Cardiothoracic Flashcards
1
Q
In patient’s with Marfan’s syndrome, what diameter of the ascending aorta typically necessitates surgery?
A
5 cm
2
Q
In a normal patient, what diameter of the ascending aorta warrants possible surgical intervention?
A
5.5 to 6 cm
3
Q
At cardiac MR, what diseases cause transmural enhancement?
A
- Infarction (most common)
- Myocarditis, severe
- Sarcoidosis, chronic
4
Q
At cardiac MR, what diseases cause mesocardial enhancement?
A
- Hypertrophic CM
- Dilated CM
- Pulmonary hypertension
5
Q
At cardiac MR, what diseases cause subendocardial enhancement?
A
- Vascular (infarction)
- Non-vascular (amyloid, hypereosinophilic syndrome, histiocytoid CM, cardiac transplant)
6
Q
At cardiac MR, what diseases cause subepicardial enhancement?
A
- Myocarditis (most common)
- Sarcoid
7
Q
At cardiac MR, what diseases cause patchy enhancement?
A
- Sarcoid
- Amyloid
- Myocarditis
8
Q
Thymomas are associated with what clinical conditions?
A
-Myasthenia gravis
-Pure red cell aplasia
-Hypogammaglobulinemia
(paraneoplastic syndromes)
-(collagen vascular diseases)
9
Q
DDx for pericardial calcification
A
- Prior surgery (MC in the West)
- TB (MC in the world)
- Pericarditis (infection)
- Radiation
- Lupus
- Metastatic calc secondary to renal failure
10
Q
What is Loeys-Dietz syndrome?
What are its characteristic features?
A
A rare autosomal dominant disorder with multiple characteristic features: arterial aneurysms/dissections frontal bossing hypertelorism craniosynostosis cleft palate
11
Q
DDx cardiophrenic angle mass
A
- Fat pad
- Pericardial cyst
- Metastasis
- Lymphoma
- Hernia (Morgagni)
- Aneurysm
- Pericardial lipomatosis
12
Q
DDx for miliary nodules
A
- Infxn (TB, histo, fungal, healed varicella pneumonia)
- Mets
- Hypersensitivity pneumonitis
- Sarcoidosis
- Pneumoconioses
- Multifocal micronodular pneumocyte hyperplasia (a/w tuberous sclerosis)
13
Q
DDx for chest wall involvement/invasion
A
"BATMAN" organisms. Batman breaks down barriers Blastomycosis Actinomycocis TB (75% of cases) Mucormycosis Aspergillus Nocardia -Neoplasm (cancer, lymphoma, mesothelioma) -Cryptococcus
14
Q
What is the most common cause of coronary artery aneurysm worldwide?
A
Kawasaki disease
atherosclerosis is the MCC in the USA
15
Q
What percentage of Kawasaki patients will develop coronary artery aneurysms?
A
When Kawasaki disease is left untreated, about 15-25% will develop coronary artery aneurysms.
16
Q
What is a Blalock-Taussig shunt?
A
- End-to-end anastomosis of the subclavian artery to the pulmonary artery, performed ipsilateral to innominate artery/opposite to aortic arch
- ToF, tricuspid atresia with pulmonic stenosis
17
Q
What is a Fontan procedure?
A
1) External conduit from R atrium to pulm trunk (=venous return enter pulmonary artery directly)
2) Closure of ASD: floor constructed from flap of atrial wall and roof from piece of prosthetic material
It is not usually used in isolation, but in combination with other repair procedures in a staged manner in an attempt to correct the underlying cardiac pathology.
-The procedure attempts to bypass the right heart. Systemic circulation is redirected into the pulmonary arteries.
-It can be used in multiple situations, including:
*tricuspid atresia
*hypoplastic left heart (part of the overall repair strategy)
other types of single ventricle physiology
18
Q
What is a Glenn shunt?
A
- End-to-end shunt between the distal end of the right pulmonary artery and SVC; reserved for pts with cardiac defects in which total correction is not anticipated
- Tricuspid atresia
19
Q
What is a Mustard procedure?
A
1) Removal of atrial septum
2) Pericardial baffle placed into common atrium such that systemic venous blood is rerouted into the LV and pulmonary venous return into RV and aorta
- Complete transposition
20
Q
What is a Ross procedure?
A
The Ross procedure (or pulmonary autograft) is where a diseased aortic valve is replaced with the person’s own pulmonary valve. A pulmonary allograft (valve taken from a cadaver) is then used to replace the patient’s own pulmonary valve. Pulmonary autograft replacement of the aortic valve is the operation of choice in infants and children, but its use in adults remains controversial.
21
Q
What is the most common location for a Morgagni hernia?
A
Anterior at the right cardiophrenic angle
(90% occur on the right side)
(relatively rare; 2% of CDH)
22
Q
What is the most common location for a Bochdalek hernia?
A
most frequently left posterior diaphragm
23
Q
In what percentage of normal patients is the left hilum located higher than the right on frontal chest radiography?
A
97%. At the same level as the right in 3%. The right hilum is never higher than the left in normal subjects.
24
Q
What are CT findings that suggest malignant pleural disease (e.g. mesothelioma or metastases)?
A
1) Circumferential involvement of pleura, including visceral pleura
2) Involvement of mediastinal aspect of pleura
3) Nodularity
4) Thickness greater than 1 cm
25
What percentage of fibrous tumors of the pleura are malignant?
12-37% (STATdx)
26
What paraneoplastic syndromes are associated with localized fibrous tumor of the pleura?
- Hypoglycemia: Doege-Potter syndrome: Postulated production of insulin-like growth factor II
- Hypertrophic osteoarthropathy, 17-35% of cases; Pierre Marie-Bamberger syndrome: Postulated production of growth hormone-like substance
- Digital clubbing
27
What organism is associated with fibrosing mediastinitis?
Most commonly Histoplasma capsulatum.
Multiple etiologies possible: Aspergillosis, Mucormycosis, Blastomycosis, Cryptococcosis, TB, radiation, trauma, drug reaction
28
What other associated disorders may be seen in patients with fibrosing mediastinitis?
Other idiopathic fibroinflammatory disorders: -Retroperitoneal fibrosis
- Sclerosing cholangitis
- Riedel thyroiditis
- Orbital pseudotumor
29
What imaging findings are seen in desquamative interstitial pneumonia/pneumonitis (DIP)?
- Seen in smokers
- Ground-glass opacity (80%): Basilar, peripheral
- Basilar reticular opacities (60%)
- Small, well-defined cysts
- Honeycombing unusual (10%)
30
What is the typical appearance of alpha 1 antitrypsin deficiency in the lungs?
- Panlobular emphysema
- bronchiectasis (up to 40%)
- frank bullae formation
- possibly bronchial wall thickening
31
DDx for bat-wing appearance on CXR
- Pulmonary edema
- Pulmonary hemorrhage
- Bronchopneumonia
- inhalational injury (e.g. noxious gas)
- PCP
- pulmonary alveolar proteinosis
32
What are the CT findings of organizing pneumonia?
-patchy consolidation with a predominantly subpleural and/or peribronchial distribution
-Reverse halo sign or Atoll sign is highly specific, but only present in 20% of cases
-small, ill-defined peribronchial or peribronchiolar nodules
large nodules or masses
-bronchial wall thickening or dilatation in the abnormal lung regions
-a perilobular pattern with ill-defined linear opacities that are thicker than the thickened interlobular septa and have an arcade or polygonal appearance
-ground glass opacity or crazy paving
33
DDx Bilateral GGO (Acute and Chronic)
```
Acute (PCP, pulm hemorrhage, atypical infection; viral)
Subacute/chronic:
-Subacute HP
-Resp bronchiolitis
-Adenocarcinoma with lepidic pattern
-NSIP (+ fibrosis)
```
34
What are CT findings of subacute HP?
- GG opacities and ill-defined small centrilobular GG nodules
- heterogeneous or small nodular opacities: with a predominance for the mid to lower lung zones
- Mosaic pattern with air-trapping
35
What are HRCT findings of acute HP?
- dominated by air space abnormality with no features of fibrosis
- homogeneous GG and alveolar opacities which are usually bilateral and symmetric but sometimes patchy and concentrated in the middle part and base of the lungs or in a bronchovascular distribution
- may be a lower zonal predilection in the acute form
- The combination of air trapping, normal lung can ground glass changes can give a HEAD CHEESE appearance.
36
What are CXR findings of chronic HP?
- Findings of fibrosis: Architectural distortion, volume loss
- Mid and upper lung zone predominant
- No pleural disease or lymphadenopathy
- Sparing of or less severe findings in lung bases
37
What are CT findings of chronic HP?
- Fibrosis: Honeycomb lung, traction bronchiectasis, architectural distortion
- Mid and upper lung zone predominance
- Lung bases less severely involved
- Superimposed subacute findings: Ground-glass opacity and small, ill-defined, centrilobular nodules
38
DDx for interstitial pattern (acute and chronic)
Acute:
1) interstitial edema (=transudate/fluid)
2) infection (=exudate or pus: viral, PCP, mycoplasma, TB)
Chronic:
1) lymphangitic carcinomatosis
2) fibrosis
3) sarcoidosis/silicosis
39
DDx crazy-paving pattern
1. alveolar proteinosis
2. infections (PCP, viral)
3. mucinous adenoca (former BAC)
4. pulmonary edema
5. hemorrhage
6. ARDS
7. radiation pneumonitis
8. drug reaction
9. lipoid pneumonia
40
DDx centrilobular nodules
1. infectious bronchiolitis (e.g. TB, mycoplasma, viral)
2. aspiration
3. subacute HP (air trapping)
4. respiratory bronchiolitis
5. vasculitis/hemorrhage
(last 3 are assoc with GG attenuation)
41
DDx perilymphatic nodules
1. Sarcoidosis
2. Lymphangitic carcinomatosis
3. Silicosis/CWP/pneumoconiosis
4. Rarely follicular bronchiolitis (e.g. sjogren's or RA)
5. Lymphoma rarely
6. LIP
7. Amyloidosis
42
What are CT findings of silicosis?
- well-defined small nodules, may calcify
- centrilobular and sub pleural predominance
- confluent subpleural nodules (pseudoplaques)
- upper lobes and posterior distribution; may be diffuse
- can see progressive massive fibrosis
- calcified (egg-shell) nodes are common
43
DDx random nodules
- Acute (infection: military TB, candidiasis, disseminated histoplasmosis)
- Chronic (metastases: thyroid, melanoma)
44
DDx for mosaic perfusion
1) Small airways disease:
- Asthma
- Obliterative bronchiolitis (post transplant, drug, toxic fumes)
- Post infectious
2) Vascular disease (chronic PE)
45
DDx cystic lung disease
1. LAM
2. Langerhans cell histiocytosis (LCH)
3. Lymphocytic interstitial pneumonia (LIP)
4. Birt-Hogg-Dube syndrome (rare)
46
What are CT findings in LAM?
- thin-walled cysts with homogeneous size; throughout the lungs
- normal intervening lung
- young women (childbearing age)
47
What are CT findings in LCH?
- Smoking-related disease
- Cysts variable sizes and shapes, thin or thick walls, bizarre
- abnormal lung parenchyma (+/- nodules)
- upper lobe predominance (relative sparing of lung bases)
48
Which patients get lymphocytic interstitial pneumonia (LIP)?
Sjogren's
| AIDS
49
What are CT findings of lymphocytic interstitial pneumonia (LIP)?
- Patchy bilateral ground glass opacity and consolidation
- Perilymphatic nodules
- Few cysts
- lower lobe predominance
50
DDx for lung fibrosis
- Idiopathic (UIP/NSIP)
- Collagen vascular disease
- Chronic HP
- Drug reaction
- Asbestosis
51
UIP vs. NSIP features
```
UIP:
-peripheral, lower lung
-honeycomb cysts
-reticulation
NSIP:
-ground glass
-traction bronchiectasis
-subpleural sparing
```
52
LCH vs. LAM features
LCH:
- bizarre-shaped cysts
- variable wall thickness
- upper lobe (spares bases)
- nodules
LAM:
- similar sized cysts
- thin-walled
- diffuse distribution
53
DDx for progressive massive fibrosis (PMF)
| -Bilateral upper lobe masses > 1 cm (with calc)
- Silicosis
- Sarcoidosis
- CWP
- IV talc granulomatosis
54
DDx for upper lobe ILD
- chronic HP
- sarcoidosis
- pneumoconiosis (CWP/silicosis)
- cystic fibrosis
- TB, histoplasmosis
55
DDx cavitary lung lesion
- Cavitary pneumonia
- Pulmonary abscess
- Septic emboli (multiple)
- Tumor necrosis (e.g. SCC)
- Atypical infection (TB, fungal, Nocardia)
- Wegener's (multiple)
- Necrobiotic nodules (in RA)
56
What is empyema necessitans?
- Empyema necessitans refers to extension of a pleural infection out of the thorax and into the neighbouring chest wall and surrounding soft tissues
- e.g. extension of empyema outside the pleural cavity.
- Etiology: Blasto, Actinomycosis, TB, Mucormycosis, Aspergillus
57
DDx "CT halo sign"
- invasive aspergillosis
- candidiasis
- mucormycosis
- vasculitis (Wegener's)
- adenocarcinoma spectrum
- hemorrhage around metastasis
- Kaposi sarcoma
- post biopsy
58
What is Fleischner sign?
Fleischner sign is a prominent central artery that can be caused either by pulmonary hypertension that develops or by distension of the vessel by a large pulmonary embolus.
59
What are the most common CT findings in Churg Strauss syndrome?
The most common CT findings in Churg-Strauss syndrome include subpleural consolidation with lobular distribution, centrilobular nodules, bronchial wall thickening, and interlobular septal thickening.
-RadioGraphics 2007;27:617–639
60
DDx "reverse CT halo sign" (aka atoll sign)
- Organizing pneumonia
- TB
- invasive fungal infections (mucor, aspergillus, paracoccidioidomyocosis)
- Wegener granulomatosis
- lymphomatoid granulomatosis
- sarcoid
- pulmonary infarct
- radiofrequency ablation
61
DDx tracheal tumor
MALIGNANT:
-SCC (55%; older adults; invasive; lower third)
-Adenoid cystic carcinoma (40%; young adults; well-marginated; may cause diffuse narrowing; posterolateral)
-Mucoepidermoid (less common)
-Metastasis possible
BENIGN:
-papilloma (common children, rare in adults)
-hamartoma (fat density is diagnostic; often popcorn calc)
-adenoma (rare)
62
DDx bronchial tumor
- Lung cancer (Most common; SCC or small cell)
- Carcinoid tumor (37% calcify)
- Mets (RCC, breast, melanoma)
- Invasion from esophageal cancer
63
DDx for multiple airway masses
- Metastases
- Papillomatosis
- Tracheopathia osteochondroplastica
- Amyloidosis
64
What are typical features of round atelectasis?
- Pleural disease
- Comet tail sign
- Incurving vessels and bronchi
- Peripheral mass
- Volume loss
65
DDx bronchiectasis
```
Congenital:
-CF
-primary ciliary dyskinesia
-immune deficiency
-Mounier Kuhn (tracheobronchomegaly)
-Williams Campbell
-Yellow nail
Acquired:
-infection
-toxic fume exposure
-central obstruction
-recurrent aspiration
-traction (pulmonary fibrosis)
```
66
DDx anterior mediastinal mass
(4 T's)- Teratoma, thymus tumors, thyroid, terrible lymphoma
- Lymph nodes: lymphoma, mets, inflam/infectious
- Thyroid: goiter, malignancy
- Parathyroid: adenoma, carcinoma
- Thymus: thymoma, carcinoma, thymolipoma, thymic cyst
- Germ cell tumors: teratoma, seminoma
- Hematoma
67
DDx middle mediastinal lesion
- Lymphadenopathy- mets, infection, idiopathic
- Airway- adenoid cystic carcinoma, carcinoid, mets
- Vascular- aneurysm, dissection
- Foregut malformation- bronchogenic cyst
- Pericardium- mets, cyst
- Hernias- hiatal, traumatic
68
What is the cervicothoracic sign?
Helps discern anterior vs. posterior mediastinal masses in the superior thorax. As the anterior mediastinum ends at the level of the clavicles the upper border of an anterior mediastinal lesion cannot be visualised extending above the clavicles. Any lesions with a discernible upper border above that level must be located posteriorly in the chest, i.e. apical segments of upper lobes, pleura, or posterior mediastinum
69
DDx posterior mediastinal lesion
- Esophageal lesions- duplication cyst, neoplasm, varices, achalasia, hiatal hernia
- Neurogenictumors-schwannoma, neurofibroma
- Vascular- descending thoracic aortic aneurysm/dissection
- Vertebral/paraspinal- hematoma, parapsinal abscess, metastases, extramedullary hematopoiesis
70
DDx for diffuse mediastinal lesions
- fibrosing mediastinitis (a/w histoplasma infxn)
- lipomatosis
- metastases
- mediastinal infiltration (edema, infection, lymphoma)
71
What is Bland-Garland-White syndrome?
(ALCAPA) Anomalous origin of the left coronary artery from the pulmonary artery
72
DDx airway narrowing
-Neoplasm
Circumferential:
-Amyloidosis (diffuse; ± Ca++)
-Wegener granulomatosis (usually focal)
-Sarcoid (look for other findings)
-Iatrogenic (focal, post intubation)
Spares membranous portion:
-Relapsing polychondritis (malacia/strictures, ± Ca++)
-Tracheopathia osteochondroplastica (Ca++)
73
What is the CXR staging of sarcoidosis?
- Stage 0- Dx, but no evidence of dz.
- Stage 1- Adenopathy only
- Stage 2- Adenopathy + lung findings
- Stage 3- Lung disease only
- Stage 4- Fibrosis
74
DDx of honeycombing on HRCT
- Idiopathic pulmonary fibrosis
- Connective tissue disease
- drug-related fibrosis
- asbestosis
- hypersensitivity pneumonitis
- sarcoidosis
- NSIP (mild honeycombing)
- Pneumoconioses other than asbestosis
- Post ARDS fibrosis
75
DDx of common causes of a UIP pattern
- IPF
- Connective tissues disease (RA most common)
- drug fibrosis
- asbestosis
76
What diseases have upper lobe predominance at HRCT?
- Sarcoidosis
- TB
- prior fungal infection
- Pneumoconioses (CWP, silicosis. beryllium, talc)
- Radiation fibrosis
- Ankylosing spondylitis
77
What diseases have lower lobe predominance at HRCT?
- IPF
- Connective tissue disease
- drug fibrosis
- asbestosis
- HP
- chronic aspiration
78
What are typical CT findings of Kaposi's sarcoma?
- earliest manifestation is thickening of the peribronchovascular interstitium
- Most suggestive feature is large (>1 cm), irregular, flame-shaped nodules with a preibronchovascular distribution
- Interlobular septal thickeing
- pleural effusions
- mediastinal lymphadenopathy
79
What infection is closely correlated with development of post-transplant lymphoproliferative disorder (PTLD)?
PTLD occurs with what types of tranplants?
When does PTLD typically occur?
- EBV infection
- may occur with solid organ or bone marrow transplantation
- Presentation within 1 year of transplantation is most typical.
80
What are HRCT findings of post-transplant lymphoproliverative disorder?
Findings resemble primary or secondary pulmonary lymphoma.
- Single or multiple pulmonary nodules, masses, or areas of consolidation
- Often with mediastinal and/or hilar lymphadenopathy
- DDx includes infections (esp. fungal), organizing pneumonia, graft vs host disease
81
DDx pleural based lesion
- pleural tumours:
- ->solitary fibrous tumour of the pleura (pleural fibroma)
- ->mesothelioma
- ->localised mediastinal malignant mesothelioma,
- metastatic pleural disease, particularly from adenocarcinomas, e.g. bronchogenic adenocarcinoma, breast cancer, ovarian cancer, prostate cancer, gastrointestinal adenocarcinoma, RCC
- lymphoma: pleural lymphoma
- invasive thymoma
- lipoma
- loculated fluid (on plain film): pleural effusion (pseudotumour), empyema, hemothorax
- mass related to ribs or chest wall, e.g. Ewing sarcoma of chest wall, Askin tumour
- mass related to the intercostal nerve; intercostal nerve neurilemmoma
- splenosis
- infection including tuberculosis
82
For a cavitary lesion, what is the significance of the wall thickness (e.g. benign vs. malignant)?
-Wall thickness is indicative of malignancy:
15 mm: 85% of lesions are malignant (most commonly SCC)
-(Primer)
83
What is the risk of tumor seeding with percutaneous lung biopsy?
```
Extremely uncommon (1:20,000)
-Primer
```
84
What is the risk of pneumothorax following percutaneous lung biopsy?
-25% risk of PTX.
-5-10% require a chest tube
(Primer)
85
What is the minimum dose required to produce radiation pneumonitis?
30 Gy. Acute phase of radiation pneumonitis usually appear 3 weeks after treatment. Fibrosis usually occurs after 6-12 months.
(Primer)
86
DDx for calcified lung metastases
-Bone tumors mets: osteosarcoma, chondrosarcoma
-Mucinous tumors: ovarian, thyroid, pancreas, colon, stomach
-Metastases after chemotherapy
(Primer)
87
DDx cavitary lung lesions
Abscess:
- pyogenic: Staph > Klebsiella > Strep
- Immunocompromised pt: Nocardia, Legionella
Cavitary tumor:
- SCC (primary SCC > H&N SCC > sarcoma mets)
- Sarcoma
- Lymphoma
- TCC of the bladder
Cavitated granulomatous mass (often multiple)
- Fungus: Aspergillus, coccidio,
- TB
- Sarcoidosis, Wegener's, rheumatoid nodules
- Necrotizing granulomatous vasculitis
Cavitated post traumatic hematoma
88
How many segments make up the left lower lobe? What are their names?
4 (apical, anteromedial basal, posterior basal, lateral basal)
89
What is a pulmonary sling?
Pulmonary artery sling is a rare condition in which the left pulmonary artery anomalously originates from a normally positioned right pulmonary artery. The left pulmonary artery then progresses posteriorly over the right main bronchus near its origin from the trachea, traverses between the trachea and the esophagus and enters the left hilum. Symptoms include cyanosis, dyspnea and apneic spells. It almost always requires surgical intervention. Rarely it is asymptomatic and is detected incidentally in asymptomatic adults.
90
DDx tracheobronchial thickening
- relapsing polychondritis
- tracheobronchial amyloidosis
- tracheobronchopathia osteochrondroplastica
91
What is scimitar syndrome?
- aka pulmonary venolobar syndrome, is a rare congenital syndrome that is more common girls.
- It consists of PAPVR below the diaphragm, hypoplasia or aplasia of one or more lobes of the right lung, and an absent or small associated pulmonary artery with primarily systemic arterial supply to the lung.
92
What is "shrinking lung" syndrome?
Progressive loss of lung volume. Common manifestation of SLE. Thought to be due to diaphragmatic dysfunction or pleuritic chest pain with restriction of respiration. CXRs show progressive loss of volume in the lower lobes, sometimes a/w linear or focal areas of atelectasis, but obvious parenchymal abnormalities are usually absent.
93
What is "hot tub" lung?
MAC infection with hypersensitivity pneumonitis
- patchy GG centrilobular nodules or small nodules with air trapping
- a/w exposure to contaminated hot tubs
94
What does RECIST stand for?
Response Evaluation Criteria for Solid Tumors (created in 2000 and revised in 2009)
95
By RECIST criteria, what is considered "partial response" to treatment?
Partial response: >30% decrease in sum of longest diameters (SLD) of target lesions
96
By RECIST criteria, what is considered "progressive disease"?
Progressive disease:
- >20% increase in SLD of target lesions with an absolute increase of >=5 mm;
- appearance of new lesions
97
By RECIST criteria, what is considered "complete response" to treatment?
Disappearance of all target lesions or lymph nodes
98
What measurements are diagnostic for tracheobronchomegaly (Mounier-Kuhn disease)?
Trachea > 3 cm
Bronchi >2.4 cm
Often see tracheal diverticula
99
DDx unilateral lucent hemithorax
"CRAWLS"
C: contralateral lung increased density, e.g. supine pleural effusion
R: rotation
A: air, e.g. pneumothorax
W: wall, e.g. chest wall mass, mastectomy, polio, Poland syndrome
L: lungs, e.g. airway obstruction, emphysema, Swyer-James syndrome, unilateral large bullae, large pulmonary embolus
S: scoliosis
100
DDx lucent rib lesion
```
F: fibrous dysplasia
E: enchondroma
M: metastasis/myeloma
A: ABC
L: lymphoma
E: eosinophilic granuloma
```
101
What is an Askin tumor?
- Essentially an Ewing sarcoma of the chest wall. It is a type of primitive neuroectodermal tumor.
- Demographics of these chest wall tumors are similar to those of Ewing sarcomas elsewhere, seen predominantly in children and young adults
- On CT these tumors are typically ill-defined with heterogeneous attenuation and multiple areas of cystic degeneration. Solid components demonstrate enhancement following the administration of contrast.
102
Following pneumonectomy, how soon should the pneumonectomy space fill with fluid?
Two thirds of the hemithorax fills with fluid in 4 to 7 days; it is important that successive films demonstrate gradual fill-in and that the residual air bubble does not get bigger; an air bubble increasing in size is suggestive of a bronchopleural fistula.
103
How often does pneumothorax occur following central venous catheter insertion?
About 5% of cases (Case Review Series)
104
How soon after mantle radiation does radiation pneumonitis occur?
Approx 6 to 8 weeks
105
What features make a lung cancer unresectable?
- T4 tumors (invasion of mediastinal structures or vertebral bodies and include tumor nodules in a separate lobe of the same lung)
- N3 lymph nodes (scalene, supraclavicular, contralateral hilar LN)
- Metastatic disease (M1a and M1b) (tumor nodules in the contralateral lung, malignant pleural effusions, pleural mets, distant mets)
106
What features make a superior sulcus tumor unresectable?
- Chest wall invasion does not necessarily make it unresectable.
- invasion of more than 50% of a vertebral body
- brachial plexus invasion above T1 nerve level
- esophageal or tracheal invasion
107
DDx centrilobular ground glass nodules
- subacute HP
- Resp bronchiolitis; RB-ILD
- follicular bronchiolitis
- PCP
- pulmonary LCH
108
Which type of immunologic reaction is associated with hypersensitivity pneumonitis?
Type 4
109
What is the recommended follow-up (Flesicherner guidelines) to evaluate a 4 mm solid nodule incidentally detected in a male with a smoking history?
CT follow-up at 12 months. If unchanged and of solid (soft tissue) attenuation, no further follow-up is necessary.
110
DDx for peripheral consolidation (photographic negative of pulmonary edema aka "reverse bat-wing appearance")
- chronic eosinophilic pneumonia
- cryptogenic organizing pneumonia (COP)
- pulmonary infarcts with or without infarction
- vasculitides
- Loffler's syndrome
111
What is the radiologic definition of tracheomegaly?
A coronal tracheal diameter of >25 mm in men and >21 mm in women, as measured 2 cm above the aortic arch on a standard PA erect CXR.
112
Which entity that narrows the airway characteristically spares the posterior wall of the trachea?
Tracheopathia osteochondroplastica
113
How long after coronary stent placement should you wait before performing MRI?
6 weeks in general. This allows endothelialization to occur, which in theory, prevents stent dislodgement.
114
Which procedure/shunt connects the subclavian artery to the pulmonary artery?
Blalock-Taussig shunt: creates a connection b/w the systemic and arterial systems and is a palliative procedure that increases systemic arterial oxygenation by increasing blood flow to the pulmonary artery.
115
Which procedure creates a conduit between the right atrium and the pulmonary artery?
Fontan procedure
116
Which procedure creates an atrial switch using an intra-atrial baffle made of pericardium?
Mustard procedure
117
Which procedure connects the SVC with the pulmonary artery?
Glenn procedure
118
Which of the following is the MOST common complication following surgical repair of tetralogy of Fallot?
Pulmonary regurgitation is the most common complication of transannular or right ventricular outflow patch repair and can lead to right ventricular dysfunction over time.
119
What is the MOST common pulmonary vein anatomic variation?
Separate vein draining the right middle lobe. This variation is noted in approximately 30% of patients.
120
What are the findings in LV non-compaction syndrome?
- Ratio of non-compacted to compacted myocardium >2.3 at end diastole
- decreased systolic function
- hypokinesis of the affected walls
- may show DGE on MR
121
What is the most common congenital cardiac malformation?
bicuspid aortic valve (1-2%)
122
What is the most common associated cardiovascular abnormality associated with bicuspid aortic valve?
Coarctation (50-80%)
Aortic interruption (36%)
VSD (20%)
123
Approximately what percentage of patients with acute PE will develop chronic thromboembolic pulmonary hypertension (CTEPH)?
approx 4%
124
DDx for branching/endobronchial lesions
- mucoid impaction (bronchiectasis, proximal obstruction)
- slow growing endobronchial tumor (e.g. carcinoid)
- foreign body
- bronchial atresia (central nodule/mass + distal hyper lucency [air trapping])
125
DDx single cavitary lung lesion
1) Infection
- TB
- fungal infection (Aspergillus)
- necrotizing pneumonia/abscess
- Nocardia
- Echinococcus
2) Neoplasm (SCC)
3) Congenital
- CPAM
- bronchigenic cyst (infected)
126
DDx multiple cavitary lesions
"TIVI"
- Tumour: SCC, multicentric adenoCA, mets (H&N, colon), papillomatosis
- Infection: septic emboli, TB, pyogenic, fungal
- Vascular: septic emboli, vasculitis, PE
- Inflammation: Wegener’s, RA nodules
127
DDx circumferential tracheal wall disease
1. Wegener’s (subglotic)
2. Amyloidosis (Ca+)
3. Sarcoidosis (more stenosis)
4. Papilomatosis (nodules in mucosa)
128
DDx tracheal wall disease sparing the posterior membrane
Relapsing polychondritis
| Tracheobronchopathia osteochondroplastica
129
DDx enhancing lymph nodes
- melanoma
- RCC
- thyroid carcinoma
- Castleman's disease
130
DDx right paratracheal mass
- Vascular (right aortic arch, dilated azygous vein, aberrant R SCA, SVC dilation)
- bronchogenic cyst
- thyroid goitre
- adenopathy
- neurogenic- vagus nerve
131
DDx unilateral pleural thickening
- post TB empyema
- post healed hemothorax
- pleural metastases
- mesothelioma
- pleurodesis
132
DDx bilateral pleural thickening
- Asbestos-related pleural disease
- pleural metastases
- connective tissue diseases (e.g. RA, SLE)
- Uremia
133
DDx low attenuation lymph nodes
- TB
- metastaes- testicular, SCC
- Treat/high grade lymphoma
- Whipple's disease
134
DDx for central bronchiectasis
- ABPA (allergic bronchopulmonary aspergillosis)
- cystic fibrosis
- Mounier Kuhn syndrome
- Williams-Campbell syndrome
135
DDx for fleeting infiltrates
- eosinophilic pneumonia
- organizing pneumonia
- ABPA
- vasculitis
136
What are the different types of TAPVR?
- Type I: Supracardiac TAPVR
- ->"Vertical" common pulmonary vein carries blood from both lungs and joins left innominate vein
- Type II: Cardiac TAPVR
- ->Common pulmonary vein joins coronary sinus or right atrium directly
- Type III: Infracardiac TAPVR
- ->Common pulmonary vein traverses diaphragm to join portal vein, ductus venosus, or inferior vena cava
137
What diseases are associated with necrobiotic lung nodules?
Rheumatoid and IBD (UC more than CD)
138
DDx for cavitary lung lesions
"CAVITY"
Cancer (SCC, metastases most likely from SCC)
Autoimmune (Wegener, RA)
Vascular (septic emboli, bland emboli)
Infection (pulmonary abscess, TB)
Trauma (pneumatoceles)
Youth (CPAM, pulmonary sequestration, bronchogenic cyst)
139
DDx for lung consolidation
5 things:
1. infection
2. hemorrhage
3. cells (cancer)
4. protein (alveolar proteinosis)
5. fluid (alveolar edema)
140
What is the upper limit of normal for diameter of the right or left main pulmonary arteries?
Inter lobar artery?
- 2 cm
| - 1.5 cm on CXR
141
What is a Ghon focus?
| What is a Ranke complex?
A Ghon lesion or focus represents a calcified tuberculous caseating granuloma (tuberculoma) and represents the sequelae of primary pulmonary tuberculosis infection.
When associated with a calcified ipsilateral hilar node, it is known as a Ranke complex.
142
What is the inversion time in cardiac MR for nulling the myocardium?
- Approx 300 msec for normal myocardium
- IR gradient echo sequence
- Images taken 5-15 min after IV contrast
143
Most common cardiac mass?
thrombus (usually left atrium or LAA, but can be RA or LV apex)
144
Most common benign cardiac tumor?
myxoma
| -look for stalk attaching to near fossa ovalis
145
Most common malignant cardiac mass?
metastases
146
Most common primary cardiac malignancy?
angiosarcoma
147
Normal pericardial thickness
2 mm
148
Most common pericardial malignancy?
Mets >>> primary (mesothelioma)
149
Pulmonary arterial hypertension pressure?
PAH is regarded as a mean pulmonary artery pressure (mPAP) > 25 mm Hg in the setting of normal or reduced cardiac output and a normal pulmonary capillary wedge pressure
150
DDx for fleeting (migrating) infiltrates
- ABPA
- organizing pneumonia
- eosinophilic pneumonia
- vasculitis
151
DDx hyperdense mass or consolidation in the lung
- amiodarone lung
- talcosis
- round atelectasis (after IV contrast)
* lung cancer is never hyperdense
152
What are the classic radiographic findings of scimitar syndrome?
- small right hilum and small right hemithorax
- dextroposition of the heart as a result of rightward mediastinal shift
- curved vessel that courses inferiorly toward the right hemidiaphragm
153
DDx multiple calcified pulmonary nodules
1) Infection: Histoplasmosis, Tuberculosis, healed varicella
2) Inhalational disease: Silicosis
3) Miscellaneous: Hypercalcemia, Mitral stenosis, Alveolar microlithiasis
154
What makes a lung cancer unresectable?
- extrathoracic or contralateral lung metastases
- malignant pleural or pericardial effusion
- contralateral or scalene/supraclavicular LN
- significant invasion of non-resectable structures
155
What is Williams-Campbell syndrome?
- Rare type of cystic bronchiectasis
- Due to defective cartilage
- CT can show areas of central cystic bronchiectasis with distal regions of air trapping.
- Air fluid levels are a very specific sign of bronchiectasis, and are not usually seen in patients with lung cysts.
156
DDx bubbly lucencies in a pulmonary nodule
```
Bubbly lucencies may be seen within an SPN in patients with:
-adenocarcinoma,
-lymphoma
-sarcoidosis
-organizing pneumonia
(RG 2014)
```
157
When should Fleischner criteria not be used in evaluating a SPN?
Fleischner Society recommendations do not apply
to patients with a history of malignancy, young patients (those who are less than 35 years old and, thus, have a low risk for lung cancer), and patients with a fever because the nodules may be infectious.
*(RG 2014)
158
DDx upper lung bilateral pulmonary pathologies
"CASSET P"
- Cystic fibrosis
- Ankylosing spondylitis
- Sarcoidosis
- Silicosis
- Eosinophilic granuloma (LCH)
- TB
- PCP
159
DDx lower lung bilateral pulmonary pathologies
"BAD RASH"
- Bronchiolitis obliterates w organizing pneumonia (BOOP)
- Asbestosis
- DIP, Drugs (INH, nitrofurantoin, hydrazine, amiodarone, chemo drugs)
- Rheumatic disease
- Aspiration (chronic)
- Scleroderma
- Hamman Rich (acute interstitial pneumonitis)
160
What percentage of pulmonary AVM are associated with osler Weber rendu syndrome?
70%
161
DDx broncholithiasis
- histoplasmosis
- TB
- actinomycosis
- Coccidioidomycosis, cryptococcosis
- silicosis
162
DDx pleural thickening with calcification
- fibrothorax (e.g. post hemothorax, pyothorax, radiation tx, CVD)
- talc pleurodesis
- asbestos related pleural disease
- TB, histo
163
DDx acyanotic with shunt vascularity
- VSD (LA enlargement, normal AA)
- PDA (LA enlargement, prominent AA)
- ASD (no LAE)
- PAPVC and sinus venosus ASD (no LAE)
164
DDx acyanotic with normal pulmonary vascularity
- Aortic stenosis
- Coarctation
- Pulmonic stenosis
- Mitral stenosis (LA enlargement)
165
DDx cyanotic with increased vascularity
5 T's
- TGA (most common)
- Truncus arteriosis
- TAPVC
- Tricuspid atresia (if TGA)
- Tingle ventricle
166
DDx cyanotic with normal vascularity
With cardiac enlargement:
* Ebstein's anomaly
* Pulmonic atresia
* Tricuspid atresia (if no TGA)
Without cardiac enlargement:
*TOF
