Cardiovascular Radiology Practice Questions

Q: Earliest sign of left atrial enlargement is -

Posterior displacement of esophagus. ***Posterior displacement of esophagus*** - As the **left atrium enlarges**, it expands posteriorly, pushing against the **esophagus**, which is anatomically located directly behind the left atrium. - This displacement can be visualized early on a **lateral chest X-ray** or during a **barium swallow study**, making it an early radiological sign. *Widening of carinal angle* - **Left atrial enlargement** can eventually lead to a widened **carinal angle** (the angle where the trachea bifurcates into the main bronchi), but this often indicates more significant enlargement. - This sign is often seen later as the expanding atrium pushes the **left main stem bronchus** superiorly and laterally. *Elevation of left bronchus* - **Elevation of the left main stem bronchus** is a sign of left atrial enlargement, but it is typically a later finding than the posterior displacement of the esophagus. - It occurs as the greatly enlarged left atrium pushes the **bronchus upwards**. *Double shadow of right border* - A **double shadow of the right cardiac border** (also known as a "double density" or "double contour") is a classic sign of significant left atrial enlargement on a **PA chest X-ray**. - This occurs when the enlarged left atrium bulges to the right, creating an additional shadow superimposed on the normal right heart border, indicating **advanced enlargement**.

Q: Investigation of choice for vascular ring around airway:

CT. ***CT*** - **CT angiography (CTA)** is the **investigation of choice** for diagnosing vascular rings due to its ability to provide detailed anatomical visualization of the great vessels and their relationship to the trachea and esophagus. - It offers high spatial resolution, allowing precise identification of the type of vascular anomaly, the degree of **airway and esophageal compression**, and guiding surgical planning. *PET* - **PET scans** are primarily used for assessing **metabolic activity**, particularly in oncology or to evaluate organ function, and do not provide sufficient anatomical detail for vascular rings. - While it can detect metabolically active lesions, it is **not suitable** for visualizing the structural abnormalities of blood vessels and their compressive effects on the airway. *Catheter directed angiography* - **Catheter-directed angiography** is an **invasive procedure** involving radiation and contrast, primarily used for assessing blood flow dynamics, identifying stenosis, or guiding interventions. - While it can visualize vessels, CTA is **less invasive**, provides comparable or superior anatomical detail for vascular rings, and is generally preferred for initial diagnosis. *MRI* - **MRI** can provide good soft tissue contrast and visualize vascular structures without radiation, but it is often **less readily available** and can be more challenging for pediatric patients due to the need for sedation and longer scan times. - For comprehensive anatomical detail including bone and calcifications, and in patients who might struggle with breath-holding, **CT angiography** often offers clearer and more consistent images of complex vascular anatomy.

Q: In aortic dissection, the most accurate investigation is:

CT scan. ***CT scan*** - **CT angiography** of the chest is the **gold standard** and most accurate readily available imaging modality for diagnosing acute aortic dissection, with sensitivity and specificity both >95%. - It offers **rapid acquisition** (3-5 minutes), high spatial resolution, and is widely available in emergency settings. - It clearly visualizes the **true and false lumens**, intimal flap, entry/re-entry tears, extent of the dissection (Stanford/DeBakey classification), involvement of branch vessels, and any associated complications like pericardial effusion or mediastinal hematoma. *MRI scan* - **MRI/MRA** offers comparable diagnostic accuracy (sensitivity ~98%, specificity ~95%) without radiation exposure and is excellent for chronic dissections or surveillance. - However, its use in acute settings is limited by **longer acquisition times** (20-30 minutes), limited availability in emergency departments, and contraindications (pacemakers, metallic implants, claustrophobia). - It is **not feasible** in hemodynamically unstable patients requiring rapid diagnosis and intervention. *ECG* - An **ECG** is routinely performed to evaluate chest pain and rule out acute coronary syndrome, but it does **not visualize** the aorta or diagnose dissection. - It may show non-specific ST-T changes or signs of **myocardial ischemia** if coronary ostia are involved in the dissection, but these findings are neither sensitive nor specific for aortic dissection. *Aortography* - **Conventional aortography** (invasive catheter-based angiography) was historically the gold standard but has been **replaced by CT and MRI** as first-line imaging. - It has lower sensitivity (~85-90%) than modern cross-sectional imaging and carries procedural risks including **arterial access complications**, contrast-induced nephropathy, and stroke. - Currently reserved for cases where intervention is planned or when non-invasive imaging is inconclusive.

Q: Double atrial shadow in mitral stenosis due to -

Left Atrial enlargement. ***Left Atrial enlargement*** - **Mitral stenosis** obstructs blood flow from the left atrium to the left ventricle, leading to increased pressure and **enlargement of the left atrium**. - On a chest X-ray, this enlarged left atrium can cause a **"double atrial shadow"** or **"double contour"** sign, where the right border of the enlarged left atrium is seen through the right atrium, creating a double density along the right heart border. - This is the **classic radiological sign** of left atrial enlargement in mitral stenosis. *Right Atrial enlargement* - **Right atrial enlargement** is typically associated with conditions like **pulmonary hypertension** or **tricuspid valve disease**, not primarily mitral stenosis. - Right atrial enlargement does not cause the characteristic **"double atrial shadow"** seen in mitral stenosis, which specifically represents the enlarged left atrium projecting through the right heart border. *Right Atrium appendages* - **Right atrial appendages** are normal anatomical structures and do not cause a double atrial shadow. - The **"double atrial shadow"** is specifically a radiological manifestation of **left atrial enlargement**, not related to normal right atrial anatomy. *Tumor in Right Atrium* - A **right atrial tumor** is a rare finding and not a consequence of **mitral stenosis**. - While a tumor could cause an abnormal cardiac silhouette, it would not produce the characteristic **"double atrial shadow"** sign, which is specifically due to **left atrial enlargement**.

Q: Which one of the following investigations is considered to be "Gold standard" technique for diagnosis of arterial occlusive disease –

Digital subtraction angiography (DSA). ***Digital subtraction angiography (DSA)*** - **DSA** is considered the **gold standard** because it provides highly detailed, real-time images of arterial anatomy and blood flow within the vessels. - It allows for precise localization and characterization of **stenosis**, **occlusions**, and other vascular abnormalities, which is crucial for treatment planning. *Doppler ultrasound blood flow detection* - While useful for measuring blood flow velocities and identifying areas of stenosis, **Doppler ultrasound** is operator-dependent and less accurate than DSA for detailed anatomical mapping. - It provides functional information but lacks the comprehensive anatomical detail necessary to be the gold standard. *Treadmill* - A **treadmill test** is a functional assessment used to evaluate exercise-induced symptoms and the physiological impact of arterial occlusive disease. - It does not directly visualize the arterial pathology but rather assesses the patient's functional capacity and symptom response to exertion. *Duplex imaging* - **Duplex imaging** combines B-mode ultrasound (for anatomical visualization) with Doppler ultrasound (for blood flow assessment). - It is a very good non-invasive screening tool, but it is not as precise or comprehensive as DSA, particularly for complex anatomies or smaller vessels, and can be limited by factors such as obesity or bowel gas.

Q: In which of the following a 'Coeur en Sabot' shape of the heart is seen:

Tetralogy of Fallot. ***Tetralogy of Fallot*** - The "Coeur en Sabot" or **boot-shaped heart** on a chest X-ray is characteristic of Tetralogy of Fallot, due to **right ventricular hypertrophy** and an upturned apex with a prominent aorta. - This shape is caused by hypoplasia of the pulmonary artery and **right ventricular outflow tract obstruction**, leading to concentric right ventricular hypertrophy. *Transposition of great arteries* - Often presents with an **egg-on-a-string** appearance on chest X-ray due to a narrow vascular pedicle and cardiomegaly. - This condition involves the aorta originating from the right ventricle and the pulmonary artery from the left, leading to two parallel circulations. *Ventricular septal defect* - Chest X-rays typically show **cardiomegaly** and **increased pulmonary vascular markings** due to left-to-right shunting, but not a boot shape. - The defect allows blood to flow from the left ventricle to the right ventricle, increasing pulmonary blood flow. *Tricuspid atresia* - Chest X-ray may show a **mildly enlarged heart** with **decreased pulmonary vascularity** if the ventricular septal defect is small. - It involves the absence of the tricuspid valve, requiring an atrial septal defect or patent foramen ovale for survival.

Q: In coarctation of aorta the rib changes are seen from:

3-8th. ***3-8th*** - In **coarctation of the aorta**, increased blood flow through dilated intercostal arteries causes **rib notching**, typically observed on chest X-rays. - This notching is most commonly seen on the inferior margins of the **3rd to 8th ribs** due to pressure erosion from enlarged collateral vessels. - The **first and second ribs are spared** because they are perfused by the costocervical trunk, which originates proximal to the coarctation site. - This is a **classic radiological sign** seen in longstanding coarctation with well-developed collateral circulation. *4-9th* - While notching can occasionally extend to the 9th rib, the range **4-9th** is not the standard teaching and misses the 3rd rib which is commonly affected. - Starting from the 4th rib would exclude the 3rd rib, which typically shows notching in established cases. *1-12th* - Notching is **not observed on all ribs** from 1st to 12th. - The **first two ribs are consistently spared** due to their blood supply from the costocervical trunk proximal to the coarctation. - The **lower ribs (10-12)** are also typically spared as they lack true posterior intercostal arteries. *8-12th* - This range is **too low** and misses the primary site of rib notching. - The notching pattern begins much higher (at the 3rd rib) and typically does not extend significantly beyond the 8th or 9th rib. - The lower floating ribs are not affected by the intercostal collateral circulation pattern.

Q: Gas shadow in the heart and great vessels on chest imaging most commonly appears in association with-

Post-procedural complications. ***Post-procedural complications*** - **Most common cause** of gas shadow in the heart and great vessels on chest imaging in modern clinical practice - Iatrogenic air introduction during **central venous catheter insertion**, cardiac catheterization, hemodialysis, or cardiopulmonary bypass - Air can enter through catheter placement, line flushing, or during interventional procedures - Also seen with mechanical ventilation causing barotrauma leading to systemic air embolism - Typically appears as **discrete gas bubbles** or linear lucencies within cardiac chambers or great vessels *Cardiac trauma* - While penetrating or severe blunt chest trauma can introduce air into the heart, it is **less common** than iatrogenic causes in current practice - Would require direct communication between air-containing spaces (lung, atmosphere) and cardiac chambers - Usually associated with other traumatic findings like hemopericardium or pneumothorax *Gas embolism* - Can occur with decompression illness (diving), surgical procedures, or pulmonary barotrauma - May show intracardiac gas, but is **less common** as a primary presentation on chest imaging - Often presents with neurological or systemic symptoms rather than as an incidental imaging finding *Pneumopericardium* - Refers to air in the **pericardial sac** surrounding the heart, not within the cardiac chambers or great vessels themselves - Creates a different radiological appearance with air outlining the heart border - Does not produce gas shadows **within** the heart chambers as described in the question

Q: Snowman appearance on x-ray is seen in which cardiac pathology -

TAPVC. ***TAPVC*** - The **snowman sign**, or **figure-of-8 heart**, on a chest X-ray is characteristic of supracardiac **Total Anomalous Pulmonary Venous Connection (TAPVC)**, where pulmonary veins drain into the superior vena cava via a vertical vein and an innominate vein, causing the dilated superior vena cava and innominate vein to form the "head" of the snowman and the cardiac silhouette the "body". - This appearance is due to the **dilated superior vena cava** and the **vertical vein**, which return all pulmonary venous blood to the systemic circulation, leading to right heart enlargement and increased pulmonary vascularity. *TGA* - **Transposition of the Great Arteries (TGA)** typically presents with an **egg-on-a-string** appearance on chest X-ray, characterized by a narrow vascular pedicle and an enlarged cardiac silhouette. - This is due to the transposed great arteries, where the aorta arises from the right ventricle and the pulmonary artery from the left ventricle. *Ebstein's anomaly* - **Ebstein's anomaly** usually shows a **massive cardiomegaly**, often described as a **box-shaped heart**, due to severe right atrial and right ventricular enlargement. - The characteristic finding is the apical displacement of the tricuspid valve leaflets into the right ventricle. *Fallots tetralogy* - **Tetralogy of Fallot** classic X-ray finding is a **boot-shaped heart** (coeur en sabot), caused by right ventricular hypertrophy and a concave pulmonary artery segment. - Pulmonary oligaemia is also common due to the right ventricular outflow tract obstruction.

Q: Flask shaped heart is seen in –

Pericardial effusion. ***Pericardial effusion*** - A **"flask-shaped"** or **"water bottle-shaped" heart** on chest X-ray is a classic finding in significant pericardial effusion. - This appearance results from the accumulation of a large amount of fluid in the **pericardial sac**, which causes the cardiac silhouette to enlarge symmetrically and assume a globular shape. *TOF (Tetralogy of Fallot)* - TOF typically presents with a **"boot-shaped" heart** (coeur en sabot) on chest X-ray due to right ventricular hypertrophy and a concave pulmonary artery segment. - This morphology is distinctly different from the flask-shaped appearance of pericardial effusion. *Ebstein anomaly* - Ebstein anomaly is characterized by apical displacement of the tricuspid valve, leading to **massive right atrial enlargement**. - On chest X-ray, this often results in a **markedly enlarged oval-shaped heart**, which can be quite massive but does not typically have the distinct flask/water bottle shape. *TAPVC (Total Anomalous Pulmonary Venous Connection)* - TAPVC can present with different X-ray findings depending on the type, but a classic finding for the supracardiac type is a **"snowman" or "figure-of-8" heart** in children. - This appearance is due to the dilated superior vena cava and anomalous veins draining to it, not a flask shape.

Question 1

Earliest sign of left atrial enlargement is -

Accepted Answer

Posterior displacement of esophagus

Answer

Widening of carinal angle

Answer

Elevation of left bronchus

Answer

Double shadow of right border

Question 2

Investigation of choice for vascular ring around airway:

Accepted Answer

CT

Answer

PET

Answer

Catheter directed angiography

Answer

MRI

Question 3

In aortic dissection, the most accurate investigation is:

Accepted Answer

CT scan

Answer

MRI scan

Answer

ECG

Answer

Aortography

Question 4

Double atrial shadow in mitral stenosis due to -

Accepted Answer

Left Atrial enlargement

Answer

Right Atrial enlargement

Answer

Right Atrium appendages

Answer

Tumor in Right Atrium

Question 5

Which one of the following investigations is considered to be "Gold standard" technique for diagnosis of arterial occlusive disease –

Accepted Answer

Digital subtraction angiography (DSA)

Answer

Doppler ultrasound blood flow detection

Answer

Treadmill

Answer

Duplex imaging

Question 6

In which of the following a 'Coeur en Sabot' shape of the heart is seen:

Accepted Answer

Tetralogy of Fallot

Answer

Transposition of great arteries

Answer

Ventricular septal defect

Answer

Tricuspid atresia

Question 7

In coarctation of aorta the rib changes are seen from:

Accepted Answer

3-8th

Answer

1-12th

Answer

8-12th

Answer

4-9th

Question 8

Gas shadow in the heart and great vessels on chest imaging most commonly appears in association with-

Accepted Answer

Post-procedural complications

Answer

Gas embolism

Answer

Pneumopericardium

Answer

Cardiac trauma

Question 9

Snowman appearance on x-ray is seen in which cardiac pathology -

Accepted Answer

TAPVC

Answer

TGA

Answer

Ebstein's anomaly

Answer

Fallot's tetralogy

Question 10

Flask shaped heart is seen in –

Accepted Answer

Pericardial effusion

Answer

TOF

Answer

Ebstein anomaly

Answer

TAPVC

Cardiovascular Radiology — MCQs

Cardiovascular Radiology — MCQs

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