4.1: Week 4 pt 1

Question 1

The normal ascending aorta should not project farther to the right than the___________________ on a PA radiograph

Answer 1

right heart border

Question 2

How do you assess a chest radiograph for heart disease?

Answer 2

1) Cardiac Ratio – is it <50%
2) Atria enlarged?
3) Left P Art enlarged? (normal here)
4) Aorta or aortic knob enlarged?

Question 3

Why is it important to ask “Is heart >50 % of chest diameter?”

Answer 3

1) Heart responds to stenotic valves with hypertrophy
2) Heart responds to regurgitant valves with enlargement
3) Cardiomegaly often from fluid overload; therefore, look for other indications of fluid overload (Kerley B lines, prominent fissures, pleural effusions)

Question 4

Is a lateral view important to assess for cardiomegaly?

Answer 4

Mainly confirmatory finding
Look at diminished space posterior to the heart

Question 5

1) Why may pericardial effusion occur
2) What can CT help with?
3) What is the study of choice?

Answer 5

1) CHF, Infection, Metastasis, Lupus, Trauma, post-surgical
-Most common cause is simply the “AP chest”
2) CT can help differentiate soft-tissue density of the heart vs. fluid density of effusion
3) Study of choice is U/S (echo)

Question 6

What can you do about the AP problem?

Answer 6

You can still roughly gauge cardiomegaly with this view
-If heart appears borderline = probably normal heart size
-If heart appears significantly enlarged = likely enlarged
-If heart is touching or almost touching left lateral chest wall = definitely enlarged

Question 7

What are the 2 most common causes of CHF?

Answer 7

CAD and HTN

Question 8

List some S/Sx of interstitial edema

Answer 8

1) Thickening of interlobular septa (Kerley B)
2) Peri-bronchial cuffing
3) Fluid in the fissures
4) Pleural effusions

Question 9

Where should you look for kerley b lines for interstitial edema?

Answer 9

Interlobular Septa for Kerley B line
Look in the periphery or near the costophrenic angles
1-2 cm long, less than 1mm thickness, straight

Question 10

Peri-bronchial cuffing (interstitial edema): What causes it? What does it look like?

Answer 10

Fluid build-up
“Ring around the bronchial wall”
Looks like a doughnut

Question 11

Fluid in the fissures (interstitial edema): Where is it? What does it look like?

Answer 11

1) Fluid build-up between the lobes within major or minor fissures
Between layers of visceral pleura; or between visceral pleura and parenchyma
2) You might see the fissure lines normally (A), but note the difference with CHF (B)

Question 12

Pleural Effusion (interstitial edema):
1) Bilat or unilat in CHF?
2) Where should you look for it?

Answer 12

1) In CHF usually bilat
2) Occurs in pleural space, look to costophrenic angles

Question 13

Alveolar Edema:
1) What is it?
2) What does it look like?
3) What is the most common cause?

Answer 13

1) When fluid leaves the interstitium and moves to the airspace
-Sometimes this steals the general term “pulmonary edema”
2) Just like most airspace disease, it’s fluffy and indistinct!
3) CHF

Question 14

What is Noncardiogenic Pulmonary Edema?

Answer 14

Increased capillary permeability resulting from one of the following:
-Sepsis
-Uremia
-DIC
-Smoke inhalation
-Near drowning
-Volume overload
-Lymphangitic spread of malignancy
-High-altitude edema, neurogenic edema, re-expansion edema, drug overdose

Question 15

Describe the difference in noncardiogenic pulmonary edema (vs cardiogenic)

Answer 15

Noncardiac is:
1) Less likely to show effusion and Kerley B lines
2) More likely to have normal sized heart shadow
-Though be aware that CHF does not always accompany cardiomegaly
3) More likely to be peripheral; highly variable

Question 16

Hypertensive Cardiovascular Disease:
1) What does chronic HTN lead to?
2) What is the overall heart size?
3) What do you need to watch for?

Answer 16

1) Chronic HTN leads to LVH
-hypertrophy is contained in the thickness of the “wall”
2) The overall heart size is therefore normal or only slightly increased
3) Also watch for unfolding of the aorta
-Appearing more prominent in the ascending and descending portions

Question 17

Prominent aorta & LV thickened walls are symptoms of?

Answer 17

Hypertensive Cardiovascular Disease

Question 18

What does mitral stenosis cause?

Answer 18

Left atrial pressure builds and left atrium enlarges > left-sided HF ensues

Question 19

Pulmonary Arterial HTN
1) What are some causes besides mitral stenosis?
2) What is the classic finding?

Answer 19

1) Idiopathic, emphysema, PE
2) Enlarged main right and left pulmonary arteries when compared with peripheral arteries

Question 20

What are some other findings with pulmonary arterial HTN?

Answer 20

1) Main pulmonary artery is larger than aorta (normally about the same size)
2) Also note decrease in diameter of peripheral vessels

Question 21

Dilated cardiomyopathy:
1) Is it common? What is it assoc with?
2) What are the signs?
3) How do you Dx?

Answer 21

1) Dilated is Most Common and associated with DM, ischemia, ETOH
2) “Big floppy heart”
Enlarged, dilated ventricles; poor contractility; with signs of CHF
3) Diagnosed with echocardiogram

Question 22

Hypertrophic cardiomyopathy:
1) What causes it?
2) How is it evaluated? What are the signs?

Answer 22

1) Is often genetic and associated with sudden cardiac death
Can also be assoc with LV outflow obstruction that is known as HOCM
2) Evaluated with Echocardiogram or MRI
Asymmetric thickening of LV

Question 23

Restrictive cardiomyopathy:
1) What causes it?
2) What does it look like? What imaging do you use?

Answer 23

1) Rare and usually secondary to infiltrative process—amyloid, autoimmune dz, radiation; stiff myocardium, decreased ventricular filling
2) Normal sized heart with signs of CHF—normal pericardium distinguishes this from restrictive pericarditis (Done with MRI)

Question 24

Describe aortic aneurysms

Answer 24

Enlargement of vessel more than 50% its normal size
Ascending aorta < 3.5 cm; descending < 3cm
Thoracic aorta considered aneurysmal above 4cm
More than 5-6 cm at risk of rupture
Diagnosis made with contrast CT

Question 25

What are some typical causes of aortic dissections?

Answer 25

Usually Hypertensive patient -May have history of cocaine use or syphilis -May have predisposing illness: Marfan syndrome, Ehlers-Danlose

Question 26

You will not nail down the diagnosis of aortic dissection with CXR, but what are some signs?

Answer 26

1) Plain films can show you very concerning signs, i.e. “widened mediastinum”    2) Other XR findings include: Loss of normal shadow of aortic knob + Deviation of trachea or esophagus

Question 27

Intimal flap may be seen on CTA with what Dx?

Answer 27

Aortic dissection

Question 28

CAD: During stress test, ________________ is obtained to evaluate movement of cardiac tissue under increased stress

Answer 28

echocardiogram