Vascular Flashcards
3) A 32-year-old female presents with shortness of breath and hemoptysis. There is no leg swelling and an ECG is normal. A chest radiograph shows a triangular, plurally based opacity in the right mid-zone with an ipsilateral effusion. Which investigation would be most helpful in making the diagnosis?
a. V =Q scan
b. CT pulmonary angiogram
c. conventional pulmonary angiogram
d. high-resolution CT
e. staging CTof chest
b. CT pulmonary angiogram
The differential diagnosis is between pulmonary embolus or pneumonia with effusion, with investigation directed accordingly. High-resolution CT would be unhelpful with lack of contrast. A staging chest CT is performed in the aortic phase of contrast so pulmonary arteries will be sub optimally seen. CT pulmonary angiogram is the best investigation in this case, because, when there is consolidation/ opacification present on a chest radiograph, a _V =_Q scan has a high likelihood of being no diagnostic. Conventional pulmonary angiography is a high-risk procedure and is rarely performed in modern practice.
4) A 56-year-old female patient presents with shortness of breath. A chest radiograph is unremarkable. A highresolution CT scan is performed which shows mosaic perfusion with no air trapping on expiratory scan. What is the most likely diagnosis?
a. bronchiolitis obliterans
b. cystic fibrosis
c. hypersensitivity pneumonitis
d. chronic thromboembolic disease
e. asthma
d. chronic thromboembolic disease
Mosaic perfusion is caused by abnormalities of ventilation, or vascular obstruction. Expiratory scans help to distinguish causes by establishing whether there is air trapping. With no air trapping present, pulmonary emboli of any cause are most likely. Air trapping would suggest airway disease such as bronchiolitis obliterans, or other causes of small airway obstruction such as bronchiectasis or cystic fibrosis.
22) A 25-year-old male presents with recurrent epistaxis, which is progressively worsening. On examination, he is noted to have multiple, red, vascular skin blemishes. A chest radiograph shows several opacities in the lung measuring up to 3 cm with bands of opacification extending to the hila. No calcification is seen. What is the most likely diagnosis?
a. hereditary hemorrhagic telangiectasia
b. neurofibromatosis
c. tuberous sclerosis
d. Wegener’s granulomatosis
e. sarcoidosis
a. hereditary hemorrhagic telangiectasia
hemorrhagic telangiectasia (HHT), or Rendu–Osler–Weber syndrome, is a disorder that produces telangiectasia, arteriovenous malformations (AVMs) and aneurysms, affecting multiple organ systems. Recurrent epistaxis is seen in up to 85% of cases. Up to 15% of patients with HHT have multiple pulmonary AVMs, and 60% of patients with pulmonary AVMs have HHT. Wegener’s granulomatosis is also associated with epistaxis, due to granulomas of the nasal septum, but pulmonary findings are of multiple granulomas
34) In ventilation–perfusion scintigraphy, which of the following is suggestive of an intermediate probability of pulmonary embolism?
a. matched non-segmental defects with a normal chest radiograph
b. multiple unmatched small perfusion defects with normal ventilation
c. large, segmental, matched defect with similar-sized opacity on chest radiograph
d. reverse mismatch
e. two large, unmatched, segmental, perfusion defects
c. large, segmental, matched defect with similar-sized opacity on chest radiograph
With ventilation–perfusion scintigraphy, matched segmental defects are considered low probability.
When there is a similar-sized area of opacification on the chest radiograph, which indicates ‘triple match’, this becomes intermediate probability.
Matched non-segmental defects, reverse mismatch and multiple small perfusion defects are all indicators of low probability.
Two large segmental perfusion defects that are not matched are considered high probability
- A young girl with known sickle cell disease presents with chest pain, fever, leucocytosis and hypoxia. Which of the following statements is most appropriate?
A. Consolidation is found more commonly than groundglass opacification on HRCT
B. Ground-glass change typically has a lobar distribution
C. The lower lobes are more frequently affected in adults
D. Infarction results in linear scarring
E. There is a correlation between severity of a chest crisis and extent of radiological findings
D. Infarction results in linear scarring
HRCT often reveals ground-glass opacification, which does not have a lobar distribution and may have a scattered or mosaic pattern. Adults tend to have lower lobe or multilobar involvement, compared to the upper lobe pattern more often seen in children. Microvascular occlusion causes a reduction in the vascular markings and infarction results in linear scarring
- Which of the following favours Hughes-Stovin syndrome rather than Behçet’s syndrome?
A. Diffuse airspace nodularity
B. Pulmonary consolidation
C. Pulmonary artery aneurysm
D. A lack of oral/genital ulcers
E. Mosaic perfusion on CT
D. A lack of oral/genital ulcers
Hughes-Stovin syndrome, also known as incomplete Behçet’s disease, overlaps in radiologic and histopathologic findings, but there is an absence of oral and genital ulcerations.
48) A 42-year-old female patient presents with dyspnea and pleuritic chest pain. She has previously had pulmonary emboli diagnosed. A CT pulmonary angiogram is performed. Which feature would indicate chronic rather than acute thrombus on the CT?
a. complete occlusion of segmental vessel
b. filling defects centrally with peripheral contrast enhancement
c. peripheral mural filling defect forming acute angle with wall
d. peripheral mural filling defect forming obtuse angle with wall
e. linear atelectasis
d. peripheral mural filling defect forming obtuse angle with wall
The differentiation of acute from chronic thromboembolic disease can be difficult. Secondary changes may be present, such as hypertrophy of the right atrium and ventricle with cardiomegaly as well as pulmonary hypertension. Chronic emboli usually form peripheral flattened defects, forming obtuse angles with the arterial wall. Complete vessel occlusion may be seen in both acute and chronic emboli. The presence of recanalization or collateral formation is also suggestive of chronicity. In addition, calcification of the clot may occur, which also indicates chronicity. Parenchymal abnormalities such as atelectasis and wedgeshaped opacities may be seen in both acute and chronic pulmonary emboli.
2- A 54-year-old woman with a 20 pack per year smoking history presents with worsening chronic dyspnea. CXR shows prominence of the central pulmonary vasculature. Contrast enhanced CT is performed. Which of the following features would not support a diagnosis of pulmonary arterial hypertension?
(a) The patient’s demographics
(b) Mosaic attenuation of the lung parenchyma
(c) Bowing of the interventricular septum convex to the right
(d) Pruning of peripheral pulmonary arteries
(e) Bronchial arteries measuring up to 4 mm in diameter
(c) Bowing of the interventricular septum convex to the right
There are multiple causes of pulmonary arterial hypertension which can broadly be divided into vascular, lung and cardiac causes along with idiopathic PAH. Signs include enlargement of the main PA (greater than 2.9 cm), a PA to corresponding aorta ratio of > 1 and signs of right ventricular strain which would eventually cause bowing of the interventricular system convex to the left
4- A 25-year-old presents with an acute seizure- CT shows a 2-cm ring enhancing lesion in the frontal lobe with surrounding edema- CXR 3 opacities measuring between 1—3 cm in size, projected over the left lower zoneContrast enhanced CT shows these lesions to be round, well defined and containing linear structures radiating away from the lesions- What is the likeliest diagnosis?
(a) Lymphangioeiomyomatosis
(b) Takayasu’s arteritis
(c) Sarcoidosis
(d) Osler-Weber-Renudu syndrome
(e) Wegener’s granulomatosis
(d) Osler-Weber-Renudu syndrome
Also known as hereditary hemorrhagic telangiectasia, it is a group of inherited disorders that result in a number of systemic fibrovascular disorders affecting mucus membranes, skin, brain and lung. “It is associated with the presence of multiple pulmonary arterio-venous fistulae. These can act as a right to left shunt and embolic sequelae in the brain can be the presenting symptom.
22- Regarding CT PA for the investigation of pulmonary emboli. Which of the is not a cause of a false-positive CT PA result?
(a) Hilar lymphadenopathy
(b) Low signal-to-noise ratio
(c) Narrow windowing
(d) Respiratory artefact
(e) SVC obstruction
(c) Narrow windowing
If a technically adequate study is performed CT PA is > 90% sensitive and specific for large, central PEs.
Falsepositive results may occur if there is increased noise (hence reduced SNR), particularly in larger patients or if patients are too unwell to lift their arms above their head.
Others include SVC obstruction (due to partial opacification of the vessels), hyperdynamic circulation, lymphadenopathy, and respiration/ motion (due to partial voluming).
Narrow windowing produces ‘brighter’ contrast thus filling defects may be obscured, resulting in a false negative result. Emboli can be detected within the proximal arteries of 5th/6th generation, sub-segmental emboli are usually undetectable (thus effectively produce a false negative result).
2 A 35 year old Japanese man with a long history of mouth ulceration and a recent diagnosis of posterior uveitis presents to the emergency department with breathlessness. A CTPA is performed which demonstrates bilateral pulmonary emboli. What is the most likely diagnosis?
(a) Sarcoidosis
(b) Systemic Lupus Erythematosus
(c) Behcet’s disease
(d) Polyarteritis nodosa
(e) Amyloidosis
(c) Behcet’s disease
Behcet’s disease is an autoimmune condition that is characterised by oro-genital ulceration and uveitis. There are numerous systemic complications which include vasculitis, arterial and venous thrombosis, pulmonary artery aneurysms and pulmonary haemorrhage
@# 13 Which of the following drugs used in treating patients with haematological malignancy is not associated with pulmonary haemorrhage?
(a) Bleomycin
(b) Cytarabine
(c) Amphotericin B
(d) Rituximab
(e) Cyclophosphamide
(a) Bleomycin
Bleomycin may result in one of two conditions: an organising pneumonia with multiple foci of consolidation or tree-in-bud opacification, or diffuse alveolar damage which gives appearances akin to ARDS.
16 Which of the following CT signs is the most specific for a diagnosis of pulmonary hypertension?
(a) Aorta:pulmonary artery ratio > 1.0
(b) Main pulmonary artery diameter ~ 2.9 cm
(c) Mosaic perfusion pattern
(d) Reflux of contrast into IVC
(e) Segmental artery:bronchus ratio > 1.0 in ~ 3 lobes
(b) Main pulmonary artery diameter ~ 2.9 cm
There is a good correlation between a main PA ~2.9 cm and right heart catheter studies in demonstrating PHT. Some argue that the PA diameter is affected by body habitus, thus the ratio of aorta to main PA is more specific (note this is a PA : aorta ratio > 1 ). Segmental artery: bronchus ratio >1 in 3 of 4 lobes (RUL, RLL, LUL and LLL) has been used by some authors, however, this ratio may exceed 1 in normal individuals and, rarely, a ratio of ~1.25 can be within normal limits. Mosaic perfusion is indicated of small vessel disease which can lead to PHT but is not specific, and reflux of contrast into the IVC is indicative of tricuspid regurgitation which may be secondary to PHT, but is not specific. A combination of 2 or more features greatly increases specificity.
30 A 24 year old lady, 27 weeks pregnant, presents with chest pain and you are contacted for imaging advice. Which of the following is not a risk factor/ indicator of pulmonary embolism?
(a) Raised D-dimer
(b) Gestational diabetes
(c) Thrombophilia
(d) Obesity
(e) Multiparity
(a) Raised D-dimer
In addition, increasing age, prolonged bed rest, familial disposition, previous venous thromboembolism, varicose veins and smoking are all risk factors. D-dimer is often elevated in pregnancy and the test is not indicated-in this situation.
@# 32 Plain radiographic signs seen more commonly in patients with acute pulmonary embolism include all but which of the following?
(a) Cardiomegaly
(b) Decreased vascularity
(c) Pulmonary oedema
(d) Pleural opacity
(e) Atelectasis
(c) Pulmonary oedema
Pulmonary oedema is seen in patients with PE rarely (4% vs 13% in patients without PE). Other signs include pleural effusion.
@# 62 A 72 year old woman with a history of recent surgery presents with shortness of breath and pleuritic chest pain. On examination there is a slight swelling of the right leg compared to the left. The D-dimer level is raised. Which imaging investigation should be performed next?
(a) Chest X-ray
(b) CTPA
(c) Pulmonary angiogram
(d) Ultrasound bilateral lower leg veins
(e) V/Q scan
(a) Chest X-ray
The patient is at high risk for a PE. The CXR is less likely to be diagnostic, but may provide a differential diagnosis in some cases (e.g. spontaneous pneumothorax) and forms an important part of the diagnostic flow chart.
A normal CXR means a V/Q scan would be the next appropriate investigation, abnormal CXR requires CTPA.
The right leg swelling may be post-operative rather than due to a DVT, but regardless, it is important to diagnose a PE over a DVT as most clinicians recommend a longer treatment period for the former.
Pulmonary angiography is invasive and is now rarely used in the context of PE diagnosis.