Cardiovascular Radiology Practice Questions

Q: Which condition is most likely associated with the following angiography findings?

Polyarteritis nodosa. ***Polyarteritis nodosa*** - Classic angiographic finding shows **multiple microaneurysms** at branch points of medium-sized vessels, particularly in **renal**, **hepatic**, and **mesenteric arteries**. - The **"beading" or "rosary" appearance** on angiography is pathognomonic for PAN, caused by segmental necrotizing inflammation. *Kawasaki disease* - Angiographic findings typically show **coronary artery aneurysms** rather than systemic vessel involvement. - Affects **large coronary arteries** in children, not the medium-sized visceral vessels characteristic of PAN. *Takayasu arteritis* - Angiography reveals **smooth stenosis** and **occlusions** of large vessels like the **aorta** and its major branches. - Shows **long segment narrowing** without the multiple small aneurysms seen in PAN. *Giant cell arteritis* - Primarily affects **large vessels** including the **temporal**, **ophthalmic**, and **vertebral arteries**. - Angiographic findings include **smooth stenosis** and **occlusions**, not the microaneurysmal pattern of PAN.

Q: This x-ray is suggestive of what condition?

Tetralogy of Fallot. ***Tetralogy of Fallot*** - Classic **"boot-shaped heart"** (coeur en sabot) appearance on chest X-ray due to **right ventricular hypertrophy** and **upturned cardiac apex**. - **Decreased pulmonary vascular markings** due to pulmonary stenosis causing reduced pulmonary blood flow. *Total anomalous pulmonary venous connection (TAPVC)* - Chest X-ray shows characteristic **"snowman sign"** or **"figure-of-8 sign"** due to dilated superior vena cava and vertical vein. - **Increased pulmonary vascular markings** and pulmonary edema due to increased pulmonary blood flow. *Tricuspid atresia* - Shows **decreased pulmonary markings** but with **left-sided heart prominence** due to left atrial and ventricular enlargement. - Heart shape is typically **normal** or shows left heart enlargement, not boot-shaped configuration. *Ebstein's anomaly* - Presents with **massively enlarged, box-shaped heart** due to severe right atrial dilatation from tricuspid regurgitation. - **Normal or decreased pulmonary markings** with characteristic **wall-to-wall heart** appearance filling the thoracic cavity.

Q: The 'egg on its side' appearance of the heart on a radiograph is characteristic of which congenital heart anomaly?

Transposition of the great arteries (TGA). ### Explanation The correct answer is **Transposition of the Great Arteries (TGA)**. **1. Why TGA is correct:** The "egg-on-a-string" or "egg-on-its-side" appearance is the classic radiographic sign of D-TGA. This morphology occurs due to two main anatomical changes: * **The "Egg":** Represents the globular enlargement of the right atrium and right ventricle (cardiomegaly). * **The "String":** Represents the **narrowing of the superior mediastinum (vascular pedicle)**. This happens 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. Why the other options are incorrect:** * **TAPVC (Option A):** Characteristically shows the **"Snowman sign"** or **"Figure-of-8"** appearance (in the supracardiac type) due to a dilated vertical vein and superior vena cava. * **ASD/VSD (Options C & D):** These typically present with non-specific cardiomegaly and increased pulmonary vascular markings (plethora) but do not produce the specific "egg" configuration. **3. High-Yield Clinical Pearls for NEET-PG:** * **TGA** is the most common cyanotic heart disease presenting in the **first 24 hours of life**. * **Boot-shaped heart (Coeur en Sabot):** Seen in Tetralogy of Fallot (TOF) due to right ventricular hypertrophy and an upturned apex. * **Box-shaped heart:** Seen in Ebstein’s Anomaly due to massive right atrial enlargement. * **Sitting Duck sign:** Also associated with TGA. * **Management:** Prostaglandin E1 (to keep the ductus open) followed by the **Arterial Switch Operation (Jatene procedure)**.

Q: Which is true about the CT angiography report shown?

Fibromuscular dysplasia. ***Fibromuscular dysplasia*** - The CT angiogram shows a **"string of beads" appearance** (indicated by the arrow), which is characteristic of fibromuscular dysplasia (FMD) of the renal artery. - FMD is an **idiopathic, non-inflammatory, non-atherosclerotic condition** that can affect medium-sized arteries, most commonly the renal and carotid arteries, leading to stenosis, aneurysms, or dissections. *Hydronephrosis* - **Hydronephrosis** refers to the **swelling of a kidney** due to a build-up of urine, usually caused by a blockage in the urinary tract. - This image is a CT angiogram visualizing the **renal arteries and aorta**, not the renal collecting system, and therefore cannot directly assess for hydronephrosis. *Duplication of renal collecting system* - **Duplication of the renal collecting system** involves the presence of two separate collecting systems (ureters) draining a single kidney. - This is an arterial phase image focusing on the vascular anatomy and does not provide information about the **collecting system architecture**. *Renal artery stenosis* - While the image does show narrowing in the renal artery (stenosis), simply stating "renal artery stenosis" is a less specific diagnosis. - The **"string of beads" pattern specifically points to fibromuscular dysplasia** as the cause of the stenosis rather than atherosclerosis or other etiologies.

Q: One-month-old child with tet spells. Incorrect about the image shown?

Pulmonary oligaemia. ***Pulmonary oligaemia*** - This is the **INCORRECT** statement about the image shown. - The chest X-ray demonstrates **increased pulmonary vascular markings** (pulmonary plethora), not oligaemia. - While **Tetralogy of Fallot** classically presents with **pulmonary oligaemia** due to right ventricular outflow tract obstruction, this particular image shows **increased pulmonary blood flow**, which is atypical and may suggest associated findings or a different physiology. - **Pulmonary oligaemia** would show decreased vascular markings with clear, dark lung fields, which is not seen in this image. *Increased CT ratio* - The **cardiothoracic (CT) ratio** is within normal limits or mildly increased for an infant. - In Tetralogy of Fallot, the heart size is typically **normal to mildly enlarged**, which is consistent with this image. - This statement is **CORRECT** about the image. *Right sided aortic arch* - A **right-sided aortic arch** can be identified in this image, with the aortic knob positioned on the right side of the trachea. - This finding is present in approximately **15-25% of patients with Tetralogy of Fallot** and is a classic associated anomaly. - This statement is **CORRECT** about the image. *Coeur en sabot* - The cardiac silhouette demonstrates the classic **"boot-shaped heart"** (coeur en sabot) appearance. - Characteristic features include an **upturned cardiac apex**, **concave pulmonary artery segment**, and **right ventricular hypertrophy**. - This morphology results from **pulmonary artery hypoplasia** and **right ventricular hypertrophy**, both hallmarks of Tetralogy of Fallot. - This statement is **CORRECT** about the image.

Q: What does the following angiogram in a hypertension patient show?

Fibromuscular dysplasia. ***Fibromuscular dysplasia*** - The angiogram shows a classic **"string of beads" appearance** in the renal artery, which is pathognomonic for **fibromuscular dysplasia (FMD)**. - This condition is a common cause of **renovascular hypertension**, particularly in **young to middle-aged women**, due to progressive stenosis with alternating areas of arterial dilatation and stenosis. - FMD most commonly affects the **mid to distal portions** of the renal artery. *Atherosclerosis* - **Atherosclerotic renal artery stenosis** typically presents with focal or eccentric narrowing, often with calcifications, and **not** the regular "string of beads" pattern. - It predominantly affects the **ostial or proximal segments** of the renal arteries and is more common in **older patients** with cardiovascular risk factors (smoking, diabetes, hyperlipidemia). *Takayasu arteritis* - **Takayasu arteritis** is a large-vessel vasculitis that causes inflammation and narrowing of the aorta and its major branches, including the renal arteries. - Angiographic findings typically show **long, smooth stenoses** or occlusions, wall thickening, and involvement of the aorta and multiple vessels. - More common in **young Asian women** and presents with constitutional symptoms and vascular insufficiency. *Polyarteritis nodosa* - **Polyarteritis nodosa (PAN)** is a medium-vessel vasculitis that can affect renal arteries and cause hypertension. - Angiographic findings show **multiple microaneurysms** (1-5 mm) scattered throughout medium-sized arteries, creating a "rosary bead" appearance that is **distinct from** the larger, regular "string of beads" of FMD. - Associated with systemic symptoms, livedo reticularis, and multi-organ involvement.

Q: What condition is suggested by inferior rib notching in a setting of hypertension?

Postductal coarctation. ***Postductal coarctation*** - **Inferior rib notching** is a classic radiological finding in coarctation of the aorta, particularly **postductal coarctation**. It is caused by the enlargement and tortuosity of **collateral arteries** (intercostal arteries) supplying blood distal to the coarctation, which erode the inferior margins of the ribs (typically ribs 3-8). - The associated **hypertension** is a direct consequence of the narrowed aorta, leading to increased pressure proximal to the coarctation (upper extremities and head). - This classic triad of **rib notching + hypertension + chest X-ray findings** (including "3 sign" of aorta) is pathognomonic for postductal coarctation. *Preductal coarctation* - Occurs proximal to the ductus arteriosus insertion, typically presenting in neonates with cyanosis and heart failure. - **Does not cause rib notching** because collateral circulation doesn't have time to develop significantly. *Patent ductus arteriosus* - Presents with continuous "machinery" murmur and bounding pulses. - Does **not cause rib notching** or the specific pattern of upper extremity hypertension with lower extremity hypotension. *Takayasu arteritis* - An inflammatory vasculitis affecting large vessels, can cause hypertension and diminished pulses. - **Rib notching is not a characteristic finding**; imaging typically shows vessel wall thickening and stenosis on angiography.

Q: In the condition shown below, rib notching is present in which of the following ribs? (AIIMS Nov 2015)

3rd to 9th ribs. **3rd to 9th ribs** - The image provided depicts **coarctation of the aorta**, characterized by a narrowing of the aorta, typically distal to the origin of the left subclavian artery. - In coarctation of the aorta, collateral circulation develops through the **intercostal arteries** to bypass the constriction, leading to their enlargement and subsequent erosion of the inferior margins of the **3rd to 9th ribs**, a finding known as "rib notching." *1st to 9th ribs* - While rib notching affects upper ribs, it typically **spares the 1st and 2nd ribs** because the superior intercostal arteries (which supply these ribs) originate directly from the subclavian artery, often proximal to the coarctation, so they do not participate in collateral circulation as significantly. - The pattern of notching is usually more concentrated in the mid-thoracic region. *11th and 12th ribs* - Rib notching from coarctation of the aorta is rarely observed in the **floating ribs** (11th and 12th ribs). - These ribs have a different anatomical relationship with the pleura and typically do not bear the brunt of increased collateral flow from the intercostal arteries in the same way as the higher ribs. *All ribs* - Rib notching is a localized phenomenon reflecting increased blood flow through specific intercostal arteries involved in collateral circulation due to aortic coarctation. - Therefore, it does **not affect all ribs**, and its absence in certain ribs (like the 1st, 2nd, 11th, and 12th) helps differentiate this condition radiologically.

Question 1

In which aspect is transesophageal echocardiography superior to transthoracic echocardiography?

Accepted Answer

Evaluation of the left atrium and left atrial appendage thrombus

Answer

Evaluation of the left ventricle

Answer

Evaluation of pericardial fluid

Answer

Evaluation of commissural fusion

Question 2

Which condition is most likely associated with the following angiography findings?

Accepted Answer

Polyarteritis nodosa

Answer

Kawasaki disease

Answer

Takayasu arteritis

Answer

Giant cell arteritis

Question 3

What is the most important sign of significance of renal artery stenosis on an angiogram?

Accepted Answer

Presence of collaterals

Answer

A percentage diameter stenosis >70%

Answer

A systolic pressure gradient >20 mmHg across the lesion

Answer

Post stenotic dilatation of the renal artery

Question 4

This x-ray is suggestive of what condition?

Accepted Answer

Tetralogy of Fallot

Answer

Total anomalous pulmonary venous connection (TAPVC)

Answer

Tricuspid atresia

Answer

Ebstein's anomaly

Question 5

The 'egg on its side' appearance of the heart on a radiograph is characteristic of which congenital heart anomaly?

Accepted Answer

Transposition of the great arteries (TGA)

Answer

Total anomalous pulmonary venous connection (TAPVC)

Answer

Atrial septal defect (ASD)

Answer

Ventricular septal defect (VSD)

Question 6

Which is true about the CT angiography report shown?

Accepted Answer

Fibromuscular dysplasia

Answer

Hydronephrosis

Answer

Duplication of renal collecting system

Answer

Renal artery stenosis

Question 7

One-month-old child with tet spells. Incorrect about the image shown?

Accepted Answer

Pulmonary oligaemia

Answer

Increased CT ratio

Answer

Right sided aortic arch

Answer

Coeur en sabot

Question 8

What does the following angiogram in a hypertension patient show?

Accepted Answer

Fibromuscular dysplasia

Answer

Atherosclerosis

Answer

Takayasu arteritis

Answer

Polyarteritis nodosa

Question 9

What condition is suggested by inferior rib notching in a setting of hypertension?

Accepted Answer

Postductal coarctation

Answer

Preductal coarctation

Answer

Patent ductus arteriosus

Answer

Takayasu arteritis

Question 10

In the condition shown below, rib notching is present in which of the following ribs? (AIIMS Nov 2015)

Accepted Answer

3rd to 9th ribs

Answer

1st to 9th ribs

Answer

11th and 12th ribs

Answer

All ribs

Cardiovascular Radiology — MCQs

Cardiovascular Radiology — MCQs

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