Cardiovascular Radiology for Postgraduate Exam

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Cardiovascular Radiology for Postgraduate Exam

18 Aug, 1:30 PM

[Music] good evening everyone this is our second program in netflix platform and second program turf expansion under the leadership of dr m c j prakash president of iria kerala dr teacher matthew secretary ira kerala with turf expansion program headed by dr jose corville just a word to our co-organizers pgs and attendees please keep your audio mute while presentation is on and if there's any clarification or questions please write on the comment box on the left side of the screen this evening we have professor dr chandra shekar and keshavadas from sri chitra tirunal institute for medical sciences and technology for the opening remarks may i request professor dr keshavadas for the same welcome sir good evening thank you dr judy and welcome to dr rangarajan as well as jasim it is indeed a pleasure to join this session of turf expansion on cardiovascular radiology in the early 90s in 91 when i joined md we used to use two uh textbooks one is the saturn and the other was the bridge i don't know whether you still use granger i'm sure it's still there and during those days the chapter in cardiovascular imaging was something which we used to read very fast because there were hardly much questions going which were going to come and most of the work in cardiovascular was being done by the cardiologist so we had to just report x-rays x-ray of the cardiac x-rays as well as lung x-rays related to cardiac diseases so that was the only thing that we had to report during those days but later on things have changed and we know now that ct especially multi-slice ct uh the very fast cities that we have today as well as the mr has really revolutionized the imaging of cardiac diseases of course the nuclear medicine has also its role and the echocardiography was there for quite some time but it is mostly the cardiologists who are still doing it but the field has really grown so much that along with interventional radiology and neuro radiology there have many institutions which have started fellowship programs and even dm programs bm program is available at present in two institutions uh one is the holiday institute of medical sciences and the other is sri chitradinar institute of medical sciences where we have a course in cardiovascular radiology and into an interventional radiology so vascular interventional radiology so these two departments are there and there is a lot of scope in cardiovascular radiology when you work very closely with cardiologists and cardiac surgeons and cardiac anesthesiologists you learn a lot that this whole field we can contribute a lot the radiologists can really contribute a lot in this area there is the society also of cardiac imaging which is doing wonderful work a lot of teaching programs they are conducting and the ira of course is also conducting a lot of programs and i am sure that at least a few of the postgraduate students who are attending this today's session will be inspired by the talk and will be joining this particular course either a dm in cardiovascular radiology or a fellowship program where with these words i uh i invite all of you to ask questions and also you can ask questions related to the subject because as i understand dr vingrajan is also a dm in cardiovascular radiology from all in the institute of medical sciences and they are present in one of the best institutions in the country where the radiology is really doing a great job all in the institute of medical sciences so i give it back to judy judy you can take over thank you thank you thank you sir our moderator this evening is dr ranger assistant professor and cardiovascular interventional radiologist of ames youth poor welcome sir his residents dr smith smiley and dr mayuk will be presenting the cases which will surely be interesting for those who are getting ready for the exams on behalf of the organizers i welcome dr dengaraj and raja gopal to start this session over to you sir uh thank you sir and thank you ma'am for your introduction and thank you ira kira for giving me this opportunity and as sir previously highlighted most of the cardiac patients are now dependent on cross-sectional imaging for their diagnosis right starting right from ct coronary angiography to going to structural heart disease as well as congenital heart disease so cardiac city and cardiac hammer have sort of become inevitable in the management algorithm of patients who are admitted under cardiology and ctbs so i i my talk is basically four long cases which can be given to the residents during their exams so uh two of our brilliant minds dr smiley and dr mayu will be presenting these two cases so and then briefly at the end i'll just give a short briefing on how to approach a cardiac case if it is given in the postgraduate examination and some pointers to outs towards the acquisition techniques and the recent advances so now i would like i would invite dr smiley and my you smiley miu can switch on their videos actually [Music] yup so the first case first dr mayuk will be presenting two cases so we just start yeah good evening i am doctor finally rpg i shall be presenting two cases of cardiovascular radiology my first case is of a 25 year old male patient who presented with gradual onset of breathlessness and atypical chest pain the patient had no cardiovascular comorbidities in no cardiovascular comorbidities were known in the patient and the clinical examination showed an elevated jugular venous pulse the the patient uh underwent a chest radiograph as an initial examination and the frontal chest radiograph shows a normal heart size and there is evidence of biatrial enlargement as we can see the lateral margin of the right atrium is present at a distance of greater than 5 centimeter from the line joining the vertebral spinous processes and there is evidence of left atrial enlargement as we can see because the left main bronchus has been pushed up it is slightly more horizontal and as well as there is some straightening of the left heart margin near the region of the left atrial appendage i can also see some evidence of curvilinear calcification surrounding the cardiac shadow mainly along its diaphragmatic surface and along the left left margin of the heart there is some evidence of back pressure seen in the form of a prominent shadow of the svc seen just superior to the shadow of the right atrium as well as some prominent pulmonary venous shadows venous markings are seen in bilateral lung fields and few septal markings are seen towards the lung bases in the periphery this is a zoomed in view of the same which is more clearly depicting the curvilinear calcification surrounding the cardiac shadow along its diaphragmatic aspect and also along the left margin of the heart and to sum up my findings there is a normal heart size along with biatrial enlargement calcification surrounding the heart likely in the in the pericardium there are some signs of back pressure in the form of pulmonary venous hypertension and dilated superior vena cava and the patient underwent a cardiac city these are consecutive ct sections of the same in the four chambered view here we can see that the thickened calcific pericardium is surrounding almost the almost the entire heart in uh including the right and the left ventricles and the shape of the ventricular chambers is somewhat more tubular and elongated suggestive of constriction of the ventricles by the unyielding thick calcific pedicardium [Music] these are consecutive ct sections in the coronal view which is depicting the calcification in the pericardium the thick calcific pericardium which is seen to envelop chiefly both the ventricular chambers and reaching almost up to the root of the great vessels these are a few these are some few representative images on the left are the coronal images as they were seen in the previous city sections and on the right side these are short axis views uh of the heart uh showing an enveloping of almost both the ventricles the right ventricle and the left ventricle in a circumferential manner by the thickened calcific pericardium [Music] these are again ct images in four chambered view uh showing the heart in the face of systole and the diastole these images clearly depict that as we move from the systole to the diastole there is not much receptive relaxation taking place in the ventricular chambers because they are being constricted by the fibrotic calcific pericardium leading to diastolic dysfunction at the same time the atrial chambers appear quite prominent due to back pressure these are vrt images showing the thick plaque-like calcification in the pericardium which is surrounding chiefly the ventricular portion of the cardiac chambers both the right and the left ventricles um these are these are contrast enhanced ct sections of the abdomen and these depict some calcific lymph nodes uh in the paratrooper region as well as we can see that the thickened calcific pericardium which was surrounding the ventricles is almost reaching up to the root of the great presence which is an indicator of dilated spc as we see also at this prominence yeah this is a condition where the compliance of the pericardium is decreased resulting ultimately in diastolic dysfunction and ultimately heart failure various causes can lead to this condition first and foremost is tuberculosis pericarditis which is commonest in india other other forces could be pyogenic pericarditis this is any bacterial cause and now as the incidence of tb is decreasing some other causes are becoming more common and emerging in front and one of the most important causes is post authority also irradiation for treatment of any malignancies also uranic pericarditis can lead to calcified constricted particle varieties now speaking about calcium calcified constrictive pericarditis here there there is a generalized thickening of the pericardium surrounding the heart with calcifications this calcific thickening of the pericardium is most pronounced over the right heart the right ventricle and the anterior heteroventricular groove the underlying cardiac cavities are constricted by this abnormal unyielding pericardium which is leading to its flattening and tubular shepherd appearance of the ventricles also there are a few indirect signs which are mainly the signs of back pressure due to diastolic failure of the ventricles and these include unilateral or bilateral atrial enlargement along with dilation of the superior inferior vena cava and the hepatic veins this back pressure can also lead to pleural effusion and ascites this condition could easily be recognized on the ct images because ct defects calcification quite easily mr can also help in mr we can see thickened fibrotic and calcific pericardium which would show a low signal on the t1 and t2 weighted images pericardial enhancement can also be depicted in mri and any presence of pericardial enhancement it's suggestive of a continuing inflammatory process going on in the end stage of the disease where there is chronically fibrous form of constrictive pericarditis there is no enhancement seen anymore so the other cases which can be given in the exam are processes so in that you will see a fluid density between the two layers of pericardium versus we can see enhancement the same for the same case you might also be given cardiac mr images and restriction can be demonstrated in the abscess as well as uh there can be enhancement of the pericardium late phases so uh that was in a nice case and going on to the second case yes sir yes my second case is of a pediatric patient a four-year-old male patient who had multiple episodes of cyanotic spells and difficulty in feeding frontal chest radiograph was performed for the patient and it shows here in this frontal chest radiograph we can see that the major portion of the liver that is the right lobe the larger part of the liver is present on the right side of the abdomen and we can see the splenic shadow towards the left side now tracing the tracheal and the bronchial margins bronchial tracheal and bronchial shadow i can see that the right main bronchus with its characteristic morphologic appearance which is more vertical and broad is present towards the right side of the thorax all these findings add up to a cytosolitis in the viscera atrial situs and looking towards the cardiac shadow we can see that the cardiac shadow is near about normal in size with no major significant enlargement i can see that the cardiac apex is having a right ventricular morphology it is lifted up and in the upper part of the left heart border there is a concavity of pulmonary bay now in the bilateral lung lung fields i can see that the highlight markings are greatly diminished and the lungs also appear hyperloosened and over penetrated likely due to size stream of pulmonary oligarmia so to sum up the findings we had a cytosolitis in the visceration situs with normal heart size right ventricular configuration of the cardiac apex along with pulmonary olegemia and a prominent thymic shadow [Music] the patient underwent a cardiac city these are consecutive city sections of cardiac city in the four chambered view here we can see that there is a prominent aorta arising from the left ventricle but no pulmonary artery is seen to arise and in the lower set of images i can see that that is presence of a vsd in the interventricular septum and the aorta is seen to override the interventricular septum these are consecutive ct sections along the right ventricular outflow tract here i can see that the pulmonary trunk is not seen to exit from the right ventricle so as to your pulmonary atresia upper row of ct images are sequential sections along the left ventricular outflow tract here i can see that a very prominent aotic root and ascending iota is seen to come out of the left ventricle the lower set of images are consecutive coronal sections which depict the superior and the inferior vena cava draining into a cardiac chamber on the right side suggestive of morphological right atrium being on the right side as per the law of phenoatrial concordance these are a few representative ct images the image on the left depicts the large major portion of the liver on the right side and the spleen and the stomach on the left side suggestive of situ solidus in the abdomen the image on the right side is mainly showing the bronchial branching and morphology the morphological right bronchus as evidenced by its more broad configuration and more vertical alignment along with early branching of the right upper lower bronchus it is present on the right side so that is also a cytosolic in the thoraco abdominal situs the image on the left side is a coronal image here i can see that both the vena cava are draining into the a cardiac chamber which is present on the right side suggestive of right atrium morphologic right atrium being on the right side as per the law of genoaterial concordance all these three findings ultimately lead to the conclusion that in the visceral arterial situs that is cytosolic arrangement towards the right side the upper image here we can see the morphologic right ventricle as evidenced by the presence of the moderator brand is present anteriorly suggestive of deconfiguration of the ventricular loop the image which is present below on the right side uh is showing a very prominent ascending root uh arising from the heart but there is no pulmonary root arising size to your pulmonary atresia image on the left is a 4 chambered view representative image which is showing the deficiency in the membranous part of the interventricular septum system of membranous vsd and upon it there is overriding of the aorta and image on the right side is the image on the right side is a short axis view of the heart which is depicting the vsd and the overriding of the iota over it image on the left is is a ct section along the right ventricular output track which is showing the pulmonary atresia the middle image is a city section along the left ventricle outflow tract showing the enlargement of the aortic root and the ascending aorta the rightmost image here we can see that a dilated vessel is arising from the descending thoracic aorta and entering the right lung which is suggestive of the pulmonary collaterals secondary to pulmonary atresia so our diagnosis the to sum up the major findings these are a very membranous type of vsd which is sub-aortic in location with aortic ovarian there is pulmonary atracia along with right ventricular hypertrophy there are major aortic pulmonary collaterals and there is a tree of ventricular and ventricular arterial concordance so our diagnosis is tetralogy of valid the severe form of tetralogy of phthalate that is tetralogy of followed with pulmonary atracia so a few slides about this condition of tetralogy of phthalate it is one of the it is the most common congenital cyanotic heart disease its components include pulmonary stenosis this pulmonary stenosis is usually present at multiple levels in infundibular level valvular level and supra-alveolar level it can be present at various levels but in almost all the cases the infundibular level stenosis is always present and it is accompanied with stenosis at other levels that is secondary right ventricular hypertrophy secondary to pulmonary stenosis there is overriding of aorta over the intraventricular septum and there is a non-restrictive type of vsd tautology of fallout could also be associated with other cardiac anomalies one of the most commonest among them is the right-sided aot arch also there could be additional sites of stenosis in the distal pulmonary arterial branches another anomaly could be that the left anterior descending branch of coronary artery could be arising from the right coronary artery and passing in front of the right ventricular outflow tract the main radiographic findings in tetology fallout include decreased pulmonary vascularity the cardiac size is normal or nearly normal because in this case the hypertrophy which takes place in the right ventricle is due to pressure overload this is a concentric type of ventricular hypertrophy in the later cases in the late case when failure and ventricular enlargement take place then the cardiac size could increase that is right this right ventricular prominence leads to upliftment of the cardiac apex there is a concavity of the main pulmonary arterial segment due to its stenosis and reduced blood flow the highlight shadow where the main component is the pulmonary artery due to reduced blood flow in the pulmonary arteries the high level shadows become small and there is prominent ascending yoga as which has inverse relationship with the size of the pulmonary artery as the size of pulmonary artery decrease the ascending outer size increases the next two cases shall be presented by dr smiley yeah so briefly talking about congenital heart disease mostly you might be given a chest x-ray of tetralogy of phallit or dapvc which is which gives a figure of 8 appearance that is well known so uh cardiacity you can get images of top or transmission of great arteries where importantly you should focus on which great artery is arising from which ventricle and other cardiac conditional cardiac diseases that you can get are epstein's anomaly where you see an effect apocalypse displacement of the septal posterior threats of the tricuspid valve so that should also be noted so these are the commonest things that can be given for the exam and when you're starting to comment upon a congenital case always start with the cytos just as my you started so comment on the abdominal site is the bronchial situs and then the cardiac cycles then go on to describe the defects that you are starting to see so you should also have a look at the lung windows and most often these patients also have associated tuberculosis because of their deranged immunity and due to pulmonary overflow also in overflow conditions so you should always carefully look at the lungs also and tell whether there are any central lobular nodules or any patches of consolidation so we'll go for the third case and dr smiley is our current cardiac fellow she will be presenting the third and the fourth case yes good evening sir a very good evening to all of you i am going to present the next two cases on cardiovascular radiology the first case is of a 55 year old male who presented to trauma and emergency with complaints of shortness of breath and intense chest pain radiating to back for three days there was a history of fall from height four days back the patient did not have any significant past history the patient underwent a frontal chest radiograph this frontal chest radiograph shows mediastinal widening with abnormal iotic contour and loss of definition of iota pulmonary window there is mild displacement of the trachea towards the right side and depression of the left main bronchus the left cp angle is planted and diffuse haziness is seen along the left hemithorax there is no significant bony or soft tissue abnormality based on the radiograph findings in the setting of trauma and the finding of mediastinal widening the most the probable diagnosis was of iotic trauma in a case of mediastinal widening in the setting of trauma we have to consider traumatic iotic injury the differentials in other clinical settings include thoracic ionic aneurysm mediastinal lymphadenopathy mediastinitis mediastinal masses or a prominent thymus in case of a child the patient underwent ecg gated ct angiography these are the non uh these are the non contrast exe contiguous axial sections of the thorax which show medial displacement of the intimal calcification this is well appreciated in the first image in the lower row there is a hyperdense span in the descending thoracic iota and contiguous mediastinal hematoma the subsequent non-contrast sections show the mediastinal hematoma and the contiguous left-sided pleural effusion minimal right-sided pleural effusion was also seen the arterial face these are the arteria these are the axial sections of the arterial face contrasting on ct angiogram where we can see a dissection flap in the descending thoracic aorta separating the true and the false humans in the lower three images we can see the true and the false humans the true lumen is on the medial aspect as it is continuous with the iota and has similar enhancement like that of the rest of the ayat and they are sending ayotta we can see a calcific focus along its outer wall which is very specific sign for true human the lumen on the lateral side is a false lumen as it is showing lesser enhancement as compared to the true human it in the last third image we can see the percentage shape of the false human and the con the flap is convex towards the false human in the last second image we can also see the site of the entry tier in the descending thoracic iota these are the subsequent sections where we can see spiraling of the false lumen around the true human contiguous mediastinal hematoma and left sided pleural effusion is seen these are the sagittal mip images where we can see the differentially enhancing true and the false humans in the second image in the first row we can see the proximal extent of the dissection which was distal to that of the left subclavian artery this was suggestive of type b stand for dissect stand for type b iotic dissection and there was a contiguous mediastinal hematoma with pleural effusion suggestive of rupture summarizing our findings with few representative sections these are the this is the axial non-contrast ct section where we can see a hypertense band in the descending thoracic iota with mediastinal hematoma surrounding the descending thoracic iota these are the few representative image images in the delayed phase where we can see more enhancement of the false human as it is a delayed phase imaging in the first image on the left side we can see the site of entry tier in the descending thoracic aorta in the first image in the lower row we can see the crescentic shape of the false human and the sagittal image shows the proximal extent of the dissection distance to the left subclavian artery these are the sagittal and the coronal images showing the spiraling of the false human around the true neumann and the proximal extent of the dissection distance to the left subclavian artery these are the delayed phase images in the coronal and the sagittal view the first image shows the distant extent of the dissection that was in the infrarenal iota there was a large reentry pair at this in the juxta in these images we can see that the light renal artery was seen to arise from the false human whereas the left renal artery in the first image and the superior mycentric artery in the second image were seen to arise from the true lumen so our diagnosis was stand for type biotic dissection with mediastinal hematoma and left continuous pleural effusion suggestive of rupture so stanford type biotic dissection is amenable to endovascular treatment the indications for endovascular management include any complicated dissection as was in our case with rupture any impending rupture or already ruptured iotic dissection in chronic or subacute cases if the ionic diameter is more than 0.5 uh more than 5.5 centimeter and if serial examinations are available there is increase in the iotic diameter more than 0.5 centimeter in 6 months very important to know are the chest radiograph signs of iotic rupture as were seen in our case these include mediastinal widening abnormal iotic contour left apical gap tracheal displacement towards the right side displacement of the nasogastric tube towards the right side depression of the left main bronchus and loss of definition of the ayato pulmonary window almost all these signs were present in our radiograph the patient underwent endovascular management with thoracic and vascular aneurysm repair the first the digital subtraction angiograph image in the left anterior oblique view of the thoracic aorta shows the differentially uh differential pacification of the true and the false human the second image shows the placement and the deployment of the iot extent graph and the third post procedural image shows the iot extent craft in c2 a follow-up radio graph showed the iot extent graphed in c2 with decrease in the mediastinal biotiny the follow-up ct on the right side image shows the endova the thoracic iotic craft in c2 and we can see that the true lumen has normally a pacifier and there is significant reduction in the opacification of the false tumor so we have seen a good case of type b stand for stanford type biotic dissection very important to know is the difference between true and false human in a case of ionic dissection the true lumen is one which is contiguous with rest of the iota and usually has a round or oval configuration whereas the false human has a crescentic configuration the curvature of the flap is usually convex towards the false lumen there is delayed enhancement of the false human as compared to the thrombosis is common in the false human and a specific sign which is present in the false human are thin linear strands known as cop fifth signs which represent uncompleted medial uh medial dissection uh one of the specific signs in true lumen is the outer wall calcification which was seen in our case the size of the true lumen is usually large in the iotic root and ascending iota and it is small in the descending iota uh whenever we are we have to report a case of iotic dissection we have to remember a few points like uh which can be easily remembered by a mnemonic dissection which include the first d of the dissection stands for that weathery dissection or any acute ionic syndrome is present or not and whether there is involvement of the ascending iota we have to mention about the site of the intimal tier we have to mention about the size of the iota and the false human we have to mention about the segment of the iota involved the extent of the dissection and any complication associated we have to mention whether the falsely false human is thrown we have to inspect the false or the true human for any uh like for any complication and we have to consider other factors in the history of the patient for example the cause to rule out the cause of the dissection like hypertension any vasoconstrictive drugs the history of trauma etc if we are doing a serial examination it is important to notify the progression of the iotic dissection the size of the false human and of the iota ah so that was a great case so uh the cases that can be given in the exam or a stand for type b d section or a type a dissection also can come in the exam so in addition to this case if you are given a case of type a dissection you should always comment on whether the coronaries are arising from the false lumen or or the true lumen so that is one important finding which has to be even reported on the ct reports because that gives immense information to the cardiac surgeon second thing is also look for the amount of lv dilatation so that can give a [Music] vague estimate of how much the ar is there so that will again give some details to the cardiac surgeon on when he has to operate so always try to comment about the presence of plural or pericardial effusions and mediastinal hematoma which is which can be seen around the trachea as well as the main bronchi on either sides and also always look at the intensity because sometimes there is only a haziness in the uh peritracheal and berry bronchial fat so that is also an indicator of impending rupture and so always also comment about the compression of left left main bronchus if there is a dilatation of that segment and if there is any compression of the left pulmonary artery that should also be commented so these are the important things that you should uh see when you are reporting a case of a type a iot section or a type b iot section in addition you can be asked in squatters about penetrating iot ulcers or image so uh always uh when you're given a chest squatter always look at the uh iota also so what that is one thing which is commonly missed by the students in postgraduate examination so we'll go to the last case the last case is of a 29 year old male who had history of polycythemia and presented with the chief complaints of cuff and fever for which the patient underwent a frontal chest radiograph the frontal chest radiograph pa view shows a well-defined soft tissue density mass in the right upper and mid lung zone with the lobulated margin there is no presence of any calcification cavitation or air fluid level within the mass the surrounding lung parenchyma appears to be normal there is dilation of right upper low pulmonary artery which is seen feeding into the mass rest of the lung fields appear to be unremarkable the trachea is central the cardiac size is normal by lateral cp angles are clear and there is no evidence of any bony or soft tissue abnormality so with the finding of a well-defined multi-lobulated mass station in the right upper and mid lung zone with feeding artery enlargement the probable x-ray diagnosis was given to be of pulmonary avm to confirm the presence of pulmonary avm the patient underwent ct pulmonary angiogram these are the axial pulmonary angiography images showing the the presence of a tuft of vessels in the posterior segment of right upper lobe with a large training vein having an enhancement similar to that of the pulmonary artery there are few prominent vessels also seen in the vicinity of the tuft of vessels and the training vein these are the subsequent these are the contiguous coronal sections representing the tuft of vessels in the right upper low uh of in the right upper low and showing the draining of the the draining vein into the right superior pulmonary vein as seen in the last three images these are the sagittal images representing the presence of multiple arterial feeders supplying the tuft of vessels which were arising from the posterior segmental branch of light apollo pulmonary artery so considering the presence of tuft of vessels with the presence of an early draining vein and multiple arterial feeders the diagnosis of a complex pulmonary avm was confirmed summarizing our findings with a few representative sections these are the mediational window and the lung window ct pulmonary angiography images showing the tuft of muscles in the posterior in the posterior segment of right and below with the prominent training vein having enhancement similar to that of pulmonary artery and few prominent vessels representing the feeding arteries of the pulmonary avm these are the sagittal mip images where we can see the draining vein running into the super right superior pulmonary vein the the first vessel on the top is represents the draining vein and multiple arterial feeders are seen arising from the posterior segmental branch of the right upper lobe familiar tree supplying the pulmonary avian these are the representative axial and the coronal images where if we carefully carefully see there was another small pulmonary avm just medial to the main lesion and it had similar drainage and supply as that of the main pulmonary avm so we had a case of two pulmonary avms with one of them being complex and other being the simple permeability the diagnosis was of pulmonary avm with the arterial feeders from right upper low pulmonary artery and draining into the right superior pulmonary discussing a few points about pulmonary avm these are abnormal communications between the pulmonary arterial and the venous system with bypassing of the capillary bed the most important association to remember with pulmonary avm is of hereditary hemorrhagic tilanjectasia these can be simple if there is only single feeding artery and single training vein and complex if multiple arterial feeders are there as was seen in our case this can also be diffuse involving a segment of the lung or whole of the lung the test radiograph finding is of a non-specific soft tissue density nodule or mass where we may or may not see the feeding vessels city pulmonary angiography is the modality of choice where we can see a serpogenous mass connected with vessels cct helps to determine the feeding artery the aneurysmal component and the early draining vein so these are the salient points of pulmonary artery venous malformation which we should remember thank you smiley that was again a fantastic case and uh one thing we should remember is uh the mainstay of treatment in case of pulmonary artery venous malformations nowadays is uh endovascular uh embolization unless it is a diffuse uh low bar pulmonary avm where surgical resection is offered otherwise a lesser number of patients go for surgery for simple pulmonary avms and so when you see nodular lesions on the chest x-ray which have dilated the vessels which are going towards the lesion so you should always consider vascular masses and aneurysms or abms as a differential diagnosis so sometimes you might be given a case of vested species where that can be pulmonary artery aneurysms or pulmonary avm is also one of the common cases that has been given in the exam so uh i just kept my presentation short and i just showed four important cases which can be given in the md radiology exam so i just briefly tell the points which you have to remember while discussing um radiographs and cts ct angiograms cardiac cities in the exam so you should always comment upon the cytos first then always talk about the cardiac size whether it is enlarged or normal in size then talk about the configuration of the apex in the chest x-ray talk about the pulmonary vascularity so it can be pulmonary plethora pulmonary or leukemia pulmonary arterial hypertension pulmonary venous hypertension or differential vascularity so you should always categorize the pulmonary vascularity into one of these conditions if you are describing the chd and then see the iota and the media stand-up for all the findings that i told so these are the main things to concentrate upon a cardiac case in the exam otherwise in the theory part you can be asked about the reset advances such as strain imaging t1 t2 maps iron quantification and dual energy ct ct perfusion which is coming up in a big way for uh as a one-stop shop and also we have started doing cta ffr and ctfr is one very big upcoming modality which helps the cardiologists to categorize lesions which should be treated lesions which need not be treated and can be observed on medical management and again in cmr you should learn to basically identify a case of ischemic cardiomyopathy and basic other cardiomyopathies like hypertrophy cardiomyopathy identify lg first on a ir image and see how lg looks if so that picking up energy at the md level is a will be considered as a great positive uh will give you a lot of marks basin so these are the things and uh so i would like to finally thank uh kerala ira um and all the other coordinators sir everyone who gave me this opportunity and i am unfortunate that the session was very short so and next time probably we'll try to show more cases and discuss more studies thank you dr rangirajin raja gopal from and your residents for their excellent cases and its class presentations from dr smiley sharma and dr mayok now i welcome dr jasim joint secretary of ira kerala for the vote of thanks dr jason hi am i audible yes yes yeah good evening everyone it's my pleasure to give the vote of thanks for this program uh firstly let me thank the president of iria kerala dr the secretary the energizing power behind everything good that's happening in ira uh dr keshav dasa who is always ever present in all the academic programs and dr jose kuruvilla who is the coordinator of the turf expansion program and of course the excellent talks that were given by the ames jokpo team headed by dr rangarajan and of course dr mayuk and dr smiley who presented the case i thank you very much they were excellent presentations and good cases i'm sure all the people who have attended today have taken valuable notes from these sessions and of course doctor ramesh nyser who is always ever present with all the technical support and the technical team of netflix who provided the platform and all the viewers who've attended here today i thank you all and of course the ever smiling dr judy thank you so much for the wonderful comparing thank you all very much you

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IRIA, Kerala brings another interesting session for all the radiology exam going students to brush up all the basics of CVS radiology, learn some new hacks and tricks from the one of the best faculty across the country. Join us for an insightful discussion.

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