Cardiovascular Radiology Practice Questions

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 of the following chest x-ray findings is a common feature of ARDS and cardiogenic pulmonary edema?

Alveolar and interstitial opacities. ### Explanation The correct answer is **D. Alveolar and interstitial opacities.** Both **Acute Respiratory Distress Syndrome (ARDS)** and **Cardiogenic Pulmonary Edema (CPE)** represent forms of pulmonary edema, though their underlying mechanisms differ. In both conditions, fluid accumulates within the lung parenchyma (interstitium) and eventually spills into the air sacs (alveoli). On a chest X-ray, this manifests as bilateral, patchy, or confluent opacities. While the distribution may vary—CPE often shows a "bat-wing" perihilar pattern and ARDS is often more peripheral—the presence of alveolar and interstitial opacities is the fundamental radiographic hallmark shared by both. #### Analysis of Incorrect Options: * **A. Cardiomegaly:** This is a classic feature of **CPE** (due to heart failure). In ARDS (non-cardiogenic edema), the heart size is typically normal. * **B. Pleural effusions:** These are common and often bilateral in **CPE**. While they can occur in ARDS, they are usually absent or very small. Their prominent presence strongly favors a cardiac etiology. * **C. Pulmonary vascular redistribution:** Also known as "cephalization" (prominent upper lobe vessels), this is an early sign of increased pulmonary venous pressure seen in **CPE**. It is not a feature of ARDS. #### High-Yield Clinical Pearls for NEET-PG: * **PCWP (Pulmonary Capillary Wedge Pressure):** The gold standard to differentiate the two. In CPE, PCWP is **>18 mmHg**; in ARDS, it is **≤18 mmHg**. * **Air Bronchograms:** More commonly seen in ARDS due to the dense alveolar consolidation. * **Kerley B Lines:** Horizontal lines at the lung bases indicating interstitial edema; these are characteristic of **CPE**, not ARDS. * **Key Differentiator:** If the CXR shows a normal heart size, no pleural effusion, and peripheral opacities, think **ARDS**.

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: Plethoric lung fields are seen in all of the following conditions, except?

Ebstein's anomaly. **Explanation:** The term **"Plethoric lung fields"** refers to increased pulmonary vascular markings on a chest X-ray, indicating increased pulmonary blood flow (Left-to-Right shunts). **1. Why Ebstein’s Anomaly is the Correct Answer:** Ebstein’s anomaly is characterized by the downward displacement of the tricuspid valve leaflets into the right ventricle, leading to "atrialization" of the ventricle. This results in severe tricuspid regurgitation and a functional reduction in right ventricular output. Consequently, there is **decreased pulmonary blood flow**, leading to **Oligemic lung fields** (translucent/darker lungs) rather than plethoric ones. It is classically associated with a "Box-shaped" heart. **2. Analysis of Incorrect Options:** * **Atrial Septal Defect (ASD):** A classic left-to-right shunt where blood flows from the left atrium to the right atrium, increasing the volume handled by the right heart and lungs, leading to plethora. * **Ventricular Septal Defect (VSD):** The most common congenital heart disease causing a left-to-right shunt at the ventricular level, resulting in increased pulmonary blood flow and plethora. * **Total Anomalous Pulmonary Venous Connection (TAPVC):** This is a cyanotic heart disease with **increased pulmonary blood flow** because all pulmonary veins drain into the right atrium (mixing of blood), leading to pulmonary plethora. **Clinical Pearls for NEET-PG:** * **Plethora (↑ Flow):** ASD, VSD, PDA, TAPVC, Transposition of Great Arteries (TGA). * **Oligemia (↓ Flow):** Fallot’s Tetralogy (TOF), Ebstein’s Anomaly, Tricuspid Atresia, Pulmonary Stenosis. * **Radiological Signs:** * **Ebstein’s:** Box-shaped heart. * **TAPVC (Supracardiac):** Snowman sign / Figure of 8 appearance. * **TOF:** Boot-shaped heart (Coeur en sabot).

Question 1

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 2

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 3

Which of the following is NOT a feature of a normal venous Doppler study?

Accepted Answer

Triphasic pattern

Answer

Flow ceases with Valsalva maneuver

Answer

Flow augmentation with distal compression

Answer

Compressibility

Question 4

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 5

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 6

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 7

Which of the following chest x-ray findings is a common feature of ARDS and cardiogenic pulmonary edema?

Accepted Answer

Alveolar and interstitial opacities

Answer

Cardiomegaly

Answer

Pleural effusions

Answer

Pulmonary vascular redistribution

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

Plethoric lung fields are seen in all of the following conditions, except?

Accepted Answer

Ebstein's anomaly

Answer

Atrial septal defect (ASD)

Answer

Total anomalous pulmonary venous connection (TAPVC)

Answer

Ventricular septal defect

Cardiovascular Radiology — MCQs

Cardiovascular Radiology — MCQs

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