2. Vascular Diseases

Question 1

1. A 35 year-old woman fell while jogging, striking her head on the ground. Though the patient was initially unconscious, she soon seemed to be fine and was able to talk and act normally. Paramedics and an ambulance which initially responded to the accident were told they were not needed and left. Refusing medical attention, she returned home and about three hours later was taken to a local hospital after complaining of a headache. She was transferred from there by ambulance in critical condition and was admitted about seven hours after the fall. She died the next day. This is most characteristic of a hemorrhage into which location?
2. Which vascular structure was damaged?
3. Which complications might occur if the patient starts to herniate?
4. Treatment of choice for symptomatic epidural hematoma is…

Answer 1

1. Epidural hematoma
2. Middle meningeal artery
3. CN III compression, PCA compression, Duret hemorrhage
   
   • CN III compression
     
     • Ipsilateral pupillary dilation and “down and out”
   • PCA compression
     
     • Ischemia of ipsilateral visual cortex and contralateral visual field deficit
   • Duret hemorrhage
     
     • Small areas of bleeding in the midbrain and upper pons
     • Can cause compression of contralateral cerebral peduncle, causing ipsilateral hemiparesis = false localizing sign
4. Immediate nuerosurgical evacuation of the hematoma

Summary

• Bleeding is under arterial pressure and can progress rapidly
• Classically, trauma that causes loss of consciousness → lucid period of several hours → rapid neurological deterioration
• Tx: immediate neurosurgical intervention

Question 2

1. An 80 year-old man was involved in a car accident. He did not lose consciousness and examination at that time showed a small contusion to his forehead. A CT was normal and he was discharged from the ER. A month later he began complaining of headaches, becoming irritable and forgetful. This is most characteristic of a hemorrhage into which location?
2. Which vascular structure was damaged?

Answer 2

1. Subdural hematoma
2. Bridging veins draining from the surface of the brain into the venous sinuses

Summary

• Bleeding under venous pressure and can present insidiously
• Common in elderly patients and alcoholics
  
  • Brain atrophy causes stretching of bridging veins
  • Often no known history of trauma
• Presents as subacute dementia, headache, or slowly progressive focal neurological signs

Question 3

1. A 47 year-old man complains of the sudden onset of a severe, diffuse headache. He vomits then collapses. On exam, he is obtunded and there are no focal neurological signs, but he does groan in pain when his neck is flexed. This is most characteristic of a hemorrhage into which location?
2. Which vascular structure was damaged?
3. 10 days later, patient starts to become aphasic and weak on the right. he is rushed for angiogram, shown below. What is the appropriate treatment in this patient?
4. What factor best predicts clinical outcome in this patient?

Answer 3

1. Subarachnoid hemorrhage (SAH)
2. Ruptured berry aneurysm
   
   1. 80% in anterior circulation, 20% in posterior circulation
   2. The larger the aneurysm, the more likely it is to rupture
3. Nimodipine (calcium channel blocker)
   
   1. Vasospasm is a common complication of SAH. It can result in stroke and should be prevented with a CCB
4. The patient’s level of consciousness

Summary

• Trauma is most common cause, non-traumatic cases caused by ruptured berry aneurysm
• Risk factors:
  
  • Drug use (cocaine, amphetamine, smoking, alcohol), PCKD, fibromuscular dysplasia
• Classically presents as “worst headache of my life”
  
  • Sentinel headache = smaller headaches days/weeks prior to rupture, caused by leakage
• CT scan reveals most SAHs but sometimes LP is needed to detect blood in CSF
  
  • Xanthochromia = yellow-tinge CSF due to breakdown of RBCs
• Tx:
  
  • Neurosurgical clipping or endovascular coiling of aneurysm
  • Nimodipine to prevent vasospasm
  • “Triple-H” therapy - HTN, hypervolemia, hemodilution

Question 4

1. A 76 year-old man with HTN complains of a headache and develops slurred speech. Over the course of 15 minutes, he becomes gradually unable to move the right side of his body and has difficulty speaking. By the time he reaches the ER, he is arousable, but stuporous. This is most characteristic of a hemorrhage into which location?
2. These hemorrhages are commonly seen in which locations?
3. Hemorrhage in which location is most likely to need neurosurgical intervention?
4. What is the main risk factor for these hemorrhages?
5. Hemorrhages in the lobes of the brain, especially in elderly patients are often caused by what?
6. Other causes?

Answer 4

1. Intracerebral hemorrhage
2. Putamen, pons, cerebellum, thalamus
3. Cerebellum
   
   1. Mass lesion or swelling of cerebellum can cause occlusion of 4th ventricle → obstruction of CSF → hydrocephalus → death
4. Hypertension
5. Cerebral amyloidosis
6. Trauma, bleeding into ischemic infarct, AVMs, tumors, or cavernomas
   
   1. ​Cavernoma = masses of abnormal vessels
      
      1. Can cause headaches, seizures, focal neurological deficits
      2. “Popcorn” masses on imaging

Summary

• More progressive onset than ischemic strokes, associated with decreased level of consciousness and headache
  
  • CT scan will distinguish between bleeds and infarcts

Question 5

Anterior cerebral artery infarct - what are the deficits?

Answer 5

• Contralateral motor/sensory deficits
  
  • Leg > arm/face
• Frontal lobe behavioral abnormalities, akinetic mutism
• Transcortical motor aphasia (left side)
• Neglect syndrome (righ side)
• Urinary incontinence

Question 6

Middle cerebral artery infarct - what are the deficits?

Answer 6

• Contralateral motor/sensory deficits
  
  • Face/arm > leg
• Contralateral hemianopsia
  
  • Visual field deficits
  • Eye deviates towards lesion
• Aphasia (left side)
  
  • Superior division = Broca’s aphasia (expressive aphasia)
    
    • Slow and broken speech, follows syntax
  • Inferior division = Wernicke’s aphasia (receptive)
    
    • Fluent spech, gibberish
• Neglect (right side)

Question 7

Posterior cerebral artery infarct - what are the deficits?

Answer 7

• Contralateral hemianopsia
• Alexia WITHOUT agraphia (left-sided)
• Large lesions may cause contralateral motor/sensory deficits due to involvement of midbrain or thalamus

Question 8

A 56 y.o. smoker with a history of DM and HTN developed R hemiparalysis affecting the face, arm, and leg with no other findings. On neurological exam, he displays no sensory loss or cognitive dysfunction. NCHCT was normal. On MRI, the finding will most likely be:

Answer 8

Posterior limb on internal capsule

Question 9

A 70-year-old female developed the sudden onset of right-sided numbness, including her face, right arm, and right leg. Motor function is intact (5/5 bilaterally). She was previously on aspirin for her aortic valve replacement, but discontinued it for a surgery. MRI performed the next day showed an infarct in what location?

Answer 9

Thalamus

Question 10

1. What are the common locations of lacunar strokes?
2. What are the clinical presentations?

Answer 10

1. Refer to imaging:
   
   • A. subcortial white matter
   • B. cerebellum
   • C. thalamus
   • D. pons
   • E. posterior limb of internal capsule
   • F. basal ganglia
2. Classical signs
   
   1. Pure motor - localizes to internal capsule
   2. Pure sensory - localizes to thalamus
   3. Ataxic hemiparesis
   4. Clumsy-hand/dysarthria
   5. NOT associated with higher cortical functions (aphasia, neglect syndrome)

Question 11

1. What is the clinical pattern found in brainstem strokes?
2. What are the typical signs and symptoms?

Answer 11

1. “Crossed findings”
   
   1. Ipsilateral cranial nerve deficit
   2. Contralateral motor and sensory deficits
2. Signs and symptoms:
   
   1. Dizziness/vertigo, ataxia, nausea, imbalance, double vision, nystagmus, dysarthria, dysphagia
   2. Coma - if damage to reticular activating system

Question 12

1. What is Wallenberg syndrome (lateral medullary syndrome)?
2. What are the signs and symptoms?

Answer 12

1. Occlusion of vertebral artery or PICA
2. Signs and symptoms:
   
   1. Dysphagia, hoarseness, dizziness, nausea/vomiting, nystagmus, imbalance, gait incoordination
   2. Intractable hiccups
      
      1. Treat with thorazine
   3. Loss of pain and temperature
      
      1. Contralateral side of body
      2. Ipsilateral side of face
   4. Ipsilateral Horner’s syndrome
      
      1. Ptosis, miosis, anhidrosis

Question 13

1. What are the signs and symptoms of a cerebellar stroke?
2. What are the complications?

Answer 13

1. Symptoms
   
   1. Ipsilateral ataxia
      
      1. Lateral cerebellar stroke = ipsilateral arm/leg weakness
      2. Medial cerebellar stroke = gait imbalance + incoordination
   2. Nausea/vomiting, vertigo, dysarthria, nystagmus
2. Complications
   
   1. Risk for hydrocephalus + occlusion of 4th ventricle

Question 14

1. What are the causes of watershed infarct?
2. What are the signs and symptoms?

Answer 14

1. Hypoperfusion of brain from
   
   1. Hypotension, CHF, carotid stenosis
2. ACA/MCA distribution presents with weakness of proximal arm and leg muscles with preservation of distal strength

Question 15

What are the causes of embolic stroke?

Answer 15

Artery-to-artery thrombosis

• Carotid stenosis

Heart-to-artery

• Intracardiac clot usually from A-fib
• Paradoxical embolus
  
  • Embolus originates from venous system → reaches brain by traveling through cardiac defect, avoiding pulmonary circulation

Question 16

1. What are the risk factors of venous infarct?
2. What are the signs and symptoms?
3. What is the treatment?

Answer 16

1. Risk factors: hypercoaguable state, pregnancy/postpartum, infections, medications (oral contraceptives + smoking)
2. Indolent presentation compared to arterial infarcts
   
   1. Seizures, headache, signs of increased ICP
   2. LP will show elevated opening pressure
   3. Papilledema
3. ​Immediate heparin (even in presence of bleeding)

*Most patients with strokes before age 30 have venous infarctions

Question 17

A patient has the scan below. The symptom that most likely brought the patient to medical attention was transient…

Answer 17

Monocular blindness

Amaurosis fugax

• Curtain coming down over one eye
• Central retinal artery temporarily occluded

Question 18

A patient suffers a stroke and is thought to be comatose. An observant clinician notices the patient moving their eyes up and down and determines that the patient can respond to questions through these eye movements. The likely site of the occlusion is the…

Answer 18

Tip of the basilar artery

Locked-in syndrome

• Condition in which patient is aware and awake but can only move the eyes
• Caused by lesion in ventral pons

Question 19

A patient goes to a chiropractor who twists her head in a rapid fashion. This is a known risk factor for which condition?

Answer 19

Vertebral artery dissection

A dissection occurs when there is a tear in an arterial wall, and blood flows in between the layers of the artery rather than through the lumen of the artery. This serves as a nidus for clot formation.

Risk factors of dissection:

• Healthy young people
• Neck trauma
• Connective-tissue disorders

Signs and symptoms:

• Neck pain + symptoms of ischemia
• Carotid dissection can present with Horner’s syndrome

Question 20

1. A 75 year-old man notices that he is weak on the right side of his body when he gets up from his chair after eating breakfast. He is brought to the ER within 30 minutes. A CT there is normal. The preferred treatment in this patient is…
2. A 75 year-old man notices that he is weak on the right side of his body when he gets up from his chair after eating breakfast. He is brought to the ER within 7 hours. A CT there is normal. The preferred treatment in this patient is…

Answer 20

1. tPA (tissue plasminogen activator)
2. Aspirin

Question 21

You strongly suspect a patient has an ischemic stroke based on history and physical. You feel that the patient is a good candidate for thrombolytic therapy. Your next step is…

Answer 21

Noncontrast head CT (NCHCT)

The main reason to do a CT scan is not to see evidence of an acute stroke, but rather to rule out mass lesions or bleeds, which can mimic acute ischemic stroke. Even in a massive stroke, a CT may be normal for many hours, though clot within the affected vessel may be seen, termed the dense MCA sign.

CT without contrast:

• Bright = blood and calcium

Question 22

What are the contraindications for administering tPA?

Answer 22

Contraindications:

• Minor or rapidly resolving deficits
• Glucose < 50 mg/dL
• Recent trauma or surgery
• Hemorrhage
• Blood pressure > 185/110
• INR > 1.7
• Platelet count < 100,000/uL

tPA should be administered within 3 (maybe 4.5) hours from onset of symptoms

• The goal is to save the ischemic (not yet infarcted) tissue = penumbra

Main complications of tPA = hemorrhage

• Occurs in 6% of patients
• tPA is safe to give to non-stroke patients

Question 23

A 36 year-old woman develops the acute onset of left-sided weakness. An MRI confirms that she has had a stroke. The patient has had several prior miscarriages. A hematology consult is ordered, and the patient is found to have a positive lupus anticoagulant. The preferred treatment to prevent another stroke in this patient is…

Answer 23

Warfarin

Question 24

The most sensitive scan for revealing an acute ischemic stroke is…

Answer 24

Diffusion-weighted imaging (DWI)

• Hyperintensity on DWI + hypointensity on ADC = restricted diffusion
  
  • Characteristic of ischemia
• Other lesions (tumors, active MS lesions, etc.) can also cause restricted diffusion

Question 25

A patient suffered an ischemic stroke. Which psychiatric symptom is most likely after this?

Answer 25

Depression

• Post-stroke mania is likely due to a right-sided stroke

Question 26

1. What are the secondary stroke prevention methods?
2. Should a patient take anticoagulant or antiplatelet agents?
3. What are these agents?
4. When should a patient have a carotid endarterectomy or carotid stent?
5. What ist he management of young stroke patients?

Answer 26

1. All stroke patients:
   
   1. Statin (regardless of of lipid profile)
   2. Goal BP 120/80
   3. Treat diabetes (blood glucose, HA1c)
   4. Smoking cessation, dietary modification, physical exercise
2. Anticoagulant for cardioembolic source and antiplatelet for atherosclerotic event
   
   1. TEE shows clot = anticoagulation
   2. EKG shows A-fib = anticoagulation
3. Agents
   
   1. Antiplatelets
      
      1. Aspirin, clopidogrel (Plavix), aspirin/dipyridamole (Aggrenox)
   2. Anticoagulants
      
      1. Dabigatran (Pradaxa), rivaroxaban (Xarelto), apixaban (Eliquis), warfarin
4. Carotid doppler/MRA shows > 70% stenosis
5. Hypercoaguable/rheumatological work-up
   
   1. ​Inherited coagulation cascade disorders:
      
      1. Antithrombin III deficiency
      2. Protein C and S deficiency
      3. Activated protein C resistance
      4. Factor V Leiden
      5. Prothrombin gene mutation
   2. Antiphospholid syndrome
      
      1. Lupus anticoagulant, anticardiolipin antibodies
   3. Check for cocaine, syphilis, HIV

Question 27

A patient suffers several small strokes the age of 45. The same thing happened to his brother and father, each of who became demented at an early age. The patient tells you he has a history of migraines. An MRI shows innumerable old, lacunar strokes and white matter disease. You suspect…

Answer 27

Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL)

Inherited stroke disorders:

• CADASIL
  
  • Presents with migraines, dementia, multiple lacunar strokes
• MELAS (mitochondrial encephalopathy with lactic acidoses and stroke)
  
  • Maternal inheritance
  • Stroke-like episodes often in occipital region
  • Seizures and dementia
• Sickle-cell disease

Question 28

A 45 year-old woman develops headaches and multiple small strokes. An angiogram is performed and shown below. What is the diagnosis?

Answer 28

CNS vasculitis

Signs on imaging:

• “Beads on a string” appearance

Question 29

A patient suffered from cardiac arrest. CT of the head is shown below. What is the diagnosis?

Answer 29

Cerebral anoxia

Signs on imaging:

• “Reversal sign” = cerebellum is bright
• Blurring of gray and white matter

Causes

• Cardiac arrest, respiratory arrest, near-drowning, asphyxia, carbon monoxide poisoning

Vulnerable parts

• Baal ganglia - putamen, caudate, globus pallidus, substantia nigra, pars reticularis

Symptoms

• Comatose state
• Parkinsonism, dystonia

Treatment

• Induce hypothermia

Question 30

A 36 year-old male develops the acute onset of confusion and cortical blindness. His MRIs are below. What is the diagnosis?

Answer 30

Posterior reversible encephalopathy syndrome (PRES)

• Commonly seen as a consequence of sudden, drastic increases in blood pressure
  
  • In women, common in eclampsia
• Occipital lobes are most commonly affected
  
  • Other structures in posterior circulation can be affected
    
    • Cerebellum
• Signs and symptoms:
  
  • Seizures, visual disturbance, headache, mental status changes