosa and pemphigoid. A likely cause in a breast oncology patient would be
radiation; however, this patient is currently only having neoadjuvant chemotherapy.
(The Final FRCR Complete Revision Notes Page 158)
10. (d) Morquio syndrome
Morquio syndrome is the most common mucopolysaccharidosis, associated with multiple
skeletal abnormalities and presenting within the first 18 months of life. There are several
features seen on spinal radiographs; central beaking of the anterior vertebral bodies is
relatively specific. Other features include platyspondyly, posterior vertebral body scalloping,
exaggeration of the lumbar lordosis and atlantoaxial subluxation due to odontoid
hypoplasia. Appendicular skeleton findings include lateral sloping of the tibial plateau, genu
valgus, bullet-shaped metacarpals and short, wide tubular bones with metaphyseal
irregularity. The other conditions provided as options are examples of anteroinferior
vertebral body beaking.
(The Final FRCR Complete Revision Notes Page 114)
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most commonly affected, other sites such as the vertebral, iliac, coeliac and extracranial internal
carotid arteries can also be involved. Therefore symptoms including headache, stroke, angina
or mesenteric ischaemia are possible, depending on the site of involvement.
If asymptomatic, patients are kept under observation but if presenting symptomatically the
condition is amenable to angioplasty and responds well. Stenting is rarely required.
Patients with fibromuscular dysplasia have weakened vascular walls and can encounter
complications, including dissection and aneurysm formation.
(The Final FRCR Complete Revision Notes Page 252)
17. (b) Cowden syndrome
The lesion described is typical for Lhermitte-Duclos disease (also known as dysplastic
cerebellar gangliocytoma) which is associated with Cowden syndrome. Other features include
thyroid goitres, skin lesions and gastrointestinal polyps. Although Cowden syndrome and
dysplastic cerebellar gangliocytoma are rare, the answer to this question can also be deduced
from knowledge of the other, more common conditions.
Ataxia telangiectasia leads to cerebellar atrophy and on imaging low T2 signal foci likely
represent haemosiderin deposition secondary to bleeds from abnormal telangiectatic vessels.
Neurofibromatosis 1, Sturge-Weber syndrome and tuberous sclerosis have multiple central
nervous system manifestations, none of which are present in this case. Cerebellar tumours and
thyroid goitres are not typical features.
(The Final FRCR Complete Revision Notes Page 292)
18. (a) DWI + ADC map
It can be difficult to determine the underlying cause of intra-axial lesions on imaging,
particularly when differentiating abscess from a malignant process. Abscesses are commonly
low on T1, high on T2 and FLAIR sequences with significant adjacent oedema and mass effect.
The ring of enhancement is often described as thinner compared to malignancy; however, the
sequence that can be most helpful in differentiating the two is DWI and ADC map. The
presence of central diffusion restriction favours abscess over a necrotic tumour.
The ‘dual rim’ sign may be seen in cases of intracranial abscesses. It is an outer hypointense
rim and inner hyperintense rim. This may be appreciated best on T2 and susceptibility
weighted imaging.
MR perfusion may be helpful as the relative cerebral blood flow (rCBF) in the surrounding
oedema of an abscess is usually reduced compared to tumour oedema.
(The Final FRCR Complete Revision Notes Pages 411–412)
19. (e) Upper lobe diversion
Pulmonary oedema is commonly due to cardiac failure or fluid overload. The earliest feature
is upper lobe diversion. Following this, interstitial oedema develops, causing ground glass
opacification and interlobular septal thickening. Alveolar oedema will develop if the condition
continues to progress and this manifests as consolidation. Cardiomegaly may be present and
can be assessed by measuring the cardiothoracic ratio.
(The Final FRCR Complete Revision Notes Page 52)
20. (e) Osteosarcoma
There are features of Paget disease, a bone disorder due to excessive bone remodelling, indicated
by enlarged bone with coarse trabeculae and cortical thickening. The presence of periostitis with a
‘hair-on-end’ or ‘sunburst’ periosteal reaction is indicative an aggressive bone lesion, consistent
with development of a secondary osteosarcoma, a complication of Paget disease. Osteosarcoma is
most common in children and adolescents, with a second peak in 70–80 year olds.
Bizarre parosteal osteochondromatous proliferation is characterised by heterotopic ossification
arising from cortical bone.
Haemangiomas are benign bone lesions, which can manifest as coarsened trabeculae. The bone
cortex is not usually affected and there is no aggressive periostitis.
Multiple myeloma is the most common primary bone tumour in adults. This may manifest as a
plasmacytoma, a solitary expansile soft tissue bone lesion or as well-demarcated, punched-out
radiolucent lesions without a sclerotic border.
Osteoblastoma is a benign lesion, without aggressive features, presenting between 20 and
30 years.
(The Final FRCR Complete Revision Notes Page 148)
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ultrasound are that of a joint effusion in the anterior recess without synovial thickening, which
resolves after 10–15 days.
Developmental dysplasia of the hip is often undetected until adulthood; however, children
with risk factors (including breech delivery, oligohydramnios, family history) are now
screened. Ultrasound is the test of choice in infants less than 6 months old. On radiographs
there may be an abnormal acetabular angle, it should measure less than 22° in children older
than 1 year of age.
Juvenile rheumatoid arthritis is associated with synovial hypertrophy and effusion.
Septic arthritis is an important consideration; radiographs may be normal in the very acute
phase. There may be juxta-articular osteoporosis due to hyperaemia, narrowing of the joint
space due to cartilage destruction, as well as destruction of the subchondral bone on both sides
of a joint. Spontaneous resolution would not be expected.
Slipped upper femoral epiphysis is most commonly seen in those 10–16 years of age. Early
slippage is best seen on lateral or frog lateral views and the epiphysis may be reduced in height
due to slippage.
(The Final FRCR Complete Revision Notes Pages 108−109)
27. (c) Periampullary tumour
Periampullary tumours tend to be small and are often not seen with imaging. On CT they can
appear as a low-density mass centred on the ampulla. Alternatively, the ‘double duct sign’
(dilated common bile duct and pancreatic duct), with no detectable pancreatic head mass, can
be the only finding. On MRCP there is an abrupt cutoff of the distal common bile duct.
An annular pancreas encircles the duodenum and is associated with Down syndrome.
Pancreas divisum is commonly an incidental finding of two different pancreatic ducts
draining dorsal and ventral parts of the pancreas. It can predispose patients to pancreatitis.
Duodenal atresia is associated with the ‘double bubble’ sign and presents in neonates with
bilious vomiting.
(The Final FRCR Complete Revision Notes Page 230)
28. (c) Two ureters with upper moiety ureter inserting inferomedial to lower moiety ureter
A duplex kidney does not necessarily imply a complete ureteric duplication; however, with
the ultrasound appearances of ureterocele there is suspicion of an ectopic insertion of the upper
moiety ureter.
Incomplete duplication is when the ureters converge above the level of the bladder and often
this can exist with a degree of ‘yo-yo’ reflux from one ureter into the other. When there is
complete duplication the upper pole moiety often obstructs due to the presence of a
ureterocele. This can cause the ‘drooping lily’ sign due to hydronephrosis and lack of filling of
the upper pole moiety and subsequent displacement of the opacifying lower pole moiety.
The upper moiety ureter inserts ectopically, often into the urinary bladder, but this can insert
into the urethra, vagina or seminal vesicles, potentially causing continuous wetting in older
children. The lower moeity ureter inserts normally but is prone to reflux. The Weigert-Meyer
rule states that the upper moiety ureter inserts inferomedial to the lower moiety ureter.
(The Final FRCR Complete Revision Notes Pages 264−265)
29. (b) Cardiomegaly
The case describes a vein of Galen malformation. These are often diagnosed in third trimester
antenatal scans as a vascular anechoic structure close to the third ventricle. They cause a left-to-
right shunt and therefore lead to high-output cardiac failure leading to cardiomegaly,
pulmonary oedema and widening of the superior mediastinum.
The other conditions are not associated with vein of Galen malformations but may be
associated with other congenital abnormalities.
(The Final FRCR Complete Revision Notes Page 306)
30. (c) Neurofibromatosis (NF) 2
NF2 usually presents in young adults. Half of cases are spontaneous and half of cases are
inherited through an autosomal dominant pattern of inheritance. The condition causes multiple
central nervous system tumours including bilateral acoustic neuromas (as described in this
case) which are pathognomonic of the condition. NF2 is also associated with ependymomas,
meningiomas and schwannomas. These can occur on spinal roots or cranial nerves.
(The Final FRCR Complete Revision Notes Page 382)
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indicative of Marchiafava-Bignami disease. In the acute stage of the disease there is oedema
and over time this progresses to necrosis and atrophy. It often starts in the body of the corpus
callosum and progresses to the genu and splenium. Treatment is with B vitamins.
Susac syndrome has a preference for the corpus callosum with lesions affecting the body and
splenium. There tend to be multiple small lesions which resemble ‘snowballs’ on T2 sequences.
The other radiological features of excess alcohol intake in this case make Marchiafava-Bignami
more likely. The clinical history in Susac syndrome is usually one consistent with brain, retinal
and vestibulocochlear involvement.
Multiple sclerosis is a differential for hyperintense T2 lesions; however the distribution is
different and typically affects areas including the inferior aspect of the corpus callosum,
internal capsule, optic tracts and periventricular white matter.
Methanol intoxication affects the putamina causing haemorrhage and necrosis.
Wernicke encephalopathy can also cause haemorrhage and necrosis; however it typically
affects the mamillary bodies, periaqueductal grey matter, posteromedial thalami and tectal plate.
(The Final FRCR Complete Revision Notes Page 418)
36. (d) Normal study
The abnormalities associated with hypoxic ischaemic injury in neonates depend on the
gestational age. Frequently cranial ultrasounds are normal within the first 2 days. Hyperechoic
changes are then commonly encountered. In a term baby the deep grey matter structures are
affected; however, in a preterm baby it is more typically the periventricular white matter. In
older children (>2 years) there can be a reversal of normal grey−white matter appearances and
a ‘white cerebellum’ due to cerebellar sparing in diffuse cerebral oedema.
(The Final FRCR Complete Revision Notes Page 298)
37. (c) Myocardial infarct involving the left anterior descending artery
The left anterior descending artery and its branches supply the anterolateral and apical walls of
the left ventricle and the interventricular septum. The high T2 weighted signal in this region is
secondary to oedema suggesting a relatively acute insult, and the delayed hyperenhancement is
typical in infarcted myocardium and tends to be subendocardial or full thickness.
Myocardial stunning and hibernation often have similar imaging findings. Stunning is caused
following a transient period of ischaemia, whereas hibernation is thought to be related to more
chronic ischaemia where the myocardial cells adapt to reduced perfusion by hibernating and
reducing metabolic activity. Both these conditions lead to impaired function, manifesting as
reduced contractility. Stunned myocardium tends to have preserved perfusion whereas it can be
reduced in myocardial hibernation.
Acute myocarditis may demonstrate increased myocardial T2 weighted signal however other
findings such as a focal area of wall motion abnormality would also be expected. Enhancement in
myocarditis tends to involve the epicardium and be early rather than the delayed subendocardial
enhancement described in this case.
(The Final FRCR Complete Revision Notes Page 11)
38. (e) Torus fracture
The features describe a buckle or torus fracture which occurs due to compression injury, for
example falling on an outstretched hand. In a greenstick fracture, there is a cortical break on
one side of the bone; the cortex on the other side remains intact, this is an unstable fracture.
A lead pipe fracture is characterised by a torus fracture on one side of the bone and a greenstick
fracture on the other side of the bone. In a plastic bowing fracture, there is no discernible
cortical compression or break; however the bone appears deformed or bent. A Salter-Harris
fracture is a fracture of the physis, which is divided into types 1–5.
(The Final FRCR Complete Revision Notes Page 110)
39. (c) Reduced signal on T1 and T2 weighted images in the liver and pancreas.
Haemochromatosis is the deposition of iron in the body and haemosiderosis is haemosiderin
deposition. Haemochromatosis is an autosomal recessive condition leading to hepatomegaly,
arthralgia, diabetes, skin hyperpigmentation and cardiac failure. On MRI there is reduced
signal in the liver, pancreas and heart.
Haemosiderosis is associated with multiple blood transfusions. In contrast to
haemochromatosis, there is reduced MRI signal in the liver and spleen.
(The Final FRCR Complete Revision Notes Pages 210−211)
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difficult to tell if they are large). They abut the articular surface and have a well-defined non-
sclerotic margin. There is no internal matrix mineralisation. They are usually seen in the long
bones, most commonly the femur, and they can occur with Paget disease. Malignant
transformation can rarely occur (less than 1%).
(The Final FRCR Complete Revision Notes Page 141)
45. (d) D2–3
Duodenal trauma is most likely to affect the retroperitoneal D2–3 segments, as they are
relatively fixed. Deceleration injuries in particular are associated with duodenal trauma.
Duodenal rupture is suggested if there is retroperitoneal free gas, wall thickening,
discontinuity of the wall, adjacent free fluid and fat stranding. This requires surgical
management and may be associated with other intra-abdominal injuries.
In the context of trauma, duodenal wall thickening and a heterogenous soft tissue
attenuation mass adjacent to the duodenum without any evidence of perforation would be in
keeping with a duodenal haematoma. This is usually managed conservatively unless there is
evidence of active haemorrhage. The distinction between haematoma and rupture can be
challenging especially with other concomitant trauma findings.
The D1 segment of the duodenum is least likely to be affected. The ligament of Treitz at the
duodenojejunal flexure is another possible site of injury due to the fixation the ligament provides.
(The Final FRCR Complete Revision Notes Page 166)
46. (c) Internal maxillary
Juvenile angiofibromas are benign lesions which typically present with epistaxis in
adolescent males. Characteristic imaging findings include widening of the pterygopalatine
fossa, erosion of the medial pterygoid plate and anterior bowing of the posterior wall of the
maxillary sinus. They can spread through the skull base and typically enhance homogenously
and avidly. Biopsy is contraindicated due to their high vascularity. Preoperative embolisation
can be helpful prior to surgical management. These lesions are most commonly supplied by the
internal maxillary artery, a branch of the external carotid artery.
(The Final FRCR Complete Revision Notes Page 427)
47. (e) Right third to ninth ribs
Rib notching occurs secondary to dilated intercostal collateral vessels which allow blood to
bypass the coarctation and reach the descending aorta. The first and second ribs do not become
notched because the first and second posterior intercostal arteries arise from the costocervical
trunk, a branch of the subclavian artery. They therefore do not communicate with the aorta and
so are not involved in collateral formation. Rib notching commonly affects the third to ninth ribs
bilaterally due to the coarctation being distal to both subclavian arteries. If there is unilateral right
rib notching, as in this case, then the coarctation lies distal to the brachiocephalic trunk but
proximal to the origin of the left subclavian artery, or there may be a right sided aortic arch with
aberrant left subclavian artery which is distal to the coarctation.
(The Final FRCR Complete Revision Notes Page 312)
48. (b) Diffuse brainstem glioma
The history and description of the mass are typical for diffuse brainstem glioma.
Acute demyelinating encephalomalacia (ADEM) and rhombencephalitis usually have a
different history with features such as fever or recent infectious illness or vaccination. Both
conditions can affect the brainstem but lesions usually have some enhancement or restricted
diffusion.
Osmotic demyelination is also not typical with this history and the condition is commonly
secondary to iatrogenic correction of hyponatraemia. The MRI features are also not typical and
restricted diffusion is an early feature.
Medulloblastomas are classically related to the roof of the fourth ventricle rather than the
floor. Unlike this lesion, they diffusely enhance and demonstrate restricted diffusion.
(The Final FRCR Complete Revision Notes Page 389)
49. (a) Anteriorly
Acute respiratory distress syndrome (ARDS) is caused by diffuse alveolar damage leading to
bilateral pulmonary oedema with normal hydrostatic pressures, that is non-cardiogenic
oedema. Typically this causes patchy, peripheral consolidation rather than the perihilar
oedema seen in cardiac and renal failure. Cardiomegaly and prominent pulmonary vessels
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would not be expected, and pleural effusions and interstitial lines are also less frequent than in
cardiac or renal failure, although some patients may have a mix of underlying pathologies.
Often on CTs of ITU patients with ARDS, the ground glass consolidation is more marked in the
dependent region of the lungs, which protects this region from barotrauma caused by
ventilation. Hence the long-term fibrotic changes associated with the condition are typically
anteriorly distributed, although many patients do not demonstrate any significant chronic
pulmonary changes.
(The Final FRCR Complete Revision Notes Page 16)
50. (d) No further investigation required
The description is that of a haemangioma. This is a benign vascular malformation; the
vertebral bodies and skull are commonly affected. The trabeculae appear coarse, causing a
‘polka-dot’ appearance on axial slices. The differential diagnosis is Paget disease. The cortex is
spared in a haemangioma compared to Paget disease where it is thickened and sclerosis is more
apparent. On MRI the lesion would be high signal on T1 and T2 imaging; however the CT
images are adequate to make the diagnosis. The lesions are usually incidental and
asymptomatic. In atypical rare cases, symptoms may occur due to soft tissue extension or
haemorrhage.
(The Final FRCR Complete Revision Notes Page 142)
51. (d) Multicystic dysplastic kidney
Multicystic dysplastic kidney (MCDK) in infancy can demonstrate multiple cysts of varying
sizes with intervening hyperechoic fibrous tissue and very little normal parenchyma. The
kidney appears enlarged due to the multiple cysts. This condition is caused by ureteral
obstruction in utero which stops normal nephron formation. The condition can be
asymptomatic, going unrecognised and causing an atrophic kidney later in life. The condition
is typically unilateral; bilateral involvement is fatal.
Autosomal recessive kidney disease also causes large kidneys but is bilateral and
symmetrical with small 1- to 2-mm cysts. It can also cause hepatosplenomegaly.
Juvenile nephronopthisis causes normal or small kidneys cysts, atrophy and fibrosis. There is
reduction in corticomedullary differentiation and multiple <15 mm cysts later in the disease
process.
Mesoblastic nephroma is a solid lesion but sometimes there can be areas of cystic
degeneration or necrosis within it.
Multilocular cystic nephroma, or simply cystic nephroma, also has imaging features of
multiple cysts with fibrosis; however, it tends to be a discrete renal mass rather than affecting
the whole kidney and is often described as herniating into the renal hilum. There can also be
Doppler flow seen in the septations of these lesions.
(The Final FRCR Complete Revision Notes Page 254)
52. (d) Minimally enhancing pituitary lesion on MRI brain
Multiple endocrine neoplasia (MEN) 1 predisposes patients to pancreatic tumours,
parathyroid adenoma and pituitary adenoma. This patient is therefore most likely to have a
minimally enhancing pituitary lesion on MRI brain.
A hypoechoic ill-defined thyroid nodule is suggestive of thyroid carcinoma and medullary
thyroid carcinoma in particular is associated with MEN 2. Medullary thyroid carcinoma
frequently contains microcalcification.
Phaeochromocytomas cause markedly T2 hyperintense adrenal lesions, referred to as the
‘light bulb’ sign. They are commonly part of MEN 2. MEN 2B is also associated with
gastrointestinal and cutaneous neuromas, marfanoid habitus and prognathism.
(The Final FRCR Complete Revision Notes Page 230)
53. (e) This likely represents pulmonary interstitial emphysema
The child has features of pulmonary interstitial emphysema (PIE). This typically develops in
premature infants with severe surfactant deficiency causing respiratory distress syndrome.
Surfactant deficiency is associated with reduced lung volumes. Artificial ventilation can cause
air to track into the interstitial space causing pneumothoraces. Air can also track centrally and
cause pneumomediastinum. The appearance of the thymus in this case is consistent with
pneumomediastinum, with surrounding air and displacement of the thymic lobes laterally.
Both pneumothorax and pneumomediastinum are important complications to recognise and
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Actinomycosis, cryptococcosis and histoplasmosis are not associated with aortic aneurysms.
Actinomycosis causes homogenous, often lobar, pulmonary opacification with a propensity for
cavitation and associated pleural thickening and effusions. Crytococcosis is a fungus which can
cause both lung and central nervous system infection. Histoplasmosis is another fungus which
can manifest in both the lungs and mediastinum causing pulmonary nodules, calcified hilar
and mediastinal lymph nodes and fibrosing mediastinitis.
(The Final FRCR Complete Revision Notes Page 1)
62. (b) Cartilaginous defect on T1
Osteochondritis dissecans is an osteochondral fracture of the articular epiphysis thought most
likely due to trauma and ischaemia. It is more common in males and most commonly affects the
knee, talar dome, tibia, patella and femoral head. Features on plain film include flattening and
cortical irregularity of the articular surface and a detached loose osteochondral defect may also be
visible. On MRI a cartilaginous defect may be seen on T1, the defect may demonstrate high T2 signal
in keeping with fluid and there may also be high signal seen within the articular cartilage.
Synovial proliferation is a feature of pigmented villonodular synovitis, which may also show
blooming on gradient echo imaging due to haemosiderin deposition. A fat-fluid level may be seen in
an acute intra-articular fracture, not typically seen in osteochondritis dissecans.
(The Final FRCR Complete Revision Notes Page 119)
63. (c) Peripancreatic inflammation
The CT severity index (CTSI) is based on the Balthazar score and the extent of pancreatic
necrosis.
In order to calculate the CTSI, the pancreas is scored based on its appearance from 0 to 4,
with 0 been least severe and 4 the being most severe. The five categories are:
• Normal appearance
• Focal/diffuse enlargement
• Peripancreatic inflammation
• Single peripancreatic fluid collection
• >2 collections ± retroperitoneal gas
Following this, points are awarded for the amount of pancreatic necrosis. No necrosis gains 0
additional points, <30% scores 2 points, 30–50% scores 4 points and >50% gains 6 points.
Therefore, the maximum CTSI score is 10. A score of >7 is associated with 20% mortality.
A modified CTSI was released in 2014 which also takes into account extrapancreatic
complications such as pleural effusions and vascular complications.
(The Final FRCR Complete Revision Notes Pages 233−235)
Balthazar EJ. Acute pancreatitis: assessment of severity with clinical and CT evaluation. Radiology.
2002;223(3):603–613.
64. (e) Renal vein thrombosis
There is reverse flow in diastole on the arterial trace which is consistent with renal vein
thrombosis; flow should always be flowing forwards even in diastole. The typical
presentation is with tenderness and decreased urine output in the first week following
transplant. The kidney can appear swollen and can be hypoechoic on ultrasound. The renal
vessels can be difficult to clearly visualise immediately following transplant depending on
position and body habitus. If the renal vein could be visualised and assessed with Doppler,
there would be no venous flow.
Renal artery thrombosis is also an early complication but thankfully quite rare. There
would be no vascularity on the ultrasound Doppler, and diagnosis is imperative as it requires
prompt return to theatre to try and salvage the graft.
Pseudoaneurysm formation, rejection and renal artery stenosis are late complications.
Pseudoaneurysms usually form as a result of biopsy, not due to the transplant surgery itself.
On Doppler ultrasound there will be a focus of abnormal colour flow with very turbid flow.
Rejection is also a late complication. Typically the kidney is enlarged with large renal
pyramids and reduced corticomedullary differentiation. The resistive index tends to be high
and there can be mild pelvicalyceal dilatation.
Features of renal artery stenosis on ultrasound Doppler include increased resistive indices
(>0.7) and a parvus-tardus wave form, in contrast to the sharp upstroke seen in a normal
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procedures such as uterine artery embolisation. Symptoms include fever, nausea and pain and
they usually peak around 48 hours post procedure and then improve within a week. Gas within a
recently embolised lesion is relatively common and this does not necessarily infer infection.
With endometritis, the endometrium would be thickened with other findings including fluid
and/or gas in the endometrial cavity and increased vascularity.
Fibroid torsion is uncommon and is associated with pedunculated subserosal fibroids. It can
present with pain; however uterine artery embolisation does not predispose to this and the most
likely diagnosis in this case remains post-embolisation syndrome.
Non-target organ ischaemia can occur as a complication following any embolisation procedure
but the most common organs affected by this are the ovaries rather than the uterus. Normal
uterine tissue tolerates the ischaemia induced by uterine artery embolisation compared to fibroids.
(The Final FRCR Complete Revision Notes Page 14)
74. (d) Renal cortical thickness of 5 mm on abdominal ultrasound
The question describes a pathological fracture through a Brown tumour of the distal radius.
These are lytic expansile lesions which are similar to giant cell tumours histologically and can
contain fluid-fluid levels on MRI. The other findings of osteosclerosis and subperiosteal
resorption of the phalanges are typical for hyperparathyroidism.
Brown tumours are historically most commonly attributed to primary hyperparathyroidism, of
which the most frequent cause is a parathyroid adenoma. This could be detected with a nuclear
medicine 99-Tc-MIBI scan which should reveal the parathyroid adenoma. A pertechnetate
thyroid scan investigating for a parathyroid adenoma (e.g. in answer A) would detect a region of
decreased tracer uptake compared to the thyroid, rather than increased uptake.
In recent times, secondary hyperparathyroidism has become more common, and the most
frequent cause of the secondary form of the condition is chronic renal failure, which would
manifest with renal cortical thinning. Other causes of secondary hyperparathyroidism include
vitamin D deficiency which may lead to Looser zones, a type of insufficiency fracture (described
in answer E).
The other answers describe Graves disease on a nuclear medicine thyroid scan and liver
metastases on a CT abdomen and pelvis, which are not associated with hyperparathyroidism.
(The Final FRCR Complete Revision Notes Page 80)
75. (a) Abdominal radiograph in 24 hours
The case demonstrates typical imaging findings of ulcerative colitis with the submucosal low
attenuation consistent with fat deposition seen in chronic cases. The patient is at risk of toxic
megacolon. This condition also affects patient with colitis of other causes but accounts for the
majority of deaths related to ulcerative colitis and should therefore should be kept in mind
when reporting acute imaging. Toxic megacolon does not always cause bowel dilatation;
however, if the colon is dilated >5 cm, particularly the transverse colon, where gas tends to
collect, it should be considered. Colonoscopy and barium studies are contraindicated due to the
risk of perforation. Frequent (often daily) abdominal radiographs are suggested to monitor
bowel dilatation. Repeat CT may be warranted during admission; however, this patient is
relatively young and abdominal radiographs should be considered in the first instance if he is
clinically stable. Urgent surgical referral is not indicated at this point.
(The Final FRCR Complete Revision Notes Page 187)
76. (a) Above the urogenital diaphragm
Signs of urethral injury include inability to void, haematuria and blood at the urethral
meatus. The urethra is split into anterior and posterior sections, with anterior being penile and
bulbous portions, and posterior being prostatic and membranous. The anterior urethra is more
commonly injured in straddle type injuries and the posterior urethra in blunt trauma,
sometimes with pelvic fractures. Iatrogenic causes are also important to consider.
The Goldman classification helps to distinguish between the different types of injury.
The important landmark is the urogenital diaphragm. If the contrast extravasates into the
retropubic space it suggests injury above the urogenital diaphragm. Conversely, if the contrast
leaks into the perineum it suggests injury below the urogenital diaphragm. Above the
urogenital diaphragm relates to the posterior urethra.
Incomplete urethral injuries, such as in this case, are often treated conservatively with
catheterization; however complete transection may require surgery. Urethral stricture is the
most common long-term complication of urethral injury, with post-traumatic strictures tending
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Caffey disease presents in infancy. Focal scleroderma may demonstrate subcutaneous and
periarticular calcification. Osteopoikilosis is a condition of multiple enostoses, a benign condition in
which the bone islands align parallel to the trabeculae and tend to cluster around joints.
Pyknodysostosis is a condition diagnosed early in childhood in which there is dwarfism with
associated with multiple skeletal abnormalities as well as learning disability.
(The Final FRCR Complete Revision Notes Page 82)
81. (c) Hepatopetal portal venous flow
The patient has the clinical signs and symptoms of portal hypertension with bleeding
secondary to oesophageal varices. Portal hypertension is defined as an increase in portal
venous pressure >10 mmHg.
Sonographic features of portal hypertension include loss of the normal triphasic portal vein
Doppler waveform, reduced portal vein flow (<10 cm/sec) and reversal of flow. Normal portal
vein flow should be hepatopetal (towards the liver); however, in portal hypertension this can
eventually reverse causing hepatofugal flow, and collaterals form, such as oesophageal and
splenic varices.
Other common ultrasound findings in portal hypertension include splenomegaly, ascites and
gallbladder oedema.
(The Final FRCR Complete Revision Notes Page 218)
82. (b) H-shaped vertebrae
The patient has features consistent with sickle cell disease. Young patients may have
splenomegaly but over time the spleen becomes small and calcified. The kidneys are often
enlarged in children but over the patient’s lifetime may become small due to renal failure. The
previous consolidation which has now resolved may represent acute chest syndrome. An
associated musculoskeletal finding is H-shaped vertebrae due to endplate infarction.
Anterior inferior vertebral body beaking is a feature of conditions such as Hurler syndrome
and achondroplasia.
Posterior vertebral body scalloping is caused by a variety of pathologies including
achondroplasia, mucopolysaccharidoses and dural ectasia.
Ribbon ribs are classically associated with neurofibromatosis.
A narrowed interpedicular distance is encountered in achrondroplasia and thanatophoric
dysplasia.
(The Final FRCR Complete Revision Notes Page 348)
83. (c) Pineal germinoma
As is the case with other pineal masses, germinomas tend to present with obstructive
hydrocephalus and Parinaud syndrome (paralysis of upward gaze). Pineal germinomas are the
most common cause of a mass in this region. They usually present in young adults and have a
male predilection. The description in this case is typical for a pineal germinoma. Iso or
hyperdense on CT with central calcification and isointense to grey matter on T1 and T2
weighted imaging with enhancement post contrast and no haemorrhage. Five to ten percent of
patients will have synchronous tumours within the midline at the time of diagnosis.
Pineoblastomas are aggressive lesions and therefore more infiltrative, less well-defined and
any calcification is peripheral, causing an ‘exploded calcification’ appearance.
As well as calcification, teratomas are also likely to contain fat and haemorrhage, both of
which are not features of pineal germinomas.
Pineocytomas have quite non-specific imaging findings; however, familiarity with the
common features of the other pineal region tumours helps to exclude other causes.
Pineal yolk sac tumours also have no specific imaging findings, but these tumours are
unusual and therefore a pineal germinoma is much more likely.
(The Final FRCR Complete Revision Notes Page 403)
84. (e) Porencephaly
The characteristics of the lesion are consistent with it containing cerebrospinal fluid (CSF).
The connection with the ventricular system, the lack of septations and the white matter lining
are all consistent with porencephaly.
Schizencephaly is a connection between the pial and ependymal surfaces, often
communicating with the ventricular system and lacking septations; however, the key
differentiating factor is the lining. Schizencephaly is lined with grey matter. In the closed-lip
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subtype there is no CSF in the cleft, whereas in the open-lipped variety there is CSF in the cleft.
Hydrancephaly is thought to occur secondary to bilateral carotid artery occlusion in-utero and
therefore causes significant bilateral forebrain abnormality.
Neuroglial cysts are located in the white matter; however, they do not have a connection with
the ventricular system.
(The Final FRCR Complete Revision Notes Page 303)
85. (e) Obliterative bronchiolitis
Obliterative bronchiolitis causes bronchiolar inflammation and fibrosis leading to
bronchiectasis and bronchial wall thickening with subsequent air flow obstruction. This causes
the CT finding of mosaic perfusion, which is lucency created by trapped air during expiration.
The vessels are decreased in calibre in the low attenuation lucent lung and comparatively
increased calibre in the normal lung. Causes are varied and can be post-infective, following
inhalation of toxic substances and due to aspiration.
The changes associated with acute interstitial pneumonia are non-specific and include
ground glass opacification and often dependent consolidation and fibrosis, which can lead to
traction bronchiectasis.
Alveolar proteinosis typically causes a ‘crazy paving’ appearance with ground glass
opacification and thickened interlobular septa
CT findings in chronic eosinophilic pneumonia are often described as the photographic
negative of pulmonary oedema, with predominantly peripheral consolidation, and pleural
effusions are not typical.
The chronic form of hypersensitivity pneumonitis commonly causes mid and upper lobe
fibrosis, subsequent traction bronchiectasis and honeycombing. It is often described as sparing
the costophrenic angles.
(The Final FRCR Complete Revision Notes Page 24)
86. (a) Haemophilia
The features described are typical for haemophilia. Repeated episodes of bleeding into the
joint causes pannus formation which leads to erosion of cartilage and other degenerative
features. There may also be proliferation of the synovium and periarticular osteopenia.
In homocysteinuria there is frequently generalised osteoporosis and widespread skeletal
abnormalities, rather than the quite focal abnormality described in this case. Lens dislocation is a
typical feature. There may be sternal abnormalities and the epiphyses and metaphyses are
frequently affected. Imaging of the spine may reveal biconcave vertebrae and scoliosis.
Juvenile rheumatoid arthritis occurs in patients less than 16 years old. The imaging features may
also include a squared patella and widened intercondylar notch.
Pigmented villonodular synovitis is a proliferative condition of the synovium with haemosiderin
deposition. The radiographic features may include marginal erosions.
In primary synovial chondromatosis there is proliferation of the synovium which can cause
intra-articular loose bodies; these may or may not calcify. Imaging features in this condition can
include soft tissue swelling around the joint and widening of the joint space as well as erosion of
the adjacent bone. Multiple calcific densities may be present in the joint space, which are uniform
in size.
(The Final FRCR Complete Revision Notes Page 110)
87. (b) CT chest abdomen pelvis with arterial and portal venous phase contrast
Multiple endocrine neoplasia (MEN) 1 is associated with proliferative lesions in the pancreas,
pituitary and parathyroid glands. MEN 2 is associated with medullary thyroid cancer,
parathyroid hyperplasia and phaeochromocytomas.
The patient likely has MEN 1, as he has symptoms of Zollinger-Ellison syndrome secondary
to a gastrinoma. These commonly occur in the pancreas but are also seen elsewhere, for
example in the duodenum.
The most appropriate test is a CT, including arterial phase contrast, as the tumours are
hypervascular and are most likely to be seen on this phase of imaging. A barium meal would
likely reveal features of Zollinger-Ellison syndrome, such as thickened gastric folds and
erosions/ulcers, but would likely not identify the gastrin-secreting lesion. An MRCP would be
more helpful than an MRI small bowel, as the gastrinomas commonly occur in the pancreas.
18F-FDG PET/CT may be helpful in poorly differentiated metastatic disease with
neuroendocrine tumours but would not be indicated in this case.
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A 111In-Octrotide scan may be more helpful in localising the gastrinoma and any metastatic
spread. Patients with MEN 1 may also have pituitary lesions which an MRI brain would help to
characterise, but in the first instance, the CT would be most helpful.
(The Final FRCR Complete Revision Notes Pages 189, 230)
88. (c) Pyeloureteritis cystica
Horseshoe kidneys are often asymptomatic and discovered incidentally. They are
positioned lower than normal and their ascent into the upper abdomen is halted by the
inferior mesenteric artery, usually around the level of L3. On ultrasound it may sometimes
not be recognised, especially if the lower poles are not well seen and the fusion not
appreciated. These abnormally positioned kidneys are more prone to trauma, calculi,
pyelouretitis cystica, transitional cell carcinoma (TCC) and pelviureteric junction obstruction
due to poor drainage.
TCC is a concern in patients with horseshoe kidneys and potentially in patients with
pyelouretitis cystica due to the chronic inflammation associated with the condition. However,
with TCC the lesions would be expected to have a soft tissue density and enhance, although
compared to the adjacent renal parenchyma this can be difficult to appreciate.
Pyelouretitis cystica causes multiple small cysts and is often associated with diabetes and
recurrent infection. This, along with the impeded drainage that can occur in a horseshoe
kidney, further predispose patients to the condition.
Multiple calculi are unlikely in the clinical setting of painless haematuria, and the density of
these small lesions is not typical for calculi. Leukoplakia is also associated with recurrent
infection but is more common in the urinary bladder than the upper tracts. Tuberculous
urethritis causes intermittent stricturing and dilatation, as well as urinary tract calcification.
(The Final FRCR Complete Revision Notes Pages 252, 265)
89. (b) Duodenojejunal flexure is at the level of the duodenal bulb
Ultrasound and fluoroscopy can be helpful in assessing for midgut volvulus. Ultrasound
findings include the ‘whirlpool’ sign caused by a twisting of the mesenteric vessels. The
superior mesenteric vein usually lies to the right of the superior mesenteric artery; in
malrotation it lies to the left. The retro-mesenteric D3 part of the duodenum may not be visible
between the aorta and superior mesenteric vessels.
On fluoroscopy establishing the position of the duodenojejunal (DJ) flexure is key. It should
cross the midline to lie to the left of the left vertebral body pedicle at, or above, the level of the
duodenal bulb. The caecum may have a normal position even in malrotation; however, a
cephalad position of the caecum would be suspicious given the other findings. The ‘corkscrew’
appearance is an additional finding that may be seen due to twisting of the duodenum and
proximal jejunum.
(The Final FRCR Complete Revision Notes Page 343)
90. (e) Precuneus, posterior cingulate cortex, posterior temporoparietal lobes
Nuclear medicine studies can be a helpful tool in neurodegenerative conditions but clinical
history and correlation is vital because radiological findings often overlap. Alzheimer disease
typically has reduced activity in the precuneus, posterior cingulate cortex and the posterior
temporal and parietal lobes.
Lewy body dementia tends to also have reduced visual cortex and cerebellar uptake.
Reduced uptake in vascular dementia is associated with defects in the basal ganglia and cortex.
Focal, and sometimes asymmetrical changes, can be seen in Pick disease with a more anterior
temporal and frontal lobe distribution. Progressive supranuclear palsy is associated with
reduced uptake in the corpus striatum. Tracer activity in Huntington disease is classically
reduced in the caudate nuclei but the basal ganglia and frontal lobes more generally can also
demonstrate reduced metabolism.
(The Final FRCR Complete Revision Notes Pages 423−434)
91. (b) Cryptogenic organising pneumonia
The ground glass opacification surrounded by dense crescentic opacification in the left mid
zone is a description of the ‘atoll sign’ or ‘reverse halo sign’, which is a feature characteristic of
organising pneumonia. The migratory consolidation is also typical. Consolidation is often
bilateral and predominantly subpleural, affecting the mid and lower zones.
‘Halo sign’ is associated with invasive fungal infection; in contrast to this case, the
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description of this is a solid nodule or opacification with surrounding ground glass change.
Pulmonary infarct tends to be found at the lung periphery but is less likely to be migratory.
Lung adenocarcinoma in situ was previously known as bronchoalveolar cell carcinoma; it can
appear as a ground glass opacification or more dense consolidation. It can be multifocal;
however it persists on serial imaging.
(The Final FRCR Complete Revision Notes Page 38)
92. (a) Type I
A slip injury is a type I injury. Table 3.5 describes the Salter-Harris classification of growth
plate fractures.
(The Final FRCR Complete Revision Notes Page 124)
Source: Modified from and reprinted with permission from V Helyar and A Shaw. The Final FRCR: Complete
Revision Notes. CRC Press, Taylor & Francis Group, 2018, p. 124.
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ventricular septum is not an option for this question but can have very similar appearances to
Ebstein anomaly.
Total anomalous pulmonary venous return causes cyanosis and plethoric lungs.
Transposition of the great arteries (the D-transposition subtype) is also a cause of cyanosis, but
lung appearance can be variable. It typically cases an ‘egg-on-a-string’ appearance of the
mediastinum due to narrowing of the superior mediastinum.
Aortic coarctation is an acyanotic congenital cardiac disease with normal pulmonary flow.
(The Final FRCR Complete Revision Notes Pages 310, 313)
96. (d) Medullary thyroid carcinoma
Nodules containing medullary thyroid carcinoma, along with their metastases frequently
contain microcalcification. The age group it affects tends to be around 30–50 years of age and
it is associated with multiple endocrine neoplasia 2 syndrome.
The most common thyroid malignancy is papillary thyroid carcinoma, appearing as a
hypoechoic nodule with ill-defined margins, and microcalcifications may be present. Regional
lymph node metastases can occur early and may have a cystic component.
Follicular thyroid carcinoma is more likely to have haematogenous metastases compared to
regional lymph node involvement, and 20% of patients may have distant disease at
presentation.
Anaplastic thyroid carcinoma may contain microcalcification; however, it is usually
associated with an older age group and has a poor prognosis, with nodal disease common at
presentation.
Thyroid lymphoma is usually the non-Hodgkins type. Microcalcification is uncommon and
lymphoma would not usually be treated with total thyroidectomy.
(The Final FRCR Complete Revision Notes Pages 434−435)
97. (c) Pleural thickening and calcification
This is a typical description of round atelectasis associated with asbestos exposure. Although
many men who have worked in the construction and manufacturing industries are at risk, their
family members would have also potentially been exposed to asbestos fibres on their clothing.
Round atelectasis can look mass-like − it is caused by collapsed infolded lung adjacent to calcified
or non-calcified pleural thickening. Enhancement is a feature because of the presence of lung
parenchyma. The bronchovascular crowding and distortion described is known as the ‘comet tail’
sign. Round atelectasis tends to be relatively stable over time but can sometimes demonstrate
interval growth. Asbestos exposure can also lead to asbestosis − an interstitial lung disease
typically associated with lower zone fibrosis.
The other features listed in the question are not associated with round atelectasis. Causes of
cavitating pulmonary nodules include tuberculosis, primary or metastatic squamous cell
carcinoma, abscesses and septic emboli.
Intralesional fat and popcorn calcification is typical for a pulmonary hamartoma. The water-lily
sign is associated with pulmonary hydatid disease.
Right hilum lymph node enlargement in the presence of a solitary lung lesion would be more
indicative of a primary lung malignancy.
(The Final FRCR Complete Revision Notes Page 19)
98. (a) An Insall-Salvati ratio of 0.6
Patella baja describes an abnormally low lying patella, compared to patella alta which is a
high riding patella – this can be remembered as ‘baja – below’ and ‘alta – above’. The typical
presentation is described in the question. The condition has various associations including
pathology causing quadriceps dysfunction. For example poliomyelitis and following trauma,
whether from fractures or secondary to surgery, including post anterior cruciate ligament
repair or knee replacement. Patella baja is usually symptomatic in post-traumatic conditions.
Chondromalacia patellae is associated with patella alta.
Patella baja or alta can be assessed on lateral knee radiograph or sagittal MRI with the knee
flexed to 30 degrees. The Insall-Salvati ratio calculates the patella tendon length (TL) versus
the patella length (PL) and patella baja is when this ratio is <0.8 and patella alta is diagnosed
when it is >1.2, although some variation to the quoted figures exists. The Blackburne-Peel ratio
is often also described and measures patella height.
(The Final FRCR Complete Revision Notes Page 90)
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99. (d) The minor papilla drains the pancreatic body and tail
Pancreas divisum is the most common congenital pancreatic anomaly and is secondary to a
failure in fusion of the dorsal and ventral pancreatic ducts. The ventral duct (duct of Wirsung)
drains the head of the pancreas via the ampulla of Vater and a minor papilla drains the dorsal
duct (duct of Santorini) which drains the pancreatic body and tail. Pancreas divisum is often
an incidental finding but it may cause pancreatitis and is associated with an increased risk of
pancreatic cancer. There are three subtypes, and type 1, where there is no communication
between the ducts, is the most common. It can result in a santorinicoele which is a cystic
dilatation of the distal dorsal duct immediately proximal to the minor papilla. Pancreas
divisum is not associated with choledochal cysts.
(The Final FRCR Complete Revision Notes Page 229)
100. (c) Magnification views
Following a screening recall for microcalcification, magnification views are obtained to
further assess its characteristics. Clustered or branching pleomorphic microcalcification is
suspicious for ductal carcinoma in situ. A true lateral view can also be helpful, along with the
standard mediolateral oblique (MLO) and craniocaudal (CC) views, to aid localisation of the
microcalcification in the breast.
Ecklund technique is used for breast implants to displace the implants more posteriorly and
make the breast tissue easier to assess. Paddle views apply focal compression to an area in an effort
to assess if apparent distortion or spiculation may be real or caused by overlapping structures.
Increasingly paddle views are superseded by tomosynthesis. Contrast-enhanced mammography is
available at some breast units and can help detect abnormal areas of enhancement.
(The Final FRCR Complete Revision Notes Pages 282, 284)
101. (a) Brachycephaly
Craniosynostosis presents with abnormal head shape and is due to premature fusion of the
cranial sutures. The resulting head shape depends on which suture/s have fused.
Brachycephaly is when the head appears short and wide, and is secondary to fusion of the
lambdoid or coronal sutures.
Oxycephaly affects the sagittal, lambdoid and coronal sutures causing a tower-like or
conical appearance to the head.
Plagiocephaly is a unilateral abnormality and can be anterior or posterior depending on
whether the coronal or lambdoid suture has fused.
Scaphocephaly causes the head to appear long and thin and is caused by fusion of the
sagittal suture.
Trigonocephaly is fusion of the metopic sutures and causes a triangular appearance to the
front of the skull.
(The Final FRCR Complete Revision Notes Pages 292−293)
102. (a) Craniopharyngioma
The mass in the question is typical for a craniopharyngioma. They are most commonly
suprasellar tumours containing solid and cystic components with calcification, but they can be
partially intrasellar. They are benign, WHO grade I tumours and they have two peaks of
incidence: 5–10 years and around 50–60 years. They often present with hydrocephalus due to
obstruction of the foramen of Munro. They often have a mixed solid and cystic appearance.
The solid components demonstrate contrast enhancement. Variable signal is seen on T1
weighted MRI due to proteinaceous material.
Rathke cleft cysts will not have a solid enhancing component. Pituitary macroadenoma can look
very similar but will tend to have an intrasellar epicentre rather than a suprasellar location and
calcification is very rare. Although meningiomas can calcify and enhance following contrast, they
are unlikely to have cystic components. Intracranial teratomas tend to be of lower density due to fat.
(The Final FRCR Complete Revision Notes Page 397)
103. (b) Bronchiolitis obliterans
Bronchiolitis obliterans is a manifestation of chronic rejection. It usually occurs 6–18 months
after transplant, but can occur as early as 3 months. It occurs in approximately 50% of patients
and is a major cause of mortality in these patients. Repeated episodes of acute transplant and
cytomegalovirus infection are predisposing factors. The radiological features in this condition
are that of bronchiectasis: mildly hyperinflated lungs, airway wall thickening and mosaicism
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(representing air trapping). Post-transplant lymphoproliferative disease can occur from 1 month
to several years after lung transplantation. It represents lymphoid proliferation (B- or T-cell
proliferation) on a spectrum of benign proliferation to high grade lymphoma. It usually occurs
after Epstein-Barr viral infection. Radiographically it manifests as single or multiple nodules,
less commonly consolidation and hilar or mediastinal lymph nodes. These do not match the
description provided in the main stem. The description in the main stem is also not consistent
with acute transplant rejection or reperfusion syndrome, as these complications occur in the
acute setting. Infection can occur at any time following transplant, however the radiological
features described, and the time frame provided is typical for bronchiolitis obliterans.
(The Final FRCR Complete Revision Notes Pages 41, 24)
104. (e) Schmorl nodes are one of the most common features
Scheuermann’s disease is also known as adolescent kyphosis, the second most common
paediatric spinal deformity. The most common findings are Schmorl nodes and anterior
vertebral body wedging and disc space narrowing. The thoracic spine is most commonly
affected. Usually three to five vertebral bodies are affected and the kyphosis must be >35°.
(The Final FRCR Complete Revision Notes Page 124)
105. (c) T1: Spleen < liver, T2: Spleen > liver, No change between in- and out-of-phase
Liver MRI is frequently employed to help clarify either CT or ultrasound appearances,
especially for challenging cases such as in hepatitis B surveillance or in patients with a high
body mass index, which can make ultrasound challenging. Normal liver parenchymal signal
is hyperintense compared to the spleen on T1 and hypointense compared to the spleen on T2
and there should be no reduction of signal on out-of-phase imaging. Liver signal is also
frequently compared to muscle – it should be a similar signal except on inversion recovery
sequences. Diffuse signal reduction on out-of-phase imaging can be suggestive of a fatty liver
and similarly the T1 signal may be increased in these patients.
(The Final FRCR Complete Revision Notes Page 193)
106. (d) Osteopetrosis
This is a rare disease of abnormal osteoclast activity leading to thickened sclerotic bones
which are weak and brittle. Increased bone density and Erlenmeyer flask deformity are very
suggestive for this condition. Other features on appendicular plain film include ‘bone-in-bone’
appearance and alternative sclerotic and lucent bands in the metaphysis.
Melorheostosis is a bone dysplasia with sclerotic foci, typically described as flowing candle
wax. Fibrous dysplasia has varied manifestations and can affect a single bone or multiple
bones. It can demonstrate ground glass appearance, lucency or sclerosis. Lead poisoning may
demonstrate metaphyseal bands as well as the bone-in-bone appearance. In pyknodysostosis
there is generalised increased density of the long bones; however the medullary cavity is
spared, unlike in osteopetrosis.
(The Final FRCR Complete Revision Notes Page 117)
107. (d) Corpus callosum agenesis
Partial dysgenesis of the corpus callosum usually manifests as the posterior portion being
absent and is frequently asymptomatic. However, this is not the case in complete agenesis.
The description of the brain in agenesis is of a ‘racing car’ appearance due to widely separated
lateral ventricles. The third ventricle is elevated, often located between the lateral ventricles; it
is dilated and may communicate with the interhemispheric cistern. The interhemispheric
fissure is widened and the splenium is absent.
Cavum septum pellucidum, cavum vergae and cavum velum interpositum are all normal
variants of an additional cerebrospinal fluid space in the midline.
An interhemispheric arachnoid cyst is possible and associated with corpus callosum
abnormality; however, the description in the question is typical for corpus callosum agenesis.
(The Final FRCR Complete Revision Notes Page 290)
108. (a) Enhancement present, Low choline level, Low relative cerebral blood flow (rCBF)
Radiation necrosis can occur in the years following treatment with radiotherapy. The
lesions can look very similar to tumour recurrence with rim enhancement; however, there are
features which can help to differentiate between them. Whereas tumour recurrence would
have a choline peak on MRI spectroscopy, radiation necrosis does not. Similarly, tumour
recurrence causes an increase in relative cerebral blood flow, whereas radiation necrosis
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causes a reduction. 18F-FDG PET/CT can also be employed; in tumour recurrence there
would be increased tracer uptake compared to radiation necrosis. Pseudoprogression also has
the same features as radiation necrosis on MRI spectroscopy and perfusion studies.
(The Final FRCR Complete Revision Notes Pages 421, 386)
109. (c) Gallium 68 PET/CT
The question describes a typical carcinoid tumour. These are often centrally located, centred
on an airway and therefore can cause peripheral atelectasis and recurrent infection. They often
enhance avidly and 30% can calcify. Some carcinoids secrete hormones which can lead to
additional symptoms. Although generally considered benign, they can invade locally and
metastasise to cause sclerotic bone deposits, enlarged local nodes and liver metastases.
Gallium 68 PET/CT is used to stage carcinoid. Carcinoids can be negative on both 18F FDG
PET/CT and 18F DOPA PET/CT. Although carcinoids can metastasise to the liver, the most
appropriate test would be the Gallium 68 PET/CT rather than liver MRI as it would help to
exclude disease elsewhere, for example in the enlarged right hilar and mediastinal nodes.
However, these nodes may also be enlarged due to concurrent infection. Follow-up CT in this
symptomatic young patient would not be appropriate.
(The Final FRCR Complete Revision Notes Pages 25−27)
110. (d) Short radius with a triangularised distal epiphysis
The patient has a known Madelung deformity, which is a dysplasia of the radius. Features
on plain film include lateral and dorsal curvature and short radius with a triangularised distal
epiphysis. The articular surface of the distal radius will be angled in an ulnar and volar
direction, and dorsal dislocation of the ulnar head is possible. The proximal carpal row is
sometimes described as having a ‘V’-shape due to the deformity. The condition can be
idiopathic, post-traumatic, dysplastic or genetic.
Madelung deformity may be seen in Turner syndrome. Shortening of the third and fourth
metacarpals may be seen in this condition, as well as shortening of the second and fifth middle
phalanges (which can also be seen in Down syndrome). Ulnar impingement is seen in
negative ulnar variance. Madelung deformity is associated with positive ulnar variance.
(The Final FRCR Complete Revision Notes Page 82)
111. (a) Invasion of the duodenum
Pancreatic cancer is associated with a poor prognosis, and 5-year survival is only around
3%. The most common type (approximately 90% of cases) is ductal adenocarcinoma. Only a
minority can be resected at diagnosis with a Whipple procedure.
Factors which make a tumour resectable include involving <25% of the circumference of the
superior mesenteric vein, invasion of the duodenum (because it will be removed during a
Whipple procedure) and the tumour extending to no more than 25–50% of the circumference
of the superior mesenteric artery (SMA).
Irresectability is confirmed when the tumour starts to invade adjacent organs (except the
duodenum), there are enlarged regional lymph nodes beyond the planned resection margin
and the tumour is contacting >50% of the SMA.
(The Final FRCR Complete Revision Notes Pages 230−231)
112. (c) Renal arterial anatomy with CT angiogram
Horseshoe kidneys are prone to having multiple ectopic renal arteries and therefore a CT
angiogram prior to any surgery would be helpful, especially because this patient was
diagnosed incidentally on a CT cologram, which is a portal venous phase study.
18F-FDG PET/CT is not routinely indicated in renal cell carcinoma due to limited tracer
uptake in renal tumours. Furthermore, the tumour is small with no locoregional nodes so
occult metastatic disease is unlikely.
Horseshoe kidneys are associated with conditions that can cause urinary tract filling defects
such as pyelouretitis cystica and transitional cell carcinoma; however CT urogram is not part
of the imaging workup in a renal cell carcinoma diagnosis.
Nuclear medicine studies can be very helpful for management planning in the Urology
multidisciplinary team meeting, especially if there is concern regarding renal function,
because the results of these studies may lead to more conservative surgery being considered.
However, this kidney is unobstructed with otherwise normal appearances and normal serum
renal function tests. Therefore, there are no indications that partial nephrectomy should
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Epidermoid cysts do not widen the IAC and do not enhance. Unlike a schwannoma, they
demonstrate restricted diffusion.
(The Final FRCR Complete Revision Notes Pages 405−406)
117. (c) Grade III
The presence of a parenchymal laceration >3 cm in depth and the absence of active bleeding
makes this grade III.
(The Final FRCR Complete Revision Notes Page 240)
TABLE 3.6: The American Association for the Surgery of Trauma (AAST)
Spleen Injury Scale (2018 Revision)
Grade
I Subcapsular haematoma <10% surface area, parenchymal laceration <1 cm depth, capsular tear
II Subcapsular haematoma 10–50% surface area, intraparenchymal haematoma <5 cm, parenchymal
laceration 1–3 cm
III Subcapsular haematoma >50% surface area, ruptured subcapsular or intraparenchymal haematoma ≥5 cm,
parenchymal laceration >3 cm in depth
IV Any injury in the presence of a splenic vascular injury or active bleeding confined within splenic
capsule parenchymal laceration involving segmental or hilar vessels producing >25%
devascularisation
V Shattered spleen any injury in the presence of splenic vascular injury with active bleeding extending
beyond the spleen into the peritoneum
Source: The American Association for the Surgery of Trauma. 2018 revision. AAST Spleen Injury Scale. Table 7.
https://www.aast.org/library/traumatools/injuryscoringscales.aspx#spleen.
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perpendicular to the lateral ventricles; this is best appreciated on sagittal FLAIR images. An
important feature is multiple white matter lesions separated in time and place, and the use of
gadolinium can delineate active plaques versus inactive lesions. FLAIR is the best sequence
for supratentorial assessment. T2 spin echo/STIR/proton echo/STIR/proton density
sequences are best for imaging the posterior fossa. Active disease may have either increased or
decreased diffusion.
(The Final FRCR Complete Revision Notes Page 419)
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PAPER 4
1. An 81 year old retired ship builder with a pacemaker has a CT pulmonary angiogram for pleuritic
chest pain and shortness of breath. There is no evidence of pulmonary embolus; however you
notice that he has small bilateral pleural effusions and widespread bilateral pleural thickening
involving the hemidiaphragms. There are a couple of prominent, but not frankly enlarged, hila
nodes. Ultrasound guided pleural biopsy is inconclusive. The clinical team call you asking for
advice regarding further imaging to help distinguish malignant from benign pleural thickening.
What is the most appropriate test?
a. Contrast enhanced ultrasound
b. CT abdomen and pelvis
c. MRI
d. 18F-FDG PET/CT scan
e. Portal venous phase contrast CT chest
2. A 47 year old female patient is reviewed in the rheumatology clinic with joint pains in her
hands. Radiographs are requested which demonstrate a bilateral symmetrical arthropathy
with osteopenia, reduction in joint space, osteophytosis and flattening of the index and middle
finger metacarpal heads. There are subchondral cysts and irregularity of the articular surface
which is particularly affecting the metacarpal phalangeal joints and the carpal bones.
What other imaging appearance would correspond with these findings?
a. Dilated oesophagus on chest radiograph
b. Hyperdensity in the sagittal sinus on CT head
c. Pancreatic low signal on T1, T2 and T2* sequences on MRI of the upper abdomen
d. Multiple small foci of subcortical T2* low signal on MRI head
e. Symmetrical hilar and mediastinal lymph node enlargement on CT chest
3. An adult male patient with abdominal pain undergoes a CT scan of the abdomen and pelvis
under the surgical team. The bowel loops are unremarkable and there is no free gas. However,
there is a 5.5-cm bulky tumour centred on the right adrenal gland which has an irregular
margin, foci of low attenuation and demonstrates heterogeneous enhancement. The tumour
does not contain calcification or haemorrhage, and abuts but does not invade the inferior vena
cava. There are multiple low attenuation, ill-defined lesions seen within the liver and several
lucent foci within the lumbar spine, which are suspicious for metastases. The lungs have not
been included on the scan.
What is the most likely cause of the appearances of the right adrenal gland?
a. Adrenocortical carcinoma
b. Collision tumour
c. Metastasis from adenocarcinoma
d. Myelolipoma
e. Phaeochromocytoma
4. A usually fit and well 73 year old man is investigated for weight loss and anaemia. There is a
history of left nephrectomy for organ donation 5 years previously. Contrast enhanced CT
chest, abdomen, pelvis is performed as part of this workup and demonstrates multiple
endophytic, homogenous right renal lesions. The renal lesions appear mildly hypodense to the
surrounding parenchyma. There are several enlarged, rounded retroperitoneal and pelvic
lymph nodes. The renal vessels opacify normally. There are homogenous appearances of the
other solid upper abdominal viscera. The chest is clear. The spleen measures 15.2 cm in
craniocaudal extent. Renal MRI is performed to help characterise further and the renal lesions
exhibit intermediate T1 and intermediate T2 signal.
What is the most likely diagnosis?
a. Leiomyosarcoma
b. Metastases
c. Primary lymphoma of the kidney
d. Renal cell carcinoma
e. Secondary lymphoma of the kidney
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5. A young child has been diagnosed with an infantile haemangioendothelioma on imaging after
presenting with a right upper quadrant mass and cardiac failure. An ultrasound confirmed a
vascular heterogenous mass which was confirmed as a haemangioendothelioma following an
MRI abdomen.
Which of the following post contrast MRI findings correlates most closely with this diagnosis?
a. Contrast washout on delayed phase imaging
b. Early peripheral enhancement with delayed central enhancement
c. Heterogenous arterial phase enhancement
d. Heterogenous delayed phase enhancement
e. Minimal enhancement on all phases
6. A 30 year old male who has multiple cutaneous nodules presents with recurrent episodes of
right sided weakness. An intracranial CT angiogram shows bilateral occlusion of the
intracranial portion of the internal carotid arteries. There are extensive leptomeningeal and
dural arterial vessel collaterals.
What is the most likely diagnosis?
a. Radiation vasculitis
b. Moyamoya syndrome
c. Sickle cell disease
d. Cerebral atherosclerosis
e. Systemic lupus erythematous
7. A 33 year old female undergoes a lung transplant for cystic fibrosis. She has an uneventful
recovery from theatre; however her mobile chest radiograph on ITU performed at 24 hours
demonstrates bilateral perihilar airspace opacification. This finding continues to worsen over
the next 48–72 hours. Echocardiogram excludes left ventricular failure and there is low clinical
suspicion of infection. She receives supportive care and after 5 days the opacities improve. They
have resolved by day 10.
What is the most likely aetiology?
a. Acute transplant rejection
b. Bronchiolitis obliterans
c. Infection
d. Post-transplant lymphoproliferative disease
e. Reperfusion syndrome
8. A 13 year old boy with a known chromosomal abnormality has a chest radiograph for
investigation of fever and general malaise, looking for an infective source. This shows a
hypersegmented manubrium as well as 11 pairs of ribs and scoliosis.
What is the most likely chromosomal abnormality?
a. Monosomy X
b. Triploidy
c. Trisomy 13
d. Trisomy 18
e. Trisomy 21
9. A junior radiology colleague asks you to review an upper gastrointestinal barium study that
they have performed on a 57 year old male patient referred by his GP for difficulty
swallowing and non-specific abdominal discomfort. The oesophagus and stomach outline
normally with prompt gastric emptying. In the D2 part of the duodenum there is a posterior
well-defined nodular protrusion into the duodenal lumen. Barium collects centrally within
this protrusion. Transit through the duodenum is swift and the duodenojejunal flexure is
positioned to the left of the vertebral column at the level of the duodenal bulb.
What is the most likely diagnosis?
a. Adenocarcinoma of the papilla of Vater
b. Benign lymphoid hyperplasia
c. Duodenal ulceration
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high resolution CT chest and referral to the respiratory team. The CT scan shows a left sided
pleural effusion and extensive, irregular nodular pleural thickening with suspected
involvement of the mediastinal surface.
What is the most likely diagnosis?
a. Fibrothorax
b. Liposarcoma of the pleura
c. Metastatic adenocarcinoma
d. Pleural mesothelioma
e. Primary pleural lymphoma
20. An active 61 year old patient has an MRI spine requested by his GP for a 7 month history of
lumbar back pain which is stopping him from playing tennis and has not responded to
physiotherapy. This is reported as a moderate disc bulge at L3/4, generalised facet joint
hypertrophy and Modic type II endplate changes at L4/5.
Which of the options below correlate with the finding of Modic type II endplate changes?
Table 4.1:
T1 Endplate Signal T2 Endplate Signal T2 Disc Signal
21. A female patient is discussed at the cancer of unknown primary multidisciplinary team
meeting. An MRI lumbar spine incidentally detected multiple liver lesions and several
paraaortic lymph nodes measuring up to 15 mm in short axis. A malignant looking gastric
lesion was subsequently identified on endoscopy.
Regarding malignant metastatic gastric lesions, what is the most common primary site?
a. Breast
b. Colon
c. Endometrium
d. Pancreas
e. Skin
22. A 6 month old child is referred for an MRI brain due to developmental delay and
macrocephaly. This shows an enlarged posterior fossa with elevated torcular herophili.
There is cystic enlargement of the fourth ventricle. The cerebellum is hypoplastic and the
lateral and third ventricles are dilated.
What is the most likely diagnosis?
a. Chiari I malformation
b. Chiari II malformation
c. Dandy-Walker malformation
d. Dandy-Walker variant
e. Mega cisterna magna
23. A 36 year old woman who is 19 weeks pregnant undergoes an abdominal ultrasound. This
demonstrates an echogenic 2-cm mass in the right lobe of the liver. It is well defined and has a
lobulated contour.
What is the most appropriate next step?
a. Contrast enhanced low dose CT abdomen
b. Contrast enhanced MRI
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a. Haemosiderosis
b. Metastatic infiltration
c. Myelofibrosis
d. Red marrow reconversion
e. Yellow marrow reconversion
33. A 26 year old man is a passenger in a road traffic collision. On clinical examination he has a
tender right upper quadrant and is noted to be tachycardic and hypotensive. He undergoes a
split bolus trauma protocol CT of his chest, abdomen and pelvis. This demonstrates a
subcapsular haematoma extending more than 50% around the border of the liver. There is also
a linear area of hypodensity in segment VI of the liver extending to the capsule consistent with
a laceration. This measures 4 cm in depth. No contrast extravasation or blush is identified to
indicate active bleeding.
Using The American Association of Surgery for Trauma (AAST) grading scale, what is the
grade of liver laceration?
a. Grade I
b. Grade II
c. Grade III
d. Grade IV
e. Grade V
34. A 3 year old boy is referred to the paediatric neurology team with increasing clumsiness,
headache and vomiting over a period of a few weeks. An MRI brain finds a posterior fossa
mass. This is poorly defined and in the midline, filling the fourth ventricle. Signal
characteristics are low T1 and high T2 compared to the grey matter. There is adjacent oedema
causing mass effect and evidence of early hydrocephalus. It enhances homogenously
following contrast and demonstrates restricted diffusion.
What is the most likely diagnosis?
a. Astrocytoma
b. Brainstem glioma
c. Choroid plexus papilloma
d. Ependymoma
e. Medulloblastoma
35. A 10 year old girl is referred for an MRI spine due to lower limb sensory and motor deficit.
This shows a single cord with termination at the L3 level. There is an intradural,
extramedullary mass adjacent to the conus which is T1 and T2 hyperintense. There is no post-
contrast enhancement or restricted diffusion. The mass does not extend into the dorsal
subcutaneous tissues. Appearances of the vertebrae are within normal limits.
What is the most likely diagnosis?
a. Diastematomyelia
b. Ependymoma
c. Lipomyelomeningocele
d. Paraganglioma
e. Tethered cord syndrome
36. A neonate is born at 35 weeks’ gestation following premature rupture of membranes and
emergency caesarean section. The child develops tachypnoea and nasal flaring within the first
24 hours. The clinical team are concerned about infant respiratory distress syndrome due to
surfactant deficiency. A chest radiograph is requested.
Which of the following radiographic features would be most likely to be associated with
respiratory distress syndrome caused by surfactant deficiency?
a. Interstitial oedema
b. Lack of air bronchograms
c. Normal chest radiograph at 6 hours
d. Perihilar streaky opacities
e. Reduced lung volumes
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37. A 44 year old male patient has had repeated GP attendances for mild fever, cough and
breathlessness over the past 3 months. Several chest radiographs over this time have
demonstrated patchy air space opacification varying in distribution with intervening normal
chest films.
Which investigation could confirm the diagnosis?
a. Anti-basement membrane antibody
b. Bronchoalveolar lavage
c. cANCA
d. Serum eosinophil count
e. Urine 5-HIAA levels
38. A 15 year old male with pectus excavatum has a plain film of the thoracolumbar spine which
demonstrates scoliosis and scalloping of the posterior lumbosacral vertebral bodies. A pelvic
radiograph demonstrates acetabular protrusion. He also has several cardiac investigations to
assess the mitral valve and aortic root. Of note, he performs well at school academically.
What is the most likely cause of pectus excavatum in this patient?
a. Down syndrome
b. Foetal alcohol syndrome
c. Homocysteinuria
d. Marfan syndrome
e. Prematurity
39. A barium swallow is performed for symptoms of regurgitation and dysphagia in a 42 year old
female patient. There is a smooth, wide-based filling defect projecting into the lumen in the
lower third of the oesophagus causing slow transit of barium. There is no evidence of mucosal
ulceration. On review of the control images there is calcification in this region.
What is the most appropriate next step?
a. Breast triple assessment
b. Endoscopic ultrasound and 18F-FDG PET/CT
c. Follow-up in 1 year
d. MRI head, physical assessment and family history
e. Surgical referral
40. A CT abdomen pelvis requested to assess for diverticulitis as a cause of upper abdominal
discomfort in a 63 year old woman identifies a cystic right ovarian lesion. A subsequent MRI
pelvis helps to evaluate this lesion further. It is predominantly high signal on T2 weighted
imaging with a thin septation and a small amount of enhancing, nodular, peripheral,
intermediate T1 and T2 signal. The lesion otherwise demonstrates low T1 signal. There are no
size-significant lymph nodes within the pelvis. There is a trace of free fluid in the pouch of
Douglas. The left ovary has normal post-menopausal appearances.
What is the most likely diagnosis?
a. Kruckenberg tumour
b. Mucinous cystadenoma
c. Mucinous cystadenocarcinoma
d. Serous cystadenoma
e. Serous cystadenocarcinoma
41. A 3 year old boy is referred for an MRI brain. The request form says he has a facial cleavage
abnormality and therefore a diagnosis of holoprosencephaly is suspected by the paediatric
team.
If holoprosencephaly is confirmed on the MRI, which structure will be absent?
a. Corpus callosum
b. Falx cerebri
c. Olfactory tracts
d. Septum pellucidum
e. Third ventricle
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42. An 8 month old patient under the care of ophthalmology has an MRI orbits following clinical
review for right proptosis. This demonstrates a unilateral right orbital mass. The mass spans
both intra- and extraconal compartments. It is lobulated and septated with signal which is T1
hypointense to fat and T2 isointense to fat but hyperintense to muscle. The mass enhances
intensely following contrast injection. There are thin, curvilinear, very low signal foci within
the mass.
What does this mass most likely represent?
a. Capillary haemangioma
b. Cavernous haemangioma
c. Lymphangioma
d. Retinoblastoma
e. Venous varix
43. A 45 year old female with a past medical history of well-controlled diabetes mellitus attends
her GP with a productive cough and fever. She has a chest radiograph which shows dense
opacification in the right lower zone with the presence of air bronchograms.
What is the most likely organism?
a. Haemophilus influenzae
b. Klebsiella pneumoniae
c. Legionella pneumophila
d. Staphylococcus aureus
e. Streptococcus pneumoniae
44. A 10 year old boy presents with a couple of months history of intermittent left knee pain and
is reviewed by the paediatric team. Radiograph demonstrates soft tissue swelling adjacent to
his distal left femur. Within the bone, adjacent to the distal femoral metaphysis, there is a
longitudinally orientated, ill-defined lytic lesion with surrounding sclerosis. Emanating from
this is a linear lytic area extending towards the physis.
What is the most likely diagnosis?
a. Eosinophilic granuloma
b. Giant cell tumour
c. Osteomyelitis
d. Osteoid osteoma
e. Osteosarcoma
45. A 62 year old male with known liver cirrhosis secondary to hepatitis C presents with an acute
upper gastrointestinal bleed. The patient is fluid resuscitated and transfused. Endoscopy is
performed which identifies large oesophageal varices. Unfortunately thrombin injection does
not stop the bleeding. An emergency transjugular intrahepatic portosystemic shunt (TIPSS)
procedure is planned.
Regarding TIPSS, an iatrogenic communication is made between the portal vein and which
vessel?
a. Inferior vena cava
b. Aorta
c. Hepatic vein
d. Hepatic artery
e. Splenic vein
46. A 45 year old man of no fixed abode, with a background of alcoholism, is admitted via the
emergency department. He appears confused with a fluctuating GCS and is noted to have a
spastic quadriparesis. CT brain shows a focal area of low attenuation crossing the midline in
the lower pons. The same area on MRI brain demonstrates high T2/FLAIR and low T1 signal.
The lesion also shows high DWI/low ADC signal. There is no enhancement of the affected
area after intravenous gadolinium administration.
What is the most likely diagnosis?
a. Brainstem metastasis
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a. Desmoid tumour
b. Fibroma of the tendon sheath
c. Ganglion cyst
d. Glomus tumour
e. Tenosynovial giant cell tumour
57. A 70 year old woman undergoes a CT colonography which identifies an incidental pancreatic
head mass. This measures 1.5 cm and has a HU density of 10. It contains multiple tiny cysts
with a central area of calcification. The pancreatic duct measures 2 mm in diameter.
What is the most likely diagnosis?
a. Serous cystadenoma
b. Main duct intraductal papillary mucinous neoplasm
c. Mucinous cystadenoma
d. Pancreatic adenocarcinoma
e. Islet cell tumour
58. A 12 year old female has ongoing pain in the lower left leg. The pain is worse at night and
settles with aspirin. On plain film, there is a 6 mm lucent lesion within the tibial metaphyseal
cortex with thickening of the cortex and surrounding sclerosis. On scintigraphy there is a
double density sign, with markedly increased uptake centrally and surrounding more modest
activity.
What is the most likely diagnosis?
a. Fibrous cortical defect
b. Osteoblastoma
c. Osteochondroma
d. Osteoid osteoma
e. Osteosarcoma
59. Hydrops fetalis is identified on antenatal scans of a male fetus in the second trimester of
pregnancy. Following close observation of the mother into the third trimester, the baby boy is
delivered early by emergency caesarean section. The baby suffers with respiratory distress
and is transferred immediately to the neonatal intensive care unit where a chest radiograph is
obtained. The lungs appear clear; however there are bilateral pleural effusions. Drainage of
the pleural fluid reveals chylous effusions.
What is the underlying cause likely to be?
a. Extralobar sequestration
b. Lymphangioleiomyomatosis
c. Pulmonary lymphangiectasia
d. Thoracic duct atresia
e. Turner syndrome
60. A 40 year old man with a background of previous renal cell carcinoma presents with nausea
and headaches. On clinical examination he is noted to have papilloedema. An MRI brain
shows a large cystic mass in the posterior fossa which is obstructing the fourth ventricle
causing hydrocephalus. The mass also demonstrates a small enhancing nodule on the T1 post
contrast sequence and serpiginous low T2 signal areas at the periphery.
What is the most likely diagnosis?
a. Cavernoma
b. Ependymoma
c. Haemangioblastoma
d. Metastasis
e. Pilocytic astrocytoma
61. A 63 year old male patient is seen in the vascular clinic with a pulsatile mass posterior to his
right knee. Ultrasound confirms a 2-cm right popliteal artery aneurysm. The vascular team
request a CT angiogram to help plan management.
Which imaging protocol is most appropriate?
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71. A GP requested a CT chest, abdomen and pelvis for a 58 year old post-menopausal female
patient with type 2 diabetes and unintentional weight loss. The CT is performed without
contrast due to mildly reduced renal function. There is mediastinal, hilar and upper
abdominal lymph node enlargement which is noted to be relatively low attenuation compared
to adjacent soft tissues.
Regarding the causes of low attenuation lymph nodes, which one of these is NOT associated
with this radiological finding?
a. Coeliac disease
b. Kaposi sarcoma
c. Systemic lupus erythematosus
d. Tuberculosis
e. Whipple disease
72. An 11 year old girl is referred to the paediatric neurologist with refractory temporal lobe
epilepsy. An MRI brain is performed. This shows a partially cystic mass in the left temporal
lobe. The solid component is intermediate T1 signal and T2 hyperintense with heterogenous
enhancement. There is no surrounding oedema and no dural tail sign. The mass demonstrates
blooming artefact on T2*.
What is the most likely diagnosis?
a. Pilocytic astrocytoma
b. Dysembryoplastic neuroepithelial tumour
c. Ganglioglioma
d. Oligodendroglioma
e. Pleomorphic xanthoastrocytoma
73. A 35 year old male patient is diagnosed with asymptomatic hypertension following a medical
examination at his place of work. Following hospital referral and further investigations he is
found to have an aortic coarctation. Chest radiograph reveals unilateral inferior rib notching
of the left third to eighth ribs.
What is the most likely cause of this appearance?
a. Anomalous origin of the left subclavian artery
b. Anomalous origin of the right subclavian artery
c. Right sided aortic arch with anomalous left subclavian artery
d. Stenosed left subclavian artery
e. Stenosed left costocervical trunk
74. A 63 year old male patient represents to the emergency department febrile following a recent
admission for pneumonia. His respiratory symptoms have improved but he now has acute
pain in his left elbow without a history of trauma. Radiographs show the anterior fat pad is
elevated and there is soft tissue swelling with subtle periarticular osteopenia. The orthopaedic
junior doctor on call overnight asks for advice.
What would the most appropriate next step be?
a. Joint aspiration
b. Oral antibiotics and orthopaedic clinic the following day
c. MRI left elbow
d. Triple phase nuclear medicine bone study
e. Ultrasound left elbow
75. A 38 year old female patient with no significant medical history apart from a high body mass
index presents to hospital with abdominal pain. Bloods demonstrate slightly raised inflammatory
markers. Urine human chorionic gonadotrophin test is negative. The solid abdominal viscera have
normal size and appearances on ultrasound and there is no free fluid in the abdomen or pelvis. At
the site of maximal tenderness there is an ovoid hyperechoic mass without increased vascularity.
It is not compressible. A CT scan is performed to characterise this further. The mass is adjacent to
the colon, peripherally enhances, has a density of −90 HU and there is adjacent fat stranding.
Where is the most common location for this pathology?
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80. A 44 year old male presents with ongoing knee pain. Plain films are performed which
demonstrate an eccentrically based lucent lesion which is well defined in the epiphysis of the
distal femur. It has a narrow zone of transition and abuts the articular surface.
What is the most likely diagnosis?
a. Aneurysmal bone cyst
b. Eosinophilic granuloma
c. Fibrous dysplasia
d. Giant cell tumour
e. Non-ossifying fibroma
81. A 65 year old patient has an enhanced CT abdomen pelvis at the request of the urology team
to monitor recurrent renal calculi. There are bilateral renal calculi which have not significantly
changed in size or position compared to the previous symptomatic study and the kidneys are
unobstructed. You notice mildly increased density in the fat around the root of the jejunal
mesentery, which has a hazy appearance. This has marginally increased compared to the
previous CT. There are a couple of small sub-centimetre lymph nodes in this region. The
urology team confirm that the patient is currently asymptomatic.
Which other radiological finding would be consistent with mesenteric panniculitis?
a. Displacement of adjacent vessels and bowel loops
b. Low attenuation halo surrounding vessels
c. Low attenuation lymph nodes
d. Nodular shrunken liver
e. Thickening of the adjacent bowel wall
82. A 49 year old male patient is diagnosed with T2b N0 M0 right renal cell carcinoma of clear cell
subtype. Also noted on his staging CT are two small left renal angiomyolipomas and several
small pancreatic cysts. The patient reports a history of previous brain tumour although there
is no imaging of his head available on your PACs system for review.
What is the most likely underlying hereditary condition?
a. Burt-Hogg-Dubé
b. Gorlin-Goltz
c. Osler-Weber-Rendu
d. Tuberous sclerosis
e. Von Hippel-Lindau
83. A 10 year old girl has a systolic murmur. A chest radiograph is performed which shows
pulmonary plethora.
Which of the following radiological signs will help differentiate between a diagnosis of patent
ductus arteriosus versus ventricular septal defect?
a. Enlarged aorta
b. Enlarged left atrium
c. Enlarged left ventricle
d. Enlarged pulmonary vasculature
e. Normal right atrium
84. A 30 year old woman has been experiencing vague neurological symptoms including left-
sided headaches and facial paraesthesia. An MRI brain reveals subtle loss of grey−white
matter differentiation in the left temporal and parietal lobes with minor, diffuse gyral
expansion. The affected area is extensive and involves the ipsilateral basal ganglia structures;
it is T1 hypointense and T2 hyperintense to grey matter. There is moderate effacement of the
left lateral ventricle. There is no enhancement following gadolinium administration and the
affected area does not restrict on diffusion weighted imaging.
What is the most likely clinical diagnosis?
a. Encephalitis
b. Gliomatosis cerebri
c. Primary CNS lymphoma
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89. A neonate born at term has respiratory distress. A chest radiograph is performed which shows
multiple cystic partially air-filled lucencies in the left lower zone. There is associated mass
effect with depression of the left hemidiaphragm and contralateral mediastinal shift. The
patient then undergoes a CT thorax which shows the left lower lobe is occupied by multiple
large-sized cysts with air-fluid levels causing atelectasis of the remaining left lower lobe and
associated contralateral mediastinal shift. This lesion is supplied by a branch of the bronchial
artery. The diaphragm is intact.
What is the most likely diagnosis?
a. Bronchogenic cyst
b. Bronchopulmonary sequestration
c. Congenital diaphragmatic hernia
d. Congenital lobar over inflation
e. Congenital pulmonary airway malformation
90. A patient is diagnosed with acute Hashimoto thyroiditis following clinical, serological,
ultrasound and nuclear medicine assessment in a one-stop thyroid clinic.
Which of the following profiles fits this diagnosis most accurately?
Table 4.2:
Serological Greyscale Ultrasound Doppler Ultrasound Technetium-99m
Result Appearance Appearance Pertechnetate Tracer
Uptake
91. A GP contacts you to ask for your advice regarding a pulmonary nodule which has been
reported on a CT pulmonary angiogram, performed after a patient attended the emergency
department with chest pain. The patient is a 39 year old female with no previous smoking
history. The nodule is 8 mm in the right lower lobe with evidence of central calcification. On
review of previous imaging, it was present on a unenhanced CT urinary tract performed
6 months prior and is unchanged in size.
What is the most important feature when assessing for benignity of a pulmonary nodule?
a. Presence of calcification
b. Upper lobe location
c. Volume doubling time ≤400 days
d. Volume doubling time 400–600 days
e. Volume doubling time ≥600 days
92. A 17 year old with a known chromosomal abnormality has an MRI of the whole spine which
demonstrates a scoliosis, posterior vertebral body scalloping, enlarged neural foramina and
dural ectasia as well as several well-defined dumbbell-shaped extra-axial lesions within the
nerve exit foramina at multiple levels. All lesions demonstrate low signal on T1 pre-contrast,
intermediate signal on T2 and there is T1 post contrast enhancement. A similar intra-axial
lesion is seen within the canal at T12.
You review the patient’s previous imaging. What other musculoskeletal finding is the patient
most likely to have?
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Table 4.3:
MRI T1 Signal MRI T2 Signal MRI In- and Out-of-Phase Sequences
94. A neonatal chest and abdominal radiograph is reported as having a correctly sited umbilical
venous catheter in situ.
Which of the following catheter positions would correlate with this statement?
a. Catheter passes inferiorly from umbilicus into pelvis, turning cephalad with the tip at the
level of T8
b. Catheter passes inferiorly from umbilicus into pelvis, turning cephalad with the tip at the
level of the diaphragm
c. Catheter passes superiorly from umbilicus with the tip at the junction of the superior vena
cava and right atrium
d. Catheter passes superiorly from umbilicus with the tip at the level of T8
e. Catheter passes superiorly from umbilicus with the tip projected over the left upper
quadrant
95. A neonate has a contrast enema after not passing meconium at 48 hours following delivery.
Contrast passes quickly into the rectum and colon. The proximal large bowel is mildly dilated
with a transition point to a narrower calibre in the sigmoid colon. The small bowel is normal
calibre. The rectosigmoid ratio is 0.8.
Which of the following would help diagnose the underlying condition causing these findings?
a. Antenatal history of oligohydramnios
b. Confirmed maternal history of diabetes
c. Newborn heel prick test
d. Rectal biopsy
e. Sweat chloride test
96. A newborn undergoes a chest radiograph which shows a right sided aortic arch.
What underlying condition are they most likely to have?
a. Ebstein anomaly
b. Tetralogy of Fallot
c. Transposition of the great arteries
d. Tricuspid atresia
e. Truncus arteriosus
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97. A 44 year old patient with a history of excess alcohol intake is admitted with acute severe
pancreatitis. Initial chest radiograph shows bibasal atelectasis and a small left pleural effusion.
Within 24 hours of admission the patient is transferred to intensive care. Following 48 hours
on the intensive care unit the team report increased oxygen demand despite optimal therapy.
CT scan demonstrates bilateral posterior consolidation with ground glass opacification more
anteriorly. There is a small left pleural effusion. Appearances of the pancreas correlate with
the clinical diagnosis of pancreatitis.
What is the most likely explanation for the CT chest findings?
a. Adult respiratory distress syndrome
b. Aspiration pneumonia
c. Cardiac failure
d. Fat embolism
e. Hospital-acquired pneumonia
98. An active 38 year old man has repeated GP visits for right hip pain which is stopping him
from playing squash and does not improve despite several weeks of physiotherapy. A pelvic
radiograph shows preserved joint space of both hips without significant degenerative change.
There is relative reduction in the subchondral cortical thickness on the right and reduced bone
density of the right proximal femur compared to the left. There is no periosteal reaction or soft
tissue mass. An MRI scan reveals a joint effusion and low T1 and high T2 signal in the right
femoral head which is particularly marked in the subchondral region with corresponding
early post-contrast enhancement.
What is the most likely diagnosis?
a. Avascular necrosis of the proximal femur
b. Complex regional pain syndrome
c. Idiopathic transient osteoporosis of the hip
d. Septic arthritis
e. Stress fracture of the proximal femur
99. A 37 year old female patient with poorly controlled type 1 diabetes has an MRI liver
requested. During an inpatient admission for cholecystitis an ultrasound abdomen
identified a 50-mm hyperechoic area in the right hepatic lobe. The MRI confirms a
heterogenous lesion which is mildly T1 and T2 hyperintense with signal reduction on out-of-
phase imaging. There is heterogenous arterial enhancement following gadolinium
administration and the lesion washes out, becoming isointense on portal venous phase
sequences. A sequence with a hepatocyte specific agent is also performed which reveals the
lesion is hypointense.
What is the most likely diagnosis?
a. Adenoma
b. Fibrolamellar carcinoma
c. Focal nodular hyperplasia
d. Haemangioma
e. Metastatic deposit from breast primary malignancy
100. A 13 week old baby boy is being investigated following in-utero diagnosis of bilateral
hydronephrosis. Imaging identifies bilateral hydronephrosis and hydroureters with reflux of
contrast from the urinary bladder into the ureters. The anterior abdominal wall is
underdeveloped with characteristic ‘prune belly’ appearance. The paediatric team diagnose
Eagle-Barrett syndrome.
What other imaging should be performed in this patient?
a. Echocardiogram
b. MRI head
c. MRI spine
d. Neck ultrasound
e. Testicular ultrasound
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101. Regarding the imaging findings of choroid plexus papilloma in children, which of the
following statements is most accurate?
a. Calcification is present in the majority of cases
b. Hydrocephalus is an uncommon presentation
c. It is a common cause of a posterior fossa mass
d. MRI signal is usually T1 and T2 isointense with homogenous enhancement
e. They are most common at the temporal horn of the lateral ventricle
102. The MRI brain of a 3 year old boy suffering with seizures and spasticity is reviewed. It
demonstrates symmetrical high T2 signal throughout the cerebellar white matter and the basal
ganglia, including the caudate nucleus, with a similar pattern of abnormal enhancement. A
previous MRI brain had less marked changes with symmetrical T2 hyperintensity and
enhancement only affecting the frontotemporal lobes.
Which of the following conditions best matches this radiological pattern?
a. Adrenoleukodystrophy
b. Alexander disease
c. Canavan disease
d. Krabbe disease
e. Leigh syndrome
103. A 45 year old male smoker presents with chest pain and cough. After an abnormal chest
radiograph, he has a CT which shows a 2-cm pleurally based soft tissue lesion in the left upper
lobe with evidence of rib invasion. There is a further 11-mm pulmonary nodule in the left
upper lobe. There are enlarged right hilar and mediastinal nodes including the left lower
paratracheal lymph node as well as a left-sided pleural effusion. Biopsy of the pleural based
lesion demonstrates primary lung cancer.
What is the most likely type of lung malignancy in this case?
a. Adenocarcinoma in situ
b. Invasive adenocarcinoma
c. Mesothelioma
d. Small cell lung cancer
e. Squamous cell carcinoma
104. A 15 year old with known XO chromosomal abnormality has aortic coarctation and a
horseshoe kidney. Plain films of the hand demonstrate several characteristic features.
What is the most likely finding?
a. Absent pisiform
b. Avascular necrosis of the scaphoid
c. Increased carpal angle
d. Shortened third and fourth metacarpals
e. Terminal tuft resorption
105. A concerned patient with a complex medical history asks to speak to a doctor regarding
Buscopan administration for an MRI small bowel study. The CT radiographer calls asking for
your assistance. You are the senior specialist registrar covering MRI.
Which of the following would be a contraindication for Buscopan administration?
a. Chronic open-angle glaucoma
b. History of prostate cancer
c. Hypothyroidism
d. Poorly controlled left ventricular failure
e. Pacemaker device
106. A 34 year old woman attends the breast one-stop clinic with a right breast lump. She noticed it
1 month ago and she is unsure if it has changed over that time. There is no significant past
medical or breast-related history. Her grandmother died from breast cancer at the age of
72 years.
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On examination, the lump is in the right upper outer quadrant at the 10 o’clock position,
6 cm from the nipple. It is firm, nontender and relatively mobile. At ultrasound the lesion
measures 25 mm. It is horizontally orientated, well defined and slightly hypoechoic with a
lobular contour. There are internal cystic spaces and posterior acoustic enhancement. There is
vascularity in the solid component of the mass. An ultrasound guided biopsy is performed.
Which of the following is the most likely diagnosis?
a. Breast carcinoma
b. Fat necrosis
c. Fibrocystic change
d. Papilloma
e. Phyllodes tumour
107. A newborn baby is noted to have dextrocardia and bilobed lungs. Left isomerism and
polysplenia syndrome are suspected.
Which of the following is associated with polysplenia syndrome?
a. Bilateral right atria
b. Bilateral hyparterial bronchi
c. Cyanotic congenital heart abnormality
d. Cystic hygroma
e. Total anomalous pulmonary venous return
108. A 33 year old patient is admitted with fever, headache and reduced GCS. The patient had been
previously well apart from a similar fever 1 week previously. A CT head on admission
demonstrated patchy hypodensity. On an MRI the following day there are multifocal FLAIR
hyperintense subcortical lesions in the right frontal and left temporal lobes with surrounding
oedema and mass effect. There are similar areas in the cerebellum. They all have peripheral
restricted diffusion and enhancement. Within these areas there are small foci of very low T2
signal with associated hypointensity on gradient echo sequences.
What is the most likely diagnosis?
a. Acute demyelinating encephalomyelitis
b. Acute haemorrhagic leukoencephalitis
c. Cerebral abscesses
d. Herpes simplex encephalitis
e. Progressive multifocal leukoencephalopathy
109. A 58 year old female patient with a history of asthma presents with 2–3 of months of feeling
generally unwell, breathlessness, weight loss and cough. CT chest demonstrates bibasal
atelectasis with peripheral upper and middle lobe air space opacification, ill-defined ground
glass opacities and mildly increased reticular markings. There are no pleural effusions. The hila
nodes are prominent bilaterally but there are no size significant hila or mediastinal lymph nodes.
What is the most likely diagnosis?
a. Chronic eosinophilic pneumonia
b. Cryptogenic organising pneumonia
c. Pulmonary infarct
d. Pulmonary oedema
e. Simple pulmonary eosinophilia
110. A 45 year old male has plain films of the left knee for investigation of ongoing knee pain.
There is a 3-cm well-defined lucent lesion seen within the proximal tibia. It abuts the articular
surface and has a thin sclerotic rim.
What is the most likely feature of an intraosseous ganglion cyst on MRI?
a. Low signal on protein density sequence
b. Internal septations
c. Most common around the knee
d. T2 low signal
e. Periosteal new bone formation
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111. A 31 year old male patient has a long history of symptoms of early satiety, abdominal pain after
eating and occasional vomiting. The discomfort is relieved when the patient lies down. The
patient had been treated as an adolescent for anorexia nervosa and still has a low body mass
index. An arterial and portal venous phase CT abdomen and pelvis helps establish the diagnosis
and demonstrates an angle of 15° between the superior mesenteric artery (SMA) and aorta.
Which other radiological findings correlate with this diagnosis?
a. Aortomesenteric distance of 15 mm
b. Dilatation of the proximal duodenum and stomach
c. Reduced contrast enhancement of the small bowel in the distribution of the superior
mesenteric artery
d. Small bowel wall thickening
e. SMA mural thickening and enhancement
112. A 4-cm right upper pole renal mass is found incidentally on an MRI lumbar spine of a 61 year
old female patient performed for lower back pain caused by a protruding L3 disc. She is
otherwise fit and well. The renal lesion has multiple well-defined components of variable signal
ranging from T2 bright and T1 low signal to intermediate T2 signal and T1 hyperintensity. CT
chest abdomen pelvis reveals there is peripheral and septal enhancement between the locules
and extension of the mass into the renal pelvis, although no hydronephrosis and no vascular
invasion. There is no evidence of distant metastatic disease.
What management is the multidisciplinary team likely to recommend for this patient?
a. Follow-up CT in 6 months
b. Partial nephrectomy
c. Radiological guided embolisation
d. Radiofrequency ablation
e. No further management required
113. A neonate, born at 28 weeks, has an ongoing need for ventilation and oxygenation. A chest
radiograph performed at 30 days shows hyperinflation, coarse linear densities and focal areas
of emphysema.
What is the most likely diagnosis?
a. Bronchopulmonary dysplasia
b. Bronchopulmonary sequestration
c. Congenital lobar emphysema
d. Transient tachypnoea of the newborn
e. Viral pneumonia
114. A 66 year old female presents with a sudden decrease in GCS. A non-contrast CT head is
performed which shows multiple bilateral, supratentorial, hyperdense intra-axial lesions
(55HU). The lesions are predominantly distributed at the grey−white matter junction of the
cerebral hemispheres. There is hypodensity surrounding the lesions consistent with oedema
and associated mass effect.
From which of the following primary malignancies are these lesions most likely to be
disseminated?
a. Cervical squamous cell carcinoma
b. Colonic adenocarcinoma
c. Endometrial endometroid carcinoma
d. Pancreatic ductal adenocarcinoma
e. Thyroid papillary carcinoma
115. A 3 day old neonate with respiratory distress has a chest radiograph which shows increased
lucency in the right middle and lower zones with increased rib interspacing on the right
compared to the left. A water-soluble contrast upper gastrointestinal (GI) study and arterial
phase CT chest are performed and a vascular cause is identified, confirming the diagnosis of
an aberrant left pulmonary artery.
What did the upper GI study most likely show?
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Table 4.4:
T1 Signal T2 Signal Restricted Diffusion Ossicular Displacement
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120. A 17 year old male has a CT of the spine for ongoing mid-thoracic back pain. There is a lytic,
expansile lesion within the posterior elements of the T5 vertebral body, with extension into the
vertebral body. On MRI the lesion is multicystic of different signal intensities, there are fluid-
fluid levels within the multiple thin-walled cysts. Heterogeneous enhancement of the septae is
seen post-contrast.
What is the most likely diagnosis?
a. Aneurysmal bone cyst
b. Fibrous dysplasia
c. Giant cell tumour
d. Simple bone cyst
ANSWERS 4
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Lissencephaly is an abnormally smooth brain surface. The cortex is thickened and the lateral
ventricles may be dilated, especially posteriorly. The cerebellum is usually not affected.
Pachygyria (broad gyri) and agyria (no gyri) also exist as subtypes within this spectrum of
disorders.
Schizencephaly is a cleft lined by grey matter extending between the pia mater and
ependymal surface and often connecting the surface of the brain to the lateral ventricles. The
open-lipped subtype has cerebrospinal fluid in the cleft and the closed lip subtype does not.
Porencephaly occurs secondary to an in-utero insult, usually before the second trimester. It
leaves a fluid-filled space communicating with the ventricles lined by white matter.
Holoprosencephaly is incomplete septation of the two cerebral hemispheres.
Hemimegalencephaly is when part of the brain is enlarged due to hamartomatous overgrowth;
this can be an entire hemisphere or more limited.
(The Final FRCR Complete Revision Notes Page 291)
12. (a) Ameloblastoma
Ameloblastoma typically affect patients >40 years of age and presents as a painless hard
lump. They are multilocular and characteristically have a ‘bubbly’ or ‘honeycomb’ appearance.
On MRI they have both cystic and soft tissue components which enhance avidly. In contrast to
this, odontogenic keratocysts often enhance poorly. Ameloblastomas are commonly expansile
and can cause root resorption.
Metastases are an important differential in this age group; however they usually have more
ill-defined margins.
Dentigerous and radicular cysts are more commonly unilocular lucencies related to
dentition, the former related to the crown of an unerupted tooth and the latter related to the
roots.
(The Final FRCR Complete Revision Notes Page 441)
13. (e) Xenon ventilation study
The ongoing pneumothorax and bubbling chest drain are suspicious for a bronchopleural
fistula. They can occur following surgery or as a sequelae of chemo- or radiotherapy and also
sometimes with infections, such as tuberculosis. CT can often be used to diagnose this
condition; however, in this case when further clarification is required, a Xenon ventilation
study can confirm the diagnosis by demonstrating tracer activity in the pleural space.
A CT pulmonary angiogram and a ventilation perfusion (VQ) study would not add anything
further to the existing CT chest for this indication and would be more appropriate if pulmonary
embolus was suspected.
Inserting a larger bore chest drain is unlikely to clinically improve the situation and would
not aid diagnosis. Larger bore chest drains can be indicated in the context of pleural effusions
with thick fluid, for example empyema or haemothorax.
Removing the chest drain when there is suspicion of a bronchopleural fistula could
potentially lead to tension pneumothorax and therefore this is not an appropriate management
plan.
(The Final FRCR Complete Revision Notes Page 25)
14. (b) Langerhans cell histiocytosis
Langerhans cell histiocytosis is the most common cause of vertebral plana in children. Other
imaging features include lucent bone lesions, occurring most commonly in the skull, mandible, ribs
and pelvis. Bone lesions are associated with periostitis. Lesions may resolve or become sclerotic.
Hand-Schüller-Christian disease is a variant which typically affects children 1–5 years old.
Multiple bones are involved, with evidence of extraskeletal involvement (classic triad of diabetes
insipidus, proptosis, and lytic bone lesions). Letterer-Siwe disease is a multisystem variant which
affects children less than 2 years old and is often fatal.
(The Final FRCR Complete Revision Notes Page 113)
15. (d) Fibrolamellar hepatocellular carcinoma (HCC)
Fibrolamellar HCC is an uncommon variant of HCC affecting young patients with no risk
factors. The tumour is typically large at diagnosis. The central scar is usually hyperechoic on
ultrasound and hypointense on MRI sequences, which helps to differentiate it from the T2
hyperintense central scar in focal nodular hyperplasia (FNH). The central scar generally does
not enhance in fibrolamellar HCC but does in FNH.
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The age of the patient in this case is highly suggestive of fibrolamellar HCC over standard
HCC. Fibrolamellar HCC can calcify; however this is less likely in HCC. Furthermore,
fibrolamellar HCC is commonly isointense on venous phase imaging, whereas HCC shows
early washout.
Hepatic adenoma can occur in a similar age group; however they do not contain a central
scar. They frequently contain fat and haemorrhage. The former leads to a drop of signal on
out-of-phase imaging.
Haemangiomas can appear hyperechoic on ultrasound but their enhancement is quite
characteristic with peripheral enhancement that progresses centrally with time. They do not
contain a central scar.
(The Final FRCR Complete Revision Notes Pages 205−206)
16. (c) No further investigation required
The imaging appearances are consistent with medullary sponge kidney. On intravenous
urograms the appearance used to be likened to a paintbrush; otherwise known as a ‘striated
nephrogram’. Other causes for this appearance bilaterally include acute pyelonephritis, acute
tubular necrosis, hypotension and autosomal recessive polycystic kidney disease. The latter is
associated with paediatric patients. The history does not fit with hypotension, acute
pyelonephritis or acute tubular necrosis. Urine dip would typically be abnormal in
pyelonephritis and acute tubular necrosis, either showing signs of nitrites, blood or protein. If
these conditions were suspected clinically, then answers B and D may be appropriate.
If systemic lupus erythematous is suspected then an antinuclear antibody test would be
helpful; however, this tends to be associated with glomerulonephritis, which causes swollen
kidneys.
Renal vein thrombosis would cause a unilateral striated nephrogram and is also unlikely in a
patient without risk factors; therefore an ultrasound Doppler is unlikely to provide any
additional information.
Medullary sponge kidney does not progress to renal failure, and for most patients the condition
is asymptomatic. It is often picked up incidentally and further follow-up is not required.
(The Final FRCR Complete Revision Notes Page 253)
17. (c) Just distal to the ampulla of Vater in D2
The case describes a classic case of duodenal atresia. This may be suspected antenatally if there is
polyhydramnios and postnatally within the first week when infants experience vomiting. The
radiographic appearance in the case is called the ‘double bubble’ sign. The majority of cases have
an obstructive level which is just distal to the ampulla of Vater and hence the vomiting is bilious.
Non-bilious vomiting would suggest a more proximal obstruction. The finding that there is no gas
more distally in the bowel excludes other differentials such as duodenal stenosis or a duodenal
web. Duodenal atresia is associated with an annular pancreas, VACTERL anomalies and Down
syndrome.
(The Final FRCR Complete Revision Notes Page 336)
18. (c) Creutzfeldt-Jakob disease (CJD)
CJD is a spongiform encephalopathy which causes abnormal signal in the thalamus, basal
ganglia (particularly the caudate and putamen) and cortex with T2 hyperintensity and
restricted diffusion. The condition causes myoclonus and dementia. The sporadic type is most
common and tends to affect older age groups. CT findings are frequently of atrophy.
The history may fit with manganese poisoning, which causes parkinsonism; however the area
of the brain affected is different, with T1 hyperintensity in the globus palladi. Similarly the
globus pallidi are affected in carbon monoxide poisoning; however, the history is not consistent.
Imaging findings in Alzheimer’s and Lewy body dementia can be non-specific and they
require clinical correlation. The typical description in Alzheimer’s disease is mesial temporal lobe
volume loss and volume loss in the parietal-occipital region. Similarly Lewy body dementia also
leads to volume loss, usually in the frontal, parietal and temporal regions.
(The Final FRCR Complete Revision Notes Page 381)
19. (c) Metastatic adenocarcinoma
The imaging features described are suspicious for a malignant process, with secondary
metastases to the pleura being the most common pleural malignancy. Lung, breast, ovarian and
lymphoma are the most common malignancies to metastasise to the pleura.
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Pleural mesothelioma is the second most common pleural malignancy (after metastases),
strongly associated with exposure to asbestos and a latency period of up to 40 years.
Primary pleural lymphoma is extremely rare. When it occurs, it tends to be associated with
immunodeficiency and chronic pyothorax. Secondary pleural lymphoma is more common than
primary pleural lymphoma.
Liposarcoma of the pleura is demonstrated as a mixed attenuation mass with some areas of
fat tissue (this is a different entity to liposarcomatous differentiation of malignant
mesothelioma).
Fibrothorax is a benign entity that can occur as a sequelae to inflammation, tuberculosis or
haemothorax. In this condition, pleural thickening is smooth, it may be calcified and does not
usually involve the mediastinal surface.
(The Final FRCR Complete Revision Notes Page 44)
Jaramillo FA, Gutierrez F, Bhalla S. Pleural tumours and tumour-like lesions. Clinical Radiology.
2018;73(12):1014–1024.
20. (b) High T1 and T2 endplate changes with low T2 disc signal
Modic endplate changes are associated with degenerative disease of the lumbar spine. Type II
changes are most common.
The difference between Modic type I changes and discitis is the disc signal. Normally discs are
intermediate signal or, if there is disc dehydration, they may demonstrate low T2 signal, whereas
in discitis they would be high on T2 and low signal on T1 sequences, due to inflammation.
Answer A would be consistent with discitis.
Modic type I is associated with pain and due to bone marrow oedema, and inflammation there
is increased fluid in the region, hence T1 endplate signal is low and T2 endplate signal is high.
Answer C would be consistent with Modic type I change.
Modic type II changes are due to red marrow replacement, which is fatty; hence T1 endplate
signal is high, as is T2 signal.
Modic type III changes are due to subsequent sclerosis and so both T1 and T2 endplate signals
are low. Answer D would be consistent with Modic type III change.
(The Final FRCR Complete Revision Notes Page 83)
21. (e) Skin
The most common metastatic lesion in the stomach is malignant melanoma. Other common
primary sites of metastatic malignancy include breast, lung, cervix, prostate and renal. Spread
can be contiguous from adjacent structures, for example via the gastrocolic ligament, or
haematogenous. The latter is more common. On a barium meal haematogenous metastases can
produce multiple nodules and a characteristic ‘bull’s-eye’ appearance, which is so called due to
the central ulceration the lesions demonstrate. Metastases often affect the proximal and middle
part of the stomach and can present with weight loss, melaena and haematemesis.
(The Final FRCR Complete Revision Notes Page 170)
22. (c) Dandy-Walker malformation
Dandy-Walker malformation is a constellation of congenital anomalies including absent or
hypoplastic cerebellar vermis, a posterior fossa cyst connected to the fourth ventricle and a
resulting enlarged posterior fossa. The torcular herophili (the confluence of the intracranial
venous sinuses) is abnormally elevated. The variant condition is when not all of the findings
are present and often the posterior fossa is not enlarged.
If there is a posterior fossa cerebrospinal fluid cyst and the cerebellar vermis are normal in
appearance, then the differential lies between arachnoid cyst and mega cisterna magna. The
latter is a normal variant. An arachnoid cyst is suspected if there is adjacent mass effect.
Chiari malformations do not cause an enlarged posterior fossa. Chiari I is when the cerebellar
tonsils descend >5 mm through the foramen magnum. Chiari II is more severe and can cause a
small posterior fossa and descent of the torcular herophili. There is caudal descent of the
medulla, cerebellar vermis and fourth ventricle with a myelomeningocele.
(The Final FRCR Complete Revision Notes Pages 293−294)
23. (c) Non-contrast enhanced MRI
The most likely cause of a hyperechoic liver lesion in a young patient is an incidental
haemangioma and if the patient was not pregnant than a contrast enhanced MRI would be the
most appropriate investigation. However, gadolinium-based contrast agent is avoided in
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pregnancy unless essential for diagnosis and management. An unenhanced MRI may still be
helpful and is worth pursuing in the first instance. MRI should be avoided in the first trimester,
and then in the second and third trimesters it is worth considering whether acoustic noise and
specific absorption rate (SAR) can be reduced by amending the protocol.
A contrast-enhanced CT would not be suitable in a pregnant patient for this indication due to
the risks of ionising radiation. Similarly, Technetium 99-m red blood cell scan, although very
helpful in diagnosing haemangioma, would also be contraindicated.
Imaging could be performed following completion of the pregnancy; however this is >4 months
away. A repeat ultrasound is unlikely to add more information.
(The Final FRCR Complete Revision Notes Page 209)
24. (d) Neurosarcoidosis
Central nervous system involvement of sarcoidosis can cause symptoms including bilateral
facial nerve palsy, seizures and diabetes insipidus. It characteristically causes basal
leptomeningeal thickening which can lead to hydrocephalus. Appearances can be similar to
tuberculous meningitis; however, bilateral cranial nerve involvement, most commonly the
facial or optic nerves, is suggestive of sarcoidosis.
Leptomeningeal carcinomatosis can be due to a primary intracranial tumour however there
would be evidence of this on the MRI. Lymphoma, leukaemia and metastatic disease, for
example from a breast or lung primary, are possible; however this tends to cause diffuse
thickening affecting all parts of the brain rather than having a basal predilection.
(The Final FRCR Complete Revision Notes Page 382)
25. (a) Acute eosinophilic pneumonia
Acute eosinophilic pneumonia often presents with a short febrile illness and marked
hypoxia. CT changes include bilateral consolidation and ground glass opacification with
pleural effusions and interlobular septal thickening. In contrast to the chronic and simple
subtypes of eosinophilic lung disease, the acute form is not associated with serum eosinophilia
and instead there are elevated eosinophil levels in the bronchoalveolar fluid.
Eosinophilic granulomatosis with polyangiitis (previously known as Churg-Strauss) can
have ground glass opacification and consolidation but you may also expect centrilobular
nodularity and serum eosinophilia.
Sarcoidosis is also associated with nodularity, and mediastinal and hilar lymphadenopathy
is also common. Pleural effusions are not typical.
Bronchopneumonia can cause bilateral scattered consolidation with Staphylococcus aureus
infection potentially leading to cavitating pneumonia and empyema; however, in a young
patient the full blood count would usually be abnormal.
Subacute hypersensitivity pneumonitis is usually associated with centrilobular nodularity as
well as air trapping and mosaicism.
(The Final FRCR Complete Revision Notes Page 29)
26. (b) Lead poisoning
Lead poisoning may present with loss of appetite, abdominal pain, constipation and
vomiting; patients may also be anaemic. The presence of high-density bands within the
metaphysis represents lead deposition. Patients may be short for their age, with skeletal
immaturity present on imaging, and a ‘bone-in-bone’ appearance may also be seen.
Metaphyseal bands can also be seen in healed rickets; however ‘bone-in-bone’ appearance is
not a typically described feature of this condition.
The presence of dense metaphyseal bands may be physiological in children aged less than
3 years old.
Dense metaphyseal bands can be seen in scurvy, which is relatively uncommon. It is
caused by dietary lack of vitamin C. Other imaging features include generalised
osteopenia, cortical thinning, periosteal reaction, Wimberger ring sign, Frankel line and
Trümmerfeld zone.
Fracture at the distal radius may cause increased density at the metaphysis; however it
does not account for the other clinical and radiographic features described.
(The Final FRCR Complete Revision Notes Page 113)
27. (b) Gastrointestinal stromal tumour
The gastric soft tissue mass has imaging features in keeping with a gastrointestinal stromal
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tumour (GIST). They can be very large and have necrotic, haemorrhagic and cystic
components. They may be asymptomatic or present with vague abdominal symptoms.
Sometimes, similar to this case, they can present with haemorrhage. The most common site is
the stomach, followed by the small intestine. They are usually benign but larger tumours,
greater than 5 cm, are more likely to have malignant potential. Ninety percent of GISTs express
c-KIT (CD117) antigen, a tyrosine kinase growth factor receptor.
GISTs can be associated with several syndromes, including neurofibromatosis type I. The
intracranial appearances are consistent with this – sphenoid wing dysplasia and focal areas of
signal intensity (FASIs). Carney triad is also associated with GISTs. The lack of lymph node
enlargement makes malignancy such as gastric adenocarcinoma, metastatic malignancy or
lymphoma less likely. Gastric hamartomas can be seen in several polyposis syndromes such as
Cowden and Peutz-Jegher syndrome.
(The Final FRCR Complete Revision Notes Page 172)
28. (c) Surgical resection
The imaging description is of a heterogenous renal lesion with coarse calcification and a
central scar. The differential lies between renal cell carcinoma and oncocytoma. Classical
imaging characteristics for an oncocytoma include an isoechoic renal mass with a hypoechoic
centre on ultrasound. CT of larger lesions such as this one can demonstrate a heterogenous
mass and there can be perinephric fat stranding. Both CT and MRI demonstrate the typical non-
enhancing central scar. Other MRI features include T1 hypointensity and T2 hyperintensity
compared to the renal cortex. In this case an MRI is unlikely to add more information.
Oncocytomas are benign but they are difficult to differentiate from renal cell carcinoma on
imaging alone, and even a biopsy of a carcinoma can contain oncocytic components.
Renal sarcomas are aggressive lesions. Often at this size there may be vascular invasion, and
early haematogenous metastases are common. The CT scan on this patient does not
demonstrate evidence of metastatic infiltration.
Therefore, the most appropriate answer is surgical resection to help confirm what the lesion
is and plan for the most appropriate management. Repeat ultrasound guided biopsy may not
be successful given the issues during the first attempt. Ablation would not help with
histological diagnosis and is therefore not indicated.
(The Final FRCR Complete Revision Notes Pages 255−256)
29. (b) Dilatation of the intrahepatic ducts
The Todani classification helps differentiate between choledochal cysts, and ranges from I to V.
Caroli disease is the cystic dilatation of intrahepatic ducts and consistent with Todani type V.
Type I is fusiform cystic dilatation of the extrahepatic duct.
Type II is an extrahepatic bile duct diverticulum.
Type III is dilatation of the extrahepatic bile duct within the duodenal wall.
Type IV is the presence of intra- and extrahepatic cysts.
(The Final FRCR Complete Revision Notes Page 335)
30. (c) Melanoma
Uveal melanoma is the most common primary eye tumour in adults, and when they
affect the choroid at the posterior aspect of the globe, they can be detected incidentally or
following visual loss caused by retinal detachment. Cutaneous melanoma can also
metastasise to the eye, along with other primary tumours such as breast and lung.
Typically ocular melanoma is hyperdense on CT with a lenticular, well-defined shape. The
mass enhances and demonstrates high T1 and low T2 signal due to melanin content. There
may be haemorrhage associated with it.
Drusen are usually small areas of bilateral calcification overlying the optic nerve and are
not a unilateral finding, such as in this case. Choroidal osteomas do occur unilaterally and
manifest as curvilinear calcification which are usually larger than drusen and normally
spare the optic disc.
Retinoblastoma affects a younger age group than this patient and are the most common
paediatric eye tumour. On imaging they manifest as a heterogenous soft tissue mass
containing areas of necrosis and calcification.
Retinal detachment can sometimes be incidentally identified on imaging as a ‘V’ shape
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Table 4.5: American Association for the Surgery of Trauma (AAST) Grading of
Liver Laceration (2018 Revision)
I Subcapsular haematoma <10% surface area, laceration <1 cm deep
II Subcapsular haematoma 10–50% surface area, intraparenchymal haematoma <10 cm, laceration <3 cm
deep/10 cm long
III Subcapsular haematoma >50%, intraparenchymal haematoma >10 cm, laceration >3 cm deep and >10
cm long, active bleeding contained within liver parenchyma
IV Active bleeding beyond liver parenchyma into peritoneum, parenchymal disruption of 25–75% of
liver lobe
V Parenchymal disruption of >75% of lobe, juxtahepatic venous injuries − IVC, major hepatic vein, etc.
Source: The American Association for the Surgery of Trauma. 2018 revision. AAST grading of liver laceration.
Table 8. https://www.aast.org/library/traumatools/injuryscoringscales.aspx#liver.
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Medulloblastomas are solid masses which can grow quickly causing a relatively rapid onset
of symptoms. They typically have low T1 signal and are T2 iso/hyperintense to grey matter.
They are commonly more homogenous than other posterior fossa masses and demonstrate
both enhancement and restricted diffusion. They arise from the roof of the fourth ventricle. It is
important to image the rest of the neuroaxis to exclude drop metastases.
Astrocytomas typically have a large cystic component with an enhancing mural nodule. The
fourth ventricle is often displaced anteriorly.
Ependymomas are frequently also in the fourth ventricle; however, they arise from the floor
of the fourth ventricle and can extend out of the foramen of Magendie and Luschka. They are
more heterogenous and commonly calcify.
Brainstem glioma tend to occur in the pons causing diffuse enlargement, although they can
sometimes cause an exophytic masses. Like medulloblastoma, they can return low T1 and high
T2 signal; however, their enhancement and restricted diffusion is minimal in comparison.
Paediatric choroid plexus papilloma are more common in the lateral ventricles and are
usually well-defined cauliflower-like masses rather than the ill-defined mass described in this
child.
(The Final FRCR Complete Revision Notes Page 300)
35. (e) Tethered cord syndrome
The cord usually terminates around the level of L1/2; below this level it is low and is
associated with a tethered cord. There are various associations with tethered cord including
spinal lipoma, diastematomyelia, thickened filum terminale, Chiari malformation,
myelomeningocele and dermal sinus. In this case, the cord is tethered due to a lipoma; it
follows fat on all sequences and does not enhance.
Ependymoma and paraganglioma are other causes of filum terminale masses.
Ependymomas are the most common but they are often more heterogenous than the mass
described in this question with haemorrhage, cystic change and calcification. Paragangliomas
are also usually more heterogenous and they also intensely enhance.
Lipomyelomeningocele is a form of spina bifida. Although they do contain fat, it extends
within the subcutaneous tissues and there are other important features such as neural arch
defects. The bones in this case are normal.
Diastematomyelia is a split cord malformation however the question states that there is a
single cord.
(The Final FRCR Complete Revision Notes Pages 305, 451)
36. (e) Reduced lung volumes
Respiratory distress syndrome in neonates is due to surfactant deficiency. It affects
premature infants (<37 weeks) and is associated with low lung volumes, air bronchograms and
granular opacities. If a chest radiograph is normal at 6 hours it excludes the diagnosis.
Interstitial oedema is more commonly associated with transient tachypnoea of the newborn,
which also affects babies relatively quickly following delivery and is more commonly
associated with term infants delivered by caesarean section. It usually resolves within days.
Meconium aspiration is typically associated with increased lung volumes, streaky perihilar
opacities and lack of air bronchograms. Perihilar opacities may also be seen in neonatal pneumonia.
(The Final FRCR Complete Revision Notes Page 328)
37. (d) Serum eosinophil count
Simple pulmonary eosinophilia, or Löffler syndrome, is associated with elevated serum
eosinophil levels and presents with transient air space opacification.
Anti-basement membrane antibody is associated with Goodpasture syndrome. This tends to
cause pulmonary haemorrhage which may have similar appearances on chest radiograph but
would be associated with more constitutional symptoms and haemoptysis.
Bronchoalveolar lavage demonstrating eosinophils would help to diagnose acute or chronic
eosinophilic pneumonia. Both are associated with raised eosinophils in bronchoalveolar fluid,
and the latter also with serum eosinophilia.
Serum cANCA positivity is found in vasculitic conditions such as eosinophilic
granulomatosis with polyangiitis (Churg-Strauss) and microscopic polyangiitis.
The presence of 5-HIAA in urine suggests increased serotonin metabolism, which may be a
feature of a carcinoid tumour.
(The Final FRCR Complete Revision Notes Page 29)
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Capillary haemangiomas often affect the periorbital region and are also called strawberry
haemangiomas when they are external on the skin surface. However, they can cause
intraorbital masses presenting with proptosis. They usually increase in size over the first few
months of life and then slowly regress. On imaging they appear as lobulated, septated masses
which can span both the intra and extraconal compartments. They have curvilinear flow voids
and enhance intensely.
Cavernous haemangioma are more common in the adult population and are usually
intraconal. They are rounded and well defined with the appearance of a capsule. Their
enhancement tends to be slower and more patchy than a capillary haemangioma.
Lymphangioma are usually extraconal and are more heterogenous with solid and cystic
components and fluid-fluid levels. They can cause sudden proptosis due to haemorrhage. Due
to their proteinaceous cystic components they are commonly high on T1 and T2 with minimal
enhancement.
Retinoblastomas are related to the globe and are heterogenous solid masses containing
necrosis and calcification.
On imaging, a venous varix appears as a dilated intraconal vessel and can be congenital or
acquired, following trauma for example. It presents with intermittent proptosis on coughing or
straining, and therefore imaging before and after Valsalva manoeuvre can be helpful.
(The Final FRCR Complete Revision Notes Page 437)
43. (e) Streptococcus pneumoniae
The chest radiograph is describing lobar consolidation. Opacification usually appears
rapidly on a chest radiograph and resolves slowly after treatment. The most common
causative organism is Streptococcus pneumoniae (pneumococcal pneumonia). This accounts for
more than 50% of bacterial pneumonia. It can be multi-lobar or bilateral, and pleural
effusions are also common. In children, consolidation can appear mass-like, referred to as
‘round pneumonia’.
Haemophilus influenzae is a Gram-negative pneumonia, usually found in debilitated
patients. This usually affects the lower lobes.
Klebsiella produces consolidation similar to streptococcus. It may be associated with
bulging fissures and it can cavitate.
Legionella pneumophila (Legionnaires’ disease) can produce consolidation similar to
Streptococcus pneumoniae. There is often rapid progression to other lobes and cavitation may
be present.
Staphylococcus aureus usually occurs in debilitated inpatients. It is commonly associated
with cavitation and pleural effusion, sometimes empyema.
(The Final FRCR Complete Revision Notes Page 47)
44. (c) Osteomyelitis
The case describes a Brodie abscess, which is a form of chronic osteomyelitis and represents
an intraosseous abscess. Typical radiographic appearances are described in the question, in
particular the orientation along the long axis of the bone. They usually occur in the metaphysis,
and the pathognomic sign is the lucent channel extending towards the physis in a patient with
an unfused skeleton. They can have similar appearances to osteoid osteoma, although the latter
are usually cortically based, but this can vary.
Eosinophilic granulomas do occur in children and can affect the metadiaphysis; however
they would not typically have a sclerotic rim.
Osteosarcomas are more aggressive lesions and would usually cause more adjacent
periosteal reaction and soft tissue extension without the sclerosis
Giant cell tumours typically involve the metaphysis but tend to occur in an older age group
with fused skeletons.
(The Final FRCR Complete Revision Notes Pages 87, 106)
45. (c) Hepatic vein
A transjugular intrahepatic portosystemic shunt (TIPSS) is performed to treat portal
hypertension and can be utilised for bleeding oesophageal or gastric varices when endoscopic
therapy has failed. Vascular access is usually via the right jugular vein and a shunt is created
between the portal vein and a hepatic vein with a stent to allow blood to bypass the liver.
Contraindications include severe right heart failure, severe encephalopathy, sepsis and severe
chronic liver disease. Complications include haemorrhage, infection and specifically
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Exudative tracheitis is less likely in this age group as it usually affects older children.
Radiographic findings would include membranous tracheal filling defects and irregularity.
Retropharyngeal abscess is suspected if the retropharyngeal soft tissues are thickened;
however, they are normal in this case.
The subglottic narrowing and hypopharyngeal distension in this case is below the pharynx
and therefore not consistent with pharyngitis.
(The Final FRCR Complete Revision Notes Page 322)
54. (d) Pial vessels peripheral to the mass
Differentiating intra- from extra-axial masses helps to narrow the imaging differential. Extra-
axial masses can have various characteristics that may aid this task. An extra-axial mass will
displace the subarachnoid and pial vessels medially towards the brain. If the pial vessels are
peripheral to the mass it suggests it is a parenchymal, intra-axial mass.
Extra-axial masses can cause adjacent skull changes such as hyperostosis with meningiomas;
however, this is unlikely with an intra-axial lesion. Buckling of the grey−white matter interface
is caused by the pressure exerted by an extra-axial mass on the adjacent brain. In contrast, an
intra-axial mass will usually cause swelling and expansion of the white matter and cortex. The
cerebrospinal fluid (CSF) cleft sign is described as a thin rim of CSF or FLAIR hyperintensity
between the mass and the brain parenchyma.
(The Final FRCR Complete Revision Notes Page 386)
55. (e) Primary (autoimmune) pulmonary alveolar proteinosis
Pulmonary alveolar proteinosis (PAP) usually affects middle-aged men. It is strongly
associated with smoking. It represents filling of airspaces with proteinaceous fluid with
preservation of the interstitium. Imaging features are often more severe than the clinical
symptoms. The ‘crazy paving’ description is typical for PAP but not pathognomonic. It refers to
ground glass opacification in combination with smooth interlobular septal thickening. It is
usually of primary (or autoimmune) origin (approximately 90%).
Secondary PAP is less common. It can be precipitated by silica dust inhalation or
haematological malignancy as well as immunodeficiency with infection, for example
Cryptococcus, Nocardia or Aspergillus. The information provided in the main stem is most likely
in keeping with primary PAP, as this is most common, and no information that could account
for a secondary cause has been provided. Congenital PAP presents in the neonatal period and
so is not considered a possible aetiology in this case.
(The Final FRCR Complete Revision Notes Page 49)
56. (e) Tenosynovial giant cell tumour
These tumours are pigmented villonodular synovitis affecting the tendon sheath and have
similar imaging characteristics on MRI with low T1 and T2 signal and evidence of blooming on
gradient echo sequences due to haemosiderin deposition.
Although desmoid tumours are most common in the abdomen, they can affect limbs but tend
not be in direct contact with the tendon sheath. They can look similar on ultrasound if well
defined, and also demonstrate low signal on T1 and T2 sequences; however, they would not
demonstrate susceptibility artefact.
Fibromas can look similar but are not associated with susceptibility artefact either.
Ganglion cysts are cystic rather than solid lesions and would not demonstrate internal
vascularity.
Glomus tumours are vascular tumours also known as glomangiomas, and present as painful
small blue/red nodules under the fingernails. Due to their small size they are difficult to see on
radiograph and there may just be mild soft tissue swelling. The lesions will be hypervascular if
visible on ultrasound.
(The Final FRCR Complete Revision Notes Pages 90, 142)
57. (a) Serous cystadenoma
The mass fits well with being a serous cystadenoma; it is in the pancreatic head, there are
multiple small cysts, calcification is central and the patient is an elderly woman.
A mucinous cystadenoma is more common in middle-aged women and the cysts are less
numerous and larger. Calcification is peripheral and the majority of masses are in the
pancreatic body or tail.
Main duct intraductal papillary mucinous neoplasms (IPMNs) do occur in a more elderly age
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group and more commonly in the pancreatic head; however, they usually cause pancreatic duct
dilatation (>3 mm). Calcification is not a typical feature.
Islet cell tumours are neuroendocrine tumours, and when small are usually homogenous
solid lesions rather than the cystic mass described in this question. The most common islet cell
tumour is an insulinoma followed by gastrinoma. They exhibit arterial phase enhancement and
so usually appear isodense to the pancreas on portal venous phase CT.
(The Final FRCR Complete Revision Notes Page 229)
58. (d) Osteoid osteoma
The history of night pain relieved by salicylate is typical for an osteoid osteoma. This is a
benign bone lesion which has a lucent central nidus (<1.5 cm) with surrounding sclerosis
centred on the metaphyseal or diaphyseal cortex. On scintigraphy there is ‘double density sign’
where the central nidus demonstrates focal intense activity and the surrounding sclerosis
demonstrates more modest activity. Treatment options include radiofrequency ablation of the
lucent focus.
Fibrous cortical defect are benign, well-defined lytic lesions less than 2 cm. They are
intracortical affecting the metaphysis, have a narrow zone of transition with a thin sclerotic rim,
and on scintigraphy there is increased uptake.
Osteoblastomas are histologically similar to an osteoid osteoma. The central nidus is larger
than 1.5 cm and they are usually seen between 20 and 30 years old.
Osteochondromas are composed of cortical and medullary bone protruding from a bone
with the presence of a cartilage cap.
Osteosarcoma is the most common primary bone tumour in children. It is an ill-defined
lytic/sclerotic metaphyseal lesion with an internal osteoid matrix.
(The Final FRCR Complete Revision Notes Page 147)
59. (d) Thoracic duct atresia
Chylothorax is most commonly due to an iatrogenic injury of the thoracic duct, for example
following thoracic surgery such as oesophagectomy. Chylothoraces can also be caused by
traumatic injury or by malignancy. In a neonate these causes are less likely, although birth
trauma is a possibility. The most likely causes are thoracic duct atresia, lymphangiectasia and
pulmonary abnormalities such as congenital pulmonary airway malformation and extralobar
sequestration. Certain congenital conditions such as Turner, Noonan and Down syndrome are
also associated with chylothoraces.
In this case, the child is male so this excludes Turner syndrome. The normal appearance of the
lungs excludes lymphangiectasia and extralobar sequestration. The former causes dilated
lymphatics, which leads to other radiological findings such as interstitial thickening and perihilar
infiltrates. Lymphangioleiomyomatosis is not a diagnosis made in this age group, as it usually
affects young women. Therefore the most likely cause in this patient is thoracic duct atresia.
(The Final FRCR Complete Revision Notes Page 320)
60. (c) Haemangioblastoma
The most common cause of a posterior fossa mass in adults is a metastasis; however the
second most common is a haemangioblastoma, which fits the description in this case. The
history of a relatively young man with a history of renal cell carcinoma is also suggestive of
possible von Hippel-Lindau syndrome. On imaging, haemangioblastomas are most commonly
located in the posterior fossa. They are well-defined cystic masses with an enhancing mural
nodule. They may demonstrate flow voids, particularly at the periphery of the lesion.
Pilocytic astrocytomas can have a similar appearance with a cystic mass and enhancing
mural nodule; however, they usually occur in a much younger age group.
A cavernoma is not a cystic mass and on MRI can have variable appearances depending on
the presence of haemorrhage and haemosiderin. This causes blooming on susceptibility
weighted imaging.
Ependymomas often contain cystic components; however they also contain significant solid
elements, calcification and haemorrhage.
(The Final FRCR Complete Revision Notes Page 392)
61. (d) Arterial phase CT from diaphragm to toes
Approximately 30–50% of popliteal artery aneurysms are associated with an abdominal
aortic aneurysm; therefore the abdominal aorta needs to be included on the study. In lower
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limb studies, the contralateral lower limb will automatically be included on the study and
assessment of the contralateral popliteal artery is also vital, as they can be bilateral. Other
important factors to consider when planning interventional radiological management is the
tortuosity of the common and external iliac arteries and mural calcification, particularly at the
femoral vessels where vascular access will be required for endovascular repair. The CT should
extend to the toes to assess the vessel quality peripheral to the aneurysm, as popliteal
aneurysms are associated with peripheral thromboembolic complications.
(The Final FRCR Complete Revision Notes Page 2)
62. (d) Scleroderma
The differentials for acro-osteolysis, or terminal tuft resorption, include scleroderma,
psoriatic arthritis, hyperparathyroidism, syringomyelia and trauma, such as burns or frostbite.
Clavicle involvement further narrows the differential; it is described in scleroderma and
hyperparathyroidism as well as rheumatoid arthritis and other less common congenital
conditions such as cleidocranial dysostosis and pyknodysostosis.
Therefore, the acro-osteolysis and clavicle erosions combined with the other findings make
scleroderma the most likely answer.
Hyperparathyroidism, particularly secondary hyperparathyroidism, can also cause
generalised osteopenia, soft tissue calcification, acro-osteolysis and distal clavicle resorption.
However, the described deformity and the dilated oesophagus on chest radiograph make
scleroderma more likely.
Scleroderma causes an erosive arthropathy affecting the interphalangeal joints and there is
commonly deformity with ulnar deviation of the fingers or radial subluxation at the first
carpometacarpal joint. Osteopenia can be either periarticular or generalized, and soft tissue
wasting and calcification is also common. Another typical finding on chest radiograph is
oesophageal dilatation.
(The Final FRCR Complete Revision Notes Pages 95, 107)
63. (e) Thickened ileocaecal valve
Tuberculosis (TB) affecting the bowel can present with pain, weight loss, bowel symptoms
and fever. It most commonly involves the ileocaecal region, and often preferentially affects the
caecum. The ileocaecal valve can become thickened, patulous and over time, rigid. Like
Crohn’s disease, there can be both deep fissures and ulceration. The ulceration in TB is usually
circumferential, whereas in Crohn’s they are typically longitudinal and typically on the
mesenteric border. With chronicity, both conditions can lead to strictures, and in TB the caecum
can appear retracted.
Crohn’s disease tends to be associated with very little ascites whereas there is often more
fluid in cases of TB, which can be relatively high density. Both conditions may cause abdominal
lymph node enlargement; however in TB these lymph nodes typically demonstrate low
attenuation. TB can also cause peritonitis with nodularity and peritoneal thickening.
(The Final FRCR Complete Revision Notes Pages 183−184)
64. (a) Contrast enhanced MRI
Renal cell carcinoma extending into the renal vein corresponds to at least T3 disease, with
proximal extension an important factor in surgical planning. If it extends into the inferior vena
cava, then a midline laparotomy is required, and if beyond the level of the hepatic veins, then
thoracic surgeons will likely need to be involved.
It can be difficult to assess tumour thrombus versus bland thrombus. Sometimes contrast
enhancement is identified on post-contrast CT within the thrombus, consistent with tumour;
however, MRI is superior to CT for assessment. Tumour thrombus on MRI would also enhance
and on T1 weighted imaging the normal vascular flow voids would be replaced by
comparatively high tumour signal.
18F-FDG PET/CT currently has a limited role in the staging of renal cell carcinoma due to
renal excretion causing high renal tracer uptake and therefore making assessment difficult.
However, there are reports of tracer uptake in tumour thrombi.
Ultrasound Doppler may identify thrombus; however the assessment of bland thrombus
versus tumour thrombus would be challenging on ultrasound.
Digital subtraction angiography does not have a role in this case.
(The Final FRCR Complete Revision Notes Page 258)
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Source: Reprinted with permission from V Helyar and A Shaw. The Final
FRCR: Complete Revision Notes. CRC Press, Taylor & Francis Group,
2018, p. 149.
The features are in keeping with a Brown tumour, also known as an osteoclastoma. These
are solitary lesions seen in primary and secondary hyperparathyroidism. They can mimic
metastases and myeloma.
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non-specific changes such as joint effusion and joint swelling. More advanced manifestations
include periarticular osteopenia, joint space narrowing and bone destruction.
The history is key; the patient is febrile and the recent pneumonia suggests this could be
caused by haematogenous spread from the recent infection. The most commonly affected
joints are hip, knee, elbow or ankle, and the most common pathogen is Staphylococcus aureus.
The best way to obtain a diagnosis and target antibiotics appropriately is with joint
aspiration followed by microscopy and culture of the synovial fluid. Radiology can offer
assistance with ultrasound-guided aspiration if needed, but if clinical suspicion is high, joint
washout may be pursued regardless.
MRI in septic arthritis can confirm the joint effusion and demonstrate marrow and soft
tissue oedema and synovial enhancement.
There will be increased tracer uptake on all phases of a triple phase nuclear medicine bone scan.
(The Final FRCR Complete Revision Notes Page 96)
75. (c) Anterior to the sigmoid colon
The imaging characteristics are typical for epiploic appendagitis. This usually affects women
more than men and is more common in patients with a raised body mass index. Differentials
would include appendicitis and diverticulitis; however the patient is young and diverticulitis
would be less likely. The imaging appearances are not characteristic for appendicitis.
The epiploic appendages are small fatty appendages sited along the large bowel. When these
twist they cause acute abdominal pain which can be difficult to clinically differentiate from other
causes of pain. This most commonly occurs anterior to the rectosigmoid colon. On ultrasound the
appearance of a hyperechoic mass indicates fat. Sometimes a slightly hypoechoic line can be seen
peripherally, and there is no internal vascularity. CT is usually diagnostic and demonstrates a
lesion of fat density adjacent to the colon with peripheral enhancement and surrounding fat
stranding. Sometimes a hyperechoic dot centrally can be seen representing thrombosed vessels.
(The Final FRCR Complete Revision Notes Page 167)
76. (a) Abdominal ultrasound
The patient has a right-sided varicocele. Varicoceles are more common on the left due to the
drainage of the left testicular vein into the left renal vein. The right testicular vein drains
directly into the lower pressure inferior vena cava. If a varicocele is just on the right side, then
ultrasound of the abdomen, to focus on the retroperitoneal structures, should be performed to
ensure there is not an underlying pathology, such as a mass, impeding venous return. If
ultrasound cannot be confidently used to assess this, for example in patients with a high body
mass index, then other modalities could be considered. Treatment for uncomplicated
varicoceles include surgical ligation or embolisation.
There are a couple of tiny hyperechoic foci in the right testicle of unlikely clinical
significance; when >5 this is consistent with microlithiasis. Guidance from the European
Society of Urogenital Radiology suggests annual follow-up until the age of 55 only if there are
other risk factors present, such as a history of orchidopexy or maldescent. The presence of a
testicular mass would prompt tumour marking testing but is not indicated in this case.
(The Final FRCR Complete Revision Notes Page 281)
Richenberg J, Brejt N. Microlithiasis: is there a need for surveillance in the absence of other risk
factors. European Radiology. 2012:22(11);2540–2546.
77. (d) ‘Finger-in-glove’ opacities
The child has cystic fibrosis. The first signs on chest radiograph are hyperinflation and
bronchial wall thickening. High resolution CT can show cylindrical bronchiectasis, mucous
impaction and mosaic attenuation due to air trapping. Although the entire lung can be
affected, there is a predilection for the upper lobes, the apices of the lower lobes and a
perihilar distribution. The ‘finger-in-glove’ appearance is due to bronchial obstruction by
mucous. The bronchus distal to the obstructing mucous is dilated. This can be observed in
other conditions such as allergic bronchopulmonary aspergillosis which can occur in isolation,
or in combination with cystic fibrosis.
Atelectasis in cystic fibrosis is more likely to be in the upper lobes. Cardiomegaly may
eventually occur secondary to pulmonary hypertension and resulting cardiac failure;
however, this is unlikely at diagnosis. Chylothoraces and thin-walled pulmonary cysts are not
associated with cystic fibrosis.
(The Final FRCR Complete Revision Notes Page 322)
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increased risk of renal cell carcinoma, which can be bilateral and is typically of clear cell
subtype.
Tuberous sclerosis can cause angiomyolipomas. It carries an increased risk of renal cell
carcinoma and is associated with intracranial tumours such as subependymal giant cell
astrocytomas as well as other parenchymal brain abnormalities. However, the other features
in the question are not typical. Pulmonary cysts, sclerotic bone lesions and cardiac
rhabdomyomas are also encountered.
Osler-Weber-Rendu is also known as hereditary haemorrhagic telangiectasia and is
characterised by multiple arteriovenous malformations.
Birt-Hogg-Dubé is associated with renal tumours such as renal cell carcinomas and
oncocytomas as well as pulmonary cysts and cutaneous manifestations; however, the other
lesions mentioned in the question are not consistent with this diagnosis.
Gorlin-Goltz is characterised by multiple basal cell carcinomas and musculoskeletal and
craniofacial abnormalities. Intracranial tumours are possible but the other features are not
described.
(The Final FRCR Complete Revision Notes Pages 266, 306)
83. (a) Enlarged aorta
With a patent ductus arteriosus, a left-to-right shunt occurs as high-pressure blood passes
from the aorta to the pulmonary circulation via the patent ductus. The ductus arteriosus
usually closes within 48 hours of birth. If this remains open, then eventually the left atrium
and ventricle can become enlarged and the aorta dilated; however the right heart is
unaffected. With a ventricular septal defect the left atrium and both ventricles may enlarge;
however, the aorta remains normal in size.
(The Final FRCR Complete Revision Notes Page 314)
84. (b) Gliomatosis cerebri
Gliomatosis cerebri is a diffuse infiltrative parenchymal process involving two or more
lobes of the brain. The peak onset is 30–40 years of age. It affects large portions of the brain
with relatively little mass effect considering the extent of involvement. Due to its isodense
appearance relative to adjacent brain, it can be difficult to define on CT. On MRI there is often
T1 hypointensity and T2 hyperintensity within the white matter and gyral thickening. There is
limited enhancement and restricted diffusion.
The history is not suggestive of progressive multifocal leukoencephalopathy (PML) which
is encountered in the setting of immunosuppression, for example HIV and AIDS. There is also
no mass effect in PML. Primary CNS lymphoma would usually demonstrate avid, uniform
enhancement. Tumefactive demyelinating lesions also typically enhance with incomplete ring
enhancement. Encephalitis has a different clinical presentation. The most common type is due
to herpes simplex infection usually causing bilateral temporal lobe abnormalities.
(The Final FRCR Complete Revision Notes Page 392)
85. (d) Distal right renal artery
The case is describing findings of right renal artery stenosis, which in this patient is an
incidental finding identified on an ultrasound performed for another clinical indication.
Sonographic findings include a size discrepancy in the kidneys, a renal artery to aortic
velocity ratio of >3.5, a renal artery peak systolic velocity >180 cm/sec, increased resistive
index (>0.7) and a slow rising parvus and tardus waveform distal to the stenosis. The most
common cause for renal artery stenosis is atheroma, which affects the proximal renal artery
close to its origin; however this is most common in older patients. In young patients, such as
in this case, the most common cause is fibromuscular dysplasia, which causes multiple short
stenoses leading to a ‘string of beads’ appearance. This tends to affect the mid-distal renal
artery; however other arteries such as carotid, iliac and mesenteric arteries can also be
affected. Treatment is with angioplasty and tends to have good results.
(The Final FRCR Complete Revision Notes Pages 14, 252)
86. (c) Symmetrical enlargement of the inferior rectus muscles on MRI orbits
The appearance of painless symmetrical periosteal reaction in the tubular bones,
particularly of the hands and feet, is typical for thyroid acropachy. The thyroid itself does not
have to be abnormal, as patients can be euthyroid or post-treatment. The condition is almost
always associated with thyroid eye disease, which manifests as an increase in orbital fat and
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Inferior rectus
Medial rectus
Superior rectus
Lateral rectus
Obliques
Another cause for periosteal reaction of the long bones is hypertrophic osteoarthropathy,
but this tends to be painful. Secondary causes of hypertrophic osteoarthropathy include lung
cancer, bronchiectasis and mesothelioma as well as non-pulmonary causes such as
inflammatory bowel disease and coeliac disease. The latter causes reversal of the normal
jejunoileal fold pattern with increased ileal folds and reduced jejunal folds.
Primary hypertrophic osteoarthropathy, or pachydermoperiostosis, is most common in
young black men and typically has skin changes with skin fold thickening, often on the scalp.
The patient demographics do not fit with this diagnosis.
(The Final FRCR Complete Revision Notes Page 99)
87. (a) CT chest with contrast
The imaging features are suspicious for a soft tissue sarcoma. The most appropriate next
step is a CT chest to assess for any evidence of disease elsewhere. An MRI pelvis may also be
helpful to more accurately delineate the extent of the mass. Discussion at a tertiary sarcoma
centre prior to biopsy is important; however imaging should be completed prior to this
referral. There are frequently concerns regarding tumour seeding with sarcomatous lesions,
and sometimes sarcoma centres will request to biopsy the lesion themselves. Identifying the
most appropriate biopsy site may also be aided by completing imaging, as a more superficial
lymph node could be more easily accessible than an intrapelvic or abdominal mass. 18F-FDG
PET/CT may be helpful but would not be clearly indicated at this point.
(The Final FRCR Complete Revision Notes Page 192)
88. (e) Ultrasound urinary tract within 6 weeks
NICE guidelines state that for children less than 6 months old an ultrasound within 6 weeks of
a lower urinary tract infection (LUTI) is appropriate. If there are atypical features, such as raised
creatinine, poor urine flow, failure to respond to treatment with 48 hours, sepsis or non-Escherichia
coli bacteria, this would necessitate an immediate ultrasound. This child is being prescribed oral
treatment with close outpatient follow-up and therefore atypical infection is unlikely.
For children older than 6 months the recommendation is for immediate ultrasound if there are
features of atypical LUTI and dimercaptosuccinic acid (DMSA) test within 4–6 months.
Otherwise, imaging is not routinely indicated for a single episode of LUTI unless infections are
recurrent (≥3 LUTI episodes) when an ultrasound within 6 weeks and DMSA test within 4–6
months is indicated.
Micturating cystourethrograms are only advised if there is a family history of vesicoureteral
reflux, a non-E. coli infection, poor urine flow or urinary tract dilatation on ultrasound.
(National Institute for Health and Care Excellence (NICE) Clinical Guideline 54: Urinary tract infection
in under 16s: diagnosis and management, 2007, updated 2018)
89. (e) Congenital pulmonary airway malformation (CPAM)
CPAM was previously known as congenital cystic adenomatoid malformation. It can be
diagnosed on antenatal ultrasound scans. It is a condition causing cystic lung lesions arising
from abnormal airway development. There are three subtypes; however the most common is
as described with multiple large air-filled cysts. Immediately following birth these lesions may
predominantly contain fluid and air-fluid levels. They can cause mass effect with atelectasis of
adjacent lung and flattening of the diaphragm.
The mass described in the question is unlikely to be a bronchogenic cyst because there is no
airway connection and therefore no gas in bronchogenic cysts unless complicated by infection,
for example.
The supply of the lesion by the bronchial artery helps exclude pulmonary sequestration,
which receives a systemic arterial supply. Similarly, this makes a diaphragmatic hernia, such
as a Bochdalek hernia, unlikely. The question also states that the diaphragm is intact.
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Congenital lobar over inflation would have a hyperlucent and hyperinflated lung segment
and would not have any cystic components.
(The Final FRCR Complete Revision Notes Page 321)
90. (b) Euthyroid, heterogenous hypoechoic gland, avascular, reduced tracer uptake
Hashimoto thyroiditis can have variable ultrasound appearances but there is reduced tracer
uptake on pertechnetate scans. The gland is usually enlarged and hypoechoic with reduced
vascularity. Patients are commonly euthyroid or hypothyroid. There is an increased risk of
non-Hodgkin’s lymphoma and therefore follow-up and biopsy of any focal nodularity is
recommended. Chronic changes include a shrunken heterogenous gland.
Graves disease is associated with hyperthyroidism and would be consistent with answer D
in this case. Patients may present with extrathyroid signs such as ophthalmopathy.
Ultrasound appearances are typically of an enlarged hyperechoic gland with hypervascularity
and on nuclear medicine studies there is increased tracer activity.
(The Final FRCR Complete Revision Notes Page 433)
91. (a) Presence of calcification
When assessing the incidental pulmonary nodule (nodule found incidentally in a patient
without active or previous history of cancer) there are a number of features which should be
reported, including whether the nodule is solitary or multiple, the location in the lungs, solid/
ground glass/mixed, size, margins and presence of calcification/fat. The presence of
calcification is reassuring as this is considered a feature of benignity. The most recent British
Thoracic Society guidelines advise not to offer routine follow-up in patients with a nodule
containing diffuse, central, laminated or popcorn calcification. Whilst volume doubling time
of ≥600 days is reassuring, there are some malignancies which demonstrate slow growth, and
so follow-up is required. Volume doubling time of ≤400 days is considered a suspicious
feature and may warrant further investigation.
Upper lobe location of pulmonary nodules is also considered more suspicious than lower
lobe location.
(The Final FRCR Complete Revision Notes Page 55)
Callister MEJ, Baldwin DR, Akram AR et al. British Thoracic Society Guidelines for the
investigation and management of pulmonary nodules. Thorax. 2015;70(2):ii1−ii54.
92. (c) Inferior rib notching
The chromosomal abnormality described is neurofibromatosis type 1. The well-defined
intra- and extra-axial lesions are neurofibromas. The description of enlarged neural foramina
is secondary to the presence of neurofibromas. Lateral meningocoeles may also be present and
can cause this finding. The posterior elements may be hypoplastic, also due to the presence of
neurofibromas/meningocoeles. Inferior rib notching is more likely to occur for the same
reason; superior rib notching is possible if the neurofibroma is large.
Anterior vertebral beaking is a feature of mucopolysaccharidoses, Down syndrome and
other conditions. Multiple non-ossifying fibromas may also be seen in neurofibromatosis
type 1, which are typically lucent lesions with sclerotic margins. Other musculoskeletal
manifestations include pseudarthrosis of the wrist, tibia, fibula and clavicle as well as other
bony dysplasias.
(The Final FRCR Complete Revision Notes Page 116)
93. (c) T1: Spleen < liver, T2: Spleen > liver, No change between in- and out-of-phase
Liver MRI is frequently employed to help clarify either CT or ultrasound appearances,
especially for challenging cases such as in hepatitis B surveillance or in patients with a high
body mass index, which can make ultrasound challenging. Normal liver parenchymal signal
is hyperintense compared to the spleen on T1 and hypointense compared to the spleen on T2,
and there should be no reduction of signal on out-of-phase imaging. Liver signal is also
frequently compared to muscle – it should be a similar signal except on inversion recovery
sequences. Diffuse signal reduction on out-of-phase imaging can be suggestive of a fatty liver,
and similarly the T1 signal may be increased in these patients.
(The Final FRCR Complete Revision Notes Page 193)
94. (d) Catheter passes superiorly from umbilicus with the tip at the level of T8
Umbilical venous catheters pass superiorly from the umbilical vein into the portal vein and
then through the ductus venosus into the hepatic vein and inferior vena cava. The tip should
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ideally lie at the junction of the inferior vena cava and right atrium, which is around the level
of the diaphragm at T8/9. It is important that the catheter is sited correctly because if the tip is
within the portal venous system it can lead to thrombosis. The catheter may also pass into the
superior mesenteric artery or splenic vein (and be projected over the left upper quadrant (as
described in answer E). If the catheter is inserted too far, the tip may be within the right
ventricle or the superior vena cava.
The path of umbilical arterial catheters should be inferior from the umbilicus going into the
pelvis before turning cephalad and passing into the aorta. The aim is for the tip to be within
the aorta in either a high or low position but not between the levels of T10-L3, which is where
the main aortic branches arise.
(The Final FRCR Complete Revision Notes Page 332)
95. (d) Rectal biopsy
The case describes a patient with Hirschsprung disease. There is a transition point, most
commonly at the rectosigmoid colon, where the bowel transitions to a narrowed aganglionic
segment. A longer segment can also be affected, with a transition at the splenic flexure, or less
commonly the entire colon may be involved. There is frequently dilatation of the bowel
proximal to this transition point. There may be a ‘sawtooth’ appearance of the narrowed
segment. The rectosigmoid ratio is an important factor, as normally the rectum is larger than
the sigmoid colon and should be >1. A ratio <1 is indicative of Hirschsprung disease and this
is confirmed with rectal biopsy.
If Hirschsprung disease was associated with an abnormal antenatal scan, the abnormality
would lead to polyhydramnios rather than oligohydramnios. A sweat chloride test and the
routine neonatal heel prick test could help in the detection of cystic fibrosis, which is
commonly associated with meconium ileus. A maternal history of diabetes is associated with
meconium plug syndrome.
(The Final FRCR Complete Revision Notes Page 340)
96. (b) Tetralogy of Fallot
A right-sided aortic arch with mirror imaging branching is the most common subtype of a
right-sided aortic arch and is nearly always associated with congenital heart disease. Of these,
90% are associated with tetralogy of Fallot. Therefore other radiological findings to look for
are a ‘boot-shaped’ heart and pulmonary oligaemia.
A right-sided aortic arch with an aberrant left subclavian artery is the second most common
subtype, and the persistent ductus ligament can cause tracheal compression. A Kommerell
diverticulum is also a feature, which manifests as dilatation of the aberrant left subclavian
artery at the right aortic arch origin.
(The Final FRCR Complete Revision Notes Page 315)
97. (a) Acute respiratory distress syndrome
Acute respiratory distress syndrome (ARDS) can be split into pulmonary causes (e.g. toxic
inhalation, drowning, lung contusion, pneumonia and fat embolus) and extrapulmonary
causes (e.g. burns, sepsis, blood transfusion and pancreatitis). This case describes an
extrapulmonary cause. The features of symmetrical consolidation with a gradient from
posterior to anterior with more ground glass changes anteriorly is typical. Pulmonary causes
tend to lead to asymmetrical changes without a gradient.
A hospital-acquired pneumonia is possible, although the patient has only had a brief
admission so far. An aspiration pneumonia is also possible, especially if there has been
vomiting with recent alcohol excess, but in an intensive care patient with pancreatitis and such
typical features of ARDS, this is less likely.
In cardiac failure, other features such as cardiomegaly, prominent vascular markings,
interstitial lines and pleural effusions would be more common. This patient does have a small
left pleural effusion but this is likely secondary to the pancreatitis.
One of the causes of fat embolism is pancreatitis, and features can resemble ARDS. Typical
appearances of fat embolism include geographic ground glass opacities rather than the
gradient seen in ARDS. Interlobular septal thickening and nodularity are also features, which
are less common in ARDS.
(The Final FRCR Complete Revision Notes Page 16)
98. (c) Idiopathic transient osteoporosis of the hip
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This tends to be unilateral, affecting males more than females, although it is described in late
pregnancy. The history of hip pain is long, and the classic radiological description is of osteopenia
and subchondral cortical loss. An MRI will demonstrate bone marrow oedema, centred on the
subchondral region, and early post-contrast enhancement of the abnormal marrow.
The history and presentation is not characteristic for septic arthritis and there is no indication
that the patient is unwell, as this has been managed as an outpatient.
In avascular necrosis the early post-contrast enhancement would not be typical. Although bone
marrow oedema is a feature, other signs such as subchondral linear low signal and the ‘double
line’ sign are usually present.
A stress fracture in an active young patient is possible but in the proximal femur this tends to
occur at the femoral neck rather than at the femoral head. A cortical breach and a linear low T1
signal fracture line would also be expected.
Complex regional pain syndrome commonly occurs following trauma. Due to sympathetic
dysfunction, other symptoms such as alteration to skin blood flow, hyperalgesia and oedema are
often described. This condition typically affects the extremities rather than a large joint such as the
hip. There is some overlap in radiographic features, with joint space preservation and osteopenia
being typical.
(The Final FRCR Complete Revision Notes Page 100)
99. (a) Adenoma
The appearances are typical for a hepatic adenoma. These lesions can be large and
heterogenous due to areas of necrosis and haemorrhage. Despite being benign, they are often
removed due to the risk of bleeding. They may contain fat, leading to the hyperechoic
appearance on ultrasound, T1 hyperintensity and signal drop on out-of-phase imaging.
Adenomas can demonstrate washout, and are the only benign lesions which may do so.
The hypointensity following hepatocyte specific contrast helps to differentiate it from focal
nodular hyperplasia (FNH) which would be iso to hyperintense due to their hepatocellular
origin. Similarly, the absence of a high T2 signal intensity central scar differentiates it from FNH.
A fibrolamellar carcinoma typically has a low signal intensity central scar and many cases
demonstrate calcification.
Hepatic metastases are often T1 hypointense and there is not usually fat present.
Haemangiomas commonly cause incidental hyperechoic hepatic lesions on ultrasound but the
other features in this case are not typical. They characteristically exhibit centripetal enhancement.
(The Final FRCR Complete Revision Notes Page 195)
100. (e) Testicular ultrasound
Eagle-Barrett, or prune belly syndrome is a congenital condition causing urinary tract
abnormalities, a characteristic ‘prune belly’ appearance of the anterior abdominal wall and
cryptorchidism. A testicular ultrasound would be able to confirm whether the testicles have
descended into the scrotum, and if not, may be able to locate them in the inguinal canal.
Undescended testes at birth may descend by around 3 months of age. Locating an intrapelvic
or abdominal testicle with ultrasound can be more challenging, and sometimes MRI would be
required. Eagle-Barrett syndrome is associated with cardiac anomalies in approximately 10%.
(The Final FRCR Complete Revision Notes Page 257)
101. (d) MRI signal is usually T1 and T2 isointense with homogenous enhancement
Choroid plexus papilloma are thought to increase cerebrospinal fluid production and
impede absorption by the arachnoid granulations, so hydrocephalus is a common
presentation. They typically occur at the trigone of the lateral ventricle. In children a
supratentorial location is most likely; however in adults they are more common in the
posterior fossa. The majority of tumours are benign but in up to 20% of cases they can become
malignant. MRI signal is often described as T1 and T2 isointense with avid homogenous
enhancement. Calcification occurs in around 20% of cases.
(The Final FRCR Complete Revision Notes Page 289)
102. (b) Alexander disease
Alexander disease is a progressive disease affecting the white matter in infants. It
characteristically starts in the frontal lobes and progresses posteriorly, affecting the basal
ganglia too. This causes white matter T2 hyperintensity and enhancement. In the late stages of
the disease there can be cystic cavitation.
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Viral pneumonia can cause hyperinflation and perihilar densities but the emphysematous
changes in this child are not consistent with this diagnosis.
As the name suggests, transient tachypnoea of the newborn exists for a short time, usually
resolving by 2–3 days following delivery.
(The Final FRCR Complete Revision Notes Page 319)
114. (e) Thyroid papillary carcinoma
The lesions described in the question are consistent with haemorrhagic metastases with a
density of 55 HU and adjacent mass effect. Malignancies associated with haemorrhagic
metastases include melanoma, thyroid (particularly papillary carcinoma), choriocarcinoma and
renal cell carcinoma. The other available cancers do not typically cause haemorrhagic
metastases.
(The Final FRCR Complete Revision Notes Page 394)
115. (a) Anterior oesophageal indentation and posterior tracheal indentation
The question described typical findings in a pulmonary sling or aberrant left pulmonary
artery. Neonates can present with respiratory distress due to narrowing of the trachea and
narrowing of the right main bronchus or bronchus intermedius, which can lead to air
trapping. The left pulmonary artery arises from the right pulmonary artery and passes
between the trachea anteriorly and the oesophagus posteriorly, hence indenting the posterior
wall of the trachea and the anterior wall of the oesophagus. It is the only vascular anomaly to
pass between the trachea and oesophagus.
A double aortic arch causes anterior tracheal and posterior oesophageal indentation.
Anterior tracheal compression is caused by innominate artery indentation, which tends to
occur in infants who have an arterial origin more towards the left than in adults. The
mediastinum is more crowded in infants due to the thymus, and the vessel can therefore
indent the trachea just inferior to level of the thoracic inlet.
Posterior oesophageal indentation can either be caused with a normal left aortic arch with
an aberrant right subclavian artery or with a right aortic arch if there is an aberrant left
subclavian artery.
(The Final FRCR Complete Revision Notes Pages 1, 311)
116. (e) Progressive systemic sclerosis
Progressive systemic sclerosis, also known as scleroderma, causes dilatation of the distal
two-thirds of the oesophagus due to fibrosis of the smooth muscle in this region. This leads to
poor motility, dilatation and places patients at risk of aspiration.
Other causes of oesophageal dysmotility include gastro-oesophageal reflux disease,
presbyoesophagus, achalasia and Chagas disease. The patient also has thoracic features of
scleroderma with peripheral lung reticulation and lymph node enlargement.
Presbyoesophagus is considered to be age related and affects elderly patients frequently
with comorbidities such as dementia and diabetes.
Chagas disease is caused by a protozoal infection and also leads to cardiomyopathy and
dilatation elsewhere in the gastrointestinal tract.
Achalasia frequently presents with dysphagia; over time the oesophagus becomes dilated,
lacking normal motility with distal tapering rather than dilatation.
Despite the mediastinal lymph node enlargement, the other radiological features described
in this case are not typical for oesophageal carcinoma.
(The Final FRCR Complete Revision Notes Page 180)
117. (a) Craniopharyngioma
Craniopharyngiomas are the most common suprasellar mass in children, and the history in
this question is typical with visual field defects and diabetes insipidus. Radiologically they are
usually part cystic and solid and exhibit T1 and T2 hyperintensity due to proteinaceous
content. Calcification is very common.
Germinomas are typically solid and are neither cystic nor calcified. In contrast to this,
meningiomas do commonly calcify, but a cystic component is not usually a feature. Pituitary
macroadenomas occur in an older age group and calcification is rare. Rathke cleft cysts are
thin walled, cystic and generally show no enhancement.
(The Final FRCR Complete Revision Notes Page 292)
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227
Index
18F-FDG PET/CT 171, 197; and MRI pelvis 70, 97 aortic contraction 30–1
99m
Tc-Na-pertechnetate scintigraphy 77, 105 aortic root dilatation 3, 30–1
111
In Octreotide study 13, 41–2 aperistalsis of the lower oesophagus 59, 85
aqueductal stenosis 72–3, 100
A
ARDS (acute respiratory distress syndrome) 10, 38,
AAST (American Association for the Surgery 124–5, 150–1, 192, 221
of Trauma), 2018 revision: Grading of Liver ARPKD (autosomal recessive polycystic kidney
Laceration 178, 205; Kidney Injury Scale 23, 53 disease) 16, 45
ABC (aneurysmal bone cyst) 197, 227 arrhythmogenic right ventricular dysplasia 12, 40
aberrant left pulmonary artery 131, 158, 195–6, 226 arterial phase CT from diaphragm to toes 183–4,
ABPA (allergic bronchopulmonary aspergillosis) 212–13
77, 104–5 artery of Adamkiewicz 26, 56
achondroplasia 61, 87 asbestos exposure 135, 163
acquired cystic kidney disease 1, 28 asbestosis 120, 145
acromegaly 1, 28 atrial septal defect 81, 110
actinomycosis 22, 52 autoimmune pancreatitis 139, 168
acute eosinophilic pneumonia 176, 203 autosomal recessive polycystic kidney disease
acute haemorrhagic leukoencephalopathy 194, 224 (ARPKD) 16, 45
acute respiratory distress syndrome (ARDS) 10, 38, avascular necrosis of the hip 31
124–5, 150–1, 192, 221 axial post contrast fat suppressed T1 181, 209
Adamkiewicz, artery of 26, 56 axial proton density fat saturation 24, 54
adductor magnus 25, 55
adenocarcinoma 75–6, 103, 193, 223
B
adenoma 192, 222
adenomyomatosis 11, 39, 117–18, 143 back surgery, previous 13–14, 42
adenomyosis 20, 49–50 Bailey classification (branchial cleft cysts) 181, 209
adhesive capsulitis 2, 2, 29–30 Baker’s cysts 6, 34
adjacent subchondral hypo- and hyperintense T2 Balthazar score 127–8, 154
linear signal 4, 31 band heterotopia 75, 103
adrenal haemorrhage 19, 48, 75, 102–3 bifed ureter 14, 42
alcoholic gastritis 6, 33 bilateral bilobed lungs 117, 143
Alexander disease 193, 222–3 bilateral hyparterial bronchi 194, 224
allergic bronchopulmonary aspergillosis (ABPA) biliary atresia with hepatomegaly and the ‘triangular
77, 104–5 cord’ sign 4, 31–2
alpha 1 antitrypsin deficiency 69, 96 biliary strictures 134, 162
ameloblastoma 173, 200 Bismuth classification of cholangiocarcinoma 72, 100
American Association for the Surgery of Trauma bizarre parosteal osteochondromatous proliferation
(AAST), 2018 revision: Grading of Liver Laceration 121, 147
178, 205; Kidney Injury Scale 23, 53 Bochdalek herniae 61, 87
amiodarone lung disease 115, 140 bone erosion 22, 52
amyloid angiopathy 15, 44 bone marrow biopsy 16, 44
amyloid arthropathy 84–5 bone scans 5, 8, 8
anaphylaxis management: ABCDE approach to brachycephaly 135–6, 164
diagnosis, calling for help, and adrenaline branchial cleft cysts 181, 209
73–4, 101 breast cancer 27, 57–8
ANCA associated granulomatous vasculitis 62–3, 88–9 Brodie abscess 180, 208
aneurysmal bone cyst (ABC) 197, 227 bronchiolitis obliterans 136, 164–5
angiomyolipoma 7, 34 bronchogenic cyst 70–1, 97–8, 185, 215
annular pancreas 36, 92 bronchopleural fistula 173, 200
answers: paper 1 27–58; paper 2 84–113; paper 3 bronchopulmonary dysplasia 195, 225–6
140–69; paper 4 197–227; questions See questions bronchopulmonary sequestration 82–3, 111
anterior cruciate ligament tear 82, 110–11 bronchus, carcinoma of 116, 142
anterior spinal cord infarct 26, 56 Brown tumour 74, 102, 185, 214, 214; pathological
antrochoanal polyp 185, 214 fracture through 130, 157
aorta, enlarged 188, 218 Budd-Chiari syndrome 3, 30, 84, 113
aorta-enteric fistula 4, 31 Buscopan 193, 223–4
229
INDEX
230
INDEX
231
INDEX
232
INDEX
233
INDEX
TAVPR (total anomalous pulmonary venous return) ulcerative colitis 130, 157
184–5, 214 ultrasound guided peritoneal biopsy 57, 152
tear of triangular fibrocartilage complex 115, 140 umbilical arterial catheters 22, 51
temporal lobe epilepsy 123, 149 umbilical venous catheters 191, 220–1
tenosynovial giant cell tumour 182–3, 211 unicameral bone cyst 117, 143
teratoma 72, 99 unilateral lucent lung 15, 43
terminal ileum 63–4, 89 upper lobe blood diversion 118–19, 144
testicular ultrasound 192, 222 ureter draining into the vagina associated with upper
tethered cord syndrome 178, 206 pole moiety 14, 42
tetralogy of Fallot 191, 221 ureters with upper moiety ureter inserting
thickened ileocaecal valve 184, 213 inferomedial to lower moiety ureter 120, 146
thoracic duct atresia 183, 212 urethral injury 130–1, 157–8
thrombus 184, 213 urinary bladder injury 12, 40–1
thymic hyperplasia 139 urinary tract infections, pediatric 5, 33
thyroid acropachy 189, 218–19 usual interstitial pneumonia (UIP) 142, 226
thyroid eye disease 189, 218–19 uveal melanoma 177, 204–5
thyroid papillary carcinoma 195, 226
TIPSS (transjugular intrahepatic portosystemic shunt)
V
180, 208–9
Todani classification 177, 204 VACTERL (Vertebral anomalies, Anorectal
Tornwald cyst 71–2, 99 malformations, Cardiac defects, Tracheo-
torus fracture 122, 148 oesphageal fistula, Renal and Limb anomalies)
total anomalous pulmonary venous return (TAVPR) 24, 54
184–5, 214 varicoceles 187, 216
tracer uptake in bone scan 8, 35 vein of Galen malformation 121, 146
tracheobronchial injury 185, 214 ventilation-perfusion (VQ) scan 131, 158
tracheobronchomegaly 177, 205 ventricular septal defect 24, 54
transarterial chemoembolisation (TACE) 66, 92 vertebral body collapse, benign 65, 91–2
transient synovitis of the hip 120, 145–6 vertebral metastases 30
transient tachypnoea of the newborn 69, 96 vertebra plana 19, 47–8
transjugular intrahepatic portosystemic shunt vesicoureteral reflux grading 119, 144
(TIPSS) 180, 208–9 vestibular schwannomas 139, 167–8
transverse humeral fracture 122, 147 volvulus 26–7, 57
treated lymphoma 8, 35 von Hippel-Lindau syndrome 188, 217–18
triple assessment (examination, imaging, and VQ (ventilation-perfusion) scan 131, 158
biopsy) 72, 100
trisomy 21, 172, 199 W
truncus arteriosus 79, 79, 107
tuberculosis 13, 41; affecting the bowel 184, 213; Wegener granulomatosis 62–3, 88–9
differentiating from Crohn’s disease 9, 37, 37; post- Wernicke encephalopathy 75, 103
primary 121, 147 Wilms tumour 59–60, 85
tuberous sclerosis 64, 90, 129, 157, 182, 210 Wilson disease 36, 92
tumour recurrence versus chemoradiotherapy
damage (pseudo progression) 68–9, 95, 95 X
Turner syndrome 63, 63, 89, 193, 223
type 2 endoleak 1, 27 xanthogranulomatous cholecystitis 78, 107
typhlitis 21, 51 Xenon ventilation study 173, 200
U Z
UIP (usual interstitial pneumonia) 142, 226 Zenker’s diverticulum 27, 57
234