Cardiovascular Radiology — MCQs

Q: Double density sign in mitral stenosis is a sign of enlargement of which structure?

Left Atrium. ***Left Atrium*** - The **double density sign**, or "double contour" sign, on a chest X-ray in mitral stenosis indicates an enlarged **left atrium**. - This occurs because the enlarged left atrium causes its right border to project through the right atrial silhouette, creating a **second, denser shadow**. *Right Atrium* - Enlargement of the right atrium typically presents as an increased prominence of the **right heart border** and is not associated with the double density sign. - Right atrial enlargement is more commonly seen in conditions like **tricuspid stenosis** or **pulmonary hypertension**. *Left Auricle* - The left auricle (or left atrial appendage) projects anteriorly and to the left, and its enlargement would typically manifest as a **bulge along the left heart border**, particularly between the pulmonary artery and the left ventricle. - While it is a part of the left atrium, the specific "double density" sign refers to the *main body* of the left atrium projecting posteriorly and to the right. *Right Auricle* - The right auricle is a small, muscular appendage of the right atrium that is not directly visualized as a separate contour on a standard chest X-ray in a way that would produce a "double density" sign. - Its enlargement would contribute to overall **right atrial enlargement**, which has different radiographic features.

Q: The 1-2-3 sign on chest X-ray is characteristically associated with which of the following conditions?

Coarctation of aorta. ***Coarctation of aorta*** - The **'1-2-3 sign'** (also known as the **'E sign'** or **'reverse 3 sign'**) on a chest X-ray is characteristic of coarctation of the aorta. - This sign is formed by three contours along the left mediastinal border: a dilated **proximal aorta/left subclavian artery (1)**, an **indentation at the coarctation site (2)**, and **post-stenotic dilation of the descending aorta (3)**. - This creates a figure resembling the number "3" or a reverse "E" on the frontal chest radiograph. *Tetralogy of Fallot* - Characteristically presents with a **"boot-shaped heart"** (cœur en sabot) on chest X-ray due to right ventricular hypertrophy and pulmonary artery hypoplasia. - Does not typically show the specific '1-2-3 sign' related to aortic indentation. *Mitral stenosis* - Chest X-ray findings often include **left atrial enlargement**, **pulmonary vascular congestion**, and sometimes straightening of the left heart border. - The '1-2-3 sign' is not associated with mitral valve disease. *Aortic stenosis* - Chronic aortic stenosis can lead to **left ventricular hypertrophy** and post-stenotic dilatation of the ascending aorta, but not the specific '1-2-3 sign'. - While there might be changes in the aortic contour, it typically doesn't exhibit the characteristic notches seen in coarctation.

Q: The investigation of choice for DVT is -

Doppler. ***Doppler*** - **Duplex ultrasonography** (Doppler ultrasound) is the gold standard for diagnosing DVT due to its **non-invasiveness**, high sensitivity, and specificity in visualizing blood flow and vessel compressibility [1]. - It effectively identifies thrombi in the **proximal deep veins**, which are most likely to embolize [1]. *Plethysmography* - This method measures changes in limb volume and blood flow; while useful for DVT screening, it has **lower sensitivity and specificity** compared to Doppler ultrasound, particularly for calf vein thrombosis. - It is **less commonly used as a primary diagnostic tool** due to its limitations in precisely locating and characterizing thrombi. *Venography* - Previously considered the gold standard, **contrast venography** is an invasive procedure involving injecting contrast dye into the veins to visualize thrombi. - Its use is limited by its **invasiveness**, potential for **allergic reactions**, radiation exposure, and risk of inducing phlebitis, making it secondary to Doppler [1]. *X-ray* - A plain X-ray is **not suitable for diagnosing DVT** as it cannot directly visualize blood clots within veins [2]. - It may be used to **rule out other causes of limb pain** or swelling, such as fractures or soft tissue injuries, but provides no information about venous thrombosis.

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