Aneurysm Type by Location

Question 1

Following statements are correct regarding rupture of anterior communicating artery aneurysm except?
● A. It is associated with intracerebral hematoma in 63% of cases
● B. Intraventricular hematoma is seen in 79% of cases with blood entering the ventricles from the intracerebral hematoma in about one-third of these cases
● C. Acute hydrocephalus is present in 25% of cases
● D. Frontal lobe infarction never occurs after SAH from ruptured AComA
● E. These aneurysms result in blood in the interhemispheric fissure

Answer 1

D. Frontal lobe infarction never occurs after SAH from ruptured AComA

Question 2

Surgical approaches for AComA include pterional approach, subfrontal approach, anterior interhemispheric approach, and transcallosal approach. A right pterional craniotomy is used in
all the surgical procedures for AComA except in the following case?
● A. Large AcomA aneurysm pointing to right, in this case left craniotomy, exposes neck before dome
● B. Dominant left A1 feeder to aneurysm (with no filling from right A1), left craniotomy provides proximal control in this case
● C. Additional left-sided aneurysm
● D. Left-sided hematoma causing mass effect
● E. All of the above

Answer 2

E. All of the above

Question 3

Gyrus rectus resection can be done for exposure of arteries and along with it frontal temporal orbital zygoma removal, splitting of sylvian fissure, and ventricular drainage can also be done. Which of the following are critical branches to preserve during AComA aneurysm surgery?
● A. Recurrent artery of Heubner
● B. Small anterior communicating artery perforators
● C. Frontal polar branches
● D. Anterior temporal branches
● E. Both A and B

Question 4

Anterior of the distal anterior cerebral artery (DACA) is usually located at the origin of the frontopolar artery, or at the bifurcation of the pericallosal and callosomarginal arteries at the genu of corpus callosum. Which of the following are usually
aneurysms located more distally?
● A. Post-traumatic
● B. Infectious
● C. Mycotic
● D. Tumor embolus
● E. All of the above

Question 5

Aneurysms up to 1 cm from ACoA artery may be approached through a standard pterional craniotomy with partial gyrus rectus resection while aneurysms more than 1 cm distal to the anterior communicating artery are approached through which of the following?
● A. Subtemporal craniotomy
● B. Frontal craniotomy using bicoronal skin incision
● C. Orbitotemporal zygomatic approach
● D. Quadrangular flap over Keen’s point
● E. None of the above

Question 6

Basilar artery aneurysm constitutes only 5% of aneurysms and dome of these aneurysms usually points superiorly. Critical angiographic features to assess for basilar artery aneurysms include which of the following?
● A. Orientation of the aneurysm which is important because posteriorly pointing aneurysm obscure perforators which may be adherent to the aneurysm, making surgery more difficult
● B. Patency of PCAs and SCAs
● C. Patency and size of PComAs to determine if the P1’s can be sacrificed because diameter of more than 1 mm is needed to support the collateral flow
● D. Height of the aneurysm relative to the posterior clinoid process which will affect the selection of the surgical approach
● E. All of the above

Question 7

Basilar tip aneurysm can be approached through subtemporal or pterional approach. Which of the following statements are correct for comparing subtemporal and pterional approaches?
● A. Subtemporal approach provides less distance to the basilar tip as compared to pterional approach
● B. Subtemporal approach is better than pterional approach for aneurysms projecting posteriorly or posteroinferiorly
● C. Pterional approach needs little or no retraction of temporal lobe as compared to subtemporal approach in which temporal lobe needs to be retracted
● D. There is better visualization of both P1 segments and thalamoperforators using pterional approach as compared to subtemporal approach
● E. All of the above

Question 8

The carotid artery exits the cavernous sinus and enters the subarachnoid space at the dural constrictions known as the carotid ring (also known as clinoidal ring). The supraclinoid portion of the carotid artery is divided into the following seg-
ments except?
● A. Ophthalmic segment which gives rise to ophthalmic artery
● B. Ophthalmic segment which gives superior hypophyseal artery
● C. Communicating segment from the posterior communicating artery origin to the origin of the anterior choroidal artery
● D. Chiasmal segment which gives a branch to optic chiasma
● E. Choroidal segment from the origin of anterior choroidal artery to the terminal bifurcation of the internal carotid artery

Question 9

What is the correct statement regarding ophthalmic arteryaneurysm?
● A. 45% present as subarachnoid hemorrhage
● B. 45% present as visual field defect
● C. Visual field defect can be ipsilateral monocular superior nasal quadrantanopsia or monocular inferior nasal quadrantanopsia or complete loss of vision in one eye with a superior temporal quadrant defect in the contralateral eye
● D. All of the above

Question 10

What percentage of cerebral aneurysms consist of PICA aneurysms?
● A. 2%
● B. 3%
● C. 4%
● D. 5%
● E. 6%

Question 11

A patient was found unconscious by his family and was brought to emergency department. After initial resuscitation basic workup and CT of brain were advised. CT scan shows SAH with interhemispheric subdural hematoma. Which is the most likely vessel involved?
● A. Distal anterior cerebral artery
● B. Posterior communicating artery
● C. Posterior inferior cerebellar artery
● D. Anterior inferior cerebellar artery
● E. Vertebral artery

Question 12

A 46-year-old male presented to ER with severe headache, photophobia, and vomiting. CT of brain shows interhemispheric SAH with IVH. What is the chance for acute hydrocephalus in this patient?
● A. 79%
● B. 63%
● C. 25%
● D. 50%
● E. 100%

Question 13

CT angiogram of a patient with interhemispheric SAH with IVH shows large anterior communicating artery aneurysm greater than 2.5 cm, pointing superiorly along with ICH. What is the preferred surgical approach in this case?
● A. Interhemispheric approach
● B. Pterional craniotomy
● C. Subfrontal
● D. Transcolossal
● E. Subtemporal

Question 14

If clipping is planned, right pterional approach is usually preferred. Left pterional approach is preferred in the following except?
● A. Aneurysm pointing to left
● B. Dominant left anterior feeder
● C. Left-sided ICH
● D. Left-sided another aneurysm
● E. Left occipital horn IVH

Question 15

Regarding distal anterior cerebral artery (DACA) aneurysm, which of the following statements is false?
● A. Usually located at the origin of fronto-polar artery
● B. Can be post-traumatic, infective, or due to tumor emboli
● C. Aneurysms of up to 1 cm from the ACoA may be approached through pterional craniotomy
● D. Incidence of rupture is very less
● E. Both B and C options

Question 16

A 55-year-old male presented to ER with the worst headache of his life while he was on his way to his office. On examination, he was alert, awake, and oriented with left dilated on reactive pupil with restricted upward, inward, and outward gaze.
CT shows aneurysm which impinges on the third cranial nerve. Which of the following is a false statement?
● A. Posterior communicating artery aneurysm occurs commonly with junction to carotid artery
● B. In the presence of fetal circulation, we can sacrifice Pcomm artery without deleterious effects
● C. Pcomm aneurysm points lateral, posterior, and inferior
● D. Surgical clipping may be more advantageous than endovascular coiling to treat oculomotor nerve palsies
● E. None of the above

Question 17

MCA aneurysm was incidentally found on CT of brain of a 35-year-old patient. Clipping of aneurysm was planned. Which is the best statement?
● A. Superior temporal gyrus approach has a minimum brain traction and a better proximal control with decreased risk of seizures
● B. Transsylvian approach is not preferred
● C. Temporary clipping is unavoidable in case of rupture
● D. Distal MCA and recurrent perforators from the origin of the major MCA branches are critical branches to be preserved during clipping
● F. None of the above

Answer 17

D. Distal MCA and recurrent perforators from the origin of the major MCA branches are critical branches to be preserved during clipping

Question 18

Visual field defects in ophthalmic artery aneurysm is about 45% of cases. The most common patterns of field defects may include all except?
● A. Contralateral monocular superior nasal quadrantonopsia
● B. Ipsilateral monocular inferior nasal quadrantonopsia
● C. Ipsilateral blindness with contralateral junctional scotoma
● D. Ipsilateral monocular superior nasal quadrantonopsia

Answer 18

A. Contralateral monocular superior nasal quadrantonopsia

Question 19

What is the most common location of posterior circulation aneurysm?
● A. Vertebral artery aneurysm
● B. Posterior inferior cerebellar artery
● C. Vertebrobasilar junction
● D. Basilar tip
● E. Posterior communicating artery aneurysm

Answer 19

D. Basilar tip

Question 20

In posterior circulation aneurysm, vertebral artery aneurysms are more commonly associated with which of the following?
● A. Nontraumatic is more common
● B. Dissecting aneurysm is more common
● C. May not arise with VA-PICA junction
● D. Coiling is preferred option
● E. None of the above

Answer 20

D. Coiling is preferred option

Question 21

In basilar bifurcation aneurysm, height of aneurysm relative to posterior clinoid affects the selection of approach. Which is the best statement?
● A. In aneurysm greater than 5 mm, inferior approach through supraclinoid approach
● B. 5-mm aneurysm with clinoidal approach
● C. In > 5 mm aneurysm, superior approach through infraclinoidal approach
● D. Transcolossal approach for all sizes
● E. All of the above statements are correct

Answer 21

B. 5-mm aneurysm with clinoidal approach