Angiography ,Venograpgy,Lymphangiography

Angiography ,Venograpgy,Lymphangiography

Q. 1

Deep vein thrombosis post-operatively is diagnosed by :

 A

USG

 B

Ascending venography

 C

X-ray

 D

Clinically

Q. 1

Deep vein thrombosis post-operatively is diagnosed by :

 A

USG

 B

Ascending venography

 C

X-ray

 D

Clinically

Ans. B

Explanation:

Venography is the most definitive test for the diagnosis of DVT in both symptomatic and asymptomatic patients.

It is the gold standard to which other modalities are compared.

This procedure involves placement of a small catheter in the dorsum of the foot and injection of a radiopaque contrast agent.

Venography is not routinely used for the evaluation of lower extremity DVT because of the associated complications discussed previously.

Currently, venography is reserved for imaging before operative venous reconstruction and catheter-based therapy.

It does, however, remain the procedure of choice in research studies evaluating methods of prophylaxis for DVT.
 
Ref : Liem T.K., Moneta G.L. (2010). Chapter 24. Venous and Lymphatic Disease. In T.R. Billiar, D.L. Dunn (Eds), Schwartz’s Principles of Surgery, 9e.

Q. 2

String sign in angiography is suggestive of:

 A

Arterial dissection

 B

Aorta aneurysm

 C

Stroke

 D

None of the above

Q. 2

String sign in angiography is suggestive of:

 A

Arterial dissection

 B

Aorta aneurysm

 C

Stroke

 D

None of the above

Ans. A

Explanation:

Traditional angiography remains the basis of diagnosis and characterization of arterial dissection.

Angiographic abnormalities include stenosis of the true lumen, or “string-sign,” visible intimal flaps, and the appearance of contrast in the false lumen.

Four-vessel cerebral angiography should be performed when suspicion of dissection exists.
 
Ref: Schwartz’s principle of surgery 9th edition, chapter 42.

Q. 3

Penile angiography is reliable only after intracavernosal injection of vasoactive substances. All are indications for penile angiography, EXCEPT:

 A

Painful priapism

 B

Peyronie’s disease

 C

Erectile dysfunction

 D

Arteriovenous malformation

Q. 3

Penile angiography is reliable only after intracavernosal injection of vasoactive substances. All are indications for penile angiography, EXCEPT:

 A

Painful priapism

 B

Peyronie’s disease

 C

Erectile dysfunction

 D

Arteriovenous malformation

Ans. A

Explanation:

Priapism is a prolonged, unwanted erection not associated with sexual stimulation.

It is classified as low-flow (venous) and high-flow (arterial) priapism. 

Doppler US can distinguish the type of priapism, with low-flow priapism showing decreased or no blood flow in the cavernosal arteries.

The most reliable method, however, involves testing aspirated blood from the corpus cavernosum for blood gas analysis.
 
Ref: Liu D.R. (2011). Chapter 127. Urologic and Gynecologic Problems and Procedures in Children. In J.E. Tintinalli, J.S. Stapczynski, D.M. Cline, O.J. Ma, R.K. Cydulka, G.D. Meckler (Eds), Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7e.

Quiz In Between


Q. 4

The major disadvantage of mesenteric angiography in the setting of GI bleeding is:

 A

It does not identify the specific cause of the bleeding

 B

Embolization is not possible

 C

Vasopressin infusion is not possible

 D

Transient ischemic attacks

Q. 4

The major disadvantage of mesenteric angiography in the setting of GI bleeding is:

 A

It does not identify the specific cause of the bleeding

 B

Embolization is not possible

 C

Vasopressin infusion is not possible

 D

Transient ischemic attacks

Ans. A

Explanation:

Angiography can be used to diagnose and treat severe bleeding. It can be diagnostic, only when the arterial bleeding rate is at least 0.5 mL/min.

The sensitivity is 30% to 50% 
The specificity is 100%.
 
Advantage 
  • It permits therapeutic intra-arterial infusion of vasopressin 
  • Transcatheter embolization for hemostasis.
Disadvantage:
Complications-3%
  • Hematoma formation
  • Femoral artery thrombosis
  • Contrast dye reactions
  • Acute kidney injury
  • Intestinal ischemia
  • Transient ischemic attacks 
  • Does not identify the specific cause of bleedin

Q. 5

A patient presents with sudden onset of blurring vision, micropsia and central scotoma. Fundus examination shows an oval area of retinal elevation in the macula and fundus angiography shows a smokestack configuration of fluorescein dye leaking from the choriocapillaris. What is he most likely suffering from?

 A

Macular hole

 B

Macular edema

 C

Macular dystrophy

 D

Central serous chorioretinopathy

Q. 5

A patient presents with sudden onset of blurring vision, micropsia and central scotoma. Fundus examination shows an oval area of retinal elevation in the macula and fundus angiography shows a smokestack configuration of fluorescein dye leaking from the choriocapillaris. What is he most likely suffering from?

 A

Macular hole

 B

Macular edema

 C

Macular dystrophy

 D

Central serous chorioretinopathy

Ans. D

Explanation:

This patient is showing features of central serous retinopathy which is characterized by serous detachment of the sensory retina due to multi-focal areas of hyperpermeability of the choroidal vessels and alteration in the pumping function of the retinal pigment epithelium. Patients usually presents with sudden onset of blurred vision, micropsia, metamorphopsia, and central scotoma.
 
Examination of the fundus shows round or oval area of retinal elevation usually in the macula. Diagnosis is most easily confirmed on OCT. Fluorescein angiography shows characteristic is a smokestack configuration of fluorescein dye leaking from the choriocapillaris followed by accumulation below the retinal pigment epithelium or sensory retina.
 
Ref: Fletcher E.C., Chong N., Augsburger J.J., Corrêa Z.M. (2011). Chapter 10. Retina. In P. Riordan-Eva, E.T. Cunningham, Jr. (Eds), Vaughan & Asbury’s General Ophthalmology, 18e.

Q. 6

Fundus fluorescein angiography done in a patient following cataract surgery shows a flower petal pattern. What is he MOST likely suffering from?

 A

Macular hole

 B

Cystoid macular edema

 C

Central serous retinopathy

 D

None of the above

Q. 6

Fundus fluorescein angiography done in a patient following cataract surgery shows a flower petal pattern. What is he MOST likely suffering from?

 A

Macular hole

 B

Cystoid macular edema

 C

Central serous retinopathy

 D

None of the above

Ans. B

Explanation:

He is showing features of cystoid macular edema. Cystoid macular edema refers to a condition in which there is fluid accumulation in honeycomb like spaces of the outer plexiform and inner nuclear layers. Fluorescein angiography done shows leakage of fluorescein dye from the perifoveal retinal capillaries and peripapillary region, and accumulating in a flower-petal pattern around the fovea.
 
It most frequent occur following cataract surgery, especially if the surgery was complicated or prolonged. It usually manifests at 4–12 weeks postoperatively. 
 
Ref: Fletcher E.C., Chong N., Augsburger J.J., Corrêa Z.M. (2011). Chapter 10. Retina. In P. Riordan-Eva, E.T. Cunningham, Jr. (Eds), Vaughan & Asbury’s General Ophthalmology, 18e

Quiz In Between


Q. 7

Best test to determine etiology of SAH

 A

Enhanced CT

 B

Unenhanced CT

 C

Intra arterial digital Substraction Angiography

 D

MRI

Q. 7

Best test to determine etiology of SAH

 A

Enhanced CT

 B

Unenhanced CT

 C

Intra arterial digital Substraction Angiography

 D

MRI

Ans. C

Explanation:

C i.e. Intra arterial digital Substraction 

  • Once dx is done by CT Scan; digital substraction angiography (DSA) is done to determine etiology.
  • DSA is most sensitive & best inv. for determining etiologyQ. 
  • Now DSA is being replaced by noninvasive methods as MRA (MRI – angiography) & CTA (CT – Angiography).

Q. 8

In patient with high clinical suspicion of pulmonary thromboembolism, best investigation would be?

 A

D-dimer

 B

CT angiography

 C

Catheter angiography

 D

Color Doppler

Q. 8

In patient with high clinical suspicion of pulmonary thromboembolism, best investigation would be?

 A

D-dimer

 B

CT angiography

 C

Catheter angiography

 D

Color Doppler

Ans. B

Explanation:

B i.e. CT angiography

  • Spiral or helical chest CT scan with intravenous contrast (CT pulmonary angiography) is the principal imaging test for the diagnosis of pulmonary embolsmQ. It acquires image with < 1 m resolution and visualizes up to 6th order branches and small peripheral emboli with a resolution superior to conventional invasive contrast pulmonary angiography. It obtains excellent images of right & left ventricle and can be used for diagnosis as well as risk stratification. In patients with pulmonary embolism, RV enlargement indicates 5 times more likelihood of death within next 30 days.
  • Inadequate breath holding can impair the image quality b/o change in arterial flow rates and motion artefact during breathing. The advent of multidetector CT (MDCT) allows examination of whole lung during single breath -hold. It is noninvasive.
  • Ventilation – perfusion lung scanning is now second line diagnostic testa for PE, and mostly used in patients who cannot tolerate intravenous contrast. Its utility is greatest when accompanied with a normal chest x-ray implying that a ventilation – perfusion mismatch is not due to parenchymal disease. High probability (>80%) scan have 2 large segmental V-P mismatches (perfusion defects & normal ventilation) with a normal chest radiograph. And very low probability scans have microparticles (10 – 100 1.1 m) of Tc99 micro – aggregate albumin (MAA) in patients lying supine. Ventilation scintigraphy is performed by inhalating Krypton – 81, (best), Xenon 133, Tc99 – diethylenetriamine penta acetic acid (DTPA), or technegas. Last two can’t be administered during perfusion scan as both are labelled with Tc99. Eight images (anterior, posterior, obtique & lateral on both sides) are aquired.
  • Conventional pulmonary angiography: Non invasive CT with contrast have virtually replaced invasive pulmonary angiography as a diagnostic tool. However, it remains the gold standard testa.

Q. 9

Fluorescein angiography is used to identify lesions in all EXCEPT:

 A

Retina

 B

Lens

 C

Optic nerve head

 D

Iris

Q. 9

Fluorescein angiography is used to identify lesions in all EXCEPT:

 A

Retina

 B

Lens

 C

Optic nerve head

 D

Iris

Ans. B

Explanation:

B i.e. Lens 

Lens and cornea are avascular structures of eye Q that’s why fluorescein angiography can’t be used to identify lesions.

While fluorescein angiography (FA) is an excellent method of showing the retinal circulation against the uniform dark background of retinal pigmentary epithelium. It is not helpful in delineating choroidal circulation. In contrast Indocyanine green angiography is excellent in studying choroidal circulation & is a useful adjunct in investigation of macular disease.

Quiz In Between


Q. 10

Dye is injected in which vessel in cerebral angiography:

 A

Brachial artery

 B

Cubital vein

 C

Femoral artery

 D

Carotid artery

Q. 10

Dye is injected in which vessel in cerebral angiography:

 A

Brachial artery

 B

Cubital vein

 C

Femoral artery

 D

Carotid artery

Ans. D

Explanation:

D i.e. Carotid artery


Q. 11

The initial investigation of choice for a post cholecystectomy biliary stricture is:

 A

Ultrasound scan of the abdomen

 B

Endoscopic cholangiography

 C

Computed tomography

 D

Magnetic resonance cholangiography

Q. 11

The initial investigation of choice for a post cholecystectomy biliary stricture is:

 A

Ultrasound scan of the abdomen

 B

Endoscopic cholangiography

 C

Computed tomography

 D

Magnetic resonance cholangiography

Ans. D

Explanation:

Ans. is ‘ d’ i.e. ie Magnetic resonance cholangiography

The initial investigation of choice for a post cholecystectomy stricture would be an MRCP. It is a non-invasive modality and provides high resolution images of the entire biliary tree.

“PTC is the imaging method of choice for most postoperative biliary strictures, but expertise with this is not available at all centers. ERCP may be easier to obtain in a patient with a biliary stricture and cholangitis who requires urgent cholangiography and biliary decompression. However, ERCP is only useful in patients with bile duct continuity.”- 

An ultrasound or a CT can also be used as initial study but an MRCP would be better, as it would provide better anatomic information about the location and the degree of stricture.

Management of biliary strictures

Schwartz 9/e p11.58 writes- “Percutaneous or endoscopic dilatation and/or stent placement give good results in more than one half of patients. Surgery with Roux-en-Y choledochojejunostomy or hepaticojejunostomy is the standard of care with good or excellent results in 80 to90% of patients.”


Q. 12

The gold standard for the definitive diagnosis of the extrahepatic biliary atresia is 

 A

Peroperative cholangiography

 B

Hepatobiliary scintigraphy

 C

Alkaline phosphatase level

 D

Liver biopsy.

Q. 12

The gold standard for the definitive diagnosis of the extrahepatic biliary atresia is 

 A

Peroperative cholangiography

 B

Hepatobiliary scintigraphy

 C

Alkaline phosphatase level

 D

Liver biopsy.

Ans. A

Explanation:

Ans is (a) ie., peroperative cholangiograpy 

  • Biliary atresia is difficult to clearly differentiate from other conditions of neonatal jaundice (particularly neonatal (hepatitis)
  • Following investigations are used to evaluate an infant suspected of biliary atresia
  • Ultrasound

–       to rule out other causes of biliary obstruction – e.g. choledochal cyst, choledocholithiasis.

  • Scintigraphy using technetium-99m (99mTc) iminodiacetate (DISIDA)

this radionuclide is taken up by the liver and excreted through bile. If it appears in the intestine extrahepatic bile duct patency is ensured and the diagnosis of biliary atresia is excluded. If it does not appear in the intestine, the diagnosis of biliary atresia can be presumed

  • Liver biopsy

Percutaneous liver biopsy findings might potentially distinguish between biliary atresia and other sources of jaundice such as neonatal hepatitis. Thus liver biopsy can provide most reliable discriminatory evidence.

Still it’s not the most confirmatory investigation for biliary atresia. Whenever the above mentioned investigations point towards extrahepatic biliary atresia, surgical exploration is warranted and an intraoperative cholangiography performed to confirm the diagnosis and see the severity.

Quiz In Between


Q. 13

In cholangiography CBD stone appears as ‑

 A

Meniscus sign

 B

Cut off sign

 C

Slight flow of dye from the sides of stone

 D

Chain of lake appearance.

Q. 13

In cholangiography CBD stone appears as ‑

 A

Meniscus sign

 B

Cut off sign

 C

Slight flow of dye from the sides of stone

 D

Chain of lake appearance.

Ans. A

Explanation:

Ans is a ie Meniscus sign 


Q. 14

Cholangiography via T-tube done after how many days of cholecystectomy –

 A

1-5 days

 B

5-9 days

 C

10-14 days

 D

15-20 days

Q. 14

Cholangiography via T-tube done after how many days of cholecystectomy –

 A

1-5 days

 B

5-9 days

 C

10-14 days

 D

15-20 days

Ans. C

Explanation:

Ans. is ‘c’ i.e. 10-14 days


Q. 15

Dye used in IV cholangiography is ‑

 A

Di an soil

 B

Conray

 C

Biligraffin

 D

Myodil

Q. 15

Dye used in IV cholangiography is ‑

 A

Di an soil

 B

Conray

 C

Biligraffin

 D

Myodil

Ans. C

Explanation:

Ans. is ‘c’ i.e. Biligraffin 

Quiz In Between


Q. 16

All are indications for penile angiography except:

 A

Painful priapism

 B

Peyronie’s disease

 C

Erectile dysfunction

 D

Arterio-venous malformation

Q. 16

All are indications for penile angiography except:

 A

Painful priapism

 B

Peyronie’s disease

 C

Erectile dysfunction

 D

Arterio-venous malformation

Ans. A

Explanation:

Ans is a i.e. Painful Priapism 

Priapism is of two types. A low-flow (ischemic), painful priapism and the other high-flow (non-ischemic), painless priapism.

Penile angiography is not indicated in the painful, low-flow priapism. It is indicated for the high-flow, non-ischemic priapism which is painless.

Priapism

  • Priapism is defined as prolonged erection in the absence of a sexual stimulus.
  • It can be classified into 2 types:

A. Low-flow (ischaemic) priapism.

– features little or absent intracorporal blood flow

–  due to veno-occlusion

– it represents a true compartment syndrome involving the penis

– manifests as painful, rigid erection

– cavernous blood gas values are consistent with hypoxia, hypercapnia, and acidosis

– ischaemic priapism beyond 4th hour requires emergency intervention (decompression of the corpora cavernosa is recommended for counteracting the ischemic effects)

B. High-flow (non-ischemic) priapism

– due to unregulated arterial blood flow

– presents with semi-rigid, painless erection

– Penile or perineal trauma is frequently associated

– cavernous blood gas values do not reveal hypoxia or acidosis

Penile angiography is indicated in high-flow priapism and not in low-flow, painful priapism.

Campbell Urology 8/e p845 writes‑

-Penile arterigraphy has use as an adjunctive study to identify the presence and site of a cavernous artery fistula in the patient with nonischemic priapism. At this time, arteriography is not routinely used for diagnosis and is otherwise usually performed as part of an embolization procedure.”

About other options

Peyronie’s disease

  • It is also k/a penile fibromatosis
  • It is due to fibrous plaques in one or both corpus cavernosum. They may later calcify or ossify.
  • It affects middle-aged and older men.
  • Patients present with complaints of painful erection, curvature of the penis, and poor erection distal to the involved area. The penile deformity may be so severe that it prevents satisfactory vaginal penetration.
  • Examination of the penile shaft reveals a palpable dense, fibrous plaque of varying size involving the tunica albuginea.

Spontaneous remission occurs in about 50% of cases. Initially, observation and emotional support are advised. If remission does not occur, p-aminobenzoic acid powder or tablets or vitamin E tablets may be tried for several months. However these medications have limited success. Surgery is done in refractory cases-Excision of the plaque

with replacement with a dermal or vein graft or tunica vaginalis graft. Penile prosthesis can be inserted after plaque incision.

  • We are not quite sure about use of penile angiography in Peyronie’s disease.

Campbell’s Urology 8/e p826 writes about Peyronie’s disease

“Currently, the use of vascular testing is variable. Some centers perform duplex Doppler testing on all patients with Peyronie’s disease; other centers do not perform vascular testing at all, despite that patients are routinely operated on for Peyronie’s disease and, in some cases, receive prostheses as the primary treatment option. At our center, vascular testing is done on all patients who are prospective surgical candidates. Initially, these patients are examined with color Doppler ultrasonography. If the peak systolic velocity, end-diastolic velocity, and resistive index are normal, the patients are not further tested. If the end-diastolic velocity and the resistive indices are not normal, our patients are tested with DICC.”

[What is DICC?

DICC or Dynamic Infusion Cavernosometry and Cavernosography are widely accepted as the reference diagnostic techniques for evaluation of veno-occlusive dysfunction.

Cavernosometry refers to a method of determining cavernosal pressure response to standardized rates and volumes of fluid infusion in order to define the presence and degree of venous leak.

Cavernosography refers to radiographic demonstration of the corpora cavernosa and their venous effluents after intracavernosal injection of dilute contrast agent.

A well reputed journal – American journal of Radiology in article “Penile Angiography- The Last Angiographic Frontier” at the following website-http://www.afronline.org/cgi/reprint/150/1/47.pdf writes

Cavernosometry and cavernosography as angiographic techniques which along with arteriography constitute the gold standard for diagnosis of vasculogenic impotence.

But Campbell’s urology mentions DICC separate from selective penile angiography.

Thus we are not very sure about Peyronie’s disease. But we are dead sure, painful priapism is not an indication for penile angiography]

Erectile dysfunction

  • “Penile arteriography is another invasive test mainly used prior to penile surgical revascularization in young men with posttraumatic surgical revascularization in young men with posttraumatic or congenital arteriogenic erectile dysfunction with on vascular risk factors, or in studying cases of high flow priapism.”- Handbook of Sexual and Gender Identity Disorders By David L Rowland, Luca Incrocci p5.5

A-V malformation

  • Well penile A-V malformation is quite rare. I could not find any documented evidence for use of penile angiography in A-V malformation, but its use is quite self-evident.

Q. 17

Lymphangiography of the leg is performed by ‑

 A

Injecting sodium diatrizoate retrogradely under pressure into a small vein on the dorsum of the foot

 B

Dissecting lymphatics through an incision on the dorsum of the foot

 C

The use of an infusion pump

 D

All

Q. 17

Lymphangiography of the leg is performed by ‑

 A

Injecting sodium diatrizoate retrogradely under pressure into a small vein on the dorsum of the foot

 B

Dissecting lymphatics through an incision on the dorsum of the foot

 C

The use of an infusion pump

 D

All

Ans. B

Explanation:

Ans. is ‘b’ i.e., Dissecting lymphatics through an incision on the dorsum of the foot 


Q. 18

Premature filling of veins is a manifestation incerebral angiography of –

 A

Trauma

 B

Brain tumour

 C

Arteriovenous malformation

 D

Arterial occlusion

Q. 18

Premature filling of veins is a manifestation incerebral angiography of –

 A

Trauma

 B

Brain tumour

 C

Arteriovenous malformation

 D

Arterial occlusion

Ans. C

Explanation:

Ans. is ‘c’ i.e., Arteriovenous malformation 

In A.V. malformation there is rapid blood flow in veins

Quiz In Between


Q. 19

The glomus tumor invasion of jugular bulb is diagnosed by

 A

Carotid angiography

 B

Vertebral venousvenography

 C

X-ray

 D

Jugular venography

Q. 19

The glomus tumor invasion of jugular bulb is diagnosed by

 A

Carotid angiography

 B

Vertebral venousvenography

 C

X-ray

 D

Jugular venography

Ans. D

Explanation:

 

MRI – gives soft tissue extent of tumor; Magnetic Resonance Angiography (MRA) shows compression of the carotid artery whereas magnetic resonance venography shows invasion of jugular bulb by the tumor.

 



Q. 20

Which of the following is the most specific screening test for renovascular hypertension:

 A

Magnetic Resonance Angiography (MRA)

 B

Spiral Computed Tomographic Angiography (CT Angiography)

 C

Captopril induced Radionucleotide Scan (Captopril Renogram)

 D

Duplex Doppler Ultrasonography

Q. 20

Which of the following is the most specific screening test for renovascular hypertension:

 A

Magnetic Resonance Angiography (MRA)

 B

Spiral Computed Tomographic Angiography (CT Angiography)

 C

Captopril induced Radionucleotide Scan (Captopril Renogram)

 D

Duplex Doppler Ultrasonography

Ans. A

Explanation:

Answer is A (Magnetic Resonance Angiography (MRA)

Magnetic Resonance Angiography (MRA) has now emerged as the most sensitive and specific screening test for Renovascular hypertension.

Note:

Harrison 16‘h edition (old) mentions Spiral CT scan as the most sensitive and specific screening test for Renovascular Hypertension, however most recent textbooks now prefer MRA as the screening test of choice with similar or even better sensitivity and specificity than spiral CT Angiography.

Screening Test

Test

Sensitivity (%)

Specificity (%)

Magnetic resonance

angiography (MRA)

100

96

Spiral computerized

tomography

98

94

Captopril renogram

70-93

95

Duplex Doppler

ultrasonography

69-96

86-90

IVP

—75

—85

Renovascular Hypertension

Test

Sensitivity

Specificity

Conventional Renal

 

 

Angiography

>99%

>99%


Q. 21

A 20 year old female presents with a blood pressure of 160/110 mm Hg.

Clinical examination reveals a bruit in both flanks.

Which of the following statements about this patient is not true (select one option)

 A

Enalapril may deteriorate renal function

 B

Most definitive diagnostic procedure is contrast enhanced angiography

 C

Condition is nearly always bilateral

 D

Surgical intervention may be used

Q. 21

A 20 year old female presents with a blood pressure of 160/110 mm Hg.

Clinical examination reveals a bruit in both flanks.

Which of the following statements about this patient is not true (select one option)

 A

Enalapril may deteriorate renal function

 B

Most definitive diagnostic procedure is contrast enhanced angiography

 C

Condition is nearly always bilateral

 D

Surgical intervention may be used

Ans. C

Explanation:

Answer is C (Condition is nearly always bilateral):

Presence of hypertension (BP = 160 / 110) and bruit in bilateral flanks suggest a diagnosis of Bilateral Renal Artery Stenosis in this patient.

Rena! Artery Stenosis is bilateral in 50% of cases and is not nearly always bilateral

ACE inhibitors (eg Enalapril) may deteriorate renal function in patients with Bilateral Renal Artery Stenosis  ACE inhibitors (eg Enalapril) are the agents of choice for treatment of hypertension in patients with unilateral renal artery stenosis, but are contraindicated in patients with bilateral disease.

The presence of bruit in both flanks suggest bilateral disease in this patient and hence enalapril should not be used

Contrast Enhanced Arteriography (Angiography) is the most definitive diagnostic procedure for the diagnosis of Renal Artery stenosis while Magnetic Resonance Angiography (MRA) is the most sensitive and specific non invasive test (screening test) for its diagnosis.

Fibromuscular dysplasia is the most common cause of Renal Artery stenosis in young women while Atherosclerotic disease is the most common cause in middle aged/ elderly patients.

The patient in question is a young female (20 years) and hence the most likely cause of Renal Artery stenosis in this patient is fibromuscular dysplasia

Surgical Intervention may be required in patients with Bilateral Renal Artery Stenosis

Surgical intervention in the form of angioplasty and stent placement is indicated when medical therapy has failed to control BP or resulted in > 30% increase in serum creatinine.

Renal Artery Stenosis: Review

  • Renal Artery stenosis is an important cause of Renovascular Hypertension
  • Bilateral involvement is seen in half of the affected cases (50%)

Etiology

  • Atherosclerotic disease : This is the most common cause in middle aged /elderly patients
  • Fibromuscular Dysplasia : This is the most important cause in young females

Presentation

Hypertension

– Abrupt onset of hypertension

– Acceleration of previously well controlled hypertension

– Refractory Hypertension

  • Features of increased sympathetic neural activity (which is associated with Renovascular disease)

– Flushing

– Loss of nocturnal BP decrease

– Putonomic instability

– Rapid BP swings

  •  Progressive Renal failure / Azotemia

Diagnosis

Magnetic Resonance Angiography (MRA)

  • MRA is the most sensitive (>90%) and specific (95%) non invasive test for the diagnosis of RAS

Contrast Enhanced Arteriography

  • Contrast enhanced angiography is the most definitive (but invasive) diagnostic procedure for diagnosis of RAS

Management

  • Medical Therapy with ACE Inhibitors or Angiotensin Receptor Blockers

Indications

Unilateral Renal artery Stenosis 

–     With hypertension & normal renal function (more effective than other antihypertensives)

–    With hypertension & abnormal renal function (beneficial effect on survival without affecting renal function)

–     With hypertension, diabetes, proteinuria and normal or abnormal renal function (effective antihypertensives)

Contra indications

Bilateral Renal Artery stenosis

ACE inhibitors or Angiotensin receptor blockers are contraindicated in patients with Bilateral renal artery stenosis or stenosis in a solitary kidney as their use in such patients leads to worsening of renal failure (These patients are especially sensitive to decline in intraglomerular pressure)

Note

Acute Renal Failure / Worsening of Renal Failure with Angiotension Receptor Inhibitors is a diagnostic clue to the diagnosis of renal artery stenosis (indicates bilateral disease)

Surgical Therapy with Angioplasty + Stent placement

Should be considered only after optimal medical therapy has failed to achieve goal BP or resulted in a > 30% increase in serum creatinine

Quiz In Between


Q. 22

Cerebral angiography was performed by:

 A

Sir Walter Dandy

 B

George Moore

 C

Seldinger

 D

Egas Moniz

Q. 22

Cerebral angiography was performed by:

 A

Sir Walter Dandy

 B

George Moore

 C

Seldinger

 D

Egas Moniz

Ans. D

Explanation:

Answer is D (Egas Moniz):

Egas Moniz first performed cerebral Angiography in 1927.

Antonio Egas Moniz, a Portuguese neurologist, first performed cerebral Angiography. He received the Nobel Prize for developing for developing frontal leucotomy as a treatment for psychiatric diseases. In 1927 he performed the first cerebral angiogram in a living human assisted y his colleagues Almeida Lima and Almeida Dias.


Q. 23

Angiography is the investigation of choice in:

 A

Posterior vitreous detachment

 B

Rhegmatogenous retinal detachment

 C

Retinoschisis

 D

Central serous retinopathy

Q. 23

Angiography is the investigation of choice in:

 A

Posterior vitreous detachment

 B

Rhegmatogenous retinal detachment

 C

Retinoschisis

 D

Central serous retinopathy

Ans. D

Explanation:

Ans. Central serous retinopathy


Q. 24

A young adult presents with proptosis and pain in eye after 4 days of trauma to eye. Chemosis, conjunctival congestion and extraocular muscle palsy with inability to move eye are seen. Investigation of choice:

 A

MRI

 B

Digital subtraction angiography

 C

CT

 D

MR angiography

Q. 24

A young adult presents with proptosis and pain in eye after 4 days of trauma to eye. Chemosis, conjunctival congestion and extraocular muscle palsy with inability to move eye are seen. Investigation of choice:

 A

MRI

 B

Digital subtraction angiography

 C

CT

 D

MR angiography

Ans. B

Explanation:

Ans. Digital subtraction angiography

Quiz In Between


Q. 25

Which one of the following is the preferred route for performing cerebral angiography:  

March 2009

 A

Transfemoral route

 B

Transbrachial route

 C

Transradial route

 D

Transaxillary route

Q. 25

Which one of the following is the preferred route for performing cerebral angiography:  

March 2009

 A

Transfemoral route

 B

Transbrachial route

 C

Transradial route

 D

Transaxillary route

Ans. A

Explanation:

Ans. A: Transfemoral Route

Transfemoral route is the preferred route for cerebral angiography.


Q. 26

Investigation of choice for diagnosing lung sequestration is:       

March 2009

 A

X-ray chest-PA view

 B

Plain CT scan-chest

 C

Angiography

 D

MRI

Q. 26

Investigation of choice for diagnosing lung sequestration is:       

March 2009

 A

X-ray chest-PA view

 B

Plain CT scan-chest

 C

Angiography

 D

MRI

Ans. C

Explanation:

Ans. C: Angiography

A pulmonary sequestration, also known as a bronchopulmonary sequestration or a cystic lung lesion, is a medical condition where a piece of tissue that develops into lung tissue is not attached to the pulmonary blood supply and does not communicate with the other lung tissue.

Often it gets its blood supply from the thoracic aorta.

This condition is normally detected in children and is generally held to be congenital in nature.

The treatment for this is a segmentectomy via a thoracotomy.

More and more, these lesions are diagnosed by prenatal ultrasound.

Symptoms can vary greatly, but they include a persistent dry cough.

Sequestrations can be identified in-utero via an abnormal artery on ultrasound.

The gold standard for diagnosis is pulmonary angiography, but it being a very invasive procedure is getting replaced by CT Scan with a contrasting fluid, as the investigation of choice.


Q. 27

Vessels catheterized on carotid angiography are:

 A

2 external carotids and 2 vertebral

 B

2 internal carotids and 2 vertebral

 C

2 internal carotids and 1 vertebral

 D

2 external carotids and 1 vertebral

Q. 27

Vessels catheterized on carotid angiography are:

 A

2 external carotids and 2 vertebral

 B

2 internal carotids and 2 vertebral

 C

2 internal carotids and 1 vertebral

 D

2 external carotids and 1 vertebral

Ans. C

Explanation:

Ans. 2 internal carotids and 1 vertebral

Quiz In Between


Q. 28

Dye used in IV cholangiography is:

 A

Dianosil

 B

Conray

 C

Billigraffin

 D

Myodil

Q. 28

Dye used in IV cholangiography is:

 A

Dianosil

 B

Conray

 C

Billigraffin

 D

Myodil

Ans. C

Explanation:

Ans. Billigraffin


Q. 29

Pulmonary embolism is best diagnosed by:

 A

ECG

 B

Perfusion scan

 C

Angiography

 D

Plain X-ray

Q. 29

Pulmonary embolism is best diagnosed by:

 A

ECG

 B

Perfusion scan

 C

Angiography

 D

Plain X-ray

Ans. C

Explanation:

Ans. Angiography


Q. 30

Premature filling of veins is a manifestation in cerebral angiography of:

 A

Trauma

 B

Brain tumour

 C

Arteriovenous malformation

 D

Arterial occlusion

Q. 30

Premature filling of veins is a manifestation in cerebral angiography of:

 A

Trauma

 B

Brain tumour

 C

Arteriovenous malformation

 D

Arterial occlusion

Ans. C

Explanation:

Ans. Arteriovenous malformation

Quiz In Between


Q. 31

CT scan shows a suharachnoid haemorrhage following symptoms of sudden headache and paralysis. Next investigation of choice is:

 A

4-vessel angiography

 B

SPECT

 C

Transacromial Doppler USG

 D

MRI

Q. 31

CT scan shows a suharachnoid haemorrhage following symptoms of sudden headache and paralysis. Next investigation of choice is:

 A

4-vessel angiography

 B

SPECT

 C

Transacromial Doppler USG

 D

MRI

Ans. A

Explanation:

Ans. 4-vessel angiography


Q. 32

Which one of the following is the most preferred route to perform cerebral angiography?

 A

Transfemoral route

 B

Transaxillary route

 C

Direct carotid puncture

 D

Transhrachial route

Q. 32

Which one of the following is the most preferred route to perform cerebral angiography?

 A

Transfemoral route

 B

Transaxillary route

 C

Direct carotid puncture

 D

Transhrachial route

Ans. A

Explanation:

Ans. Transfemoral route


Q. 33

Which is best for plaque morphology

 A

CCTA

 B

MRI

 C

CMR

 D

IVUS

Q. 33

Which is best for plaque morphology

 A

CCTA

 B

MRI

 C

CMR

 D

IVUS

Ans. A

Explanation:

Ans. is ‘a’ i.e., CCTA

  • Coronary lesions prone to rupture have a distinct morphology compared with stable plaques, and provide a unique opportunity for noninvasive imaging to identify vulnerable plques before they lead to clinical events. This can be achieved using a non-invasive cardiac imaging using coronary CT angiography.
  • o Large plaque volume, low CT attenuation, napkin-ring sign, positive re-moedlling, and spotty calcification are all associated with a high risk of acute cardiovascular events in patients. Intravascular USG can give comparable results but is an invasive test

Quiz In Between


Q. 34

Cerebral angiography was performed by

 A

Sir Walter Dandy

 B

George Moore

 C

Seldinger

 D

Egas Moniz

Q. 34

Cerebral angiography was performed by

 A

Sir Walter Dandy

 B

George Moore

 C

Seldinger

 D

Egas Moniz

Ans. D

Explanation:

Ans. is ‘d’ i.e., Egas Moniz


Q. 35

Puff of smoke appearance on cerebral angiography is seen in:

 A

ACA aneurysm

 B

Cavernous sinus thrombosis

 C

Moyamoya disease

 D

Vein of Galen malformation

Q. 35

Puff of smoke appearance on cerebral angiography is seen in:

 A

ACA aneurysm

 B

Cavernous sinus thrombosis

 C

Moyamoya disease

 D

Vein of Galen malformation

Ans. C

Explanation:

Ans. c. Moyamoya disease


Q. 36

Fundus flouoscien angiography is least useful in

 A

Diabetic retinopathy

 B

 Central serous retinopathy

 C

Cystoids macular edema

 D

None of the above

Q. 36

Fundus flouoscien angiography is least useful in

 A

Diabetic retinopathy

 B

 Central serous retinopathy

 C

Cystoids macular edema

 D

None of the above

Ans. D

Explanation:

Ans. is ‘d’ i.e., None of the above

  • Fluorescein angiography is useful in all conditions.

 Fluorescein angiography is used in :‑

  1. Diabetic retinopathy
  2. Neoplasm
  3. Papilloedema
  4. Central serous retinopathy
  5. Retinitis pigmentosa and other retinal degeneration
  6. Choroidal diseases : Choroidal neovascularization
  7. Vascular occlusions (CRVO, CRAO)
  8. Eale’s disease
  9. Cystoid macular edema

Q. 37

Diagnosis of all is made by fluorescein angiographyexcept‑

 A

Diabetes retinopathy

 B

Hypertensive retinopathy

 C

Central serous retinopathy

 D

Choroidal neovascularization

Q. 37

Diagnosis of all is made by fluorescein angiographyexcept‑

 A

Diabetes retinopathy

 B

Hypertensive retinopathy

 C

Central serous retinopathy

 D

Choroidal neovascularization

Ans. B

Explanation:

Ans. is ‘b’ i.e., Hypertensive retinopathy

Quiz In Between



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