CerebroVascularDisease Flashcards

1
Q
  1. Which of the following should be done next?
    a. Administer tissue plasminogen activator
    b. Call a vascular surgery consult for possible endarterectomy
    c. Order a brain CT
    d. Order a cerebral angiogram
    e. Start heparin
A

The answer is c. (Shuaib, p 58.) This is a good history for cardioembolic
stroke—sudden onset, cortical symptoms, atrial fibrillation,
and subtherapeutic INR. The immediate goal should be to rule out an
intracranial hemorrhage and confirm the diagnosis. Tissue plasminogen
activator is the treatment for acute stroke in specific circumstances. However,
it is not yet certain that this is a stroke. It may be an intracranial
hemorrhage, which would be a contraindication for tissue plasminogen
activator. Additionally, an elevated INR in a patient on warfarin is a contraindication
for tissue plasminogen activator. Carotid endarterectomy is
indicated for some cases when a transient ischemic attack or stroke is
believed to be caused by carotid artery narrowing. It is not yet known
what caused this patient’s event, and this procedure would rarely be done
emergently. A cerebral angiogram would be indicated if you had strong
suspicion of an aneurysm or vascular malformation. There is no reason to
believe one of these is causing the patient’s symptoms. Heparin may be
indicated if there is not an intracranial hemorrhage. This must first be
established by CT or MRIThe answer is c. (Shuaib, p 58.) This is a good history for cardioembolic
stroke—sudden onset, cortical symptoms, atrial fibrillation,
and subtherapeutic INR. The immediate goal should be to rule out an
intracranial hemorrhage and confirm the diagnosis. Tissue plasminogen
activator is the treatment for acute stroke in specific circumstances. However,
it is not yet certain that this is a stroke. It may be an intracranial
hemorrhage, which would be a contraindication for tissue plasminogen
activator. Additionally, an elevated INR in a patient on warfarin is a contraindication
for tissue plasminogen activator. Carotid endarterectomy is
indicated for some cases when a transient ischemic attack or stroke is
believed to be caused by carotid artery narrowing. It is not yet known
what caused this patient’s event, and this procedure would rarely be done
emergently. A cerebral angiogram would be indicated if you had strong
suspicion of an aneurysm or vascular malformation. There is no reason to
believe one of these is causing the patient’s symptoms. Heparin may be
indicated if there is not an intracranial hemorrhage. This must first be
established by CT or MRI

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2
Q
46. The patient has an MRI that is consistent with an acute stroke. The
most common cause of stroke is
a. Atherosclerosis
b. Fibromuscular dysplasia
c. Mitral valve prolapse
d. Arterial dissection
e. Meningovascular inflammation
A
  1. The answer is a. (Victor, p 825.) Atherosclerosis may produce cerebral
    infarction by a variety of mechanisms, including emboli to the brain and
    local occlusion of atheromatous vessels. Platelet emboli may form on ulcerated
    atheromatous plaques in major vessel walls and ascend to the brain. The
    atherosclerotic plaque involves subintimal proliferation of smooth muscle,
    fatty deposits in the intima, inflammatory cells, and excessive elaboration of
    the connective tissue matrix in the vessel wall. Thrombi may form on the surface
    of the plaque and occlude the vessel, even if the plaque is not large
    enough to produce substantial narrowing of the vessel. Fibromuscular dysplasia
    is a relatively uncommon cause of cranial vessel occlusion that develops
    with segmental overgrowth of fibrous and muscular tissue in the media.
    Meningovascular inflammation is a rare process that occurs in some infectious or inflammatory disorders, such as syphilis, tuberculous meningitis, or
    sarcoid.
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3
Q
  1. A pure motor stroke is most likely with damage to the
    a. Internal capsule
    b. Cerebellum
    c. Putamen
    d. Caudate
    e. Amygdala
A
  1. The answer is a. (Victor, p 831.) Pure motor deficits are especially
    likely in hypertensive persons with small infarctions called lacunae. The
    pure motor stroke is the most common type of lacunar stroke. The affected
    person usually has hemiplegia unassociated with cognitive, sensory, or
    visual deficits. The posterior limb of the internal capsule is the usual site of
    injury. The lacunae are assumed to develop because of an occlusive lesion
    in an arteriole that supplies the injured structure.
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4
Q
  1. A pure sensory stroke is most likely with damage to the
    a. Internal capsule
    b. Thalamus
    c. Hippocampus
    d. Globus pallidus
    e. Pons
A
  1. The answer is b. (Victor, p 839.) Pure sensory strokes are most likely
    in the same persons who are susceptible to pure motor strokes and other
    lacunae. With hypertensive injury to the posteroventral nucleus of the lateral
    thalamus, the affected person will report contralateral numbness and
    tingling. During recovery from this type of stroke, paradoxical pain may
    develop in the area of sensory impairment. This paradoxical pain associated
    with decreased pain sensitivity is referred to as the thalamic pain syndrome.
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5
Q

A 61-year-old man with a history of hypertension has been in excellent
health until he presents with vertigo and unsteadiness lasting for 2 days. He
then develops nausea, vomiting, dysphagia, hoarseness, ataxia, left facial
pain, and right-sided sensory loss. There is no weakness. On examination, he
is alert, with a normal mental status. He vomits with head movement. There
is skew deviation of the eyes, left ptosis, clumsiness of the left arm, and titubation.
He has loss of pin and temperature sensation on the right arm and leg
and decreased joint position sensation in
the left foot. He is unable to walk.

49. Magnetic resonance imaging (MRI) in this patient might be expected
to show which of the following?
a. Basilar artery tip aneurysm
b. Right lateral medullary infarction
c. Left lateral medullary infarction
d. Left medial medullary infarction
e. Right medial medullary infarction
A
  1. The answer is c. (Victor, pp 844–846.) Wallenberg, or lateral
    medullary, syndrome is due to infarction involving some or all of the structures
    located in the lateral medulla, including the nucleus and descending
    tract of the fifth nerve, the nucleus ambiguus, lateral spinothalamic tracts,
    inferior cerebellar peduncle, descending sympathetic fibers, vagus, and
    glossopharyngeal nerves. The patient with Wallenberg syndrome has ipsilateral
    ataxia and ipsilateral Horner syndrome. The trigeminal tract damage
    may produce ipsilateral loss of facial pain and temperature perception and
    ipsilateral impairment of the corneal reflex. The lateral spinothalamic damage
    produces pain and temperature disturbances contralateral to the injury
    in the limbs and trunk. Dysphagia and dysphonia often develop with damage
    to the ninth and tenth nerves.
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6
Q

A 61-year-old man with a history of hypertension has been in excellent
health until he presents with vertigo and unsteadiness lasting for 2 days. He
then develops nausea, vomiting, dysphagia, hoarseness, ataxia, left facial
pain, and right-sided sensory loss. There is no weakness. On examination, he
is alert, with a normal mental status. He vomits with head movement. There
is skew deviation of the eyes, left ptosis, clumsiness of the left arm, and titubation.
He has loss of pin and temperature sensation on the right arm and leg
and decreased joint position sensation in
the left foot. He is unable to walk.

50. The dysphagia in this case is secondary to involvement of which of the
following structures?
a. Nucleus solitarius
b. Nucleus and descending tract of CN V5
c. Nucleus ambiguus
d. Lateral spinothalamic tract
e. Inferior cerebellar peduncle
A
  1. The answer is c. (Victor, pp 844–845.) The nucleus ambiguus, located
    in the ventrolateral medulla, contains the motor neurons that contribute to
    the ninth (glossopharyngeal) and tenth (vagus) cranial nerves. The motor
    neurons of the nucleus ambiguus innervate the striated muscles of the larynx and pharynx as well as provide the preganglionic parasympathetic supply to
    thoracic organs, including the esophagus, heart, and lungs. Injury to this
    nucleus and its pathways causes hoarseness and dysphagia.
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7
Q

A 61-year-old man with a history of hypertension has been in excellent
health until he presents with vertigo and unsteadiness lasting for 2 days. He
then develops nausea, vomiting, dysphagia, hoarseness, ataxia, left facial
pain, and right-sided sensory loss. There is no weakness. On examination, he
is alert, with a normal mental status. He vomits with head movement. There
is skew deviation of the eyes, left ptosis, clumsiness of the left arm, and titubation.
He has loss of pin and temperature sensation on the right arm and leg
and decreased joint position sensation in the left foot. He is unable to walk.

  1. Occlusion of which of the following arteries typically produces this
    syndrome?
    a. Basilar artery
    b. Vertebral artery
    c. Superior cerebellar artery
    d. Anterior inferior cerebellar artery (AICA)
    e. Anterior spinal artery
A
  1. The answer is b. (Victor, pp 842–846.) Most cases of lateral medullary
    infarction are due to occlusion of the vertebral artery. Several small
    branches of the distal vertebral artery supply the lateral medulla. In some
    cases, occlusion of the posterior inferior cerebellar artery (PICA) causes
    this syndrome. The PICA is the last large branch of the vertebral artery, and,
    when it is occluded, there may also be infarction of the inferior cerebellum
    accompanying that of the medulla.
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8
Q
  1. A 75-year-old man with a history of recent memory impairment is
    admitted with headache, confusion, and a left homonymous hemianopsia.
    He has recently had two episodes of brief unresponsiveness. There is no history
    of hypertension. Computed tomography (CT) scan shows a right occipital
    lobe hemorrhage with some subarachnoid extension of the blood. An
    MRI scan with gradient echo sequences reveals foci of hemosiderin in the
    right temporal and left frontal cortex. The likely cause of this patient’s symptoms
    and signs is
    a. Gliomatosis cerebri
    b. Multi-infarct dementia
    c. Mycotic aneurysm
    d. Amyloid angiopathy
    e. Undiagnosed hypertension
A
  1. The answer is d. (Osborn, pp 192–194.) Cerebral amyloid angiopathy
    (CAA), or congophilic angiopathy, is the most common cause of lobar hemorrhage
    in elderly patients without hypertension. The deposition of
    β-amyloid protein (the same as that found in Alzheimer’s disease) in brain
    blood vessels leads to disruption of the vessel walls, which predisposes
    them to hemorrhage. Patients are usually over age 70 and may present with
    multiple cortical hemorrhages with or without a history of dementia. At
    times, additional hemorrhages may be seen only on special imaging techniques,
    such as gradient echo MRI, which magnifies the effects of hemosiderin
    in regions of prior hemorrhage.
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9
Q

A 22-year-old male abuser of intravenous heroin complains of severe
headache while having sexual intercourse. Within a few minutes of that
complaint, he develops right-sided weakness and becomes stuporous. His
neurologic examination reveals neck stiffness as well as right arm and face
weakness. An unenhanced emergency CT scan reveals a lesion of 3 to 4 cm
in the cortex of the left parietal lobe. The addition of contrast enhancement
reveals two other smaller lesions in the right frontal lobe but does not alter
the appearance of the lesion in the left parietal lobe.

53. The diagnostic study most likely to establish the basis for this patient’s
neurologic deficits is
a. HIV antibody testing
b. Cerebrospinal fluid (CSF) examination
c. Electroencephalography
d. Nerve conduction studies
e. Cardiac catheterization
A
  1. The answer is b. (Victor, pp 902–903.) This young man almost certainly
    has numerous problems associated with his intravenous drug abuse,
    but the cause of his current complaints is most likely bleeding from a
    mycotic aneurysm. Aneurysms are especially likely to bleed during exertion,
    such as that associated with sexual intercourse or defecation. The fact
    that the lesion appeared largely the same on unenhanced and enhanced CT
    scans suggests that it is a hematoma. HIV antibody testing might reveal evidence
    of exposure to HIV, but, aside from establishing that the patient was
    at increased risk of opportunistic infections, that test would provide little
    insight into the cause of the acute neurologic syndrome. The CSF would be
    expected to be xanthochromic (yellow) with many (>20/μL) red blood cells
    (RBCs) or grossly bloody, thereby providing evidence of a recent subarachnoid
    hemorrhage. Electroencephalography would undoubtedly reveal an
    asymmetric pattern associated with the left hemispheric lesion, but this too
    would provide little insight into the cause of the problem. Nerve conduction studies would not clarify the basis for a lesion of the central nervous
    system, because they only examine structures of the peripheral nervous
    system. Cardiac catheterization might reveal valvular abnormalities, but
    these need not be associated with disease of the central nervous system.
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10
Q

A 22-year-old male abuser of intravenous heroin complains of severe
headache while having sexual intercourse. Within a few minutes of that
complaint, he develops right-sided weakness and becomes stuporous. His
neurologic examination reveals neck stiffness as well as right arm and face
weakness. An unenhanced emergency CT scan reveals a lesion of 3 to 4 cm
in the cortex of the left parietal lobe. The addition of contrast enhancement
reveals two other smaller lesions in the right frontal lobe but does not alter
the appearance of the lesion in the left parietal lobe.

  1. The patient’s HIV antigen test is positive, but he has no depression of his
    CD4+ (helper) T lymphocyte count. Nerve conduction studies reveal generalized
    slowing in the legs, and EEG exhibits depressed voltage over the left parietal
    lobe. Cardiac catheterization suggests aortic valve disease, and his CSF is
    xanthochromic (yellow). The probable site of injury in the CNS is
    a. An arterial wall
    b. The ventricular endothelium
    c. The pia arachnoid
    d. The dura mater
    e. The perivenular space
A
  1. The answer is a. (Victor, pp 902–903.) The most likely explanation for
    this patient’s deficits is bleeding from a mycotic aneurysm. This type of
    aneurysm is usually relatively small and might not be evident on CT scanning
    or even on arteriography. An arteriogram would miss the lesion if it had
    destroyed itself when it bled or if the aneurysmal sac was completely thrombosed.
    The name mycotic is misleading. It suggests a fungal etiology, but it
    actually refers to the appearance of these aneurysms, which tend to be multiple.
    These aneurysms occur with either gram-positive or gram-negative
    infections, but the responsible organisms usually have relatively low virulence.
    Mycotic aneurysms form over the cerebral convexities with subacute
    bacterial endocarditis. The aneurysm develops from an infected embolus
    originating on the diseased heart valves and lodging in the arterial wall.
    Bleeding from these small aneurysms is largely directed into the subarachnoid
    space. More virulent organisms that produce valvular heart disease are
    more likely to produce a meningitis or multifocal brain abscess with seeding
    of infected emboli to the brain. With acquired immune deficiency syndrome
    (AIDS), a fungus could be the causative agent, but patients with endocarditis
    more typically have streptococcal or staphylococcal infections. Even if mycotic
    aneurysms form with endocarditis, they need not inevitably become
    symptomatic
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11
Q

A 22-year-old male abuser of intravenous heroin complains of severe
headache while having sexual intercourse. Within a few minutes of that
complaint, he develops right-sided weakness and becomes stuporous. His
neurologic examination reveals neck stiffness as well as right arm and face
weakness. An unenhanced emergency CT scan reveals a lesion of 3 to 4 cm
in the cortex of the left parietal lobe. The addition of contrast enhancement
reveals two other smaller lesions in the right frontal lobe but does not alter
the appearance of the lesion in the left parietal lobe.

  1. Within 1 day of admission, the patient’s right-sided weakness began to
    abate, and within 1 week it completely resolved. On the fourth day of hospitalization,
    the patient abruptly lost consciousness and exhibited clonic
    movements starting in his right side and generalizing to his left side. The
    movements stopped within 3 min, but he had residual right-sided weakness
    for 24 h. CT scan was unchanged from that obtained on admission.
    The most appropriate treatment to institute involves
    a. Heparin
    b. Recombinant tissue plasminogen activator (r-TPA)
    c. Lamotrigine
    d. Phenytoin
    e. Warfarin
A
  1. The answer is d. (Victor, pp 356–360.) Anticoagulation with warfarin
    or heparin and thrombolysis with r-TPA or urokinase are contraindicated
    in anyone with an intracranial hemorrhage. Focal seizures that secondarily
    generalize after an intracerebral or subarachnoid hemorrhage occur frequently
    and are appropriately treated with an antiepileptic drug, such as
    phenytoin (Dilantin). Lamotrigine is an anticonvulsant, but would be a
    very poor choice in this case because this patient needs a drug that will be
    immediately therapeutic. Lamotrigine must be slowly titrated over many
    weeks when first started, because of the risk of severe rash.
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12
Q

A 22-year-old male abuser of intravenous heroin complains of severe
headache while having sexual intercourse. Within a few minutes of that
complaint, he develops right-sided weakness and becomes stuporous. His
neurologic examination reveals neck stiffness as well as right arm and face
weakness. An unenhanced emergency CT scan reveals a lesion of 3 to 4 cm
in the cortex of the left parietal lobe. The addition of contrast enhancement
reveals two other smaller lesions in the right frontal lobe but does not alter
the appearance of the lesion in the left parietal lobe.

  1. The focal weakness lasting for 24 h was most likely attributable to
    a. Intracerebral hemorrhage
    b. Subarachnoid hemorrhage
    c. Encephalitis
    d. Todd’s paralysis
    e. Hyponatremia
A
  1. The answer is d. (Victor, pp 345–346.) That the patient had weakness
    after the seizure activity is evidence of a postictal paralysis, or Todd’s paralysis. Postictal weakness does not suggest extension of the bleeding or new
    areas of cerebrocortical damage, but imaging with CT scan is appropriate to
    exclude these possibilities. Postictal paralysis may last for many hours, or
    even days. The precise cause is unknown, but it appears to be due to some
    kind of neuronal exhaustion occurring after frequent repetitive discharges.
    It may reflect depletion of glucose in the neurons in the epileptic focus.
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13
Q
  1. A 16-year-old girl with complex partial seizures and mild mental retardation
    has an area of deep red discoloration (port-wine nevus) extending
    over her forehead and left upper eyelid. A CT scan of her brain would be
    likely to reveal
    a. A hemangioblastoma
    b. A Charcot-Bouchard aneurysm
    c. An arteriovenous malformation
    d. A leptomeningeal angioma
    e. A fusiform aneurysm
A
  1. The answer is d. (Greenberg, 2/e, p 601. Victor, pp 1077–1078.) This
    patient has encephalofacial angiomatosis (Sturge-Weber syndrome), a congenital
    disturbance that produces facial cutaneous angiomas with a distinctive
    and easily recognized appearance, along with intracranial abnormalities
    such as leptomeningeal angiomas. Persons with the syndrome may be mentally
    retarded and often exhibit hemiparesis or hemiatrophy on the side of the
    body opposite the port-wine nevus. Both men and women may be affected,
    and seizures may develop in affected persons. The nevus associated with
    Sturge-Weber syndrome usually extends over the sensory distribution of CN
    #6, the first division of the trigeminal nerve. The lesion usually stays to one
    side of the face. Affected persons will usually also have an angioma of the
    choroid of the eye. Intracranial angioma is unlikely if the nevus does not
    involve the upper face. Deficits develop as the person matures and may be a
    consequence of focal ischemia in the cerebral cortex that underlies the leptomeningeal
    angioma. Hemangioblastomas are vascular tumors seen in association
    with polycystic disease of the kidney and telangiectasias of the retina
    (von Hippel-Lindau syndrome). Charcot-Bouchard aneurysms are very small
    and may be microscopic. They develop in patients with chronic hypertension
    and most commonly appear in perforating arteries of the brain. The lenticulostriate
    arteries are most commonly affected. Hemorrhage from these
    aneurysms is likely, and the putamen is the most common site for hematoma
    formation. Hemorrhage may extend into the ventricles and lead to subarachnoid
    blood. Other locations commonly affected include the caudate nucleus,
    thalamus, pons, and cerebellum. The dentate nucleus of the cerebellum is
    especially susceptible to the formation of Charcot-Bouchard aneurysms.
    Fusiform aneurysms are diffusely widened arteries with evaginations along
    the walls, but without stalks as occur with the typical berry-shaped structures
    of the saccular aneurysm. This type of aneurysm may be a late consequence
    of arteriosclerotic damage to the artery wall.
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14
Q
  1. A 72-year-old woman has the abrupt onset of right face and hand
    weakness, disturbed speech production, and a right homonymous hemianopsia.
    This is most likely attributable to occlusion of the
    a. Left middle cerebral artery
    b. Left anterior cerebral artery
    c. Left vertebrobasilar artery
    d. Right anterior choroidal artery
    e. Left posterior inferior cerebellar artery (PICA
A
  1. The answer is a. (Victor, pp 834–835.) The left middle cerebral artery
    supplies the cortex around the sylvian fissure, as well as some of the frontal lobe structures involved in speech. The optic radiation loops through the
    temporal lobe on its way to the occipital cortex and is usually damaged
    with occlusion of the middle cerebral artery. The speech disorder likely
    with an injury of the left frontal lobe is a Broca’s aphasia. Comprehension
    would be expected to be largely intact, but if the patient has damage to
    enough of the temporal lobe cortex, a Wernicke’s aphasia might develop.
    Choroidal artery occlusions might produce focal weakness, but speech
    problems would be less likely. Occlusion of the PICA can produce a variety
    of brainstem and cerebellar signs, but this combination of deficits would be
    unlikely with a lesion outside the cerebral cortex.
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15
Q

A 39-year-old woman has diplopia several times a day for 6 weeks. She
consults a physician when the double vision becomes unremitting, and
also complains of dull pain behind her right eye. When a red glass is placed
over her right eye and she is asked to look at a flashlight off to her left, she
reports seeing a white light and a red light. The red light appears to her to
be more to the left than the white light. Her right pupil is more dilated than
her left pupil and responds less briskly to a bright light directed at it than
does the left pupil.A 39-year-old woman has diplopia several times a day for 6 weeks. She
consults a physician when the double vision becomes unremitting, and
also complains of dull pain behind her right eye. When a red glass is placed
over her right eye and she is asked to look at a flashlight off to her left, she
reports seeing a white light and a red light. The red light appears to her to
be more to the left than the white light. Her right pupil is more dilated than
her left pupil and responds less briskly to a bright light directed at it than
does the left pupil.

  1. Before any further investigations can be performed, the woman develops
    the worst headache of her life and becomes stuporous. Her physician
    discovers that she has marked neck stiffness and photophobia. The physician
    performs a transfemoral angiogram. This radiologic study is expected
    to reveal that the woman has
    a. An arteriovenous malformation
    b. An occipital astrocytoma
    c. A sphenoidal meningioma
    d. A pituitary adenoma
    e. A saccular aneurysm
A
  1. The answer is e. (Victor, pp 890–892.) The clinical picture suggests
    that a saccular aneurysm has become symptomatic by compressing structures
    about the base of the brain and subsequently leaking. Aneurysms
    enlarge with age and usually do not bleed until they are several millimeters
    across. Persons with intracerebral or subarachnoid hemorrhages before the
    age of 40 are more likely to have their hemorrhages because of arteriovenous
    malformations than because of aneurysms. Aneurysms occur with
    equal frequency in men and women below the age of 40; however, in their
    forties and fifties, women are more susceptible to symptomatic aneurysms.
    This is especially true of aneurysms that develop on the internal carotid on
    that segment of the artery that lies within the cavernous sinus. An angiogram
    is useful in establishing the site and character of the aneurysm. A
    CT scan would be more likely to reveal subarachnoid, intraventricular, or
    intraparenchymal blood, but it would reveal the structure of an aneurysm
    only if it were several (>5) millimeters across. An MRI will reveal relatively
    large aneurysms if the system is calibrated and programmed to look at
    blood vessels. This patient had a transfemoral angiogram, a technique that
    involves the introduction of a catheter into the femoral artery; the catheter
    is threaded retrograde in the aorta and up into the carotid or other arteries
    of interest.
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16
Q

A 39-year-old woman has diplopia several times a day for 6 weeks. She
consults a physician when the double vision becomes unremitting, and
also complains of dull pain behind her right eye. When a red glass is placed
over her right eye and she is asked to look at a flashlight off to her left, she
reports seeing a white light and a red light. The red light appears to her to
be more to the left than the white light. Her right pupil is more dilated than
her left pupil and responds less briskly to a bright light directed at it than
does the left pupil.A 39-year-old woman has diplopia several times a day for 6 weeks. She
consults a physician when the double vision becomes unremitting, and
also complains of dull pain behind her right eye. When a red glass is placed
over her right eye and she is asked to look at a flashlight off to her left, she
reports seeing a white light and a red light. The red light appears to her to
be more to the left than the white light. Her right pupil is more dilated than
her left pupil and responds less briskly to a bright light directed at it than
does the left pupil.

60. The cranial nerve injury likely to be responsible for all of these observations
is one involving
a. The second cranial nerve
b. The third cranial nerve
c. The fourth cranial nerve
d. The sixth cranial nerve
e. None of the above
A
  1. The answer is b. (Victor, p 285.) The red glass test produces two
    images because the eyes are not moving in concert. That the red image
    appears to the left indicates that the eye covered by the red glass is not
    moving to the left as much as the other eye. A convenient way to remember
    this is simply to assume that the eye is not moving where the red image
    appears to be. This assumes that the red glass is over the impaired eye and
    that ocular motor function in the other eye is completely normal. That the patient has pain behind the right eye and that the pupil of this eye reacts
    less vigorously to light than the pupil of the other eye suggests that the
    right eye is solely (or at least disproportionately) involved. Since the medial
    rectus and pupillary constrictor are involved, the lesioned nerve must be
    CN #3.
17
Q

A 39-year-old woman has diplopia several times a day for 6 weeks. She
consults a physician when the double vision becomes unremitting, and
also complains of dull pain behind her right eye. When a red glass is placed
over her right eye and she is asked to look at a flashlight off to her left, she
reports seeing a white light and a red light. The red light appears to her to
be more to the left than the white light. Her right pupil is more dilated than
her left pupil and responds less briskly to a bright light directed at it than
does the left pupil.A 39-year-old woman has diplopia several times a day for 6 weeks. She
consults a physician when the double vision becomes unremitting, and
also complains of dull pain behind her right eye. When a red glass is placed
over her right eye and she is asked to look at a flashlight off to her left, she
reports seeing a white light and a red light. The red light appears to her to
be more to the left than the white light. Her right pupil is more dilated than
her left pupil and responds less briskly to a bright light directed at it than
does the left pupil

61. The site of the lesion responsible for this woman’s symptoms and signs
is most probably the
a. Anterior communicating artery
b. Posterior communicating artery
c. Anterior cerebral artery
d. Middle cerebral artery
e. Posterior cerebral artery
A
  1. The answer is b. (Victor, pp 888–892.) An aneurysm on the posterior
    communicating artery is especially likely to compress the oculomotor
    (third) nerve. Because the pupilloconstrictor fibers lie superficially on this
    nerve, problems with pupillary activity are routinely early phenomena. An
    ischemic injury to the third cranial nerve, such as that seen with diabetes
    mellitus, will usually spare these superficial fibers, presumably because they
    have a vascular supply that is fairly distinct from that of the rest of the third
    nerve. The pupillary response to both direct and consensual stimulation will
    be impaired with compression of these parasympathetic nerve fibers. This
    means that the pupil in the right eye will not constrict in response to light
    shining into either the right or the left eye. The normal pupil on the left will
    constrict with light shining into either the left or the right eye because the
    sensory input from the right eye is unimpaired. As the aneurysm enlarges, it
    impinges upon the third-nerve fibers that supply the medial rectus muscle,
    weakness of which was responsible for this woman’s double vision. Lesions
    of the superior cerebellar artery and posterior cerebral artery can also compress
    the third nerve, which exits between them. It is therefore important
    that a complete angiogram, evaluating all four vessels, is performed in the
    evaluation for subarachnoid hemorrhage and third-nerve palsy.
18
Q

A 39-year-old woman has diplopia several times a day for 6 weeks. She
consults a physician when the double vision becomes unremitting, and
also complains of dull pain behind her right eye. When a red glass is placed
over her right eye and she is asked to look at a flashlight off to her left, she
reports seeing a white light and a red light. The red light appears to her to
be more to the left than the white light. Her right pupil is more dilated than
her left pupil and responds less briskly to a bright light directed at it than
does the left pupil.

  1. Three days after developing neck stiffness and photophobia, the woman
    develops left-sided weakness and hyperreflexia. Her left plantar response is
    upgoing. Her physician presumes that these deficits are a delayed effect of the
    subarachnoid blood and so would treat her with
    a. Heparin
    b. Warfarin
    c. Nimodipine
    d. Phenytoin
    e. Carbamazepine
A
  1. The answer is c. (Victor, pp 894–895.) Vasospasm is a relatively common
    complication of subarachnoid blood and may result in stroke.
    Nimodipine is used because it decreases the probability of stroke, but it
    does not prevent it completely. Anticoagulation with heparin or warfarin
    worsens the patient’s prospects because it increases the risk of additional
    bleeding. Antiepileptic drugs, such as phenytoin and carbamazepine, may
    reduce the risk of seizure associated with subarachnoid blood and are
    sometimes given prophylactically. This patient does not have evidence of
    seizures, however.
19
Q

A 73-year-old man with a history of hypertension complains of a 10-min
episode of left-sided weakness and slurred speech. On further questioning,
he relates three brief episodes in the last month of sudden impairment of
vision affecting the right eye. His examination now is normal.

63. Which of the following would be the most appropriate next diagnostic
test?
a. Creatine phosphokinase (CPK)
b. Holter monitor
c. Visual evoked responses
d. Carotid artery Doppler ultrasound
e. Conventional cerebral angiography
A
  1. The answer is d. (Osborn, pp 332–335.) This patient is experiencing
    the classical symptoms of extracranial internal carotid artery disease, which include episodes of ipsilateral transient monocular blindness (amaurosis
    fugax) and contralateral transient ischemic attacks consisting of motor
    weakness. Patients with symptomatic extracranial carotid artery disease
    have a high likelihood of going on to develop strokes (approximately 26%
    over 2 years on medical therapy). The appropriate test to confirm the suspicion
    of carotid stenosis is a Doppler ultrasound of the carotid arteries. This
    test utilizes the fact that sound waves will bounce back from particles moving
    in the bloodstream—primarily red blood cells—at a different frequency
    depending on the velocity and direction of the blood flow. A great deal of
    important information about the structure of the blood vessel can be
    obtained in this way. Although angiography can also provide this information,
    it is invasive, carries a risk of causing a stroke, and is more expensive
20
Q

A 73-year-old man with a history of hypertension complains of a 10-min
episode of left-sided weakness and slurred speech. On further questioning,
he relates three brief episodes in the last month of sudden impairment of
vision affecting the right eye. His examination now is normal.

63. Which of the following would be the most appropriate next diagnostic
test?
a. Creatine phosphokinase (CPK)
b. Holter monitor
c. Visual evoked responses
d. Carotid artery Doppler ultrasound
e. Conventional cerebral angiography
A
  1. The answer is d. (Osborn, pp 332–335.) This patient is experiencing
    the classical symptoms of extracranial internal carotid artery disease, which include episodes of ipsilateral transient monocular blindness (amaurosis
    fugax) and contralateral transient ischemic attacks consisting of motor
    weakness. Patients with symptomatic extracranial carotid artery disease
    have a high likelihood of going on to develop strokes (approximately 26%
    over 2 years on medical therapy). The appropriate test to confirm the suspicion
    of carotid stenosis is a Doppler ultrasound of the carotid arteries. This
    test utilizes the fact that sound waves will bounce back from particles moving
    in the bloodstream—primarily red blood cells—at a different frequency
    depending on the velocity and direction of the blood flow. A great deal of
    important information about the structure of the blood vessel can be
    obtained in this way. Although angiography can also provide this information,
    it is invasive, carries a risk of causing a stroke, and is more expensive
21
Q

A 73-year-old man with a history of hypertension complains of a 10-min
episode of left-sided weakness and slurred speech. On further questioning,
he relates three brief episodes in the last month of sudden impairment of
vision affecting the right eye. His examination now is normal.

  1. The episodes of visual loss are most likely related to
    a. Retinal vein thrombosis
    b. Central retinal artery ischemia
    c. Posterior cerebral artery ischemia
    d. Middle cerebral artery ischemia
    e. Posterior ciliary artery ischemia
A
  1. The answer is b. (Victor, pp 254–256.) The presumed mechanism of
    transient monocular blindness in carotid artery disease is embolism to the
    central retinal artery or one of its branches. Although classic teaching has
    emphasized the role that cholesterol emboli play in causing this blindness,
    it has been noted that cholesterol emboli (Hollenhorst plaques) may be
    seen on funduscopic examination even of asymptomatic individuals. Retinal
    vein thrombosis may produce a rapidly progressive loss of vision, with
    hemorrhages in the retina, but would not be associated with the transient
    ischemic attacks (TIAs) described here. Although both posterior and middle
    cerebral artery ischemia can cause visual loss, they would not be expected
    to cause the monocular blindness described here. Posterior ciliary
    artery ischemia can cause ischemic optic neuropathy, but this is usually
    acute, painless, and not associated with preceding transient monocular
    blindness or TIAs.
  2. The answer is c. (Shuaib,
22
Q

A 73-year-old man with a history of hypertension complains of a 10-min
episode of left-sided weakness and slurred speech. On further questioning,
he relates three brief episodes in the last month of sudden impairment of
vision affecting the right eye. His examination now is normal.

  1. A thorough evaluation reveals that the patient has a 90% stenosis of
    the right internal carotid artery at the bifurcation. The management option
    most likely to prevent a future stroke is which of the following?
    a. Warfarin
    b. Carotid artery angioplasty
    c. Carotid endarterectomy
    d. Extracranial-intracranial bypass
    e. Aspirin
A
  1. The answer is c. (Shuaib, pp 503–506.) Based on the results of the
    North American Symptomatic Carotid Endarterectomy Trial (NASCET), it is
    known that carotid endarterectomy can reduce the risk of stroke in patients
    with symptomatic stenosis by 70% or more. The risk of ipsilateral stroke
    was reduced from 26% in the medically treated group to 9% in the surgically
    treated group. Carotid endarterectomy should be offered to all eligible
    patients with symptomatic disease of the internal carotid artery. There is
    currently no randomized, controlled trial data to support the use of warfarin,
    carotid angioplasty, or stenting in the management of these patients,
    although studies of angioplasty are under way. Extracranial-intracranial by pass has been tried unsuccessfully, although it may still play a role for certain
    patients with inaccessible lesions or hypoperfusion in the setting of
    complete occlusions. Aspirin would be appropriate after endarterectomy.
23
Q
  1. A 62-year-old man with a history of myocardial infarction awakens
    with a dense right-sided hemiplegia. His eyes are tonically deviated to the
    left, and he does not respond to threat on the right side of his visual field.
    He appears to be alert and responds to pain on the left side of his body. His
    speech is unintelligible and nonfluent, and he follows no instructions.
    Efforts to get him to repeat simple phrases consistently fail. (SELECT 1
    DISTURBANCE)
    For each clinical scenario, pick the language disturbance that best explains
    the clinical picture.
    a. Broca’s aphasia
    b. Wernicke’s aphasia
    c. Transcortical sensory aphasia
    d. Transcortical motor aphasia
    e. Anomic aphasia
    f. Global aphasia
    g. Conduction aphasia
    h. Mixed transcortical aphasia
A
  1. The answer is f. (Victor, pp 504–515.) Given the patient’s history of
    cardiovascular disease, one must suspect that this man has suffered a stroke
    of the left cerebral hemisphere. Either the left internal carotid artery or the
    left middle cerebral artery is probably occluded. The area of infarction
    would be expected to include the frontal, temporal, and parietal lobe cortices.
    The tonic gaze deviation indicates damage to the frontal lobe center
    on the left, which directs the eyes contralaterally. The right visual field loss
    occurs with damage to the optic radiation in the left hemisphere
24
Q
  1. A 45-year-old woman with chronic atrial fibrillation discontinues warfarin
    treatment and abruptly develops problems with language comprehension.
    She is able to produce some intelligible phrases and produces
    sound quite fluently; however, she is unable to follow simple instructions
    or to repeat simple phrases. On attempting to write, she becomes very frustrated
    and agitated. Emergency MRI reveals a lesion of the left temporal
    lobe that extends into the superior temporal gyrus. (SELECT 1 DISTURBANCE
For each clinical scenario, pick the language disturbance that best explains
the clinical picture.
a. Broca’s aphasia
b. Wernicke’s aphasia
c. Transcortical sensory aphasia
d. Transcortical motor aphasia
e. Anomic aphasia
f. Global aphasia
g. Conduction aphasia
h. Mixed transcortical aphasia
A
  1. The answer is b. (Victor, pp 504–515.) Presumably, an embolus from
    this woman’s heart traveled to a branch of the middle cerebral artery that
    supplied her dominant hemisphere. The left hemisphere is usually the
    speech-dominant hemisphere. Wernicke’s aphasia is the most common of
    the so-called fluent aphasias: the affected person produces a string of
    sounds that may sound like a real language, but the sounds are generally
    meaningless. The patient seems to be unaware that his or her speech is
    incomprehensible. Comprehension and repetition are impaired. Typically,
    efforts at speaking only produce a meaningless string of phonemes that
    retain the rhythm and intonation of normal speech.
25
Q
  1. A 71-year-old man develops headache and slight difficulty speaking
    while having sexual intercourse. He has a long-standing history of hypertension,
    but has been on medication for more than 7 years. He makes frequent
    errors in finding words and follows complex commands somewhat
    inconsistently. The most obvious defect in his language function is his
    inability to repeat the simplest of phrases without making repeated errors.
    An emergency CT scan reveals an intracerebral hemorrhage in the left parietal
    lobe that appears to communicate with the lateral ventricle. (SELECT
    1 DISTURBANCE)
For each clinical scenario, pick the language disturbance that best explains
the clinical picture.
a. Broca’s aphasia
b. Wernicke’s aphasia
c. Transcortical sensory aphasia
d. Transcortical motor aphasia
e. Anomic aphasia
f. Global aphasia
g. Conduction aphasia
h. Mixed transcortical aphasia
A
  1. The answer is g. (Victor, pp 504–515.) According to one classic model
    of language organization formulated by the neurobehaviorist Norman
    Geschwind, the expressive language centers in the frontal lobe and the
    receptive centers in the temporal lobe communicate in large part along the
    arcuate fasciculus, which extends through the temporal and parietal lobes.
    This man appears to have suffered an acute hemorrhage associated with
    chronic hypertension. The blood extended into the lateral ventricle, which
    was the probable cause of the headache. Patients with the rare syndrome of
    conduction aphasia have problems with repetition that are more obvious
    than their problems with comprehension. Their speech usually does not
    sound very fluent.
26
Q
  1. A 24-year-old woman abruptly loses all speech during the third trimester
    of an otherwise uncomplicated pregnancy. She has a history of severe
    migraines during which she occasionally develops a transient right hemiplegia.
    Her comprehension is good, and she is frustrated by her inability to
    speak or write. She is unable to repeat simple phrases, but she does begin to
    produce simple words within 5 days of the acute disturbance of language.
    (SELECT 1 DISTURBANCE)
For each clinical scenario, pick the language disturbance that best explains
the clinical picture.
a. Broca’s aphasia
b. Wernicke’s aphasia
c. Transcortical sensory aphasia
d. Transcortical motor aphasia
e. Anomic aphasia
f. Global aphasia
g. Conduction aphasia
h. Mixed transcortical aphasia
A
  1. The answer is a. (Victor, pp 504–515.) Cerebrovascular occlusions are
    unusual at the age of 24, but this woman had two risk factors for stroke: her migraine headaches and her pregnancy. The stroke probably involved the
    frontal lobe cortex about the third frontal convolution on the dominant side.
    Speech becomes telegraphic (i.e., consisting of short phrases with omission
    of small connecting words such as articles and conjunctions) with a Broca’s
    aphasia, but permanent loss of all ability to produce meaningful language is
    unlikely if the area of infarction is less than a few centimeters across. The
    most persistent difficulty usually exhibited by patients with this type of
    stroke is a permanent loss of syntax.
27
Q
  1. A 78-year-old man suffers a cardiac arrest while being treated in an
    emergency room for chest pain. Resuscitation is initiated immediately, but
    profound hypotension is observed for at least 20 min. A cardiac rhythm is
    restored, but the patient remains unconscious for the next 3 days. When he
    is awake, alert, and extubated, his speech is limited to repetition of words
    and sounds produced by those around him. He has no apparent comprehension
    of language and produces few sounds spontaneously. Whenever
    the patient is spoken to, he fairly accurately repeats what was said to him.
    (SELECT 1 DISTURBANCE)
Items 66–70
For each clinical scenario, pick the language disturbance that best explains
the clinical picture.
a. Broca’s aphasia
b. Wernicke’s aphasia
c. Transcortical sensory aphasia
d. Transcortical motor aphasia
e. Anomic aphasia
f. Global aphasia
g. Conduction aphasia
h. Mixed transcortical aphasia
A
  1. The answer is h. (Victor, pp 504–515.) With protracted hypotension,
    this patient suffered a watershed infarction. The cortex at the limits of the
    supply of the principal cerebral arteries was inadequately perfused, and the
    resulting infarction isolated the speech areas in the frontal and temporal
    lobes from the cortex in other parts of the cerebrum. Language usually does
    not recover substantially after this type of infarction.