Cardiovascular Radiology Practice Questions

Q: What is the typical movement of mitral valve calcification?

Upwards and downwards. **Explanation:** The mitral valve is located between the left atrium and the left ventricle. During the cardiac cycle, the base of the heart (where the mitral annulus is located) moves dynamically along the long axis of the heart. Specifically, during ventricular systole, the mitral annulus moves toward the apex (**downwards**), and during diastole, it returns to its original position (**upwards**). Consequently, any calcification of the mitral valve or annulus follows this longitudinal excursion, appearing as an **upward and downward** movement on fluoroscopy or real-time imaging. **Analysis of Options:** * **Option A (Correct):** Reflects the physiological longitudinal displacement of the atrioventricular groove during the cardiac cycle. * **Option B & D:** Circular or counterclockwise movements are not characteristic of valvular motion. While the heart undergoes a degree of "wringing" or torsional motion, the dominant displacement of the mitral apparatus is longitudinal. * **Option C:** Side-to-side (lateral) movement is not the primary vector for the mitral valve; the heart is anchored by the great vessels, making vertical excursion more prominent than lateral shifting. **Clinical Pearls for NEET-PG:** * **Mitral Annular Calcification (MAC):** Typically appears as a dense, **C-shaped or O-shaped** opacity on a chest X-ray. * **Location on Lateral X-ray:** To differentiate valves, draw a line from the carina to the apex. The **Mitral valve** lies posterior and inferior to this line, while the **Aortic valve** lies superior and anterior. * **Fluoroscopy:** Historically used to identify valve calcifications; the rapid "dancing" motion of calcific spots is a classic radiological sign of valvular involvement.

Q: What is the radiological finding of a "sitting duck heart"?

Persistent truncus arteriosus. ### Explanation **Correct Answer: B. Persistent truncus arteriosus** **Why it is correct:** In **Persistent Truncus Arteriosus (PTA)**, a single large arterial trunk arises from the heart, supplying the systemic, pulmonary, and coronary circulations. Radiologically, this results in a **"sitting duck"** appearance. This sign is produced by the combination of a **narrow vascular pedicle** (due to the absence of a separate pulmonary artery and aorta) and a **globular, enlarged heart** that appears to sit on the diaphragm, resembling the body of a duck. Additionally, the right-sided aortic arch (seen in 30-35% of cases) and increased pulmonary plethora contribute to this unique silhouette. **Why the other options are incorrect:** * **A. TAPVC:** Characterized by the **"Snowman sign"** or **"Figure-of-8"** appearance (specifically in the supracardiac type) due to a dilated left vertical vein, innominate vein, and superior vena cava. * **C. Ebstein’s Anomaly:** Characterized by a massive, **"Box-shaped" heart** (square-shaped silhouette) due to severe right atrial enlargement and a small functional right ventricle. * **D. Constrictive Pericarditis:** Classically shows **pericardial calcification** (best seen on lateral X-ray) and a normal or small-sized heart, often described as a "straightened" cardiac border. **High-Yield Clinical Pearls for NEET-PG:** * **Boot-shaped heart (Coeur en sabot):** Tetralogy of Fallot (due to RVH and upturned apex). * **Egg-on-a-string appearance:** Transposition of the Great Arteries (TGA). * **Jug-handle sign:** Primary Pulmonary Hypertension (dilated central pulmonary arteries). * **Goose-neck deformity:** Seen on angiography in Endocardial Cushion Defects (AV Canal defects).

Q: What is the procedure of choice for the evaluation of aortic aneurysm?

Computed tomography. **Explanation:** **Computed Tomography (CT)**, specifically Multidetector CT Angiography (MDCTA), is the procedure of choice for evaluating aortic aneurysms. It provides high-resolution, 3D anatomical detail regarding the aneurysm's diameter, longitudinal extent, and relationship to major arterial branches (e.g., renal or celiac arteries). It is superior for detecting complications like leakage, intramural hematoma, or impending rupture. **Analysis of Options:** * **Ultrasonography (USG):** While USG is the **screening modality of choice** for Abdominal Aortic Aneurysm (AAA) due to its non-invasive nature and low cost, it is operator-dependent and cannot visualize the thoracic aorta or detailed branch involvement accurately. * **Magnetic Resonance Imaging (MRI/MRA):** Provides excellent detail without ionizing radiation; however, it is time-consuming, expensive, and unsuitable for unstable patients or those with metallic implants. * **Arteriography (Digital Subtraction Angiography):** Once the gold standard, it is now rarely used for primary diagnosis. It is invasive and, importantly, can **underestimate aneurysm size** because it only visualizes the patent lumen, missing the surrounding mural thrombus. **High-Yield Clinical Pearls for NEET-PG:** * **Screening/Monitoring:** USG is the investigation of choice. * **Pre-operative Planning/Diagnosis:** CT Angiography is the investigation of choice. * **Gold Standard for Aortic Dissection:** Transesophageal Echocardiography (TEE) in unstable patients; CT Angiography in stable patients. * **Surgical Threshold:** Intervention is generally indicated if the AAA diameter is **>5.5 cm in men** or **>5.0 cm in women**, or if it expands **>0.5 cm in 6 months**.

Q: A 68-year-old woman presented with unstable angina and underwent cardiac catheterization by radial access. There was difficulty advancing the guidewire; a brachial angiogram revealed the following. What is the diagnosis?

Fibromuscular dysplasia. ***Fibromuscular dysplasia*** - The brachial angiogram likely shows the classic **"string of beads"** appearance, which is pathognomonic for **fibromuscular dysplasia** affecting the brachial artery. - **FMD** is more common in **women** and can be encountered as a complication during **transradial catheterization**, causing difficulty in guidewire advancement. *Takayasu's arteritis* - Typically affects the **aorta and its major branches** in young Asian women, not isolated brachial artery involvement. - Would show **long-segment stenosis** or occlusion rather than the beaded appearance characteristic of FMD. *Arteriovenous malformation* - Would demonstrate **early venous filling** and **arteriovenous shunting** on angiography, not stenotic segments. - Presents with **pulsatile masses**, **bruits**, or **high-output heart failure**, not guidewire advancement difficulty. *Brachial artery stenosis* - Would show **smooth, focal narrowing** without the characteristic beaded appearance seen in FMD. - Usually caused by **atherosclerosis** or **trauma**, presenting as uniform stenotic lesions rather than alternating areas of stenosis and dilatation.

Q: 'Spade-like' deformity of the cardiac apex on angiography is pathognomonic of:

Hypertrophic cardiomyopathy. **Explanation:** The **'Spade-like' deformity** (or Ace of Spades appearance) is a classic angiographic finding pathognomonic for **Apical Hypertrophic Cardiomyopathy (Yamaguchi Syndrome)**. **1. Why Hypertrophic Cardiomyopathy (HCM) is correct:** In the apical variant of HCM, there is localized hypertrophy of the myocardium at the left ventricular (LV) apex. During left ventriculography (RAO view), the thickened walls obliterate the apical cavity during systole and severely narrow it during diastole. This configuration, where the base of the heart remains wide while the apex is sharply narrowed, resembles the **'Ace of Spades'** symbol. **2. Why the other options are incorrect:** * **Atrial Septal Defect (ASD):** Characterized by right-sided heart enlargement and pulmonary plethora. On imaging, it may show a "Goose-neck deformity" (if associated with endocardial cushion defects), but not a spade-like apex. * **ARVD:** Primarily affects the right ventricle, leading to fatty-fibrous replacement. Angiography typically shows RV aneurysms or "pouching" (triangle of dysplasia), not a specific LV spade deformity. * **Persistent Truncus Arteriosus (PTA):** A cyanotic congenital heart disease where a single vessel exits the heart. It does not involve localized apical hypertrophy. **3. High-Yield Clinical Pearls for NEET-PG:** * **ECG Finding:** Apical HCM is characteristically associated with **giant, deep T-wave inversions** (precordial leads V4-V6). * **Echocardiography:** Gold standard for initial diagnosis; shows "apical thickening >15mm." * **MRI:** Cardiac MRI is the most sensitive tool to visualize the apex if echo windows are poor. * **Other 'Spade' signs:** Do not confuse this with the "Spade sign" in **Scleroderma** (referring to resorption of distal phalanges/acro-osteolysis).

Q: String of beads appearance on angiography is seen in which of the following conditions?

Fibromuscular dysplasia. **Explanation:** The **"string of beads"** appearance is a classic radiological sign pathognomonic for **Fibromuscular Dysplasia (FMD)**. **1. Why Fibromuscular Dysplasia is correct:** FMD is a non-inflammatory, non-atherosclerotic vascular disease that leads to abnormal cell growth in the arterial walls. The most common type is **medial fibroplasia**, where alternating areas of thinning (aneurysmal dilation) and thickened fibromuscular ridges (stenosis) occur. On angiography, the dilated segments appear as "beads" and the stenotic segments as the "string." It most commonly affects the **renal arteries** (leading to secondary hypertension) and the internal carotid arteries. **2. Why other options are incorrect:** * **Renal and Bladder stones:** These are radiopaque or radiolucent calcifications within the urinary collecting system. On imaging (X-ray or CT), they appear as focal densities. They do not involve the arterial wall architecture and therefore cannot produce an angiographic "string of beads" sign. **Clinical Pearls for NEET-PG:** * **Demographics:** FMD is most commonly seen in **young to middle-aged females**. * **Clinical Presentation:** Often presents as **resistant hypertension** (due to renal artery involvement) or a carotid bruit/stroke in young patients. * **Treatment:** Percutaneous transluminal angioplasty (PTA) **without stenting** is the treatment of choice for renal FMD. * **Differential Diagnosis:** Do not confuse "string of beads" (FMD) with the **"string sign"** (seen in Crohn’s disease or Pyloric stenosis) or the **"beaded appearance of the bile duct"** (seen in Primary Sclerosing Cholangitis).

Q: The investigation of choice in aortic dissection is:

CT. **Explanation:** **Aortic dissection** is a life-threatening emergency characterized by a tear in the tunica intima, leading to the creation of a "false lumen" within the aortic wall. **Why CT is the Investigation of Choice:** **Contrast-Enhanced Computed Tomography (CECT)**, specifically **CT Angiography (CTA)**, is the gold standard and investigation of choice because of its high sensitivity and specificity (>95%). It is rapid, widely available, and non-invasive. It accurately identifies the **intimal flap** (separating the true and false lumens), the extent of the dissection, and involvement of major branch vessels, which is critical for surgical planning. **Analysis of Other Options:** * **USG (Transthoracic Echocardiography):** While useful for screening or detecting proximal (Type A) dissections and pericardial effusion, it has poor visualization of the descending aorta. *Transesophageal Echocardiography (TEE)* is highly accurate but invasive and often unavailable in emergency settings. * **MRI (MRA):** This is the most accurate imaging modality; however, it is **not** the investigation of choice in an acute setting because it is time-consuming, difficult to monitor unstable patients within the magnet, and less available. * **Digital Subtraction Angiography (DSA):** Once the gold standard, it is now rarely used for diagnosis as it is invasive and cannot visualize the aortic wall or thrombus, only the lumen. **Clinical Pearls for NEET-PG:** * **Classic Sign on CT:** The "Intimal Flap" (visualized as a linear lucency) and the "Bird’s Beak Sign" (seen in the false lumen). * **Chest X-ray:** May show a **widened mediastinum** (most common finding) or the "Calcium Sign" (displacement of intimal calcification >1cm). * **Stanford Classification:** Type A involves the ascending aorta (Surgical emergency); Type B involves only the descending aorta (Medical management).

Q: Comment on the diagnosis of the patient?

Pulmonary artery hypertension. ***Pulmonary artery hypertension*** - **Enlarged central pulmonary arteries** with **right heart enlargement** and **peripheral vascular pruning** are classic chest X-ray findings in pulmonary arterial hypertension. - The combination of prominent **main pulmonary artery segment** and **dilated right ventricle** creates the characteristic appearance on CXR. *Aortic dissection* - Typically presents with a **widened mediastinum** and abnormal **aortic contour** on chest X-ray, not enlarged pulmonary arteries. - Associated with **acute chest pain** radiating to the back, not the chronic progressive dyspnea seen in PAH. *Coarctation of aorta* - Chest X-ray shows **rib notching** from collateral circulation and **post-stenotic dilatation** of the descending aorta. - The **"3 sign"** or **"reverse E sign"** may be visible on the left heart border, not pulmonary artery enlargement. *Boot shaped heart* - Characteristic of **Tetralogy of Fallot** with **upturned cardiac apex** and **concave pulmonary artery segment**. - Associated with **decreased pulmonary vascular markings** (oligemic lung fields), opposite to the findings in PAH.

Q: A 20-year-old man with hypertension presents with the following chest X-ray finding. What could be the cause of the aortic shadow?

Coarctation of the Aorta (COA). ***Coarctation of the Aorta (COA)*** - The **figure-3 sign** or **reversed-3 sign** on chest X-ray is pathognomonic for coarctation, caused by pre- and post-stenotic dilatation of the aorta. - **Secondary hypertension** in a young patient with **rib notching** from intercostal collateral vessels strongly suggests COA. *Ventricular Septal Defect (VSD)* - Typically presents with **pulmonary plethora** and **cardiomegaly** on chest X-ray, not distinctive aortic shadow changes. - Usually causes **volume overload** of left ventricle and pulmonary vessels, without the characteristic aortic contour abnormality. *Aortic Aneurysm* - Shows **diffuse widening** of the aortic shadow rather than the specific figure-3 configuration seen in coarctation. - More commonly affects **older patients** and rarely causes the distinctive aortic contour changes in young hypertensive individuals. *Essential Hypertension* - Does not produce any **distinctive aortic shadow changes** on chest X-ray in young patients. - Lacks the pathognomonic **radiological signs** and typically develops gradually without structural cardiac abnormalities visible on imaging.

Q: All of the following are features of chest radiography in Tetralogy of Fallot except?

In 80% right sided arch of aorta. ### Explanation The correct answer is **B (In 80% right-sided arch of aorta)** because while a right-sided aortic arch is a classic association with Tetralogy of Fallot (TOF), it occurs in only **25%** of cases, not 80%. #### Analysis of Options: * **A. Boot-shaped heart (Coeur en sabot):** This is the hallmark radiographic sign of TOF. It is caused by the combination of an upturned apex (due to right ventricular hypertrophy) and a concave pulmonary segment (due to pulmonary stenosis/hypoplasia). * **C. Oligemic lung fields:** TOF involves right-to-left shunting and pulmonary stenosis, which reduces pulmonary blood flow. This manifests on X-ray as increased lucency (darker lungs) and smaller hilar vessels. * **D. Right ventricular enlargement:** This is one of the four primary components of TOF. On a lateral X-ray, this is seen as the filling of the retrosternal clear space. On a PA view, it pushes the apex of the heart upward. #### High-Yield Clinical Pearls for NEET-PG: * **Components of TOF:** 1. Pulmonary Stenosis (primary determinant of severity), 2. Overriding of Aorta, 3. VSD, 4. RVH. * **The "Shunt" Rule:** TOF is the most common **cyanotic** congenital heart disease after the first year of life. * **Egg-on-side appearance:** Seen in Transposition of Great Arteries (TGA). * **Snowman/Figure-of-8 appearance:** Seen in Total Anomalous Pulmonary Venous Connection (TAPVC). * **Box-shaped heart:** Seen in Ebstein’s Anomaly. * **Water-bottle heart:** Seen in Pericardial Effusion.

Question 1

What is the typical movement of mitral valve calcification?

Accepted Answer

Upwards and downwards

Answer

Counterclockwise

Answer

Side to side

Answer

Circular

Question 2

What is the radiological finding of a "sitting duck heart"?

Accepted Answer

Persistent truncus arteriosus

Answer

Total anomalous pulmonary venous connection (TAPVC)

Answer

Ebstein's anomaly

Answer

Constrictive pericarditis

Question 3

What is the procedure of choice for the evaluation of aortic aneurysm?

Accepted Answer

Computed tomography

Answer

Ultrasonography

Answer

Magnetic resonance imaging

Answer

Arteriography

Question 4

A 68-year-old woman presented with unstable angina and underwent cardiac catheterization by radial access. There was difficulty advancing the guidewire; a brachial angiogram revealed the following. What is the diagnosis?

Accepted Answer

Fibromuscular dysplasia

Answer

Takayasu's arteritis

Answer

Arteriovenous malformation

Answer

Brachial artery stenosis

Question 5

'Spade-like' deformity of the cardiac apex on angiography is pathognomonic of:

Accepted Answer

Hypertrophic cardiomyopathy

Answer

Atrial septal defect (ASD)

Answer

Arrhythmogenic right ventricular dysplasia (ARVD)

Answer

Persistent truncus arteriosus (PTA)

Question 6

String of beads appearance on angiography is seen in which of the following conditions?

Accepted Answer

Fibromuscular dysplasia

Answer

Renal stones

Answer

Bladder stones

Answer

All of the above

Question 7

The investigation of choice in aortic dissection is:

Accepted Answer

CT

Answer

USG

Answer

MRI

Answer

Digital segmental angiography

Question 8

Comment on the diagnosis of the patient?

Accepted Answer

Pulmonary artery hypertension

Answer

Aortic dissection

Answer

Coarctation of aorta

Answer

Boot shaped heart

Question 9

A 20-year-old man with hypertension presents with the following chest X-ray finding. What could be the cause of the aortic shadow?

Accepted Answer

Coarctation of the Aorta (COA)

Answer

Ventricular Septal Defect (VSD)

Answer

Aortic Aneurysm

Answer

Essential Hypertension

Question 10

All of the following are features of chest radiography in Tetralogy of Fallot except?

Accepted Answer

In 80% right sided arch of aorta

Answer

Boot shaped heart shadow

Answer

Oligemic lung fields

Answer

Right ventricular enlargement

Cardiovascular Radiology — MCQs

Cardiovascular Radiology — MCQs

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