Cardiovascular Radiology Practice Questions

Q: Which cardiac valves have been replaced?

Aortic and mitral valves. ***Aortic and mitral valves*** - **Prosthetic aortic valve** appears as a **radiopaque ring** that is relatively **superior and central** in the cardiac silhouette, representing the aortic root position. - **Prosthetic mitral valve** is visible as a **radiopaque structure** that is more **inferior and leftward** on the frontal radiograph, corresponding to the **left atrial-ventricular junction**. *Aortic and tricuspid valves* - The **tricuspid valve** position would appear more **medially** and **inferiorly** near the **right atrioventricular junction**, not at the left heart border as seen. - **Double valve replacement** with aortic and tricuspid is **less common** than aortic and mitral replacement in clinical practice. *Mitral and tricuspid valves* - **Tricuspid valve** prosthesis would be positioned more **centrally** and **lower** in the cardiac silhouette, not at the right sternal border. - The **upper radiopaque structure** clearly corresponds to the **aortic position**, not tricuspid valve location. *Pulmonary and mitral valves* - **Pulmonary valve** position would appear in the **left upper cardiac border** near the **pulmonary artery**, not at the right sternal border. - **Pulmonary valve replacement** is much **less common** than aortic valve replacement in adults with valvular disease.

Q: An 8-year-old child has exertional cyanosis, reduced exercise tolerance, and episodic palpitations. Examination reveals a holosystolic murmur at the left lower sternal border that becomes louder with inspiration. ECG shows right bundle-branch block with ventricular pre-excitation. The chest radiograph shown demonstrates moderate cardiomegaly without pulmonary edema. Which congenital heart defect is most likely?

Ebstein anomaly. Ebstein anomaly is characterized by apical displacement of the septal and posterior tricuspid valve leaflets, producing atrialization of part of the right ventricle, tricuspid regurgitation, and right atrial enlargement. Older children may present with exertional cyanosis, exercise intolerance, or supraventricular tachyarrhythmias. A holosystolic murmur that intensifies with inspiration indicates tricuspid regurgitation, and accessory pathways causing ventricular pre-excitation are strongly associated with Ebstein anomaly. Chest radiography may show moderate to marked cardiomegaly, primarily from right atrial enlargement; the extreme box-shaped or “wall-to-wall” silhouette is mainly seen in severe neonatal disease and is not required for diagnosis. An ostium secundum atrial septal defect generally causes increased pulmonary vascularity and fixed splitting of S2 rather than cyanosis with pre-excitation. Pulmonary valve stenosis may cause right ventricular hypertrophy and reduced pulmonary blood flow when severe but does not typically produce tricuspid regurgitation with accessory-pathway pre-excitation. Tricuspid atresia usually presents with significant cyanosis in infancy and does not cause tricuspid regurgitation because there is no patent tricuspid valve.

Q: What is the best investigation for diagnosing an abdominal aortic aneurysm?

CT angiography. **Explanation:** **CT Angiography (CTA)** is the gold standard for diagnosing and pre-operative planning of an Abdominal Aortic Aneurysm (AAA). While ultrasound is excellent for screening, CTA provides precise anatomical detail, including the exact diameter, longitudinal extent, involvement of visceral branches (renal, mesenteric), and the presence of mural thrombus or calcification. This information is critical for determining whether a patient is a candidate for EVAR (Endovascular Aneurysm Repair) or open surgery. **Analysis of Options:** * **Ultrasound (USG):** This is the **investigation of choice for screening** and longitudinal monitoring of small aneurysms due to its non-invasive nature and lack of radiation. However, it is operator-dependent and limited by bowel gas or obesity, making it less definitive than CTA for surgical planning. * **Classical Radiography:** X-rays may incidentally show a "eggshell calcification" of the aortic wall, but they lack the sensitivity and specificity required for diagnosis or measurement. * **Non-contrast CT scan:** While it can detect the presence of an aneurysm and mural calcification, it cannot accurately assess the lumen, flow, or the relationship with arterial branches, which are essential for management. **Clinical Pearls for NEET-PG:** * **Screening tool of choice:** Ultrasound. * **Best/Gold Standard investigation:** CT Angiography. * **Definition of AAA:** Permanent dilation of the abdominal aorta >3 cm or >1.5 times its normal diameter. * **Most common site:** Infra-renal (90%). * **Surgical indication:** Diameter >5.5 cm in men or >5.0 cm in women, or rapid expansion (>0.5 cm in 6 months).

Q: Inferior rib notching is characteristically present in which of the following congenital cardiac anomalies?

Coarctation of aorta. **Explanation:** **1. Why Coarctation of Aorta is correct:** Inferior rib notching (Roesler’s sign) is a classic radiological finding in **post-ductal coarctation of the aorta**. Due to the narrowing of the aorta distal to the left subclavian artery, the body develops collateral circulation to bypass the obstruction and supply the lower body. The primary pathway involves the **intercostal arteries**. These arteries become dilated, tortuous, and pulsatile. As they run along the inferior groove of the ribs, the constant pressure and pulsation cause pressure erosion (notching) of the **3rd to 9th ribs**. The 1st and 2nd ribs are spared because their intercostal arteries do not originate from the post-stenotic aorta. **2. Why the other options are incorrect:** * **TAPVC:** Characterized by the **"Snowman sign"** or "Figure-of-8" appearance on a chest X-ray due to a dilated supracardiac venous shadow. * **Tetralogy of Fallot:** Classically presents with a **"Boot-shaped heart"** (Coeur en Sabot) due to right ventricular hypertrophy and an upturned apex. * **Ventricular Septal Defect:** Typically shows features of increased pulmonary blood flow (plethora) and left-sided heart enlargement, but does not involve collateral arterial pathways that erode ribs. **3. High-Yield Clinical Pearls for NEET-PG:** * **Roesler’s Sign:** Inferior rib notching (3rd–9th ribs). * **3-Sign:** Seen on X-ray (formed by pre-stenotic dilation, the coarctation itself, and post-stenotic dilation). * **Reverse 3-Sign (E-sign):** Seen on Barium swallow. * **Superior Rib Notching:** Rare; associated with conditions like Neurofibromatosis-1, Marfan syndrome, or Polio. * **Clinical Hallmark:** Radio-femoral delay and upper limb hypertension.

Q: X-ray features of Atrial Septal Defect (ASD) are all except:

Left atrial enlargement. In **Atrial Septal Defect (ASD)**, the underlying pathophysiology is a left-to-right shunt at the atrial level. This leads to volume overload of the right-sided chambers and the pulmonary circulation. ### Why "Left Atrial Enlargement" is the Correct Answer: In ASD, the left atrium (LA) does not enlarge because it decompresses itself into the right atrium through the defect. Even though there is increased pulmonary venous return to the LA, the blood immediately shunts across the ASD. Therefore, **LA enlargement is characteristically absent** in ASD. If LA enlargement is seen on an X-ray in a patient with a left-to-right shunt, it points toward a Ventricular Septal Defect (VSD) or Patent Ductus Arteriosus (PDA). ### Explanation of Other Options: * **Right Atrial Enlargement:** The right atrium receives both the systemic venous return and the shunted blood from the LA, leading to dilation. * **Pulmonary Artery Hypertension (PAH):** Increased pulmonary blood flow (plethora) eventually leads to increased pulmonary vascular resistance. On X-ray, this manifests as a prominent pulmonary conus and "hilar dance" on fluoroscopy. * **Small Aortic Knuckle:** Due to the left-to-right shunt, the stroke volume entering the left ventricle and the aorta is relatively reduced compared to the massive pulmonary flow, making the aortic knob appear small or inconspicuous. ### High-Yield Clinical Pearls for NEET-PG: * **X-ray Triad of ASD:** Enlarged RA, Enlarged RV, and Pulmonary Plethora with a small Aortic Knuckle. * **Auscultation:** Wide, fixed split S2 (pathognomonic). * **ECG:** RSR' pattern in V1 (Partial RBBB) and Right Axis Deviation (in Ostium Secundum, the most common type). * **Lutembacher Syndrome:** ASD associated with Mitral Stenosis.

Q: A patient with mitral stenosis will show all of the following findings on chest imaging except?

Obliteration of the retrosternal shadow on lateral x-rays. In Mitral Stenosis (MS), the primary hemodynamic change is the enlargement of the **Left Atrium (LA)** due to pressure and volume overload. ### Why Option C is the Correct Answer **Obliteration of the retrosternal space** on a lateral X-ray is a sign of **Right Ventricular (RV) enlargement**. In pure or early mitral stenosis, the left atrium enlarges posteriorly. While chronic MS can lead to pulmonary hypertension and subsequent RV hypertrophy, the *earliest* and most characteristic findings are related to the LA. More importantly, the retrosternal space is located anteriorly; its obliteration is not a primary feature of isolated mitral disease unless significant right-sided heart failure has supervened. ### Explanation of Incorrect Options (Findings seen in MS) * **A. Lifting up of the left bronchus:** As the Left Atrium enlarges superiorly, it pushes the left mainstem bronchus upward, widening the **carinal angle** (normal < 75°). * **B. Double atrial shadow:** On a PA view, the enlarged LA grows toward the right, creating a dense shadow within the right heart border (the "double density" sign). * **C. Posterior displacement of the esophagus:** The LA is the most posterior chamber of the heart. On a barium swallow, an enlarged LA creates a smooth indentation and posterior displacement of the esophagus. ### NEET-PG High-Yield Pearls * **Straightening of the Left Cardiac Border:** This is the earliest sign of MS, caused by an enlarged left atrial appendage and a prominent pulmonary artery segment. * **Kerley B Lines:** Horizontal lines at the lung bases indicating chronic pulmonary venous hypertension (interstitial edema). * **Mitralization of the Heart:** A configuration where the left border becomes straight or convex due to LA enlargement and RV prominence. * **Cephalization (Antler Sign):** Redistribution of blood flow to the upper lobes (upper lobe diversion).

Q: A 48-year-old female presented with dyspnea, chest pain, and a feeling of pressure on her chest. A CXR was ordered as part of her investigations. The patient had a normal CXR 5 months ago with normal heart size. Which of the following is the most probable diagnosis?

Pericardial effusion. ***Pericardial effusion*** - **Rapid onset** of cardiac enlargement with **globular/water-bottle cardiac silhouette** on CXR, given normal heart size 5 months ago, strongly suggests pericardial effusion. - The water-bottle silhouette with clear lungs suggests a **large pericardial effusion** but does not diagnose tamponade; **echocardiography** is the confirmatory test. *Cardiomyopathy* - Typically presents with **gradual onset** over months to years, not acute cardiac enlargement within 5 months. - Would show **cardiomegaly with pulmonary congestion** rather than isolated cardiac silhouette enlargement without lung involvement. *Congestive heart failure* - Would demonstrate **pulmonary edema**, **Kerley B lines**, and **pleural effusions** on CXR along with cardiomegaly. - The **absence of pulmonary congestion** with isolated cardiac enlargement makes CHF unlikely. *Pulmonary embolism* - Typically presents with a **normal CXR** or may show **pleural-based consolidation** and **elevated hemidiaphragm**. - Would not cause **cardiac enlargement** or the globular cardiac silhouette seen in this case.

Question 1

Which cardiac valves have been replaced?

Accepted Answer

Aortic and mitral valves

Answer

Mitral and tricuspid valves

Answer

Pulmonary and mitral valves

Answer

Aortic and tricuspid valves

Question 2

Inferior rib notching is seen in all of the following conditions except:

Accepted Answer

Pulmonary stenosis with ventricular septal defect

Answer

Blalock Taussig shunt operation

Answer

Coarctation of the aorta

Answer

Interrupted aortic arch

Question 3

An 8-year-old child has exertional cyanosis, reduced exercise tolerance, and episodic palpitations. Examination reveals a holosystolic murmur at the left lower sternal border that becomes louder with inspiration. ECG shows right bundle-branch block with ventricular pre-excitation. The chest radiograph shown demonstrates moderate cardiomegaly without pulmonary edema. Which congenital heart defect is most likely?

Accepted Answer

Ebstein anomaly

Answer

Ostium secundum atrial septal defect

Answer

Congenital pulmonary valve stenosis

Answer

Tricuspid atresia

Question 4

The 'Oreo cookie sign' is a radiological finding suggestive of which of the following conditions?

Accepted Answer

Pericardial effusion

Answer

Aberrant subclavian artery

Answer

Left atrium enlargement

Answer

Endomyocardial fibrosis

Question 5

What is the best investigation for diagnosing an abdominal aortic aneurysm?

Accepted Answer

CT angiography

Answer

Ultrasound (USG)

Answer

Classical radiography

Answer

Non-contrast CT scan

Question 6

The plain X-ray chest finding that suggests syphilitic cardiovascular disease is:

Accepted Answer

Linear calcification of the ascending aorta

Answer

Linear calcification of the aortic arch

Answer

Speckled calcification of the ascending aorta

Answer

Speckled calcification of the aortic arch

Question 7

Inferior rib notching is characteristically present in which of the following congenital cardiac anomalies?

Accepted Answer

Coarctation of aorta

Answer

Total anomalous pulmonary venous connection (TAPVC)

Answer

Tetralogy of Fallot

Answer

Ventricular septal defect

Question 8

X-ray features of Atrial Septal Defect (ASD) are all except:

Accepted Answer

Left atrial enlargement

Answer

Right atrial enlargement

Answer

Pulmonary artery hypertension

Answer

Small aortic knuckle

Question 9

A patient with mitral stenosis will show all of the following findings on chest imaging except?

Accepted Answer

Obliteration of the retrosternal shadow on lateral x-rays

Answer

Lifting up of the left bronchus

Answer

Double atrial shadow

Answer

Posterior displacement of the esophagus on barium swallow

Question 10

A 48-year-old female presented with dyspnea, chest pain, and a feeling of pressure on her chest. A CXR was ordered as part of her investigations. The patient had a normal CXR 5 months ago with normal heart size. Which of the following is the most probable diagnosis?

Accepted Answer

Pericardial effusion

Answer

Pulmonary embolism

Answer

Congestive heart failure

Answer

Cardiomyopathy

Cardiovascular Radiology — MCQs

Cardiovascular Radiology — MCQs

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