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Cardiothoracic and vascular Flashcards

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1
Q
  1. A 50 year old male presents with a history of occasional haemoptysis and exertional
    shortness of breath which has been getting progressively worse. Plain chest radiograph
    demonstrates bibasal reticular shadowing with volume loss. HRCT demonstrates bibasal
    fibrosis and traction bronchiectasis. Incidental note is made of a patulous oesophagus.
    Which of the following is the most likely cause?
    a. Tuberculosis
    b. SLE
    c. Rheumatoid arthritis
    d. Wegener’s granulomatosis
    e. Scleroderma
A
  1. e. Scleroderma
    Whilst haemoptysis may be a presentation in tuberculosis and Wegener’s and bibasal
    fibrosis maybe seen in all of the above except tuberculosis (where apical fibrosis is the
    more likely feature), scleroderma is the only condition resulting in a patulous lower
    oesophageal sphincter, oesophageal shortening and stricture formation.
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2
Q
  1. A 35 year old woman presents with chest infection and pyrexia and the plain film reveals
    dense lobar consolidation with bulging fissures. The likely micro-organism is:
    a. Legionella pneumophila
    b. Pneumocystis carinii
    c. Staphylococcus
    d. Streptococcus
    e. Klebsiella
A
  1. e. Klebsiella
    Klebsiella causes a dense pneumonia with bulging of fissures often associated with an
    empyema. Pneumococcal pneumonitis can also mimic this.
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3
Q
  1. A 40 year old has a routine chest radiograph as a part of pre-immigration work up. This
    demonstrates a mass on the left with loss of the upper left heart border. The descending
    aorta can, however, be seen despite the mass. Which of the following is the most likely
    location of the mass?
    a. Apico-posterior segment
    b. Lingula
    c. Anterior segment of the upper lobe
    d. Posterior basal segment of the lower lobe
    e. Lateral basal segment of the lower lobe
A
  1. b. Lingula
    This is an example of the silhouette sign where an anteriorly located lingular mass results
    in loss of the upper left heart border but preservation of the outline of the posterior
    descending aorta.
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4
Q
  1. In an investigation for lung malignancy, all of the following may produce a false positive
    result on a PET-CT except:
    a. Pulmonary hamartoma
    b. Intralobar sequestration
    c. Tuberculosis
    d. Pneumonia
    e. Scarring
A
  1. b. Intralobar sequestration
    Active tuberculosis, consolidation, atypical pulmonary hamartomas and scars may cause
    false positive results. Uncomplicated sequestration will not demonstrate FDG uptake.
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5
Q
  1. A 70 year old man, previously working in a ship-building yard, presents with progressive
    breathlessness. Chest radiograph demonstrates bilateral calcified pleural plaque disease with volume loss. Lung function shows a restrictive pattern. HRCT reveals pulmonary fibrosis. The most likely site of these changes would be:
    a. Perihilar
    b. Apical
    c. Peribronchial
    d. Subpleural
    e. Fissural
A
  1. d. Subpleural
    Pulmonary fibrosis associated with asbestos exposure is seen mainly in a subpleural
    distribution towards the lung bases.
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6
Q
  1. A 35 year old man undergoes autologous bone marrow transplantation following
    successful treatment of lymphoma. Two weeks later he develops scattered bilateral
    progressive breathlessness and dry cough. HRCT demonstrates several areas of bilateral
    ground glass changes with associated reticular changes, but no effusions. What is the
    most likely explanation?
    a. Angioinvasive aspergillosis
    b. Lymphoid interstitial pneumonia
    c. CMV pneumonia
    d. Drug toxicity
    e. Pulmonary oedema
A
  1. d. Drug toxicity
    Post transplant pulmonary complications may develop in up to 40–60% of patients. In the
    first two weeks or so after transplantation, neutropaenia is the underlying cause for most of
    these. Angioinvasive aspergillosis presents in the first two to three weeks, usually as multiple
    ground glass nodules with or without cavitation and peribronchiolar consolidation.
    Lymphoid interstitial pneumonia (LIP) is a late-phase complication usually seen more than
    three months after transplantation and may be an indication of chronic graft-versus-host
    response. CMV pneumonia may manifest at any time in the first 100 days after transplantation
    Multiple nodules with associated ground glass changes or consolidation are usually seen, but
    reticular change is not a feature. Pulmonary oedema is also seen in the neutropaenic phase in
    the first two to three weeks. Whilst ground glass changes and interstitial lines are seen in
    pulmonary oedema, associated pleural effusion is common.
    Drug toxicity due to a variety of chemotherapeutic agents is seen in the neutropaenic
    phase as a combination of ground glass and reticular changes.
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7
Q
  1. A 67 year old man presents with abdominal discomfort three months after endovascular
    repair of an abdominal aortic aneurysm. The patient undergoes a non-contrast CT
    followed by an arterial phase study. There is high attenuation on the non-contrast study
    between the stent and the aortic wall, which enhances further in the arterial phase. The
    graft itself is intact, as are the attachment sites. Which of the following is the most likely
    cause for the appearance?
    a. Type I endoleak
    b. Type II endoleak
    c. Type III endoleak
    d. Graft infection
    e. Dissection
A
  1. b. Type II endoleak
    Type II endoleaks are due to retrograde flow from the small branches of the aorta such as
    the lumbar arteries. A Type I endoleak is due to a seal failure at either end, type III is due to
    a defect in the graft and type IV is due to graft porosity.
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8
Q
  1. A 16 year old with headache and hypertension has a chest radiograph which demonstrates
    plain radiographic signs of coarctation of the aorta. Further investigations reveal
    anomalous post-coarctation origin of the right subclavian artery. The ribs most likely to
    demonstrate inferior rib notching would be:
    a. Left third to ninth ribs
    b. Bilateral third to ninth ribs
    c. Right third to ninth ribs
    d. Bilateral first and second ribs
    e. Left first and second ribs
A
  1. a. Left third to ninth ribs
    Due to the anomalous origin of the right subclavian artery from the post-coarctation
    segment, there is no collateral flow to the intercostal arteries on the right. Subsequently,
    there is no right-sided rib notching.
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9
Q
  1. A 38 year old man with progressive dyspnoea and chest pain undergoes an echocardiogram
    which reveals a pedunculated intracardiac mass which is hypointense to myocardium on
    T1-weighted images and markedly hyperintense on T2-weighted images. The most likely
    intracardiac location of the lesion would be:
    a. Right atrium
    b. Right ventricle
    c. Left atrium
    d. Under-surface of tricuspid valve
    e. Anterior papillary muscle
A
  1. c. Left atrium
    The case describes an atrial myxoma, which is more common in the left atrium (75–80%
    of cases). These tumours are usually attached to the inter-atrium septum.
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10
Q
  1. A 56 year old female is found to have a small, well-defined anterior mediastinal mass on
    a chest radiograph which demonstrates homogeneous soft-tissue density with some
    peripheral calcification on CT. On MRI it is isointense to skeletal muscle on T1-weighted
    images and slightly increased signal on T2-weighted images. It is most likely to be:
    a. Thymic cyst
    b. Thymoma
    c. Thymolipoma
    d. Thymic hyperplasia
    e. Thymic carcinoma
A
  1. b. Thymoma
    This case describes the typical features of a thymoma. Thymic hyperplasia and thymic
    carcinoma are usually ill-defined abnormalities. The signal from the lesion is not typical for
    a thymic cyst or thymolipoma.
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11
Q
  1. A 51 year old man with long standing history of an erosive arthropathy of the acromioclavicular
    joints and bilateral arthropathy in his hands subsequently develops progressive
    shortness of breath. The most likely abnormality on his chest radiograph would be:
    a. Cavitating nodules
    b. Peripheral basal reticulonodular shadowing
    c. Cardiomegaly
    d. Bronchiectasis
    e. Pleural effusion
A
  1. e. Pleural effusion
    Pleural effusion is the commonest thoracic manifestation of rheumatoid arthritis, much
    more common in men (M:F¼9:1). It is unilateral in the vast majority of cases. The fluid is
    an exudate with low sugar content and is often seen in the absence of other pulmonary
    changes.
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12
Q
  1. A 22 year old is diagnosed with tuberculosis. Which of the following features will make
    a diagnosis of primary tuberculosis more likely?
    a. Mediastinal enlargement
    b. Septal thickening
    c. Upper zone cavitation
    d. Miliary nodules
    e. Apical consolidation
A
  1. a. Mediastinal enlargement
    Mediastinal lymph node enlargement is a feature of primary TB. The others are seen with
    reactivation or fibrocavitary TB. Miliary TB can be seen in any phase with haematogenous
    dissemination but primary presentation is uncommon
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13
Q
  1. A 26 year old man suffers a blunt injury to his chest in a road traffic accident. The most
    common abnormality seen on CT as a result of blunt thoracic injury is:
    a. Pneumothorax
    b. Pulmonary laceration
    c. Haemothorax
    d. Tracheo-bronchial injuries
    e. Pulmonary contusion
A
  1. e. Pulmonary contusion
    Pulmonary contusion is the commonest manifestation of blunt trauma and indicates
    trauma to alveoli with alveolar haemorrhage without significant alveolar disruption. Whilst plain film changes may not be apparent for up to six hours, CT will demonstrate changes
    almost immediately post-trauma and signs of resolution can be seen as early as 48 hours.
    If unresolved, it may progress to ARDS.
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14
Q
  1. A 26 year old undergoes a routine chest radiograph as part of the Australian residency
    application. The left upper lobe is hyperlucent and hyperexpanded and a lobular mass
    is demonstrated adjacent to the left hilum. CT reveals the presence of a dilated
    bronchus containing a plug of soft tissue. The surrounding lung is emphysematous.
    The most likely diagnosis is:
    a. Central carcinoid tumour
    b. Bronchogenic cyst
    c. Bronchial atresia
    d. Cystic adenomatoid malformation
    e. Congenital lobar emphysema
A
  1. c. Bronchial atresia
    The case describes bronchial atresia with mucoid impaction. Bronchial atresia is a congenital
    abnormality that is usually discovered incidentally. It results in local obliteration of the
    proximal lumen of a segmental bronchus. The apicoposterior segment of the left upper lobe
    is most commonly affected. Airways distal to the atretic segment continue to produce
    mucous which can lead to mucoid impaction/mucocoele. The airways distal to the atretic
    segment also develop normally and are ventilated by collateral air shift. This results in the
    affected lobe appearing hyperexpanded, oligaemic and hyperlucent.
    Congenital lobar emphysema can look similar, however there is usually no mucous plug
    and patients tend to present early.
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15
Q
  1. A 58 year old man with pancreatic cancer presents with recurrent pulmonary emboli
    despite adequate anticoagulation. He is shown on this admission to also have a right
    femoral DVT. He subsequently undergoes an IVC filter placement. Following a flush injection in the IVC, injecting contrast at which of the following site is essential prior
    to stent placement?
    a. Right hepatic vein
    b. Left renal vein
    c. Right common iliac vein
    d. Right renal vein
    e. Left common iliac vein
A
  1. e. Left common iliac vein
    The presence of the renal veins will be demonstrated on the flush IVC injection, and
    selective injection into the renal veins is not usually necessary. However, it is mandatory
    to exclude a double IVC. A second IVC originates from the left iliac vein and can be a cause
    for failure of the filter despite good positioning.
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16
Q
  1. A 40 year old man presents with worsening breathlessness, fever and chills following a
    visit to an aviary earlier in the day. HRCT is most likely to demonstrate:
    a. Mid-zone interstitial lines
    b. Areas of air-space shadowing
    c. Pleural effusions
    d. Lymphadenopathy
    e. Crazy paving
A
  1. b. Areas of air-space shadowing
    Acute extrinsic allergic alveolitis is predominantly a type III hypersensitivity reaction. There
    is poor correlation between the clinical presentation and the radiological changes. Lymphadenopathy
    is unusual in the acute phase, but is seen more commonly in recurrent disease.
    The early changes are mainly in the mid zones, but the fibrosis that develops in chronic
    extrinsic allergic alveolitis is mainly in the upper zones. In the acute phase, diffuse air-space
    shadowing or multiple opacities are seen.
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17
Q
  1. The staging chest CT of a 40 year old man with a known primary malignancy demonstrates
    cavitating pulmonary metastases. The least likely type of primary lesion would be:
    a. Squamous cell carcinoma
    b. Malignant melanoma
    c. Renal cell cancer
    d. Sarcomas
    e. Colonic carcinoma
A
  1. c. Renal cell cancer
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18
Q
  1. A 25 year old woman with a longstanding history of non-erosive arthritis of the hands
    and a malar rash presents with progressive breathlessness and respiratory dysfunction.
    Blood serology demonstrates anti-DNA antibodies. Which of the following is the most
    common feature on the chest radiograph?
    a. Pleural effusion
    b. Consolidation
    c. Cavitating nodules
    d. Pulmonary oedema
    e. Pulmonary fibrosis
A
  1. a. Pleural effusion
    Whilst all the above are seen in SLE, pleural effusions are the commonest radiographic
    abnormality.
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19
Q
  1. A 40 year old man with a known malignancy presents with pericardial metastases and
    pericardial effusion. The metastatic deposits are high signal on T1-weighted imaging.
    Which is the likely primary diagnosis?
    a. Lymphoma
    b. Lung cancer
    c. Melanoma
    d. Fibrosarcoma
    e. Colorectal cancer
A
  1. c. Melanoma
    Whilst most metastases are low on T1-weighted and high on T2-weighted imaging,
    metastases from melanoma have a high signal on T1-weighted imaging due to the paramagnetic
    effects of melanin.
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20
Q
  1. The diagnostic role of CT in patients with pulmonary emboli is well established, but a
    prognostic role is being proposed as well. Which of the following has the most widely
    accepted prognostic value?
    a. PA clot burden score
    b. Leftward bowing of the intraventricular septum
    c. Reflux of contrast into the IVC
    d. RV/LV diameter ratio
    e. PA diameter measurement
A
  1. d. RV/LV diameter ratio
    (Ref: Ghaye B et al. Can CT pulmonary angiography allow assessment of severity and
    prognosis in patients presenting with pulmonary embolism? What the radiologist needs to
    know.
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21
Q
  1. A 55 year old man has a repeat chest radiograph which demonstrates a persistent patch
    of consolidation four months after a previous radiograph. Bronchioloalveolar carcinoma
    (BAC) is suspected. Which of the following makes the diagnosis less likely?
    a. Low attenuation consolidation
    b. Negative PET-CT
    c. Central location
    d. Long history of smoking
    e. Associated cavitation
A
  1. c. Central location
    BAC can present in a local form as a mass, usually peripheral, subpleural in location or as
    diffuse persistent/progressive consolidation in patients with a history of smoking. The area
    of consolidation is often of low attenuation on CT due to copious mucin production. It is
    the second most common type of malignancy associated with cavitation.
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22
Q
  1. A 62 year old man presents with right shoulder pain which radiates down his arm.A plain
    radiograph confirms the presence of a right apical mass with destruction of the surrounding
    ribs. CT-guided biopsy is performed and is likely to reveal:
    a. Large cell lung cancer
    b. Squamous cell cancer
    c. Small cell lung cancer
    d. Adenocarcinoma
    e. Carcinoid
A
  1. b. Squamous cell cancer
    The case describes a Pancoast tumour for which squamous is the most common cell type
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23
Q
  1. A 25 year old man has a routine chest radiograph prior to a work permit application.
    It demonstrates a well-defined, rounded mediastinal mass. Which of the following
    features on CT would make a diagnosis of bronchogenic cyst less likely?
    a. Soft-tissue density
    b. Thick wall
    c. Precarinal location
    d. Communication with tracheal lumen
    e. Unilocularity
A
  1. b. Thick wall
    Bronchogenic cyst is the most common intrathoracic foregut duplication cyst. It could
    have all the above features, but in a mediastinal location, the cyst walls are usually thin.
    Thick-walled cysts are more likely to be oesophageal.
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24
Q
  1. A 45 year old man presents with a history of cough and occasional haemoptysis. Plain
    chest radiograph demonstrates a right paracardiac shadow with loss of the right heart
    border. Bronchoscopy demonstrates an endoluminal obstructive mass. The most likely
    site of the lesion would be:
    a. Right upper lobe anterior segmental bronchus
    b. Right lower lobe lateral basal segmental bronchus
    c. Bronchus intermedius
    d. Right upper lobe posterior segmental bronchus
    e. Right middle lobe bronchus
A
  1. e. Right middle lobe bronchus
    The features described are of an endoluminal lesion causing right middle lobe collapse.
    A lesion in the bronchus intermedius is likely to cause both middle and lower lobe collapse.
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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
25. 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.
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26. A 34 year old IV drug abuser presents with fever, rigors and back pain. Blood cultures reveal staphylococcal septicaemia. CT demonstrates a mycotic aneurysm. Which of the following is the most likely CT feature? a. Fusiform shape b. Perianeurysmal soft-tissue mass c. Pseudoaneurysm d. Periaortic gas collection e. Mural thrombus
26. b. Perianeurysmal soft-tissue mass Mycotic aneurysms are usually saccular true aneurysms. Periaortic soft-tissue mass is a common feature seen in up to 48% of cases. Periaortic gas is an uncommon feature. Mural thrombus and calcification are rare features. (Ref: Lee WK et al. Infected (mycotic) aneurysms: spectrum of imaging appearances and management.
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27. An area of abnormality is noted within the juxtahepatic IVC of a patient with cirrhosis undergoing an MR scan. The area is hyperintense on T1-weighted imaging, and appears as a filling defect on three-dimensional fat-suppressed volume-interpolated breathhold sequence. Appearances vary in shape and location on different images. The abnormality is likely to represent: a. Flowing blood b. Thrombus c. Tumour thrombus d. Artefact due to aortic pulsation e. Pseudolipoma
27. e. Pseudolipoma The described feature is a partial volume artefact called pseudolipoma caused by juxtacaval fat above the caudate lobe. It has an association with cirrhosis of liver.
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28. A 60 year old female underwent a right pneumonectomy for bronchogenic carcinoma. Which feature on plain chest radiographwould be a cause ofworry seven days after surgery? a. A sequential increase in the fluid level b. Shift of the previously central trachea to the right c. Shift of the previously central trachea to the left d. Elevation of the right hemi-diaphragm e. Shift of the cardiac silhouette to the right
28. c. Shift of the previously central trachea to the left All the other changes are expected changes at this stage following a pneumonectomy. However, contralateral shift of the trachea may be indicative of a post-surgical bronchopleural fistula.
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29. A 22 year old asthmatic presents with recurrent wheeze and productive cough with expectoration of brown sputum. Plain chest radiograph demonstrates multiple pulmonary infiltrates. Which of the following appearances on HRCT would be the most appropriate for acute allergic bronchopulmonary aspergillosis? a. Finger-in-glove opacity b. Thick-walled cavity c. Pleural thickening with or without an effusion d. Endobronchial mass with distal atelectasis e. Tree-in-bud appearance
29. a. Finger-in-glove opacity Acute allergic bronchopulmonary aspergillosis is seen as homogeneous, tubular, finger-inglove areas of increased opacity in a bronchial distribution, usually involving the upper lobes. These shadows are related to plugging of airways by hyphal masses with distal mucoid impaction and can migrate from one region to another on HRCT. Thick-walled cavities and pleural thickening are features of saprophytic aspergillosis. Endobronchial lesion with distal atelectasis is seen mainly in chronic necrotising aspergillosis, whilst tree-in-bud appearance is seen with bronchiolitis in airway invasive aspergillosis.
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30. A 36 year old female with history of pelvic pain and severe dysmenorrhoea undergoes a pelvic ultrasound examination which reveals uterine fibroid disease. Which of the following imaging features would be associated with the best outcome following uterine artery embolisation? a. Submucosal location b. Subserosal location c. Associated adenomyosis d. Calcification e. Multiple fibroids
30. a. Submucosal location Subserosal fibroids, especially pedunculated ones, may often draw their blood supply from adjacent viscera, which may be a cause of failure of the procedure. They are also associated with a higher incidence of complications. Calcific fibroids are less vascular and may not respond well to embolisation. Bulky and multiple fibroids may need multiple interventions or surgery. Adenomyosis is a known cause for failure of the procedure.
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31. A young man presents with progressive productive cough and halitosis. He had severe pneumonia as a child. Plain chest radiograph demonstrates bronchial dilatation and bronchial wall thickening with some volume loss. Which of the following HRCT findings is the most sensitive finding for bronchiectasis? a. Air trapping b. Mucous-filled dilated bronchi c. Bronchial wall thickening d. Bronchi seen in the subpleural region e. Lack of bronchial tapering
31. e. Lack of bronchial tapering Whilst all the above can be seen in patients with bronchiectasis, a lack of progressive tapering of the bronchi is the most sensitive (80%).
32
32. A 35 year old female presents with generalised malaise and cough, occasionally bringing up grape-skin-like material. Blood screen reveals eosinophilia. The patient has a history of travel to several countries worldwide. Which of the following plain film features is unlikely? a. Homogenous ovoid opacity b. Cyst with a fluid level c. Bilateral opacities d. Calcification e. Lower zone location
32. d. Calcification The case describes hydatid disease. Hydatid cyst of the lungs can present as solid ovoid solitary or occasionally multiple lesions on plain films. When the cyst communicates with a bronchial tree, an air fluid level is demonstrated. Several other signs are described. Whilst bilaterality is less likely (up to 20%), calcification is extremely rare (0.7%).
33
33. A 33 year old male patient suffering from AIDS presents with constitutional symptoms and dry cough. His CD4 count is 150. HRCT is least likely to show: a. Pleural effusion b. Ground glass changes c. Bilateral interstitial infiltrates d. Diffuse alveolar infiltrates e. Pneumatocoeles
33. a. Pleural effusion Pneumocystis carinii is the most common cause of pneumonia at this stage of the disease. Pleural effusions and lymphadenopathy are not features of PCP.
34
34. A 26 year old female patient with an optic nerve tumour and café-au-lait spots presents with exertional breathlessness. Imaging of the chest is most likely to reveal which of the following? a. Multiple small lower lobe cysts b. Emphysema c. Lower zone fibrosis d. Thick-walled cavities in the upper zone e. Asymmetrical upper zone fibrosis
34. c. Lower zone fibrosis The case describes neurofibromatosis I, which is associated with lower zone fibrosis and thin-walled bullae, mainly in the upper zones. Apart from the pulmonary changes, skeletal abnormalities involving the ribs and spine and mediastinal masses may also be seen.
35
35. A 52 year old with cardiomyopathy is referred for delayed contrast-enhanced cardiovascular MR (DE-CMR). The following are all false except: a. An inversion recovery pulse of an appropriate TI is applied to nullify the signal from the ischaemic myocardium b. A long TI would nullify the signal from both the normal and diseased tissue c. A TI of 200 ms would nullify the signal intensity from the normal myocardium d. Imaging should be commenced immediately after contrast injection e. The images are T1-weighted ECG-gated fast spin-echo sequences with an inversion recovery sequence
35. c. A TI of 200 ms would nullify the signal intensity from the normal myocardium After an initial LV function study, gadolinium is administered and imaging is commenced 100 minutes later in the same spatial location as the preceding LV study. Inversion recovery pulse is used to nullify the signal from the normal myocardium with a TI of approximately 200 ms. The healthy myocardium appears dark, whilst the ischaemic myocardium appears bright. Too short a TI results in loss of signal from both abnormal and normal myocardium, whilst too long a TI would result in loss of contrast. The images are T1-weighted ECG-gated fast gradient echo images.
36
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
36. b. Early myocarditis – patchy, focal subendocardial pattern In early myocarditis, the enhancement pattern is typically epicardial
37
37. A 30 year old man has a routine chest radiograph which reveals a small soft-tissue shadow resulting in loss of part of the mid-descending aortic outline. Which of the following is the most likely cause? a. Thymoma in the left lobe of thymus b. Hilar lymphadenopathy c. Lingular collapse d. Intercostal schwannoma e. Teratoma
37. d. Intercostal schwannoma The description is of a posterior mediastinal lesion obscuring part of the descending thoracic aorta. The other lesions are anterior mediastinal apart from hilar lymphadenopathy, which is hilar/middle mediastinal.
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38. A 68 year old miner develops an irregular opacity in the upper zone on plain chest radiograph. Which imaging feature would be more in favour of malignancy than progressive massive fibrosis (PMF)? a. Peripheral enhancement on contrast-enhanced MR b. Peripheral location on axial images c. Presence of calcification d. High signal on T2-weighted images e. Avid lesion on PET-CT
38. d. High signal on T2-weighted images PMF has a peripheral location which moves towards the hilum on follow-up imaging. Calcification and cavitation may also be seen. PMF lesions can be FDG-avid on PET-CT. However, high signal in a mass on T2-weighted images is strongly suspicious for malignancy.
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39. A 36 year old asthmatic attends an outpatient respiratory clinic complaining of recent increasing dyspnoea. Bloods show an elevated white cell count and eosinophilia. Chest radiograph reveals multiple areas of ill-defined peripherally based consolidation. Subsequent chest radiographs over the coming week show the consolidation to resolve in places but commence in other previously unaffected areas. The most likely cause is: a. Alveolar sarcoidosis b. Bronchioalveolar carcinoma c. Acute eosinophilic pneumonia d. Chronic eosinophilic pneumonia e. Loffler syndrome
39. e. Loffler syndrome This is described as simple eosinophilic pneumonia but is of unknown aetiology. Pathologically, there is interstitial and alveolar oedema. Patients are usually asthmatic/atopic but have mild or no symptoms. Classical chest radiograph appearance is of fleeting infiltrates with transient and shifting peripheral consolidation
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40. The plain chest radiograph of a 52 year old male presenting with cough and haemoptysis reveals a veil-like opacity over the left upper zone. CT reveals an endobronchial lesion in the left upper lobe bronchus causing lobar collapse. Bronchoscopic biopsy is least likely to reveal: a. Squamous cell carcinoma b. Carcinoid c. Lymphoma d. Metastatic renal cell cancer e. Bronchioloalveolar carcinoma
40. e. Bronchioloalveolar carcinoma BAC usually presents as a peripheral, subpleural mass or persistent patch of consolidation. All the others can present as endobronchial lesions
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41. A 60 year old man who recently suffered a haemorrhagic stroke develops pulmonary emboli. He is referred for an IVC filter insertion and angiography is performed prior to this. The usual reasons for doing so would be all of the following except: a. To identify the renal veins b. To identify the hepatic veins c. To size the IVC d. To rule out the presence of a left IVC e. To evaluate for the presence of an IVC thrombus
41. b. To identify the hepatic veins The hepatic veins do not need to be identified routinely prior to filter insertion. Most filters are deployed in an infrarenal position, unless there is IVC thrombus which would preclude this, in which case the filter is positioned in the suprarenal position. A left iliac injection is performed to rule out a left IVC, which could be a cause of filter failure.
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42. A 22 year old female patient with a known phakomatosis presents with anaemia and hypotension. CT angiogram reveals evidence of active bleeding in some of the multiple areas of low attenuation (approximately –20) seen scattered throughout both her kidneys. Which of the following features may be seen on chest CT? a. Multiple pulmonary AVMs b. Multiple bilateral small cysts c. Mediastinal mass d. Thin-walled upper zone bullae e. Cardiac rhabdomyomas
42. b. Multiple bilateral small cysts Phakomatoses are a group of neurocutaneous syndromes, several of which have other multi-system abnormalities, including intrathoracic findings. These include neurofibromatosis I and II, Sturge–Weber syndrome, von Hippel Lindau syndrome, Osler–Rendu–Weber syndrome and tuberous sclerosis. The above features describe multiple renal angiomyolipomas, which are a feature of tuberous sclerosis. These patients may demonstrate multiple thin-walled cysts with lower zone fibrosis (forme fruste of LAM).
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43. A 33 year old female patient presents with a longstanding history of fever, dry cough and weight loss. The chest radiograph reveals mediastinal lymphadenopathy. Blood investigations reveal hypercalcemia and elevated angiotensin-converting enzyme (ACE). Which of the following appearances of lymphadenopathy on CT would be the least likely feature in favour of the clinical diagnosis? a. Bilateral hilar lymphadenopathy b. Egg-shell calcification c. Predominant involvement of the right paratracheal lymph nodes d. Lymphadenopathy without any parenchymal involvement e. Posterior mediastinal lymph nodes
43. e. Posterior mediastinal lymph nodes All the above are features of mediastinal lymphadenopathy in sarcoidosis. Whilst sarcoidosis can involve different mediastinal and hilar groups, posterior mediastinal lymphadenopathy is a feature of NHL.
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44. The HRCT of a 35 year old patient with shortness of breath and reticulonodular disease pattern on plain chest radiograph reveals cavitating nodules with interstitial septal thickening. Which of the following diagnoses is the least likely? a. Lymphangioleiomyomatosis b. Langerhans’ cell histiocytosis c. Wegener’s granulomatosis d. Sarcoidosis e. Rheumatoid lung
44. a. Lymphangioleiomyomatosis (LAM) The cysts in LAM are thin-walled air-containing cysts, rather than cavitation in nodules.
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45. Eight days after lung transplantation for alpha-1 antitrypsin deficiency, a 45 year old man develops pyrexia, breathlessness and desaturation. HRCT reveals perihilar heterogenous opacities and ground glass changes with new pleural effusion and septal thickening. Which of the following is the most likely cause? a. Reperfusion oedema b. Acute rejection c. Anastomotic dehiscence d. Post-transplantation PCP infection e. Hyperacute rejection
45. b. Acute rejection Hyperacute rejection presents within hours of the transplantation. Reperfusion oedema usually presents within 24 hours of the transplantation, peaking by about day four. Posttransplant infections can be broadly divided into those occurring within the first month (gram-negative bacteria, fungi (candida, aspergillosis)) and those occurring after the first month (CMV, PCP). Anastomotic dehiscence is usually an early feature, but the presentation and features are not those described.
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46. A 45 year old female patient with history of rheumatic fever as a child presents with progressive shortness of breath and paroxysmal nocturnal dyspnoea. Clinical examination reveals a pansystolic murmur associated with a mid-diastolic murmur with presystolic accentuation best heard over the cardiac apex. Clinical examination and plain film do not reveal evidence of heart failure, but several features of left atrial enlargement are noted. Which of the following is not one of those? a. Double atrial shadow on the right b. Straightening of the right heart border c. Elevation of the left main bronchus d. Splaying of the carina e. Displacement of the descending aorta to the left
46. b. Straightening of the right heart border Left atrial enlargement results in straightening of the left heart border as a result of enlargement of the left atrial appendage. This is especially a feature of rheumatic mitral valve disease.
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47. A 70 year old man undergoes surgery for AAA. Two weeks following surgery, he is readmitted to the A&E department with abdominal pain and fever. Palpation of the abdomen suggests a pulsatile mass. A CT angiogram is performed, which does not demonstrate contrast extravasation. Which of the features on CT angiogram would be most worrisome? a. Presence of a pseudoaneurysm b. Periaortic soft tissue c. Thickening of a fluid-filled third part of the duodenum d. Some ectopic gas in the vicinity e. Loss of fat plane between the grafted aorta and the adjacent duodenum
47. c. Thickening of a fluid-filled third part of the duodenum Two weeks post-procedure, all the other features including the presence of ectopic gas may be postoperative. However, presence of a thickened fluid-filled bowel loop would be extremely worrying for an aorto-enteric fistula. Presence of ectopic gas beyond four weeks is much more likely to be abnormal
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48. A seven year old boy with no known medical history presents with hypertension and postprandial abdominal pain. CT reveals an abnormality in the abdominal vasculature. Subsequent angiogram demonstrates occlusion of the coeliac axis and superior mesenteric artery and tapering of the mid-aorta. Delayed imaging shows vessel reconstitution through collaterals. The most likely diagnosis is? a. Takayasu arteritis b. Midaortic syndrome c. Neurofibromatosis d. Marfan’s syndrome e. Syphilitic aortitis
48. b. Midaortic syndrome Midaortic syndrome is a rare vascular abnormality which manifests as narrowing of the abdominal aorta and its branches (including renal arteries – hence hypertension). Its cause is unknown but it is noninflammatory and nonatheromatous. Patients typically present after the age of five years. Diagnosis is made with angiography which reveals smooth, segmental stenoses. Takayasu arteritis (TA) and neurofibromatosis (NF) are amongst the differentials (the latter can have midabdominal aortic stenosis). However, TA usually affects older patients (12–66 years) and affects females to a much greater degree (M:F¼1:8). Patients with NF and Marfan’s would usually have prior medical history. Syphilitic aortitis is rare and typically affects older patients (40–65 year olds).
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49. A patient with a known collagen vascular disease has pulmonary fibrosis. HRCT reveals bilateral lower lobe bronchiectasis. Which collagen vascular disease is most likely? a. Sjogren syndrome b. Progressive systemic sclerosis c. SLE d. Rheumatoid arthritis e. Dermatomyositis
49. a. Sjogren syndrome Whilst pulmonary fibrosis is a feature of all the above conditions, bronchiectasis is most likely seen in Sjogren syndrome.
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50. A 30 year old female patient with a history of recurrent lower respiratory tract infections as a child presents with cough and dyspnoea. Chest radiograph demonstrates a smaller hyperlucent left lung. Which of the following features is unlikely to be seen on HRCT? a. Air trapping b. Small left hemithorax c. Diminished size of pulmonary vessels d. Bronchiectasis e. Left hilar enlargement
50. e. Left hilar enlargement The case describes Swyer–James syndrome (Macleod syndrome). This is a post-infectious constrictive bronchiolitis which causes a small, hyperlucent lung with bronchiectasis and air trapping in expiration. The number and size of pulmonary vessels are also diminished, resulting in a small ipsilateral hilum.
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51. A 60 year old man presents with a 6 month history of shortness of breath, wheeze and a recent episode of haemoptysis. Plain chest radiograph reveals partial right middle and lower lobe collapse. This is further confirmed on CT which also suggests an endobronchial lesion in the bronchus intermedius. It is FDG-avid on PET-CT scan. Bronchoscopy reveals a smooth submucosal lesion. The histopathology of the lesion is most likely to be: a. Mucoepidermoid carcinoma b. Atypical carcinoid c. Renal cell carcinoma metastasis d. Adenoid cystic carcinoma e. Squamous cell papilloma
51. d. Adenoid cystic carcinoma Adenoid cystic carcinoma is the second most common malignancy of the central airways after squamous cell cancer and often presents as an endoluminal mass with an intact mucosa. Mucoepidermoid carcinoma is rare. Benign tumours are mostly of mesenchymal origin and are rare. Carcinoids in these locations are usually of the typical type.
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52. A 36 year old female awaiting liver transplantation undergoes routine pre-operative planning ultrasound examination of the abdomen. Whilst the rest of the abdomen is normal, a 4 cm splenic artery aneurysm is seen, which is subsequently confirmed on CT. Which of the following would be the preferred course of action? a. Follow-up ultrasound scan in a year’s time b. Referral to the surgeons for a splenectomy c. Thrombin injection of the aneurysm d. Endoscopic ligation of the aneurysm e. Coil embolisation of the aneurysm
52. e. Coil embolisation of the aneurysm This patient was discovered to have an incidental asymptomatic aneurysm. Prophylactic embolisation is generally offered to three groups of patients: 1. Those who have aneurysms greater than 2.5 cm in size. 2. Those with portal hypertension. 3. Those awaiting liver transplantation Percutaneous splenic artery aneurysm embolisation using coils is the preferred treatment. Thrombin injection is usually preferred in cases where embolisation has failed. Aneurysms with wider necks often need additional measures such as a detachable balloon.
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53. A 59 year old male presents with left shoulder pain and tingling in his fingers. Plain chest radiograph reveals the presence of a left apical mass with some rib destruction. CT confirms the presence of a superior sulcus tumour at the left apex with no evidence of nodal or distant metastasis. The patient is referred for a MR scan to assess resectability. Which of the following is appropriate? a. Coronal T1-weighted images are best to identify involvement of the brachial plexus b. T2-weighted images are vital to assess resectability and should be performed first c. Axial images are best to assess spinal canal and foraminal involvement d. Use of intravenous contrast is necessary to identify the subclavian vessels and their relation to the brachial plexus and the tumour e. Imaging is usually performed using a body coil
53. c. Axial images are best to assess spinal canal and foraminal involvement Sagittal and axial images are the most important acquisitions to assess the local extent and involvement of vital neurovascular structures by the tumour, with coronal imaging adding very little further information. T1-weighted images are the most important to assess resectability and should be acquired first. The subclavian vessels can be seen quite clearly as flow voids even without contrast. Gadolinium is usually given to assess for vascular invasion and following adjuvant therapy. Imaging is performed using a neck coil to improve resolution for identifying small local structures.
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54. A 60 year old hypertensive man presents with sudden-onset severe inter-scapular pain. CT reveals a high attenuation crescent in the wall of the proximal ascending aorta with inward displacement of part of the calcific wall, which extends just up to the brachiocephalic artery. Post-contrast scan does not demonstrate leak of contrast into the crescentic area or mediastinum. The patient is haemodynamically stable. The next appropriate course of action is: a. Urgent cardiothoracic referral b. Contact the interventional radiologist for consideration of endovascular stenting c. Follow-up scan after 24 hours d. Medical treatment aimed at controlling blood pressure e. Emergency cardiac MRI
54. a. Urgent cardiothoracic referral The features described are that of an acute type A intramural haematoma which needs to be treated similarly to that of a Stanford type A aortic dissection and so cardiothoracic surgical opinion is warranted. CT has delineated the extent of the acute intramural haematoma and further imaging would add little. These patients are at increased risk of progressing to a true dissection which carries a high mortality. Whilst endovascular treatment may be considered for selective cases, involvement of the proximal ascending aorta will preclude this.
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55. A 30 year old female with uncontrolled hypertension undergoes an MR angiogram of the renal arteries. This reveals bilateral renal artery abnormalities. The most likely abnormality is: a. Bilateral ostial stenosis b. Bilateral long segment stenosis c. Intrarenal aneurysms d. Atretic renal arteries with extensive collateralisation e. Multiple stenoses of the mid portion of the renal arteries
55. e. Multiple stenoses of the mid portion of the renal arteries In a female patient of this age, fibromuscular dysplasia is the most likely abnormality. Fibromuscular dysplasia involves the mid and distal portions of the renal artery as well as the intrarenal branches, with multiple stenoses and aneurysms revealing a string-of-beads appearance. The ostia and the proximal portion are much less commonly involved. It responds very well to angioplasty, unlike ostial atherosclerotic disease which often needs stenting. Typically it is the medial layer that is affected although all layers can demonstrate changes.
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56. A 45 year old woman with severe portal hypertension and variceal bleeding is referred for a trans-jugular intrahepatic porto-systemic shunt (TIPSS) procedure following the failure of endoscopic procedures in controlling the bleeding. Which of the following is the most appropriate regarding TIPSS? a. The middle hepatic vein is the preferred route of access to the portal vein b. The right portal vein is usually posterior to the right hepatic vein c. Flow of contrast towards the porta hepatis usually indicates puncture of the biliary tree d. The gradient across the shunt should be less than 20mmHg e. Stenosis tends to occur in the portal vein
56. c. Flow of contrast towards the porta hepatis usually indicates puncture of the biliary tree Usually the right hepatic vein (RHV) is the preferred route of access to the right portal vein, which lies anterior to the RHV. Flow of contrast towards the porta, and especially if it remains there, usually indicates biliary puncture. Puncture of portal vein and hepatic artery usually result in contrast flowing to the periphery. The shunt gradient should be less than 12mm of mercury. Stenoses usually tend to occur in the hepatic vein or the shunt itself.
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57. Following a deceleration injury in a road traffic accident, a young man presents to the A&E department with shock, chest wall contusion and severe chest pain. An aortic injury is suspected. Which of the following is least likely? a. A normal chest radiograph has high negative predictive value b. Aortic injury is the usual cause of mediastinal haematoma c. The aorta just beyond the left subclavian artery is the most common site of injury d. Aortic rupture is usually circumferential e. A non-contrast CT scan has a high negative predictive value in the absence of demonstrable mediastinal haematoma
57. b. Aortic injury is the usual cause of mediastinal haematoma A normal PA chest radiograph has a very high negative predictive value (95–98%) and the absence of a mediastinal haematoma on a non-contrast CT also effectively rules out the presence of aortic injury. The source of the mediastinal haematoma is usually the azygous, hemiazygous, internal mammary and intercostal vessels. Aortic injury is usually circumferential (85%).
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58. A 45 year old man with a known atrial septal defect (ASD) presents with breathlessness and mild cyanosis. Clinical examination reveals a loud second heart sound and a prominent parasternal heave, but no signs of heart failure. Echocardiogram demonstrates a shunt reversal. Which of the following is not a usual feature on the imaging? a. Paucity of peripheral pulmonary vasculature b. Enlarged central PA c. Right ventricular hypertrophy d. Dilated pulmonary veins e. Linear calcification of the main pulmonary arteries
58. d. Dilated pulmonary veins This patient has developed Eisenmenger syndrome with reversal of his longstanding left-toright shunt across the ASD. All of the features listed except dilated pulmonary veins are generally present.
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59. A 60 year old man presents with progressive breathlessness. The plain chest radiograph reveals reticular shadowing in the right lower zone, but is otherwise unremarkable. HRCT demonstrates the presence of beaded thickening of the interlobular septae forming a polygonal reticular network in the right lower lobe with central dots within. There is also a small pleural effusion. Which of the following is the most likely cause? a. Sarcoidosis b. Bronchogenic carcinoma c. Heart failure d. Extrinsic allergic alveolitis e. Fibrosing alveolitis
59. b. Bronchogenic carcinoma The changes described indicate lymphangitis carcinomatosis. Whilst similar appearances are seen in sarcoidosis, the changes are usually in the upper lobe and pleural effusion is rare. In heart failure, the interlobar septal thickening is usually smooth and usually bilateral. In EAA, pleural effusion is rare and changes are more bronchocentric and bilateral. The polygonal structure is usually distorted in both EAA and cryptogenic fibrosis, where the changes are again subpleural.
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60. A 32 year old patient with congenital heart disease is referred for a cardiac MR examination. Regarding cardiac MR imaging, which of the following applies? a. Dark rim artefacts are typically seen on the epicardial aspect on perfusion imaging b. Radiofrequency artefacts are typically sporadic and transient, affecting few images in a series c. Field inhomogeneity artefacts are more common on a 3T scanner than a 1.5T scanner d. Of the two cine MR imaging techniques, at the same bandwidth, image acquisition is quicker with an SSFP sequence than spoiled GRE imaging e. Prospective gating is preferred for assessing diastolic dysfunction
60. c. Field inhomogeneity artefacts are more common on a 3T scanner than a 1.5T scanner Dark rim artefacts are typically seen on the endocardial aspect on cardiac MR imaging. Spike artefacts are typically sporadic and transient, whilst RF artefacts usually involve all images of the series. At the same bandwidth, image acquisition is quicker with spoiled GRE acquisition. However, often, a lower bandwidth has to be used to improve the signalto- noise ratio of these sequences and so SSFP imaging may be quicker. In prospective gating, to compensate for physiologic variations in heart rate, the acquisition window is usually 10–20% shorter than the average RR interval, missing out on the end diastole, and hence it is not very useful for assessing diastolic dysfunction.

Currie (6 decks)

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