A 64-year-old diabetic man is brought to a district hospital 70 minutes after the sudden onset of right-sided weakness and difficulty in speaking. His BP is 176/98 mmHg and capillary glucose is 142 mg/dL. Which imaging should be done first?

MRI brain with diffusion imaging

Digital subtraction angiography

A 40-year-old electrician falls backwards from a ladder and strikes the back of his head on the floor. Non-contrast CT shows a small linear occipital fracture and haemorrhagic contusions in the inferior frontal lobes and both temporal poles. What best explains the site of the frontal and temporal contusions?

Contrecoup impact against the anterior skull

Venous infarction from sinus thrombosis

Shearing of axons from rotation

Coup injury directly beneath the occipital fracture

A 63-year-old man with poorly controlled hypertension is brought 90 minutes after the sudden onset of right hemiparesis. Non-contrast CT shows a 25 mL haematoma in the left basal ganglia. CT angiography shows a small bright focus of contrast inside the haematoma, with no vascular malformation or aneurysm. What does this focus of contrast mainly predict?

Bleeding from an arteriovenous malformation

Haemorrhagic change in an infarct

A 24-year-old woman is brought to casualty 10 days after a normal delivery at a PHC with severe headache, vomiting and one generalised seizure. BP is 120/80 mmHg and urine protein is nil. Non-contrast CT shows a hyperdense superior sagittal sinus and small haemorrhagic areas in both parasagittal regions. What is the investigation of choice to confirm the diagnosis?

Lumbar puncture with CSF analysis

Neuroimaging in stroke and trauma

22 NEET-PG practice questions on Neuroimaging in stroke and trauma, part of Radiology. The first 22 are below; the first 5 with answers and explanations (tap Show answer after you have chosen), the rest in Learn with a free account.

Question 1 · Medium
A 22-year-old man was hit on the left side of the head with a cricket bat. He was briefly unconscious, then talked normally for 3 hours before becoming drowsy with a dilated left pupil. Non-contrast CT shows a biconvex hyperdense collection over the left temporal lobe that does not cross the suture lines. Which vessel is most likely injured?
1. ASuperior sagittal sinus
2. BMiddle meningeal artery
3. CBridging cortical veins
4. DMiddle cerebral artery
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Answer: B · Middle meningeal artery
A lucid interval followed by deterioration and a biconvex (lentiform) hyperdensity limited by sutures is an extradural haematoma. A fracture of the thin squamous temporal bone near the pterion tears the middle meningeal artery, and arterial blood strips the dura off the skull until it is held at the sutures. The dilated ipsilateral pupil means uncal herniation compressing the oculomotor nerve, so urgent craniotomy and evacuation are needed. Prognosis is good when it is drained early.
- A: Sagittal sinus bleeding is venous and lies near the midline vertex, not over the temporal lobe.
- C: Torn bridging veins cause a crescentic subdural haematoma that crosses sutures.
- D: Middle cerebral artery rupture or occlusion gives intracerebral or subarachnoid bleeding or infarct, not an extradural lens.
Question 2 · Easy
A 64-year-old diabetic man is brought to a district hospital 70 minutes after the sudden onset of right-sided weakness and difficulty in speaking. His BP is 176/98 mmHg and capillary glucose is 142 mg/dL. Which imaging should be done first?
1. ACarotid Doppler ultrasound
2. BMRI brain with diffusion imaging
3. CNon-contrast CT of the head
4. DDigital subtraction angiography
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Answer: C · Non-contrast CT of the head
In a suspected acute stroke the first question is whether there is bleeding, because haemorrhage rules out thrombolysis. Non-contrast CT shows acute blood as hyperdense within minutes, is widely available and fast, and should be done as soon as the patient arrives. MRI with diffusion is more sensitive for early infarction but takes longer and is less available in most Indian hospitals. Carotid studies and angiography are done later to find the cause or to plan thrombectomy.
- A: Carotid Doppler looks for the source of emboli later; it does not exclude haemorrhage.
- B: MRI is more sensitive for infarct but slower and less available; it must not delay the decision on thrombolysis.
- D: Catheter angiography is invasive and is used only during thrombectomy or for vascular lesions.
Question 3 · Medium
A 40-year-old electrician falls backwards from a ladder and strikes the back of his head on the floor. Non-contrast CT shows a small linear occipital fracture and haemorrhagic contusions in the inferior frontal lobes and both temporal poles. What best explains the site of the frontal and temporal contusions?
1. AContrecoup impact against the anterior skull
2. BVenous infarction from sinus thrombosis
3. CShearing of axons from rotation
4. DCoup injury directly beneath the occipital fracture
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Answer: A · Contrecoup impact against the anterior skull
A fall onto the back of the head stops the skull suddenly while the brain keeps moving and strikes the opposite side. The rough floor of the anterior cranial fossa, the orbital roofs and the sphenoid ridges then bruise the inferior frontal lobes and temporal poles, the classic contrecoup pattern. Contusions often enlarge or blossom over the first 24-48 hours, so repeat CT is needed if the patient worsens. Coup contusions lie beneath the point of impact.
- B: Sinus thrombosis gives parasagittal venous infarcts without trauma.
- C: Shear injury gives small bleeds at the grey-white junction and corpus callosum, not polar contusions.
- D: A coup contusion would lie in the occipital lobe, under the impact.
Question 4 · Medium
A 63-year-old man with poorly controlled hypertension is brought 90 minutes after the sudden onset of right hemiparesis. Non-contrast CT shows a 25 mL haematoma in the left basal ganglia. CT angiography shows a small bright focus of contrast inside the haematoma, with no vascular malformation or aneurysm. What does this focus of contrast mainly predict?
1. AEarly growth of the haematoma
2. BBleeding from an arteriovenous malformation
3. CRupture of a saccular aneurysm
4. DHaemorrhagic change in an infarct
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Answer: A · Early growth of the haematoma
A focus of contrast within an acute haematoma on CT angiography (the spot sign) shows active leakage of blood. It is one of the strongest predictors that the haematoma will enlarge in the first hours, and expansion is linked to worse disability and death. Such patients need prompt BP lowering, reversal of any anticoagulant and close neurological watch with repeat imaging. The sign marks an ongoing bleed, not its cause.
- B: An AVM shows abnormal feeding arteries and draining veins, which were not seen.
- C: An aneurysm gives subarachnoid blood and is seen as a vessel outpouching, not a spot in a deep haematoma.
- D: Haemorrhagic transformation occurs in an infarct days later, not as a primary bleed.
Question 5 · Medium
A 24-year-old woman is brought to casualty 10 days after a normal delivery at a PHC with severe headache, vomiting and one generalised seizure. BP is 120/80 mmHg and urine protein is nil. Non-contrast CT shows a hyperdense superior sagittal sinus and small haemorrhagic areas in both parasagittal regions. What is the investigation of choice to confirm the diagnosis?
1. AMRI with MR venography
2. BLumbar puncture with CSF analysis
3. CElectroencephalography
4. DCarotid Doppler ultrasound
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Answer: A · MRI with MR venography
Headache, seizures and parasagittal haemorrhagic infarcts in the puerperium, with a dense sinus on CT, suggest cerebral venous sinus thrombosis; the puerperium is a common setting in India. MRI with MR venography shows the clot and the absent flow in the sinus (CT venography is an alternative). Normal BP and no proteinuria make eclampsia unlikely. Treatment is anticoagulation with heparin, which is given even when there are venous haemorrhages.
- B: Lumbar puncture may show raised pressure but cannot show the clot and is risky with mass lesions.
- C: EEG may show seizure activity but does not identify the cause.
- D: Carotid Doppler examines the arteries in the neck, not the dural sinuses.
Question 6 · Medium
A 78-year-old woman who has never had high BP is admitted with a right parietal lobar haemorrhage; she had a left occipital lobar haemorrhage two years ago. MRI with gradient echo sequences shows many small dark microbleeds in the cortex and subcortical white matter, sparing the basal ganglia, thalamus and brainstem. What is the most likely underlying cause?
1. AHypertensive small vessel disease
2. BMultiple cavernous malformations
3. CHaemorrhagic brain metastases
4. DCerebral amyloid angiopathy
Answer and explanation in LearnFree account
Question 7 · Medium
A 64-year-old man is slow to wake after coronary bypass surgery, during which he had prolonged low blood pressure. He can move his hands and legs but cannot lift either arm at the shoulder. Diffusion MRI shows strips of restricted diffusion on both sides along the junction between the anterior and middle cerebral artery territories. What is the most likely mechanism?
1. AEmbolic occlusion of the middle cerebral artery
2. BCerebral venous sinus thrombosis
3. CBorder-zone infarction from low perfusion
4. DLacunar infarction from lipohyalinosis
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Question 8 · Easy
A 74-year-old retired clerk who drinks heavily slipped in the bathroom 5 weeks ago. Over the last 2 weeks he has become forgetful and drowsy and now has mild left-sided weakness. Non-contrast CT shows a crescent-shaped hypodense collection over the right cerebral convexity that crosses the coronal suture. Rupture of which structure most likely caused this collection?
1. AMiddle meningeal artery
2. BAnterior communicating artery aneurysm
3. CBridging cortical veins
4. DLenticulostriate arteries
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Question 9 · Hard
A 45-year-old man is brought to casualty after falling from a moving bus. GCS is 8. CT shows a large right acute subdural haematoma with a 12 mm midline shift and effacement of the right ambient cistern. The right pupil is dilated and fixed, but the weakness is in the right arm and leg. What best explains weakness on the same side as the haematoma?
1. ADirect pressure on the right motor cortex
2. BInfarction in the right posterior cerebral artery
3. COpposite cerebral peduncle pressed on tentorium
4. DCompression of the right oculomotor nerve
Answer and explanation in LearnFree account
Question 10 · Medium
A 67-year-old man has right hemiplegia and global aphasia that began 3 hours ago. While reviewing his non-contrast CT of the head, the neurology resident lists four findings: 1. A hyperdense left middle cerebral artery. 2. Loss of grey-white differentiation of the left insular cortex. 3. A ring-enhancing lesion in the left basal ganglia. 4. Blurring of the outline of the left lentiform nucleus. Which of these are early CT signs of a middle cerebral artery territory infarct?
1. A2, 3 and 4 only
2. B1 and 4 only
3. C1, 2 and 3 only
4. D1, 2 and 4 only
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Question 11 · Medium
A 26-year-old man has clear watery fluid dripping from his nose after a road traffic accident; it increases when he bends forward. He has bilateral periorbital ecchymosis without direct eye injury. CT with bone windows shows small pockets of air in the frontal region of the cranial cavity. Which fracture is most likely?
1. ASquamous part of the occipital bone
2. BPetrous part of the temporal bone
3. CCribriform plate of the ethmoid
4. DZygomatic arch
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Question 12 · Hard
A 30-year-old man is assaulted with a stick and has two scans on different days, one showing an extradural and one a subdural haematoma. While teaching on these scans, the radiologist makes four statements: 1. An extradural haematoma is usually limited by the suture lines. 2. An acute subdural haematoma can cross suture lines but not dural reflections such as the falx. 3. An extradural haematoma at the vertex can cross the midline over the superior sagittal sinus. 4. An acute subdural haematoma is usually hypodense compared with brain. Which statements are correct?
1. A1, 2, 3 and 4
2. B1 and 2 only
3. C1, 2 and 3 only
4. D2 and 4 only
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Question 13 · Easy
A 46-year-old woman in Kochi collapses while lifting a pot of water, saying she has the worst headache of her life. In casualty she has neck stiffness and a GCS of 14, with no limb weakness. Non-contrast CT of the head shows hyperdensity filling the basal cisterns and both Sylvian fissures. What is the most likely diagnosis?
1. AAcute subdural haematoma
2. BAcute pyogenic meningitis
3. CHypertensive putaminal haemorrhage
4. DAneurysmal subarachnoid haemorrhage
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Question 14 · Hard
A 49-year-old man had a complete left middle cerebral artery territory infarct 30 hours ago and reached hospital too late for reperfusion treatment. Over the last 6 hours his GCS has fallen from 14 to 9. Repeat non-contrast CT shows hypodensity of the whole left MCA territory with swelling, effaced sulci, a compressed left lateral ventricle and a 9 mm midline shift to the right. What is the next best step?
1. AHigh-dose IV dexamethasone
2. BIV alteplase now
3. CDecompressive hemicraniectomy
4. DMechanical thrombectomy
Answer and explanation in LearnFree account
Question 15 · Easy
A 55-year-old man develops sudden vertigo, vomiting and inability to walk straight. Non-contrast CT done 3 hours after onset shows no abnormality. Which MRI sequence will show an acute infarct earliest?
1. AContrast-enhanced T1 imaging
2. BDiffusion-weighted imaging
3. CT1-weighted imaging
4. DGradient echo (T2*) imaging
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Question 16 · Medium
A 59-year-old shopkeeper is brought to a stroke-ready hospital 2 hours after the sudden onset of left hemiparesis and facial droop. NIHSS score is 9. BP is 172/94 mmHg, glucose 126 mg/dL and platelets 2.1 lakh/µL; he takes no anticoagulant and has had no recent surgery or bleeding. Non-contrast CT shows no haemorrhage and no established hypodensity. What is the next best step?
1. AMRI brain before any treatment
2. BLower BP below 140/90 mmHg first
3. CAspirin 300 mg and observe
4. DIntravenous thrombolysis now
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Question 17 · Medium
A 19-year-old two-wheeler rider without a helmet is thrown off at high speed and has been unconscious since the impact, with a GCS of 6. Non-contrast CT shows only a few small hyperdense foci at the grey-white junction and in the corpus callosum, with no mass lesion or midline shift. Which investigation best shows the full extent of his brain injury?
1. AElectroencephalography
2. BRepeat non-contrast CT after 6 hours
3. CCT angiography of the circle of Willis
4. DMRI with susceptibility-weighted imaging
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Question 18 · Easy
A 70-year-old woman with atrial fibrillation who stopped her anticoagulant a month ago develops sudden left hemiplegia. Non-contrast CT done 1 hour later shows a linear bright density along the course of the right middle cerebral artery, with normal-looking brain substance. What does this bright artery most likely represent?
1. AArteriovenous malformation in the fissure
2. BFresh thrombus in the artery lumen
3. CSubarachnoid blood around the artery
4. DHaemorrhagic change in an infarct
Answer and explanation in LearnFree account
Question 19 · Medium
A 68-year-old man on aspirin fell off his scooter 2 weeks ago and now has headache and mild right-sided weakness. Non-contrast CT shows effaced sulci over the left hemisphere, a compressed left lateral ventricle and a 6 mm midline shift to the right, but no obvious bright or dark collection. What is the most likely explanation?
1. ALeft middle cerebral artery infarct
2. BAcute extradural haematoma beneath a fracture
3. CNormal pressure hydrocephalus
4. DSubacute subdural haematoma isodense to brain
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Question 20 · Hard
A 61-year-old woman went to bed well at 10 pm and woke at 6 am with right hemiparesis and aphasia. MRI at 7 am shows restricted diffusion in part of the left middle cerebral artery territory, with no matching high signal on FLAIR, no haemorrhage and no large vessel occlusion on MR angiography. She has no contraindication to thrombolysis. Which is the most appropriate course?
1. ATreat as a stroke mimic and observe
2. BTreat as under 4.5 hours old; give IV alteplase
3. CTreat as over 24 hours old and give aspirin alone
4. DAvoid lysis because the time of onset is unknown
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Question 21 · Hard
A 66-year-old hypertensive man develops a sudden occipital headache, repeated vomiting and inability to stand. Six hours later his GCS falls from 15 to 11. Non-contrast CT shows a 4 cm haematoma in the right cerebellar hemisphere compressing the fourth ventricle, with dilated lateral and third ventricles. What is the next best step?
1. AExternal ventricular drain alone
2. BSuboccipital decompression and evacuation
3. CBP control and conservative care
4. DIV mannitol and a repeat CT scan after 24 hours
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Question 22 · Medium
A 52-year-old woman has a sudden severe headache followed by drooping of the right eyelid. The right pupil is dilated and the eye is turned down and out. Non-contrast CT shows subarachnoid blood in the basal cisterns. Which investigation should be done next to find the source of bleeding?
1. ALumbar puncture for xanthochromia
2. BCT angiography of the circle of Willis
3. CCarotid Doppler ultrasound
4. DMRI brain with diffusion imaging
Answer and explanation in LearnFree account

Neuroimaging in stroke and trauma

A 64-year-old diabetic man is brought to a district hospital 70 minutes after the sudden onset of right-sided weakness and difficulty in speaking. His BP is 176/98 mmHg and capillary glucose is 142 mg/dL. Which imaging should be done first?

A 55-year-old man develops sudden vertigo, vomiting and inability to walk straight. Non-contrast CT done 3 hours after onset shows no abnormality. Which MRI sequence will show an acute infarct earliest?

A 52-year-old woman has a sudden severe headache followed by drooping of the right eyelid. The right pupil is dilated and the eye is turned down and out. Non-contrast CT shows subarachnoid blood in the basal cisterns. Which investigation should be done next to find the source of bleeding?