2023 Cardio Residents Exam

Question 1

Most common cause of mitral regurgitation (Webb Thoracic Imaging, 3rd ed, p2464)

Answer 1

Annular calcification

BRANT, 5th ed
Mitral valve prolapse (MVP) is defined as bowing or prolapse of the mitral leaflet of 2 mm or more beyond the annular plane into the left atrium in ventricular systole. MVP is the most common cause of severe nonischemic mitral regurgitation.

Webb, 3rd
PROLAPSE VS FLAIL
Prolapse is ballooning of the middle of the valve beyond the annulus during systole; the tips of the leaflets to which the chordae attach do not pass beyond the annulus.

Flail is indicated by passage of the tips of the mitral leaflets beyond the annulus and into the left atrium during systole.

Question 2

The most common clinical feature of dilated cardiomyopathy is:

Answer 2

Left ventricular failure

Other choices:
-Ventricular enlargement
-Increased wall thickness of the left ventricle (FALSE: Thickness is often mildly thinned or normal)
-End-diastolic volume is decreased (FALSE: INCREASED end-diastolic volume, DECREASED ejection fraction)

Brant, 5th
Nonischemic-dilated cardiomyopathies are characterized by cardiac chamber dilation coupled with IMPAIRED CONTRACTILITY OF THE LEFT VENTRICLE or BOTH THE LEFT VENTRICLE AND RIGHT VENTRICLE. Approximately 50% of dilated cardiomyopathies are IDIOPATHIC or genetic in origin

Dilated cardiomyopathies all have:
1. Increased systolic and diastolic volumes with decreased ejection fractions
2. Ventricular thickness is often mildly thinned to normal and is associated with increased end-diastole volumes, greater than 140 mL for the LV and greater than 150 mL for the RV, indexed to body surface area

SSPF cine imaging is used to assess global or regional ventricular dysfunction and decreased LV and/or RV ejection fractions.

Question 3

The second most frequent cause of asymmetric distribution of pulmonary edema

Answer 3

Chronic obstructive pulmonary disease

Webb, 3rd
Most frequent: GRAVITATIONAL
Patients with heart disease frequently sleep lying on their right side because of consciousness of the prominent left-sided pulsation (prominent point of maximum impulse in the presence of cardiomegaly)

Question 4

What is the most common primary pericardial tumor? (Webb & Higgins, Thoracic Imaging 3rd ed., p 2602)

Answer 4

Mesothelioma

Secondary tumors of the pericardium are far more common. These occur from local invasion of lung and mediastinal malignancies and from distant metastases. Lymphomas, melanomas, lung, and breast carcinomas are the most common primary tumors that involve the pericardium

Question 5

Most common cause of constrictive pericarditis in developing countries (Webb & Higgins, Thoracic Imaging 3rd ed., p 2570)

Answer 5

Tuberculosis

Most common cause of constrictive pericarditis in industrialized countries: CARDIAC SURGERY

Question 6

On chest x-ray there was a right cardiophrenic mass, what will be your impression? (Webb & Higgins, Thoracic Imaging 3rd ed., p 2596)
a. Pericardial diverticulum
b. Pericardial cyst
c. Both but most likely B.
d. None of the above.

Answer 6

c. Both but most likely B.

Webb, 3rd
Pericardial cysts are caused by developmental abnormalities and are alleged to occur when a small portion of the pericardium is pinched off during embryonic development. Pseudocyst of the pericardium may develop after surgical pericardiotomy. Ninety percent of pericardial cysts are located in the cardiophrenic angles (70% on the right and 20% on the left side).

Pericardial cysts usually do not communicate with the pericardial cavity. In contrast, diverticula have a narrow communication with the pericardial cavity. With increase or decrease in pericardial fluid, diverticula can change in size.

Question 7

Which among the following is the most common vascular anomaly? (Swischuk p. 305)

Answer 7

Aberrant right subclavian artery

Question 8

The most common pericardial tumor in childhood. (Swischuk p. 327)

Answer 8

Teratoma

Question 9

The most common cause of arterial aneurysm in the pediatric age group. (Swischuk p. 333)

Answer 9

Mycotic aneurysm

Most are encountered in neonates and young infants undergoing umbilical artery catheterization

Question 10

Which of the following is not an associated finding of chronic venous thrombi? (Swischuk p. 331)
a. Compensatory dilatation of the azygos vein
b. Oval or bullet-shaped vascular calcification
c. Development of collateral vessels
d. None of the above

Answer 10

d. NOTA

Predisposing factors, much as with arterial thromboembolism, include sepsis, dehydration, and mechanical injury secondary to indwelling catheters.

Mature thrombus:
1. Calcify then produce characteristic oval or bullet-shaped calcifications in the various vessels involved
2. With IVC obstruction, compensatory dilatation of the azygos vein is noted. This occurs because collateral venous return must be accomplished through the azygos or hemiazygos venous systems when the inferior vena cava is obstructed.

Question 11

Myxoma is the most common benign cardiac tumor. In which chamber is it most commonly found?

Answer 11

Left atrium

Webb, 3rd
Myxoma is the most common benign cardiac tumor. It is located in the left atrium in 75% of cases and in the right atrium in 20% of cases. Multiple atrial myxomas may occur rarely, especially in Carney’s syndrome.

Left atrial myxomas are typically attached by a narrow pedicle to the area of the fossa ovalis. Myxomas can grow through a patent foramen ovale and extend into both atria, a condition that has been described as a “dumbbell” appearance.

Question 12

What is the second most common benign cardiac tumor? (Webb 2634)

Answer 12

Lipoma

Webb, 3rd
Lipomas are reported to be the second most common benign cardiac tumor in adults but may actually be the most common.

If the mass projects into the right atrium, it is called a lipoma, while lipomatous hypertrophy is confined to the atrial septum.

Lipomas are typically located in the right atrium or atrial septum

Lipomatous hypertrophy is defined as a deposition of fat in the atrial septum around the fossa ovalis that exceeds 2 cm in transverse diameter. It spares the fossa ovalis, a characteristic feature that is clearly delineated with T1- weighted SE images

Question 13

What is the most common cardiac tumor in children? (Webb 2637)

Answer 13

Rhabdomyoma

Webb, 3rd
Rhabdomyomas are the most common cardiac tumors in children, representing 40% of all cardiac tumors in this age group. Thirty to fifty percent of rhabdomyomas occur in patients with tuberous sclerosis.

They are characterized by an intramural location and involve equally the left and right ventricles (RV).

Question 14

Pheochromocytoma are predominantly encountered within and around the left atrium. What is the most common clinical symptom for patients with pheochromocytoma? (Webb 2642)

Answer 14

Hypertension

Webb, 3rd
Pheochromocytomas arise from neuroendocrine cells clustered in the visceral paraganglia in the wall of the left atrium, roof of the right and left atrium, atrial septum, behind the ascending aorta, and along the coronary arteries.

Hypertension, the most common symptom, is related to catecholamine overproduction by the mass. The average age at diagnosis is 30 to 50 years.

Cardiac pheochromocytomas are usually benign. Pheochromocytomas are generally highly vascularized.

Pheochromocytomas are hyperintense to the myocardium on T2-weighted images and isointense or hyperintense on T1-weighted images

After Gd-DTPA administration, they show strong signal enhancement because of their high vascularity.

Question 15

Angiosarcoma is the most common malignant cardiac tumor in adults. Where is it most commonly located? (Webb 2654)

Answer 15

Right atrium

Webb, 3rd
Angiosarcomas are the most common malignant cardiac tumors in adults and constitute one third of malignant cardiac tumors

This entity has been divided into two clinicopathologic forms.
-Most frequently, angiosarcomas are found in the right atrium. In this form, no evidence of Kaposi sarcoma is found.
-Another form is characterized by involvement of the epicardium or pericardium in the presence of Kaposi sarcoma. This form is associated with the acquired immunodeficiency syndrome.

Question 16

What is the most common intracardiac mass? (Webb 2665)

Answer 16

Thrombus

Thrombus is the most common intracardiac mass, involving most frequently the LV or left atrium. It is most often located in the LV at the site of myocardial infarction or at the apex in dilated cardiomyopathy.

Atrial thrombus is encountered in patients with mitral valve disease or atrial fibrillation.

Question 17

What is the most common cause of dilated cardiomyopathy? (Brant 4th ed., p. 603)

Answer 17

Ischemic cardiomyopathy

Specific causes for dilated cardiomyopathies should be pursued as the specific therapy may vary:
(1) Ischemic cardiomyopathy (the most common cause) because of chronic ischemia, prior infarction, or anomalous coronary arteries
(2) Acute myocarditis (Coxsackie virus most commonly) or long-term sequelae of myocarditis
(3) Toxins (ethanol and doxorubicin [Adriamycin])
(4) Metabolic (mucolipidosis, mucopolysaccharidosis, glycogen storage disease)
(5) Nutritional deficiencies (thiamin and selenium)
(6) Infants of diabetic mothers
(7) Muscular dystrophies

Question 18

What is the most common type of atrial septal defect? (Webb Thoracic Imaging: Pulmonary and Cardiovascular Radiology Third Edition, Sec. 8 Ch. 31 p. 2379)

Answer 18

Secundum

There are four types of atrial septal defects:
1. Secundum (most frequent) - region of the fossa ovalis, which is approximately the middle of the septum
2. Primum - lower part of the septum and bordering on the atrioventricular valve
3. Sinus venosus (superior and inferior vena caval locations) - in either the upper part of the septum and bordering on the ostium of the superior vena cava or the lower septum and bordering on the ostium of the inferior vena cava
4. Coronary sinus (least frequent)

The primum type is usually part of an atrioventricular septal defect (AVSD), which was formerly called endocardial cushion defect

The coexistence of large primum and secundum defects constitutes a common atrium.

Question 19

Which of the following is the most common cyanotic congenital cardiac anomaly? (Webb Thoracic Imaging: Pulmonary and Cardiovascular Radiology Third Edition, Sec. 8 Ch. 31 p. 2403)

Answer 19

Transposition of the great arteries

TGA is the most frequent cyanotic heart lesion. Without surgical intervention, most of the infants would die in the first year of life.

TGA is the most frequent anomaly causing pulmonary overcirculation in a cyanotic infan

Group IV
A lesion is included in this group when the radiograph displays pulmonary arterial overcirculation in the presence of cyanosis. The heart size is usually increased. The observation of increased pulmonary vascularity in a patient with cyanosis is an incongruous finding and should alert the observer to the presence of an admixture lesion rather than a strictly left-to-right shunt. An aid to remembering the major diagnoses in this category is the letter T. The most common diagnosis in this category is TGA, which is the most frequent cyanotic congenital heart lesion at birth

Question 20

Which of the following congenital heart defects is most commonly associated with right aortic arch? (Webb Thoracic Imaging: Pulmonary and Cardiovascular Radiology Third Edition, Sec. 8 Ch. 31 p. 2417)

Answer 20

Tetralogy of Fallot

Swischuck, p305
Right aortic arch with right descending aorta and mirror image branching is one of the few aortic arch anomalies frequently associated with congenital heart disease. Tetralogy of Fallot is most common.

Question 21

In terms of hemodynamics, what is the most critical component of the anomaly below?

Answer 21

Pulmonary stenosis

Swischuck, p268
Tetralogy of FaIlot is the most common cause of cyanotic congenital heart disease beyond the first 30 days of life.

Hemodynamically, the critical component of tetralogy of Fallot is pulmonary stenosis

Webb, 3rd
The major components of this anomaly are caused by a displacement of the outlet septum (conal septation) toward the right ventricle, resulting in a diminutive right ventricular outflow region and failure of alignment of the outlet portion with the remainder of the ventricular septum. The latter abnormality causes a large VSD (infracristal), and the aorta is located immediately over the defect

The extreme form of tetralogy is pulmonary atresia with a nonrestrictive VSD.

Early in life, the thoracic radiograph may not be typical, but it becomes characteristic later. Regression of the thymus reveals the concave main pulmonary artery segment, which is characteristic for tetralogy of Fallot.

Question 22

T/F: High-velocity jet flow produces bright signal within the dark signal of the blood pool on GRE cine (Webb Thoracic Imaging, 3rd ed, p2438)

Answer 22

False

High-velocity jet flow, such as occurs with the flow across a valvular stenosis or the retrograde flow across a regurgitant orifice, produces a SIGNAL VOID (low-signal region within the bright signal of the blood pool) on GRE cine.

Question 22

Part of Williams’ syndrome, which is characterized by hypercalcemia, elfin facies, variable mental retardation, and characteristic “cocktail party” personality (Webb Thoracic Imaging, 3rd ed, p2436)

Answer 22

Supravalvular aortic stenosis

Supravalvular stenosis nearly always is a congenital anomaly, either as an isolated lesion or as part of Williams’ syndrome.

The supravalvular narrowing has roughly three configurations: focal constriction at the sinotubular junction (hourglass configuration) with poststenotic dilation of the mid and distal ascending aorta, focal membrane at the sinotubular junction, and tubular narrowing from the sinotubular junction to just below the origin of the innominate artery.

Question 22

It is indicated by the passage of the tips of the mitral leaflets beyond the annulus and into the left atrium during systole (Webb Thoracic Imaging, 3rd ed, p2464)

Answer 22

Mitral valve flail

Prolapse is ballooning of the middle of the valve beyond the annulus during systole; the tips of the leaflets to which the chordae attach do not pass beyond the annulus.

Flail is indicated by passage of the tips of the mitral leaflets beyond the annulus and into the left atrium during systole.

Question 23

It is usually acquired and nearly always is caused by rheumatic fever. It is the salient lesion of rheumatic heart disease. (Webb Thoracic Imaging, 3rd ed, p2460)

Answer 23

Mitral stenosis ## Footnote Mitral stenosis usually is acquired and nearly always is caused by rheumatic fever. It is the salient lesion of rheumatic heart disease. Other etiologies are rare; these include congenital valvular, subvalvular (parachute mitral valve), or supravalvular stenoses; left atrial myxoma; and exuberant mitral annular calcification. Mitral stenosis often is accompanied by a variable degree of mitral regurgitation.

Question 24

Valvular stenosis (Webb Thoracic Imaging, 3rd ed, p2435)

Answer 24

It exerts a pressure overload, which involves compensatory myocardial hypertrophy. ## Footnote Valvular stenosis exerts a pressure overload, which involves the compensatory mechanism of myocardial hypertrophy. Regurgitation exerts a volume overload, which involves chamber dilatation.

Question 25

Severe aortic stenosis is defined as an aortic valve area less than (Webb Thoracic Imaging, 3rd ed, p2446)

Answer 25

1.0 cm2 ## Footnote Severe AS is defined as an aortic valve area less than 1.0 cm2 (less than 0.60 cm2/m2). For this measurement, the area of flow through plane at the level of the origin of the flow jet is used

Question 26

In patients with aortic stenosis, there is usually post-stenotic enlargement of the proximal ascending aorta which is greater than (Webb Thoracic Imaging, 3rd ed, p2451)

Answer 26

4.0 cm ## Footnote In patients with aortic stenosis, there is usually poststenotic enlargement of the proximal ascending aorta (greater than 4.0 cm or 2.2 cm/m2)

Question 27

The following inherited diseases are associated with aortic regurgitation, except (Webb Thoracic Imaging, 3rd ed, p2453) a. Marfan syndrome b. Ehlers-Danlos syndrome c. Leys-Dietz syndrome d. Osteogenesis imperfecta e. None of the above

Answer 27

e. None of the above

Question 28

# [](http://) T/F: In the normal subject, RV stroke volume is nearly equivalent to LV stroke volume (Webb Thoracic Imaging, 3rd ed, p2456)

Answer 28

True

Question 29

The following are MR features of mitral stenosis except (Webb Thoracic Imaging, 3rd ed, p2461) a. Diastolic signal void emanating from mitral valve b. Thickened and limited excursion of leaflet c. Left ventricular enlargement d. Normal LV end-diastolic and end-systolic volumes e. High velocity flow on VEC

Answer 29

c. Left ventricular enlargement ## Footnote Left ATRIAL enlargement

Question 30

In the severe form of this disease, the cardiac silhouette extends from one lateral chest wall to the other or “wall to wall” (Webb Thoracic Imaging, 3rd ed, p2472)

Answer 30

Tricuspid regurgitation ## Footnote Tricuspid regurgitation produces cardiomegaly with right atrial and RV enlargement. The most remarkable degree of cardiomegaly may occur with chronic severe tricuspid regurgitation. A cardiac silhouette extending from one lateral chest wall to the other (“wall to wall”) usually is due to severe tricuspid regurgitation. This lesion does not produce pulmonary venous hypertension or edema. In severe cases, the pulmonary vascularity may appear attenuated.

Question 31

The following are true of asymmetric septal hypertrophic cardiomyopathy: a. Hallmark is dynamic subvalvular aortic stenosis b. During diastole, the LV outflow tract appears normal or slightly narrowed because of the presence of upper septal hypertrophy c. None of the above d. All of the above

Answer 31

d. AOTA ## Footnote Webb, p2486 Asymmetric septal hypertrophic cardiomyopathy can cause obstruction of the LVOT. The hallmark is dynamic subvalvular aortic stenosis. During diastole, the LVOT appears normal or slightly narrowed because of the presence of upper septal hypertrophy

Question 32

True about pulmonary venous hypertension (PVH) a. Ossific nodules appear in the lungs only after multiple episodes of edema and chronic PVH. b. The pulmonary venous pressure in acute disease is approximately 5 mm Hg greater for each grade of PVH compared to that in chronic disease. c. There is no correlation between left atrial pressure and radiographic signs of pulmonary edema because of phase lag between rapid pressure changes and slower changes in radiographic alterations. d. All of the above

Answer 32

a. Ossific nodules appear in the lungs only after multiple episodes of edema and chronic PVH. ## Footnote Webb, p2295 Ossific nodules are small foci of bony metaplasia that appear in the lungs only after multiple episodes of edema and chronic PVH. The venous pressure in CHRONIC disease is approximately 5 mm Hg greater for each grade of PVH compared to that in acute disease. Left atrial mean pressure is usually inferred from the mean pulmonary wedge pressure. Correlation between left atrial pressure and radiographic signs of pulmonary edema is only fair because of phase lag between rapid pressure changes and slower changes in radiographic alterations.

Question 32

# [](http://) Which of the following salient radiographic features of myocardial infarction is true? a. Normal chest x-ray in about 70% of first acute infarctions b. Cardiomegaly is usually indicative of Restrictive Cardiomyopathy c. Normal heart size with pulmonary venous hypertension or pulmonary edema in about 50% of first acute infarctions d. All of the above

Answer 32

c. Normal heart size with pulmonary venous hypertension or pulmonary edema in about 50% of first acute infarctions

Question 33

True about radiographic features of Aortic stenosis except: a. Enlargement of the ascending aorta due to post-stenotic dilatation b. Mild or no cardiomegaly in compensated stage c. Pulmonary venous hypertension or pulmonary edema d. Calcification of aortic valve may be discernible on radiograph but is more readily shown on CT

Answer 33

c. Pulmonary venous hypertension of pulmonary edema

Question 34

Double density sign

Answer 34

LA enlargement

Question 35

Grade II sign of pulmonary ventricular hypertension: a. Perihilar alveolar filling b. Subpleural edema c. Large upper lobe vessels d. Confluent acinar shadows

Answer 35

b. Subpleural edema ## Footnote a. Perihilar alveolar filling - Grade III c. Large upper lobe vessels - Grade I d. Confluent acinar shadows - Grade III

Question 35

One of the following x-ray findings is not a radiographic sign of Left Atrial enlargement: a. Left retro-cardiac double density b. Splaying of the carina c. Posterior displacement of the left upper lobe bronchus d. Horizontal orientation of the distal portion of the left bronchus

Answer 35

a. Left retro-cardiac double density ## Footnote Should be RIGHT retrocardiac double density

Question 36

Hoffman-rigler sign

Answer 36

LV enlargement

Question 36

# [](http://) Walking man sign

Answer 36

LA enlargement

Question 37

A semiquantitative estimation of pericardial effusion can be obtained by measuring the width of the pericardial space in front of the right ventricle. A moderate effusion is associated with a width of more than _ mm. (Webb & Higgins, Thoracic Imaging 3rd ed., p 2564)

Answer 37

5 mm

Question 37

Shmoo sign

Answer 37

LV enlargement ## Footnote Brant, 4th ed, p575 Left ventricular or “Shmoo” configuration (after Al Capp’s Shmoo) describes lengthening and rounding of the left heart border with a downward extension of the apex resulting from left ven- tricular enlargement.

Question 37

Findings which can differentiate hemorrhagic pericardial effusion from nonhemorrhagic effusion except: (Webb & Higgins, Thoracic Imaging 3rd ed., p 2564) a. Homogenenous, high signal on T2W SE b. Higher than 40-45 density units on CT c. If chronic, low signal on all types of MR sequences d. High intensity on T1W SE

Answer 37

a. Homogenenous, high signal on T2W SE

Question 38

Which of the following is not included in the diagnostic features of acute pericarditis? (Webb & Higgins, Thoracic Imaging 3rd ed., p 2570) a. Early contrast enhancement of pericardium b. Pericardial thickness of > 2 mm on CT and MRI c. Pericardial effusion d. All may be seen in acute pericarditis

Answer 38

b. Pericardial thickness of > 2 mm on CT and MRI ## Footnote > 4 mm

Question 39

True or False: The classic picture of constrictive pericarditis is classified as chronic fibrous constrictive pericarditis and consists of fibrotic changes and must have associated calcifications consequent to a previous chronic inflammatory process. (Webb & Higgins, Thoracic Imaging 3rd ed., p 2571)

Answer 39

False ## Footnote The classic picture is classified as chronic fibrous constrictive pericarditis and consists of fibrotic changes WITH OR WITHOUT associated calcifications consequent to a previous chronic inflammatory process

Question 40

A 30-year old male underwent chest x-ray for pre-employment. On x-ray you noted leftward deviation of the cardiac silhouette with normal lung parenchyma. What will be your impression on your report? (Webb & Higgins, Thoracic Imaging 3rd ed., p 2571) a. Cardiac findings, as detailed above. Please correlate clinically. b. Consider absent pericardium. CT correlation may be done for further evaluation. c. (Descriptive) d. No significant chest findings.

Answer 40

b. Consider absent pericardium. CT correlation may be done for further evaluation. ## Footnote The most reliable signs of complete absence of the left pericardium are interposition of lung between the aorta and main pulmonary artery, in the aortopulmonary window, and a rotation of the cardiac axis to the left side

Question 41

You suggested a chest CT with contrast for the patient below. The patient had no history of cardiac surgery. You noted a narrow communication of the mass with the pericardial cavity, what will be your diagnosis? (Webb & Higgins, Thoracic Imaging 3rd ed., p 2596)

Answer 41

Pericardial diverticulum

Question 42

# [](http://) True of pericardial effusion: (Brant and Helms, Fundamentals of Diagnostic Radiology 4th ed., p. 580) a. Water bottle appearance on lateral view b. Negative for differential density sign PA c. Differential density sign on AP d. Positive epicardial fat pad sign on lateral view

Answer 42

d. Positive epicardial fat pad sign on lateral view ## Footnote Webb, p2341 The varying density sign is also sometimes present on the frontal radiograph (see Fig. 30.40). This consists of a lesser density at the periphery of the cardiac contour compared to the central portion of the cardiac contour. The cause of this varying density is that the x-ray beam encounters only fluid toward the periphery of the pericardial effusion, while in the center of the pericardial effusion, the radiographic beam must pass through both water anteriorly and the cardiac substance more centrally. Brant, 4th Pericardial Effusion. Between the visceral and parietal lay- ers is the pericardial space, which usually contains 20 mL of serous fluid. More than 50 mL of fluid is clearly abnormal, but 200 mL is required for detection by plain film radiography. Mediastinal and epicardial fat enable the pericardium to be visualized as a thin arcuate line paralleling the anterior heart border in the retrosternal region. A pericardial stripe exceed- ing 2 to 3 mm is indicative of pericardial thickening or effu- sion. Unfortunately, the thickened pericardial stripe can be seen on the lateral radiograph in only about 15% of patients with pericardial effusion. The “differential density sign” refers to a lucent margin along the left heart border on the PA radio- graph or along the posterior cardiac border on the lateral radiograph. It is seen in up to 63% of patients with pericar- dial effusion but is less specific than the thickened pericardial stripe. Large pericardial effusions cause the heart to appear on frontal radiographs in the shape of a sac of water sitting on a tabletop (Fig. 21.21).

Question 43

True of cardiac tamponade: (Brant and Helms, Fundamentals of Diagnostic Radiology 4th ed., p. 580) a. Rapid enlargement of cardiac silhouette with normal vascularity b. Diastolic collapse of the LV on 2D echo c. Appreciated radiographically with at least 50 mL of pericardial fluid d. Paradoxical narrowing of the SVC and IVC

Answer 43

a. Rapid enlargement of cardiac silhouette with normal vascularity

Question 44

# [](http://)[](http://) The pericardial space normally contains ____ ml of fluid. (Webb & Higgins, Thoracic Imaging 3rd ed., p 2551)

Answer 44

up to 50 mL ## Footnote The pericardial cavity normally contains up to 50 mL of serous fluid that distributes diffusely around the heart surface and inside the pericardial recesses.

Question 45

Which of the following is false regarding atrial septal defects? (Swischuk p. 243) a. The secundum defect results from the absence of, or a defect in, the flap of tissue derived from the septum primum b. Ostium primum defects are low defects resulting from maldevelopment of the primitive endocardial cushions. c. The secundum defect results from the absence of, or a defect in, the flap of tissue derived from the septum secundum d. These defects cause left-to-right shunting of blood

Answer 45

Answer in the answer key: a. The secundum defect results from the absence of, or a defect in, the flap of tissue derived from the septum primum ## Footnote Choice A is true Choice C is false

Question 46

In cases of double aortic arch, what is seen on barium esophagram? (Swischuk p. 308) a. Reverse S-shaped indentation of the esophagus b. Indentation of the anterior border of the esophagus c. Indentation of the posterior border of the esophagus d. None of the above

Answer 46

a. Reverse S-shaped indentation of the esophagus

Question 46

# [](http://) In cases of aberrant left pulmonary artery, what is seen on barium esophagram? (Swischuk p. 315) a. Indentation of the posterior border of the esophagus b. Indentation of the anterior border of the esophagus and posterior border of the trachea c. Reverse S-shaped indentation of the esophagus d. None of the above

Answer 46

b. Indentation of the anterior border of the esophagus and posterior border of the trachea

Question 47

Which of the following is not an associated finding of pulmonary embolism? (Swischuk p. 332) a. Cardiomegaly with right ventricular hypertrophy b. Prominence of the pulmonary artery c. Diminution of the pulmonary vasculature d. None of the above

Answer 47

d. NOTA ## Footnote Swischuk, p332 Roentgenographically, there will be cardiomegaly with right ventricular hypertrophy, prominence of the pulmonary artery, and diminution of the pulmonary vasculature. Pulmonary emboli also can calcify lain films, when embolism is massive, tend to show decreased pulmonary vascularity and cardiomegaly with a right-side enlargement pattern. Most often, however, with pulmonary embolism, plain films are normal.

Question 48

Identify the MISMATCHED sequence (Webb 2622) a. Cine MRI: movement b. Spin echo: white blood c. Gradient echo: white blood d. Steady-state free precession (SSFP): white blood

Answer 48

b. Spin echo: white blood

Question 49

# [](http://)[](http://) Which of the following characteristics are suggestive of a MALIGNANT cardiac tumor? (Webb 2654) a. Combined intramural and intracavitary components b. Simple pericardial effusion c. Narrow attachment to the cardiac wall d. None of the above

Answer 49

a. Combined intramural and intracavitary components

Question 50

Which of the following are suggestive of a BENIGN cardiac tumor? (Webb 2654) a. Mediastinal extension b. Pulmonary metastasis c. Narrow attachment to the cardiac wall d. Tumor necrosis

Answer 50

c. Narrow attachment to the cardiac wall

Question 51

True or false: Rhabdomyosarcomas typically appear as single tumors. (Webb 2657)

Answer 51

False ## Footnote Rhabdomyosarcomas are the most common malignant cardiac tumors in children. They can arise anywhere in the myocardium and are often multiple. Their signal intensity on MRI is variable. Rhabdomyosarcomas may be isointense to the myocardium on T1- and T2-weighted images, but areas of necrosis can exhibit heterogeneous signal intensity and patchy hyperenhancement after Gd-DTPA administration (see Fig. 35.22). Extracardiac extension into the pulmonary arteries and descending aorta has been clearly delineated with MRI.

Question 52

True or false: On imaging alone, it IS possible to differentiate among PRIMARY CARDIAC fibrosarcoma, osteosarcoma, leiomyosarcoma, or liposarcoma. (Webb 2657)

Answer 52

False

Question 53

True or false: Primary cardiac lymphoma is more common than secondary lymphoma involving the heart.

Answer 53

False ## Footnote Primary cardiac lymphoma is less common than secondary lymphoma involving the heart, which usually represents the spread of non-Hodgkin’s lymphoma. Primary lymphoma of the heart most often occurs in immunocompromised patients and is highly aggressive. Almost all primary cardiac lymphomas are B-cell lymphomas.

Question 54

Which of the following cardiac MR sequences is acquired for the purpose of quantifying ventricular volumes, mass, and global function? (Webb 3rd ed., p. 2478)

Answer 54

Cine MRI with FIESTA ## Footnote Cine MR images are acquired for the purpose of quantifying ventricular volumes, mass, and global function. Cine MR images are now usually done with some form of balanced steady-state free precession sequence. A set of these images at multiple levels encompassing the heart provides a volumetric data set for the direct measurement of the end-diastolic, end- systolic, and stroke volumes, mass, and ejection fraction of both the left ventricle and right ventricles. The blood pool is bright on cine MRI.

Question 55

All of the following are imaging features of myocarditis, EXCEPT? (Webb 3rd ed., p. 2526) a. Increased LV +/- RV volumes b. Decreased LV ejection fraction c. Focal early GAD hyperenhancement in the LV subepicardium d. Global LV hypokinesis

Answer 55

c. Focal early GAD hyperenhancement in the LV subepicardium

Question 56

Which of the following imaging features will differentiate restrictive cardiomyopathy from constrictive pericarditis? (Webb 3rd ed., p. 2505) a. Normal pericardial thickness b. Non-enhancing myocardium c. Decreased LV volume and ejection fraction d. Increased LV wall thickness

Answer 56

a. Normal pericardial thickness ## Footnote In constrictive pericarditis, the pericardium is nearly always thickened, whereas restrictive cardiomyopathy does not have this feature.

Question 57

Which type of cardiomyopathy typically presents with a normal ventricular wall thickness? (Brant 4th ed., p. 602) a. Hypetrophic b. Dilated c. Restrictive d. All of the above e. None of the above

Answer 57

c. Restrictive

Question 58

Which of the following types of cardiomyopathies may present with decreased cardiac compliance? (Brant 4th ed., p. 602) a. Hypetrophic b. Dilated c. Restrictive d. All of the above e. None of the above

Answer 58

d. All of the above

Question 59

This rare form of cardiomyopathy is limited to the RV, with dilation of the RV chamber, marked thinning of the anterior right ventricular wall and abnormal RV wall motion: (Brant 4th ed., p. 605)

Answer 59

“Arrhythmogenic right ventricular dysplasia” (ARVD)

Question 60

Which of the following is characterized by loose networks of trabeculations in the endocardial wall of the left ventricle, LV enlargement and decreased ejection fraction? (Webb 3rd ed., p. 2534) a. Cardiac sarcoidosis b. Cardiac amyloidosis c. Cardiac Noncompaction d. Dilated cardiomyopathy

Answer 60

c. Cardiac Noncompaction

Question 60

Apical aneurysm of the left ventricle is a characteristic chronic finding in: (Webb 3rd ed., p. 2532)

Answer 60

Chagas disease ## Footnote hagas’ disease is caused by the protozoan Trypanosoma cruzi. Cardiac involvement is frequent. This infection is characterized by acute, intermediate, and chronic phases. In chronic Chagas’ disease, the heart is the most frequently affected organ, and lymphocytic infiltration can be observed. Regions of focal inflammation have been shown to enhance strongly on T1-weighted images after the administration of Gd-DTPA and on DE-MR. The regional distribution of LGE is typically inferolateral basal and apical. Apical aneurysm of the left ventricle is a characteristic of chronic Chagas disease. LGE is seen more frequently in more advanced diseases and worse clinical statuses.

Question 61

Regional dysfunction, with no delayed hyperenhancement and acute transient decrease in myocardial perfusion are indicative of which type of myocardial injury? (Webb 3rd ed., 2769)

Answer 61

Stunned myocardium ## Footnote Stunned myocardium shows regional myocardial dysfunction, which recovers to normal in hours to days; there is no irreversible injury (acute infarctions). Hibernating myocardium is chronic ischemia that causes persistent myocardial dysfunction but is not so severe that infarctions occur. Reduction in myocardial blood flow below a critical threshold for a sufficiently long time causes myocardial infarction.

Question 62

# [](http://) All of the following are delayed enhancement patterns characteristic of myocardial infarction, EXCEPT? (Webb 3rd ed., 2771) a. Always involves at least the subendocardial layer of the myocardium b. Corresponds to the distribution of one or more coronary arteries or branch arteries c. Both d. None of the above

Answer 62

d. None of the above ## Footnote The delayed enhancement caused by acute or chronic myocardial infarction has two features that are characteristic: (1) always involves at least the subendocardial layer of myocardium and (2) corresponds to the distribution of one or more coronary arteries or branch arteries

Question 63

It is defined as right ventricular failure secondary to pulmonary parenchymal or pulmonary arterial disease: (Brant 4th ed., p 604)

Answer 63

Cor pulmonale

Question 64

An acyanotic patient presents with evidence of increased pulmonary vascularity, left atrial enlargement, biventricular enlargement. What is your primary consideration? (Webb Thoracic Imaging: Pulmonary and Cardiovascular Radiology Third Edition, Sec. 8 Ch. 31 p. 2389)

Answer 64

Ventricular septal defect

Question 65

What congenital heart defect shows pulmonary plethora, right atrial and ventricular enlargement, and a diminutive ascending aorta and aortic arch? (Webb Thoracic Imaging: Pulmonary and Cardiovascular Radiology Third Edition, Sec. 8 Ch. 31 p. 2380)

Answer 65

Atrial septal defect

Question 66

The NICU intern messaged Radio Telegram to request for a wet read of the chest radiograph of a preterm infant. You noted evidence of pulmonary arterial overcirculation, left atrial and ventricular enlargement, and an enlarged aortic arch. You suspect a significant left-to-right shunt. What is your primary diagnosis? (Webb Thoracic Imaging: Pulmonary and Cardiovascular Radiology Third Edition, Sec. 8 Ch. 31 p. 2392)

Answer 66

Patent ductus arteriosus

Question 67

A cyanotic patient presents with decreased pulmonary vascularity, right ventricular enlargement, a concave pulmonary arterial segment, and a prominent ascending aorta and aortic arch. Because you’ve already seen several similar studies you quickly come up with a primary diagnosis, noting that it can also present with asymmetric blood flow towards which structure? (Webb Thoracic Imaging: Pulmonary and Cardiovascular Radiology Third Edition, Sec. 8 Ch. 31 p. 2397)

Answer 67

Right lung ## Footnote Branch pulmonary arterial stenosis, especially at the origin of the left pulmonary artery, may cause asymmetric pulmonary blood flow. However, even in the absence of branch stenosis, preferential flow occurs to the right lung due to the orientation of the right ventricular outflow tract.

Question 68

Based on the Collett and Edward Classification, what type of truncus arteriosus is shown when the right and left pulmonary arteries arise separately from the posterior aspect of the truncus? (Webb Thoracic Imaging: Pulmonary and Cardiovascular Radiology Third Edition, Sec. 8 Ch. 31 p. 2415)

Answer 68

Type II

Question 69

The snowman sign on chest radiographs is commonly attributed to total anomalous pulmonary venous return. Which specific type do we expect to see this? (Webb Thoracic Imaging: Pulmonary and Cardiovascular Radiology Third Edition, Sec. 8 Ch. 31 p. 2417)

Answer 69

Supracardiac ## Footnote Swischuck, p251 Roentgenographically, the changes in total anomalous pulmonary venous retUrn are varied and depend on the specific type ofvenous connection. The most characteristic and diagnostic plain film configuration in the type I anomaly group is that of the so-called "snowman" or "figure 8" heart.

Question 70

This cardiac deformity presents with displacement of one or more triscuspid valve leaflets into the inflow portion of the right ventricle. Notable findings include decreased pulmonary vascularity, enlargement of the right atrium and ventricle, a small main pulmonary arterial and hilar segments, and a small thoracic aorta. (Webb Thoracic Imaging: Pulmonary and Cardiovascular Radiology Third Edition, Sec. 8 Ch. 31 p. 2420)

Answer 70

Ebstein anomaly

Question 71

Which of the following is true in patients with corrected transposition of the great arteries (L-TGA)? (Webb Thoracic Imaging: Pulmonary and Cardiovascular Radiology Third Edition, Sec. 8 Ch. 31 p. 2404-5) a. Blood from the pulmonary veins drains into the left atrium, to the right ventricle, and into the aorta b. The morphologic right ventricle is located to the left of the morphologic left ventricle c. There is a prominent convexity of the upper left cardiac border on radiographs d. All of the above

Answer 71

d. AOTA

Question 72

Diagnosis

Answer 72

VENTRICULAR SEPTAL DEFECT

Question 73

A: Which type of partial anomalous pulmonary venous return would this radiograph be typically attributed? B: What is your diagnosis? (Separate answers for A and B with a comma)

Answer 73

INFRACARDIAC, SCIMITAR SYNDROME INFRACARDIAC TYPE, SCIMITAR SYNDROME

Question 74

Diagnosis? Specify specific phenotype/classification

Answer 74

ASYMMETRIC HYPERTROPHIC CARDIOMYOPATH ASYMMETRIC SEPTAL HYPERTROPHIC CARDIOMYOPATHY HYPERTROPHIC CARDIOMYOPATHY

Question 75

Representative cut of a delayed T1W-contrast enhanced cardiac MR study, short axis view. Diagnosis?

Answer 75

MYOCARDIAL INFARCTION

Question 76

In terms of hemodynamics, what is the most critical component of the anomaly below?

Answer 76

PULMONARY STENOSIS

Question 77

Diagnosis?

Answer 77

MYOCARDIAL BRIDGING BRIDGING OF THE LEFT ANTERIOR DESCENDING ARTERY BRIDGING OF THE LAD

Question 78

Gradient echo images. Pointed mass has NO early enhancement on post-contrast sequences. Impression?

Answer 78

THROMBUS INTRACARDIAC THROMBUS

Question 79

Impression, ECG-gated T1 spin-echo images (left); same image with fat saturation (right); (Webb 2622

Answer 79

LIPOMA

Question 80

Identify the location of mass; Intracavitary, intramural, pericardial, paracardiac (Webb 2623)

Answer 80

INTRAMURAL

Question 81

Name the vascular anomaly associated with these imaging findings

Answer 81

ABERRANT LEFT PULMONARY ARTERY

Question 82

Name the vascular anomaly associated with these imaging findings

Answer 82

DOUBLE AORTIC ARCH

Question 83

Diagnosis. (Pointed by the arrows)

Answer 83

PERICARDIAL EFFUSION

Question 84

What do you call this sign? (Same image as previous)

Answer 84

OREO COOKIE SIGN

Question 85

Diagnosis.

Answer 85

CONSTRICTIVE PERICARDITIS

Question 86

Diagnosis

Answer 86

AORTIC REGURGITATION

Question 87

Diagnosis

Answer 87

MITRAL STENOSIS

Question 88

Diagnosis

Answer 88

TRICUSPID REGURGITATION

Question 89

Complication of myocardial infarction

Answer 89

TRUE ANEURYSM LEFT VENTRICLE TRUE LEFT VENTRICULAR ANEURYSM TRUE ANEURYSM OF THE LEFT VENTRICLE

Question 90

What disease entity is this? (arrows)

Answer 90

PULMONARY ARTERIAL HYPERTENSION

Question 91

Identify lesion along the right side of the heart.

Answer 91

PERICARDIAL CYST