Aneurysm—Introduction, Grading, and Special Conditions Flashcards
Trauma is the most common cause of subarachnoid hemorrhage. Which of the following statements are correct regarding aneurysmal subarachnoid hemorrhage?
● A. 10 to 15% of patients die before reaching medical care
● B. Mortality is 10% within first few days of aneurysmal subarachnoid hemorrhage
● C. 30-day mortality rate was 46% in one series and in others over half the patients died within 2 weeks of their subarachnoid hemorrhage
● D. Among patients surviving the initial hemorrhage treated without surgery, rebleeding is the major cause of morbidity and mortality, the risk of which is 15 to 20% within 2 weeks. The goal of early surgery is to reduce this risk
● E. About 30% of survivors have moderate to severe disability, with rates of persistent dependence estimated between 8 and 20% in population-based studies
● F. All of the above
F. All of the above
Etiologies of subarachnoid hemorrhage include trauma and spontaneous subarachnoid hemorrhage (which includes ruptured intracranial aneurysms which includes 75 to 80% of spontaneous subarachnoid hemorrhage, cerebral AVM, certain
vasculitides, rarely due to tumor or cerebral artery dissection). Which of the following are the risk factors of aneurysmal subarachnoid hemorrhage?
● A. Behavioral including hypertension, cigarette smoking, alcohol abuse, sympathomimetic drugs such as cocaine or amphetamines
● B. Gender and race
● C. History of cerebral aneurysm (unruptured aneurysm, bottleneck shape of aneurysm, and increased ratio of size of aneurysm to parent vessel)
● D. Family history of aneurysms
● E. Genetic syndromes like autosomal dominant polycystic kidney disease or type 4 Ehlers Danlos syndrome
● F. All of the above
F. All of the above
A patient presents with sudden onset of severe headache usually with vomiting, syncope, neck pain, and photophobia. All of the following are causes of coma in a patient with aneurysmal subarachnoid hemorrhage except?
● A. Low ICP
● B. Damage to brain tissue due to intraparenchymal hemorrhage
● C. Hydrocephalus
● D. Diffuse ischemia
● E. Seizure
A. Low ICP
What is the gold standard test for evaluation of cerebral aneurysms?
● A. CT angiography of brain
● B. MRA
● C. Catheter angiogram
● D. LP
● E. Plain CT of brain
C. Catheter angiogram
Plain CT of brain can predict aneurysm location based on the pattern of blood in 78% of cases while other findings that can be seen on plain CT of brain include ventricular size, hematoma, and amount of blood in cisterns and fissures. What is the size of aneurysms that can be detected on CT angiography with 98% sensitivity and 100% specificity?
● A. More than 1 mm
● B. More than 2 mm
● C. More than 3 mm
● D. More than 4 mm
● E. More than 5 mm
C. More than 3 mm
Lowering the CSF pressure with an LP may possibly precipitate rebleeding by increasing the transmural pressure (the pressure across the aneurysmal wall) which is prevented using less than or equal to 20-gauge spinal needle and removing only a small amount of CSF. Which of the following are the findings that can be obtained using an LP?
● A. Opening pressure usually elevated with subarachnoid hemorrhage
● B. Nonclotting bloody fluid that does not clear with sequential collection tubes and xanthocromia which is yellow coloration of CSF supernatant due to the lysis of RBCs
● C. RBC count is usually more than 1,00,000/mm cube in subarachnoid hemorrhage
● D. Elevated protein due to blood breakdown products
● E. All of the above
E. All of the above
The size of aneurysm dome, neck size of aneurysm, and dome to neck ratio can be obtained using a catheter angiogram. Narrow necks less than 5 mm are ideal for coiling. What is the dome to neck ratio that is associated with higher rate of successful coil occlusion?
● A. More than 1
● B. More than 1.5
● C. More than 2
● D. More than 2.5
● E. More than 3
C. More than 2
Grades 1 and 2 of Hunt and Hess classification are operated upon as soon as the aneurysm is diagnosed while grades more than or equal to 3 are managed until the condition improves to grade 1 or 2. Exception to this include life-threatening hematoma or multiple bleeds which are operated upon regardless of any grade. Which of the following statements is correct regarding Hunt and Hess classification of SAH?
● A. Grade 1 is asymptomatic or mild headache and slight nuchal rigidity
● B. Grade 2 is cranial nerve 3 or 6 palsy with moderate-to-severe headache and nuchal rigidity
● C. Grade 3 is mild focal deficit, lethargy, or confusion
● D. Grade 4 is stupor, moderate-to-severe hemiparesis, and early decerebrate rigidity
● E. Grade 5 is deep coma, decerebrate rigidity, and moribund appearance
● F. All of the above
F. All of the above
Which of the following statements is incorrect regarding WFNS SAH grading?
● A. Grade 0 is intact patient
● B. Grade 1 is GCS score 15 without any major focal deficit
● C. Grade 2 is GCS score 13–14 without any major focal deficit
● D. Grade 3 is GCS score 13–14 with major focal deficit
● E. Grade 4 is GCS score 7–12 with or without major focal deficit
● F. Grade 5 is GCS score 3–6 without major focal deficit
F. Grade 5 is GCS score 3–6 without major focal deficit
Acute hydrocephalus (HCP) after SAH can result from blood interfering with CSF flow through the sylvian aqueduct, 4th ventricle, or subarachnoid spaces and/or reabsorption at the arachnoid granulations. What is the best management option
for acute hydrocephalus after SAH with poor Hunt and Hess grade?
● A. Urgent ventriculostomy
● B. Keeping the ICP in the range of 15 to 25 mmHg in case of EVD to avoid rapid pressure reduction to decrease the risk of IVC-induced aneurysmal bleeding
● C. Draining CSF slowly after performing an EVD to avoid rapid changes in transmural pressure
● D. Ventriculostomy can cause improvement in 80% of patients with acute hydrocephalus after SAH who are having poor Hunt and Hess grading (grade 4 or 5)
● E. All of the above
E. All of the above
A 70-year-old male presented in the emergency with sudden-onset severe headache followed by loss of consciousness. CT of brain revealed subarachnoid hemorrhage (SAH). What is the most common cause of SAH?
● A. Trauma
● B. Hypertension
● C. Vascular malformations
● D. Telangiectasia
● E. Aneurysm
A. Trauma
A 34-week pregnant woman was brought to the emergency with history of sudden severe headache and altered sensorium. What is the risk of aneurysmal SAH in pregnancy?
● A. 2-fold
● B. 4-fold
● C. 5-fold
● D. 10-fold
● E. No risk
E. No risk
A 45-year-old female presented in the emergency with sudden loss of consciousness. She has a family history of aneurysms. CT of brain showed SAH. Fundoscopy revealed ocular hemorrhages within vitreous humor. What is this condition is called?
● A. Bouchard syndrome
● B. Turcot syndrome
● C. Terson syndrome
● D. Amyloid angiopathy
● E. Gardener syndrome
C. Terson syndrome
A middle-aged female was referred for definitive treatment for aneurysmal SAH. What is the gold standard test for evaluation of cerebral aneurysms?
● A. CT with contrast
● B. Magnetic resonance arteriogram
● C. Lumbar puncture and CSF examination for xanthochromia
● D. Catheter angiogram
● E. Magnetic resonance venogram
D. Catheter angiogram
A middle-aged man presented with sudden-onset headache, altered level of consciousness, and right hemiparesis. On examination, the patient was stuporous with signs of early decerebrate rigidity. What is the Hunt and Hess grade in this case?
● A. 0
● B. 1
● C. 2
● D. 3
● E. 4
E. 4
