Cardiovascular Radiology Practice Questions

Q: A young female undergoes renal angiography for evaluation of secondary hypertension. Based on her angiogram, what is the most likely diagnosis?

Fibromuscular dysplasia. ### ***Fibromuscular dysplasia*** - This is the most common cause of **secondary hypertension** in **young women**, characterized classically by a **'string of beads' appearance** on angiography due to focal areas of medial fibroplasia. - It typically affects the **mid-to-distal segments** of the renal arteries, sparing the origin and proximal portions, which aids in differentiation from atherosclerotic disease. *Polyarteritis nodosa* - This systemic **necrotizing vasculitis** typically affects medium-sized vessels and is associated with **microaneurysms** on angiography rather than the typical beads appearance. - Patients usually present with distinct systemic symptoms such as **fever, weight loss, and neuropathy**, rather than isolated hypertension. *Atherosclerotic renal artery stenosis* - This condition is overwhelmingly more common in **elderly patients** with long-standing risk factors like **smoking, diabetes, and hyperlipidemia**. - Angiography typically reveals stenosis at the **ostium or proximal portion** of the renal artery, rather than the distal involvement seen in FMD. *Takayasu arteritis* - This is a large-vessel vasculitis that primarily affects the **aorta and its major branches**, leading to narrowed, thickened vessel walls. - It is typically seen in **women under 40** and is characterized by a pulse deficit, rather than the specific beaded dysplastic changes found in FMD.

Q: Which one of the following is used in Cardiovascular imaging?

Multidetector CT. **Explanation:** **Multidetector CT (MDCT)** is the gold standard for cardiovascular imaging because it overcomes the two biggest challenges in cardiac radiology: **cardiac motion** and **respiratory motion**. 1. **Why MDCT is correct:** MDCT utilizes multiple rows of detectors, allowing for sub-millimeter isotropic resolution and high temporal resolution. When combined with **ECG-gating** (synchronizing data acquisition with the diastolic phase of the cardiac cycle), it allows for motion-free imaging of the coronary arteries. Modern MDCT (64-slice and above) can image the entire heart in a single breath-hold, making it essential for Coronary CT Angiography (CCTA). 2. **Why other options are incorrect:** * **Second and Third Generation CT:** These are historical iterations. Second-generation used a "translate-rotate" motion with a fan beam, and Third-generation used a "rotate-rotate" motion. While Third-generation is the basis for modern scanners, the basic configuration lacked the speed and detector density required to freeze cardiac motion. * **Spiral (Helical) CT:** While a prerequisite for MDCT, early single-slice spiral CTs were too slow to capture the heart without significant motion artifacts and could not provide the necessary spatial resolution for small vessels like the coronary arteries. **High-Yield Clinical Pearls for NEET-PG:** * **Temporal Resolution:** The time required to acquire data for one image. High temporal resolution is vital to "freeze" the heart. * **Electron Beam CT (EBCT):** Historically known as the "Ultrafast CT," it was the previous gold standard for Calcium Scoring but has been largely replaced by MDCT. * **Calcium Scoring (Agatston Score):** Performed on MDCT to predict the risk of future adverse cardiac events. * **Beta-blockers:** Often administered before a Cardiac CT to lower the heart rate (ideally <60-65 bpm) to improve image quality.

Q: Which of the following is NOT a characteristic feature of mitral stenosis on X-ray?

Prominence of veins in the lower lobes. In Mitral Stenosis (MS), the narrowing of the mitral valve leads to increased pressure in the left atrium (LA), causing **Left Atrial Enlargement (LAE)** and subsequent pulmonary venous hypertension. ### Why Option D is the Correct Answer In MS, pulmonary venous hypertension leads to a phenomenon called **Cephalization** (Antler sign). Due to perivascular edema in the lower lobes, there is reflex vasoconstriction of the lower lobe veins and compensatory dilatation of the **upper lobe veins**. Therefore, prominence of veins in the *lower* lobes is incorrect; they are actually constricted, while upper lobe veins are prominent. ### Explanation of Incorrect Options (Features of LAE) * **Double contour of the right border:** As the LA enlarges, its right border pushes toward the right and overlaps the right atrium, creating a "double shadow" or "double density" sign on a PA view. * **Elevation of the left main bronchus:** An enlarging LA pushes the left main bronchus upward, making it more horizontal. * **Widening of the carinal angle:** The subcarinal angle (normally 60–75°) increases to >90° as the LA expands superiorly between the two main bronchi. ### High-Yield Clinical Pearls for NEET-PG * **Straightening of the left cardiac border:** This occurs due to a prominent pulmonary artery segment and an enlarged left atrial appendage (filling the "mitral surf"). * **Kerley B Lines:** Horizontal lines at the lung bases indicating chronic pulmonary venous hypertension and interstitial edema. * **Most sensitive view for LAE:** Lateral view with barium swallow (shows posterior indentation of the esophagus). * **Walking Man Sign:** On a lateral X-ray, the posterior displacement of the left main bronchus resembles a person walking.

Q: A patient presents with chest pain. What is the diagnosis?

Ascending aortic aneurysm. ***Ascending aortic aneurysm*** - Chest X-ray shows **widened mediastinum** and **prominent right paracardiac border** due to dilatation of the ascending aorta. - Often presents with **chest pain** and may cause compression of surrounding structures, leading to characteristic radiological findings. *Acute pulmonary embolism* - Chest X-ray is typically **normal** or may show subtle signs like **Westermark sign** (oligemia) or **Hampton's hump** (wedge-shaped opacity). - Diagnosis primarily relies on **CT pulmonary angiogram (CTPA)** or **V/Q scan**, not chest X-ray findings. *Hypertrophic cardiomyopathy* - Chest X-ray may show **left ventricular enlargement** with a **boot-shaped heart** configuration. - Lacks the characteristic **mediastinal widening** seen with aortic pathology, instead showing cardiac silhouette changes. *Coarctation of the aorta* - Chest X-ray demonstrates **rib notching** due to collateral circulation and **figure-of-3 sign** from pre- and post-stenotic dilatation. - Shows **left heart enlargement** but lacks the prominent right paracardiac border characteristic of ascending aortic aneurysm.

Q: Classification of aortic dissection depends upon?

Level of aorta affected. Aortic dissection is classified based on the **anatomical location** of the intimal tear and the extent of the involvement of the aorta. This is because the anatomical level determines the clinical management (surgical vs. medical). ### Why the Correct Answer is Right: The two primary classification systems used in clinical practice are: 1. **Stanford Classification:** The most widely used system. It divides dissections into **Type A** (involves the ascending aorta, regardless of the site of origin) and **Type B** (involves only the aorta distal to the left subclavian artery). 2. **DeBakey Classification:** Categorizes based on the origin and extent. **Type I** involves the ascending aorta, arch, and descending aorta; **Type II** is confined to the ascending aorta; **Type III** is confined to the descending aorta. ### Why Other Options are Wrong: * **A. Cause of dissection:** While hypertension, Marfan syndrome, and trauma are common causes, they do not dictate the classification. * **C. Percentage of aorta affected:** Classification depends on *which* specific segments are involved (ascending vs. descending), not the total percentage of the vessel's length. ### High-Yield Facts for NEET-PG: * **Management Rule:** Stanford Type A is a **surgical emergency** (due to risk of aortic regurgitation, tamponade, or coronary involvement). Stanford Type B is generally managed **medically** with aggressive blood pressure control (Beta-blockers). * **Gold Standard Investigation:** **CT Angiography (CTA)** is the investigation of choice. * **Classic Sign:** On X-ray, look for **mediastinal widening**. On CT, the pathognomonic finding is an **intimal flap** separating the true and false lumens. * **Double Barrel Aorta:** A term used when there are two distinct flow channels.

Q: Which of the following is NOT a sign of right atrial enlargement?

Haffman-Rigler Sign (Lateral view). **Explanation:** Right atrial (RA) enlargement is primarily assessed on the Chest X-ray (CXR) by observing changes in the right heart border and the retrosternal space. **Why Option D is the correct answer:** The **Hoffman-Rigler sign** is a classic radiological sign used to identify **Left Ventricular (LV) enlargement**, not right atrial enlargement. It is measured on a lateral CXR: if the distance between the posterior border of the LV and the posterior border of the Inferior Vena Cava (IVC) is greater than 1.8 cm (at a point 2 cm above the diaphragm), it indicates LV hypertrophy/dilatation. **Analysis of Incorrect Options:** * **Option A:** In the PA view, the right heart border is formed entirely by the RA. Enlargement causes the border to shift further to the right (more than 5.5 cm from the midline) with increased convexity. * **Option B & C:** On a lateral view, the RA forms the upper portion of the anterior cardiac contour. When enlarged, it expands anteriorly and superiorly, encroaching upon and eventually **obliterating the retrosternal clear space** (the lucent area between the heart and the sternum). **High-Yield Clinical Pearls for NEET-PG:** * **Right Ventricular (RV) Enlargement:** Also obliterates the retrosternal space but typically causes an "upturned apex" (Coeur en Sabot) on PA view. * **Left Atrial (LA) Enlargement:** Look for the "Double atrial contour" sign, "Splaying of the carina," and "Walking cane appearance" of the left main bronchus. * **Most sensitive view for RA enlargement:** PA view (displacement of the right heart border). * **Most sensitive view for LA enlargement:** Lateral view (posterior displacement of the esophagus if barium swallow is used).

Q: What diagnosis is suggested by the results of this coronary angiogram?

Polyarteritis nodosa. ***Polyarteritis nodosa*** - Coronary angiogram showing **multiple microaneurysms** and **beading pattern** is pathognomonic for polyarteritis nodosa affecting medium-sized arteries. - The characteristic **rosary bead appearance** on angiography distinguishes it from other vasculitides and represents segmental arterial inflammation. *Marfan syndrome* - Angiographic findings typically show **aortic root dilatation** and **mitral valve prolapse**, not coronary microaneurysms. - Coronary arteries may show **tortuosity** but lack the characteristic beading pattern seen in vasculitis. *Diabetes mellitus* - Coronary angiography in diabetes shows **diffuse narrowing** and **calcified plaques**, not microaneurysms. - Findings include **small vessel disease** and **atherosclerotic stenosis**, contrasting with the inflammatory changes of PAN. *Fibromuscular dysplasia* - Primarily affects **renal** and **carotid arteries**, rarely involving coronary circulation. - Angiographic appearance shows **string of beads** in renal arteries, but coronary involvement is extremely uncommon.

Q: A triangular shaped heart is a radiological finding of which of the following conditions?

Constrictive pericarditis. **Explanation:** The correct answer is **Constrictive Pericarditis**. In this condition, the pericardium becomes thickened, fibrotic, and often calcified, which restricts the diastolic filling of the heart chambers. On a chest X-ray, this rigid "shell" prevents the normal rounded contour of the heart, resulting in a flattened, **triangular, or "tent-shaped" cardiac silhouette**. **Analysis of Options:** * **Constrictive Pericarditis:** The hallmark radiological feature is **pericardial calcification** (best seen on a lateral X-ray). The heart size is usually normal or small, but the rigid pericardium gives it a characteristic straight-edged, triangular appearance. * **Mitral Incompetence (Regurgitation):** This leads to left atrial and left ventricular enlargement, resulting in a **globular or enlarged heart** with a "double atrial shadow." * **TAPVC (Supracardiac type):** This presents with the classic **"Snowman sign" or "Figure-of-8" appearance** due to the dilation of the vertical vein, innominate vein, and superior vena cava. * **Ebstein’s Anomaly:** Characterized by massive right atrial enlargement, leading to a massive, **"box-shaped" heart**. **High-Yield Clinical Pearls for NEET-PG:** * **Pericardial Effusion:** Shows a **"Water-bottle" or "Money-bag"** appearance. * **Tetralogy of Fallot:** Shows a **"Boot-shaped" heart (Coeur en sabot)** due to RVH and upturned apex. * **Transposition of Great Arteries (TGA):** Shows an **"Egg-on-side"** appearance. * **Coarctation of Aorta:** Shows the **"Figure of 3" sign** on X-ray and **Rib notching** (inferior aspect of 3rd to 8th ribs).

Question 1

A young female undergoes renal angiography for evaluation of secondary hypertension. Based on her angiogram, what is the most likely diagnosis?

Accepted Answer

Fibromuscular dysplasia

Answer

Polyarteritis nodosa

Answer

Atherosclerotic renal artery stenosis

Answer

Takayasu arteritis

Question 2

Which one of the following is used in Cardiovascular imaging?

Accepted Answer

Multidetector CT

Answer

Second generation CT

Answer

Third generation CT

Answer

Spiral CT

Question 3

Which of the following is NOT a characteristic feature of mitral stenosis on X-ray?

Accepted Answer

Prominence of veins in the lower lobes

Answer

Double contour of the right border

Answer

Elevation of the left main bronchus

Answer

Widening of the carinal angle

Question 4

Which of the following statements is true regarding cardiac MRI?

Accepted Answer

Viable myocardium can be differentiated from infarcted myocardium.

Answer

Infarcted myocardium is hypointense on T2-weighted MRI.

Answer

Prosthetic heart valves are an absolute contraindication for MRI.

Answer

Cardiac MRI is better than CT for the non-invasive assessment of coronary arteries.

Question 5

A patient presents with chest pain. What is the diagnosis?

Accepted Answer

Ascending aortic aneurysm

Answer

Acute pulmonary embolism

Answer

Hypertrophic cardiomyopathy

Answer

Coarctation of the aorta

Question 6

Which condition is associated with a 'figure of 8' appearance on a chest X-ray?

Accepted Answer

Supracardiac Total Anomalous Pulmonary Venous Connection (TAPVC)

Answer

Tetralogy of Fallot

Answer

Transposition of the Great Arteries (TGA)

Answer

None of the above

Question 7

Classification of aortic dissection depends upon?

Accepted Answer

Level of aorta affected

Answer

Cause of dissection

Answer

Percentage of aorta affected

Answer

None of the above

Question 8

Which of the following is NOT a sign of right atrial enlargement?

Accepted Answer

Haffman-Rigler Sign (Lateral view)

Answer

Prominent right heart border with increased convexity (PA view)

Answer

Prominent anterosuperior part of cardiac shadow (lateral view)

Answer

Obliteration of retrosternal clear space (Lateral view)

Question 9

What diagnosis is suggested by the results of this coronary angiogram?

Accepted Answer

Polyarteritis nodosa

Answer

Marfan syndrome

Answer

Diabetes mellitus

Answer

Fibromuscular dysplasia

Question 10

A triangular shaped heart is a radiological finding of which of the following conditions?

Accepted Answer

Constrictive pericarditis

Answer

Mitral incompetence

Answer

Total anomalous pulmonary venous connection (TAPVC)

Answer

Ebstein's anomaly

Cardiovascular Radiology — MCQs

Cardiovascular Radiology — MCQs

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