Download IPR 2016 Cardio Session May 20, 2016 SAM Questionnaire Basic

IPR 2016 Cardio Session
May 20, 2016
SAM Questionnaire
Basic CMR Physics
Taylor Chung, MD
1. How does a MR image depends on the k-space data?
A. The center of k-space controls the image contrast
B. The center of k-space controls both image contrast and spatial resolution of the image
C. Both image space and k-space are measured in units of centimeters
D. One k-space full of data can be used to generate multiple images
E. An image cannot be generated unless the entire k-space is filled with data
Correct Answer: A
Reference
https://www.imaios.com/en/e-Courses/e-MRI/The-Physics-behind-it-all/K-space.
Rationale
The center of k-space controls the image contrast; the peripheral of k-space controls the spatial
resolution of the image. There is a one-to-one correspondence between a k-space and an image.
The units of k-space is in frequency. Reference #1 gives an animated depiction of k-space
2. In order to collect data throughout the entire cardiac cycle such as in flow quantification, which
type of cardiac synchronization scheme should be used?
A. Prospective triggering with ECG leads
B. Retrospective gating with peripheral pulse transducer
C. Real time imaging
D. Prospective triggering with peripheral pulse transducer
E. Retrospective gating with ECG leads
Correct Answer: E
Reference
Ridgway JP. Cardiovascular magnetic resonance physics for clinicians: Part 1. JCMR 2010;
12:71-99.
Biglands JD, Radjenovic A, Ridgeway JP. Cardiovascular magnetic resonance physics for
clinicians: Part 2. JCMR 2012; 14:66-106
Rationale
Prospective triggering does not allow collection of data throughout the entire cardiac cycle. In
prospective triggering mode, the MR scanner can start and stop collecting data at pre-determined
points in the cardiac cycle and has stop collecting data to wait for the next R wave.
Comparatively, retrospective mode collects data continuous throughout the cardiac cycle and
therefore is used for cine phase contrast sequence for flow quantification. See Figure #25 of
Reference #2. Real time imaging schemes do not use any cardiac synchronization. Typically,
ECG chest leads are preferred over peripheral pulse transducers for all cardiac MR sequences.
CMR Techniques
Taylor Chung, MD
1. What scan parameter needs to be adjusted in a cine acquisition with segmented k-space technique
to change the true temporal resolution?
A. Vary the number of signal averages (NSA) or number of excitations (NEX)
B. Vary the number of frequency encoding steps or the frequency matrix
C. Vary the views per segment (VPS), or Turbo factor, or the TFE factor
D. Vary the entered heart rate to multiples of the true heart rate
E. Vary the flip angle
Correct Answer: C
Reference
Ridgway JP. Cardiovascular magnetic resonance physics for clinicians: Part 1. JCMR 2010;
12:71-99.
Rationale
VPS or Turbo factor or TFE factors all means the same (used by different MR manufacturers) as
the numbers of lines of k-space per segment that the pulse sequence collects at one time. Please
refer to the slides of the talk for detail explanation of how varying the lines per segment can
change the temporal resolution of a cine acquisition. The number of signal averages, the flip
angle, and entered heart rate do not alter the temporal resolution. The number of frequency
encoding steps, unlikely the phase encoding steps, will not affect the acquisition time and
therefore do not indirectly affect the temporal resolution.
2. How does parallel imaging help in cardiovascular imaging?
A. Allows imaging of different portion of the thorax at the same time
B. Allows imaging with higher spatial resolution without more scan time
C. Can speed up acquisition and at the same time increase signal-to-noise ratio (SNR)
D. Allows imaging with higher spatial resolution and increase SNR without increasing scan time
E. Can increase SNR and temporal resolution at the same time
Correct Answer: B
Reference
Biglands JD, Radjenovic A, Ridgeway JP. Cardiovascular magnetic resonance physics for
clinicians: Part 2. JCMR 2012; 14:66-106
Rationale
Parallel imaging (SENSE, iPAT, ASSET, ARC) allows for imaging with either higher temporal
and/or spatial resolution without the typical trade off of increasing scan time. However, there is a
trade off of lower SNR. Parallel imaging is used in many CV MR techniques routinely such as
cine SSFP and contrast-enhanced MRA as discussed in the talk. See slides and reference #2
figure 1 and related text.
Basic CT Physics
Christina Sammet, PhD
1. The CTDIvol displayed on the screen before you scan a patient is defined as:
A. The dose that will be delivered to the patient lying on the table
B. The average dose that was delivered to all patients scanned using the selected protocol
C. The dose that would be delivered to an industry-standard plastic phantom
D. The dose that would be delivered to a standard 75 kg man
E. The dose that was delivered to the last patient scanned using that protocol
Correct Answer: C
Reference
Bushberg, Jerrold, et al. The Essential Physics of Medical Imaging. Philadelphia, 2012
2. Children have a higher sensitivity to radiation than adults because they:
A. Have a higher metabolism
B. Have higher heart rates
C. Have higher respiratory rates
D. Have increased growth rates
E. Have higher corporal temperatures
Correct Answer: D
Reference
Donald J. Peck and Ehsan Samei, Image Wisely “How to Understand and Communicate
Radiation Risk”, Image Wisely, ACR (2010)
CT Techniques
Aurelio Secinaro, MD
1. Which cardiac CT scan strategy is best for children/neonates with heart rate >70 bpm?
A. Sequential ECG-gated (systolic) on a dual-source CT system
B. Non-gated spiral high-pitch acquisition
C. Sequential ECG-gated on a single-source CT system
D. None of the above
Correct Answer: A
Reference
Low-dose coronary-CT angiography using step and shoot at any heart rate: comparison of image
quality at systole for high heart rate and diastole for low heart rate with a 128-slice dual-source
machine. Jean-François Paul, Aude Amato, Adela Rohnean. International Journal of
Cardiovascular Imaging (2013) 29:651–657
2. What technical consequence do you expect in high-pitch scanning on cardiac CT?
A. Reduced scan time
B. Reduced patient movement artefacts
C. Increased “over-ranging effect”
D. Less radiation dose compared to lower pitch acquisition (same kV and mAs)
E. All of the above
Correct Answer: E
Reference
Multidetector CT in children: current concepts and dose reduction strategies Rutger A. J.
Nievelstein, Ingrid M. Van Dam, Aart J. Van der Molen. Pediatr Radiol (2010) 40:1324–1344
MRI for Assessment of Left-to-Right Shunts
Lorna Browne, MD
1. A patient with right upper lobe partial anomalous pulmonary venous (RUL PAPVR) return to the
SVC. The Qp: Qs is calculated at 2.2: 1. This is consistent with the RUL PAPVR?
A. True
B. False
Correct Answer: B
Reference
Cardiovascular shunts: MRI Evaluation, Higgins CB et al, Radiographics October 2003
Rationale
PAPVR from the RUL is a relatively small shunt Qp:Qs of <1.5:1. This shunt fraction suggests
additional shunts are present, special attention for a sinus venosus defect should be performed.
2. Outlet VSDs of the malalignment type are typically seen in which of the following CHDs?
A. Tetralogy of Fallot
B. Double outlet right ventricle
C. Truncus arteriosus
D. Interrupted aortic arch
E. All of the above
Correct Answer: E
Reference
Cardiovascular shunts Part I Cardiac MRI, Raijaih P, Kanne JB, AJR 2011, 197:4, W603-W620
Rationale
Anterior malalignment VSDs are associated with TOF and DORV while posterior malalignment
defects are associated with Truncus Arteriosus and LV outlet obstruction
MRI for Postoperative Assessment of Tetralogy of Fallot
Andrew Taylor, MD
1. For an asymptomatic patient with conduit narrowing, when should the patient be offered
pulmonary valve replacement?
A. Only when symptomatic
B. When gradient across the conduit is > 60 mmHg systemic pressure
C. When gradient across the conduit is > 80 mmHg systemic pressure
D. Only when there is severe pulmonary regurgitation
Correct Answer: C
Reference
Table 15 page 2939 of ESC Guidelines for the Management of Grown-Up Congenital Heart
Disease (new version 2010). European Heart Journal (2010) 31, 2915–2957.
2. For an asymptomatic patient with conduit regurgitation, patients should definitively be offered
pulmonary valve replacement when:
A. There is severe pulmonary regurgitation
B. The right ventricular end-diastolic volume is greater > 150 mL/m2
C. The right ventricular ejection fraction is < 45%
D. When there is evidence of sustained atrial/ ventricular arrhythmias
Correct Answer: D
Reference
Table 15 page 2939 of ESC Guidelines for the Management of Grown-Up Congenital Heart
Disease (new version 2010). European Heart Journal (2010) 31, 2915–2957.
MRI for Iron Imaging
Cynthia K. Rigsby, MD, FACR
1. What form of cardiac iron is imaged with T2* sequences?
A. Free iron (Fe3+)
B. Stored bound iron
C. Iron sulfate
D. Iron chloride
Correct Answer: B
Reference
Wood JC. Cardiac iron across different transfusion dependent diseases. Blood Reviews (2008) 22
suppl 2 S14-S21.
2. When the cardiac T2* value is 6 ms or less, what is the approximate risk of heart failure
developing within one year?
A. 10%
B. 30%
C. 50%
D. 70%
Correct Answer: C
Reference
Kirk, P et al. Cardiac T2* Magnetic Resonance for Prediction of Cardiac Complications in
Thalassemia Major. Circulation 120.20 (2009): 1961–1968.
MRI for Assessment of Myocarditis and Cardiomyopathy
Phillip Lurz, MD
1. Which of the following statements is correct:
A. According to clinical presentation, the course of myocarditis is rather predictable.
B. Heart-failure-like presentation is associated with a superior clinical outcome as compared to
infarct-like-myocarditis
C. Epicardial late enhancement is specific to myocarditis and therefore allows to establish the
diagnosis of myocarditis on cardiac magnetic resonance imaging.
D. According to the Lake-Louise-Criteria, the diagnosis of myocarditis is highly likely when 2
out of 3 criteria (Late enhancement, edema ratio, early relative enhancement) are
pathological.
E. An edema ratio of > 1 is considered to be pathological
Correct Answer: D
References
Lurz P, Eitel I, Adam J, et al. Diagnostic performance of CMR imaging compared with EMB in
patients with suspected myocarditis. JACC Cardiovasc Imaging 2012;5:513-24.
Friedrich MG, Sechtem U, Schulz-Menger J, et al. Cardiovascular magnetic resonance in
myocarditis: A JACC White Paper. J Am Coll Cardiol 2009;53:1475-87.
2. Which of the following statements is correct:
A. Native T1 mapping results in higher T1 values in the presence of intracellular edema only
B. Native T1 mapping results in higher T1 values in the presence of extracellular edema only
C. Native T1 mapping results in higher T1 values in the presence of myocardial fibrosis only
D. T2 mapping is more specific to myocardial edema than myocardial fibrosis
E. Native and post-contrast T1 mapping allow for calculation of the extracellular volume
fraction, which is equivalent to extent of diffuse myocardial fibrosis
Correct Answer: D
References
Thavendiranathan P, Walls M, Giri S, et al. Improved detection of myocardial involvement in
acute inflammatory cardiomyopathies using T2 mapping. Circulation Cardiovascular imaging
2012;5:102-10.
Bohnen S, Radunski UK, Lund GK, et al. Performance of t1 and t2 mapping cardiovascular
magnetic resonance to detect active myocarditis in patients with recent-onset heart failure.
Circulation Cardiovascular imaging 2015;8.
Moon JC, Messroghli DR, Kellman P, et al. Myocardial T1 mapping and extracellular volume
quantification: a Society for Cardiovascular Magnetic Resonance (SCMR) and CMR Working
Group of the European Society of Cardiology consensus statement. J Cardiovasc Magn Reson
2013;15:92.
Imaging of Pulmonary Hypertension
Catherine M. Owens, MBBS
1. In this patient with evidence of pulmonary hypertension
with extensive interlobular septal thickening, the presence
of enlarged mediastinal lymph nodes suggests which of
the following causes of pulmonary hypertension?
A.
B.
C.
D.
E.
Chronic thromboembolism
Idiopathic pulmonary arterial hypertension
Pulmonary veno-occlusive disease
Langerhans cell histiocytosis
Neurofibromatosis
Correct Answer: C
References
Rossi et al. Rare causes of pulmonary hypertension: spectrum of radiological findings and review
of the literature. Radiol Med (2014) 119:41-53 DOI 10.1007/s11547-013-0305-8
Ivy et al. Pediatric Pulmonary Hypertension. JACC (2013) 62 (25 supp) D117-D126 DOI
10.1016/j.jacc.2013.10.028
Rationale
All of these except LCH are recognised causes of pulmonary hypertension in the paediatric
population, however, lymphadenopathy is a common feature of pulmonary veno-occlusive
disease.
Option A) is not correct. Chronic thromboembolism causes pulmonary hypertension, often
associated with vascular filling defects (emboli, webs etc), but is not associated with mediastinal
lymphadenopathy
Option B) is not correct. Idiopathic pulmonary arterial hypertension is a diagnosis of exclusion
and is not associated with mediastinal lymphadenopathy
Option C) is correct. Pulmonary veno-occlusive disease is associated with mediastinal
lymphadenopathy in addition to the typical features of pulmonary hypertension (interlobular
septal thickening, mosaic attenuation, plexiform lesions, abnormal arborisation of the pulmonary
vessels etc)
Option D) is not correct.
Option E) is not correct. Neurofibromatosis is associated with pulmonary hypertension and thin
walled apical cysts / emphysematous change, but no mediastinal lymphadenopathy.
2. This adolescent patient’s pulmonary hypertension is likely secondary to…
A.
B.
C.
D.
E.
An atrial septal defect (ASD)
Chronic thromboembolic disease (CTEPH)
A ventricular septal defect (VSD)
A patent ductus arteriosis
Pulmonary veno-occlusive disease
Correct Answer: D
Reference
Kilner, PJ. Imaging congenital heart disease in adults. BJR 2011 84 (spec Iss 3): S258-S268 DOI
10.1259/bjr/74240815
Rationale
The images demonstrate right heart dilation, plexiform lesions, abnormal pulmonary vascular
branching and patchy ground glass change in keeping with pulmonary hypertension. The left
hand image demonstrates a patent ductus arteriosus (*)
Option A) is not correct. No ASD has been
demonstrated.
Option B) is not correct. No vascular filling defects (emboli, webs etc) have been demonstrated.
Option C) is not correct. No VSD has been demonstrated.
Option D) is correct. The right hand image demonstrates the PDA arising at the aortic isthmus.
Option E) is not correct. No specific features of pulmonary veno-occlusive disease (most notably
lymphadenopathy on a background of PH) have been demonstrated
Coronary Imaging
Aurelio Secinaro, MD
1. In this Tetralogy of Fallot patient scanned for coronary arteries there is a large vessel arising from
the right coronary ostium, coursing anterior to the obstructed
infundibulum, giving rise to some (but not all) septal and diagonal
branches and directing towards the heart apex. The left coronary
artery bifurcation is present. Which coronary anomaly are you
suspecting?
A.
B.
C.
D.
Large conal branch
Double left anterior descending artery
Left anterior descending artery from the right coronary ostium
None of the above
Correct Answer: B
Reference
A Rare Coronary Artery Anomaly: Double Left Anterior Descending Artery. Guray Oncel and
Dilek Oncel. J Clin Imaging Sci. 2012; 2: 83.
2. In case of anomalous aortic origin of a coronary, which of the following CT findings is
influencing the need for surgical treatment?
A. intramural course
B. abnormal ostium morphology
C. dynamic proximal coronary changes throughout the cardiac cycle
D. all of the above
Correct Answer: D
Reference
Anomalous Aortic Origin of a Coronary Artery: Toward a Standardized Approach. Carlos M.
Mery, Silvana M. Lawrence, Rajesh Krishnamurthy, Kristen Sexson-Tejtel, Kathleen E.
Carberry, E. Dean McKenzie and Charles D. Fraser Jr.
Newborn CTA
Rajesh Krishnamurthy, MD
1. What is the correct diagnosis?
A.
B.
C.
D.
Right aortic arch with aberrant left subclavian artery
Innominate artery compression syndrome
Scimitar syndrome
Pulmonary sling with complete tracheal rings
Correct Answer: D
Reference
Krishnamurthy R, Hernandez A, Kavuk S, Annam A, Pimpalwar S. Dynamic MR
Lymphangiography (d-MRL): A New Technique to Assess the Central Conducting Lymphatics.
Radiology 2015;274(3):871-8.
Rationale
A. Right aortic arch with aberrant left subclavian artery. False. Although the patient also has a
left aortic arch with an aberrant right subclavian artery, this is not the primary diagnosis.
B. Innominate artery compression syndrome. False. There is no mass effect on the trachea from
the innominate artery.
C. Scimitar syndrome. False. There is no anomalous draining vein.
D. Pulmonary sling with complete tracheal rings. True. There is aberrant origin of the left
pulmonary artery from the right PA, with course between the trachea and esophagus. There
is associated long segment tracheal stenosis due to complete cartilaginous tracheal rings.
2. Pick the correct answer about this newborn male patient with pulmonary atresia and major
aortopulmonary collateral arteries:
A. The image shows non-confluent branch pulmonary arteries
B. This patient is a good candidate for a central aortopulmonary shunt
C. Cardiac catheterization is mandatory for decision making in the neonatal
period
D. Initial palliation is not needed for this patient, and delayed repair may be
performed at 2 years of age.
Correct Answer: B
Reference
Krishnamurthy R, Hernandez A, Kavuk S, Annam A, Pimpalwar S. Dynamic MR
Lymphangiography (d-MRL): A New Technique to Assess the Central Conducting Lymphatics.
Radiology 2015;274(3):871-8.
Rationale
A. The image shows non-confluent branch pulmonary arteries. False. The image shows
confluent branch pulmonary arteries
B. This patient is a good candidate for a central aortopulmonary shunt. True. Central shunt is a
good option for initial palliation in the newborn period, and allows for growth of the
hypoplastic branch pulmonary arteries prior to planned unifocalization at a later stage.
C. Cardiac catheterization is mandatory for decision making in the neonatal period. False. With
the advent of CTA, CC is no longer mandatory for decision making regarding initial
palliation. It is helpful when planning unifocalization, which is the definitive palliation
procedure.
D. Initial palliation is not needed for this patient, and delayed repair may be performed at 2
years of age. False. Initial palliation is needed in order to allow the pulmonary arteries to
grow. An alternative approach is to perform definitive repair with unifocalization in the
newborn period.