Emergency radiology tests rapid decision-making in trauma and acute vascular and abdominal emergencies. These free samples from the RadioQBank published set come with full explanations, exam pearls, and references.
Question 1 · Chest Trauma · easy
A 38-year-old woman is brought to the trauma bay after a horse riding accident. Erect CXR shows blunting of the left costophrenic angle with a fluid level. There is no rib fracture visible. What volume of pleural fluid does blunting of the costophrenic angle on erect CXR typically indicate?
- a. 50–100 mL
- b. 150–200 mL
- c. 300–400 mL
- d. 500–600 mL
Answer: C. Blunting of the costophrenic angle on an erect PA CXR typically requires approximately 300–400 mL of pleural fluid. Fluid first accumulates in the posterior costophrenic recess (seen on lateral view with ~200 mL) before the lateral recess blunts on the PA view at 300–400 mL. Subpulmonic effusions can obscure this pattern and appear as apparent diaphragmatic elevation.
Exam pearl: CP angle blunts on erect PA CXR at ~300–400 mL; posterior recess blunts at ~200 mL on lateral.
AIIMS-MAMC-PGI Chest Radiology; Grainger & Allison 7th ed
Question 2 · Blunt Abdominal Trauma · moderate
A 52-year-old man is brought to the ED following a fall from a building. FAST examination reveals free fluid in Morrison's pouch and the splenorenal space. CT abdomen shows a Grade III liver laceration and a Grade II splenic laceration. He is haemodynamically stable (BP 118/76, HR 90). The CT shows no active extravasation. What is the most appropriate initial management?
- a. Hepatic angioembolisation
- b. Emergency laparotomy
- c. Observation, serial clinical assessment, and serial haematocrit
- d. Splenic angioembolisation
Answer: C. In haemodynamically stable patients with Grade II–III solid organ injuries and NO active CT extravasation, non-operative management (NOM) with close observation is the standard of care. NOM success rates exceed 85–90% for Grade I–III injuries without a vascular blush. Serial clinical monitoring, haematocrit every 4–6 hours, and repeat imaging only if clinical deterioration occurs is appropriate. Admission to a monitored setting with surgical backup is mandatory.
Exam pearl: Stable + Grade I–III injury + no CT blush = NOM with observation; blush or Grade IV–V = angioembolisation.
EAST Trauma Practice Guidelines; AJR 2019;212:W72
Question 3 · Chest Trauma · moderate
A 36-year-old male construction worker falls from scaffolding. CXR shows fractures of the left 4th, 5th, and 6th ribs with paradoxical movement of the left chest wall on inspiration. He is tachypnoeic with SpO₂ 88% on room air. What is this injury pattern called and what is the priority intervention?
- a. Pneumothorax — needle decompression
- b. Flail chest — positive pressure ventilation
- c. Pulmonary contusion — high-flow oxygen only
- d. Traumatic haemothorax — chest drain insertion
Answer: B. Flail chest is defined as fracture of ≥3 consecutive ribs in ≥2 places creating a free-floating chest wall segment that moves paradoxically (inward on inspiration, outward on expiration). The clinical severity is driven primarily by the underlying pulmonary contusion and impaired respiratory mechanics. Positive pressure ventilation (non-invasive if possible, intubation if failing) provides internal pneumatic splinting and maintains alveolar recruitment.
Exam pearl: Flail chest = ≥3 consecutive ribs in ≥2 places + paradoxical motion → positive pressure ventilation.
ATLS 10th ed; Radiographics 2020;40:21
Question 4 · Abdominal Emergency · hard
A 70-year-old man with atrial fibrillation presents with acute onset of severe periumbilical pain out of proportion to examination findings, with no peritonism. Lactate is 3.1 mmol/L. CT angiography of the mesenteric vessels shows absence of flow in the superior mesenteric artery (SMA) with gas in the portal venous system. What is the diagnosis and its prognostic implication?
- a. Mesenteric venous thrombosis; portal gas is reversible with anticoagulation
- b. Acute embolic occlusion of the SMA with established intestinal ischaemia and infarction; portomesenteric gas indicates irreversible bowel necrosis
- c. Non-occlusive mesenteric ischaemia (NOMI); portomesenteric gas is caused by secondary bacterial overgrowth
- d. Chronic mesenteric ischaemia with acute exacerbation; portal venous gas is incidental from air swallowing
Answer: B. Acute SMA embolism is the most common cause of acute mesenteric ischaemia in a patient with AF (cardiac embolic source). Gas in the portal venous system (portomesenteric gas) on CT indicates intestinal infarction with transmural necrosis — bowel wall gas (pneumatosis intestinalis) enters the mesenteric venous system. This is a late, catastrophic sign indicating irreversible bowel infarction with very high mortality (>70–90%). Immediate surgical consultation for emergency laparotomy is required.
Exam pearl: Pain out of proportion to exam + AF + elevated lactate = acute mesenteric ischaemia. Portal gas = irreversible necrosis, mortality >70%.
Grainger & Allison 7th ed; Radiographics 2015
Question 5 · Vascular Emergency · hard
A 60-year-old man develops sudden onset severe back pain and lower limb weakness after a TEVAR procedure performed 3 days ago for thoracic aortic aneurysm. MRI spine shows T2 hyperintensity in the anterior spinal cord at T8–T10. What is the diagnosis and the key artery involved?
- a. Epidural haematoma from the procedure; posterior cord affected with dorsal column signs
- b. Spinal cord ischaemia from coverage of the artery of Adamkiewicz; anterior spinal artery syndrome
- c. Aortic dissection propagation into spinal arteries; complete cord transection
- d. Post-procedural spinal oedema from venous outflow obstruction; manage conservatively
Answer: B. Spinal cord ischaemia is a dreaded complication of TEVAR, occurring in 3–8% of cases. The artery of Adamkiewicz (arteria radicularis magna) is the dominant blood supply to the anterior spinal artery for the lower thoracic and upper lumbar cord, typically originating from T8–T12 segmental arteries. Coverage of intercostal arteries at this level during TEVAR can deprive the anterior spinal artery, causing anterior cord ischaemia (anterior spinal artery syndrome): bilateral lower limb weakness/paralysis + loss of pain/temperature sensation with preserved vibration/proprioception (posterior columns spared).
Exam pearl: TEVAR paraplegia = anterior spinal cord ischaemia from Adamkiewicz coverage. CSF drainage + MAP >90 mmHg are the treatments of choice.
Kandarpa IR Handbook 5th ed; Radiographics 2015