Cardiovascular Radiology Practice Questions

Q: In which of the following conditions is an increased cardiac silhouette NOT seen, except?

Tetralogy of Fallot. This question uses a double negative ("NOT seen, except"), which essentially asks: **"In which of the following conditions is an increased cardiac silhouette NOT seen?"** ### **Explanation** In **Tetralogy of Fallot (TOF)**, the heart size is typically **normal** on a chest X-ray. Although there is right ventricular hypertrophy (RVH), the heart does not enlarge overall because the pulmonary artery segment is concave (due to infundibular stenosis) and the left ventricle is often smaller than normal. The classic "Cœur en sabot" (boot-shaped heart) appearance is due to the upward tilting of the apex by RVH, not a generalized increase in the cardiac silhouette. ### **Analysis of Other Options** * **Pericardial Effusion:** Characterized by a significantly enlarged, globular, or "water-bottle" shaped heart once more than 250ml of fluid accumulates. * **Aortic Regurgitation:** Leads to left ventricular volume overload, resulting in significant cardiomegaly and a "down and out" apex. * **Ebstein Anomaly:** This condition produces some of the largest cardiac silhouettes seen in pediatric radiology ("box-shaped" heart) due to massive right atrial enlargement. ### **NEET-PG High-Yield Pearls** * **Normal Heart Size in Cyanotic Heart Disease:** Think **TOF** or **Tricuspid Atresia** (early stages). * **Classic X-ray Signs:** * **TOF:** Boot-shaped heart (Cœur en sabot). * **Ebstein Anomaly:** Box-shaped heart. * **TGA (Transposition of Great Arteries):** Egg-on-side appearance. * **TAPVC (Total Anomalous Pulmonary Venous Connection):** Snowman or Figure-of-8 appearance. * **Cardiothoracic (CT) Ratio:** A ratio >0.5 in adults or >0.6 in neonates indicates cardiomegaly.

Q: A "water can" appearance of the heart shadow in a Chest X-ray is seen in which of the following conditions?

Pericardial effusion. **Explanation:** The **"Water Can" (or "Money Bag" / "Flask-shaped")** appearance is a classic radiological sign of **Pericardial Effusion**. This occurs when an abnormal amount of fluid accumulates in the pericardial sac. Due to gravity, the fluid collects in the dependent portions of the pericardium, causing a symmetric, globular enlargement of the cardiac silhouette with sharp margins. The heart loses its normal contours (like the left atrial appendage or pulmonary artery segment), resembling an old-fashioned leather water bottle. **Analysis of Incorrect Options:** * **Tetralogy of Fallot (TOF):** Characterized by a **"Boot-shaped" heart (Coeur en sabot)**. This is due to right ventricular hypertrophy (lifting the apex) and a small/concave pulmonary artery segment. * **Ebstein’s Anomaly:** Characterized by a **"Box-shaped" heart**. This massive cardiomegaly is caused by severe right atrial enlargement and a "functional" right ventricle being incorporated into the atrium (atrialization). * **Hypertrophic Cardiomyopathy (HCM):** Usually presents with a normal-sized heart or mild left ventricular enlargement. It does not typically produce a specific named "shape" on a chest X-ray like the others. **High-Yield Clinical Pearls for NEET-PG:** * **Minimum fluid for X-ray detection:** At least **200–250 ml** of fluid must accumulate before the cardiac silhouette enlarges on a PA view. * **Echocardiography:** The gold standard and most sensitive investigation for diagnosing pericardial effusion. * **Differential Diagnosis:** A very large pericardial effusion can mimic the "Box-shaped" heart of Ebstein’s, but the "Water Can" description is specifically pathognomonic for effusion in exams. * **Clinical Sign:** Look for **Beck’s Triad** (hypotension, JVD, muffled heart sounds) if the effusion leads to cardiac tamponade.

Q: What is the characteristic radiographic appearance of aoitis?

Calcification of ascending aorta. **Explanation:** The characteristic radiographic finding in **syphilitic aortitis** is **calcification of the ascending aorta**. This occurs because *Treponema pallidum* involves the *vasa vasorum*, leading to endarteritis obliterans. This results in ischemia and subsequent destruction of the elastic tissue in the tunica media, which later undergoes dystrophic calcification. * **Why Option A is correct:** While atherosclerotic calcification typically involves the aortic arch and descending aorta, **linear calcification isolated to the ascending aorta** is highly specific for syphilitic aortitis. * **Why Option B is incorrect:** Calcification of the descending aorta is a common feature of **atherosclerosis**, especially in elderly, hypertensive, or diabetic patients. It is not specific to aortitis. * **Why Option C is incorrect:** While aortitis can lead to aneurysmal dilation of the ascending aorta, "dilation of the aortic arch" is a non-specific finding seen in chronic hypertension and aging (aortic unfolding). * **Why Option D is incorrect:** Left atrial enlargement is a hallmark of **Mitral Stenosis** or chronic mitral regurgitation, not primary aortic pathology. **High-Yield Clinical Pearls for NEET-PG:** * **"Eggshell calcification"** of the ascending aorta on a chest X-ray should immediately trigger suspicion of tertiary syphilis. * **Complications of Aortitis:** Aortic regurgitation (due to root dilation), coronary ostial stenosis, and saccular aneurysms. * **Atherosclerosis vs. Syphilis:** Atherosclerosis = Descending aorta; Syphilis = Ascending aorta.

Q: Which of the following statements is FALSE regarding Coarctation of the Aorta?

Rib notching is seen in 1-8 ribs. **Explanation:** In Coarctation of the Aorta (CoA), the narrowing typically occurs distal to the origin of the left subclavian artery. To bypass this obstruction, the body develops extensive collateral circulation via the intercostal arteries. **1. Why Option C is False (The Correct Answer):** Rib notching (Roesler’s sign) occurs due to the pressure erosion of the inferior surface of the ribs by dilated, tortuous intercostal arteries. It typically involves the **3rd to 8th ribs**. * **1st and 2nd ribs** are spared because their intercostal arteries arise from the costocervical trunk, which originates proximal to the coarctation. * **Lower ribs (9th-12th)** are spared because they do not participate in the collateral pathway to the descending aorta. **2. Analysis of Other Options:** * **Option A & B (Double Bulge / Double Aortic Knuckle):** These refer to the **"Figure of 3" sign** seen on a PA chest X-ray. The upper bulge is the dilated pre-stenotic segment (arch and left subclavian), and the lower bulge is the post-stenotic dilatation. On a Barium swallow, this corresponds to the **"Reverse 3" or "E" sign**. * **Option D:** Rib notching is rarely seen in infants. It develops over time as collaterals enlarge; thus, the prevalence and prominence of notching **increase with age**, usually becoming visible after 6–8 years of life. **Clinical Pearls for NEET-PG:** * **Turner Syndrome:** Most common chromosomal association. * **Bicuspid Aortic Valve:** Most common associated cardiac anomaly (up to 85%). * **Physical Exam:** Radio-femoral delay and upper limb hypertension. * **Imaging Gold Standard:** Cardiac MRI or CT Angiography.

Q: A chest radiograph is obtained from a male patient with hypertension. What is the probable diagnosis?

Coarctation of the Aorta. ***Coarctation of the Aorta*** - Classic chest X-ray findings include **rib notching** (ribs 3-8 bilaterally) due to intercostal artery dilatation and the **"3-sign"** at the aortic knuckle from pre- and post-stenotic dilatation. - **Hypertension in a young male** with these characteristic radiographic features strongly suggests coarctation of the aorta as the underlying cause. *Mitral Stenosis* - Chest X-ray typically shows **left atrial enlargement** with a prominent left heart border and **pulmonary edema** patterns. - Associated with **rheumatic heart disease** and presents with dyspnea rather than systemic hypertension as the primary feature. *Transposition of Great Arteries* - Chest X-ray shows a **"egg-on-string" appearance** with a narrow mediastinum and increased pulmonary vascular markings. - Presents in **neonates with cyanosis** and severe heart failure, not hypertension in older patients. *Aortic Stenosis* - Chest X-ray may show **left ventricular hypertrophy** and **post-stenotic aortic dilatation** but lacks rib notching. - Typically presents with **syncope, angina, and dyspnea** rather than isolated hypertension on imaging.

Q: What is the investigation of choice to confirm hemochromatosis as the cause of cardiomyopathy?

MRI. **Explanation:** The investigation of choice for confirming and quantifying iron overload in the heart is **MRI**. Hemochromatosis leads to the deposition of paramagnetic iron (hemosiderin) in the myocardium, which causes a restrictive cardiomyopathy. **Why MRI is the Correct Answer:** MRI is uniquely sensitive to the magnetic properties of iron. Specifically, **T2* (T2-star) weighted imaging** is the gold standard. Iron deposits shorten the T2* relaxation time; the lower the T2* value (measured in milliseconds), the higher the concentration of iron in the tissue. This allows for non-invasive quantification of myocardial iron, which correlates directly with the risk of heart failure and guides chelation therapy. **Why Other Options are Incorrect:** * **ECG:** While it may show low voltage complexes or arrhythmias, these findings are non-specific and cannot confirm iron deposition. * **Echocardiogram:** Useful for assessing functional changes (diastolic dysfunction or reduced ejection fraction), but it cannot distinguish between different causes of restrictive cardiomyopathy (e.g., amyloidosis vs. hemochromatosis). * **CT Scan:** CT may occasionally show increased attenuation of the liver, but it lacks the sensitivity and specificity of MRI for myocardial iron quantification and involves ionizing radiation. **High-Yield Clinical Pearls for NEET-PG:** * **T2* MRI Value:** A value **<20 ms** indicates myocardial iron overload; **<10 ms** indicates a high risk of developing heart failure. * **Liver vs. Heart:** Myocardial iron deposition often lags behind hepatic deposition, making cardiac MRI essential even if liver enzymes are stable. * **Reversibility:** Unlike many other cardiomyopathies, iron-induced heart failure is often **reversible** with aggressive chelation therapy (e.g., Deferoxamine).

Q: Which of the following is the most common feature of aortitis on chest x-ray?

Calcification of the ascending aorta. **Explanation:** **Aortitis**, particularly when caused by **Syphilis (Luetic aortitis)**, has a predilection for the proximal aorta. The underlying pathology involves *vasa vasorum* endarteritis, which leads to ischemia of the aortic media, destruction of elastic tissue, and subsequent dystrophic calcification. 1. **Why Option A is correct:** Calcification of the **ascending aorta** is the hallmark radiologic sign of syphilitic aortitis. While atherosclerotic calcification commonly affects the aortic arch and descending aorta, it rarely involves the ascending aorta in isolation. Therefore, seeing a "linear shell" of calcification in the ascending aorta on a chest X-ray is highly specific for aortitis. 2. **Why other options are incorrect:** * **Option B:** Calcification of the **descending aorta** is a very common finding in elderly patients and is typically a sign of routine **atherosclerosis**, not specific to inflammatory aortitis. * **Option C:** Calcification of the **pulmonary artery** is rare and usually associated with long-standing pulmonary arterial hypertension (PAH) or Eisenmenger syndrome, not aortitis. * **Option D:** **Focal oligemia** (Westermark sign) is a classic radiologic sign of **Pulmonary Embolism**, representing decreased vascularity distal to an occluded vessel. **High-Yield Clinical Pearls for NEET-PG:** * **Syphilitic Aortitis:** Most common site is the ascending aorta; can lead to **Aortic Regurgitation** (due to root dilatation) and **Coronary Ostial Stenosis**. * **Tree-barking appearance:** A gross pathological description of the intimal wrinkling seen in syphilitic aortitis. * **Takayasu Arteritis:** Another cause of aortitis ("Pulseless disease") common in young females, but it typically presents with arterial narrowing/stenosis rather than isolated ascending aortic calcification on X-ray.

Q: In which of the following conditions is a 'Coeur-en-Sabot' (boot-shaped) heart seen?

Tetralogy of Fallot. **Explanation:** The **'Coeur-en-Sabot'** (French for "heart in a clog") or **boot-shaped heart** is a classic radiological finding in **Tetralogy of Fallot (TOF)**. This characteristic shape occurs due to two primary anatomical changes: 1. **Right Ventricular Hypertrophy (RVH):** The pressure overload from pulmonary stenosis causes the right ventricle to thicken and enlarge, which **lifts the cardiac apex** upward and outward. 2. **Pulmonary Hypoplasia:** The narrow pulmonary infundibulum and small main pulmonary artery create a **concave pulmonary bay** (a "scooped out" appearance of the left heart border). **Analysis of Incorrect Options:** * **Tricuspid Atresia:** Characterized by a "wall-to-wall" heart or a horizontal lower border, but more importantly, it shows **Left Axis Deviation** on ECG (unlike TOF which shows Right Axis Deviation). * **Ventricular Septal Defect (VSD):** Small VSDs show a normal heart size, while large VSDs lead to **cardiomegaly** with increased pulmonary vascular markings (plethora), not a boot shape. * **Transposition of Great Arteries (TGA):** Classically presents with an **"Egg-on-a-string"** appearance due to a narrow mediastinum (stress-induced thymic atrophy) and a globular heart. **High-Yield Clinical Pearls for NEET-PG:** * **X-ray Findings in Cyanotic Heart Disease:** * **TOF:** Boot-shaped heart + Oligemic lung fields. * **TGA:** Egg-on-a-string appearance. * **TAPVC:** Snowman sign or Figure-of-8 appearance. * **Ebstein’s Anomaly:** Box-shaped heart (massive right atrium). * **TOF Components:** VSD, Overriding of Aorta, Right Ventricular Outflow Tract Obstruction (RVOTO), and RVH. * **Most common** cyanotic heart disease after infancy is TOF.

Q: A digital subtraction angiography of a 35-year-old smoker is shown. What is the possible diagnosis?

Buerger's disease. ***Buerger's disease*** - **Thromboangiitis obliterans** affecting young male smokers shows characteristic **segmental occlusions** of distal vessels with **corkscrew collaterals** on DSA. - Strong association with **heavy smoking** in patients under 45 years, causing **inflammatory thrombosis** of small and medium-sized arteries. *Atherosclerosis* - Typically affects **older patients** (>50 years) with **proximal vessel involvement** and **calcified plaques** visible on angiography. - Shows **smooth tapering** rather than the **abrupt segmental occlusions** characteristic of Buerger's disease. *Takayasu's arteritis* - Primarily affects **young women** with involvement of **large vessels** including the **aorta and its major branches**. - DSA shows **smooth stenoses** and **wall thickening** of proximal vessels, not distal segmental disease. *Kawasaki disease* - Occurs predominantly in **children under 5 years** with **coronary artery involvement** causing aneurysms. - Associated with **acute febrile illness** and **mucocutaneous manifestations**, not peripheral vascular disease in adults.

Question 1

A 63-year-old patient with a history of tachyarrhythmias is on an implantable cardioverter-defibrillator (ICD). The patient suddenly develops shock. Which of the following is the best investigation to assess the position and integrity of the ICD?

Accepted Answer

Plain radiograph

Answer

MRI

Answer

USG

Answer

Contrast CT

Question 2

In which of the following conditions is an increased cardiac silhouette NOT seen, except?

Accepted Answer

Tetralogy of Fallot

Answer

Pericardial effusion

Answer

Aortic regurgitation

Answer

Ebstein anomaly

Question 3

A "water can" appearance of the heart shadow in a Chest X-ray is seen in which of the following conditions?

Accepted Answer

Pericardial effusion

Answer

Tetralogy of Fallot

Answer

Ebstein's anomaly

Answer

Hypertrophic cardiomyopathy

Question 4

What is the characteristic radiographic appearance of aoitis?

Accepted Answer

Calcification of ascending aorta

Answer

Calcification of descending aorta

Answer

Dilation of the aortic arch

Answer

Enlargement of the left atrium

Question 5

Which of the following statements is FALSE regarding Coarctation of the Aorta?

Accepted Answer

Rib notching is seen in 1-8 ribs

Answer

Double bulge sign is seen

Answer

Double aortic knuckle is seen

Answer

Rib notching increases with age

Question 6

A chest radiograph is obtained from a male patient with hypertension. What is the probable diagnosis?

Accepted Answer

Coarctation of the Aorta

Answer

Mitral Stenosis

Answer

Transposition of Great Arteries

Answer

Aortic Stenosis

Question 7

What is the investigation of choice to confirm hemochromatosis as the cause of cardiomyopathy?

Accepted Answer

MRI

Answer

ECG

Answer

Echocardiogram

Answer

CT scan

Question 8

Which of the following is the most common feature of aortitis on chest x-ray?

Accepted Answer

Calcification of the ascending aorta

Answer

Calcification of the descending aorta

Answer

Calcification of the pulmonary artery

Answer

Focal oligemia

Question 9

In which of the following conditions is a 'Coeur-en-Sabot' (boot-shaped) heart seen?

Accepted Answer

Tetralogy of Fallot

Answer

Tricuspid atresia

Answer

Ventricular septal defect

Answer

Transposition of great arteries

Question 10

A digital subtraction angiography of a 35-year-old smoker is shown. What is the possible diagnosis?

Accepted Answer

Buerger's disease

Answer

Atherosclerosis

Answer

Takayasu's arteritis

Answer

Kawasaki disease

Cardiovascular Radiology — MCQs

Cardiovascular Radiology — MCQs

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