Cardiovascular Radiology Practice Questions

Q: An MRI heart shows 'zebra' pattern in left ventricle. Which additional finding would best support Fabry disease?

Delayed enhancement. ***Delayed enhancement*** - The **zebra stripe pattern** in Fabry disease refers to the characteristic histopathological appearance on electron microscopy showing lamellar inclusions in lysosomes. - On cardiac MRI, Fabry cardiomyopathy characteristically shows **late gadolinium enhancement (LGE)** in a **mid-wall inferolateral distribution** of the left ventricle. - This LGE pattern, combined with the clinical context of glycosphingolipid accumulation, is highly specific for Fabry disease and represents **myocardial fibrosis** secondary to sphingolipid storage. - LGE is one of the major diagnostic criteria for cardiac involvement in Fabry disease. *T1 shortening* - **T1 shortening** is not characteristic of Fabry disease. - In fact, Fabry cardiomyopathy typically shows **increased native T1 values** (T1 prolongation) in the inferolateral wall due to sphingolipid accumulation and interstitial expansion. - Native T1 mapping shows elevated T1 values before contrast administration, making T1 shortening an incorrect finding. *Pericardial effusion* - **Pericardial effusion** is not a characteristic or common finding in Fabry disease. - It is more typically associated with inflammatory pericarditis, heart failure, uremia, hypothyroidism, or malignancy. - Fabry disease primarily affects the myocardium through intracellular glycosphingolipid deposition, not the pericardium. *Wall motion abnormality* - **Wall motion abnormalities** can occur in advanced Fabry cardiomyopathy but are **non-specific** and seen in many cardiac conditions. - These represent a late manifestation of disease when significant myocardial damage has occurred. - They do not specifically support the diagnosis of Fabry disease compared to the characteristic LGE pattern.

Q: An MRA shows 'string of pearls' appearance in renal arteries. Which additional finding would best support fibromuscular dysplasia?

Beaded appearance of carotids. ***Beaded appearance of carotids*** - **Fibromuscular dysplasia (FMD)** is a systemic arteriopathy that commonly affects the renal and carotid arteries, often presenting with the characteristic "string of pearls" or **beaded appearance** due to alternating stenoses and aneurysms. - The presence of this finding in the carotid arteries, in addition to the renal arteries, strongly suggests widespread FMD rather than a localized process. *Atherosclerotic plaques* - **Atherosclerotic plaques** are focal deposits of lipids and fibrous tissue within the arterial wall, which can cause stenosis and are a common cause of **renal artery stenosis**. - However, atherosclerosis does not typically produce the diffuse **"string of pearls"** appearance seen in FMD and is a distinct vascular disease. *Arterial dissection* - While **arterial dissection** can occur in FMD, it is a complication rather than the primary characteristic finding of the disease itself. - A dissection involves a tear in the arterial wall, leading to a false lumen, and does not typically manifest as a "string of pearls" morphology on imaging. *Vessel wall thickening* - **Vessel wall thickening** can be a non-specific finding in various vascular conditions, including inflammation or chronic hypertension, and does not specifically point to FMD. - While FMD involves structural changes to the vessel wall, the key diagnostic feature is the specific **"string of pearls"** pattern, which is more detailed than mere thickening.

Q: Comment on the diagnosis of the CT chest image shown below.

Aortic dissection. ***Aortic dissection*** - The image shows a **flap-like linear structure** within the aortic lumen, which represents an **intimal flap** separating the true and false lumens, characteristic of an aortic dissection. - This condition involves a tear in the **aortic intima**, allowing blood to flow between the layers of the aortic wall, a serious and life-threatening event. *Aortic aneurysm* - An aortic aneurysm would present as a **focal dilation** of the aorta, exceeding its normal diameter, without evidence of an intimal flap or separate lumens. - While it can be a precursor to dissection, an aneurysm itself does not show the distinct internal flap seen in dissection. *Pulmonary embolism* - Pulmonary embolism involves a **filling defect** within the pulmonary arteries, typically caused by a blood clot, and would be located in the pulmonary vasculature, not the aorta. - The image clearly depicts an issue with the aorta, not the pulmonary arteries. *Cardiac myxoma* - A cardiac myxoma is a **benign tumor** typically found in the atria of the heart, most commonly the left atrium. - It would appear as an intracardiac mass and not as an intimal flap within the aortic lumen.

Q: What is the Investigation of Choice (IOC) for Acute Aortic Dissection?

CT-Angio. ***CT-angio*** - **Computed tomography angiography (CTA)** is considered the **gold standard** imaging modality for diagnosing acute aortic dissection due to its rapid acquisition, wide availability, and excellent visualization of the aorta and its branches. - It precisely demonstrates the **intimal flap**, true and false lumens, and assesses the extent of the dissection and involvement of major branch vessels. *Usg* - **Ultrasound (USG)**, specifically **transesophageal echocardiography (TEE)**, is highly sensitive and specific for proximal aortic dissections. - However, its utility is operator-dependent and it has limitations in visualizing the entire aorta, especially the distal descending aorta. *Doppler* - **Doppler ultrasound** is used to assess blood flow velocity and patterns within vessels. - While it can detect flow disturbances, it is not the primary imaging modality for diagnosing the anatomical extent and characteristics of an aortic dissection flap. *Mr-Angio* - **Magnetic resonance angiography (MRA)** provides excellent soft tissue contrast, no radiation exposure, and detailed anatomical information for aortic dissection. - However, it is often less accessible, time-consuming, and contraindicated in patients with certain metallic implants or claustrophobia, making it less ideal for an acute emergency setting compared to CTA.

Q: Pulmonary plethora is not seen in:

TOF. ***TOF*** - In **Tetralogy of Fallot (TOF)**, the **right ventricular outflow tract obstruction** (pulmonary stenosis) limits blood flow to the lungs, resulting in **pulmonary oligemia** (reduced pulmonary vascular markings) rather than plethora. - The combination of **pulmonary stenosis** and the **ventricular septal defect (VSD)** causes a right-to-left shunt, diverting deoxygenated blood away from the lungs and into the systemic circulation. *Truncus arteriosus* - **Truncus arteriosus** involves a single great artery overriding a **VSD**, leading to **unrestricted blood flow** into both the systemic and pulmonary circulations. - This typically results in **excessive pulmonary blood flow** and thus **pulmonary plethora**. *TAPVC* - In **total anomalous pulmonary venous connection (TAPVC)**, all pulmonary veins drain into the systemic venous circulation, causing **volume overload** of the right heart. - This excessive pulmonary venous return to the right side of the heart leads to **increased pulmonary blood flow** and **pulmonary plethora**. *VSD* - A **ventricular septal defect (VSD)** allows blood to shunt from the high-pressure left ventricle to the lower-pressure right ventricle. - This **left-to-right shunt** increases blood flow to the pulmonary circulation, causing **pulmonary plethora**.

Q: In a child with coarctation of aorta, all the following are seen in plain chest radiograph except:

'E' Sign or 'Reverse Three sign'. ***'E' Sign or 'Reverse Three sign' (Reverse ε sign)*** - The **'E' sign** or **'reverse three sign'** is seen on **barium esophagram** (lateral view), NOT on a plain chest X-ray - On barium swallow, the esophagus shows indentation creating a reverse '3' or 'ε' shape due to impression from the dilated pre-stenotic aorta, the coarctation site, and the dilated post-stenotic aorta - **This is the correct answer** as the question asks specifically about plain chest radiograph findings - This sign requires contrast study and cannot be visualized on plain radiography *Three sign ('3' sign)* - The **'three sign'** is a **classic finding** in coarctation on plain chest X-ray (PA view) - Seen on the **left heart border** representing: (1) dilated left subclavian artery, (2) indentation at coarctation site, (3) post-stenotic dilation of descending aorta - Creates the shape of the numeral '3' along the aortic knuckle region - This is directly visible on plain radiograph *Prominent ascending aorta* - **Commonly seen** in coarctation due to increased afterload on the left ventricle - Results in **left ventricular hypertrophy** and dilation of the ascending aorta - Part of the cardiovascular remodeling in response to chronic pressure overload - Visible as widening of the superior mediastinum on plain chest X-ray *Rib notching* - **Classic finding** in long-standing coarctation of the aorta (usually after 5-6 years of age) - Due to **collateral circulation** through dilated intercostal arteries that erode the inferior rib margins - Typically affects **ribs 3-9** bilaterally - Represents chronic compensatory mechanism to bypass the obstruction

Q: Deep vein thrombosis post-operatively is diagnosed by:

USG. ***USG*** - **Duplex ultrasonography** is the preferred and most common imaging modality for diagnosing deep vein thrombosis (DVT) due to its non-invasive nature, accessibility, and high accuracy. - It visualizes the **vein lumen** and assesses **compressibility**, a key diagnostic feature for DVT. *Clinically* - Clinical diagnosis of DVT is unreliable, as symptoms like **leg swelling, pain, and tenderness** are non-specific and can be caused by other conditions. - While clinical suspicion can warrant further investigation, it is **insufficient for definitive diagnosis**. *Ascending venography* - **Ascending venography** was once considered the gold standard but is now rarely used due to its invasive nature, use of ionizing radiation, and potential complications. - It involves injecting **radiocontrast dye** into a foot vein and taking X-rays, making it less practical for routine use compared to ultrasound. *X-ray* - **X-rays do not directly visualize veins** or blood clots and are therefore not useful for diagnosing DVT. - They may be used to rule out other causes of leg pain or swelling, such as **bone fractures** or **arthritis**, but offer no diagnostic value for DVT itself.

Q: Aortic calcification is diagnosed on fluoroscopy by identifying:

Dense rim-like calcifications. ***Dense rim-like calcifications*** - Aortic calcification on fluoroscopy typically appears as a **dense, rim-like structure**, particularly visible around the aortic valve or along the aortic wall. - These calcifications indicate deposits of **calcium salts** within the aortic tissue, often associated with aging or degenerative processes. *Eggshell calcification pattern* - **Eggshell calcification** is more characteristic of conditions like **hydatid cysts** or certain **lymph node calcifications**, not typically seen within the aortic wall itself. - This pattern refers to a thin, curvilinear rim of calcification surrounding a lesion. *Punctate calcifications in aortic wall* - While calcifications can be punctate early in their development, the definitive fluoroscopic sign for significant aortic calcification is more often a **dense, rim-like appearance**, indicating more extensive deposition. - **Punctate calcifications** may be subtle and less clear for definitive diagnosis on fluoroscopy compared to the more pronounced rim-like pattern. *Linear calcifications along aortic contour* - While calcifications can follow the aortic contour, the term **"linear calcifications"** is broad and less specific for the characteristic fluoroscopic appearance of significant aortic calcification than "dense rim-like." - **Linear calcifications** might be seen in other vascular structures or soft tissues and may not always imply the same degree of calcific burden or morphology as a dense rim.

Q: IOC for Acute Aortic Dissection in a Clinically Unstable patient is?

TEE. ***TEE (Transesophageal Echocardiography)*** - **TEE is the investigation of choice** for acute aortic dissection in **hemodynamically unstable patients** due to its **portability and rapidity**. - Can be performed at the **bedside** without transporting the critically ill patient, minimizing risk. - Provides rapid diagnosis (5-10 minutes) with **>95% sensitivity and specificity** for detecting intimal flap and false lumen. - Simultaneously assesses **complications** such as aortic regurgitation, pericardial effusion/tamponade, and ventricular function. - Particularly excellent for visualizing the **ascending aorta** and aortic root. *CT-Angio* - **CT angiography** is the **investigation of choice** for acute aortic dissection in **hemodynamically STABLE patients**. - Provides excellent anatomical detail of the entire aorta, clearly showing the intimal flap, true and false lumens, and branch vessel involvement. - Requires **patient transport** to the radiology department, which is **unsafe in unstable patients**. - Best for comprehensive surgical planning in stable patients. *MRI* - **MRI** offers the highest anatomical detail and is considered the gold standard for **chronic dissection follow-up**. - Its lengthy acquisition time (30-60 minutes) and incompatibility with monitoring equipment make it **unsuitable for acutely unstable patients**. *NCCT* - **Non-contrast CT** may show indirect signs like the **hyperdense crescent sign** in the aortic wall. - Cannot reliably differentiate true and false lumens or assess the full extent of dissection. - Insufficient for definitive diagnosis or management planning.

Question 1

An MRI heart shows 'zebra' pattern in left ventricle. Which additional finding would best support Fabry disease?

Accepted Answer

Delayed enhancement

Answer

T1 shortening

Answer

Pericardial effusion

Answer

Wall motion abnormality

Question 2

An MRA shows 'string of pearls' appearance in renal arteries. Which additional finding would best support fibromuscular dysplasia?

Accepted Answer

Beaded appearance of carotids

Answer

Atherosclerotic plaques

Answer

Arterial dissection

Answer

Vessel wall thickening

Question 3

Comment on the diagnosis of the CT chest image shown below.

Accepted Answer

Aortic dissection

Answer

Aortic aneurysm

Answer

Pulmonary embolism

Answer

Cardiac myxoma

Question 4

What is the Investigation of Choice (IOC) for Acute Aortic Dissection?

Accepted Answer

CT-Angio

Answer

USG

Answer

Doppler

Answer

MR-Angio

Question 5

Pulmonary plethora is not seen in:

Accepted Answer

TOF

Answer

Truncus arteriosus

Answer

TAPVC

Answer

VSD

Question 6

In a child with coarctation of aorta, all the following are seen in plain chest radiograph except:

Accepted Answer

'E' Sign or 'Reverse Three sign'

Answer

Three sign

Answer

Prominent ascending aorta

Answer

Rib notching

Question 7

Deep vein thrombosis post-operatively is diagnosed by:

Accepted Answer

USG

Answer

Clinically

Answer

Ascending venography

Answer

X-ray

Question 8

MRI is superior in all of the following conditions except

Accepted Answer

Serial evaluation of liver functions in a 54-year-old female with metastatic carcinoma breast with doxorubicin chemotherapy

Answer

Diagnosis of iron overload cardiomyopathy in a pediatric patient with β-thalassemia major and congestive heart failure.

Answer

Diagnosis of aortic coarctation in a 17-year-old female with hypertension and radiofemoral delay on physical examination.

Answer

Diagnosis of arrhythmogenic right ventricular cardiomyopathy in a 24-year-old man who survived recent cardiac arrest.

Question 9

Aortic calcification is diagnosed on fluoroscopy by identifying:

Accepted Answer

Dense rim-like calcifications

Answer

Eggshell calcification pattern

Answer

Punctate calcifications in aortic wall

Answer

Linear calcifications along aortic contour

Question 10

IOC for Acute Aortic Dissection in a Clinically Unstable patient is?

Accepted Answer

TEE

Answer

NCCT

Answer

MRI

Answer

CT-Angio

Cardiovascular Radiology — MCQs

Cardiovascular Radiology — MCQs

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