A 30-year-old hypertension patient presents with daily headaches. The CXR done shows the following?

Ans. (b) Postductal coarctation. POSTDUCTAL/ADULT type: 1. Lesion at the level distal to ductus arteriosus 2. It is more common 3. Short segment 4. Proximal (prestenotic) & distal (poststenotic) aortic dilatation 5. Collateral circulation 6. Left ventricular overloading: PROMINENT FEATURE PREDUCTAL/INFANTILE type: 1. Lesion at the level proximal to ductus arteriosus 2. Long segment 3. Left ventricular overloading with PULMONARY HYPERTENSION PROMINENT FEATURE - right-sided overload Remember: * Rib notching is due to intercostal vessel dilatation * Scapular notching is due to internal mammary artery Ref - Rib notching refers to deformation of the superior or inferior surface of the rib. It can affect a single rib (from trauma or solitary masses e.g. schwannoma) or can affect multiple ribs. Differential diagnosis The differentials differ according to whether it is the superior or inferior surface that is notched. Superior rib notching abnormal osteoblastic activity osteogenesis imperfecta connective tissue diseases rheumatoid arthritis systemic lupus erythematosus (SLE) Marfan syndrome Sjogren's syndrome local pressure abnormal osteoclastic activity hyperparathyroidism miscellaneous neurofibromatosis type 1 restrictive lung disease poliomyelitis progeria abnormal muscle pull Inferior rib notching (Roesler sign) enlarged collateral vessels coarctation of the aorta interrupted aortic arch subclavian artery obstruction Takayasu disease Blalock-Taussig shunt: involves only upper two rib spaces arteriovenous malformation (AVM) of the chest wall superior vena cava obstruction with enlarged venous collaterals pulmonary AVM neurogenic tumours schwannoma (usually single) neurofibromatosis type 1 (rarely can be superior if neurofibroma is very large) Superior and inferior rib notching hyperparathyroidism neurofibromatosis type 1