Cardiovascular Radiology Practice Questions

Q: The following X-ray shows:

Ebstein anomaly. ***Ebstein anomaly*** - Shows characteristic **"wall-to-wall" heart** or **box-shaped cardiomegaly** with massive right atrial enlargement filling the entire cardiac silhouette. - Associated with **decreased pulmonary vascularity** due to reduced pulmonary blood flow from tricuspid valve dysfunction. *Persistent pulmonary hypertension of the newborn (PPHN)* - X-ray typically shows **normal heart size** with **decreased pulmonary vascular markings** due to pulmonary vasoconstriction. - May have **clear lung fields** without the massive cardiomegaly seen in this image. *Tetralogy of Fallot (TOF)* - Classic **"boot-shaped" heart** appearance due to **right ventricular hypertrophy** and **upturned cardiac apex**. - Shows **decreased pulmonary vascularity** but with a distinctive coeur en sabot (boot-shaped) configuration, not box-shaped cardiomegaly. *Transient tachypnea of the newborn (TTNB)* - Demonstrates **"wet lung" appearance** with **increased interstitial markings** and **fluid in the fissures**. - Heart size is typically **normal**, contrasting with the massive cardiomegaly shown in this X-ray.

Q: What is the best investigation for diagnosing an abdominal aortic aneurysm?

CT angiography. **Explanation:** **CT Angiography (CTA)** is the gold standard for diagnosing and pre-operative planning of an Abdominal Aortic Aneurysm (AAA). While ultrasound is excellent for screening, CTA provides precise anatomical detail, including the exact diameter, longitudinal extent, involvement of visceral branches (renal, mesenteric), and the presence of mural thrombus or calcification. This information is critical for determining whether a patient is a candidate for EVAR (Endovascular Aneurysm Repair) or open surgery. **Analysis of Options:** * **Ultrasound (USG):** This is the **investigation of choice for screening** and longitudinal monitoring of small aneurysms due to its non-invasive nature and lack of radiation. However, it is operator-dependent and limited by bowel gas or obesity, making it less definitive than CTA for surgical planning. * **Classical Radiography:** X-rays may incidentally show a "eggshell calcification" of the aortic wall, but they lack the sensitivity and specificity required for diagnosis or measurement. * **Non-contrast CT scan:** While it can detect the presence of an aneurysm and mural calcification, it cannot accurately assess the lumen, flow, or the relationship with arterial branches, which are essential for management. **Clinical Pearls for NEET-PG:** * **Screening tool of choice:** Ultrasound. * **Best/Gold Standard investigation:** CT Angiography. * **Definition of AAA:** Permanent dilation of the abdominal aorta >3 cm or >1.5 times its normal diameter. * **Most common site:** Infra-renal (90%). * **Surgical indication:** Diameter >5.5 cm in men or >5.0 cm in women, or rapid expansion (>0.5 cm in 6 months).

Q: Inferior rib notching is characteristically present in which of the following congenital cardiac anomalies?

Coarctation of aorta. **Explanation:** **1. Why Coarctation of Aorta is correct:** Inferior rib notching (Roesler’s sign) is a classic radiological finding in **post-ductal coarctation of the aorta**. Due to the narrowing of the aorta distal to the left subclavian artery, the body develops collateral circulation to bypass the obstruction and supply the lower body. The primary pathway involves the **intercostal arteries**. These arteries become dilated, tortuous, and pulsatile. As they run along the inferior groove of the ribs, the constant pressure and pulsation cause pressure erosion (notching) of the **3rd to 9th ribs**. The 1st and 2nd ribs are spared because their intercostal arteries do not originate from the post-stenotic aorta. **2. Why the other options are incorrect:** * **TAPVC:** Characterized by the **"Snowman sign"** or "Figure-of-8" appearance on a chest X-ray due to a dilated supracardiac venous shadow. * **Tetralogy of Fallot:** Classically presents with a **"Boot-shaped heart"** (Coeur en Sabot) due to right ventricular hypertrophy and an upturned apex. * **Ventricular Septal Defect:** Typically shows features of increased pulmonary blood flow (plethora) and left-sided heart enlargement, but does not involve collateral arterial pathways that erode ribs. **3. High-Yield Clinical Pearls for NEET-PG:** * **Roesler’s Sign:** Inferior rib notching (3rd–9th ribs). * **3-Sign:** Seen on X-ray (formed by pre-stenotic dilation, the coarctation itself, and post-stenotic dilation). * **Reverse 3-Sign (E-sign):** Seen on Barium swallow. * **Superior Rib Notching:** Rare; associated with conditions like Neurofibromatosis-1, Marfan syndrome, or Polio. * **Clinical Hallmark:** Radio-femoral delay and upper limb hypertension.

Q: X-ray features of Atrial Septal Defect (ASD) are all except:

Left atrial enlargement. In **Atrial Septal Defect (ASD)**, the underlying pathophysiology is a left-to-right shunt at the atrial level. This leads to volume overload of the right-sided chambers and the pulmonary circulation. ### Why "Left Atrial Enlargement" is the Correct Answer: In ASD, the left atrium (LA) does not enlarge because it decompresses itself into the right atrium through the defect. Even though there is increased pulmonary venous return to the LA, the blood immediately shunts across the ASD. Therefore, **LA enlargement is characteristically absent** in ASD. If LA enlargement is seen on an X-ray in a patient with a left-to-right shunt, it points toward a Ventricular Septal Defect (VSD) or Patent Ductus Arteriosus (PDA). ### Explanation of Other Options: * **Right Atrial Enlargement:** The right atrium receives both the systemic venous return and the shunted blood from the LA, leading to dilation. * **Pulmonary Artery Hypertension (PAH):** Increased pulmonary blood flow (plethora) eventually leads to increased pulmonary vascular resistance. On X-ray, this manifests as a prominent pulmonary conus and "hilar dance" on fluoroscopy. * **Small Aortic Knuckle:** Due to the left-to-right shunt, the stroke volume entering the left ventricle and the aorta is relatively reduced compared to the massive pulmonary flow, making the aortic knob appear small or inconspicuous. ### High-Yield Clinical Pearls for NEET-PG: * **X-ray Triad of ASD:** Enlarged RA, Enlarged RV, and Pulmonary Plethora with a small Aortic Knuckle. * **Auscultation:** Wide, fixed split S2 (pathognomonic). * **ECG:** RSR' pattern in V1 (Partial RBBB) and Right Axis Deviation (in Ostium Secundum, the most common type). * **Lutembacher Syndrome:** ASD associated with Mitral Stenosis.

Q: A patient with mitral stenosis will show all of the following findings on chest imaging except?

Obliteration of the retrosternal shadow on lateral x-rays. In Mitral Stenosis (MS), the primary hemodynamic change is the enlargement of the **Left Atrium (LA)** due to pressure and volume overload. ### Why Option C is the Correct Answer **Obliteration of the retrosternal space** on a lateral X-ray is a sign of **Right Ventricular (RV) enlargement**. In pure or early mitral stenosis, the left atrium enlarges posteriorly. While chronic MS can lead to pulmonary hypertension and subsequent RV hypertrophy, the *earliest* and most characteristic findings are related to the LA. More importantly, the retrosternal space is located anteriorly; its obliteration is not a primary feature of isolated mitral disease unless significant right-sided heart failure has supervened. ### Explanation of Incorrect Options (Findings seen in MS) * **A. Lifting up of the left bronchus:** As the Left Atrium enlarges superiorly, it pushes the left mainstem bronchus upward, widening the **carinal angle** (normal < 75°). * **B. Double atrial shadow:** On a PA view, the enlarged LA grows toward the right, creating a dense shadow within the right heart border (the "double density" sign). * **C. Posterior displacement of the esophagus:** The LA is the most posterior chamber of the heart. On a barium swallow, an enlarged LA creates a smooth indentation and posterior displacement of the esophagus. ### NEET-PG High-Yield Pearls * **Straightening of the Left Cardiac Border:** This is the earliest sign of MS, caused by an enlarged left atrial appendage and a prominent pulmonary artery segment. * **Kerley B Lines:** Horizontal lines at the lung bases indicating chronic pulmonary venous hypertension (interstitial edema). * **Mitralization of the Heart:** A configuration where the left border becomes straight or convex due to LA enlargement and RV prominence. * **Cephalization (Antler Sign):** Redistribution of blood flow to the upper lobes (upper lobe diversion).

Q: A 48-year-old female presented with dyspnea, chest pain, and a feeling of pressure on her chest. A CXR was ordered as part of her investigations. The patient had a normal CXR 5 months ago with normal heart size. Which of the following is the most probable diagnosis?

Pericardial effusion. ***Pericardial effusion*** - **Rapid onset** of cardiac enlargement with **globular/water-bottle cardiac silhouette** on CXR, given normal heart size 5 months ago, strongly suggests pericardial effusion. - Clinical triad of **dyspnea**, **chest pain**, and **pressure sensation** is characteristic of **cardiac tamponade** from large pericardial effusion. *Cardiomyopathy* - Typically presents with **gradual onset** over months to years, not acute cardiac enlargement within 5 months. - Would show **cardiomegaly with pulmonary congestion** rather than isolated cardiac silhouette enlargement without lung involvement. *Congestive heart failure* - Would demonstrate **pulmonary edema**, **Kerley B lines**, and **pleural effusions** on CXR along with cardiomegaly. - The **absence of pulmonary congestion** with isolated cardiac enlargement makes CHF unlikely. *Pulmonary embolism* - Typically presents with a **normal CXR** or may show **pleural-based consolidation** and **elevated hemidiaphragm**. - Would not cause **cardiac enlargement** or the globular cardiac silhouette seen in this case.

Q: Left atrial enlargement is best seen with which imaging view?

Barium swallow right anterior oblique view. ### Explanation **1. Why the Correct Answer is Right:** The **Left Atrium (LA)** is the most posterior chamber of the heart. In the mediastinum, it lies in direct contact with the anterior wall of the mid-esophagus. When the left atrium enlarges, it displaces the esophagus posteriorly and to the right. In a **Barium swallow Right Anterior Oblique (RAO) view**, the esophagus is projected between the heart and the spine. This specific orientation provides the highest sensitivity for detecting early LA enlargement, as the opacified esophagus will show a characteristic **posterior indentation or displacement**. **2. Why the Other Options are Wrong:** * **Chest X-ray AP View:** While LA enlargement can be seen here (e.g., double atrial shadow, splaying of the carina), it is less sensitive than barium studies for early detection because the heart is a 3D structure projected onto a 2D plane, leading to overlap. * **Chest X-ray Left Lateral View:** This view can show posterior displacement of the esophagus or the left main bronchus (walking-man sign), but the RAO view with barium provides better anatomical separation and visualization of the esophageal-atrial interface. * **Barium Swallow LAO View:** In the Left Anterior Oblique view, the left atrium is not the primary structure indenting the esophagus; this view is better suited for evaluating the aortic arch and the right ventricle. **3. High-Yield Clinical Pearls for NEET-PG:** * **Earliest sign of LA enlargement on CXR PA view:** Straightening of the left cardiac border. * **Most specific sign on CXR PA view:** Double atrial shadow (Double density sign). * **Carinal Angle:** LA enlargement causes widening of the subcarinal angle (>90 degrees) and elevation of the left main bronchus (**"Walking Man Sign"** on lateral view). * **Mitral Stenosis:** The most common cause of isolated left atrial enlargement.

Question 1

Inferior rib notching is seen in all of the following conditions except:

Accepted Answer

Pulmonary stenosis with ventricular septal defect

Answer

Blalock Taussig shunt operation

Answer

Coarctation of the aorta

Answer

Interrupted aortic arch

Question 2

The following X-ray shows:

Accepted Answer

Ebstein anomaly

Answer

Persistent pulmonary hypertension of the newborn (PPHN)

Answer

Tetralogy of Fallot (TOF)

Answer

Transient tachypnea of the newborn (TTNB)

Question 3

The 'Oreo cookie sign' is a radiological finding suggestive of which of the following conditions?

Accepted Answer

Pericardial effusion

Answer

Aberrant subclavian artery

Answer

Left atrium enlargement

Answer

Endomyocardial fibrosis

Question 4

What is the best investigation for diagnosing an abdominal aortic aneurysm?

Accepted Answer

CT angiography

Answer

Ultrasound (USG)

Answer

Classical radiography

Answer

Non-contrast CT scan

Question 5

The plain X-ray chest finding that suggests syphilitic cardiovascular disease is:

Accepted Answer

Linear calcification of the ascending aorta

Answer

Linear calcification of the aortic arch

Answer

Speckled calcification of the ascending aorta

Answer

Speckled calcification of the aortic arch

Question 6

Inferior rib notching is characteristically present in which of the following congenital cardiac anomalies?

Accepted Answer

Coarctation of aorta

Answer

Total anomalous pulmonary venous connection (TAPVC)

Answer

Tetralogy of Fallot

Answer

Ventricular septal defect

Question 7

X-ray features of Atrial Septal Defect (ASD) are all except:

Accepted Answer

Left atrial enlargement

Answer

Right atrial enlargement

Answer

Pulmonary artery hypertension

Answer

Small aortic knuckle

Question 8

A patient with mitral stenosis will show all of the following findings on chest imaging except?

Accepted Answer

Obliteration of the retrosternal shadow on lateral x-rays

Answer

Lifting up of the left bronchus

Answer

Double atrial shadow

Answer

Posterior displacement of the esophagus on barium swallow

Question 9

A 48-year-old female presented with dyspnea, chest pain, and a feeling of pressure on her chest. A CXR was ordered as part of her investigations. The patient had a normal CXR 5 months ago with normal heart size. Which of the following is the most probable diagnosis?

Accepted Answer

Pericardial effusion

Answer

Cardiomyopathy

Answer

Congestive heart failure

Answer

Pulmonary embolism

Question 10

Left atrial enlargement is best seen with which imaging view?

Accepted Answer

Barium swallow right anterior oblique view

Answer

Chest X-ray AP view

Answer

Chest X-ray left lateral view

Answer

Barium swallow left anterior oblique view

Cardiovascular Radiology — MCQs

Cardiovascular Radiology — MCQs

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