MCQ Flashcards
Spontaneous coronary dissection
Rare
80% women
Late preganancy, post-partum, perimenopausal often (1/3)
Healthy individuals
Cardiac sarcoidosis
May manifest as bradycardia secondary to AV block
Arrythmias may cause sudden death
5-10% symptomatic, with findings in 25%
May cause ventrircular aneurysms
Restrictive cardiomyopathy
Caval filter
3rd lumbar vertebra level, infrarenal
Intra-aortic balloon pump
Should be located at proximal descending aorta, just beyond origin of left subclavian.
Most common cause of bronchial artery hypertrophy leading to massive haemoptysis
Bronchiectasis
Wells score
Clinical signs and symptoms Alternative diagnosis Tachycardia Immobilisation or surgery Previous DVT or PE Haemoptysis Malignancy
HOCM
The majority of patient show asymmetric septal hypertrophy
Associated with systolic anterior motion of mitral valve, which can cause LVOT obstruction
Tends to cause MR as above, with left atrial enlargementff
Pancoast tumour
Syndrome - mass, Horners, shoulder pain, radicular arm pain.
Left atrial enlargement associations
Can cause left lower lobe collapse
Takayasu arteritis
Most common aortic segment involved is abdominal aorta
Cardiac myxoma
Most common benign cardiac mass in adults
Infrequent in children - rhabdomyomas instead
Low T1, variable T2 (some high - myxo)
Heterogeneous enhancement
Arrythmias, dyspnoea, murmur
Solitary in left atrium most common, attached to septum at fossa ovale
Associated with Carneys complex MEN
Bronchiolitis obliterans
Bilateral peripheral patchy opacities without zonal distribution
Mosaic perfusion
May have decreased vascular marking and hyperinflation
May be seen in chronic rejection, and graft-v-host disease
Also post infectious. E.g. in CF, or in Swyer-James
Air trapping
Most commonly superior segments of lower lobes, or anterior middle lobe or lingula, on expiratory CT
AIP
AKA Hamman-Rich
Previously healthy subjects
Diffuse alveolar damage
Infection v lymphoma v kaposi
Thalium and gallium scanning
Infection (e.g. PCP) and lymphoma are gallium positive (kaposi not)
Lymphoma and kaposi sarcoma thalium positive
Thalium scanning performed prior to gallium
IPF
Can be diagnosed with ATS major and minor criteria in absence of surgical biopsy
Minor: Age > 50 plus symptoms and signs - crackling
Major: absence of alternative on lavage or transbronchial biopsy, exclusion of other causes, UIP on CT
Hodgkin lymphoma, lung
10%
Nodules or masses, single or multiple, may cavitate, discrete or indistinct
Best place for PICC
Basilic vein
Basilic vein drains ulnar hand. Joins with brachial veins to form axillary vein. Cephalic then joints the axillary vein.
Rebound thymic hyperplasia
May occur post chemo
Organising pneumonia
Peripheral, lower zone predominant chronic consolidation
Adenopathy in 27%
Effusion in 30%
Atol sign
Non or ex-smokers
Idiopathic, collagen vascular disease, drugs
CPAM
25% of congenital lung disease
95% of cystic
1 - 50%
2 - 40%
3 - 10%
Type 2 associated with renal agenesis / dysgenesis, pulmonary sequestration, congenital cardiac disease
No lobar prediliction of sex predominance
Bronchopleural fistula risk factors post pneumonectomy
Pre-op radiation Pre-op uncontrolled infection Post-op PPV Faulty closure of stump Right pneumonectomy - shorter bronchus
Pulmonary infarct stats
Only in 10-15% of emboli
Lower lobe 75%
Haemorrhage can occur without infarction
Extralobar sequestration M:F
4:1
TB resolution
2/3 no sequelae
Ghon focus is calcified granuloma in lungs
Ghon complex is above plus lymph node
Ranke complex is above but calcified lymph node
Calcified lung disease is inactive
Or no change for 6 months
ARDS
10% have chronic changes in non-dependent lung
Mild chronic fibrosis
PIOPED
High probability scan plus high probability clinically is PE confirmed
Low probability or normal scan + low clinical probability, PE excluded
Otherwise uncertain, and lower limb US or angiography of pulmonary arteries recommended
High probability - 2 or more large mismatched defects
Intermediate - rest
Low - non segmental or subsegmental defects, or matched defects with normal radiograph, or substantially larger radiograph abnormality than perfusion decect
Normal - no defect
Rasmussen aneurysm
Complication of TB
Pulmonary artery aneurysm adjacent to a tuberulous cavit
Lateral CXR
Posterior wall bronchus intermedius / posterior stem line <3mm
RUL bronchus above LUL bronchus
Left artery superoanterior to bronchus
Right artery anterior to bronchus
The left pulmonary artery marks superior and posterior contour of hilar complex
Earliest asbestos related disease
Pleural effusions, 8-10years post exposure
Aortic dissection
Anterior and right lateral wall, just distal to valve, in 65%
Transverse or oblique tears, 1-5cm in length with jagged edges
Intimal flap detectable in 85-90%
Occlusion of coronary arteries in 8%
De Bakey - 1 and 2 A, 3 B
1 ascending and descending, 2 ascending only
HTN almost invariably Structural abnormalities - bicuspid valve, coarctation, connective tissue e.g. Marfans Turners Pregnancy Balloon pumps
Libman-Sachs endocarditis
Non-infective, SLE endocarditis
Mitral valve (or tricuspid)
Intense valvulitis and fibrinoid necrosis
Sterile, granular pink vegetations
SLE vasculitis can cause pancreatitis, peritonitis, colitis
Antiphospholipid syndrome
34% have SLE
Thrombotyic disease, thrombocytopenia, miscarriages
RI
PSV - EDV / PSV
PI
PSV - EDV / mean V
Kasabach-Merritt
Haemangioma causing thrombocytopaenia
Endoleak treatment
1 - ASAP repair
2 - If have not stopped spontaneously in 1 month, thrombose
3 - repair with an additional graft
Renal artery stenosis
Acceleration time > 0.07 in intrarenal arteries (tardus)
Renal aortic ratio >3.5 –> 60% stenosis
RI > 0.7
PSV > 180
Carotid stenosis
> 115 <230 50-69 (ratio 2-4)
>240 >69 (Ratio >4)
Renal artery aneurysm
Saccular, non-calcified, occur at bifurcation
FMD common cause
Female prediliction
PAN, IVDU, SLE, RCC, AML, metastatic arterial myxoma, transplant rejection
2/3 extrarenal, 1/3intra
FMD
Bilateral renal arteries in 50%
Responds well to angioplasty
Restenosis 12-25% over 2 years, but HTN doesn’t necessarily recur
Cardiac MR
Spin echo - black blood
Gradient echo - bright blood
Gradient echo are flow sensitive
Retrospective gating better for diastole
Femoral venous catheter
Higher incidence of infection, limit mobility, risk iliac vein stenosis
Intended use <30 days
Fibrin sheath, tunneled line
Treat with thrombolysis
Dural venous sinus thrombosis
Higher risk in puerperium than pregnancy
AV fistula stenosis treatment
Angioplasty
Surgery if recurrent or in lower forearm
Idiopathic inflammatory AAA
5-25%
Fusiform often
Delayed enhancement of soft tissue component
Dense perianeursymal fibrosis
Mycotic aneurysm
2.5% AAA
Saccular
Perianeurysmal gas, stranding, psoas involvement
Staph, salmonella most common
Azygous IVC
Associated with polysplenia, dextrocardia
Polyarteritis nodosa
Kidneys 70-80%
Multiple small aneurysms
CNS 10%
Most common systemic vasculitis to involve CNS
Transmural necrotising vasulitis, fibrinoid necrosis
pANCA positive (correlates with disease activity)
Good response to treatment
Associated with HBV and HIV antigenaemia
Males, 5th-7th decade
Churg-Strauss
Asthma, hypereosinophilia, systemic small vessel granulomatous necrotising vasculitis
May be histo identical to PAN
pANCA in 20-70% (Wegeners is cANCA)
Renal disease infrequent - heart lungs skin spleen
Coronary arteritis and myocarditis
Endocardial fibroelastosis
Enlarged left heart and pulmonary venous congestion
Restrictive cardiomyopathy
Fatal by 2
Endocardial deposition of colagen and elastic tissue
Calf vein thrombosis
<5% PE incidence
Propogate in 20%
Marantic endocarditis
Non-infective endocarditis
Libman Sachs (SLE) or cancer - mucinous adeno of pancreas most common, trauma - catheters
Thrombi causing strokes
Previous rheumatic fever predisoses
Wegeners
Focal necrotising or granulomatous vasculitis
cANCA highly specific, correlates with disease activity
Cresentic glomerulonephritis
Upper and lower respiratory tract
Goodpastures
Autoimmune type 2 hypersensitivity to glomerular and alveolar basement membrane
Mitral annular calc
Age related - women 60s
More common if LV pressure up - HTN, aortic stenosis, HOCM
May be a nidus for infective endocarditis,
or a focus for thrombus - increased stroke risk
Generally does not affect valvular function - rarely does,
Associated with mitral regurgitation and conduction defect
Lung abscess
Staph, kleb, pseudomonas, proteus
Immunocompromised: candida, leigonella, PCP
Plaque on carotid USS
Heterogeneous tends to be unstable
USS bad at detecting intimal flap in dissection - and may be too high to assess
Cystic fibrosis
Fibrosing colonopathy usually of ascending colon, complication from excessive doses of pancreatic enzymes
Pseudomonas most common respiratory pathogen isolated
Survive 40 years
Males often infertile
Pansinusitis
Staging cancer, Diaphragm, Parietal pericardial invasion, chest wall, visceral pleural invasion N Satellite nodules Collapse Size
Diaphragm T4, Parietal pericardium and chest wall (or phrenic nerve) T3 Visceral pleura T2 Same lobe nodule T3 Same lung nodule T4
Ipsilateral hilar N1
Ipsilateral mediastinal and subcarinal N2
Contralateral or supraclav N3
Main bronchus but not carina now T2, carina T4
Atelectasis or obstructive pneumonitis, extending to hilar region T2
<3 1, 3-5 2, 5-7 3, >7 4
Klebsiella pneumonia
Prediliction for posterior upper lobe
Can cause purulent pericarditis, but staph more common
One of the more common causes of empyema (along with strep and staph)
Bulging fissures characteristic, but unusual
Gram negative
Pulmonary amyloid
May cause calcified nodules
Diffuse (alveolar septal), localised nodular, localised tracheobronchial
ARDS
Absene of cardiomegaly, pulmonary venous congestion, pleural effusions favour ARDS
As does 24 latency of CXR changes
May be more peripheral than in hydrostatic oedema
Thrombosis may complicate
HPOA
Causes identical to clubbing
Usually painful
Periosteal reaction of diaphysis and metaphysis of distal extremities without underlying bone reaction
Tram-track / symmetric linear uptake on bone scan
Differential - pachydermoperiostosis - primary POA, with skin thickening also, thyroid acropachy (presentation of autoimmune thyroid disease, almost always with thyroid eye disease),
Hypervitaminosis A
Chronic venous insufficiency
Thymic PET activity
In young female with lymphoma, may be a normal finding before and after treatment
Septic emboli
Most commonly IVDU tricuspid endocarditis
SLE lung
Pulmonary involvement more common than any other connective tissue disease
Pleurisy, pleural disease most common (effusion, thickening)
Fibrosis is less common compared with other collagen vascular disease
Pulmonary HTN is rare. Can be due to lung disease, or thromboembolism, or may occur similar to primary
Myasthenia gravis, thymus
Follicular thymic hyperplasia most common abnormality
But also associated with thymoma
10-25% of MG have a thymoma
30-50% of thymomas get MG
Benign v malignant thymoma
T1 high in carcinoma, low in benign
Can see calcification in both (amorphous, flocculent)
Pleural seeding in invasive or malignant
SUV cutoff of 5 can give reasonable differentiation on PET for carcinoma v thymoma
Thymomas are 50-60 - rare in <20
Thymolipoma
Large, fatty, pliable
Drapes over heart and vessels
Doesn’t compress
Doesn’t invade
Mediastinal mass
Most commonly thymic in adults, lymphoma or rebound thymic hyperplasia in kids
NF1 lung
Lung disease in 10-20% of adults
Upper lobe bullae, basal fibrosis
Thoracic meningoceles are on the convex side of the scoliosis
Unilateral complete perfusion defect
More common in extrinsic compression than in acute PE
Primary, secondary TB
Primary
Patchy or lobar consolidation, any lobe, preference for middle and lower lobes
Lymphadenopathy (especially in children - 90%, only 10-30% adults. Low density with rim enhancement, usually unilateral)
May be miliary (immunocompromised more)
Pleural effusions (30-40% adults, 10% children)
(so nodes more common in children but effusion more in adults. Adults can present just with lymph nodes [acc to old answers. probably kids can too])
May resolve without any radiological abnormality, or Ghon focus scar may remain (calcified granuloma)
Symptoms only in 5%
Cavitation uncommon
May have massive haemoptysis from erosion into a bronchial artery
May have atelectasis in children from compression of airways from lymph nodes.
Ghon focus is calcified caseous granuloma in lung
Ranke complex is this plus a calcifed node
Secondary
Apical, cavitates
Assman focus
Pulmonary hamartoma
Popcorn calc
Fat diagnostic
6% of solitary nodules
Kaposi sarcoma
Doesn’t take up gallium, but does thalium
Mid to lower zone, peribronchovascular (and perihilar i.e. cetnral)
Strongly enhancing nodes
Pleural effusion in 1-2/3. Worse prognosis
Pulmonary sling
Aberrant left PA
Goes behind trachea, in front of oesophagus
Only vascular ring to pass between
Atrial septal defect
Less common than VSD
Secundum 60-90%, then Primum, 5-20%, then sinus venosus 5%, with unroofed coronary sinus <1%
Secundum usually isolated (secundum at fossa ovalis)
Primum associated with mitral valve cleft (becomes AVSD)
Sinus venosus associated with PAPVR
Holt Oram may give secundum ASD, as well as radial ray anomalies (and clavicle hypoplasia)
Unroofed coronary sinus associated with left SVC and heterotaxy
Pericardial effusion
Idiopathic Inflammatory (e.g. Dresslers, collagen vascular disease) Infectious (inc TB) PAH Malignancy Radiotherapy Hypothyroidism
VSD
Membranous most common (80-90%)
Other types: muscular, inflow, outflor
Marfans
AD
Ascending aorta aneurysm
Aortic incompetence, mitral valve prolapse
(myxomatous degeneration of mitral valve)
Aortic dissection - cystic medial necrosis
Pulmonary artery aneurysms
Vascular compression disorders
Eagle syndrome - stylohyoid compresses ICA (CN5,7,9,10 may be involved)
Thoracic outlet
Nutcracker - L renal vein by SMA
Posterior nutcracker - retroaortic L renal vein
Median arcuate - Coeliac
Popliteal artery entrapment - medial head of gastroc, or popliteus
Quadrilateral space syndrome - posterior humeral circumflex, and or axillary nerve. Shoulder pain and paraesthesia
Paget-Shroetter (subclavian vein)
May-Thurner (Left iliac vein by right iliac artery)
Malignant coronary artery
Hypothenar hammer
Also SMA syndrome (D3), and vascular rings and slings
Pulmonary artery aneurysm
Trauma Infection e.g. syphilis, TB (Rasmussen) Idiopathic Post valvular dilatation PAH Marfans Vasculitis e.g. Behcets, Takayasu
Swan-Ganz catheter placement
Lung nodule, risk of malignancy
<7mm, 1%
8-20, 15%
>20, 75%
Transudate v Exudate
Exudate: Protein >30g/L Protein, fluid:serum ratio >0.5 LDH > 20 IU/L LDH, fluid:serum ratio >0.6
Also pH
Fleishner guidelines
HR is smoking or other RF (1st degree relative, other exposure)
<6mm: LR no FU, HR optional 12m CT
6-8mm: LR 6-12 month, possible 24. HR 6-12 and 18-24 if no change
>8mm: 3month CT, PET, or biopsy
Multiple 6-8: LR FU 3 month, possibly 24. HR 3 and 24
Multiple >8: LR 3-6 and maybe 24, HR 3-6 and 18-24
Ground glass: no FU if <6, if >6 do 6-12 month and every 2 years
Multiple subsolid, 3-6 month and possibly more
Bronchial artery embolisation
Particles
Gelatin or PValcohol
DVT
Acute thrombus anechoic
Chronic echogenic
Inspiration increased abdominal pressure and reduces flow, increases diameter (like a valsalva)
PEs in 50%
PCP
Pleural effusions and lymphadenopathy uncommon
May have crazy paving
Gallium positive (before xray findings visible)
Reticular pattern, perhiliar distribution
Subpleural blebs
Atypical findings are more common in those on inhaled prophylaxis
Fat emboli
Symptoms often transient
CT abnormalities last 2 weeks
Extent of lung opacification usually reflects severity of disease
Can have non-traumatic aetiology e.g. bone infarct, osteomyelitis, acute fatty liver, pancreatitis
Amiodarone lung
Pulmonary toxicity in 10%
Chronic interstitial pneumonia (includes UIP, NSIP - this most common)
Organising pneumonia
Diffuse alveolar damage
Foamy histiocytes with intracytoplasmic osmiophilic lamellar bodies
Peripheral air space opacity, upper lobe predominant, and interstitial fibrosis
Methotrexate lung
5% Organising pneumonia Acute interstitial pneumonia Fibrosis Effusions
(answers said hypersensitivity pneumonitis, and can have adenopathy)
Eosinophilic pneumonia
Many drugs: Penicillamine Sulfasalazine Nitrofurantoin NSAIDs Ampicillin Anticonvulsants ACE inhibitors Beta blockers Methotrexate Amiodarone
Cyclosporine lung
Can cause a solitary pulmonary mass (previous question)
Thymic cysts
Congenital or acquired Acquired from: Thoracotomy Radiotherapy or chemotherapy for mediastinal tumour Thymic tumours Inflammation May be unilocular or multilocular
Mesothelioma
May seed along biopsy tract
Calc seen in 20%, probably engulfed pleural plaques
Predominantly parietal, and to a lesser extent visceral pleura
Peritoneal 12-33%, strongly assocaited with asbestos, but 50% have no known exposure. Calc rare.
Gallium scan
Positive in infection and lymphoma, not in Kaposi
Also in:
Sarcoid - pulmonary uptake correlates with disease activity and response to treatment (lambda sign)
Amyloid (intense cardiac)
Persitant uptake following therapy in Hodgkin lymhoma is a poor prognostic indicator, high risk of recurrence
Scan performed 48-72 hours post injection
Normal uptake in liver, bone marrow, spleen, salivary glands
Hilar adenopathy, drugs
Bleomycin Phenytoin (/dilantin) Methotrexate Cyclosporine Carbamazepine Cotrimoxazole Indomethacin Penicillins
(not amiodarone or cyclophosphamide)
Phenytoin
Can cause eosinophilic lung disease
And hilar adenopathy
Bleomycin
A chemotherapy drug
SCC of head and neck, cervix, vagina, testicular cancer, Hodgkin lymphoma
Organising pneumonia, NSIP, other fibrosis
Legionella
SIADH in 15%
Gram negative
Pulmonary abscess
Staph Klebs Pseudomonas Proteus Immunocompromised: candida, leigonella, PCP
Pulmonary cavity
Strep Staph Haemophilus Other gram negatives (Klebsiella) Anaerobes Aspergillis Legionella (also gram negative)
Empyema
Chidren - pneumococcus
Adults - stap, gram negatives (klebsiella, pseudomonas, haemophilus), anaerobes (usually polymicrobial e.g. bacteroides, actinomyces, clostridium)
Empyema necessitans
TB
Actinomyces
Nocardia
Klebsiella
Gram negative
Higher incidence in alcoholics and debilitated
One of the most common causes of empyema
Abscess, effusions
Uni/multilocular cavities in 50%, appearing within 4 days
Propensity for posterior upper lobe and superior lower lobe
Dense lobar consolidation - associated with fissure displacement
ABPA
Asthmatics Central and upper lobe bronchiectasis Finger in glove Transient consolidation - eosinophilic pneumonia Cavitation in 10% Effusions and adenopathy not a feature
Hypersensitivity pneumonitis
Can rarely have nodes and effusions
Upper zone predominant fibrosis
Can have consolidation, ground glass depending on stage of disease
Sarcoid
ACE has 40% false negative and 10% false positive. May have hypercalcaemia and hypercalcuria Schaumann bodies (laminated calcium containing concretions) (may also be seen in other granulomatous diseases - HSP, beryllosis, uncommonly Crohns and TB) Asteroid bodies (seen in giant cells of granulomas)
Fibrosing mediastinitis
Encasement and compression of mediastinal structures by fibrosis
Histoplasmosis and TB most common cause
Can cause pulmonary artery hypertension
Histoplasmosis
Endemic fungi Can cause calcified granuloma Can cause nodule Can mimic TB Can cause fibrosing mediastinitis
Thymoma assoications
MG Red cell aplasia Hypogammaglobulinaemia SLE RA Non-thymic cancers
Nodes - hyper, hypodense, and calcified
Hypo: Mets (lung, testis, ovary), lymphoma, infections (inc mycobacterial, fungal), Whipples
Hyper: vascular mets (RCC, melanoma, carcinoid, papillary thyroid, Kaposis), castlemans, mild enhancement may be seen in TB, fungal, lymhoma, metastatic lung, sarcoid
Calc: treated lymphoma, old granulomas, sarcoid, silicosis, PCP, calcifying mets (BOTOM)
Pulmonary hydatid
Second most common organ after liver, most common in children
Only coexists with liver disease in 6%
Multiple or solitary cystic lesions, uni or bilateral, favous lower lobes.
Pulmonary artery hypoplasia
Right > L 3:1, RML then RUL
Associated with bronchiectasis
Lung cancer MR
Low to intermediate T1
High T2
Behcets
Vasculitis M 2-5x F Mediterranean, middle east, east asia Oral ulceration, genital ulceration, ocular manifestations Aorta and SVC Pulmonary artery aneurysms CNS
Lung and bone
LCH Malignancy TB Fungal disease Other infection Sarcoid Gauchers (rarely involves lungs, resembles DIP) Phakomatoses - TS, NF1 (lower zone fibrosis, upper zone bullae, cor pulmonale)
Ritalin lung
IV ritalin
Causes panlobular emphysema
May look like alpha-1-antitrypsin
Heroin and Cocaine lung effects
IV heroin can cause pulmonary oedea, haemorrhage, eosinophilic pneumonia
IV cocaine can cause pulmonary oedema
Crack lung is from smoking crack cocaine
Diffuse alveolar damage / alveolar haemorrhage
Talc lung
Talcosis - inhalation of talc
Pulmonary talc granulomatosis - from injection of tablets intended for oral consumption. Widespread small nodules, may have mid zone prediliction. Coalesce and cause PMF.
Talc embolus is often the start of the granulomatosis pathology
Alpha-1-antitrypsin
Basal predominant pan-lobular emphysema
Metastatic pulmonary calcification
Generally upper lobes. Ground glass nodules
Uptake on bone scan is confirmatory
Renal failure, HPT, sarcoid, vit D or Ca intoxication, multiple myeloma, massive osteolysis
Solo met, septic emboli, met calc zones
Apparently are mostly upper zone (according to a 1987 paper)
Apparently septic emboli are predominantly lower lobe.
Metastatic calc is predominantly upper.
Pulmonary alveolar microlithiasis
Mid to lower zone predominant.
Sand like calc in the lungs
Calcium phosphate microliths
Young adults
Endobronchial metastases
RCC, thyroid, melanoma
Breast
Colorectal
Cervical
Cannonball mets
Kidney, choriocarcinoma
Less commonly, prostate, endometrial, synovial sarc
Lymphangitic carcinomatosis
Breast Lung Colon Stomach Prostate Cervical Thyroid
Pleural mets
Lung Breast Ovarian Lymphoma Gastric Invasive thymoma
