Cardiovascular Radiology Practice Questions

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.

Q: Which imaging modality is used to diagnose a vascular ring causing external airway compression?

Angiography of aortic and pulmonary circulation. **Explanation:** The diagnosis of a **vascular ring**—a congenital anomaly where the aortic arch and its branches encircle and compress the trachea and esophagus—requires precise visualization of the vascular anatomy in relation to the airway. **1. Why Option D is Correct:** Historically and for definitive diagnostic confirmation, **Angiography of the aortic and pulmonary circulation** is considered the gold standard. It provides a detailed "map" of the aberrant vessels, their origins, and their relationship to the pulmonary arteries. In the context of NEET-PG, while non-invasive imaging is common in practice, angiography remains the classic academic answer for definitive diagnosis of complex vascular malformations causing mechanical compression. **2. Why Other Options are Incorrect:** * **CT (Option A):** While MDCT (Multidetector CT) is excellent for visualizing the airway (tracheomalacia) and vessel wall, it involves ionizing radiation and was traditionally secondary to angiography for surgical planning. * **PET CT (Option B):** This is a functional imaging modality used primarily for oncology and inflammation; it has no role in diagnosing structural vascular anomalies. * **MRI (Option C):** Cardiac MRI is excellent for flow dynamics and anatomy without radiation, but it is often limited by long acquisition times and is less effective than angiography for fine branching patterns in infants. **Clinical Pearls for NEET-PG:** * **Most common vascular ring:** Double Aortic Arch. * **Clinical Presentation:** "Stridor since birth," "barking cough," and dysphagia (dysphagia lusoria). * **Barium Swallow Finding:** Posterior indentation of the esophagus is a classic sign of a vascular ring. * **Echocardiography:** Often the first-line screening tool, but limited by the "acoustic window" in visualizing the retro-esophageal vessels.

Q: Which condition is characterized by an "egg in cup" appearance on imaging?

Constrictive pericarditis. **Explanation:** **1. Why Constrictive Pericarditis is Correct:** The "egg in cup" appearance is a classic radiological sign of **Constrictive Pericarditis**. In this condition, chronic inflammation leads to a thickened, fibrotic, and often calcified pericardium. On a lateral chest X-ray or CT scan, the heart (the "egg") appears encased within a rigid, calcified shell (the "cup"). This calcification is most commonly seen in the atrioventricular grooves. **2. Analysis of Incorrect Options:** * **Tetralogy of Fallot (TOF):** Characterized by a **"Boot-shaped heart"** (Coeur en sabot) due to right ventricular hypertrophy and an upturned apex. * **Mitral Regurgitation (MR):** Typically presents with left atrial and left ventricular enlargement. While it can lead to a "double atrial shadow," it does not produce a calcified "cup" appearance. * **Transposition of the Great Vessels (TGA):** Characterized by an **"Egg-on-a-string"** appearance. The "egg" represents the globular cardiomegaly, and the "string" represents the narrowed superior mediastinum due to the stress-induced thymic atrophy and the anteroposterior alignment of the great vessels. **3. Clinical Pearls for NEET-PG:** * **Most common cause** of constrictive pericarditis in India is **Tuberculosis**. * **Kussmaul’s sign** (paradoxical rise in JVP on inspiration) and **Pericardial knock** (early diastolic sound) are key clinical findings. * **Imaging Gold Standard:** Cardiac MRI or CT is superior to X-ray for visualizing pericardial thickening (>3mm). * **Surgical Treatment:** Pericardiectomy.

Q: The "Inveed Moustache Sign" is seen in which of the following conditions?

Congestive heart failure (CHF). ### Explanation The **"Inverted Moustache Sign"** (also known as the **Antler Sign** or **Cephalization**) is a classic radiological finding in **Congestive Heart Failure (CHF)**, specifically indicating pulmonary venous hypertension. **1. Why CHF is Correct:** In a healthy upright individual, gravity causes better perfusion of the lower lung zones. However, in CHF, as the Left Atrial Pressure (LAP) rises (typically to 12–18 mmHg), there is a redistribution of blood flow to the upper lobes. This occurs due to perivascular edema in the lower lobes causing reflex vasoconstriction. On a chest X-ray, the upper lobe pulmonary veins become dilated and prominent, curving upward and outward, resembling an **inverted moustache** or **deer antlers**. **2. Analysis of Incorrect Options:** * **TAPVC (Total Anomalous Pulmonary Venous Connection):** Supracardiac TAPVC is associated with the **"Snowman Sign"** or **"Figure of 8"** appearance due to a dilated vertical vein and SVC. * **PAPVC (Partial Anomalous Pulmonary Venous Connection):** Often associated with the **"Scimitar Sign,"** where an anomalous pulmonary vein drains into the IVC, appearing as a curved sword parallel to the right heart border. * **Constrictive Pericarditis:** The hallmark radiological sign is **pericardial calcification** (best seen on a lateral X-ray) and a narrow, tubular heart. **3. Clinical Pearls for NEET-PG:** * **Stages of Pulmonary Edema on CXR:** * **Stage 1 (Redistribution):** Cephalization/Inverted Moustache Sign (PCWP 13–18 mmHg). * **Stage 2 (Interstitial Edema):** Kerley B lines, peribronchial cuffing, and hazy hila (PCWP 18–25 mmHg). * **Stage 3 (Alveolar Edema):** **"Bat-wing"** or **"Butterfly"** opacities (PCWP >25 mmHg). * **Kerley B lines** are short, horizontal lines perpendicular to the pleura at the lung bases, representing thickened interlobular septa.

Q: Which technique is not recently used to check for disorder or patency of coronary artery circulation?

Ultrasound (USG). **Explanation:** The core of this question lies in the anatomical location and size of the coronary arteries. The coronary arteries are small vessels (2–4 mm) located deep within the chest, behind the bony rib cage and air-filled lungs, and are constantly moving due to the cardiac cycle. **Why Ultrasound (USG) is the correct answer:** Standard transabdominal or surface **Ultrasound (USG)** cannot be used to visualize coronary artery patency. This is because ultrasound waves cannot penetrate bone (ribs/sternum) or air (lungs) effectively to reach the heart with enough resolution to see tiny coronary vessels. Therefore, conventional USG has no role in assessing coronary circulation. **Analysis of Incorrect Options:** * **Intravascular Ultrasound (IVUS):** This is a "gold standard" invasive imaging modality where a miniature ultrasound probe is placed *inside* the artery via a catheter. It provides high-resolution cross-sectional images of the vessel wall and plaque. * **CT Angiography (CCTA):** This is the most common non-invasive method used recently to check patency. Multidetector CT (MDCT) allows for excellent visualization of the coronary lumen and detection of stenosis. * **Echocardiography:** While it doesn't see the arteries directly as well as CT, it is used to check for "regional wall motion abnormalities" (RWMA). If a coronary artery is blocked, the corresponding heart muscle won't contract properly, indirectly indicating a circulation disorder. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard for Coronary Anatomy:** Conventional Coronary Angiography (Invasive). * **Best Non-Invasive Screening:** CT Coronary Angiography (High Negative Predictive Value). * **IVUS Use:** Best for assessing stent apposition and plaque morphology during PCI. * **Fractional Flow Reserve (FFR):** The modern standard for assessing the *functional* significance of a coronary stenosis.

Q: Which imaging modality is best for assessing plaque morphology in atherosclerosis?

Coronary Computed Tomography Angiography (CCTA). **Explanation:** **Coronary Computed Tomography Angiography (CCTA)** is the correct answer because it is the only non-invasive modality capable of visualizing the vessel wall itself, rather than just the lumen. CCTA utilizes Hounsfield Units (HU) to differentiate between various plaque components based on their density. It can identify **calcified plaques** (high density), **non-calcified/soft plaques** (low density), and **lipid-rich necrotic cores**. This ability to characterize plaque morphology is crucial for identifying "vulnerable plaques" (e.g., positive remodeling, low-attenuation plaque, and the "napkin-ring sign") which are prone to rupture. **Why other options are incorrect:** * **Coronary Angiography (CAG):** While it is the "Gold Standard" for assessing luminal stenosis, it is a **luminogram**. It shows the flow of dye within the vessel but cannot visualize the vessel wall or the internal morphology of the plaque. * **Echocardiography:** This is excellent for assessing cardiac chambers, valves, and wall motion abnormalities, but it lacks the spatial resolution to visualize coronary artery plaque morphology. * **Electrocardiogram (ECG):** This measures the electrical activity of the heart. It can detect ischemia or infarction resulting from plaque rupture but cannot visualize the plaque itself. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard for Plaque Morphology (Invasive):** Intravascular Ultrasound (IVUS) or Optical Coherence Tomography (OCT). * **Best Non-Invasive Modality:** CCTA. * **Negative Predictive Value (NPV):** CCTA has a very high NPV (~99%), making it excellent for ruling out Coronary Artery Disease (CAD) in low-to-intermediate risk patients. * **Calcium Scoring:** Uses the **Agatston Score** on non-contrast CT to predict future cardiovascular events.

Q: Ground glass appearance of the ventricular septum is seen in which of the following conditions?

Hypertrophic Obstructive Cardiomyopathy (HOCM). ### Explanation **Correct Answer: B. Hypertrophic Obstructive Cardiomyopathy (HOCM)** The "ground glass appearance" of the ventricular septum is a characteristic finding on **Echocardiography** (specifically 2D-Echo) in patients with HOCM. This appearance is due to the **disarray of myocardial fibers** and the presence of interstitial fibrosis. In HOCM, the normal parallel arrangement of myocytes is replaced by a disorganized, "whorled" pattern. These abnormal interfaces reflect ultrasound waves differently, resulting in a speckled, bright, or "ground glass" echogenicity within the thickened interventricular septum. **Analysis of Incorrect Options:** * **A. Tetralogy of Fallot (TOF):** Characterized by a "boot-shaped heart" (Coeur en sabot) on X-ray due to right ventricular hypertrophy and an upturned apex, but it does not feature ground glass septal changes. * **C. Transposition of the Great Arteries (TGA):** Classically presents with an "egg-on-a-string" appearance on a chest X-ray due to a narrow mediastinum. * **D. Congestive Heart Failure (CHF):** Radiological hallmarks include cardiomegaly, Kerley B lines, cephalization of pulmonary veins (Antler sign), and pleural effusion. **High-Yield Clinical Pearls for NEET-PG:** * **HOCM Echo Triad:** Asymmetric Septal Hypertrophy (ASH), Systolic Anterior Motion (SAM) of the mitral valve, and mid-systolic closure of the aortic valve. * **Genetic Basis:** Most commonly due to mutations in the **Beta-myosin heavy chain** or Myosin-binding protein C genes. * **Murmur:** Harsh systolic ejection murmur that **increases** with Valsalva or standing (decreased preload) and **decreases** with squatting (increased preload).

Q: What is the likely diagnosis based on the provided chest X-ray?

Tetralogy of Fallot (TOF). ***Tetralogy of Fallot (TOF)*** - Classic **"boot-shaped heart"** (coeur en sabot) appearance on chest X-ray with **upturned apex** due to right ventricular hypertrophy and **concave main pulmonary artery segment**. - **Decreased pulmonary vascularity** (oligemia) is characteristic due to pulmonary stenosis limiting blood flow to the lungs. *Total anomalous pulmonary venous connection (TAPVC)* - Typically shows the **"snowman sign"** or **"figure-of-8"** configuration on chest X-ray due to dilated vertical vein and left innominate vein. - Associated with **increased pulmonary vascularity** and **cardiomegaly**, not the boot-shaped heart seen here. *Ventricular septal defect (VSD)* - Chest X-ray shows **increased pulmonary vascularity** due to left-to-right shunting and **cardiomegaly** from volume overload. - Heart shape remains **normal** without the characteristic boot appearance or decreased pulmonary flow. *Atrial septal defect (ASD)* - Presents with **cardiomegaly** and **prominent pulmonary vasculature** due to increased pulmonary blood flow from left-to-right shunting. - **Right heart enlargement** may be present but lacks the specific boot-shaped configuration and pulmonary oligemia.

Question 1

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 2

Cardiac CT is best performed during which phase of the cardiac cycle?

Accepted Answer

Mid diastole

Answer

Early systole

Answer

Mid systole

Answer

Early diastole

Question 3

What does a CT of the Thorax primarily represent?

Accepted Answer

Descending aortic dissection

Answer

Ascending aortic dissection

Answer

Aortic aneurysm

Answer

Cystic fibrosis

Question 4

Which imaging modality is used to diagnose a vascular ring causing external airway compression?

Accepted Answer

Angiography of aortic and pulmonary circulation

Answer

CT

Answer

PET CT

Answer

MRI

Question 5

Which condition is characterized by an "egg in cup" appearance on imaging?

Accepted Answer

Constrictive pericarditis

Answer

Tetralogy of Fallot (TOF)

Answer

Mitral Regurgitation (MR)

Answer

Transposition of great vessels

Question 6

The "Inveed Moustache Sign" is seen in which of the following conditions?

Accepted Answer

Congestive heart failure (CHF)

Answer

Total anomalous pulmonary venous connection (TAPVC)

Answer

Partial anomalous pulmonary venous connection (PAPVC)

Answer

Constrictive pericarditis

Question 7

Which technique is not recently used to check for disorder or patency of coronary artery circulation?

Accepted Answer

Ultrasound (USG)

Answer

Intravascular Ultrasound (USG)

Answer

CT guided angiography

Answer

Echocardiography

Question 8

Which imaging modality is best for assessing plaque morphology in atherosclerosis?

Accepted Answer

Coronary Computed Tomography Angiography (CCTA)

Answer

Echocardiography

Answer

Electrocardiogram (ECG)

Answer

Coronary Angiography

Question 9

Ground glass appearance of the ventricular septum is seen in which of the following conditions?

Accepted Answer

Hypertrophic Obstructive Cardiomyopathy (HOCM)

Answer

Tetralogy of Fallot (TOF)

Answer

Transposition of the Great Arteries (TGA)

Answer

Congestive Heart Failure (CHF)

Question 10

What is the likely diagnosis based on the provided chest X-ray?

Accepted Answer

Tetralogy of Fallot (TOF)

Answer

Total anomalous pulmonary venous connection (TAPVC)

Answer

Ventricular septal defect (VSD)

Answer

Atrial septal defect (ASD)

Cardiovascular Radiology — MCQs

Cardiovascular Radiology — MCQs

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