RD CVS formatted Flashcards

Question

5. Re: lower limb angiography, which is LEAST correct? a. Peroneal artery terminates above ankle b. 5Fr catheter adequate for diagnostic studies c. Adductor canal is in the lower thigh d. The profunda femoris origin is best seen with leg in external rotation

Answer 1

d. The profunda femoris origin is best seen with leg in external rotation F this will bring the postero lat origin behind the SFA (can’t find a reference)

Answer 2

4.TOF. F – have small left heart chambers due to ↓ blood returning from lungs (RVOT) 7. Left Atrial enlargement which is false (JS) 1. VSD - T - Increased pulmonary venous return leads to volume overload of the LA and LV, leading to dilation. 2. Endocardial fibroelastosis T – focal or diffuse fibroelastic endocardial thickening of LV +/- LA from deposition of collagen and elastic tissue, causes CHF during first 6mths of life and if diffuse is often fatal by 2 years of age (Dahnert). Get enlarged LA & LV, pulmonary venous congestion. Accompanied by aortic valve obstruction & other CHD in one-third (Robbins). A cause of restrictive cardiomyopathy. * *LJS opinion: atria dilated due to pressure overload b/c can't fill ventricles 3. HOCM. T - LV hypertrophy leads to rapid blood flow through the outflow tract and anterior displacement of the anterior leaflet of the MV causing mitral regurgitation and subsequent LA enlargment (Dahnert) 4. TOF. F – have small left heart chambers due to ↓ blood returning from lungs (RVOT) 5. Atrial myxoma. T - typically causes enlargement of the LA without enlargement of the atrial appendage

Answer 3

1. Isolated calf vein thrombosis in ambulatory patients has an incidence of PE of <5%. - T - risk factors: surgery (esp. legs/pelvis), severe trauma, prolonged immoblisation, malignancy, pregnancy, meds (OCP), previous DVT... UTD: Distal calf vein thrombosis is felt to be of lesser clinical importance than proximal vein thrombosis and its optimal treatment has yet to be defined. If anticoagulation is not administered for isolated asymptomatic distal venous thrombosis, serial noninvasive studies of the lower extremity should be performed over the next 10 to 14 days to assess for proximal extension of the thrombus, which has a higher incidence of pulmonary embolism. 8. In lower limb DVT, which is true: (GC) CME00.08 and 03.42 (mixture) 1. Isolated calf vein thrombosis in ambulatory patients has an incidence of PE of <5%. - T - risk factors: surgery (esp. legs/pelvis), severe trauma, prolonged immoblisation, malignancy, pregnancy, meds (OCP), previous DVT... UTD: Distal calf vein thrombosis is felt to be of lesser clinical importance than proximal vein thrombosis and its optimal treatment has yet to be defined. If anticoagulation is not administered for isolated asymptomatic distal venous thrombosis, serial noninvasive studies of the lower extremity should be performed over the next 10 to 14 days to assess for proximal extension of the thrombus, which has a higher incidence of pulmonary embolism. 2. Approx 40% of calf vein thrombi propagate superiorly to involve at least the popliteal or femoral veins. - F - up to 20% propagate. Serial evaluation every 3-5 days is therefore important in patients who remain symptomatic with conservative therapy to dx clot propagation and prevent PE. [B&H pg 1052] 3. Clinical diagnosis is accurate in 80%. - F - The clinical presentation and physical examination findings are unreliable in making the diagnosis [B&H]. 2/3 of DVT are clinically silent and clinically suspected DVT is accurate in only 26-45% [Dahnert]. 4. Vein diameter typically increases in chronic thrombosis. - F - chronic clot does not expand the lumen of the vein and appears more echogenic than an acute clot. The walls appear thickened, irregular and echogenic and the vein is incompletely compressible. Collaterals can be seen on colour Doppler. [B&H] 5. A phasic change with respiration on Doppler of implies thrombosis. - F - normally there is a cyclic variation in flow velocity with respiration - should decrease in expiration and increase in inspiration. Absence of phasicity (ie. continuous venous signal) is suspicious for proximal obstruction. [Dahnert pg 634]

Answer 4

true 1,4 11. Vascular US, T/F: (GC/TW) 1. In the femoral artery a doubling of the peak systolic velocity in a zone of stenosis (cf. the normal vessel proximal to the stenosis) indicates that the stenosis is about 50%. - T - A ratio of 2 (ie. a doubling of the PSV) represents a hemodynamically significant stenosis with a greather than 50% lumen narrowing (see below about measurements). 2. 55% reduction in cross sectional area is equivalent to 70% diameter stenosis. - F - the new remaining radius % squared (ie 70% = 30% radius or 0.3) multipled by the initial CSA = new CSA. Therefore the reduction is (1-remaining radius squared). See below. 3. Power Doppler gives information regarding the direction of flow but is less sensitve to low velocities than is colour Doppler. - F - power doppler is more sensitive at detecting flow, particularly slow flow, but is unable to demonstrate direction or velocity of flow. 4. Doppler evaluation of renal artery stenosis may be performed by interrogation of the intrarenal (parenchymal) branches. - T - Two approaches are used to detect RAS with Doppler US: direct visualization of the renal arteries and analysis of intrarenal Doppler waveforms. The segmental renal arteries are evaluated by means of a translumbar approach; the different segments must be scanned systematically to detect a stenosis of a segmental or accessory RA. A dampened appearance (pulsus tardus) of an intrarenal Doppler waveform indicates stenosis. The presence of an early systolic peak can be interpreted as a sign of normality; however, its absence does not necessarily indicate stenosis. [Renovascular HTN, RG 2000] 5. Evaluation of the sapheno-femoral junction for venous incompetence is performed with the patient supine. - F - examination of the CFV/SFV is performed in the supine postion with a linear 5-7.5MHz transducer in a slight reverse Trendelenburg position. [B&H pg 1051]

Answer 5

4. Scleroderma - F - Scleroderma affects the renal arterioles and causes cortical necrosis. 12. Renal vein thrombosis, not a risk factor: (TW) 1. Dehydration - T - Renal vein thrombosis in infants most commonly due to dehydation/sepsis. 2. Membranous GN - T - see ans 5. 3. Amyloid - T 4. Scleroderma - F - Scleroderma affects the renal arterioles and causes cortical necrosis. 5. Nephrotic syndrome - T - In adults, most commonly due to nephrotic syndrome (which in turn is most commonly due to membranous glomerulonephritis

Answer 6

4. Retrospective gating better than prospective for diastolic function - T - although prospective gating is more common, given the trigger window is typically 10-15% of the R-R window, prospective gating sequences will exclude late diastole. Retrospective gaiting is more computationally intensive, but is also helpful in patients with arrhythmias. In retrospective gating there is no trigger window and the whole cardiac cycle is imaged. 17. Which is true re cardiac MRI: (TW) 1. Gradient sequences used for dark blood - F - T2* weighted coherent GE sequences used so that blood ro CSF appears bright. GE sequences are flow sensitive, as gradient reversl is not slice selective (as in spine echo). Therefore, a flowing nucleus produces signal after gradient rephasing, regardless of its slice location during excitation. T1WI has moving blood produce a signal void. 2. Contrast used for cine - F - most cardiac cine acquisitions are generally acquired with gradient echo sequence with retrospective gating techniques. Since cine is performed with a gradient echo sequence, flowing blood appears bright. 3. Short anterior oblique (SAO) view shows aortic valve en face - F - horizontal long-axis plane / 4-chamber view. LVOT view used to look at aortic valve in perpendicular plane. 4. Retrospective gating better than prospective for diastolic function - T - although prospective gating is more common, given the trigger window is typically 10-15% of the R-R window, prospective gating sequences will exclude late diastole. Retrospective gaiting is more computationally intensive, but is also helpful in patients with arrhythmias. In retrospective gating there is no trigger window and the whole cardiac cycle is imaged. 5. 50% R-R gating for assessing systolic function (this recall a bit hazy) - F - peak fo the R wave is used to trigger each pulse sequence because, electrically, it has the greatest amplitude (prospective gating). Retrospective gating (performed during many cardiac cine acquisitions) acquires image data and times to the cardiac cycle during reconstruction (after the scan acquisition). The trigger window is typically 10-15% of the R-R window. The acquisiton window is the duration of the data aquisition (wiht standard trigger window and no trigger delay, this would be 85-90% of the R-R window). Because of the trigger window, prospectively gating sequences will exclude late diastole.

Answer 7

2. Embolism is the most common treatment – F – usually require no treatment. Treatment depends on type and sequelae. Embolisation often used pre-resection 18. Peripheral haemangiomas in infants, which is false: (TW) 1. More common in premature infants – T – hemangiomas are the most common tumor of childhood occurring in 12% of infants. UTD: the incidence of hemangiomas is increased in preterm infants; the most signficiant risk factor appears to be low birth weight. 2. Embolism is the most common treatment – F – usually require no treatment. Treatment depends on type and sequelae. Embolisation often used pre-resection 3. Increased size after 12 months is atypical - T – characteristically 2-stage process of growth and regression. At birth lesionas are often small and inconspicuous. Shortly after birth, perior of rapi proliferation that lasts several months, and typically, involution begins at approximately 10 months of age. 50% lesions completely resolved by 5yo. UTD: the spontaneous involution phase typically begins in the latter part of the 1st year 4. More common in the head and neck – T – have a predilection for head and neck, although they can occur anywhere in the skin, mucous membranes, or internal organs 5. Sequester platelets – T – Kasabach-Merritt syndrome = hemorrhagic diathesis due to platelet sequestration by tumor / disseminated intravascular coagulation; characterised by an associateion of hemangioma or hemangioendothelioma, or angiosarcoma with thrombocytopenia and purpura (secondary to increased systemic fibrinolysis). There is an increased incidence of hemangiomas in females and in premature infants weighing less than 1500 grams Over half of all hemangiomas occur in the cervicofacial region

Answer 8

2.Aortorenal ratio of 2.5 means greater than a 70% stenosis - F - >3.5 for >60% (Dahnert 6) increased renal arterial resistive index (RI): a cut-off value of 0.7 may be a good approximation in clinical practice (RI difference between kidneys > 0.05 - 0.07 ) increased peak systolic velocity (PSV): some advocate 180cm/s 4increased renal-interlobar ratio (RIR): some advocate values greater than 5 3increased renal/aortic ratio (RAR) i.e. PSVrenal/PSVaorta: usually taken as >3.5, although some advocate >3 4turbulent flow in a post-stenotic areapulsus parvus et tardus waveform (slow-rising) due to stenosisintraparenchymal resitive indices > 0.8intraparenchymal acceleration time > 0.07 s

Answer 9

2.Increased velocity by 50cm/sec compared with baseline on a follow up study indicates possible stenosis - T – a change of >50cm/s (increase or decrease) relative to the baseline study can indicate stenosis. in addition to looking for a narrowing, elevated maximum and depressed minimum stent velocities are signs of stent stenosis (one system uses 90cm/sec and 190cm/sec as the lower and upper limits, of normal stent velocities). Additional signs of dysfunction are low PV velocity, a temporal increase or decrease in max and min stent velocities on sequential examinations, and reversal of flow in the draining hepatic vein (US requisites). 20. Regarding TIPS, which is true: (TW) 1. Ascites is a contraindication - F - if it was, there probably wouldn't be many TIPS procedures done. See below for contraindications. 2. Increased velocity by 50cm/sec compared with baseline on a follow up study indicates possible stenosis - T – a change of >50cm/s (increase or decrease) relative to the baseline study can indicate stenosis. in addition to looking for a narrowing, elevated maximum and depressed minimum stent velocities are signs of stent stenosis (one system uses 90cm/sec and 190cm/sec as the lower and upper limits, of normal stent velocities). Additional signs of dysfunction are low PV velocity, a temporal increase or decrease in max and min stent velocities on sequential examinations, and reversal of flow in the draining hepatic vein (US requisites). 3. Demonstration of flow reversal (ie retrograde flow) in the intrahepatic portal veins indicates stenosis - F - this could potentially be true if saying 'reversal of flow from the 'normal' post TIPS flow' which itself is reversed. When first placing the TIPS, the stent decompresses the portal system directly into the low pressure hepatic venous system, portal flow in the right and left portal vein usually reverses after stent placement and is directed into the stent instead of into the liver 4. Need to have the same pressures as SVC for best results 5. Left common femoral approach is best - F - transjugular. Wire through heart into MHV. Then ream through the liver to where you expect the PV to be, and if you miss - try again. Some use a transcutaneous needle into PV and leave a little marker or wire to provide a target for the 'reaming', some use US.

Answer 10

4. Central increased uptake is seen on sulphur colloid scans - T – (Sulphur-colloid was used previously, but has generally been replaced by other imaging modalities). Hypertrophy of the caudate lobe associated with BCS is demonstrated by its preferential uptake of the radionuclide. However, more than half of patients with BCS do not demonstrate this pattern (UTD). Sulfur colloid liver scan may show a central area of increased activity believed to be secondary to enlargement of the caudate lobe (AJR). See below. 21. Budd Chiari syndrome, which is true: (TW) 1. Spider like appearance of portal veins on portal venography is diagnostic - F – "Spider web" pattern of hepatic venous collaterals. 2. 70% are idiopathic – Previously T, but now is F - in approx 75% of pts, a hematological abnormality or a cause of thrombotic diathesis can be identified that predisposes the patient to the occurrence of BCS (Radiographics 2009). Underlying disorcer can be identified in over 80% of patients with BCS (UTD). (Dahnert says 66% idiopathic) 3. TIPS is not an option for treatment - F - TIPS is a good alternative method for relieving liver congestion, with lower mortality and morbidity than those assoc with open surgical procedures. Other options: medical, thrombolysis, angioplasty + stent of stenoses. 4. Central increased uptake is seen on sulphur colloid scans - T – (Sulphur-colloid was used previously, but has generally been replaced by other imaging modalities). Hypertrophy of the caudate lobe associated with BCS is demonstrated by its preferential uptake of the radionuclide. However, more than half of patients with BCS do not demonstrate this pattern (UTD). Sulfur colloid liver scan may show a central area of increased activity believed to be secondary to enlargement of the caudate lobe (AJR). See below. BCS is a heterogeneous group of disorders characterised by hepatic venous outflow obstruction at the level of the hepatic veins, IVC or right atrium. BCS is not a primary condition of the liver parenchyma; it is the result of partial or complete obstruction of hepatic venous outflow. The "classic" scintigraphic pattern is caudate lobe hypertrophy, at expense of the rest of the liver, in which uptake may be normal, reduced, absent or patchy. Often colloid shift to spleen and bone marrowis seen. Caudate has own venous efferent connections directly with the IVC, so even so maintains good function cf rest of the liver - and maintains good tracer uptake and significant compensatory hypertrophy.This question could be answered as 2. correct (if using old numbers) and 4. incorrect using the argument that there is ‘normal’ (not increased) uptake centrally with relative decreased uptake around it.

Answer 11

4.Bilateral in 50% - T 22. Regarding fibromuscular dysplasia of the renal artery: (JS) 1. Most common at osteum - F - most commonly occurs in the middle and distal renal artery, causing "string of beads" appearance. 2. Recurs post dilation - F - FMD classically responds well to angioplasty with success rates approaching 98% (B&H). Dahnert mentions 90% success rate with very low restenosis rates. Restenosis 12-25% over 6months to 2y, but restenosis is not necessarily associated with HTN. 3. Osteal stenosis - F - more common with atherosclerotic disease 4. Bilateral in 50% - T 5. Intimal fibroplasia is the most common type and causes the classic stenoses alternating with aneurysms - F - This is Type 2

Answer 12

1. Kinking = moved - T most correct – diminished diameter of the aneurysm after stent – graft implantation also decreases length of aneurysm – associated with distal migration of graft. 23. AAA stent graft, which is true: (TW) 1. Kinking = moved - T most correct – diminished diameter of the aneurysm after stent – graft implantation also decreases length of aneurysm – associated with distal migration of graft. 2. Not possible if AAA >8cms in length - F - for example the Zenith AAA grafts range from 82mm to 149mm in length. 3. Endoleak lumbar artery needs fixing -?T (controversial) - = most common endoleak (type II). Significance and management of type II endoleaks is controversial. Some argue that as spontaneous resolution occurs 30-100% of cases, a "wait and see" approach is preferable. UTD recommendations are occluding type II endoleaks that have not spontaneously thrombosed in one month (as systemic pressures have been noted in aneuyrsm sac in the presence of type II endoleaks). 4. Endoleak needs immediate fixing - - type I endoleak (ie incompetent seal at either proximal or distal attachment site) must be repaired as soon as possible. Type III endoleaks represtn flow into sac from separation between components of a modular system, or tears in the endograft - these are repaired with an additional endograft. Type IV leaks are due to egress of blood through the pores of the fabric - these heal spontaneously. 5. Best grade stent with angio catheter and angiogram

Answer 13

24. Carotid Doppler: (TW) 1. 280cm/sec is >70% stenosis - T - >230cm/s equals >70% stenosis, ICA/CCA ratio >4.0. 125-230cm/s equals 50-69% stenosis, ICA/CCA ratio 2.0-4.0. <125cm/s equals <50% stenosis, ICA/CCA ratio <2.0. (US requisites) 2. Maximal velocity is proximal to stenosis - F - maximal velocity is at stenosis. Calculating a ratio of PSV at stenosis vs PSV proximal to stenosis is also used as a calculation of % stenosis, where as ratio of 2 (ie., double PSV) equals >50% stenosis.

Answer 14

1. Diabetes - F - causes diabetic nephropathy (diffuse glomerulosclerosis); other GU manifestations include renal a. stenosis, papillary necrosis, renal/perirenal abscess, emphysematous pyelonephritis/cystitis, XGP, fungal infection. 25. Small renal artery aneurysm, which is not true: (GC) CME 03.40 1. Diabetes - F - causes diabetic nephropathy (diffuse glomerulosclerosis); other GU manifestations include renal a. stenosis, papillary necrosis, renal/perirenal abscess, emphysematous pyelonephritis/cystitis, XGP, fungal infection. 2. Polyarteritis nodosa - T - microaneurysms in 50%, esp. at branch points. 3. IVDU - T - drug-abuse vasculitis may be due to immunologic injury from circulating hepatitis Ag-Ab complexes, bacterial endocarditis, direct toxicity, impurity-related. Methamphetamine, heroin, LSD. Mulitple small aneurysms in interlobar branches near corticomedullary jxn. 4. SLE - T - aneurysms in interlobar and arcuate aa. (similar to but less frequent than PAN). Kidneys involved in 100% of cases (focal membranoproliferative GN). 5. RCC - T - in 14% (also adult Wilm's). Other neoplasms that may cause RAAs include AML (in 50%), metastatic arterial myxoma.

Answer 15

4. IJV thrombosis precludes performance of TIPS - F - RIJV usually used, LIJV can be used if right side can't be used. Femoral venous approach techniques have also been described, but are used less commonly, and are technically more demanding (eMed). 29. Which is false re transjugular intrahepatic portosystemic shunt (TIPS) (TW) 1. It is a recognized treatment of choice for refractory ascites - T 2. Contraindicated in the presence of right heart failure - T - right-sided heart failure with increased central venous pressure (eMed). Pulmonary HTN and hepatopulmonary syndrome is a contraindication. 3. May cause biliary dilatation acutely - T - potential complication of fistula to biliary tree. Studies have also shown biliary epithelial proliferation with creation of large cystlike spaces (but this is not acute). 4. IJV thrombosis precludes performance of TIPS - F - RIJV usually used, LIJV can be used if right side can't be used. Femoral venous approach techniques have also been described, but are used less commonly, and are technically more demanding (eMed).

Answer 16

2. Libman Sachs nodules do not cause valve destruction - F - Libman-sacks (verrucous) endocarditis. The verrucae, most common on the aortic and mitral valves. Accumulations of immune complexes, mononuclear cells, hematoxylin bodies, and fibrin and platelet thrombi. Typically asymptomatic, however they can fragment and produce systemic emboli (UTD). Spectrum of valvular disease in SLE ranges from valve leaflet thickening to Libman-Sacks endocarditis. The latter is characterised by formation of small single or multiple, sterile, granular pink vegetations ranging from 1-4mm that may be associated with intense valvulitis and lead to valve destruction (Radiographics 2004). Intense valvulitis and fibrinoid necrosis of the valve substance (Robbins). 30. SLE which is false? (TW) 1. Less likely to cause lower lobe fibrosis than RA - T - pulmonary fibrosis is less common relative to other collagen vascular diseases. 2. Libman Sachs nodules do not cause valve destruction - F - Libman-sacks (verrucous) endocarditis. The verrucae, most common on the aortic and mitral valves. Accumulations of immune complexes, mononuclear cells, hematoxylin bodies, and fibrin and platelet thrombi. Typically asymptomatic, however they can fragment and produce systemic emboli (UTD). Spectrum of valvular disease in SLE ranges from valve leaflet thickening to Libman-Sacks endocarditis. The latter is characterised by formation of small single or multiple, sterile, granular pink vegetations ranging from 1-4mm that may be associated with intense valvulitis and lead to valve destruction (Radiographics 2004). Intense valvulitis and fibrinoid necrosis of the valve substance (Robbins). 3. Pancreatitis secondary to vasculitis - T - GIT is often involved with SLE, but more commonly from medication side effects than from active SLE. SLE vasculitis can lead to pancreatitis, peritonitis, and colitis (UTD). 4. 30% of antiphospholipid syndrome has SLE - T - APS is defined by 2 major components: presence in plasma of at least one type of autoantibody known as antiphospholipid antibody (aPL); occurrence of at least one clinical feature from a diverse list of potential disease manifestations. 34% of patients with aPL have SLE. About 50% of individuals with lupus anticoagulants meed the Am College of Rheum criteria for classification of SLE. Previously had 3. as False, rest True.

Answer 17

3.Complete unilateral loss of perfusion is more commonly seen in extrinsic compression by bronchogenic carcinoma than in massive pulmonary embolism - T - Acutally not sure about this one - but was True in the CME 03.37. Dahnert says 2% incidence of unilateral lung perfusion of which PE 23%, Bronchogenic carcinoma 23%. A paper from1987 (Radiographics, Cho et al) said PE is one of the least common causes, which was in agreement with another series. 31. With respect to ventilation / perfusion scintigraphic lung scans: (TW) 1. Using the PIOPED criteria for classification of results, a high probability scan is defined as showing one or more unmatched segmental perfusion defects - F - 2 or more large (segmental) perfusion defects without match 2. Classification of a lung scan as low probability excludes the diagnosis of pulmonary embolism - F - Low probability of PE accounted for 34% cases, and 16% of these were positive for PE on angiogram. Even normal VQ (14% cases) had angiogram positive findings in 9%. 3. Complete unilateral loss of perfusion is more commonly seen in extrinsic compression by bronchogenic carcinoma than in massive pulmonary embolism - T - Acutally not sure about this one - but was True in the CME 03.37. Dahnert says 2% incidence of unilateral lung perfusion of which PE 23%, Bronchogenic carcinoma 23%. A paper from1987 (Radiographics, Cho et al) said PE is one of the least common causes, which was in agreement with another series. 4. Pregnancy is an absolute contraindication for performing a scintigraphic V/Q scan - F - pregnancy has 5x increase risk of VTE, and PE is leading preventable cause of maternal death. Mixed recommendations - it is VQ is favored by PIOPED II investigators as a means of imaging in pregnancy, has lower breast dose and lower nondiagnostic rate in pregnant population. Can reduce dose by eliminating the ventilation portion of examination in patients with normal perfusion (plus whack an IDC in to stop the bladder-fetus exposure). Of note - ther test: D-dimer can have false-positive results as pregnancy progresses, however NPV remains accurate regardless of trimester (but PE has still been found in normal D-dimers). 5. something else which is false

Answer 18

1. non-contrast CT is needed to evaluate T - Unenhanced CT can be helpful to diagnose acute haemorrhage and intramural haematoma and displacement of intimal calcifications - Not sure about "needed to evaluate" but it is helpful.... 32. Regarding aortic dissection, which is true? (JS) 1. non-contrast CT is needed to evaluate T - Unenhanced CT can be helpful to diagnose acute haemorrhage and intramural haematoma and displacement of intimal calcifications - Not sure about "needed to evaluate" but it is helpful.... 2. type B starts proximal to left subclavian artery - F - Stanford type B involves the descending aorta only (ie beyond the brachiocephalic vessels) 3. tear in ascending aorta mostly posterolateral - F – anterior and right lateral wall of ascending aorta, just distal to aortic valve in 65% 4. intramural thrombus not a precusor to aortic dissection - F - this represents a localised haematoma within the aortic wall which may represent a controlled dissection and can progress to dissection (especially type A)

Answer 19

3. Peak systolic velocity in the internal carotid artery of >270 cm/sec suggests a stenosis of >70% - T - >230cm/s equals >70% stenosis, ICA/CCA ratio >4.0. 125-230cm/s equals 50-69% stenosis, ICA/CCA ratio 2.0-4.0. <125cm/s equals <50% stenosis, ICA/CCA ratio <2.0. (US requisites) 39. With regards to imaging of the extracranial carotid arteries which of the following statements is TRUE: (TW) 1. Echogenic plaque on US is more likely to be associated with cerebral transient ischaemic events than hypoechoic plaque - F - heterogeneous plaques, especially those with focal hypoechoic regions, tend to be unstabel. Homogeneous plaques tend to be stable. 2. Conventional angiography is a reliable predictor of plaque ulceration - F 3. Peak systolic velocity in the internal carotid artery of >270 cm/sec suggests a stenosis of >70% - T - >230cm/s equals >70% stenosis, ICA/CCA ratio >4.0. 125-230cm/s equals 50-69% stenosis, ICA/CCA ratio 2.0-4.0. <125cm/s equals <50% stenosis, ICA/CCA ratio <2.0. (US requisites) 4. The intimal flap is visible on US imaging in approximately 80% of cases presenting with internal carotid artery dissection - F - detection of the intimal flap has not been reliable with US and the intimal tear may be too high in the ICA to be assessed with carotid US. 5. Diastolic flow is lower in the internal carotid artery than the external carotid artery, - F - Like other parenchymal organs, the brain has a low resistance to arterial flow; therefore, waveforms from the ICA have broad systolic peaks and well-maintained dyastolic flow throughout the cardiac cycle. The ECA supplies the scalp, muscles, and face, all of which have a high resistance to arterial inflow. This results in a high-resistance arterial waveform with narrower systolic peaks and decreased or absent diastolic flow. CME 01.30 (30)

Answer 20

4. Approx 40% of calf vein thrombi propagate superiorly to involve at least the popliteal or femoral veins. - F - up to 20% propagate. Serial evaluation every 3-5 days is therefore important in patients who remain symptomatic with conservative therapy to dx clot propagation and prevent PE. [B&H pg 1052] 40. Regarding lower limb deep venous thrombosis, which is false: (GC) CME 03.42 and CME 00.08 1. Failure of superficial femoral vein Doppler signal to augment on calf compression indicates thrombus distal to the point of interrogation. - T - augment by squeezing calf or plantarflexing foot; indicates venous occlusion/compression in intervening venous segments. 2. Diameter of the thrombosed vein is not typically increased in chronic thrombosis. - T - chronic clot does not expand the lumen of the vein and appears more echogenic than an acute clot. The walls appear thickened, irregular and echogenic and the vein is incompletely compressible. Collaterals can be seen on colour doppler. (B&H) 3. DVT in the leg most often begins in the sinuses of the soleal veins of the calf. - T 4. Approx 40% of calf vein thrombi propagate superiorly to involve at least the popliteal or femoral veins. - F - up to 20% propagate. Serial evaluation every 3-5 days is therefore important in patients who remain symptomatic with conservative therapy to dx clot propagation and prevent PE. [B&H pg 1052] Changed option b from "is typically" so only 1 false; changed option c from "Isolated calf thrombosis occurs least often in the peroneal veins" to CME stem.

Answer 21

43.VSD (TW) 1.membranes > muscular - T - multiple factos are involved in closure of the region encompassing the membranous septum, thus this is the most common site of VSDs (75% are membranous (component 3 with extension into component 2 - see below)). Membranous VSDs like just beneath the AV and behind septal leaflet of the TV. 10-15% of VSDs are muscular defects (located along the RV free wall-septal junction, central, or in the apical septum). 3 main components of the interventricular septua are 1) the septum of the AV canal, 2) muscular septum, 3) pareital band or distal conal septum. VSDs may occur at various locations in any of these components. Embyrologically, closure of the IV septum depends on 3 factors: projections into the AV canal from the right-sided endocardial cushions (component 1); continued growth of connective tissue on the crest of the muscular septum (component 2); and downward growth of ridges dividing the conus (component 3).

Answer 22

t 1, 2 4 5. Bowel Ischaemia: (TW) 1. Can be related to superior mesenteric vein thrombosis - T - venous occlusion <10%. SMV > IMV > PV. 2. Is associated with paroxysmal nocturnal haemoglobinuria - T - PNH is a disorder characterised by a defect in the GPI anchor due to an abnormality in th PIG-A gene. Result in abnormalities in hemopoietic function, including hemolytic anemia, a hypercoagulabel state, and diminished hematopoiesis. 3. Vasospasm indicates underlying atherosclerosis and stenosis - F 4. Occlusion is typically 10cm distal to the SMA origin - F - SMA thrombosis (20-40%) at origin + site of atherosclerotic narrowing. Embolus (40-50%) just distal to middle colic artery. 5. Plain film changes are only seen after bowel infarction - F - ischaemia, oedematous bowel, thumb printing. Could also have bowel obstruction as cause of ischaemia (pre-infarction).

Answer 23

t 2 46. Aortic Stent Grafts: (TW) 1. Sac size greater than 8cm is a contraindication - F - for example the Zenith AAA grafts range from 82mm to 149mm in length. 2. The neck of the aneurysm is defined as the distance from the inferior most renal artery to the start of the aneurysm - T - the proximal neck is defined as the segment of aorta between the origin of the lowest renal artery and superior aspect of the aneurysm. Most endographs require a length of greater than 15mm to ensure adequate proximal seal. 3. Immediate endoleak always needs further intervention - F - depends on type. type I endoleak (ie incompetent seal at either proximal or distal attachment site) must be repaired as soon as possible. Type III endoleaks represtn flow into sac from separation between components of a modular system, or tears in the endograft - these are repaired with an additional endograft. Type IV leaks are due to egress of blood through the pores of the fabric - these heal spontaneously. Type II enodleak (most common) - management is controversial. Some argue that as spontaneous resolution occurs 30-100% of cases, a "wait and see" approach is preferable. UTD recommendations are occluding type II endoleaks that have not spontaneously thrombosed in one month (as systemic pressures have been noted in aneuyrsm sac in the presence of type II endoleaks 4. Retro leak from lumbar arteries needs further intervention - ?T/F - controversial, see ans c. 5. Luminal diameter is best measured via angiography with a graded catheter - ?F

Answer 24

t 1, 2, 5 not sure about 3 47. Regarding Cervico Cephalic Vessel Dissection: (GC) 1. Causes 5% to 20% of CVAs in young to middle aged patients - T - 5-20% in those aged 40-60yrs [Dahnert]; up to 1/4 of strokes,with a peak prevalence in the 5th decade [RG]. 2. Has a rim of T1 hyperintensity surrounding a void in the vessels - T - subacute hematoma (7days-2mths) on T1 + fat sat appears as a bright crescent-shaped area around an eccentric flow void. Note that in the early and chronic stage, the haematoma is usually isointense to surrounding structures on T1. 3. Imaging identifies vasculopathy in the majority 4. The location of vertebral artery dissections is most often proximal (between C2 and C6) - F - at the level of C1/2 in 65% [Dahenrt]. ie. predominantly located in the pars transversaria (V2, 35%) or the atlas loop (V3, 34%) [RG]. Bilateral vertebal artery dissections in 5%. 5. The location of an ICA dissection is most often just immediately distal to the bulb - T - extracranial ICA dissection affects the cervical part of the artery distal to the carotid bulb and tends not to extend beyond its entry into the petrous portion. [Craniocervical a. dissection, RG 2008]

Answer 25

1, 3, 4, probably 5 48. Fixed inferior defects in a thallium scan are caused by: (GC) 1. Diaphragmatic attenuation - T - variation in tracer intensity by 15-20% btn regions on planar images may be normal (due to soft tissue attentuation artifacts from subdiaphragmatic abdominal contents or breast tissue). 2. Mastectomy - F - implants could cause attentuation artifact. 3. Right coronary artery infarct - T - RCA territory is 5-8 o'clock on the short axis (oblique coronal). 4. Pacemaker leads - T - attentuation artifact. 5. Left bundle branch block - ?T

Answer 26

everything is false 49. Pulmonary Emboli: (GC/TW) 1. Septic emboli most commonly arise from the pelvic veins - F - most common cause of septic emboli in IVDU is tricuspid valve endocarditis. Other causes include septic thrombophlebitis, pelvic thrombophlebitis, infected lines, AV fistula, skin infection... Can't find anything more specific than this. 2. The defect on chest x-rays is often larger than the V/Q defect - F - An upright PA and lateral CXR should ideally be obtained as close as possible to the V/Q scan. Perfusion defects substantially larger than the corresponding CXR abnormalities are suggestive of PE, whereas perfusion defects substantially smaller than corresponding CXR abnormalities are not commonly associated with PE (Thoracic Imaging). 3. Matched defects on V/Q scans exclude PE - F - a PE presents as a segmentally hypoperfused but normally ventilated lung (V/Q mismatch). A normal perfusion scan excludes a PE for practical purposes. A perfusion defect requires further evaluation with ventilation scan and CXR - if both (V and CXR) are normal, suspect PE. Matched V and Q defects + normal CXR = low prob. Matched V and Q and CXR defect = indeterminate. 4. PE is associated with pulmonary infarction in 30% - F – false if using Path notes. If use Dahnert numbers (10-60%) then true. More likely to develop if cardiopulmonary disease with obstruction of pulmonary venous outflow. 5. The presence of a pleural effusion indicates pulmonary infarction - F - pleural effusions are non specific - present in 48% of those with PE vs. 31% of those with no PE. Pulmonary infarction = any opacity developing as a result of thromboembolic disease. [Dahnert p524]

Answer 27

t 1, 3, 4 50.With regard to cerebral aneurysms: (TW) 1. In children are associated with trauma and infection - T - Aneuyrsms in children may be congenital or idiopathic (77%), inflammatory or mycotic (11%), or traumatic (11%). 2. Multiple aneurysms are strongly associated with male gender - F - Female > Male (Neuroradiology 2004). Female preponderance has been reported in up to 70% of multiple aneurysms and a 2.4:1 ratio of females > males was reported in the Cooperative Study of Intracranial Aneurysms and SAH. 3. A truly azygos anterior cerebral artery is associated with lobar holoprosencephaly and saccular aneurysms - T - azygos ACA is a rare variation of the COW in which the A2 segments of both ACAs are represented by a singl common vessel from which arise all the major vessels supplying most of both anterior cerebral hemispheres, as well as the corpus callosum (ie a true azygos). Associated with holoprosencephaly. High indicence of berry aneurysms. Abnormal medial and intimal elements in the vessel wall of this developmental variant may account for the increased prevalence of associated saccular aneurysms. 4. Are multiple in 15% to 20% - T 5. Occur in the posterior circulation in 40% - F - 90-95% of aneurysms arise from COW - 90% from anterior circulation, 10% from posterior circulation. ACom 30-35%, PCom 30-35%, MCA 20-30%, Basilar apex 5-10%, other posterior 1-3%. Variations of the distal ACA: trus azygos artery, from which all major branches are given off to both cerebral hemispheres; a bihemispheric ACA, where both right and left ACAs are present, but one is rudimentary and most of the major branches to both hemispheres arise from the other ACA; a triple ACA, with the accessory ACA arising from the anterior communcating artery.

Answer 28

true 2,3,4,5 51. Cerebral angiography: (TW) 1. The supraclinoid internal carotid artery is best seen in a caudal (Waters) projection - ?F - ICA/ophthalmic: transorbital oblique (15-30 degree rotation, and 7 degrees cephalad); Caldwell's oblique (15-30 degrees rotation, and 7 degrees caudad). Waters is ~30 degrees caudad? 2. The origin of the opthalmic artery is intradural in the majority of people - T - The origin of the ophthalmic artery is intradural in approx 90% of anatomic dissections (Diagnostic cerebral angiography, AG Osborn). 3. Internal carotid injections are of 8mls at 2mls per second - T - CCA 4-5ml/s for 2s (ie total 8-10mls) 4. Cavernous haemangiomata are angiographically occult - T - cavernous malformation: DSA is usually normal "angiographically occult vascular malformation" 5. The enhancement of meningiomas persist late into the venous phase - T - mother-in-law - "comes early, stay late" - could always remember this as the pre-mature ejaculator who wants to cuddle afterwards.

Answer 29

5.Nephritic syndrome - F - haematuria, oliguria + azotemia, hypertension +/- some proteinuria. Nephrotic syndrome (proteinuria >3.5g/day) is one of the rarer causes of hypercoagulable state that can cause DST. 52. Dural venous sinus thrombosis is associated with: (GC) 1. Pregnancy - T - hypercoagulable state. 2. Meningioma - T - tumour compressing sinus. 3. Gastroenteritis - T - dehydration (low-slow states). 4. Trauma - T - hfracture through sinus wall, cranial surgery, IJV catheterisation. 5. Nephritic syndrome - F - haematuria, oliguria + azotemia, hypertension +/- some proteinuria. Nephrotic syndrome (proteinuria >3.5g/day) is one of the rarer causes of hypercoagulable state that can cause DST. Causes: Idiopathic Septic (esp. kids) - sinusitis, otitis, mastoiditis, meningitis, septicaemia etc. Aseptic causes - tumour (compression), trauma, low-flow states, hypercoagulability, chemotherapy. Unusual causes - Behcet's disease, AIDS, UC, SLE, nephrotic syndrome, sarcoidosis. [Dahnert] Added options d and e.

Answer 30

4. Acute thrombus is highly hyperechoic in the majority of cases. - F - a significant no. of clots are isoechoic to flowing blood, such that visualisation of intraluminal thrombus is not a reliable finding. Other findings are: loss of compressibility, distension, colour Doppler defect or void, lack of augmentation on spectral Doppler, loss of respiratory phasicity. [B&H] 54. Regarding DVT, which is false: (GC) CME03.42 1. Lack of augmentation indicates thrombus distal to the point of interrogation. - T - augment by squeezing calf or plantarflexing foot; indicates venous occlusion/compression in intervening venous segments. 2. There is a phasic change with respiration on Doppler of the normal femoral vein. - T - normally there is a cyclic variation in flow velocity with respiration - should decrease in expiration and increase in inspiration. Absence of phasicity (ie. continuous venous signal) is suspicious for proximal obstruction. [Dahnert pg 634] 3. Usually begin in the sinuses of the soleal veins. - T 4. Acute thrombus is highly hyperechoic in the majority of cases. - F - a significant no. of clots are isoechoic to flowing blood, such that visualisation of intraluminal thrombus is not a reliable finding. Other findings are: loss of compressibility, distension, colour Doppler defect or void, lack of augmentation on spectral Doppler, loss of respiratory phasicity. [B&H] 5. Thrombus in a duplicated femoral vein is a recognised cause of a false negative study. - T Changed option b from "the 40% propagate" stem (repeated elsewhere); changed option d from "Most common isolated vein is the peroneal vv." to CME option.; added option e from CME.

Answer 31

1.ASD - T - congenital left to right shunts cause enlarged PA. Other causes of enlarged pulmonary trunk are: pulmonary valve stenosis with post-stenotic dilatation, pulmonary regurgitation, pulmonary arterial hypertension and aneurysms.

Answer 32

1 and 4 56. Enlarged L atrium is seen in: 1. HOCM T - LV hypertrophy leads to rapid blood flow through the outflow tract and anterior displacement of the anterior leaflet of the MV causing mitral regurgitation and subsequent LA enlargment (Dahnert) 2. TOF - F 3. Ebstein’s Anomaly - F - enlarged right atrium 4. Endocardial something - T (I presume they are referring to endocardial fibroelastosis) - diffuse endocardial thickening of LV and LA from deposition of collagen and elastic tissue, causes CHF during first 6mths of life and is fatal by 2 years of age Causes of left atrial enlargement - volume overload (mitral incompetence, VSD, PDA or ASD with shunt reversal), pressure overload (mitral stenosis, myxoma of left atrium) secondary to left ventricular failure. (Chapman)

Answer 33

t 1, 3 57. Regarding Renal artery stenosis: (GC) 1. Peak velocity of 100cm/sec is normal - T - PSV in normal RAs averages 120cm/s ±12. RAS if >150cm/s for angles <60, or 180cm/s for angles >70 (many false positives due to suboptimal Doppler angles). 2. In renal artery stenosis the aortic PSV is less than the renal artery PSV - F * *LJS - also true, see other Q 3. There is increased RI in subcapsular haematoma - T - perinephric / subcaspular fluid collection. Elevated RI (>0.70) may also be seen in significant systemic HTN, markedly decreased heart rate, neonates and infants. [Dahnert p895] 4. Increased RI excludes ureteric obstruction - FThere is a biphasic haemodynamic response to complete ureteral obstruction - short period of Pg-mediated vasodilatation, followed by vasoconstriction (latter initially thought to be due to increased blood flow and collecting system pressures; now suggested that complex interactions btn several regulatory pathways are responsible). The potential role of Doppler sonography in the evaluation of renal colic is controversial. In two initial series, either an RI greater than 0.70 or a difference of >0.06–0.10 in mean RI values between kidneys was found to be highly specific and sensitive for acute obstruction. Perhaps more important, several cases of obstruction were identified before the development of collecting system dilatation. Unfortunately, to our knowledge, these results were not duplicated in later series. [RI in renal Doppler US, AJR 2003].

Answer 34

2.SMA high resistance in fasting - T - normal preprandial (fasting) waveform for the SMA is high resistance, and the normal postprandial (after eathing a meal) waveform is low resistance. Normal flow resistances: Aorta = high; Renal artery = low; Celiac artery = low; SMA = high (preprandial), low (postprandial); splenic artery = low

Answer 35

1. Goes behind trachea - T - arises from the posterior aspect of the RPA and passes btn the trachea & oesophagus to reach the left hilum; forms a sling around the distal trachea and proximal RMB. 59. Regarding Aberrant Left pulmonary artery - which is true: (GC) 1. Goes behind trachea - T - arises from the posterior aspect of the RPA and passes btn the trachea & oesophagus to reach the left hilum; forms a sling around the distal trachea and proximal RMB. 2. Causes a posterior impression on the oesophagus - F - forms an anterior indentation on oesophagogram. 3. Presents 6-8 yrs - F - those affected may be classified generally into 2 groups: normal bronchial pattern - high mortality and morbidity during infancy. malformations of the tracheobronchial tree - eg. long segment tracheal stenosis, "napkin-ring trachea" (absence of pars membranacea); CVS abnormalities (PDA, ASD, persistent left SVC); this group includes very few asymptomatic adults. [RG 2006]

Answer 36

2. Aberrant L SCA - T - with right aortic arch + left ductus/ligamentum arteriosus. 3. Aberrant R SCA - T - with left aortic arch + right ductus/ligamentum arteriosusBoth b and c cause anterior tracheal indentation + large posterior oesophageal impression.Posterior tracheal indentation + anterior oesophageal impression - aberrant L pulmonary a.Anterior tracheal indentation only - innominate a. with origin more distal along Ao arch; L CCA with origin more proximal to arch; common origin of innominate and L CCA.[Dahnert p592]

Answer 37

2. negative for cANCA - approximately 90-95% of patients with active, Wegener's granulomatosis are ANCA-positive. 63. Which finding makes it less likely to be Wegener's granulomatosus ? (TW) 1. lack of sinus involvement - essentally all patients with classic or limited Wegener's granulomatosis have upper airway OR pulmonary involvement, and the majority have both. 2. negative for cANCA - approximately 90-95% of patients with active, Wegener's granulomatosis are ANCA-positive. 3. lack of renal involvement - a "limited" form, with clinical findings isolated to the upper respiratory tract or lungs, occurs in approximately 1/4 of cases. These however, eventually develop systemic involvement.

Answer 38

1.Rheumatic fever

Answer 39

5. more common in the right atrium - F - left to right ratio is 4:1 with 90% located in the atria 65.Atrial myxoma - atypical feature (JS) 1. 3cm papillary soft tissue mass sessile - T - sessile or pedunculated masses that vary from hard globular masses mottled with haemorrhage to soft, translucent, papillary or villous lesions having a gelatinous appearance 2. 8 cm globular mass pedunculated - T - size range is 1 to 10cm and they are usually solitary 3. atrial septum - T - fossa ovalis in the atrial septum is a common site 4. can prolapse into ventricle - T - pedunculated form mobile enough to move into or through the AV valves during systole causing intermittent and often position dependent obstruction or "wrecking ball" effect 5. more common in the right atrium - F - left to right ratio is 4:1 with 90% located in the atria

Answer 40

1 true? 3 true 68. Aortic dissection (JS) 1. Can occur without an intimal flap - T - There is usually (but not always) an intimal tear that extends into but not through the media of the ascending aorta (Robbins). According to Primer, intimal flap is detectable in 85-90%. 2. Longitudinal - F - tears are usually transverse or oblique, 1-5cm in length with sharp jagged edges 3. 30-50cm long ? - not sure if they mean the length of the tear (1-5cm) or the length of the dissection which is variable 4. Aortic valve prevents involvement coronary arteries - F - occlusion of coronary aa in 8%

Answer 41

1.An isolated finding - T - Isolated secundum atrial septal defects account for approximately 7% of congenital cardiac defects; occasionally demonstrates familial inheritance in an autosomal dominant pattern, esp. when assocd with prolonged AV conduction (ie, prolonged PR interval on ECG). Familial secundum ASD also occurs in Holt-Oram syndrome. May be assocd with prolpasing MV (20-30%), PV stenosis, tricuspid atresia, TAPVR, hypoplastic left heart, interrupted Ao arch. (cf. Ostium primum ASD which is almost always assocd with anomalies, including cleft MV and Down's syndrome).

Answer 42

3.Type III hypersensitivity - T - Immunocomplex disease. Induced by antigen-antibody complexes that produce tissue damage as a result of their capacity to active the complement system. Can be generalized (immune complexes formed in circulation adn deposited in many organs etc), or localized to particular organs such as kidney (GN), joints (arthritis) or the small blood vessels of the skin if the complexes are formed an deposited locally (the local Arthus reaction). See below. eg serum sickness 72. IV contrast reaction 4-12 hours afterwards, it results in skin necrosis. It's a repeatable response. What type of reaction is it? (TW) 1. Type I hypersensitivity - F- Anaphylactic type. Rapidly developing immunologic reaction developing within minutes after combination of antigen with antibody bound to mast cells or basophils in individuals previously sensitized to antigen 2. Type II hypersensitivity - F - Cytotoxic type. Mediated by antibodies directed toward antigens present on surface of cells or other tissue component (subtypes: complement-dependent reactions; antibody-dependent cell mediated cytotoxicity; antibody mediated cellular dysfunction)- eg ABO 3. Type III hypersensitivity - T - Immunocomplex disease. Induced by antigen-antibody complexes that produce tissue damage as a result of their capacity to active the complement system. Can be generalized (immune complexes formed in circulation adn deposited in many organs etc), or localized to particular organs such as kidney (GN), joints (arthritis) or the small blood vessels of the skin if the complexes are formed an deposited locally (the local Arthus reaction). See below. eg serum sickness 4. Type IV hypersensitivity - F - Cell mediated (delayed). Initiated by specifically sensitized T lymphocytes. Eg TB 5. Not immune reaction - F - unless someone is repeatedly extravasating a lot of contrast! Maybe fun, but not ethical.

Answer 43

75. A prominent aortic arch is seen with the following. (GC) 1. PDA - T 2. ASD - F 3. Mitral stenosis - F 4. Syphilis - T 5. Hypertension - T

Answer 44

1. Are consistently seen in severe aortic stenosis on plain films. - T - good correlation btn amount of Ca2+ and degree of stenosis:- heavy Ca2+ = significant stenosis; none = AS unlikely. 76. Calcified valves. (GC) 1. Are consistently seen in severe aortic stenosis on plain films. - T - good correlation btn amount of Ca2+ and degree of stenosis:- heavy Ca2+ = significant stenosis; none = AS unlikely. 2. Occur in aortic incompetence with rheumatic heart disease. - F - AR is rare in RHD, most commonly MS (70%), then MS+AS (25%). Isolated rheumatic AS is seen as a dense cluster of calcific deposits without a bicuspid contour (as in BAV). In patients 30-60yo, AV Ca2+ suggest RHD. 3. Indicate progressive mitral valve degeneration. - F - mitral annular calcification is degenerative (physiologic in elderly). Mitral valve Ca2+ is virtually always due to RHD (see below). 4. Is seen in 10% of congenital aortic stenosis. - F - in patients <30yo, AV Ca2+ are mostly due to bicuspid AV; usually extensive cluster of dense calcific deposits (nearly circular Ca2+ with interior linear bar DIAGNOSTIC; also get poststenotic dilatation). There is valvular calcification in 60% of patients >24yo.Aortic valve: Ca2+ best seen on lateral view. Causes: congenital BAV (<30yo), isolated rheumatic AS (30-60yo), degenerative AS (>65yo).Mitral valve: RHD, infective endocarditis, tumour attached to MV, MVP. Pulmonary valve: tetralogy of Fallot, PS, ASDTricuspid valve: RHD, septal defect, TV defect, IE.[Dahnert p595]

Answer 45

t 1, 2 45. Bowel Ischaemia: (TW) 1. Can be related to superior mesenteric vein thrombosis - T - venous occlusion <10%. SMV > IMV > PV. 2. Is associated with paroxysmal nocturnal haemoglobinuria - T - PNH is a disorder characterised by a defect in the GPI anchor due to an abnormality in th PIG-A gene. Result in abnormalities in hemopoietic function, including hemolytic anemia, a hypercoagulabel state, and diminished hematopoiesis. 3. Vasospasm indicates underlying atherosclerosis and stenosis - F 4. Occlusion is typically 10cm distal to the SMA origin - F - SMA thrombosis (20-40%) at origin + site of atherosclerotic narrowing. Embolus (40-50%) just distal to middle colic artery. 5. Plain film changes are only seen after bowel infarction - F - ischaemia, oedematous bowel, thumb printing. Could also have bowel obstruction as cause of ischaemia (pre-infarction).

Answer 46

t 2 46.Aortic Stent Grafts: (TW) 1. Sac size greater than 8cm is a contraindication - F - for example the Zenith AAA grafts range from 82mm to 149mm in length. 2. The neck of the aneurysm is defined as the distance from the inferior most renal artery to the start of the aneurysm - T - the proximal neck is defined as the segment of aorta between the origin of the lowest renal artery and superior aspect of the aneurysm. Most endographs require a length of greater than 15mm to ensure adequate proximal seal. 3. Immediate endoleak always needs further intervention - F - depends on type. type I endoleak (ie incompetent seal at either proximal or distal attachment site) must be repaired as soon as possible. Type III endoleaks represtn flow into sac from separation between components of a modular system, or tears in the endograft - these are repaired with an additional endograft. Type IV leaks are due to egress of blood through the pores of the fabric - these heal spontaneously. Type II enodleak (most common) - management is controversial. Some argue that as spontaneous resolution occurs 30-100% of cases, a "wait and see" approach is preferable. UTD recommendations are occluding type II endoleaks that have not spontaneously thrombosed in one month (as systemic pressures have been noted in aneuyrsm sac in the presence of type II endoleaks 4. Retro leak from lumbar arteries needs further intervention - ?T/F - controversial, see ans c. 5. Luminal diameter is best measured via angiography with a graded catheter - ?F

Answer 47

t 1, 2, 5 not sure about 3 47. Regarding Cervico Cephalic Vessel Dissection: (GC) 1. Causes 5% to 20% of CVAs in young to middle aged patients - T - 5-20% in those aged 40-60yrs [Dahnert]; up to 1/4 of strokes,with a peak prevalence in the 5th decade [RG]. 2. Has a rim of T1 hyperintensity surrounding a void in the vessels - T - subacute hematoma (7days-2mths) on T1 + fat sat appears as a bright crescent-shaped area around an eccentric flow void. Note that in the early and chronic stage, the haematoma is usually isointense to surrounding structures on T1. 3. Imaging identifies vasculopathy in the majority 4. The location of vertebral artery dissections is most often proximal (between C2 and C6) - F - at the level of C1/2 in 65% [Dahenrt]. ie. predominantly located in the pars transversaria (V2, 35%) or the atlas loop (V3, 34%) [RG]. Bilateral vertebal artery dissections in 5%. 5. The location of an ICA dissection is most often just immediately distal to the bulb - T - extracranial ICA dissection affects the cervical part of the artery distal to the carotid bulb and tends not to extend beyond its entry into the petrous portion. [Craniocervical a. dissection, RG 2008]

Answer 48

1, 3, 4, probably 5 48. Fixed inferior defects in a thallium scan are caused by: (GC) 1. Diaphragmatic attenuation - T - variation in tracer intensity by 15-20% btn regions on planar images may be normal (due to soft tissue attentuation artifacts from subdiaphragmatic abdominal contents or breast tissue). 2. Mastectomy - F - implants could cause attentuation artifact. 3. Right coronary artery infarct - T - RCA territory is 5-8 o'clock on the short axis (oblique coronal). 4. Pacemaker leads - T - attentuation artifact. 5. Left bundle branch block - ?T

Answer 49

everything is false 49. Pulmonary Emboli: (GC/TW) 1. Septic emboli most commonly arise from the pelvic veins - F - most common cause of septic emboli in IVDU is tricuspid valve endocarditis. Other causes include septic thrombophlebitis, pelvic thrombophlebitis, infected lines, AV fistula, skin infection... Can't find anything more specific than this. 2. The defect on chest x-rays is often larger than the V/Q defect - F - An upright PA and lateral CXR should ideally be obtained as close as possible to the V/Q scan. Perfusion defects substantially larger than the corresponding CXR abnormalities are suggestive of PE, whereas perfusion defects substantially smaller than corresponding CXR abnormalities are not commonly associated with PE (Thoracic Imaging). 3. Matched defects on V/Q scans exclude PE - F - a PE presents as a segmentally hypoperfused but normally ventilated lung (V/Q mismatch). A normal perfusion scan excludes a PE for practical purposes. A perfusion defect requires further evaluation with ventilation scan and CXR - if both (V and CXR) are normal, suspect PE. Matched V and Q defects + normal CXR = low prob. Matched V and Q and CXR defect = indeterminate. 4. PE is associated with pulmonary infarction in 30% - F – false if using Path notes. If use Dahnert numbers (10-60%) then true. More likely to develop if cardiopulmonary disease with obstruction of pulmonary venous outflow. 5. The presence of a pleural effusion indicates pulmonary infarction - F - pleural effusions are non specific - present in 48% of those with PE vs. 31% of those with no PE. Pulmonary infarction = any opacity developing as a result of thromboembolic disease. [Dahnert p524]

Answer 50

t 1, 3, 4 50. With regard to cerebral aneurysms: (TW) 1. In children are associated with trauma and infection - T - Aneuyrsms in children may be congenital or idiopathic (77%), inflammatory or mycotic (11%), or traumatic (11%). 2. Multiple aneurysms are strongly associated with male gender - F - Female > Male (Neuroradiology 2004). Female preponderance has been reported in up to 70% of multiple aneurysms and a 2.4:1 ratio of females > males was reported in the Cooperative Study of Intracranial Aneurysms and SAH. 3. A truly azygos anterior cerebral artery is associated with lobar holoprosencephaly and saccular aneurysms - T - azygos ACA is a rare variation of the COW in which the A2 segments of both ACAs are represented by a singl common vessel from which arise all the major vessels supplying most of both anterior cerebral hemispheres, as well as the corpus callosum (ie a true azygos). Associated with holoprosencephaly. High indicence of berry aneurysms. Abnormal medial and intimal elements in the vessel wall of this developmental variant may account for the increased prevalence of associated saccular aneurysms. 4. Are multiple in 15% to 20% - T 5. Occur in the posterior circulation in 40% - F - 90-95% of aneurysms arise from COW - 90% from anterior circulation, 10% from posterior circulation. ACom 30-35%, PCom 30-35%, MCA 20-30%, Basilar apex 5-10%, other posterior 1-3%. Variations of the distal ACA: trus azygos artery, from which all major branches are given off to both cerebral hemispheres; a bihemispheric ACA, where both right and left ACAs are present, but one is rudimentary and most of the major branches to both hemispheres arise from the other ACA; a triple ACA, with the accessory ACA arising from the anterior communcating artery.

Answer 51

true 2,3,4,55 1. Cerebral angiography: (TW) 1. The supraclinoid internal carotid artery is best seen in a caudal (Waters) projection - ?F - ICA/ophthalmic: transorbital oblique (15-30 degree rotation, and 7 degrees cephalad); Caldwell's oblique (15-30 degrees rotation, and 7 degrees caudad). Waters is ~30 degrees caudad? 2. The origin of the opthalmic artery is intradural in the majority of people - T - The origin of the ophthalmic artery is intradural in approx 90% of anatomic dissections (Diagnostic cerebral angiography, AG Osborn). 3. Internal carotid injections are of 8mls at 2mls per second - T - CCA 4-5ml/s for 2s (ie total 8-10mls) 4. Cavernous haemangiomata are angiographically occult - T - cavernous malformation: DSA is usually normal "angiographically occult vascular malformation" 5. The enhancement of meningiomas persist late into the venous phase - T - mother-in-law - "comes early, stay late" - could always remember this as the pre-mature ejaculator who wants to cuddle afterwards.

Answer 52

5.Nephritic syndrome - F - haematuria, oliguria + azotemia, hypertension +/- some proteinuria. Nephrotic syndrome (proteinuria >3.5g/day) is one of the rarer causes of hypercoagulable state that can cause DST. 52. Dural venous sinus thrombosis is associated with: (GC) 1. Pregnancy - T - hypercoagulable state. 2. Meningioma - T - tumour compressing sinus. 3. Gastroenteritis - T - dehydration (low-slow states). 4. Trauma - T - hfracture through sinus wall, cranial surgery, IJV catheterisation. 5. Nephritic syndrome - F - haematuria, oliguria + azotemia, hypertension +/- some proteinuria. Nephrotic syndrome (proteinuria >3.5g/day) is one of the rarer causes of hypercoagulable state that can cause DST. Causes: Idiopathic Septic (esp. kids) - sinusitis, otitis, mastoiditis, meningitis, septicaemia etc. Aseptic causes - tumour (compression), trauma, low-flow states, hypercoagulability, chemotherapy. Unusual causes - Behcet's disease, AIDS, UC, SLE, nephrotic syndrome, sarcoidosis. [Dahnert] Added options d and e.

Answer 53

4. Acute thrombus is highly hyperechoic in the majority of cases. - F - a significant no. of clots are isoechoic to flowing blood, such that visualisation of intraluminal thrombus is not a reliable finding. Other findings are: loss of compressibility, distension, colour Doppler defect or void, lack of augmentation on spectral Doppler, loss of respiratory phasicity. [B&H] 54. Regarding DVT, which is false: (GC) CME03.42 1. Lack of augmentation indicates thrombus distal to the point of interrogation. - T - augment by squeezing calf or plantarflexing foot; indicates venous occlusion/compression in intervening venous segments. * AJL need to be careful with the use of 'distal'. If meaning distal leg (as in inferior) this question is correct. If meaning distal vein (as in superior) this question is incorrect. (I hate proximal and distal with blood veins) 2. There is a phasic change with respiration on Doppler of the normal femoral vein. - T - normally there is a cyclic variation in flow velocity with respiration - should decrease in expiration and increase in inspiration. Absence of phasicity (ie. continuous venous signal) is suspicious for proximal obstruction. [Dahnert pg 634] 3. Usually begin in the sinuses of the soleal veins. - T 4. Acute thrombus is highly hyperechoic in the majority of cases. - F - a significant no. of clots are isoechoic to flowing blood, such that visualisation of intraluminal thrombus is not a reliable finding. Other findings are: loss of compressibility, distension, colour Doppler defect or void, lack of augmentation on spectral Doppler, loss of respiratory phasicity. [B&H] 5. Thrombus in a duplicated femoral vein is a recognised cause of a false negative study. - T Changed option b from "the 40% propagate" stem (repeated elsewhere); changed option d from "Most common isolated vein is the peroneal vv." to CME option.; added option e from CME.

Answer 54

1.ASD - T - congenital left to right shunts cause enlarged PA. Other causes of enlarged pulmonary trunk are: pulmonary valve stenosis with post-stenotic dilatation, pulmonary regurgitation, pulmonary arterial hypertension and aneurysms.

Answer 55

1 and 4 56. Enlarged L atrium is seen in: 1. HOCM T - LV hypertrophy leads to rapid blood flow through the outflow tract and anterior displacement of the anterior leaflet of the MV causing mitral regurgitation and subsequent LA enlargment (Dahnert) 2. TOF - F 3. Ebstein’s Anomaly - F - enlarged right atrium 4. Endocardial something - T (I presume they are referring to endocardial fibroelastosis) - diffuse endocardial thickening of LV and LA from deposition of collagen and elastic tissue, causes CHF during first 6mths of life and is fatal by 2 years of age Causes of left atrial enlargement - volume overload (mitral incompetence, VSD, PDA or ASD with shunt reversal), pressure overload (mitral stenosis, myxoma of left atrium) secondary to left ventricular failure. (Chapman)

Answer 56

t 1, 3 57. Regarding Renal artery stenosis: (GC) 1. Peak velocity of 100cm/sec is normal - T - PSV in normal RAs averages 120cm/s ±12. RAS if >150cm/s for angles <60, or 180cm/s for angles >70 (many false positives due to suboptimal Doppler angles). 2. In renal artery stenosis the aortic PSV is less than the renal artery PSV - F * *LJS - true. Markedly elevated renal artery PSV compared with aortic PSV. Ratio > 3.5 indicates severe stenosis https: //radiopaedia.org/cases/renal-artery-stenosis-2?lang=gb 3. There is increased RI in subcapsular haematoma - T - perinephric / subcaspular fluid collection. Elevated RI (>0.70) may also be seen in significant systemic HTN, markedly decreased heart rate, neonates and infants. [Dahnert p895] 4. Increased RI excludes ureteric obstruction - FThere is a biphasic haemodynamic response to complete ureteral obstruction - short period of Pg-mediated vasodilatation, followed by vasoconstriction (latter initially thought to be due to increased blood flow and collecting system pressures; now suggested that complex interactions btn several regulatory pathways are responsible). The potential role of Doppler sonography in the evaluation of renal colic is controversial. In two initial series, either an RI greater than 0.70 or a difference of >0.06–0.10 in mean RI values between kidneys was found to be highly specific and sensitive for acute obstruction. Perhaps more important, several cases of obstruction were identified before the development of collecting system dilatation. Unfortunately, to our knowledge, these results were not duplicated in later series. [RI in renal Doppler US, AJR 2003].

Answer 57

2.SMA high resistance in fasting - T - normal preprandial (fasting) waveform for the SMA is high resistance, and the normal postprandial (after eathing a meal) waveform is low resistance. Normal flow resistances: Aorta = high; Renal artery = low; Celiac artery = low; SMA = high (preprandial), low (postprandial); splenic artery = low

Answer 58

1.Goes behind trachea - T - arises from the posterior aspect of the RPA and passes btn the trachea & oesophagus to reach the left hilum; forms a sling around the distal trachea and proximal RMB. 59. Regarding Aberrant Left pulmonary artery - which is true: (GC) 1. Goes behind trachea - T - arises from the posterior aspect of the RPA and passes btn the trachea & oesophagus to reach the left hilum; forms a sling around the distal trachea and proximal RMB. 2. Causes a posterior impression on the oesophagus - F - forms an anterior indentation on oesophagogram. 3. Presents 6-8 yrs - F - those affected may be classified generally into 2 groups: normal bronchial pattern - high mortality and morbidity during infancy. malformations of the tracheobronchial tree - eg. long segment tracheal stenosis, "napkin-ring trachea" (absence of pars membranacea); CVS abnormalities (PDA, ASD, persistent left SVC); this group includes very few asymptomatic adults. [RG 2006]

Answer 59

2. Aberrant L SCA - T - with right aortic arch + left ductus/ligamentum arteriosus. 3. Aberrant R SCA - T - with left aortic arch + right ductus/ligamentum arteriosusBoth b and c cause anterior tracheal indentation + large posterior oesophageal impression.Posterior tracheal indentation + anterior oesophageal impression - aberrant L pulmonary a.Anterior tracheal indentation only - innominate a. with origin more distal along Ao arch; L CCA with origin more proximal to arch; common origin of innominate and L CCA.[Dahnert p592]

Answer 60

yap **LJS - early microvascular disease

Answer 61

2. negative for cANCA - approximately 90-95% of patients with active, Wegener's granulomatosis are ANCA-positive. 63. Which finding makes it less likely to be Wegener's granulomatosus ? (TW) 1. lack of sinus involvement - essentally all patients with classic or limited Wegener's granulomatosis have upper airway OR pulmonary involvement, and the majority have both. 2. negative for cANCA - approximately 90-95% of patients with active, Wegener's granulomatosis are ANCA-positive. 3. lack of renal involvement - a "limited" form, with clinical findings isolated to the upper respiratory tract or lungs, occurs in approximately 1/4 of cases. These however, eventually develop systemic involvement.

Answer 62

1.Rheumatic fever

Answer 63

5. more common in the right atrium - F - left to right ratio is 4:1 with 90% located in the atria 65. Atrial myxoma - atypical feature (JS) 1. 3cm papillary soft tissue mass sessile - T - sessile or pedunculated masses that vary from hard globular masses mottled with haemorrhage to soft, translucent, papillary or villous lesions having a gelatinous appearance 2. 8 cm globular mass pedunculated - T - size range is 1 to 10cm and they are usually solitary 3. atrial septum - T - fossa ovalis in the atrial septum is a common site 4. can prolapse into ventricle - T - pedunculated form mobile enough to move into or through the AV valves during systole causing intermittent and often position dependent obstruction or "wrecking ball" effect 5. more common in the right atrium - F - left to right ratio is 4:1 with 90% located in the atria

Answer 64

1 true? 3 true 68. Aortic dissection (JS) 1. Can occur without an intimal flap - T - There is usually (but not always) an intimal tear that extends into but not through the media of the ascending aorta (Robbins). According to Primer, intimal flap is detectable in 85-90%. 2. Longitudinal - F - tears are usually transverse or oblique, 1-5cm in length with sharp jagged edges 3. 30-50cm long ? - not sure if they mean the length of the tear (1-5cm) or the length of the dissection which is variable 4. Aortic valve prevents involvement coronary arteries - F - occlusion of coronary aa in 8%

Answer 65

1.An isolated finding - T - Isolated secundum atrial septal defects account for approximately 7% of congenital cardiac defects; occasionally demonstrates familial inheritance in an autosomal dominant pattern, esp. when assocd with prolonged AV conduction (ie, prolonged PR interval on ECG). Familial secundum ASD also occurs in Holt-Oram syndrome. May be assocd with prolpasing MV (20-30%), PV stenosis, tricuspid atresia, TAPVR, hypoplastic left heart, interrupted Ao arch. (cf. Ostium primum ASD which is almost always assocd with anomalies, including cleft MV and Down's syndrome).

Answer 66

3. Type III hypersensitivity - T - Immunocomplex disease. Induced by antigen-antibody complexes that produce tissue damage as a result of their capacity to active the complement system. Can be generalized (immune complexes formed in circulation adn deposited in many organs etc), or localized to particular organs such as kidney (GN), joints (arthritis) or the small blood vessels of the skin if the complexes are formed an deposited locally (the local Arthus reaction). See below. eg serum sickness 72. IV contrast reaction 4-12 hours afterwards, it results in skin necrosis. It's a repeatable response. What type of reaction is it? (TW) 1. Type I hypersensitivity - F- Anaphylactic type. Rapidly developing immunologic reaction developing within minutes after combination of antigen with antibody bound to mast cells or basophils in individuals previously sensitized to antigen 2. Type II hypersensitivity - F - Cytotoxic type. Mediated by antibodies directed toward antigens present on surface of cells or other tissue component (subtypes: complement-dependent reactions; antibody-dependent cell mediated cytotoxicity; antibody mediated cellular dysfunction)- eg ABO 3. Type III hypersensitivity - T - Immunocomplex disease. Induced by antigen-antibody complexes that produce tissue damage as a result of their capacity to active the complement system. Can be generalized (immune complexes formed in circulation adn deposited in many organs etc), or localized to particular organs such as kidney (GN), joints (arthritis) or the small blood vessels of the skin if the complexes are formed an deposited locally (the local Arthus reaction). See below. eg serum sickness 4. Type IV hypersensitivity - F - Cell mediated (delayed). Initiated by specifically sensitized T lymphocytes. Eg TB 5. Not immune reaction - F - unless someone is repeatedly extravasating a lot of contrast! Maybe fun, but not ethical.

Answer 67

``` 75.A prominent aortic arch is seen with the following. (GC )1.PDA - T 2.ASD - F 3.Mitral stenosis - F 4.Syphilis - T 5.Hypertension - T ```

Answer 68

1. Are consistently seen in severe aortic stenosis on plain films. - T - good correlation btn amount of Ca2+ and degree of stenosis:- heavy Ca2+ = significant stenosis; none = AS unlikely. 76. Calcified valves. (GC) 1. Are consistently seen in severe aortic stenosis on plain films. - T - good correlation btn amount of Ca2+ and degree of stenosis:- heavy Ca2+ = significant stenosis; none = AS unlikely. 2. Occur in aortic incompetence with rheumatic heart disease. - F - AR is rare in RHD, most commonly MS (70%), then MS+AS (25%). Isolated rheumatic AS is seen as a dense cluster of calcific deposits without a bicuspid contour (as in BAV). In patients 30-60yo, AV Ca2+ suggest RHD. 3. Indicate progressive mitral valve degeneration. - F - mitral annular calcification is degenerative (physiologic in elderly). Mitral valve Ca2+ is virtually always due to RHD (see below) .4.Is seen in 10% of congenital aortic stenosis. - F - in patients <30yo, AV Ca2+ are mostly due to bicuspid AV; usually extensive cluster of dense calcific deposits (nearly circular Ca2+ with interior linear bar DIAGNOSTIC; also get poststenotic dilatation). There is valvular calcification in 60% of patients >24yo.Aortic valve: Ca2+ best seen on lateral view. Causes: congenital BAV (<30yo), isolated rheumatic AS (30-60yo), degenerative AS (>65yo).Mitral valve: RHD, infective endocarditis, tumour attached to MV, MVP. Pulmonary valve: tetralogy of Fallot, PS, ASDTricuspid valve: RHD, septal defect, TV defect, IE.[Dahnert p595]

Answer 69

2. Affects the pulmonary valve greater than the triscupid valve. - F - mitral valve alone in 70%; MV and AV in 25%. 77. Rheumatic heart disease: (GC) 1. Antibiotics should be used when performing a barium enema. - T - there is approx 10% incidence of transient bacteraemia with Ba enema; pts with acquired valvular dysfunction (ie. chronic RHD) are considered at moderate risk of IE, whilst those with a previous hx of IE are high risk. However, despite accepted recommendations for prophylaxis and the decrease in the incidence of RHD, the number of reported cases of IE has remained fairly constant. [American Society of Colon & Rectal Surgeons] 2. Affects the pulmonary valve greater than the triscupid valve. - F - mitral valve alone in 70%; MV and AV in 25%. 3. Increase in size of the left atrial appendage is greater with rheumatic compared with non-rheumatic heart disease. - T - enlargement of the LAA is rare to uncommon in the wide range of nonrheumatic cardiac lesions which can lead to enlargement of the body of the LA (eg. L-R shunts, endocardial cushion defects, MVP). There is a very good correlation btn the presence of a dilated LAA and clincial/lab evidence of rheumatic MV disease, esp in severe enough cases that cause some degree of pulmonary venous obstruction. Proposed that this is a consequence of myocardial inflammation rather than mere haemodynamic factors (MV and LAA emb. derived from cardiac tissue, while LA body derived from pulmonary vein). [Significance of LAA in RHD, Radiology 1975] 4. Pericardial effusions are seen acutely. - T - RHD is a pancarditis (any of the 3 layers can be affected). Causes a fibrinous or serofibrinous pericardial exudate, which generally resolves without sequelae. [Robbins]

Answer 70

2 and 4 true 78. Ebsteins anomaly includes or is associated with (JS) 1. Mitral regurgitation - F - Tricuspid regurgitation 2. Atrial septal defect - T - PDA or ASD nearly always present, with right to left shunt (80%) 3. Enlarged aortic knuckle - F - hypoplastic aorta and pulmonary trunk 4. Right heart failure in infancy - T - tends to present in infancy 5. Cyanosis in all cases - F - +/- cyanosis depending on the degree of right to left shunt

Answer 71

t 3,4 79. The following are features of Marfan's syndrome (JS) 1. Autosomal recessive - F - 70-85% are familial with autosomal dominant inheritence, the remainder are sporadic and arise from new mutations. 2. Aneurysm of the descending thoracic aorta - F - aneurysms occur in the ascending aorta due to cystic medial dilation 3. Aortic incompetence - T - loss of connective tissue support in the aortic valve ring and root of the aorta give rise to aortic incompetence. 4. Aneurysms of the pulmonary arteries - T - Marfans is associated with aortic sinus dilatation, aortic aneurysm, aortic insufficiency and pulmonary aneurysm (Dahnert) 5. Tricuspid incompetence - F - Mitral valve prolapse and Aortic regurgitation are the only valve probs I could find * *LJS - also get TR (less common than AR and MR)

Answer 72

2,3, 4 true 80. Features of Kawasaki's disease (mucocutaneous lymph node syndrome) (JS) 1. Gallstones - F 2. Hydrops of the gallbladder - T 3. Coronary artery Anuerysms - T - approximately 20% develop CVS sequelae including coronary artery aneurysms 4. Desquamation of the skin - T - erythema of palms and soles with desquamation (88%) 5. Cataracts - F KAWASAKI SYNDROME (MUCOCUTANEOUS LYMPH NODE SYNDROME) arteritis involving large, medium-sized, and small arteries (often the coronary arteries) associated with the mucocutaneous lymph node syndrome, usually in young children and infants (80% younger than 4 years old). The acute illness is manifested by fever, conjunctival and oral erythema and erosion, edema of the hands and feet, erythema of the palms and soles, a skin rash often with desquamation, and enlargement of cervical lymph nodes It is usually self-limited Epidemic in Japan, the disease has also been reported in Hawaii and increasingly in the United States Approximately 20% of patients develop cardiovascular sequelae, with a range of severity from asymptomatic vasculitis of the coronary arteries, coronary artery ectasia, or aneurysm formation to giant coronary artery aneurysms (7 to 8 mm) with rupture or thrombosis, myocardial infarction, or sudden death. Kawasaki syndrome is the leading cause of acquired heart disease in children in the United States Acute fatalities occur in approximately 1% of patients owing to coronary arteritis with superimposed thrombosis or ruptured coronary artery aneurysm. Pathologic changes outside the cardiovascular system are rarely significant. Although the vasculitis resembles that of polyarteritis nodosa, with necrosis and pronounced inflammation affecting the entire thickness of the vessel wall, fibrinoid necrosis is usually less prominent in Kawasaki syndrome