Pediatric Interventional Radiology — MCQs
What is the next best step for a 22-year-old with a hepatic hemangioma on ultrasound?
Child with aspiration risk needs emergency surgery. Best induction sequence is:
What is the best method to treat a large port-wine stain?
The best inhalational agent of choice for induction of anesthesia in a six-year-old child who refuses IV access is –
The ideal indication for injection of sclerosing agents is:
Deep vein thrombosis most commonly occurs at which site?
Investigation of choice to diagnose hypertrophic pyloric stenosis in infants is
Balloon valvotomy is successful in all of the following cases except –
A postnatal X-ray of the abdomen of a neonate shows a "double bubble sign". It is seen with:
The "triangular cord sign" on ultrasonography is indicative of which condition in a neonate?
Pediatric Interventional Radiology Indian Medical PG Practice Questions and MCQs
Question 1: What is the next best step for a 22-year-old with a hepatic hemangioma on ultrasound?
- A. Angiography
- B. CT
- C. Biopsy
- D. MRI (Correct Answer)
Explanation: ***MRI*** - **Magnetic Resonance Imaging (MRI)** is the most sensitive and specific imaging modality for confirming the diagnosis of a **hepatic hemangioma** due to its characteristic enhancement patterns. - An MRI with contrast (e.g., gadolinium) can definitively distinguish a hemangioma from other **benign or malignant liver lesions**, especially when the ultrasound findings are equivocal. *Angiography* - **Angiography** is an invasive procedure and is typically reserved for cases where **embolization** or surgical resection of a very large or symptomatic hemangioma is being considered. - It is not the initial diagnostic choice for confirming a suspected hemangioma identified on **ultrasound**. *CT* - A **CT scan** with contrast can also characterize a hemangioma, showing peripheral nodular enhancement followed by progressive centripetal fill-in. - However, **MRI** generally offers superior soft tissue contrast and provides more definitive diagnostic features for hemangiomas, particularly in younger patients where radiation exposure from CT is a concern. *Biopsy* - **Biopsy** of a suspected hepatic hemangioma is generally contraindicated due to the risk of **hemorrhage** and is rarely necessary for diagnosis. - Imaging characteristics (especially on MRI) are usually sufficient to confirm the diagnosis without the need for an invasive procedure.
Question 2: Child with aspiration risk needs emergency surgery. Best induction sequence is:
- A. Preoxygenation-ketamine-succinylcholine
- B. Sevoflurane-propofol-succinylcholine
- C. Midazolam-propofol-rocuronium
- D. Preoxygenation-propofol-succinylcholine (Correct Answer)
Explanation: ***Preoxygenation-propofol-succinylcholine*** - This sequence describes a **rapid sequence intubation (RSI)**, which is the preferred method for patients at high risk of aspiration, including children needing emergency surgery with an unknown fasting status. - **Preoxygenation** provides an oxygen reserve during the apneic period, **propofol** offers rapid induction with good hemodynamic stability, and **succinylcholine** provides fast-onset, short-acting neuromuscular blockade, crucial for preventing aspiration. *Preoxygenation-ketamine-succinylcholine* - While preoxygenation and succinylcholine are appropriate for RSI, **ketamine** may not be the optimal choice for a child with aspiration risk due to its potential to increase secretions and maintain laryngeal reflexes, which could complicate intubation. - Ketamine can also cause **emergence delirium** in some children, making it less favorable for a smooth anesthetic course compared to propofol. *Sevoflurane-propofol-succinylcholine* - **Sevoflurane** is an inhaled anesthetic often used for mask induction in children due to its non-pungent odor and rapid onset. However, it is generally **not suitable for RSI** in patients with aspiration risk as it has a slower induction time compared to intravenous agents and can cause coughing or laryngospasm. - Using both sevoflurane and propofol for induction in an RSI scenario is redundant and prolongs the induction phase, increasing aspiration risk. *Midazolam-propofol-rocuronium* - **Midazolam** is a benzodiazepine used for anxiolysis and sedation but has a **slower onset** and longer duration of action compared to propofol for rapid induction. - **Rocuronium** is a non-depolarizing neuromuscular blocker with a slower onset of action than succinylcholine, making it less ideal for RSI where immediate paralysis for intubation is critical to prevent aspiration.
Question 3: What is the best method to treat a large port-wine stain?
- A. Radiotherapy
- B. Excision with skin grafting
- C. Pulsed dye laser (Correct Answer)
- D. Tattooing
Explanation: ***Pulsed dye laser*** - The **pulsed dye laser (PDL)** is considered the **gold standard** for treating port-wine stains due to its specific targeting of hemoglobin in the dilated capillaries without damaging surrounding tissue. - This treatment involves multiple sessions to progressively lighten the stain and prevent complications such as **nodularity** and **tissue hypertrophy**. *Radiotherapy* - **Radiotherapy** is generally not recommended for port-wine stains due to its potential for **scarring**, **pigment changes**, and risk of **malignancy**. - It is an aggressive treatment typically reserved for **cancerous conditions** or severe proliferative vascular lesions not amenable to other treatments. *Tattooing* - **Tattooing** involves injecting skin-colored pigments into the lesion to camouflage it, but it does not treat the underlying vascular abnormality. - This method can result in an **artificial appearance**, **uneven coverage**, and potential for **allergic reactions** or infections. *Excision with skin grafting* - **Surgical excision** of a large port-wine stain would result in a **significant scar** and require **skin grafting**, which carries risks of graft failure, poor aesthetic outcome, and color mismatch. - This method is generally reserved for very small, localized lesions or those with significant **nodular hypertrophy** that cannot be effectively managed by laser therapy.
Question 4: The best inhalational agent of choice for induction of anesthesia in a six-year-old child who refuses IV access is –
- A. Sevoflurane (Correct Answer)
- B. Methoxyflurane
- C. Desflurane
- D. Isoflurane
Explanation: ***Sevoflurane*** - **Sevoflurane** has a **low pungency** and a **rapid onset** due to its low blood/gas solubility, making it ideal for inhalational inductions in children who are often uncooperative with IV access. - Its pleasant odor and non-irritating properties minimize coughing and breath-holding, ensuring a smooth and quick induction. *Methoxyflurane* - **Methoxyflurane** is **nephrotoxic** and has a very slow onset, making it unsuitable for rapid inhalational induction, especially in children where kidney function can be more sensitive. - Due to its significant side effects and slow induction profile, it is rarely used today for general anesthesia. *Desflurane* - **Desflurane** has a very **pungent odor** and a high incidence of airway irritation, including coughing and breath-holding, which makes it a poor choice for gas induction, particularly in children. - Although it has a rapid onset due to very low blood/gas solubility, its irritating properties outweigh this benefit for pediatric inhalational induction. *Isoflurane* - **Isoflurane** is also highly **pungent** and associated with significant airway irritation, making it uncomfortable for inhaled induction and poorly tolerated by children. - It has a slower onset compared to sevoflurane and desflurane, further diminishing its suitability for uneventful inhalational induction in pediatric patients.
Question 5: The ideal indication for injection of sclerosing agents is:
- A. External hemorrhoids
- B. Internal hemorrhoids (Correct Answer)
- C. Immediate surgery for strangulated hemorrhoids
- D. Surgical intervention for prolapsed hemorrhoids
Explanation: ***Internal hemorrhoids*** - Sclerotherapy is most effective for **first- and second-degree internal hemorrhoids**, where symptomatic bleeding is the primary concern. - The injected agent causes **fibrosis** and **scarring**, leading to fixation of the hemorrhoidal tissue and reduced blood flow. *External hemorrhoids* - External hemorrhoids are located **below the dentate line** and are covered by sensitive anoderm. - Sclerosing agents can cause **significant pain** and are generally ineffective for external hemorrhoids. *Immediate surgery for strangulated hemorrhoids* - **Strangulated hemorrhoids** are a medical emergency requiring **urgent surgical intervention** to prevent tissue necrosis. - Sclerotherapy is absolutely **contraindicated** in this scenario due to the risk of exacerbating ischemia and complications. *Surgical intervention for prolapsed hemorrhoids* - While sclerotherapy can be used for some early-stage prolapsed internal hemorrhoids (second degree), **surgical intervention** is more appropriate for **third- and fourth-degree prolapsed hemorrhoids**. - These more advanced hemorrhoids often require techniques like **hemorrhoidectomy** or stapling for definitive treatment.
Question 6: Deep vein thrombosis most commonly occurs at which site?
- A. Femoral vein (Correct Answer)
- B. Subclavian vein
- C. External jugular vein
- D. Internal jugular vein
Explanation: ***Femoral vein*** - The **femoral vein**, along with the **popliteal** and **iliac veins**, are the most common sites for **deep vein thrombosis (DVT)** in the lower extremities [1]. - Due to their size and the dynamics of blood flow in these regions, they are prone to clot formation, especially in the presence of **Virchow's triad**. *Subclavian vein* - While DVT can occur in the subclavian vein (an **upper extremity DVT**), it is less common than in the lower extremities [1]. - Upper extremity DVTs are often associated with **central venous catheters** or **thoracic outlet syndrome**. *External jugular vein* - **External jugular vein thrombosis** is rare and usually associated with local trauma, infection, or central line placement, not typically primary DVT [1]. - It is a superficial vein and not considered a common site for typical deep vein thrombosis. *Internal jugular vein* - **Internal jugular vein thrombosis** is also uncommon as a primary DVT and often secondary to neck infections, malignancies, or indwelling catheters [1]. - Like the subclavian vein, it's considered an upper extremity DVT site, but less frequent than lower extremity sites.
Question 7: Investigation of choice to diagnose hypertrophic pyloric stenosis in infants is
- A. Gastroscopy
- B. CT scan abdomen
- C. Ultrasound abdomen (Correct Answer)
- D. Contrast radiology
Explanation: ***Ultrasound abdomen*** - **Abdominal ultrasound** is the diagnostic procedure of choice due to its **non-invasive nature**, **lack of radiation exposure**, and high accuracy in visualizing the pylorus. - It allows for direct measurement of the **pyloric muscle wall thickness** (typically >3-4 mm) and **pyloric channel length** (typically >14-17 mm), which are characteristic findings of hypertrophic pyloric stenosis. *Gastroscopy* - While gastroscopy can visualize the gastric outlet, it is an **invasive procedure** and not the primary diagnostic tool due to the risk associated with endoscopy in infants. - It is often reserved for cases where the diagnosis is unclear or other upper gastrointestinal pathologies are suspected. *CT scan abdomen* - **CT scans** expose infants to **ionizing radiation**, making it an unsuitable primary diagnostic investigation, especially when a highly accurate non-irradiating alternative exists. - Although it can show pyloric thickening, its disadvantages outweigh its benefits for this diagnosis. *Contrast radiology* - **Barium studies** are less sensitive and specific than ultrasound for diagnosing pyloric stenosis, especially for distinguishing muscle thickening from spasm. - This method also involves **radiation exposure** and poses a risk of aspiration, making it a secondary choice.
Question 8: Balloon valvotomy is successful in all of the following cases except –
- A. Congenital pulmonary stenosis
- B. Congenital aortic stenosis
- C. Mitral stenosis in pregnancy
- D. Calcified mitral stenosis (Correct Answer)
Explanation: ***Calcified mitral stenosis*** - **Heavily calcified valves** are generally considered a contraindication for balloon valvotomy due to the high risk of **valve tearing**, embolism, and suboptimal results. - The rigid, non-compliant nature of heavily calcified valves prevents effective leaflet separation, reducing the chances of a successful procedure and increasing the risk of adverse events. *Congenital pulmonary stenosis* - **Balloon pulmonary valvotomy** is the treatment of choice for most cases of symptomatic congenital pulmonary stenosis with a significant gradient. - It effectively dilates the stenotic valve, leading to a good prognosis and long-term results. *Congenital aortic stenosis* - **Balloon aortic valvotomy** is often performed for severe congenital aortic stenosis, especially in infants and young children, to relieve obstruction. - While it can be associated with some risk of aortic regurgitation, it is a viable option to improve hemodynamics. *Mitral stenosis in pregnancy* - **Balloon mitral valvotomy** is a safe and effective treatment for symptomatic severe mitral stenosis during pregnancy, especially if medical management fails. - It can significantly improve maternal and fetal outcomes by reducing pulmonary congestion and improving cardiac output.
Question 9: A postnatal X-ray of the abdomen of a neonate shows a "double bubble sign". It is seen with:
- A. Duodenal atresia (Correct Answer)
- B. Ileal atresia
- C. Pyloric stenosis
- D. Esophageal atresia
Explanation: **Duodenal atresia** - The **"double bubble sign"** on an abdominal X-ray is classic for **duodenal atresia**, representing a dilated stomach and a dilated proximal duodenum separated by the pylorus. - This finding indicates a complete obstruction at the level of the duodenum, preventing the passage of gas distally. *Ileal atresia (may show distension throughout the bowel)* - In **ileal atresia**, the obstruction is further down the small bowel, leading to multiple dilated loops of bowel proximal to the atresia. - The X-ray would typically show more widespread **abdominal distension** with multiple air-fluid levels rather than the distinct double bubble. *Pyloric stenosis (typically presents with a single bubble sign)* - **Pyloric stenosis** involves narrowing of the pylorus but not an complete obstruction in the same way as duodenal atresia, leading to gastric outlet obstruction. - While it might show a **distended stomach (single bubble)**, it typically does not obstruct distally enough to create a second prominent bubble in the duodenum. *Esophageal atresia (associated with airless abdomen on X-ray)* - **Esophageal atresia** is an interruption in the continuity of the esophagus, preventing swallowed air from reaching the stomach and intestines. - An abdominal X-ray in this condition would typically show an **airless abdomen** because air cannot pass into the gastrointestinal tract.
Question 10: The "triangular cord sign" on ultrasonography is indicative of which condition in a neonate?
- A. Galactosemia
- B. Biliary atresia (Correct Answer)
- C. Hepatitis
- D. None of the above
Explanation: **Explanation:** The **triangular cord sign** is a highly specific ultrasonographic finding for **Biliary Atresia (BA)**. It represents a cone-shaped or triangular fibrotic mass of the cranial part of the extrahepatic biliary tree. On ultrasound, it appears as an echogenic (hyperechoic) area located anterior to the bifurcation of the portal vein. A thickness of **>4 mm** is generally considered diagnostic. **Why Biliary Atresia is correct:** In BA, there is progressive fibro-obliterative destruction of the extrahepatic biliary system. The "triangular cord" is the sonographic visualization of this fibrous remnant at the porta hepatis. When combined with an absent or small, irregular gallbladder (ghost gallbladder sign), it is a pathognomonic finding. **Why other options are incorrect:** * **Galactosemia:** This is a metabolic disorder. While it can cause neonatal jaundice and hepatomegaly, it does not involve anatomical obliteration of the bile ducts; diagnosis is via enzyme assays and urine reducing sugars. * **Hepatitis (Neonatal):** This is the primary differential for BA. On ultrasound, neonatal hepatitis typically shows a patent biliary tree and a normal-sized gallbladder. It lacks the specific fibrous cord seen in BA. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** Intraoperative Cholangiogram (IOCG). * **Best Initial Screening:** Ultrasound (looking for the triangular cord sign). * **Functional Imaging:** HIDA scan (shows uptake by the liver but **no excretion** into the bowel even after 24 hours). * **Surgical Management:** Kasai Procedure (Hepatoportoenterostomy), ideally performed before 60 days of life. * **Liver Biopsy:** Shows bile duct proliferation and portal fibrosis.
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