Cardiac/Vascular Flashcards
Cardiac MRI linear midwall LGE?
DCM
Adult = think Alcohol or idopathic
Child = Muscular dystrophy
IV
Cardiac MRI lateral free wall midwall and epicadrial and septal epicardial LGE DDx ?
- Myocarditis
- Sarcoidosis
also Chagas, Fabrys
Cardiac MRI focal areas anteroseptal and inferoseptal midwall (RV insertion points) LGE?
HOCM
Septal wall thickness.
Systolic anterior motion (SAM) of mitral valve → anterior leaflet pulled into LVOT via Venturi effect
Cardiac MRI global endocardial LGE DDx?
- Amyloidosis
-causes restrictive cardiomyopathy and thus diastolic dysfunction
-speckle appearances on ECHO)
- increase in the thickness of the interatrial septum and right atrial
free wall > 6 mm
- concentric LV hypertrophy - systemic sclerosis
- Post cardiac transplant
Which coronary artery anomaly arises from the right coronary sinus and courses between the aorta and pulmonary trunk?
Inter-arterial LCA
Dangerous, risk sudden death
Bi-atrial dilation, normal ventricular cavity size, abnormal diastolic functionand preserved systolic function?
Restrictive cardiomyopathy
DDx -
Amyloid (Thick myocardial wall )
Haemochromatosis
Eosinophilic
Long T1 is needed for amyloid - ‘difficult to suppress myocardium’
Eosinophilic (Loeffler) - bilateral ventricular thrombus
Thickened pericardium (>2mm MR or 0.4cm CT), Interventricular dependence, bi-atrial dilatation and normal ventricular size?
Constrictive pericarditis
**Ca2+ pericardium
TB or viral
Fibrofatty replacement of the RV myocardium. Dialted RV and reduced function?
ARVC
Common site for cardiac mets?
Pericardium
30x more common than primary cardiac
Melanoma*, Lung, mesothelioma, lymphoma, breast
Most common primary malignant cardiac tumour in adults and features?
Angiosarcoma
**Right atrium **and involve more than one chamber
Broad based attachment
Can encase the Coronary
Present - septic emboli or invasion into pericardium = effusion/tamponade
Heterogeneously high signal on T1 and T2-weighted images with heterogeneous enhancement
Undifferentiated sarcoma mostly arises in the left atrium, although they can also involve the cardiac valve
DDx
Lymphoma
- Primary cardiac lymphomas
- Right atrium, with frequent involvement of more than one chamber and
invasion of the pericardium
-isointense on T1-weighted images and heterogeneously hyperintense on T2-weighted images
Most common primary pericardial malignancy
Mesothelioma
Most common benign cardiac tumour in adults?
Atrial Myxoma
LA and stalk attached to interatrial septum.
Prolapse through MV
Enhance with Gd (thrombus will not)
Associated with
Carneys syndrome (myxoma, facial/buccal blue neavi, sertoli tumours testes)
Most common fetal cardiac tumour?
Rhabdomyoma
LV. Associated with TS
Second commonest in childhood?
Fibroma
IV septum. T1 and T2 dark. Avid enhancement
Cardiac tumour arising from the valve, mobile, no valve dysfuncrtion?
Papillary Fibroelastoma
can act as focus for platelet aggregation and thus septic emboli
Low on T2
RWMA and thinned myocardium, low T2 signal, abnormal fixed perfusion will not redistribute delayed thallium?
Myocardial scar/chronic infarct
RWMA, High T2 signal and normal thallium perfusion ?
Stunned myocardium
RWMA, abnormal fixed decreased perfusion. Redistribution delayed thallium and take up tracery on FDG PET ?
Hibernating myocardium
Signs of LA enlargement on CXR ?
Splaying carina (>90deg)
Double density sign
Dumbell bilobed fat density in the atrial septum ?
Lipomatous hypertrophy of the intra-atrial septum
Spare the fossa ovalis = thus bilobed
if doesnt spare think LIPOMA
Hot on PET - brown fat
Supravalvular aortic or pulmonary stenosis
Williams
Bicuspid AV and coarctation?
Turners
Cyanotic, Box shaped heart, enlarged RA, atrialised RV (small) and TR?
Ebsteins (Tricuspid atresia)
Mother use of lithium.
Most common aortic arch anomaly
Left arch aberrant right subclavian artery
Posterior indentation of oesophagus.
If symptomatic = Dysphagia lusoria
Indentation both oesophagus ‘reverse S’
Posterior indention and anterior indentation of the trachea?
Double aortic arch
Most common vascular ring
What is pulmonary artery sling
Aberrant left pulmonary artery
Anomalies origin of the left pulmonary artery from the right pulmonary artery.
passes above the right main bronchus and in between the trachea and oesophagus
anterior indentation of the oesophagus and posterior trachea
Only vascular ring to between the oesophagus and trachea
Mirror right sided arches are linked with ?
TOF
Truncus
What type of TAPVR causes severe pulmonary oedema in Newborn ?
Type 3 (infra-cardiac)
Cardiomegaly (types I and II), small heart (type III)
What TAPVR causes snowman appearance on CXR?
Type 1 (supra-cardiac)
Cardiomegaly (types I and II), small heart (type III)
What is the most common cause of cyanosis in forst 24 hrs?
Transposition
D type - worst on a PDA connecting two systems
L type - ‘lucky’ double discordant
Most common cyanotic heart disease?
TOF
Which syndrome is Truncus arteriosus linked with ?
CATCH 22- (Di-george)
Follow up for AAA ?
3 - 4.4 cm (small) = 12 month US
4.5 - 5.4 cm (medium) = 3 month US
> 5.5cm (large) = Vascular ref and CT if Sx candidate
Hydronephrosis, retroperitoneal fibrosis, anuerymsal abdominal aneurysm, soft tissue thickening of wall?
Inflammatory aortic aneurysm
More fusiform shape.
Extend to distal aorta and iliacs
assoicated with other ig4-related diseases
Rapidly growing lobulated saccular aneurysm arising eccentrically from abdominal aortic wall. Adjacent periaortic soft tissues sweeling and gas locules?
Mycotic aneurysm
Bacterial. Look for adjacent Psoas abscess or vertebral infection.
DDx Syphilitic aortitis shows curvilinear calcifications
Renal artery stenosis parameters on US?
*** RI > 0.7
Pulsus parvus et tardus waveform (slow rising)
Peak systolic velocity > 150cm/s
Ratio of PSV of renal artery to aorta > 3.5
Assoicated with NF-1
old = proximal stenosis = Atherosclerosis
young - mid/distal = FMD
Smoker, young, arterial occlusion with corkscrew collaterals in hands and feet ?
Buerger
Soft tissue swelling in lower limb, varicose veins, port wine stain ?
Kippel - trenaunay - weber
Classic triad
Bone and soft tissue hypertrophy
Cutaneous capillary malformation (port-wine stain)
Congenital lymphatic and venous malformations (slow flow)
Soft tissues of the right leg diffusely enlarged . Soft tissue enlargement is secondary to multiple low-flow vascular malformations and fat hypertrophy.
A phlebolith is present within 1 of the venous malformations.
May-thurner?
obstruction of the left common iliac vein by compression right common iliac artery
Describe Cystic advential degeneration
Mucus cysts on wall of popliteal artery.
High T2 and T1 (depending on mucin present)
Popliteal artery entrapment syndrome
Anomalous insertion of the medial gastrocnemius
claudication in young fit people
IVC filter CI
IVC < 15 or > 30mm
Complete occlusion of IVC
Bacteraemia
relative CI - INR > 1.5 and Plt <50
Indication for IVC filter
CI to anticoagulation
Complications with standard anticoagulation
Recurrence of PE/DVT despite adequate anticoagulation
Presence of a large IVC thrombus
EVAR favourable parameters
Distance to renal arteries = if less than 10mm landing zone = fenestrated
Angle of the neck acceptable cut off <120 or <60 degrees
CIA length shoud be > 2cm = if shorter deliberated occlusion of the internal iliac arteries.
CIA diamter = < 7mm is hard to stent
Most measure
aorta at the level of the most inferior renal artery
the aortic neck 15 mm distal to the lowest renal artery
aorta at the bifurcation
largest aneurysm sac diameter
size and length of the common iliac arteries
Types of endoleaks ?
Type 1 = proximal or distal graft attachment site
Type 2 = Retrograde filling of sac from persistent collateral
Type 3 = mechanical problem with endograft (fabric tear/graft disruption)
Type 4 = Porous graft material
Type 5 = Endotension
What type of vascuilitis is Takasayau and what does MRI/CT show?
Large vessel vasculitis
Young, female
**High STIR signal in wall = oedema
CT mural thickening, mural enhancement and aneurysmal dilatation, pseudoaneurysm +/- large vessel occlusion
what type of vasculitis is PAN and what condition strongly assoiciated with?
Medium vessel vasculitis
Branches of aorta
Associated with Hep B
Multiple 1-5 mm peripheral aneurysms , Occlusions , Irregular stenoses
Diffuse wall thickening of medium-sized arteries
Kidneys (70-80%)
GI tract, peripheral nerves, and skin (50%)
Skeletal muscles and mesentry (30%)
What condition in children assoaicted with Coronary artery aneurysm?
Kawaski
Lung features in Granulomatosis With Polyangiitis (Wegener)
**Multiple lung nodules or masses ± cavitation
GGO ( pulmonary hemorrhage)
Severe chronic rhinosinusitis septal cartilaginous and osseous destruction
Tracheal wall thickening Circumferential (involvement of posterior membranous trachea)
** Spared in relapsing polychondritis
C- ANCA
Transient, peripheral consolidation in patient with asthma and positive p-ANCA
Eosinophilic Granulomatosis With Polyangiitis (churg struss)
Peripheral, transient consolidations
Mimics eosinophilic pneumonia
Microscopic polyangitis
Consider MPA in patients with alveolar hemorrhage (i.e., ground-glass opacities &/or consolidation) and concomitant renal disease (i.e., glomerulonephritis)
also P-ANCA
Angio vessels affected are too small unlike PAN etc
Bechets
Consider multiple pulmonary artery aneurysms, particularly young men of Mediterranean, Middle Eastern, or Asian ethnicity
Oral and genital mucosal ulcers, uveitis
Involves distal ileum and closely mimics Crohn disease or malignancy
what are some of the main artefacts from cardiac CT
- Step = misregistration of anatomy - irregular hear beat, large FOV, short detector row
- Motion = breathing, tachycardia, RCA worst affected - pading can help
- Streak = metallic, Ca2+, contrast
Branches of the aorta and there levels
CI to adenosine stress MRI
Causes coronary artery vasodilation
CI
- 2/3 deg HB
- Asthma
- SBP < 90
- MI last 48hrs
- Uncontrolled arrhythmia
- Severe AS
CI to dobutamine stress MRI
Sympathomimetic
CI
- SBP > 220
- UA
- Severe AS
- uncontrolled AF
- HOCM
- CCF
Stop test if
- Drop on SBP by 40
- New arryhtmia
- RWMA
- The heart rate has increased to the target rate of (85% x (200-age)
- The patient becomes too symptomatic to continue the scan
- Blood pressure rises above 240/220mmHg
what is leriche syndrome?
Aorto-iliac claudication
Absent femoral pulses
Erectile dysfunction
Flow rates in IR?
Patterns on late enhancement if cardiomyopathies on MRI
inferior vena cava receives tributaries from
Common iliac veins (origin at L5) – drain lower limbs and gluteal regions
Lumbar veins (between L1 and L5) – drain the posterior abdominal wall
**Right gonadal vein (L2) **– drain the right testis/ovary
**Renal veins (L1) **– drain the kidneys, left adrenal gland, left testis/ovary
Right adrenal vein (L1) – drains the right adrenal glanb
Right, middle and left hepatic veins (T8) – drain the liver
Right and left inferior phrenic veins (T8) – drain the diaphragm
Hodgkins vs NHL
Hodgkins
-spread is contiguous
-anterior mediastinal nodes
- Thorax predominantly
- abdo involvement ~ 4 %
NHL
-spread is non-contiguous
- Abdomen predominantly
- posterior mediastinal nodes
- thorax involvement in ~50%
Pseudoaneurysm management post Cath
<2cm manual compresion
>2cm and around 3cm thrombin injection. (need to be able to occlude the neck)
if cant then surgical ligatation
NEVER stent
Classification of aortic dissection?
see picture
CI to TACE
Absolute contraindications:
* Decompensated cirrhosis (Childs–Pugh C or higher)
* Jaundice
* Clinical encephalopathy
* Refractory ascites
* Extensive tumour with massive replacement of both lobes
* Severely reduced portal vein flow
* Technical contraindications to hepatic intra-arterial treatment
* Renal insufficiency (creatinine clearance <30 mL/min)
CI to TIPSS
see picture
