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Learning Radiology > Ch.9 - Recognizing Adult Heart Disease > Flashcards

Ch.9 - Recognizing Adult Heart Disease Flashcards

1
Q

Extracardial causes which can make the heart appear enlarged:

A
  1. AP portable studies.
  2. Factors which inhibit a deep inspiration.
  3. Abnormalities of the bony thorax.
  4. Presence of a pericardial effusion.
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2
Q

On the lateral projection, the heart usually …?

A

Does not extend posteriorly to overlap the spine unless it is enlarged or there is a pericardial effusion.

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3
Q

In an infant heart may normally be …?

A

65% of the cardiothoracic ratio.
Other factors should be assessed in an infant with apparent cardiomegaly such as the pulmonary VASCULATURE and the clinical signs/symptoms.

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4
Q

The … is usually seen in infants superimposed on the upper portion of the cardiac silhouette and could mimic cardiac enlargement.

A

Thymus gland.

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5
Q

2 patterns of CHF are:

A
  1. Pulmonary interstitial edema.

2. Pulmonary alveolar edema.

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6
Q

4 key findings of pulmonary interstitial edema are:

A
  1. Thickening of the interlobular septa.
  2. Peribronchial cuffing.
  3. Fluid in the fissures.
  4. Pleural effusions.
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7
Q

3 key findings in pulmonary alveolar edema:

A
  1. Fluffy, indistinct, patchy airspace densities.
  2. Bat-wing or butterfly configuration - frequently sparing the outer 3rd of the lungs.
  3. Pleural effusions, especially with cardiogenic pulm. edema.
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8
Q

Cardiogenic pulmonary edema is more likely to have:

A
  1. Pleural effusions.
  2. Kerley B lines.
  3. Cardiomegaly.
  4. Elevated capillary wedge pressure than non cardiogenic Pulm. Edema.
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9
Q

Non cardiogenic causes of pulm. Edema:

A

A diverse group of diseases:

  1. Uremia.
  2. DIC.
  3. Smoke inhalation.
  4. Near-drowning.
  5. Volume overload.
  6. Lymphangitic spread of malignancy.
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10
Q

Pulmonary HTN produces?

A

Pruning of the pulmonary vasculature and might be suspected when the main pulmonary artery achieves a diameter of 3cm or more on CT/MRI.

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11
Q

The cardiac silhouette may appear enlarged for 3 main reasons:

A
  1. The heart is enlarged (cardiomegaly).
  2. Pericardial effusion mimics the appearance of cardiomegaly on conventional radiographs.
  3. Extracardiac factor produces APPARENT cardiac enlargement.
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12
Q

In most normal adults at FULL inspiration, the cardiothoracic ratio is less than …%.

A

50%.

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13
Q

Normally, there are …-…mL of fluid in the pericardial space between the parietal and the visceral pericardial layers.

A

15-50mL.

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14
Q

The DEPENDENT portion of the pericardial space is?

A

POSTERIOR TO THE LV.

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15
Q

Study of 1st choice in pericardial effusion is?

A

US.

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16
Q

6 Extracardiac causes of APPARENT cardiomegaly:

A
  1. AP portable supine CXR - MCC.
  2. Suboptimal inspiration.
  3. Obesity/Pregnancy/Ascites –> Prevent inspiration.
  4. Pectus excavatum deformity.
  5. Rotation.
  6. Pericardial effusion.
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17
Q

Is it possible to estimate the size of the heart on a AP PORTABLE CXR?

A

Yes.

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18
Q

3 Tips about estimation of the heart size in AP PORTABLE CXR:

A
  1. If the LEFT heart border is touching the LEFT lateral chest –> Heart is enlarged.
  2. If the LEFT heart border is very close to the LEFT chest wall –> Heart is probably enlarged.
  3. If the heart is BORDERLINE enlarged on a portable AP CXR, it is probably NORMAL IN SIZE!
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19
Q

To evaluate for the presence of enlargement of the cardiac silhouette in the LATERAL projection, look at …?

A

The space posterior to the heart + Anterior to the spine at the level of the diaphragm.

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20
Q

In a normal person, the cardiac silhouette will usually?

A

NOT EXTEND POSTERIORLY and project over the spine.

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21
Q

Recognizing cardiomegaly on an AP CXR:

A

Borderline enlarged –> Normal.
Significantly enlarged –> Enlarged.
Touching, or almost touching, the LEFT LATERAL CHEST WALL –> Definitely enlarged.

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22
Q

Cardiothoracic ratio may reach up to …% in infants and still be normal.

A

65%.

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23
Q

Also, in a child the … may overlap portions of the heart and sometimes mimic cardiomegaly.

A

Thymus gland.

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24
Q

Cardiac contours - Ascending aorta:

A

Should normally NOT project further to the right than the RIGHT HEART BORDER (ie right atrium).

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25
Q

Cardiac contours - Aortic knob:

A

Normally less than 35mm (measured from the edge of the air-filled trachea) and will normally push the trachea slightly to the right.

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26
Q

Cardiac contours - Normal left atrium:

A

Does NOT contribute to the border of the heart on a nonrotated frontal CXR.

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27
Q

Cardiac contours - Enlarged LA:

A

“Fills-in” and straightens the normal concavity just inferior to the main pulmonary artery segment and may sometimes be visible on the right side of the heart as well.

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28
Q

Cardiac contours - Descending aorta:

A

Parallels the spine and is barely visible on the frontal CXR of the chest.
–> When it becomes tortuous or uncoiled, it swings further away from the thoracic spine towards the patient’s left.

29
Q

The main pulmonary artery is usually:

A

Concave or flat.

In younger females it may normally be convex outward.

30
Q

Which are larger? The blood vessels at the apex or at the base of the lung in the upright position?

A

At the base, due to increased blood flow.

31
Q

What is the MC diagnosis in hospitalized patients over 65?

A

CHF.

32
Q

2 MCCs of CHF:

A
  1. CAD.

2. HTN.

33
Q

Typically, CHF presents with one of two radiographic patterns:

A
  1. Pulmonary interstitial edema.
  2. Pulmonary alveolar edema.
    There is overlapping.
34
Q

Pulmonary INTERSTITIAL edema has 4 KEY radiologic signs:

A
  1. Thickening of the interlobular septa.
  2. Peribronchial cuffing.
  3. Fluid in the fissures.
  4. Pleural effusions.
35
Q

Kerley B line:

A

Thickened interlobular septum.

36
Q

The interlobular septae are NOT detectable on a normal CXR but can become visible if they accumulate excessive fluid, usually at a PCWP of …?

A

15mmHg.

37
Q

Do the Kerley B lines actually exist?

A

Yes - At the lung bases, at or near the costophrenic angles.

38
Q

Kerley B lines - Characteristics:

A
  1. Very short (1-2cm long).
  2. Very thin (about 1mm).
  3. Horizontal in location.
  4. Usually extend to + abut the pleural surface.
39
Q

Chronic Kerley B lines?

A

After repeated episodes of pulmonary interstitial edema, the septal lines may FIBROSE.

40
Q

Kerley A lines:

A

Appear when connective tissue around the bronchoarterial sheaths in the lung distends with FLUID.

41
Q

Kerley A characteristics:

A

Extend from the hila for several cm (up to 6cm), BUT DO NOT REACH THE PERIPHERY.

42
Q

UNILATERAL pleural effusions from CHF are ALMOST ALWAYS?

A

Right-sided. (15% can be left-sided, but generally, this should point out to other diagnoses - metastases, TB, PE).

43
Q

When the PCWP is sufficiently elevated (about …), fluid spills out of the interstitium into the airspaces –> Pulmonary alveolar edema.

A

25mmHg.

44
Q

3 key findings in pulmonary alveolar edema:

A
  1. Fluffy, indinstict, patchy airspace densities.
  2. Bat-wing or butterfly configuration frequently sparing the outer 3rd of lungs.
  3. Pleural effusions are usually present when the edema is cardiogenic in origin.
45
Q

While most patients with CHF have an enlarged heart …?

A

Most patients with an enlarged heart are NOT in CHF.

–> In any individual, cardiomegaly itself is NOT a particularly sensitive indicator for the presence/absence of CHF.

46
Q

Define cephalization:

A

REDISTRIBUTION of flow in the lungs such that the UPPER LOBE pulmonary vessels become larger that the LOWER LOBE vessels –> Difficult to identify for most beginners.

47
Q

Non cardiogenic pulmonary edema - Causes:

A
  1. ARDS.
  2. Volume overload.
  3. Lymphangitic spread of malignancy.
  4. High-altitude pulmonary edema.
  5. Neurogenic pulmonary edema.
  6. Reexpansion pulmonary edema.
  7. Heroin or other overdoses.
48
Q

Characteristically, patients with ARDS are radiographically …?

A

NORMAL FOR 24-36hrs after the initial insult.

49
Q

The typical course of radiologic findings in ARDS:

A

Stabilize after 5-7 DAYS –> Begin improving in about 2 WEEKS –> Complete clearing, when it occurs, may take MONTHS.

50
Q

Differentiating cardiogenic from NON cardiogenic pulmonary edema?

A

From the patients HISTORY + CLINICAL PICTURE.

51
Q

Chronic elevation of systemic blood pressure leads to LVH in about …% of patients (double that incidence if the patient is obese).

A

20%.

52
Q

The aorta, under increased systemic pressure?

A

Pivots outward around the aortic valve and the aortic hiatus in the diaphragm + gradually UNCOILS –> Becoming more prominent in BOTH its ascending and descending PORTIONS.

53
Q

Mitral valve stenosis - What to see?

A

CEPHALIZATION –> UPPER LOBE vessels become as large as or more prominent that LOWER LOBE vessels.

54
Q

What is the leading cause of death in primary pulmonary HTN?

A

Progressive RHF.

55
Q

What is the HALLMARK of pulmonary arterial HTN?

A

A discrepancy in size between the central pulmonary vasculature + the peripheral pulmonary vasculature.
–> PRUNING.

56
Q

On CT, the main pulmonary artery is normally about the SAME diameter as the ASCENDING aorta, but in pulmonary arterial HTN?

A

The main pulmonary artery is usually 3cm or larger in size.

57
Q

Radiographic findings in aortic stenosis:

A
  1. Heart is usually normal in size.

2. Ascending aorta may be unusually prominent because of post-stenotic dilatation –> HALLMARK.

58
Q

DCM - Best study is?

A

MRI –> Can provide the most accurate + reproducible findings for this disease.

59
Q

Why is it important to differentiate between constrictive pericarditis and restrictive cardiomyopathy?

A

Because constrictive pericarditis –> Is surgically curable.

60
Q

Which study can demonstrate the thickness of the pericardium?

A

MRI (normal is

61
Q

Aneurysms of the ASCENDING aorta?

A

May extend anteriorly + and to the right.

62
Q

Aneurysms of the AORTIC ARCH produce?

A

A MIDDLE mediastinum mass.

63
Q

Aneurysms of the DESCENDING aorta project?

A

Posteriorly, laterally, and to the left.

64
Q

What is the modality most often used to diagnose a thoracic aortic aneurysm?

A

Contrast-enhanced CT. (MRI is also excellent, but expensive and not always available).

65
Q

Aortic dissection - Radiologic findings:

A
  1. Widening of the mediastinum (Poor reliability - 25% OF CASES).
  2. Left pleural effusion - Also may produce a HEMOTHORAX.
  3. Left apical pleural cap of fluid or blood.
  4. Loss of the normal shadow of the aortic knob.
  5. Increased deviation of the trachea or esophagus to the RIGHT.
66
Q

Basic cardiac MRI terms - The 3 main cardiac imaging planes, called “Double oblique” views, are designed to best demostrate cardiac anatomy. They are:

A
  1. Short axis view.
  2. Horizontal long access –> 4-chamber view.
  3. Vertical long access –> 2-chamber view.
67
Q

Basic cardiac MRI terms - Cardiac function:

A

Usually evaluated using MRI sequences producing “bright blood” images because the blood is depicted with increased signal density.

68
Q

Basic cardiac MRI terms - Cardiac morphology:

A

Usually evaluated using MRI sequences producing “BLACK BLOOD” images –> Anatomic assessment of the cardiac structures without interference from the bright blood signal.

69
Q

In normal adults the cardiothoracic ratio is usually …%

A

<50%.

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