Cardiovascular Radiology — MCQs

Cardiovascular Radiology Indian Medical PG Practice Questions and MCQs

Question 21: "Pile of plates" appearance on angiography suggests which diagnosis?

A. Atherosclerosis
B. Fibromuscular Dysplasia (Correct Answer)
C. Takayasu's Disease
D. Moya Moya disease

Explanation: **Explanation:** **Fibromuscular Dysplasia (FMD)** is a non-inflammatory, non-atherosclerotic vascular disease that primarily affects medium-sized arteries, most commonly the **renal** and **internal carotid arteries**. The "Pile of plates" or **"String of beads"** appearance on angiography is the classic radiographic hallmark of the most common subtype, **medial fibroplasia**. This appearance is caused by alternating areas of mural thinning (aneurysmal dilatation) and thickened fibromuscular ridges (stenosis). **Analysis of Options:** * **Atherosclerosis:** Typically presents as eccentric or concentric narrowing with irregular calcified plaques, usually at the **ostium** or proximal segment of the vessel, rather than a beaded appearance. * **Takayasu’s Disease:** A large-vessel vasculitis that causes smooth, long-segment tapering or "tubular" stenosis and wall thickening, primarily involving the aorta and its main branches. * **Moya Moya Disease:** Characterized by progressive stenosis of the terminal internal carotid arteries, leading to a compensatory network of fragile collateral vessels at the base of the brain, described as a **"Puff of smoke"** appearance. **High-Yield Clinical Pearls for NEET-PG:** * **Demographics:** FMD is most common in **young to middle-aged females**. * **Clinical Presentation:** Often presents as **secondary hypertension** (due to renal artery involvement) or stroke/TIA in young patients. * **Gold Standard Diagnosis:** Digital Subtraction Angiography (DSA). * **Treatment:** Percutaneous Transluminal Angioplasty (PTA) is the treatment of choice; unlike atherosclerosis, stenting is rarely required.

Question 22: A patient with mitral stenosis will show all of the following findings on chest imaging except?

A. Lifting up of the left bronchus
B. Double atrial shadow
C. Obliteration of the retrosternal shadow on lateral x-rays (Correct Answer)
D. Posterior displacement of the esophagus on barium swallow

Explanation: 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).

Question 23: All are angiographic findings of Thromboangiitis obliterans except?

A. Corkscrew vessels
B. Rippled artery
C. Constricted vasa vasorum (Correct Answer)
D. Spider leg collaterals

Explanation: **Thromboangiitis obliterans (Buerger’s Disease)** is a non-atherosclerotic, segmental, inflammatory disease that primarily affects small and medium-sized arteries and veins of the extremities. ### **Explanation of the Correct Answer** **C. Constricted vasa vasorum:** This is the correct "except" option because Buerger’s disease is characterized by an **intense inflammatory cell infiltrate** within the thrombus and the vessel wall. In the acute phase, there is often **hypervascularization of the vasa vasorum** (the vessels that supply the vessel walls) rather than constriction. Furthermore, the internal elastic lamina remains intact, distinguishing it from systemic vasculitis. ### **Analysis of Incorrect Options (Findings seen in TAO)** * **A. Corkscrew vessels:** As the main arteries (like the ulnar, radial, or tibial) undergo segmental occlusion, the body attempts to bypass the blockages via dilated, tortuous collateral vessels. These are classically described as "corkscrew" collaterals (Martorell’s sign). * **B. Rippled artery:** This refers to a wavy or corrugated appearance of the arterial wall seen on angiography, often caused by longitudinal contraction of the vessel or stationary waves. It is a recognized, though less specific, angiographic sign of TAO. * **D. Spider leg collaterals:** Similar to corkscrew vessels, these represent exuberant collateralization around a point of occlusion, giving a "spider-like" or "tree-root" appearance. ### **High-Yield Clinical Pearls for NEET-PG** * **Classic Triad:** Claudication (arch of foot/calf), Raynaud’s phenomenon, and migratory superficial thrombophlebitis. * **Demographics:** Strongly associated with **heavy tobacco use** in young males (<45 years). * **Angiographic Hallmark:** Segmental "skip" lesions with distal occlusions and "corkscrew" collaterals in the absence of proximal atherosclerosis. * **Allen’s Test:** Often positive, indicating involvement of the radial or ulnar arteries. * **Management:** Absolute smoking cessation is the only way to halt disease progression.

Question 24: Which condition is characterized by the presence of the figure of three signs?

A. Mitral Stenosis
B. Coarctation of Aorta (Correct Answer)
C. Transposition of Great Arteries
D. Aortic Stenosis

Explanation: **Explanation:** The **Figure of 3 sign** is a classic radiological hallmark of **Coarctation of the Aorta** seen on a frontal chest X-ray. It is formed by the contour of the aorta: * **Upper convexity:** Formed by the dilated pre-stenotic segment (left subclavian artery and aortic arch). * **Indentation:** Represents the site of the actual coarctation (narrowing). * **Lower convexity:** Formed by the post-stenotic dilatation of the descending aorta. On a Barium swallow, this same pathology produces the **"E sign"** (or reverse 3 sign) due to the indentation of the esophagus by the dilated segments. **Analysis of Incorrect Options:** * **Mitral Stenosis:** Characterized by left atrial enlargement, leading to a "straightening of the left heart border," "double atrial shadow," and "Kerley B lines" due to pulmonary venous hypertension. * **Transposition of Great Arteries (TGA):** Classically presents with an **"Egg-on-a-string"** appearance due to a narrow mediastinum (atrophy of the thymus and hyperinflated lungs) and a globular heart. * **Aortic Stenosis:** Typically shows a prominent ascending aorta due to post-stenotic dilatation and a "boot-shaped heart" (though more common in Tetralogy of Fallot) or left ventricular hypertrophy (rounded apex). **High-Yield Clinical Pearls for NEET-PG:** * **Rib Notching (Roesler Sign):** Seen in Coarctation, typically involving the 3rd to 8th ribs. It is caused by pressure erosion from dilated intercostal arteries (collateral circulation). It is **not** seen in the 1st and 2nd ribs as they are supplied by the costocervical trunk. * **Clinical Triad:** Radio-femoral delay, upper limb hypertension, and a systolic murmur over the back (interscapular area).

Question 25: A left-sided cardiac bulge seen on chest X-ray is most likely due to which of the following?

A. Enlargement of the left atrial appendage (Correct Answer)
B. Azygos vein enlargement
C. Coronary artery aneurysm
D. Pulmonary edema

Explanation: ### Explanation The correct answer is **Enlargement of the left atrial appendage (LAA)**. On a standard frontal chest X-ray (PA view), the **left heart border** is formed by four distinct segments (from superior to inferior): 1. **Aortic Arch (Aortic Knuckle)** 2. **Pulmonary Trunk (Main Pulmonary Artery)** 3. **Left Atrial Appendage (LAA)** 4. **Left Ventricle** Normally, the LAA segment is flat or slightly concave. When the left atrium enlarges (most commonly due to **Mitral Stenosis**), the LAA becomes prominent, creating a "bulge" or "straightening" of the left heart border. This is often referred to as the **"Third Mogul"** sign (the first being the aorta and the second being the pulmonary artery). #### Why the other options are incorrect: * **Azygos vein enlargement:** This typically presents as a rounded opacity at the **right tracheobronchial angle**, not on the left cardiac border. * **Coronary artery aneurysm:** While these can occur, they are rarely large enough to cause a discrete bulge on a routine chest X-ray and are not a classic radiological sign for heart border changes. * **Pulmonary edema:** This presents with bilateral perihilar "bat-wing" opacities, Kerley B lines, and pleural effusions, rather than a localized focal bulge of the cardiac contour. #### High-Yield Clinical Pearls for NEET-PG: * **Mitral Stenosis (MS):** The most common cause of LAA enlargement. Look for the **"Double Density Sign"** (right side) and **"Walking-man sign"** (splaying of the carina) on the same X-ray. * **Right Heart Border:** Formed by the Superior Vena Cava (top) and the Right Atrium (bottom). The Right Ventricle does **not** form a border on the PA view (it is anterior). * **Boot-shaped heart (Coeur en sabot):** Seen in Tetralogy of Fallot due to right ventricular hypertrophy lifting the apex.

Question 26: The prominent left border of the heart is formed by all the following except:

A. Azygous vein (Correct Answer)
B. Pericardial cyst
C. Coronary artery aneurysm
D. Enlarged left auricular appendage aneurysm

Explanation: The left border of the heart on a frontal chest X-ray is formed by specific anatomical structures. Understanding these is crucial for identifying pathology. **Explanation of the Correct Answer:** **A. Azygous vein:** This is the correct answer because the azygous vein is located in the **right** posterior mediastinum. It arches over the right main bronchus to drain into the Superior Vena Cava (SVC). On a chest X-ray, an enlarged azygous vein (often due to portal hypertension or SVC obstruction) appears as a rounded opacity at the **right tracheobronchial angle**, not the left. **Explanation of Incorrect Options:** * **B. Pericardial cyst:** These are most commonly found in the right cardiophrenic angle, but they can occur on the left, where they would blur or add prominence to the left heart border. * **C. Coronary artery aneurysm:** An aneurysm of the Left Main or Left Anterior Descending (LAD) coronary artery can project laterally, creating a localized bulge or prominence on the left cardiac contour. * **D. Enlarged left auricular appendage:** The left atrium is normally posterior, but its appendage (auricle) forms a segment of the left heart border (just below the pulmonary artery). Enlargement (common in mitral stenosis) leads to the "four-bump" heart sign on the left border. **NEET-PG High-Yield Pearls:** * **Normal Left Heart Border (Top to Bottom):** Aortic arch (knuckle) → Pulmonary trunk → Left auricular appendage → Left ventricle. * **Normal Right Heart Border:** SVC → Right atrium → IVC (occasionally). Note: The **Right Ventricle** does not form a border on a PA view. * **Azygous Vein Width:** Normally <7mm on a standing CXR; >10mm suggests increased central venous pressure.

Question 27: What is the investigation of choice for radiotherapy/chemotherapy induced myocardial damage?

A. CT scan
B. MRI
C. Endomyocardial biopsy (Correct Answer)
D. Precordial Doppler

Explanation: **Explanation:** The gold standard and investigation of choice for diagnosing radiotherapy or chemotherapy-induced myocardial damage (specifically anthracycline-induced cardiotoxicity) is an **Endomyocardial Biopsy (EMB)**. **Why Endomyocardial Biopsy is correct:** Chemotherapeutic agents like Doxorubicin cause dose-dependent histological changes, such as myofibrillar loss and cytoplasmic vacuolization (Sarcoplasmic reticulum dilatation). EMB is the most sensitive and specific method to detect these subclinical changes *before* a significant drop in the Left Ventricular Ejection Fraction (LVEF) occurs, allowing for the modification of treatment to prevent irreversible heart failure. **Why other options are incorrect:** * **CT Scan:** While useful for pericardial thickening or calcification post-radiation, it lacks the resolution to detect microscopic cellular damage to myocytes. * **MRI:** Cardiac MRI (using T1/T2 mapping and Late Gadolinium Enhancement) is excellent for detecting fibrosis and inflammation. While it is the "non-invasive" investigation of choice for many cardiomyopathies, it remains secondary to biopsy for definitive histopathological grading of drug-induced damage. * **Precordial Doppler:** This is used to assess diastolic and systolic function. While commonly used for routine monitoring (via MUGA or Echo), it only detects damage once functional impairment has already started, making it less sensitive than a biopsy. **High-Yield Clinical Pearls for NEET-PG:** * **Most common Echo finding:** Decrease in LVEF is the classic sign of toxicity. * **Anthracycline Toxicity:** Characterized by "Adriamycin cells" (vacuolated myocytes). * **Radiation Heart Disease:** Often presents as restrictive cardiomyopathy, constrictive pericarditis, or accelerated coronary artery disease. * **Biomarkers:** Troponin I and BNP are increasingly used as early biochemical markers of cardiotoxicity.

Question 28: Transesophageal echocardiogram (TEE) is superior to transthoracic echocardiogram (TTE) because of which of the following advantages?

A. Convenience
B. Higher sensitivity in detecting left ventricular apical thrombus
C. Higher sensitivity in detecting atheromatous plaques in the ascending thoracic aorta (Correct Answer)
D. Higher sensitivity in detecting atrial appendage thrombus

Explanation: **Explanation:** The superiority of **Transesophageal Echocardiography (TEE)** over Transthoracic Echocardiography (TTE) stems from the transducer's proximity to the heart and the absence of intervening lung tissue or ribs. This allows for the use of higher-frequency ultrasound, providing superior spatial resolution of posterior cardiac structures. **Why Option C is Correct:** TEE is the gold standard for evaluating the **thoracic aorta** (ascending, arch, and descending). Because the esophagus lies directly behind the aorta, TEE provides high-resolution images that can detect **atheromatous plaques**, ulcers, and dissections with much higher sensitivity than TTE, which often has a "blind spot" in the distal ascending aorta and arch due to air in the trachea. **Analysis of Incorrect Options:** * **Option A:** TTE is more **convenient** as it is non-invasive, bedside-friendly, and requires no sedation. TEE is semi-invasive and requires patient preparation. * **Option B:** TTE is actually superior for detecting **Left Ventricular (LV) apical thrombi**. The LV apex is the most anterior part of the heart; it is often in the "far-field" for a TEE probe but is easily visualized using a high-frequency linear probe or standard apical views on TTE. * **Option D:** While TEE is indeed the gold standard for **Left Atrial Appendage (LAA) thrombus**, the question asks for the *best* advantage among the provided options. In many standardized exams, the visualization of the **aorta** is highlighted as a specific structural advantage of TEE over TTE. *(Note: While TEE is highly sensitive for LAA thrombus, Option C is often the preferred answer in radiology-specific contexts regarding vascular pathology).* **Clinical Pearls for NEET-PG:** * **TEE is the investigation of choice for:** Infective endocarditis (vegetations), Left Atrial Appendage thrombus (pre-cardioversion), and Prosthetic valve dysfunction. * **TTE is the first-line investigation for:** Routine screening, valvular heart disease, and global ventricular function (EF). * **Absolute Contraindication for TEE:** Esophageal pathologies (e.g., stricture, perforation, or bleeding varices).

Question 29: Which of the following statements is TRUE about Coronary Calcium Scoring, EXCEPT?

A. It is done with the help of a CT scan machine.
B. It requires the administration of iodinated contrast. (Correct Answer)
C. A score greater than 400 indicates a very high risk of ischemic heart disease.
D. The radiation dose is approximately 1-2 mSv.

Explanation: ### Explanation **Coronary Artery Calcium (CAC) Scoring** is a non-invasive screening tool used to quantify the burden of atherosclerotic plaque in the coronary arteries. **Why Option B is the correct answer (The "Except" statement):** Coronary Calcium Scoring is a **non-contrast** study. It relies on the high attenuation (density) of calcium deposits, which are naturally radio-opaque. Administering iodinated contrast would fill the vessel lumen with high-density material, making it impossible to distinguish between the contrast in the blood and the calcium in the vessel wall. Contrast is only used in *Coronary CT Angiography (CCTA)*, not for calcium scoring. **Analysis of other options:** * **Option A:** It is performed using **Multi-Detector Computed Tomography (MDCT)**, typically with ECG-gating to minimize motion artifacts from the beating heart. * **Option C:** The **Agatston Score** is the standard reporting method. A score of **>400** represents extensive plaque burden and indicates a very high risk of a major adverse cardiovascular event (MACE). * **Option D:** It is a low-dose procedure. The radiation dose typically ranges between **1–2 mSv**, which is significantly lower than a standard diagnostic CT chest or a full coronary angiogram. --- ### High-Yield Clinical Pearls for NEET-PG * **Agatston Score Categories:** * 0: No disease * 1–10: Minimal disease * 11–100: Mild disease * 101–400: Moderate disease * >400: Severe disease * **Primary Use:** It is most useful for risk stratification in **asymptomatic** individuals with intermediate risk. * **Limitation:** A score of 0 does not 100% rule out CAD, as it cannot detect **"soft" (non-calcified) plaques**, which are prone to rupture. * **Technical Requirement:** Requires a high temporal resolution; hence, a minimum of a 16-slice (preferably 64-slice) CT scanner is used.

Question 30: Which of the following is NOT a radiological sign of coarctation of the aorta?

A. Rib notching
B. 'E' sign
C. Normal shaped heart
D. 'Egg on side' appearance (Correct Answer)

Explanation: **Explanation:** The **'Egg on side' (or Egg-on-a-string) appearance** is the classic radiological hallmark of **Transposition of the Great Arteries (TGA)**, not coarctation of the aorta. It occurs due to a narrow mediastinum (caused by the anteroposterior relationship of the great vessels and thymic atrophy) and a globular, enlarged heart. **Analysis of other options:** * **Rib Notching (Roesler’s Sign):** This is a classic sign of post-ductal coarctation. It occurs due to pressure erosion of the inferior margins of the 3rd to 8th ribs by dilated, tortuous intercostal arteries acting as collateral pathways. * **'E' Sign (or Figure-of-3 Sign):** On a Barium swallow, the esophagus shows an **'E' indentation** due to the pre-stenotic dilation, the site of coarctation, and the post-stenotic dilation. On a plain Chest X-ray, the contour of the aorta itself resembles a **'3'**. * **Normal shaped heart:** In many cases of coarctation, the heart size remains normal for a long period because the left ventricular hypertrophy (LVH) is concentric. Cardiomegaly only develops once heart failure ensues. **High-Yield Clinical Pearls for NEET-PG:** * **Rib Notching:** Usually involves the **3rd to 8th ribs**. It spares the 1st and 2nd ribs because their intercostal arteries arise from the costocervical trunk, not the aorta distal to the coarctation. * **Association:** Coarctation is strongly associated with **Bicuspid Aortic Valve** (most common) and **Turner Syndrome**. * **Physical Exam:** Look for **radio-femoral delay** and a blood pressure discrepancy between upper and lower limbs.

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