RadCases Q&A Interventional Radiology (eBook)

Case Questions and Answers

The questions and answers in the following section are numbered as cases 1 through 100. The questions correspond to the respectively numbered case reviews and are intended to be answered after working through the cases.

Case 1

1. The treatment of choice for adventitial cystic disease is which of the following?

a) Surgery

b) Urgent lytic therapy

c) Stent placement

d) In fact, no therapy is required.

The correct answer is (a), because the management is surgical. Aspiration is not useful because it has been described to be associated with a high recurrence rate of the cystic lesions. Doppler ultrasound and MRI are the imaging methods of choice to confirm the diagnosis and demonstrate the cysts and the anatomic relationship with the popliteal arteries.

2. The best imaging modality to make the diagnosis of cystic adventitial disease is…

a) Angiography

b) CT scan

c) Ultrasound

d) Positron emission tomography scan

e) MRI

The correct answer is (e). MRI is the best imaging study to make this diagnosis. The perivascular cysts are well depicted with MRI. Ultrasound may be useful, but it may be difficult to demonstrate the cysts. Angiography will show only the wall irregularity in the wall of the arteries.

Case 2

1. The optimal time for inferior vena cava (IVC) filter removal is which of the following?

a) Always within 2 weeks

b) The longer the indwelling time, the easier the removable filters are to take out.

c) Each filter model has its optimal retrieval window.

d) Filter removal after recommended manufacturer’s optimal window is contraindicated.

The correct answer is (c) because each IVC filter has a recommended manufacturer optimal removal window time. However, IVC filters can be removed even after the recommended optimal window time.

2. Regarding removable or optional IVC filters, the best imaging method to identify a fractured filter is which of the following?

a) Noncontrast CT scan

b) Contrast-enhanced CT scan

c) MRI

d) Kidney, ureter, and bladder radiograph

The correct answer is (d). A kidney, ureter, and bladder (KUB) radiograph, although a very simple test, gives great detail on the status of the IVC filter. One of the most important details to investigate in an IVC filter that has a long-term indwelling time is to look for fractures. The KUB is an excellent imaging modality to identify filter fractures.

Case 3

1. Described complications of percutaneous, image-guided bone biopsies include all of the following except…

a) Infection

b) Fracture

c) Bleeding

d) Tumor seeding

e) Severe pain

The correct answer is (d). Tumor seeding is not a described complication of percutaneous bone biopsy. The complication rate of image-guided bone biopsy is as low as 1%. Open biopsy has a complication rate of ~16%. All other options are described complications of image-guided bone biopsy.

2. Regarding the diagnostic yield of bone biopsies, which of the following statements is false?

a) Target selection is crucial to success.

b) Needle pathway should be carefully evaluated.

c) The presence of a pathologist during the procedure increases the diagnostic yield.

d) MRI is superior to positron emission tomography (PET) scan in directing to the site of highest suspicion.

e) Areas of necrosis should be avoided.

The correct answer is (d). Despite the high sensitivity of MRI for the diagnosis of bone metastases, the specificity is variable. Selecting as a target area those with greater metabolic activity at PET/CT increases the diagnostic yield of a malignant process. PET is easier to interpret and is superior to MRI in guiding to the most likely target of positivity.

Case 4

1. The concept of chronic cerebrospinal venous insufficiency was first described by…

a) Zamboni

b) Zivadinov

c) Haacke

d) Sclafani

e) None of the above

The correct answer is (a). Dr. Paolo Zamboni, an Italian vascular surgeon, is the physician who coined the term “chronic cerebrospinal venous insufficiency,” or CCSVI.

2. The entity known as CCSVI is characterized by which of the following?

a) Renal artery stenosis

b) Bilateral carotid artery stenosis

c) Stroke symptoms

d) Venous obstruction affecting mainly internal jugular veins and the azygos vein

e) Stenosis of the mesenteric arteries

The correct answer is (d). CCSVI is an entity described by Dr. Zamboni. In its original description, CCSVI is a vascular condition characterized by obstructive lesions involving the main extracranial outflow pathways—mainly, both jugular veins and the azygos vein.

Case 5

1. The first report of the use of carbon dioxide as an angiographic contrast agent was published by…

a) Dr. Kurt Amplatz

b) Dr. Itsvan Seldinger

c) Dr. Irvin Hawkins

d) Dr. James Caridi

e) Dr. Charles Dotter

The correct answer is (c); Dr. Irvin Hawkins published the first article on the use of carbon dioxide as a contrast agent for digital subtraction angiography in 1982.

2. All of the following characteristics of carbon dioxide as a contrast agent are considered to be advantageous except…

a) It is non-nephrotoxic.

b) It is nonallergenic.

c) It has very low viscosity and can be injected through small catheters.

d) It is cheap.

e) It can be safely used in cerebral angiography.

The correct answer is (e). Carbon dioxide is contraindicated in arteries above the diaphragm. There is a potential risk for cerebral embolism with significant clinical consequences.

Case 6

1. All of the following statements regarding the Essure system are true except…

a) It is a device for permanent sterilization.

b) The ideal location is within the body of the uterus.

c) The ideal location is within the fallopian tubes.

d) Complications have included unintended pregnancies.

e) The device is made of nitinol.

The correct answer is (b). The Essure system is a nitinol-based permanent sterilization device. It is placed under hysteroscopy and the intended site for placement is within the fallopian tubes. Unintended pregnancy is one of the described complications of this device.

2. Reported complications related to the Essure system include which of the following?

a) Tubal perforations

b) Unintended pregnancies

c) Bleeding

d) Pain

e) All of the above

The correct answer is (e); all of the complications mentioned have been reported with the Essure system. Approved by the U.S. Food and Drug Administration in 2002 with minimal background research, the device is now being reevaluated because multiple complications associated with its use have been reported.

Case 7

1. Regarding spinal osteomyelitis and diskitis, which of the following is true?

a) The most common underlying infection is tuberculosis.

b) The most common mechanism of infection is a surgical complication.

c) Empiric antibiotic therapy is the treatment of choice.

d) Diagnosis should be established with image-guided needle aspiration.

e) None of the above

The correct answer is (d). The Infectious Diseases Society of America guidelines recommend image-guided aspiration of areas suspicious of osteomyelitis and diskitis. Empiric antibiotic treatment is not recommended.

2. Regarding spinal osteomyelitis and diskitis, which of the following is true?

a) Diagnostic sensitivity of needle aspiration is 75 to 90%.

b) Cultures need to be obtained for possible fungal infections.

c) Fungal infections are the cause in < 5% of cases.

d) Needle aspiration should not be obtained if blood cultures are positive.

e) Both a and b are true.

The correct answer is (e). Diagnostic sensitivity of needle aspiration varies depending upon the series reviewed. Sensitivities range between 75 and 90%. Cultures for possible fungal infections need to be obtained, although sensitivity of needle aspiration for fungal infection is lower. Even if blood cultures are positive, needle aspiration is still indicated if imaging studies are suggestive.

Case 8

1. The May–Thurner anatomy is which of the following?

a) The compression of the right iliac artery by the right iliac vein

b) The compression of the left iliac artery by the left iliac vein

c) The compression of the left common iliac vein by the right common iliac artery

d) The compression of the left renal vein by the superior mesenteric artery

e) None of the above

The correct answer is (c). In its classic description, May–Thurner anatomy is the compression of the left iliac vein by the right common iliac artery. This anatomic relationship, in the appropriate clinical scenario, makes the patient prone to iliofemoral venous thrombosis.

2. Regarding the management of symptomatic May–Thurner syndrome, which of the following is true?

a) No treatment is necessary.

b) Conservative therapy with compression hose is accepted as a first step.

c) In patients who present with left iliac vein thrombosis, catheter-directed thrombolysis followed by stent...