Cardiovascular Radiology Practice Questions

Q: Egg on side appearance in chest x-ray is seen in which of the following conditions?

Transposition of the great arteries (TGA). ### Explanation **1. Correct Answer: A. Transposition of the Great Arteries (TGA)** The "Egg-on-side" or "Egg-on-a-string" appearance is the classic radiographic hallmark of D-TGA. This morphology occurs due to two primary anatomical changes: * **The "Egg":** Represents the globular enlargement of the heart (cardiomegaly) due to right ventricular hypertrophy and right atrial enlargement. * **The "String":** Represents a **narrow superior mediastinum**. This narrowing occurs because the aorta and pulmonary artery are positioned anteroposteriorly (stacked) rather than side-by-side, and there is often thymic atrophy due to neonatal stress. **2. Analysis of Incorrect Options:** * **B. TAPVC (Supracardiac type):** Characterized by the **"Snowman sign"** or **"Figure-of-8 appearance"** due to a dilated vertical vein, left innominate vein, and superior vena cava. * **C. Constrictive Pericarditis:** Classically shows **pericardial calcification** (best seen on lateral view) and a normal or small-sized heart, often described as a "straightened" heart border. * **D. Tricuspid Atresia:** Typically presents with a "Wall-to-wall" heart or a **"Box-shaped" heart** (if associated with Ebstein-like features), but more characteristically shows a concave pulmonary segment and left axis deviation on ECG. **3. High-Yield Clinical Pearls for NEET-PG:** * **Boot-shaped heart (Coeur en sabot):** Tetralogy of Fallot (due to RVH and upturned apex). * **Box-shaped heart:** Ebstein’s Anomaly. * **Sitting Swan appearance:** TAPVC (Infracardiac type). * **Shmoo Sign:** Left Ventricular Hypertrophy (prominent LV bulge). * **Jug-handle sign:** Primary Pulmonary Hypertension (dilated central pulmonary arteries).

Q: In mitral stenosis, a double atrial shadow is due to enlargement of which chamber?

Left atrium. In Mitral Stenosis (MS), the narrowing of the mitral valve orifice leads to increased pressure and volume overload in the **Left Atrium (LA)**. As the LA enlarges, it expands towards the right side, eventually overlapping the right heart border. **Explanation of the Correct Answer:** * **Left Atrium (B):** On a Chest X-ray (PA view), the enlarged LA creates a dense, curvilinear silhouette that is visible through the shadow of the Right Atrium (RA). This creates a "shadow within a shadow" appearance, known as the **Double Atrial Shadow** or **Double Density Sign**. The outer border is typically the RA, while the inner, denser border is the enlarged LA. **Explanation of Incorrect Options:** * **Right Atrium (A):** While the RA forms the right heart border, its enlargement alone does not create a double shadow; it simply shifts the border further to the right. * **Both Atria (C):** Although long-standing MS can lead to secondary pulmonary hypertension and RA enlargement, the specific "double shadow" sign is pathognomonic for LA enlargement specifically. * **Left Auricle (D):** Enlargement of the left atrial appendage (auricle) causes straightening or bulging of the left heart border (the "third mogul" sign), not the double shadow on the right. **High-Yield Clinical Pearls for NEET-PG:** * **Walking stick sign / Splaying of Carina:** Enlarged LA pushes the left main bronchus upward, increasing the subcarinal angle (>90°). * **Mitralization of Heart:** Straightening of the left cardiac border due to a prominent pulmonary artery and left atrial appendage. * **Cephalization (Antler Sign):** Redistribution of blood flow to the upper lobes (early sign of pulmonary venous hypertension). * **Kerley B Lines:** Horizontal lines at the lung bases indicating interstitial edema.

Q: Which of the following is NOT seen in left atrial enlargement?

Retrosternal lucency on a lateral film. ### Explanation **Correct Option: D. Retrosternal lucency on a lateral film** The **left atrium (LA)** is the most posterior chamber of the heart. When it enlarges, it expands posteriorly and superiorly. **Retrosternal lucency** is the space located behind the sternum and in front of the heart; this space is obliterated by **Right Ventricular Enlargement (RVE)**, not left atrial enlargement. Therefore, retrosternal lucency remains preserved in isolated LA enlargement. **Analysis of Incorrect Options:** * **A. Posterior displacement of the esophagus:** Because the LA lies directly anterior to the esophagus, its enlargement pushes the esophagus backward. This is classically visualized as a posterior indentation on a **Barium Swallow** (lateral view). * **B. Straightening of the left main bronchus:** The LA sits below the carina. Enlargement causes superior displacement and "lifting" of the left main bronchus, increasing the **carinal angle** (normal < 90°) and leading to a more horizontal or "straightened" appearance. * **C. Double shadow of the right atrium:** As the LA expands toward the right, its right border overlaps the right atrium, creating a "double density" or **"double atrial shadow"** on a PA chest X-ray. **High-Yield Clinical Pearls for NEET-PG:** * **Walking Man Sign:** On a lateral X-ray, the posterior displacement of the left main bronchus relative to the right looks like a pair of open legs. * **Splaying of the Carina:** An angle > 90° is a highly specific sign of LA enlargement. * **Mitral Stenosis:** The most common cause of isolated LA enlargement. * **Left Auricle Enlargement:** Causes "straightening of the left cardiac border" (filling of the pulmonary bay).

Q: The given x-ray is suggestive of which of the following conditions?

Coarctation of the aorta. ***Coarctation of the aorta*** - Classic chest X-ray findings include the **figure-3 sign** (indentation of the aorta at the coarctation site) and **rib notching** due to enlarged intercostal arteries. - Shows **left heart enlargement** and **post-stenotic dilatation** of the descending aorta, creating the characteristic aortic contour. *Transposition of the great arteries (TGA)* - Chest X-ray typically shows the **egg-on-string** appearance with a narrow superior mediastinum and oval cardiac silhouette. - Often presents with **cyanosis** in neonates and lacks the distinctive aortic contour changes seen in coarctation. *Total anomalous pulmonary venous connection (TAPVC)* - Characteristic **snowman sign** or **figure-8 sign** due to enlarged superior vena cava and vertical vein creating a distinctive cardiac silhouette. - Shows **pulmonary venous congestion** and **right heart enlargement**, not the aortic arch abnormalities of coarctation. *Patent ductus arteriosus (PDA)* - Chest X-ray shows **cardiomegaly** with **pulmonary plethora** and prominent **pulmonary arteries** due to left-to-right shunting. - Lacks the specific **aortic arch deformity** and **rib notching** that are pathognomonic for coarctation of the aorta.

Q: Which of the following radiological signs is NOT typically seen in a patient with mitral stenosis?

Elevation of the right main bronchus. In **Mitral Stenosis (MS)**, the primary hemodynamic change is the obstruction of blood flow from the left atrium (LA) to the left ventricle, leading to **Left Atrial Enlargement (LAE)** and subsequent pulmonary venous hypertension. ### Why "Elevation of the right main bronchus" is correct: The correct radiological finding in LAE is the **elevation of the Left Main Bronchus**, not the right. As the left atrium enlarges posteriorly and superiorly, it pushes against the left main bronchus, splaying the carina (widening of the carinal angle >90°). The right main bronchus remains unaffected by LAE. ### Analysis of Incorrect Options: * **Straightening of the left heart border:** This occurs due to the enlargement of the **Left Atrial Appendage (LAA)**, which fills the normal concavity between the aortic arch and the left ventricle. * **Double density sign:** As the enlarged left atrium expands toward the right, its shadow overlaps the right atrium, creating a "double contour" or "shadow-within-a-shadow" on a PA chest X-ray. * **Kerley B lines:** These are short, horizontal lines at the lung bases representing thickened interlobular septa due to **pulmonary venous hypertension** and edema, a hallmark of significant MS. ### High-Yield Clinical Pearls for NEET-PG: * **Walking Man Sign:** Seen on lateral X-ray; the enlarged LA pushes the left main bronchus posteriorly, making it look like a person walking. * **Antler Sign:** Cephalization of pulmonary vessels (upper lobe diversion) due to pulmonary venous hypertension. * **Mitral Heart:** Characterized by a small/normal LV, enlarged LA, and prominent pulmonary artery segment. * **Most sensitive X-ray view for LAE:** Lateral view with barium swallow (shows posterior indentation of the esophagus).

Q: In atrial septal defect, what is the typical state of the aorta?

Small. In **Atrial Septal Defect (ASD)**, the typical radiological and clinical finding regarding the aorta is that it appears **small or hypoplastic**. ### Why the Aorta is Small (Option A) The underlying pathophysiology of ASD involves a **left-to-right shunt** at the atrial level. This leads to: 1. **Volume Overload of the Right Heart:** Increased blood flow into the right atrium, right ventricle, and pulmonary circulation (Pulmonary Plethora). 2. **Decreased Left Ventricular Output:** Because a significant portion of blood shunts from the left atrium to the right atrium, the volume of blood entering the left ventricle (LV) is reduced. 3. **Reduced Stroke Volume:** Since the LV output is decreased, the ascending aorta receives less blood volume over time, leading to a "small" or "narrow" appearance on a chest X-ray (the **small aortic knob**). ### Why Other Options are Incorrect * **Normal (Option B):** In hemodynamically significant ASDs, the chronic reduction in systemic output almost always results in a noticeably smaller aortic silhouette compared to the enlarged pulmonary trunk. * **Enlarged/Aneurysmal (Options C & D):** These are characteristic of conditions with increased systemic flow or high pressure, such as **Aortic Regurgitation, Hypertension, or Aneurysms**. In ASD, the enlargement occurs in the **Pulmonary Artery**, not the aorta. ### High-Yield Clinical Pearls for NEET-PG * **Chest X-ray Triad in ASD:** 1. **Cardiomegaly** (Right atrial and ventricular enlargement). 2. **Prominent Pulmonary Artery** (due to increased flow). 3. **Small Aortic Knob** (due to decreased systemic flow). * **Hilar Dance:** On fluoroscopy, the hyperdynamic pulmonary arteries in ASD show vigorous pulsations known as "hilar dance." * **ECG Finding:** RSR' pattern in V1 (Incomplete RBBB) is a classic association.

Q: Which is the best investigation for assessing the plaque of atherosclerosis?

MRI. **Explanation:** The assessment of atherosclerotic plaques focuses on **plaque characterization** (identifying vulnerability) rather than just luminal narrowing. **Why MRI is the correct answer:** MRI is considered the "gold standard" for non-invasive **plaque characterization**. Due to its superior soft-tissue contrast, MRI can accurately differentiate between the components of a plaque, such as the lipid-rich necrotic core (LRNC), intraplaque hemorrhage (IPH), and the thickness of the fibrous cap. Identifying a thin/ruptured fibrous cap or IPH is critical in diagnosing a "vulnerable plaque" at high risk for thromboembolic events. **Analysis of incorrect options:** * **CT Scan:** While excellent for detecting coronary artery calcium (Calcium Score) and luminal stenosis (CTA), it has limited soft-tissue resolution compared to MRI for distinguishing specific plaque components like hemorrhage or lipid cores. * **Angiography:** This is the gold standard for assessing **luminal narrowing (stenosis)** and anatomy, but it is "luminology" focused. It cannot visualize the vessel wall or the internal morphology of the plaque itself. * **Intravascular Ultrasound (IVUS):** This is an invasive procedure. While it provides excellent real-time visualization of the vessel wall during intervention, MRI remains the superior non-invasive modality for comprehensive plaque assessment. **High-Yield Clinical Pearls for NEET-PG:** * **Best for Plaque Characterization:** MRI. * **Best for Luminal Stenosis:** Digital Subtraction Angiography (DSA). * **Best for Coronary Artery Calcification:** Non-contrast CT (Agatston Score). * **Vulnerable Plaque:** Defined by a large lipid core, thin fibrous cap, and increased inflammatory cells.

Question 1

What is the diagnostic method for dysphagia lusoria?

Accepted Answer

CT angiography

Answer

Barium swallow

Answer

Endoscopy

Answer

PET CT

Question 2

Egg on side appearance in chest x-ray is seen in which of the following conditions?

Accepted Answer

Transposition of the great arteries (TGA)

Answer

Total anomalous pulmonary venous connection (TAPVC)

Answer

Constrictive pericarditis

Answer

Tricuspid atresia with ventricular septal defect (TDF)

Question 3

Hilar dance on fluoroscopy is seen in which condition?

Accepted Answer

Atrial Septal Defect (ASD)

Answer

Ventricular Septal Defect (VSD)

Answer

Pulmonary Stenosis (PS)

Answer

Tricuspid Regurgitation (TR)

Question 4

In mitral stenosis, a double atrial shadow is due to enlargement of which chamber?

Accepted Answer

Left atrium

Answer

Right atrium

Answer

Both atria

Answer

Left auricle

Question 5

Which of the following is NOT seen in left atrial enlargement?

Accepted Answer

Retrosternal lucency on a lateral film

Answer

Posterior displacement of the esophagus on barium meal

Answer

Straightening of the left main bronchus

Answer

A double shadow of the right atrium

Question 6

The given x-ray is suggestive of which of the following conditions?

Accepted Answer

Coarctation of the aorta

Answer

Transposition of the great arteries (TGA)

Answer

Total anomalous pulmonary venous connection (TAPVC)

Answer

Patent ductus arteriosus (PDA)

Question 7

Which of the following radiological signs is NOT typically seen in a patient with mitral stenosis?

Accepted Answer

Elevation of the right main bronchus

Answer

Straightening of the left heart border

Answer

Double density sign

Answer

Kerley B lines

Question 8

An X-ray of an asymptomatic 64-year-old male executive, who had an anterior Q wave myocardial infarction 4 years ago, shows a persistent bulge in the left ventricular contour. What is your diagnosis?

Accepted Answer

Left ventricular aneurysm

Answer

Calcific pericarditis

Answer

Hydatid cyst

Answer

Pleuropericarditis

Question 9

In atrial septal defect, what is the typical state of the aorta?

Accepted Answer

Small

Answer

Normal

Answer

Enlarged

Answer

Aneurysmal

Question 10

Which is the best investigation for assessing the plaque of atherosclerosis?

Accepted Answer

MRI

Answer

CT scan

Answer

Angiography

Answer

Intravascular ultrasound

Cardiovascular Radiology — MCQs

Cardiovascular Radiology — MCQs

On this page

Practice by Chapter

Want unlimited practice?