VIQ - CVS and IR Flashcards
@# 57) A 35-year-old man presents following a chest injury. A chest radiograph shows a smooth, curvilinear, tubular opacity adjacent to the right heart border. No other abnormality is seen. The accident and emergency team are requesting a CT of the chest. What is the most likely diagnosis?
a. pulmonary contusion
b. pneumothorax
c. pericardial injury
d. extralobar sequestration
e. partial anomalous pulmonary venous return
e. partial anomalous pulmonary venous return
The appearances are classic of partial anomalous pulmonary venous return, which occurs in 0.3–0.5% of cases of congenital heart disease and is associated with atrial septal defects and hypogenetic lung.
Contusions are seen as illdefined opacities on CT, often with rib fractures.
Anterior pneumothorax would cause increased conspicuity of the heart border.
Pericardial injury produces a thick, irregular, shaggy, soft-tissue density adjacent to the heart border.
Extralobar sequestration produces a triangular-shaped opacity adjacent to the diaphragm.
@# 18 A 2 day old neonate presents with difficulty in breathing. On examination there are widespread crepitations. The CXR shows florid pulmonary oedema. Which of the following congenital heart anomalies would be the most likely cause of these appearances?
(a) Atrial septal defect
(b) Hypoplastic Left Heart Syndrome
(c) Pulmonary atresia
(d) Tetralogy of Fallot
(e) Ventricular septal defect
(b) Hypoplastic Left Heart Syndrome
The overall incidence of CHD is 1%, the most common are structural defects bicuspid aortic valve and MVP.
The most common types of CHD presenting in the first month of life are: hypoplastic left heart syndrome (35%), TGA (25%), coarctation (20%), multiple defects (15%), pulmonary atresia/stenosis (10%), severe Tetralogy of Fallot’s (10%).
HLHS describes underdevelopment of LA, LV, MV, AV and aorta, survival requires a large ASD and PDA to allow admixing of the left and right circulations.
CXR shows marked pulmonary oedema and right heart enlargement.
HLHS and the ‘5 Ts’ present at 0-2 days, but HLHS is more common and more likely to produce marked CCF.
Coarctation and AS present at 7-14 days; VSD and PDA presents in infancy and ASD in adulthood.
@# Ped) 33 A neonate is cyanosed. A CXR is performed which shows slight cardiac enlargement and oligaemia of the pulmonary vasculature. Which of the following is the most likely diagnosis?
(a) Single ventricle
(b) Total anomalous pulmonary venous connection
(c) Transposition of the great arteries
(d) Tricuspid atresia
(e) Truncus arteriosus
(d) Tricuspid atresia
The list given is that of the ‘5 Ts’ of cyanotic heart disease with increased pulmonary vasculature.
The differential diagnosis for cyanosis and pulmonary oligaemia is tricuspid atresia, Tetralogy of Fallot, Ebstein’s anomaly and pulmonary atresia.
In tricuspid atresia there will only be increased pulmonary flow if there is an associated VSD but no pulmonary stenosis (a frequent association); the majority have reduced pulmonary blood flow.
@#e2 Ped) 27 A father of a two-month-old boy is concerned that his son has been getting progressively blue, which becomes more apparent when he cries. On examination he is cyanosed with a pansystolic murmur. A CXR reveals a moderately enlarged heart. What is the likely diagnosis?
a Tetralogy of Fallot
b Corrected transposition of great arteries
C Pulmonary atresia
d Tricuspid atresia
e Patent ductus arteriosus
27 Answer D: Tricuspid atresia
Tricuspid atresia is the second most common cause of neonatal cyanosis after transposition of the great arteries. It is characterised by an absent tricuspid valve, ASD, and a small VSD. Most occur in the absence of transposition (80%), but it may also occur in the setting of transposition. The heart may be normal in size or moderately enlarged with enlargement and hypertrophy of the left ventricle and enlargement of the right atrium.
@# 15 A patient undergoing echocardiography for an acyanotic shunt had the following findings on imaging: dilated left atrium and ventricle, dilated right ventricle, undilated right atrium and undilated aorta. What is the most likely cause of the shunt?
a Ostium primum atrial septal defect (ASD)
b Ventricular septal defect (VSD)
c Patent foramen ovale
d Ostium secundum ASD
e Patent ductus arteriosus (PDA)
15 Answer B: Ventricular septal defect (VSD)
The following features can differentiate between the position of acyanotic shunts:.
@# Ped) 41 A neonate presents with poor feeding. On examination he is found to be cyanotic, with symptoms of congestive heart failure and a systolic murmur. A CXR shows extreme right atrial enlargement and a hypoplastic aorta and pulmonary trunk. Which of the following is the most likely diagnosis?
a Ebstein’s anomaly
b Eisenmenger’s syndrome
c Transposition of the great arteries
d Patent ductus arteriosus
e Tricuspid atresia
41 Answer A: Ebstein’s anomaly
Ebstein’s anomaly is caused by apical displacement of the posterior and septal tricuspid valve leaflets, leading to part of the right ventricle becoming part of the right atrium.
It is the only cyanotic heart disease to have a hypoplastic aorta and pulmonary trunk.
@# 17 The pre-employment chest radiograph of an asymptomatic 32-year-old female shows mild pulmonary plethora. Subsequent investigation with a CT thorax reveals abnormal venous drainage of the right upper lobe. Where is this lobe most likely to drain?
a Right atrium
b Superior vena cava
C Suprahepatic portion of the inferior vena cava
d Coronary sinus
e Portal vein
17 Answer B: Superior vena cava
Partial anomalous pulmonary venous return (PAPVR) is a congenital abnormality, which can be radiologically mistaken for an anomalous SVC. One or more pulmonary veins drain directly into the right atrium or to a systemic vein.
In decreasing order of frequency, the sites of communications are to the SVC, right atrium and IVC.
This results in an extracardiac left to right shunt. The clinical signs and symptoms are related to the degree of left-to-right shunting. Although an isolated PAPVR from a single lobe is usually asymptomatic, individuals with cardiopulmonary disease may develop symptoms.
@# 32. Causes of oligaemia (decreased pulmonary blood flow) with cyanosis include: (T/F)
(a) Aortic atresia.
(b) Truncus arteriosus.
(c) Transposition of great vessels.
(d) Total anomalous pulmonary venous return.
(e) Tetralogy of Fallot.
Answers:
(a) Not correct
(b) Not correct
(c) Not correct
(d) Not correct
(e) Correct
Explanation:
Aortic atresia, Truncus arteriosus, TGA and TAPVR show plethora with cyanosis.
@#e2 49. Which of the following are correct regarding transposition of the great arteries (TGA)? (T/F)
(a) Pulmonary stenosis is an associated feature.
(b) In the D loop of TGA the atria and ventricles have a normal morphological relationship.
(c) Dextrocardia is associated with L loop of TGA.
(d) Chest radiograph shows pulmonary plethora in D loop of TGA.
(e) In the L loop (corrected) transposition there is physiologically corrected circulation.
Answers:
(a) Correct
(b) Correct
(c) Correct
(d) Correct
(e) Correct
Explanation:
In the D loop of TGA the aorta arises from the right ventricle and the pulmonary artery from the left ventricle.
A normal relationship exists between the atria and the ventricles.
In the L loop of TGA, there is transposition of the aorta and pulmonary arteries in addition to inversion of the left and right ventricles.
The atria and coronary arteries are associated with their corresponding ventricles.
@# 50. Regarding total anomalous pulmonary venous drainage (TAPVD), which of following are correct? (T/F)
(a) The supracardiac type is the most common.
(b) The left atrium is not enlarged.
(c) The infracardiac type may drain into hepatic veins.
(d) There is an association with Scimitar syndrome.
(e) Pulmonary oedema in presence of normal sized heart is a feature of Cardiac type TAPVD.
Answers:
(a) Correct
(b) Correct
(c) Correct
(d) Not correct
(e) Not correct
Explanation:
Scimitar syndrome is the association of hypogenetic lung with congenital pulmonary venolobar syndrome where all or part of hypogenetic lung is drained via an anomalous vein into the subdiaphragmatic IVC, hepatic veins, portal vein or coronary sinus.
Pulmonary oedema is a characteristic feature of infracardiac type TAPVD.
@# 6. With regards to imaging techniques in the detection of hibernating myocardium, which has the greatest specificity?
A. 2-[18F]-fluoro-2-deoxy-d-glucose positron-emission tomography
B. Thallium-201 rest-redistribution
C. Technetium-99m perfusion imaging
D. Dobutamine stress echocardiography
E. Dobutamine stress magnetic resonance imaging
E. Dobutamine stress magnetic resonance imaging
stress MRI is a well-validated method for the assessment of myocardial hibernation (using a low dose protocol) and ischaemia (using a high-dose protocol). MRI provides superior spatial resolution when compared with echocardiography, and improvement in resting wall motion abnormality is considered a sign of myocardial hibernation.
@# 19. A small pericardial metastatic deposit on the Magnetic Resonance Imaging (MRI) of a 55-year-old female demonstrates high-signal intensity on T1-weighted images. Which of the following is the most likely primary tumour?
A. Breast
B. Renal cell carcinoma
C. Colorectal
D. Melanoma
E. Lymphoma
D. Melanoma
Pericardial effusion, thickening or mass may indicate metastatic involvement of the pericardium.
Most neoplasms have a low-signal intensity on T1-weighted images and a high signal intensity on T2-weighted images, with the exception of metastatic melanoma.
The most common tumors to metastasize to the pericardium are breast and lung, followed by lymphomas and melanomas.
@# 28. A 65-year-old woman presents with palpitations and a heart murmur. Which of the following features are more in keeping with an atrial myxoma rather than thrombus as demonstrated on CT?
A. Prolapse through the mitral valve on CT
B. The presence of calcification
C. The low attenuation of the lesion
D. A lack of enhancement
E. A smooth surface of the lesion
A. Prolapse through the mitral valve on CT
On CT, prolapse through the mitral valve orifice is the only reliable discriminatory finding indicating myxoma. There is overlap in the features of calcification, mobility, attenuation characteristics, and location between myxoma and thrombus.
@# 7- A 32-year-old male patient has a routine CXR for insurance purposes. The film is well centered, the right heart border is indistinct and appears rotated. The lung parenchyma and vasculature appear normal. What is the most likely cause?
(a) Absent left pericardium
(b) Pectus excavatum
(c) Poor patient positioning
(d) Pulmonary artery enlargement
(e) Situs solitus
(a) Absent left pericardium
Congenital absence of the pericardium may be partial (91%) or total (9%).
Large defects can cause strangulation and have the appearance of the large cardiac silhouette seen in pericardial effusions,
small defects are usually asymptomatic.
Partial defects are more common on the left (complete left-sided absence 35%, foraminal defect left side 35%).
In complete left-sided absence, the heart is shifted to the left and rotated, the PA view of the heart mimics an RAO view and the heart is separated from the sternum on the lateral view.
In foraminal left-sided defects, there may only be prominence of the left atrial appendage (appears as left hilar mass, may mimic left PA enlargement). They are associated with bronchogenic cysts (30%), VSD, PDAs, CDHs and mitral stenosis.
@# 25. A 54 year old man presents with breathlessness and palpitations. Clinical examination reveals a mid-diastolic murmur with presystolic accentuation. Echocardiography confirms the presence of a mobile intracardiac mass in the left atrium attached to the septum by means of a stalk. Which of the following is the most likely feature of the lesion on MRI?
a. Hypointense relative to myocardium on T1-weighted images
b. Uniform hyperintense to myocardium on T2-weighted images
c. Uniform enhancement following gadolinium
d. Hyperintense to blood pool and hypointense to myocardium on steady-state free precession (SSFP) images
e. Prolapse of the mass through the mitral valve, best demonstrated on the short axis views
- a. Hypointense relative to myocardium on T1-weighted images
The lesion described is a left atrial myxoma which has a heterogenous appearance on most MRI sequences
and usually demonstrates varying enhancement following gadolinium injection. This is due to varying amounts of myxomatous tissue, fibrous tissue, blood products and tumour necrosis.
The majority of the lesion will be hypointense to myocardium on T1-weighted images.
On SSFP images, it is hypointense to blood pool and hyperintense to myocardium.
The tumour prolapses through the mitral valve and is best seen on cinegradient echo imaging with a four-chambered long axis view
@# 36. In the same patient (with cardiomyopathy), which underlying cause and corresponding enhancement pattern are inappropriate?
a. Ischaemic cardiomyopathy – subendocardial pattern in a coronary artery territory
b. Early myocarditis – patchy, focal subendocardial pattern
c. Hypertrophic cardiomyopathy – patchy multifocal changes, commonly the right ventricular free wall and its junction with the interventricular septum
d. Amyloidosis – global and diffuse, commonly subendocardial
e. Dilated cardiomyopathy – midwall myocardial enhancement
- b. Early myocarditis – patchy, focal subendocardial pattern
In early myocarditis, the enhancement pattern is typically epicardial.
@# 73. A 28-year-old patient is admitted from the dermatology clinic where she is being treated for basal cell carcinoma. She suffered an episode of ventricular tachycardia and imaging is requested secondary to the results of echocardiography. CXR reveals bifid ribs. Cardiac MRI reveals a well circumscribed abnormality, which is low signal on both T1WI and T2WI and shows delayed enhancement, within the myocardium of the left ventricular free wall. CT reveals a soft-tissue attenuation mass with calcification. What is the most likely diagnosis?
A. Myxoma.
B. Paraganglioma.
C. Fibroma.
D. Fibroelastoma.
E. Lipoma.
- C. Fibroma.
This patient has Gorlin’s syndrome (nevoid basal cell carcinoma syndrome, NBCCS).
This may result in abnormalities of the skin (basal cell carcinoma), skeletal (jaw odontogenic keratocysts, bifid, fused, or markedly splayed ribs), and genitourinary (ovarian fibromas) systems, as well as cardiac fibroma (relatively rare) and calcification of the falx. Medulloblastoma is a relatively less common manifestation.
The imaging characteristics of cardiac fibromas reflect their fibrous nature: low signal on T1WI and T2WI with delayed enhancement on MRI.
Most are well circumscribed with a surrounding rim of compressed myocardium.
On CT they manifest as mildly enhancing soft tissue attenuation masses.
Foci of calcification are present in up to 50% of cases.
Although benign they may cause ventricular arrhythmias and even sudden death secondary to interference with conduction pathways.
Atrial myxomas are of mixed signal on T1WI and T2WI sequences. They are most commonly found within the left atrium (80%), with 15% in the right atrium. On CT a low attenuation intracavitary mass with a smooth or slightly villous surface is seen.
Cardiac paragangliomas are well encapsulated, hypervascular (intensely enhancing), and 3–8cm in size. They are isointense to myocardium on T1WI and markedly hyperintense on T2WI. Presentation is with symptoms of catecholamine excess. They are found in the posterior wall of the left atrium, atrioventricular groove, and root of the great vessels.
Fibroelastomas arise from endocardial surfaces, most commonly the aortic and mitral valves. They are a recognized cause of sudden death and immediate resection is warranted. Trans-oesophageal echocardiography is the optimal means of visualization due to their small size and highly mobile nature.
Cardiac lipomas have characteristic imaging features consistent with fat on MRI and CT.
@# 8 A 25-year-old male was referred for a routine testicular screening ultrasound. He is known to have a cardiac myxoma and has multiple pigmented lesions on his face and lips. What is the most likely unifying diagnosis?
a Carney’s syndrome
b Peutz Jeghers syndrome
c Waardenburg’s syndrome
d Cronkhite-Canada syndrome
e Gorlin’s syndrome
8 Answer A: Carney’s Syndrome
Carney’s Syndrome or Complex refers to a familial neoplastic lentiginous syndrome consisting of the following:
primary pigmented nodular adrenocortical disease,
lentigines,
ephelides,
blue nevi of the skin and mucosa,
various tumours (including myxomas of the skin, heart and breast)
and Sertoli-cells tumours of the testes.