SERPENTINE FILLING DEFECT IN STOMACH

Q.Numerous serpentine filling defect in stomach in the barium study of upper GI may be due to

a.lymphoma

b.carcinoma

c.portal hypertension

d.hypertrophic gastropathy

e.gastric ulcer

Gastrointestinal Radiology591 × 350

7ANS--c

Gastric varices due to portal hypertension cause serpentine filling defect in the stomach. 

HEMOCHROMATOSIS---SQUID

Q.All are true regarding imaging of hepatic hemochromatosis except

a.Dual energy CT ia an accurate noninvasive means of measuring the liver iron concentration

b.Ferric iron causes extreme shortening  of T1 relaxation time

c.MRI can indicate cause of iron overload 

d.SQUID provides a quantitative estimate of liver iron

e.Amount of fibrosis can be reduced by iron depletion

ANS.---b

Ferric iron causes  shortening  of both T1 and T2 relaxation time.Although the effect on T1 is moderate ,there is extreme shortening of the T1 rate.

MRI can indicate cause of iron overload.In patients with genetic hemochromatosis,there is proportionately less deposition of iron in the reticuloendothelial system and more deposition in the parenchymal cells of organs than there is parenteral iron overload.Thus spleen usually exhibits a low signal intensity in parenteral iron overload and more signal intensity in genetic hemochromatosis.Pancreas and myocardium show a low signal in genetic hemochromatosis while theyshow normal signal in iron overload.

WHEN LIVER BE CALLED FATTY?

Q.Fat content in fatty liver exceeds ----% of the liver weight

a.1%

b. 5%

c.10%

d.15%

e.20%.

ANS.---b

Fat content(largely triglycerides) in fatty liver exceeds 5% of the liver weight

DOTTED LINE SIGN OF LIVER

Q.Ultrasonographic findings suggestive of cirrhosis of liver are all except

a.the caudate lobe/right lobe ratio greater than or equal to 0.55

b.hypoechoic nodules

c.dotted-line sign

d.coarseness

e.meshwork pattern/cobblestone appearance

ANS.—a

Harbin et al first proposed the ratio of the width of transverse caudate lobe to the width of the right lobe as a means to diagnose cirrhosis using CT.The liver cirrhosis could be separated from normal lives with a sensitivity of 84% ,a specificity of 100% and an accuracy of 94% based ona criterion of the caudate lobe/right lobe ratio greater than or equal to 0.65.

However three –dimensional  caudate lobe index to the right lobe diameter ratio on USG  has greater sensitivity than caudate lobe/right lobe ratio.

In micronodular cirrhosis the hepatic surface appears normal or subtly undulated .The hyperechoic line of the hepatic surface may be interrupted (dotted line sign ) in some cases of micronodular cirrhosis.

Tc

q.All are true regarding Technetium 99m  except

a. an  energy 140 ke V

b.optimal for gamma imaging

c.physical half life of 6 hrs

d. beta particle radiation

e.suitable for SPECT

ans.—d

Technetium 99m  has no beta particle radiation .

ANATOMICAL MARKERS FOR DIVIDING LIVER INTO LOBES

1..All the anatomic markers serve to divide the right lobe from the left lobe except

a.the intrahepatic IVC

b.the gall bladder fossa

c.the middle hepatic vein

d.the undivided portion of the right portal vein

e.falciparum ligament

1..---e

2..All are true regarding imaging of anatomy of liver except

a.the longest branch of the right hepatic vein divides the right lobe into anterior and posterior segment

b. the falciform ligament divides the left lobe into medial and lateral segment

c.IVC divides thecaudate lobe from the lateral segment of the left lobe

d.accessary fissure of liver is formed by the vagnationations of the diaphragm and peritoneum

e.the right lobe and medial segment of the left lobe is resected in trisegmentectomy

2---c

The longest branch of the right hepatic vein and bifurcation of the right portal vein divides the right lobe into anterior and posterior segment.

The left hepatic vein(cranial part),ascending  portion of the left portal vein(middle part) and the falciform ligament(caudal part ) divides the left lobe into medial and lateral segment

The fissure of the venous ligament divides the caudate lobe from the lateral segment of the left lobe

HEPATIC RESECTION

1.1.A patients has hepatic metastases from a endocrine tumour and surgeon plans to resect the liver to palliate the symptoms due to metastases . What % of liver parenchyma should the surgeon spare  for hepatic function to be adequate in postoperative stage

a.20%

b.30%

c.40%

d.50%

e.60%

1.---b

HEPATIC IMAGING

8.All are true regarding imaging of liver except

a.segmental anatomy on dynamic CT is more readily  depicted in fatty liver

b.portal vein and hepatic veins are  hypodense to normal parenchyma on delayed CT

c. portal vein and hepatic veins are  hypodense to normal parenchyma on CTAP

d.hepatic deposits are hypodense to normal parenchyma on CTAP

e.Sensitivity of CTAP is greater than MRI in detecting focal lesions

8.---c

 Portal vein and hepatic veins are  hyperdense to normal parenchyma on CTAP.

Hepatic deposits are hypodense to normal parenchyma on CTAP because hepatic deposits receive blood supply primarily from hepatic artery.

Sensitivity of CTAP is greater than dynamic CT,delayed CT and  MRI in detecting focal lesions and so it is pre-operative choice of imaging

AASLD CRITERIA FOR HCC

Q.All are true regading AASLD criteria for diagnosis of HCC in cirrhosis except

a.use of multiphasic CT/MRI

b.arterial hyperattenuation of lesion

c.portal venous phase hypoattenation of thelesion

d.delayed phase hyperatenuation of the lesion

e.portal veous phase /delayed phase washout

ANS.---d

The radiologic diagnosis of hepatocellular carcinoma can be made at either CT or MR imaging, provided that a multiphasic contrast material–enhanced study is used.

Characteristically, hepatocellular carcinoma enhances during the arterial phase because of its blood supply from abnormal hepatic arteries. Contrast medium in the surrounding liver parenchyma is diluted during this phase because the parenchymal blood supply arises mostly from the portal veins, which are not yet opacified.

 In the portal venous phase, the surrounding liver parenchyma becomes relatively hyperattenuated and the lesion is perceived to be hypoattenuated because of its lack of portal venous supply. This appearance is the so-called washout effect. Occasionally, washout is evident only during a delayed phase sequence. 

Thus, a four-phase imaging study is required: non–contrast-enhanced phase, arterial phase, portal venous phase, and delayed phase

  Images should be acquired in four phases: non–contrast-enhanced phase (before the injection of contrast material), late arterial phase (about 20 seconds after the injection), portal venous phase (50 seconds after the injection), and delayed phase (>120 seconds after the injection). The optimal timing for image acquisition in the delayed phase is debated, varying between 2 and 15 minutes after contrast material injection. Contrast-enhanced US studies have shown that approximately 90% of hepatocellular carcinomas demonstrate washout by 5 minutes after injection of the microbubble contrast agent . Use of a 5-minute delay may be the practical choice for the timing of the delayed phase.

Precontrast and dynamic postcontrast T1-weighted three-dimensional fat-suppressed gradient-echo sequences are required, in addition to T2 (with and without fat saturation) and T1 in-phase and opposed-phase imaging. Timing of the dynamic contrast-enhanced sequences is the same as that used for the CT examination. Emphasis on precise breath-holding is extremely important.

Systematic review has shown that MR imaging is more sensitive than CT in the diagnosis of hepatocellular carcinoma (81% vs 68%) 

HCC surveillance

1.The major risk factor for development of hepatocellular carcinoma are all except

a. chronic viral hepatitis

b.  alcoholic cirrhosis

c.  cirrhosis caused by hemochromatosis

d.  primary biliary cirrhosis

e.  Amyloidosis

2. For patients with an established diagnosis of cirrhosis, surveillance by means of ultrasonography (US) and measuring serum α-fetoprotein (AFP) levels has been shown to reduce hepatocellular carcinoma–related mortality

a.by 37%

b.by 10%

c.by  20%

d.by  25%

e.by  50%

ANS---

1.d--amyloidosis

2.a---by 37%

?Masaoka-Koga Staging System

 Masaoka-Koga Staging System for Thymoma


Stage I Tumor completely encapsulated

Stage IIa Microscopic tumor invasion into capsule

Stage IIb Tumor invasion into surrounding fat

Stage III Tumor invasion into a neighboring organ such as the pericardium, great vessel, or lung

 Stage IVa Pleural or pericardial dissemination

Stage IVb Lymphatic or hematogenous metastasis

? Specific for intestinal obstruction

1.Which is true regarding normal appearance of  abdomen on plain x –ray

a.relatively small  amount of gas is  present in colon

b.more than two fluid levels in dilated small bowel are said to be abnormal

c.Valvulae conniventes are usually identified in normal individual

d.gastric rugae rarely identified on supine x-ray

e.small bowel fluid levels are specific for obstruction

ANS.---b

Relatively large amounts of gas are normally present in the stomach and colon but only a small amount is usually seen in the small bowel.
The presence of bowel gas is useful in assessing the diameter and position of the bowel.
It is usual to be able to identify the gastric rugae on a supine radiograph.
There is rarely sufficient gas present in the small bowel to outline more than a short length, and although the mucosal pattern may be seen, the thin bands of the valvulae conniventes are seldom identified in a normal patient.
Air and fluid are normal contents of the small bowel, and short fluid levels are not abnormal on an erect radiograph, should one be obtained.
The following statements about fluid levels on an erect radiograph also apply to CT performed in the supine position--------
 A.----Fluid levels are common in normal people, and they usually lie in the colon. Three to five fluid levels less than 2.5 cm in length may be seen, particularly in the right lower quadrant, without any evidence of intestinal obstruction or paralytic ileus.
B.--- More than two fluid levels in dilated small bowel (calibre greater than 2.5 cm) are said to be abnormal, and usually indicate paralytic ileus or intestinal obstruction.
 C.---Fluid levels at different heights in the same loop of small bowel do not help differentiate obstruction from paralytic ileus and may occur in normal people.
D.---Small-bowel fluid levels are by no means specific for obstruction.

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HAPPY TEACHERS DAY

My salutation to all my teachers on this TEACHERS DAY.

Happy Teachers day to all my teachers

Teachers are like candles who burns himself to lighten their 

students.
.

PC&PNDT AGITATION DEFERRED

Agitation of IRIA against draconian PC& PNDT Act deferred for 2-3 months on the communication from Health Ministry .

@IRIA HQ pl make the communication of health ministry public or send it to every individual.through SMS or e-mail.

Is it sellout to health ministry? Fumes clearly seen .

Monster has grown enough ,Pl donot allow it further to grow .Every fish in the pond is susceptible .Corporate---- you may manage but u are not immune.

Free intra-abdominal gas--IDEAL VIEW IN PLAIN X-RAY

Q.All are true regarding plain radiograph of abdomen except

a)frequently first investigation in acute abdomen

b)supine abdomen and an erect chest are regarded as the basic standard radiographs in the acute abdomen

c) patient should ideally remain in a given position for 10 minutes before the horizontal-ray radiograph to detect free gas

d) erect abdominal view is ideal  for the demonstration of free intra-abdominal gas

e) supine radiograph should ideally be taken with an empty bladder

ANS .---d

The erect chest radiograph is superior to the erect abdominal view for the demonstration of free intra-abdominal gas since, in the erect abdominal view, the X-ray beam is passing through any free gas under the diaphragm at an oblique angle. The exposure is also unfavourable for detecting small amounts of gas since this part of the film is usually overexposed. On the erect chest radiograph, the beam is passing almost tangentially to the free gas, with a better exposure . The erect chest is there fore invaluable in diagnosing visceral perforation. A chest radiograph is also useful because chest diseases such as pneumonia, pulmonary infarction, aortic dissection or myocardial infarction can present with abdominal symptoms.

DIFFUSION IMAGING

3.All are true regarding MAGNETIC RESONANCE DIFFUSION IMAGING except

a. exploits the presence of random motion (Brownian motion) of water molecules to produce image contrast

b. a pair of diffusion sensitizing gradients applied symmetrically around a 180 refocusing RF pulse of a T2-weighted MR sequence.

c. loss of signal is proportional to the degree of microscopic motion that occurs during the pulse sequence

d. regions of relatively stationary water molecules appear much brighter than areas with a higher molecular diffusion

e.  signal loss is independent of  the strength and duration of the diffusion sensitizing gradient ( the ‘b-value’.)

3.—e

On diffusion-weighted images, regions of relatively stationary water molecules appear much brighter than areas with a higher molecular diffusion. The degree of phase shift and signal loss depends also on the strength and duration of the diffusion sensitizing gradient, which is expressed by the ‘b-value’. B-values used for imaging of acute stroke lie typically around 1000s mm

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by Dr.Nagendra Kumar Sinha 

This MCQ book on neuro-radiology contains 16 TEST PAPERS.Each Test Paper consists of approx.60 MCQs ,so this book contains approx.995 MCQs.Each test paper is designed to cover all the different topics of neuro-radiology.Each test paper is followed by answer with detailed explanations .Most of MCQs answer and explanation can be seen in MRI of The Brain And Spine ,3rd edition,--S.Atlas and Diagnostic neuroradiology ,Annie Osborn
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Inborn metabolic brain disorders

Q.All are true regarding inborn metabolic brain disorders except

a. Alexander's disease shows  extensive white matter abnormality beginning in the frontal and periventricular white matter

b. l-2 hydroxyglutaricaciduria  involve   the periventricular white matter and corpus callosum

c. bilateral symmetrical involvement of the globus pallidus with sparing of the thalami is seen in methylmalonic acidaemia

d. Bilateral pallidal involvement is  seen as T2 hyperintensity  in Kearns–Sayer syndrome

e. Lorenzo's oil may delay disease progression of ALD

ANS .---b

The MRI findings of  l-2 hydroxyglutaricaciduria show white matter involvement with peripheral involvement, particularly of the subcortical U fibres, internal, external and extreme capsules, sparing of the periventricular white matter and corpus callosum, and with a slight frontal predominance. There is macrocephaly

Bilateral pallidal involvement is  seen as T2 hyperintensity in methylmalonic acidaemia ,GAMT (guanidinoacetate methyltransferase deficiency), Kearns–Sayer syndrome ,kernicterus and carbon monoxide poisoning

Rasmussen encephalitis

Q.All are true regarding Rasmussen encephalitis except

a. an abrupt onset of severe and intractable epilepsy

b. usually begins in childhood(6 and 8 years )

c. tends to affect hemisphere bilaterally

d. Serial scans show focal or hemispheric atrophy

e. cortical swelling with hyperintensity on T2W--earliest change on MRI--

ANS.----c

The disease tends to affect one hemisphere. Classification and staging criteria have been proposed based on MR imaging findings on T2-weighted and FLAIR images: normal volume and signal (stage 0), swelling and hyperintense signal (stage 1), normal volume and hyperintense signal (stage 2), atrophy and hyperintense signal (stage 3), and progressive atrophy and normal signal (stage 4).

Brain malformations

Q.All are true regarding  brain malformations except

a. The posterior fossa is of normal size in cerebellar hypoplasia

b. Torcular–lambdoid inversion on MRI is seen in Dandy –Walker

syndrome

c.  ‘batwing appearance’ of the fourth ventricle  is seen in Joubert's

 syndrome

d.The ‘Molar   tooth’ appearance is noted  in

rhombencephalosynapsis

 

e. a nonenhancing mass with diffusely enlarged cerebellar folia is 

feature of  L'Hermitte-Duclos
ANS.---d

Joubert's syndrome  is  considered  as generalized developmental disorder of the midbrain and hindbrain. The imaging findings reflect a failure of formation of the decussation of the superior cerebellar peduncles, lack of the pyramidal decussations and other anomalies of the midbrain crossing tracts and their nuclei. On cross-sectional imaging the fourth ventricle is enlarged with a ‘batwing appearance’ and there is a cleft in the vermis. The midbrain is small. The ‘molar tooth’ appearance seen on axial images arises from the lack of the superior cerebellar decussation and the superior peduncles also appear enlarged.

‘Snake eyes’ appearance within the spinal cord

Q.---All are true regarding degenerative changes of spine except

a.  The commonest site of protrusion is located  posterioriorly

b. type 1 reactive changes yield high signal on T1W and high on

 T2W

c. Ossification of OPLL involves the mid- and lower cervical region in over 90 % cases

d. Retro-odontal pseudotumour  refers to thickened transverse

 ligament of the atlas and associated ligaments

e. ‘snake eyes’ appearance within the spinal cord  on axial images

 is seen in   cervical spondylotic myelopathy

ANS.---b

Modic described three types of reactive changes in the cancellous bone adjacent to the vertebral end-plates: (type 1) in the acute stage of disc disease there is invasion of the cancellous spaces by fibrovascular reactive tissue; in time this leads to (type 2) fatty replacement of red marrow; eventually this leads to (type 3) bony sclerosis. These changes are exquisitely shown by MRI: (A) type 1 changes yield low signal on T1W and high on T2W; (B) type 2 changes yield high signal on T1W and T2W (unless fat suppressed, when they will yield low signal); (C) type 3 changes yield low signal on all sequences. 

Pelizaeus-Merzbacher disease

Q.All are true regarding Pelizaeus-Merzbacher disease except

a.due to lack of lipophilin

b.patchy demyelination with sparing of perivascular white matter

c.preserved internal capsule and subcortical U fibres

d.diffuse low signal on T2w

e.hypointense basal ganglia and thalamus on T2W

ANS.---d

Severe cases of Pelizaeus-Merzbacher disease show near –total 

lack of normal myelination with  diffuse high signal on T2W image

 that extends peripherally to involve the arcuate fibres .

LEUKODYSTROPHIES

Q.All are true regarding leukodystrophies except

a.complete or near complete lack of myelination is seen 

in Pelizaeus-Merzbacher disease

b.temporal lobe white matter is most involved in Alexander disease

c.occipital lobe white matter is most involved in 

adrenoleukodystrophy

d.thick meninges is seen in Hurler syndrome

e.high density basal ganglia is seen in Krabbe disease

ANS .---b

Frontal  lobe white matter is most involved in Alexander disease.

Complete or near complete lack of mylination is seen in Canavan

 disease and Pelizaeus-Merzbacher disease

Elster’s rule

284..Which dimention is not part of Elster’s rule for maximum 

normal height (in mm) of the  pituitary gland?

a.6mm

b.8mm

c.10mm

d.12mm

e.14mm

284.---e

6mm (infants and children),8mm (men and postmenopausal 

women),10mm(women of child bearing age),12 mm( women in 

late pregnancy or postpartum women) are  maximum normal height

 (in mm) of the  pituitary gland according to Elster’s rule. 

Ependymoma

Q.All are true regarding ependymoma except

a.more tha  90% in fourth ventricle

b.extrudes through outlet foramina

c.spinal seeding relatively  common

d. 50% calcify

e.moslty isodense on NECT

ANS .---c

Spinal seeding is relatively uncommom

BRAIN METASTASES

Q.All are true regarding brain metastases except
a. deposits from malignant melanoma hyperdendse on CT
b. Increasing relaxivity of gadolinium compounds improve  detection of metastases
c.Well-differentiated adenocarcinoma metastases are hypointense on trace-weighted DWI,
d.PWI and MRS of  intratumoural region useful  in differentiating single metastasis from a glioma
e.DWI is helpful to differentiate cystic metastasis  from cerebral abscesses
ANS -------d
Metastases are characterized by oedema in the surrounding white matter, which appears dark on trace-weighted DWI and is often disproportionate to the size of the tumour itself.
Increasing the contrast dose or relaxivity of gadolinium compounds can improve the sensitivity for detection of metastases on MRI

Well-differentiated adenocarcinoma metastases are hypointense on trace-weighted DWI, whereas small cell and neuroendocrine metastases are hyperintense, due to their higher cellularity . On standard MRI it may occasionally be difficult to distinguish a single metastasis from a glioma. PWI and MRS of the peritumoural rather than intratumoural region were shown to be useful in differentiating the two.

INTRAVENTRICULAR LESIONS

Q.All are true regarding intraventricular meningioma except

a. arise from arachnoid cells of the tela choroidea

b. most commonly occur in the lateral ventricles

c. usually appearing in the middle-aged and elderly population

d.have  a smooth margin and are generally oval in configuration

e.difffuse hydrocephalus

ANS .---e

Intraventricular meningiomas can usually be differentiated from choroid plexus papillomas both clinically and with MR. Lateral ventricular choroid plexus papillomas develop mainly in young children, with meningiomas usually appearing in the middle-aged and elderly population. Meningiomas have a smooth margin and are generally oval in configuration  whereas papillomas frequently demonstrate very nodular, heterogeneous, irregular surfaces. Papillomas also usually present with diffuse hydrocephalus and not just dilation of the trapped ventricular segment. This occurs either because of their overproduction of CSF or their frequent bleeding, which may cause obstructing basal arachnoiditis and/or intraventricular ependymitis. Although papillomas are more frequently very heterogeneous, intraventricular meningiomas can also show significant heterogeneity and extensive edema . Therefore, the location of the lesion and the age of the patient are the two most valuable clues to the diagnosis

AUTOMATIC BRAIN TUMOUR DETECTOR ---PROJECT AT IIT DELHI

http://www.cse.iitd.ac.in/~cs5090255/autocom/index.html

AUTOMATIC BRAIN TUMOUR DETECTOR ---PROJECT AT IIT DELHI

The project aims at developing a tool to be used by the radiologists for detection of Brain Tumors in MRI images automatically.

Every year thousands of people die around the globe as a result of different brain tumors. Some due to human incapability because of large variations in size, location and form of the Brain Tumors, while some due to human errors because of increasing number of Neuro-patients leading to a huge manual workload on small Radiology group.

This inspired us to develop a tool which can assist radiologist by automatically detecting Brain Tumors in MRI images and thus help in Saving Time, Saving Money and Saving Radiologist for more complex and expertise requiring cases

Current Situation

Idea

To come up with next generation MRI viewers which can assist the radiologists by automatically detecting Tumor, if present and generate report based on the tumor found.

Input : Like a normal Dicom Viewer, it loads ‘n’ patient cases with 20 slices(MRI images) each of T2, T1,T1 post contrast,etc sequences.

Output : Divide the loaded ‘n’ number of cases into three categories and generate report for each patient case automatically.

The three categories are

Prototype

We have been working on this Idea from summer’11 as part of SURA (Summer Undergraduate Reasearch Award) and have developed a Prototype for testing the above made algorithm. Testing dataset so far, consist of 120 patients (each patient data consists of 20 images each of 3 sequences T1, T2 and T1 post contrast) and is gradually expanded. Out of 120, 65 were Normal and 55 abnormal (30 Tumor containing).

The AutoCom prototype showed excellent results differentiating normal-abnormal as well as identifying Tumor and generating report, when found.

cyst of the cavum Vergae

Q.All are true regarding pellucidum septum except

a. The double septum or fifth ventricle is due to the abnormal persistence of the fetal cavum septi pellucidi

b. cavum septi pellucidi  persists in 1-2% of adults

c. cyst of the cavum Vergae represents the so-called `sixth ventricle'

d.  cyst of the cavum Vergae  is backward expetion of  the septal cyst

e.  cyst of the cavum Vergae lies beneath the posterior part of corpus callosum with the velum interpositum above

ANS.----d

cyst of the cavum Vergae  lies beneath the posterior part of corpus callosum with the velum interpositum below

?ONYX

Q.All are true regarding ONYX except

a. non-adhesive liquid embolic agent

b cosists of  ethyl-vinyl alcohol polymer (EVOH)

c. dimethyl sulfoxide  (DMSO) used as solvent

d. tantalum used to make it radiopaque

e. it solidifies mor than rapidly NBCA

ANS .---e

Onyx is a new non-adhesive liquid embolic agent which consists of  a mixture of ethyl-vinyl alcohol polymer (EVOH), dimethyl sul-occlufoxide (DMSO) as a solvent and tantalum to render it radiopaque. In contrast to NBCA, it solidifies slowly, minimises the danger of insitu gluing of a microcatheter. Onyx has been used for cerebral arteriovenous malformations (AVMS) and giant cerebral aneurysms in which other forms of endovascular or surgical treatment are difficult

BIG BRAIN ---DOESNOT GENERATE BIG THOUGHT

Q. Imaging indicators of intraventricular obstructive (noncommunicating) hydrocephalus are all except
a. dilatation of the temporal horns disproportionate to lateral ventricular dilatation
b.enlargement of the anterior and posterior recesses of the third ventricle
c.dilatation of the sulcal spaces, major fissures and basal cisterns

d.inferior convexity of the floor of the third ventricle
e.transependymal oedema and bulging of fontanelles

ANS.---c

The sulcal spaces, major fissures and basal cisterns are small or obliterated in  intraventricular obstructive (noncommunicating) hydrocephalus.

Other features, such as changes in the configuration of the frontal horns of the lateral ventricles, specifically widening of the radius of the frontal horn, and a decrease in the angle it makes with the midline plane, are less useful. Further features classically described in chronic hydrocephalus, such as erosion of the dorsum sellae and copper beaten skull, are even less reliable.