Cardiovascular Radiology Practice Questions

Q: In the condition shown below, rib notching is present in which of the following ribs? (AIIMS Nov 2015)

3rd to 9th ribs. **3rd to 9th ribs** - The image provided depicts **coarctation of the aorta**, characterized by a narrowing of the aorta, typically distal to the origin of the left subclavian artery. - In coarctation of the aorta, collateral circulation develops through the **intercostal arteries** to bypass the constriction, leading to their enlargement and subsequent erosion of the inferior margins of the **3rd to 9th ribs**, a finding known as "rib notching." *1st to 9th ribs* - While rib notching affects upper ribs, it typically **spares the 1st and 2nd ribs** because the superior intercostal arteries (which supply these ribs) originate directly from the subclavian artery, often proximal to the coarctation, so they do not participate in collateral circulation as significantly. - The pattern of notching is usually more concentrated in the mid-thoracic region. *11th and 12th ribs* - Rib notching from coarctation of the aorta is rarely observed in the **floating ribs** (11th and 12th ribs). - These ribs have a different anatomical relationship with the pleura and typically do not bear the brunt of increased collateral flow from the intercostal arteries in the same way as the higher ribs. *All ribs* - Rib notching is a localized phenomenon reflecting increased blood flow through specific intercostal arteries involved in collateral circulation due to aortic coarctation. - Therefore, it does **not affect all ribs**, and its absence in certain ribs (like the 1st, 2nd, 11th, and 12th) helps differentiate this condition radiologically.

Q: A short stature female presents with history of wearing socks in summer season. Physical examination shows icy cold toes with cyanosis. CXR done shows:

Coarctation of aorta. ***Coarctation of aorta*** - The imaging provided illustrates **rib notching**, a classic radiographic sign caused by erosion of the inferior rib margins by enlarged intercostal arteries. This occurs as these arteries develop collateral circulation to bypass the narrowed aorta in **coarctation of the aorta**. - **Short stature** and **icy cold toes with cyanosis** are also consistent with coarctation of the aorta. The reduced blood flow to the lower extremities causes peripheral cyanosis and coldness, while reduced overall growth can lead to short stature. *Hyperparathyroidism* - This condition primarily affects **calcium and phosphate metabolism**, leading to bone resorption and potential features like subperiosteal bone erosion, brown tumors, and osteopenia. - It does not typically cause rib notching or the peripheral vascular symptoms described. *Neurofibromatosis* - Neurofibromatosis is a genetic disorder affecting **nerve tissue growth**, - It's associated with neurofibromas, café-au-lait spots, and Lisch nodules. While it can cause some skeletal abnormalities, **rib notching** as a primary feature is not typical, and the described peripheral vascular symptoms are not characteristic. *Multiple myeloma* - This is a **plasma cell malignancy** characterized by monoclonal immunoglobulin production, leading to lytic bone lesions, hypercalcemia, renal failure, and anemia. - While it affects bones and can produce lytic lesions in the ribs, it does not cause the characteristic **inferior rib notching** seen in the image, nor does it typically present with peripheral cyanosis and cold extremities directly related to a vascular obstruction.

Q: A 35-year-old hypertension patient has the following CXR in annual medical check up. What does it show?

Left ventricular hypertrophy. ***Left ventricular hypertrophy*** - The cardiac silhouette shows a **rounded left heart border** and an **increased cardiothoracic ratio**, particularly on the left side, indicating enlargement consistent with left ventricular hypertrophy. - This is commonly seen in patients with **long-standing hypertension** as the left ventricle works harder against elevated systemic vascular resistance. *Pulmonary artery hypertension* - This condition typically presents with **enlargement of the pulmonary arteries** in the hilar region, which is not prominently visible here. - While pulmonary hypertension can cause right ventricular enlargement, the image primarily suggests **left-sided cardiac enlargement**. *Coarctation of aorta* - While a cause of hypertension, coarctation of the aorta is often associated with specific radiographic findings such as **rib notching** (due to collateral vessel development) or a **'3' sign** in the aorta, none of which are evident in this image. - The image does not show a **narrowing of the aorta** or post-stenotic dilation. *Cor pulmonale* - Cor pulmonale involves **right ventricular enlargement** secondary to lung disease or pulmonary hypertension. - This would typically manifest as a prominent **right heart border** and potentially **increased retrosternal airspace** on a lateral view, which are not suggested by this frontal CXR.

Q: Identify the congenital heart disease presenting with cyanosis in CXR: (Recent NEET Pattern 2016-17)

Tetralogy of Fallot. ***Tetralogy of Fallot*** - The chest X-ray shows a **boot-shaped heart** (coeur en sabot) due to right ventricular hypertrophy and a concave pulmonary artery segment, which is a classic finding in Tetralogy of Fallot. - This cyanotic congenital heart disease is characterized by four defects: a **ventricular septal defect**, **pulmonary stenosis**, **overriding aorta**, and **right ventricular hypertrophy**. *Truncus Arteriosus* - This cyanotic CHD involves a **single arterial trunk** arising from the heart supplying systemic, pulmonary, and coronary circulations. - CXR typically shows **cardiomegaly with increased pulmonary vascular markings** and a **right-sided aortic arch** in 30% of cases, not the boot-shaped heart seen here. - The pulmonary artery segment is **prominent or convex**, contrasting with the concave segment in Tetralogy of Fallot. *Ebstein anomaly* - This anomaly involves the **tricuspid valve** being displaced into the right ventricle, often leading to cardiomegaly and a **"box-shaped" or "globular" heart** on CXR, which is not depicted. - It can cause cyanosis, but the characteristic CXR finding is **massive cardiomegaly with diminished pulmonary vascular markings**, not a boot-shaped heart. *Snowman heart* - The "snowman heart" or **"figure of 8" sign** is characteristic of **total anomalous pulmonary venous return (TAPVR)**, specifically the supracardiac type. - This appearance is due to the dilated superior vena cava and the vertical vein draining into it, creating the "head" of the snowman, which is not seen in the provided image.

Q: In the chest X-ray shown, identify the chamber enlargement:

Left atrium. ***Left atrium*** - The chest X-ray shows **double contour sign**, an increased **carinal angle**, and **elevation of the left main bronchus**, all classic signs of **left atrial enlargement**. - The convexity of the left heart border appears straightened, and there might be a "bulge" or straightening of the **left cardiac border**, further indicating left atrial enlargement. *Right atrium* - Right atrial enlargement would typically show a prominent **convexity of the right cardiac border** extending further to the right. - This image does not demonstrate significant prominence or bulging of the right heart border beyond what is expected. *Left ventricle* - Left ventricular enlargement usually presents as increased **cardiac apex prominence** and **downward displacement** of the cardiac apex. - While there is some cardiomegaly, the primary signs visible (double contour, carinal angle change) point more specifically to left atrial enlargement. *Right ventricle* - Right ventricular enlargement typically manifests as **increased prominence of the right ventricle** along the left heart border and an **uplifted cardiac apex**. - No clear evidence of right ventricular specific enlargement signs like severe right heart border prominence or uplifted apex is seen here.

Q: A chest X-ray (PA view) shows cardiomegaly. Identify the chamber enlargement:

Left ventricle. ***Left ventricle*** - The image shows significant **cardiomegaly**, with the **cardiac apex** shifted downwards and to the left, indicating **left ventricular enlargement**. - On a PA chest X-ray, left ventricular enlargement causes the **left heart border** to be elongated and extend beyond the **midclavicular line**. *Right atrium* - **Right atrial enlargement** typically manifests as an increased convexity of the **right heart border** on a PA chest X-ray. - While there is some right-sided prominence, it does not strongly suggest isolated right atrial enlargement in this view. *Left atrium* - **Left atrial enlargement** is characterized by a "double contour" sign, splaying of the carina, or elevation of the left main stem bronchus on a PA chest X-ray. - These signs are not clearly visible, and the overall cardiac silhouette points to ventricular enlargement. *Right ventricle* - **Right ventricular enlargement** often leads to an upward and posterior displacement of the apex or a generalized increase in the width of the heart, particularly on the left side, mimicking left ventricular enlargement in some cases. - However, the pronounced downward and leftward shift of the apex is more characteristic of left ventricular enlargement.

Q: In the chest X-ray shown below, identify the chamber enlargement:

Left ventricle. ***Left ventricle*** - The image shows **cardiomegaly** with a markedly enlarged heart shadow, particularly extending to the **left and inferiorly**. This is characteristic of severe **left ventricular enlargement**. - In cases of substantial left ventricular dilatation, the cardiac apex shifts downwards and to the left, often pushing the hemidiaphragm inferiorly, as appears to be the case here. *Right atrium* - **Right atrial enlargement** typically presents as prominent fullness or bulging of the **right heart border** on a chest X-ray. - While it can contribute to cardiomegaly, the dominant projection and extreme size seen here are more indicative of a ventricular chamber. *Right ventricle* - **Right ventricular enlargement** can cause the heart to appear enlarged, often with elevation of the **cardiac apex** or an increase in the retrosternal clear space on a lateral view. - On a PA view, significant right ventricular enlargement can push the left ventricle posteriorly and cause a rounding of the cardiac apex, but the extreme leftward and inferior extension points away from isolated right ventricular enlargement. *Left atrium* - **Left atrial enlargement** is typically identified by an enlarged **left atrial appendage** on the left cardiac border, a **double density sign** (due to the right border of the enlarged LA), or splaying of the carina. - While left atrial enlargement often accompanies left ventricular issues, the overall massive increase in heart size, especially laterally and inferiorly, suggests primary ventricular enlargement rather than isolated or dominant left atrial enlargement.

Q: A 30-year-old hypertension patient presents with daily headaches. The CXR given below shows which of the following? (Recent NEET Pattern 2016-17)

Postductal coarctation. ***Postductal coarctation*** - The image shows **rib notching** (highlighted by the arrow), a classic sign of **collateral vessel development** due to narrowing of the aorta **distal to the ductus arteriosus**. - This congenital heart defect is associated with **hypertension** in the upper extremities and can lead to symptoms like **headaches**. *Preductal coarctation* - This typically presents earlier in life, often with **heart failure** in infancy, and is less commonly associated with **hypertension** and **rib notching** in a seemingly asymptomatic adult. - The coarctation is located **proximal to the ductus arteriosus**, leading to different collateral circulation patterns. *Aortic dissection* - This condition is an acute medical emergency characterized by a tear in the **aortic wall**, often presenting with sudden, severe chest or back pain. - CXR findings typically include a **widened mediastinum**, not specifically rib notching. *Takayasu arteritis* - This is a **granulomatous vasculitis** primarily affecting the aorta and its major branches, leading to narrowing or occlusion. - While it can cause hypertension, **rib notching** is not a characteristic radiological finding; signs usually include vessel wall thickening or stenoses.

Q: Identify the chamber enlargement:

Left atrium. ***Left atrium*** - The chest X-ray shows **cephalization of the pulmonary vessels** and a **double contour sign** over the right heart border, indicating left atrial enlargement. - There is also evidence of **pulmonary congestion** and **interstitial edema**, consistent with elevated left atrial pressure. *Left ventricle* - Left ventricular enlargement would typically manifest as **cardiomegaly** with a **leftward and downward displacement of the apex**. - While there is some cardiac enlargement, the specific signs for left atrial enlargement are more prominent. *Right atrium* - Right atrial enlargement would typically show a **prominent right heart border** that extends further to the right. - This is not the dominant feature seen in this X-ray. *Right ventricle* - Right ventricular enlargement would shift the **cardiac apex superiorly**, forming a "boot-shaped" heart, or cause a **prominent outflow tract** on lateral views. - The findings here are more consistent with left-sided heart chamber issues affecting the pulmonary circulation.

Q: A chest X-ray shows the following appearance. Identify the pathology:

Pericardial effusion. ***Pericardial effusion*** - The chest X-ray shows a classic **"water bottle" or "money bag" appearance** with a markedly enlarged, globular, and symmetric cardiac silhouette characteristic of pericardial effusion. - The **clear lung fields** combined with the dramatically increased cardiothoracic ratio indicates fluid accumulation in the **pericardial space** rather than cardiac enlargement. *Boot shaped heart* - A **"boot-shaped" heart (coeur en sabot)** is pathognomonic of **tetralogy of Fallot**, characterized by an upturned cardiac apex and concave pulmonary artery segment. - This appearance results from **right ventricular hypertrophy** and **pulmonary stenosis**, which would show a different cardiac contour than the globular shape seen here. *Egg on side appearance* - The **"egg-on-a-string" appearance** is classic for **transposition of the great arteries (TGA)**, showing a narrow vascular pedicle with an oval cardiac silhouette. - This congenital heart defect presents with **cyanosis in neonates** and has a distinctly different radiological appearance from the symmetric enlargement shown. *Normal-sized heart* - The cardiac silhouette is clearly **markedly enlarged** with a cardiothoracic ratio well above the normal limit of 0.5. - A **normal heart** would have distinct great vessel outlines and proportionate cardiac chambers, not the globular symmetric enlargement demonstrated here.

Question 1

In the condition shown below, rib notching is present in which of the following ribs? (AIIMS Nov 2015)

Accepted Answer

3rd to 9th ribs

Answer

1st to 9th ribs

Answer

11th and 12th ribs

Answer

All ribs

Question 2

A short stature female presents with history of wearing socks in summer season. Physical examination shows icy cold toes with cyanosis. CXR done shows:

Accepted Answer

Coarctation of aorta

Answer

Hyperparathyroidism

Answer

Neurofibromatosis

Answer

Multiple myeloma

Question 3

A 35-year-old hypertension patient has the following CXR in annual medical check up. What does it show?

Accepted Answer

Left ventricular hypertrophy

Answer

Pulmonary artery hypertension

Answer

Coarctation of aorta

Answer

Cor pulmonale

Question 4

Identify the congenital heart disease presenting with cyanosis in CXR: (Recent NEET Pattern 2016-17)

Accepted Answer

Tetralogy of Fallot

Answer

Truncus Arteriosus

Answer

Ebstein anomaly

Answer

Snowman heart

Question 5

In the chest X-ray shown, identify the chamber enlargement:

Accepted Answer

Left atrium

Answer

Right atrium

Answer

Left ventricle

Answer

Right ventricle

Question 6

A chest X-ray (PA view) shows cardiomegaly. Identify the chamber enlargement:

Accepted Answer

Left ventricle

Answer

Right atrium

Answer

Left atrium

Answer

Right ventricle

Question 7

In the chest X-ray shown below, identify the chamber enlargement:

Accepted Answer

Left ventricle

Answer

Right atrium

Answer

Left atrium

Answer

Right ventricle

Question 8

A 30-year-old hypertension patient presents with daily headaches. The CXR given below shows which of the following? (Recent NEET Pattern 2016-17)

Accepted Answer

Postductal coarctation

Answer

Preductal coarctation

Answer

Aortic dissection

Answer

Takayasu arteritis

Question 9

Identify the chamber enlargement:

Accepted Answer

Left atrium

Answer

Left ventricle

Answer

Right atrium

Answer

Right ventricle

Question 10

A chest X-ray shows the following appearance. Identify the pathology:

Accepted Answer

Pericardial effusion

Answer

Boot shaped heart

Answer

Egg on side appearance

Answer

Normal-sized heart

Cardiovascular Radiology — MCQs

Cardiovascular Radiology — MCQs

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