Cardiovascular Radiology Practice Questions

Q: Which of the following chemicals or isotopes is used in cardiac ventriculography?

Technetium. **Explanation:** **Cardiac Ventriculography** (specifically Radionuclide Ventriculography or MUGA scan) is a nuclear medicine study used to evaluate ventricular function, wall motion, and Ejection Fraction (EF). 1. **Why Technetium is correct:** The procedure utilizes **Technetium-99m ($^{99m}Tc$)**, usually tagged to Red Blood Cells (RBCs) or human serum albumin. Because the radioactive tracer remains within the intravascular compartment, a gamma camera can visualize the blood pool within the cardiac chambers. By synchronizing the image acquisition with an ECG (Gated study), clinicians can calculate the Left Ventricular Ejection Fraction (LVEF), which is the gold standard for monitoring cardiotoxicity (e.g., in patients on Doxorubicin). 2. **Why other options are incorrect:** * **Gallium (Ga-67):** Used primarily for imaging chronic inflammation, infections (like sarcoidosis), or certain tumors (lymphoma). It is not used for functional ventricular imaging. * **Lipodate:** An oral iodinated contrast medium formerly used for cholecystography (gallbladder imaging). It has no role in cardiac imaging. * **Diatrizoate:** A high-osmolar ionic contrast medium used in conventional X-ray angiography. While used in *invasive* catheter-based ventriculography, the term "ventriculography" in the context of isotopes specifically refers to nuclear medicine studies where Technetium is the agent of choice. **High-Yield Pearls for NEET-PG:** * **MUGA Scan:** Stands for Multi-Gated Acquisition scan. * **Best Parameter:** MUGA is considered more accurate and reproducible than Echocardiography for measuring LVEF. * **Radiopharmaceutical:** $^{99m}Tc$-pertechnetate is the most common isotope used in various scans due to its short half-life (6 hours) and optimal energy (140 keV).

Q: In which of the following conditions is an increased cardiac silhouette NOT seen, except?

Tetralogy of Fallot. This question uses a double negative ("NOT seen, except"), which essentially asks: **"In which of the following conditions is an increased cardiac silhouette NOT seen?"** ### **Explanation** In **Tetralogy of Fallot (TOF)**, the heart size is typically **normal** on a chest X-ray. Although there is right ventricular hypertrophy (RVH), the heart does not enlarge overall because the pulmonary artery segment is concave (due to infundibular stenosis) and the left ventricle is often smaller than normal. The classic "Cœur en sabot" (boot-shaped heart) appearance is due to the upward tilting of the apex by RVH, not a generalized increase in the cardiac silhouette. ### **Analysis of Other Options** * **Pericardial Effusion:** Characterized by a significantly enlarged, globular, or "water-bottle" shaped heart once more than 250ml of fluid accumulates. * **Aortic Regurgitation:** Leads to left ventricular volume overload, resulting in significant cardiomegaly and a "down and out" apex. * **Ebstein Anomaly:** This condition produces some of the largest cardiac silhouettes seen in pediatric radiology ("box-shaped" heart) due to massive right atrial enlargement. ### **NEET-PG High-Yield Pearls** * **Normal Heart Size in Cyanotic Heart Disease:** Think **TOF** or **Tricuspid Atresia** (early stages). * **Classic X-ray Signs:** * **TOF:** Boot-shaped heart (Cœur en sabot). * **Ebstein Anomaly:** Box-shaped heart. * **TGA (Transposition of Great Arteries):** Egg-on-side appearance. * **TAPVC (Total Anomalous Pulmonary Venous Connection):** Snowman or Figure-of-8 appearance. * **Cardiothoracic (CT) Ratio:** A ratio >0.5 in adults or >0.6 in neonates indicates cardiomegaly.

Q: Rib notching is a feature of which congenital heart anomaly?

Coarctation of the Aorta. **Explanation:** **Coarctation of the Aorta** is the correct answer because rib notching is a classic radiological sign of this condition. In post-ductal coarctation, there is a narrowing of the aorta distal to the origin of the left subclavian artery. To bypass this obstruction, the body develops **collateral circulation**. Blood flows through the internal mammary arteries to the intercostal arteries to reach the descending aorta. The resulting high-pressure, turbulent flow causes the **intercostal arteries to become dilated and tortuous**, which leads to pressure erosion (notching) on the **inferior margins** of the 3rd to 8th ribs. **Why other options are incorrect:** * **Atrial Septal Defect (ASD):** This is an acyanotic heart disease characterized by a left-to-right shunt at the atrial level. Radiologically, it presents with cardiomegaly (RA/RV enlargement) and increased pulmonary vascular markings, but no collateral circulation involving intercostal arteries. * **Patent Ductus Arteriosus (PDA):** This involves a shunt between the aorta and the pulmonary artery. While it increases pulmonary blood flow, it does not necessitate the development of systemic collateral pathways that cause rib notching. **High-Yield Clinical Pearls for NEET-PG:** * **Roesler’s Sign:** The formal name for rib notching in Coarctation. * **Ribs Involved:** Usually the **3rd to 8th ribs**. The 1st and 2nd ribs are spared because their intercostal arteries arise from the costocervical trunk, not the aorta distal to the coarctation. * **Figure-of-3 Sign:** Seen on Chest X-ray, representing pre-stenotic dilation, the indentation (coarctation), and post-stenotic dilation. * **Reverse E Sign:** The corresponding indentation seen on a Barium swallow study. * **Clinical Finding:** Radio-femoral delay and upper limb hypertension.

Q: What is the characteristic radiographic appearance of aoitis?

Calcification of ascending aorta. **Explanation:** The characteristic radiographic finding in **syphilitic aortitis** is **calcification of the ascending aorta**. This occurs because *Treponema pallidum* involves the *vasa vasorum*, leading to endarteritis obliterans. This results in ischemia and subsequent destruction of the elastic tissue in the tunica media, which later undergoes dystrophic calcification. * **Why Option A is correct:** While atherosclerotic calcification typically involves the aortic arch and descending aorta, **linear calcification isolated to the ascending aorta** is highly specific for syphilitic aortitis. * **Why Option B is incorrect:** Calcification of the descending aorta is a common feature of **atherosclerosis**, especially in elderly, hypertensive, or diabetic patients. It is not specific to aortitis. * **Why Option C is incorrect:** While aortitis can lead to aneurysmal dilation of the ascending aorta, "dilation of the aortic arch" is a non-specific finding seen in chronic hypertension and aging (aortic unfolding). * **Why Option D is incorrect:** Left atrial enlargement is a hallmark of **Mitral Stenosis** or chronic mitral regurgitation, not primary aortic pathology. **High-Yield Clinical Pearls for NEET-PG:** * **"Eggshell calcification"** of the ascending aorta on a chest X-ray should immediately trigger suspicion of tertiary syphilis. * **Complications of Aortitis:** Aortic regurgitation (due to root dilation), coronary ostial stenosis, and saccular aneurysms. * **Atherosclerosis vs. Syphilis:** Atherosclerosis = Descending aorta; Syphilis = Ascending aorta.

Q: Which of the following statements is FALSE regarding Coarctation of the Aorta?

Rib notching is seen in 1-8 ribs. **Explanation:** In Coarctation of the Aorta (CoA), the narrowing typically occurs distal to the origin of the left subclavian artery. To bypass this obstruction, the body develops extensive collateral circulation via the intercostal arteries. **1. Why Option C is False (The Correct Answer):** Rib notching (Roesler’s sign) occurs due to the pressure erosion of the inferior surface of the ribs by dilated, tortuous intercostal arteries. It typically involves the **3rd to 8th ribs**. * **1st and 2nd ribs** are spared because their intercostal arteries arise from the costocervical trunk, which originates proximal to the coarctation. * **Lower ribs (9th-12th)** are spared because they do not participate in the collateral pathway to the descending aorta. **2. Analysis of Other Options:** * **Option A & B (Double Bulge / Double Aortic Knuckle):** These refer to the **"Figure of 3" sign** seen on a PA chest X-ray. The upper bulge is the dilated pre-stenotic segment (arch and left subclavian), and the lower bulge is the post-stenotic dilatation. On a Barium swallow, this corresponds to the **"Reverse 3" or "E" sign**. * **Option D:** Rib notching is rarely seen in infants. It develops over time as collaterals enlarge; thus, the prevalence and prominence of notching **increase with age**, usually becoming visible after 6–8 years of life. **Clinical Pearls for NEET-PG:** * **Turner Syndrome:** Most common chromosomal association. * **Bicuspid Aortic Valve:** Most common associated cardiac anomaly (up to 85%). * **Physical Exam:** Radio-femoral delay and upper limb hypertension. * **Imaging Gold Standard:** Cardiac MRI or CT Angiography.

Q: What is the investigation of choice to confirm hemochromatosis as the cause of cardiomyopathy?

MRI. **Explanation:** The investigation of choice for confirming and quantifying iron overload in the heart is **MRI**. Hemochromatosis leads to the deposition of paramagnetic iron (hemosiderin) in the myocardium, which causes a restrictive cardiomyopathy. **Why MRI is the Correct Answer:** MRI is uniquely sensitive to the magnetic properties of iron. Specifically, **T2* (T2-star) weighted imaging** is the gold standard. Iron deposits shorten the T2* relaxation time; the lower the T2* value (measured in milliseconds), the higher the concentration of iron in the tissue. This allows for non-invasive quantification of myocardial iron, which correlates directly with the risk of heart failure and guides chelation therapy. **Why Other Options are Incorrect:** * **ECG:** While it may show low voltage complexes or arrhythmias, these findings are non-specific and cannot confirm iron deposition. * **Echocardiogram:** Useful for assessing functional changes (diastolic dysfunction or reduced ejection fraction), but it cannot distinguish between different causes of restrictive cardiomyopathy (e.g., amyloidosis vs. hemochromatosis). * **CT Scan:** CT may occasionally show increased attenuation of the liver, but it lacks the sensitivity and specificity of MRI for myocardial iron quantification and involves ionizing radiation. **High-Yield Clinical Pearls for NEET-PG:** * **T2* MRI Value:** A value **<20 ms** indicates myocardial iron overload; **<10 ms** indicates a high risk of developing heart failure. * **Liver vs. Heart:** Myocardial iron deposition often lags behind hepatic deposition, making cardiac MRI essential even if liver enzymes are stable. * **Reversibility:** Unlike many other cardiomyopathies, iron-induced heart failure is often **reversible** with aggressive chelation therapy (e.g., Deferoxamine).

Q: A digital subtraction angiography of a 35-year-old smoker is shown. What is the possible diagnosis?

Buerger's disease. ***Buerger's disease*** - **Thromboangiitis obliterans** affecting young male smokers shows characteristic **segmental occlusions** of distal vessels with **corkscrew collaterals** on DSA. - Strong association with **heavy smoking** in patients under 45 years, causing **inflammatory thrombosis** of small and medium-sized arteries. *Atherosclerosis* - Typically affects **older patients** (>50 years) with **proximal vessel involvement** and **calcified plaques** visible on angiography. - Shows **smooth tapering** rather than the **abrupt segmental occlusions** characteristic of Buerger's disease. *Takayasu's arteritis* - Primarily affects **young women** with involvement of **large vessels** including the **aorta and its major branches**. - DSA shows **smooth stenoses** and **wall thickening** of proximal vessels, not distal segmental disease. *Kawasaki disease* - Occurs predominantly in **children under 5 years** with **coronary artery involvement** causing aneurysms. - Associated with **acute febrile illness** and **mucocutaneous manifestations**, not peripheral vascular disease in adults.

Question 1

Which of the following chemicals or isotopes is used in cardiac ventriculography?

Accepted Answer

Technetium

Answer

Gallium

Answer

Lipodate

Answer

Diatrizoate

Question 2

A 63-year-old patient with a history of tachyarrhythmias is on an implantable cardioverter-defibrillator (ICD). The patient suddenly develops shock. Which of the following is the best investigation to assess the position and integrity of the ICD?

Accepted Answer

Plain radiograph

Answer

MRI

Answer

USG

Answer

Contrast CT

Question 3

A 24-year-old woman presents with mildly painful swelling of her right leg and acute shortness of breath. She is 32 weeks pregnant with her second child and has no other medical history. Which of the following statements is NOT true regarding this condition?

Accepted Answer

D-Dimer assay could be an important diagnostic tool.

Answer

Deep vein thrombosis and venous obstruction by the pregnant uterus are likeliest causes.

Answer

An ultrasound of the deep veins of the right leg should be performed.

Answer

A V/Q scan can be helpful in this condition.

Question 4

In which of the following conditions is an increased cardiac silhouette NOT seen, except?

Accepted Answer

Tetralogy of Fallot

Answer

Pericardial effusion

Answer

Aortic regurgitation

Answer

Ebstein anomaly

Question 5

Rib notching is a feature of which congenital heart anomaly?

Accepted Answer

Coarctation of the Aorta

Answer

Atrial Septal Defect (ASD)

Answer

Patent Ductus Arteriosus (PDA)

Answer

All of the above

Question 6

What is the characteristic radiographic appearance of aoitis?

Accepted Answer

Calcification of ascending aorta

Answer

Calcification of descending aorta

Answer

Dilation of the aortic arch

Answer

Enlargement of the left atrium

Question 7

Which of the following statements is FALSE regarding Coarctation of the Aorta?

Accepted Answer

Rib notching is seen in 1-8 ribs

Answer

Double bulge sign is seen

Answer

Double aortic knuckle is seen

Answer

Rib notching increases with age

Question 8

What is the investigation of choice to confirm hemochromatosis as the cause of cardiomyopathy?

Accepted Answer

MRI

Answer

ECG

Answer

Echocardiogram

Answer

CT scan

Question 9

A digital subtraction angiography of a 35-year-old smoker is shown. What is the possible diagnosis?

Accepted Answer

Buerger's disease

Answer

Atherosclerosis

Answer

Takayasu's arteritis

Answer

Kawasaki disease

Question 10

What is the best initial investigation for a suspected case of Dysphagia lusoria?

Accepted Answer

Magnetic resonance angiography (MRA)

Answer

High-resolution computed tomography (HRCT)

Answer

Spiral CT

Answer

Digital subtraction angiography (DSA)

Cardiovascular Radiology — MCQs

Cardiovascular Radiology — MCQs

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