Neuro vascular etc HYs

Question 1

The most common complication of aneurysmal subarachnoid hemorrhage is __, which typically occurs 3-12 days after the initial insult and can cause delayed cerebral ischemia

Answer 1

vasospasm

CT looks normal

Question 2

Transient ischemic attacks resulting in left leg weakness and vision loss in the right eye are likely due to emboli originating from the

Answer 2

right internal carotid artery

Question 3

____ artery occlusion causes vertigo/nystagmus, ipsilateral cerebellar signs, loss of pain/temperature sensation in the ipsilateral face and contralateral body, bulbar weakness, and ipsilateral Horner syndrome.

Answer 3

Posterior inferior cerebellar

lateral medullary (Wallenberg) syndrome

Question 4

7 Upper motor signs

Answer 4

Upper motor neuron signs include abnormal plantar flexion (Babinski sign), spastic paralysis, increased muscle tone, clasp-knife rigidity, hyperreflexia, pronator drift, and pyramidal weakness (weakness more pronounced in lower extremity flexors and upper extremity extensors).

Question 5

Inadequate blood supply to the brain leads to ischemic stroke. The first microscopic changes are typically seen 12-24 hours after irreversible ischemic injury and include intense ____ and ____.

1–3 days:

3–7 days:

1–2 weeks:

2+ weeks:

Answer 5

eosinophilic staining of the neuronal cytoplasm (red neurons)

nuclear fragmentation (pyknotic nuclei, loss of Nissl substance)

1–3 days: Neutrophilic infiltration

3–7 days: Macrophage/microglia infiltration & phagocytosis begins

1–2 weeks: Reactive gliosis & vascular proliferation around the necrotic area (Liquefactive necrosis)

2+ weeks: Glial scar formation. Cystic area surrounded by dense glial fibers (>1 month)

Question 6

An aneurysm of the internal carotid artery can laterally impinge on the ____.

This can cause ipsilateral nasal hemianopia by damaging the optic nerve fiber from the temporal portion of the retina.

Answer 6

optic chiasm

Question 7

ACA strokes affect what

Answer 7

Contralateral Lower extremity

Question 8

MCA stokes affect what

Answer 8

Contralateral Upper extremity and Face

Question 9

what is Gertsmann syndrome

what structure is affected and what supplies it?

Answer 9

Agraphia, Acalcula, Left-right disorientation, Finger Agnosia

angular gyrus of the dominant parietal lobe, a brain region supplied by the middle cerebral artery.

*angular gyrus lesions can also have aphasia and alexia

Question 10

Ischemic injury to the _____, which is supplied by the posterior inferior cerebellar artery, can result in Wallenberg syndrome.

Answer 10

dorsolateral medulla

Question 11

Patients typically present with:

Contralateral hemiparesis (pyramids/CST dmg),

Contralateral propioception/vibration/ touch loss (medial lemniscal pathway/ Dorsal column dmg),

ipsilateral tongue paralysis towards lesion (hypoglossal nucleus).

an ischemic stroke syndrome caused by occlusion of the ______.

Answer 11

anterior spinal artery (paramedian br.)
or
vertebral arteries

Medial medullary syndrome

Question 12

The basal ganglia are supplied by the _____, which are deep, small vessel branches off the middle cerebral arteries. Typically affected due to long standing HTN.

Answer 12

lenticulostriate arteries

deep in the brain

Question 13

_____ of the major cerebral arteries are affected in lobar hemorrhages (occipital & parietal).
Tend to occur in the elderly due to amyloid angiopathy.

Answer 13

Cortical branches

Question 14

Ischemic injury to the ____ can lead to locked-in syndrome, a condition in which patients are unable to move or speak (due to interruption of the corticospinal and corticobulbar tracts) but retain consciousness, sensation, eye opening, and vertical eye movements.

Answer 14

bilateral ventral pons

Question 15

appears as hyperattenuated, or bright, lesions on noncontrast head CT

Answer 15

Acute bleeding

Question 16

Deep intraparenchymal hemorrhage is most commonly caused by _______ of the small penetrating branches of the cerebral arteries.

This is in contrast to rupture of _______, which typically cause subarachnoid hemorrhage.

Answer 16

hypertensive vasculopathy (Charcot-Bouchard aneurysm rupture)

saccular aneurysms

Question 17

Wernicke’s area is located in the auditory association cortex within the posterior portion of the ____ temporal gyrus in the ____ temporal lobe.

Answer 17

superior

dominant

Question 18

The middle cerebral artery supplies Broca’s area ( ___ division) and Wernicke’s area ( ___ division).

Answer 18

superior

inferior

Question 19

symmetric, bilateral wedge-shaped strips of necrosis over the cerebral convexity are characteristic of

Answer 19

global cerebral ischemia

Watershed areas affected

Question 20

The cells that are typically affected first by hypoxia are the CA1 pyramidal neurons of the ____, which can be damaged by ischemia in as little as 3 minutes.

Answer 20

hippocampus

Question 21

The ___ cells and _____ neurons are also highly susceptible to damage if ischemia lasts for 5-10 minutes

because of their high metabolic demand and unique neurochemical characteristics (inability to repolarize after anoxic depolarization)

Answer 21

cerebellar Purkinje

neocortex pyramidal

Question 22

Cytotoxic (early) edema less than 24 hours after cerebral ischemia/stroke is due to the accumulation of _____ in hypoxic cells

= raising intracranial pressured = brain herniation

Answer 22

intracellular Na+ and water

due to the failure of ATP-dependent ion transporters

Question 23

Vasogenic edema follows _____ hours after cerebral ischemia when the release of inflammatory mediators disrupts the ____ of the blood-brain barrier, allowing ___ and water to enter the _____.

Can cause persistent cerebral edema for weeks

Answer 23

24-48

tight junctions

proteins (eg, albumin)

interstitial space

Question 24

Cavernous hemangiomas are vascular malformations that occur most commonly within the brain parenchyma; they carry an increased risk of ___ and ___.

Answer 24

intracerebral hemorrhage

seizure

Question 25

Intraventricular hemorrhage (IVH) is a common complication of prematurity (< 32) and/or with birth weight (<3 lb 5 oz).

Signs are _____, seizures, coma.

Answer 25

bulging anterior fontanelle

IVH in preterm infants usually originates from the germinal matrix

Question 26

Intraventricular hemorrhage in preterm infants usually originates from the _____, a highly cellular and vascularized layer in the subventricular zone

This area contains fragile, thin-walled vessels lacking ____ making them more susceptible to hemorrhage.

Answer 26

germinal matrix

glial fibers

Question 27

______ (aka loss of conjugate lateral gaze) is caused by damage to the medial longitudinal fasciculus, which can occur with occlusion of the ___ artery.

Answer 27

Internuclear ophthalmoplegia

pontine

Question 28

Weakness of the face, arm, and leg is classically caused by contralateral motor cortex or ____ infarction

Answer 28

internal capsule

Question 29

Damage to the oculomotor nerve (CN III) can lead to impaired extraocular movements with a ____ eye

Answer 29

down-and-out

Question 30

Resting tremor is typically associated with parkinsonism due to damage of the _____ and its projections to the striatum.

Answer 30

substantia nigra

Question 31

The locus ceruleus is a paired brainstem nucleus located in the posterior ____ near the lateral floor of the ____ and functions as the principal site for ___ synthesis in the brain.

Answer 31

rostral pons
fourth ventricle
norepinephrine

Question 32

______ are produced in the posterior hypothalamus and play an important role in arousal and wakefulness.

Answer 32

Histamine and orexin

Question 33

Norepinephrine is converted to epinephrine primarily in the ____

Answer 33

adrenal medullae.

Question 34

Dopamine is produced in the _____ area and substantia nigra pars compacta located in the ___.

Answer 34

ventral tegmental

midbrain

Question 35

The major dopaminergic pathways in the brain include
mesolimbic and mesocortical pathways (regulate ___ & ___)

nigrostriatal pathway (regulates coordination of ___)

tuberoinfundibular pathway (inhibits ____ secretion).

Answer 35

cognition and behavior

voluntary movements

prolactin

Question 36

_______ is the most common cause of spontaneous and/or RECURRENT lobar hemorrhage, particularly in the ELDERLY.

The most common sites of hemorrhage include the ______

Answer 36

Cerebral amyloid angiopathy

occipital and parietal lobes

• HTN = DEEP brain
• amyloid = parietal/occipital

Question 37

Fever, Proptosis, decreased sensation in the upper face, plus CN3,4,6 deficits indicates a ____ lesion

Answer 37

Cavernous sinus

Question 38

CNS injury is associated with ___ & ____

This process leads to the formation of a glial scar, which compensates for the volume loss that occurs after neuronal death.

Answer 38

Astrocyte hypertrophy/glial hyperplasia

Proliferation (gliosis).

Glial scar (Months to years) = Astrocytes

Question 39

Transient global amnesia is a self-limited syndrome characterized by the sudden onset of prominent anterograde amnesia accompanied by repetitive questioning where is the dysfunction located?

Answer 39

Transient dysfunction of the hippocampus

Question 40

pure motor hemiparesis and a small cavitary lesion in the internal capsule, characteristic of a

Answer 40

lacunar infarct.

Question 41

lipohyalinosis, microatheroma formation, and hardening/thickening of the vessel wall (hypertensive arteriolar SCLEROSIS) found in what kind of infarcts

Answer 41

Lacunar (image 8)

Question 42

pure motor hemiparesis
or
ataxia-hemiplegia syndrome (ipsilateral limb ataxia out of proportion to motor deficit) caused by

Answer 42

Posterior limb of the internal capsule and/or

basal pons lesions

Question 43

Dysarthria-clumsy hand syndrome (dysarthria and dysphagia with clumsiness of one hand) caused by

Answer 43

Genu/anterior limb of the internal capsule and/or

basal pons lesions

Question 44

Ventroposterolateral or ventroposteromedial thalamus cause

Answer 44

pure sensory stroke

Question 45

List 2 complications of Subarachnoid Hemorrhage

Answer 45

Vasospasm (give nimodipine) 3-12 days later

Hydrocephalus (impaired absorption from granulations)

Question 46

Brain ____ malformation is the most common cause of intracranial hemorrhage in children/ non-neonate infants and tends to be a single lesion.

Answer 46

arteriovenous

Question 47

___ artery atherosclerosis and cardiac embolism may cause acute ischemic stroke, which typically presents with sudden neurologic deficits that are maximal at symptom onset.

Answer 47

Carotid

Question 48

____ rupture is usually due to chronic hypertension and typically causes hemorrhage involving deep brain structures ( basal ganglia, cerebellar nuclei, thalamus, pons).

Answer 48

Charcot-Bouchard aneurysm (image 1)

Question 49

On CT, subarachnoid hemorrhage appears as hyperattenuation of the ___ and basal cisterns.

Answer 49

sulci (Image 25)

Question 50

Cerebral ____ is the most common cause of spontaneous lobar hemorrhage, particularly in the elderly. The most common sites of hemorrhage include the occipital and parietal lobes

Answer 50

amyloid angiopathy

Question 51

Head CT reveals multiple, small lobar hemorrhages of varying ages in the occipital and parietal areas with a medium-size acute bleed in the left parietooccipital lobe.
Diagnosis?

Answer 51

Cerebral amyloid angiopathy

Question 52

The first sign of ____ is a fixed, dilated pupil on the side of the lesion.

Answer 52

uncal herniation

*Paralysis of the oculomotor muscles occurs later and leads to ptosis and a down-and-out position of the ipsilateral eye.

Question 53

A fixed, dilated pupil on the side of the lesion. Contralateral or ipsilateral hemiparesis (Cerebral Peduncle) and contralateral homonymous hemianopsia (PCA) with macular sparing may also occur.

Answer 53

uncal herniation

Question 54

An Epidural Hematoma can cause an ___ herniation of the cingulate gyrus/ Falx cerebri leading to compression of the ACA

Answer 54

subfalcine

Question 55

An Epidural Hematoma on the Temporal lobe can cause an ___ herniation leading to compression of CN 3

Answer 55

Uncal

through tentorium cerebelli

Question 56

the combination of left leg weakness and vision loss in the right eye (amaurosis fugax) suggests a lesion in the right ____ artery.

Answer 56

internal carotid

Question 57

transient episodes of focal neurologic impairment that occur due to localbrain ischemia; tissue infarction does not occur, and brain imaging is normal.

Answer 57

Transient ischemic attacks (TIAs)

Question 58

used for thrombolysis in patients with acute, potentially debilitating, ischemic stroke, which would present with persistent neurologic deficits. They are NOT indicated as this patient’s symptoms resolved without intervention.

Answer 58

Tissue plasminogen activator TPA (alteplase)

Question 59

An aneurysm of the ____ artery can laterally impinge on the optic chiasm (Nasal Hemianopia)

Answer 59

internal carotid

Question 60

Blood Between dura mater & arachnoid mater

Answer 60

Subdural Hematoma

Question 61

Blood Between arachnoid mater & pia mater

Answer 61

Subarachnoid Hemorrhage

Question 62

Blood in the basal cistern and nuchal rigidity + HA

Answer 62

Subarachnoid Hemorrhage

Question 63

Lacunes are small cavitary infarcts located within the basal ganglia, posterior limb of the internal capsule, pons, and cerebellum. The infarcts result from occlusion of the _____ arteries that supply these deep brain structures.

Answer 63

(small penetrating arteries) lenticulostriate

image 12

Question 64

Infarcts occur most commonly in the setting of chronic uncontrolled hypertension or diabetes mellitus.

Answer 64

Lacunar infarcts (Lenticulostriate branches of MCA)

Question 65

Lipohyalinosis and microatheromas are believed to be the primary causes of ____ infarcts.

Answer 65

lacunar

• Lipohyalinosis due to leakage of plasma proteins through damaged endothelium causes hyaline thickening of the vascular wall, collagenous sclerosis, and accumulation of FOAMY MQs.
• Microatheromas result from atherosclerotic accumulation of lipid-laden macrophages within the INTIMAL layer of a penetrating artery near its origin off the parent vessel.

Question 66

On autopsy, the symmetric, bilateral wedge-shaped strips of necrosis over the cerebral convexity are characteristic of

Answer 66

global cerebral ischemia.
Image 13
*This patient with a history of drug use developed fever and new-onset aortic regurgitation, which are suggestive of endocarditis. His pulmonary edema (crackles) and hypotension are due to subsequent cardiogenic shock.

Question 67

It is characterized by:
Neck, torso, shoulder, and pelvic girdle pain and morning stiffness.

Monocular vision loss is a common complication

*Fatigue, fever and weight loss may also occur.

Answer 67

Polymyalgia rheumatica

due to Temporal arteritis–Large Vessel

Question 68

Characterized by:

Dysphagia, no Gag-reflex, hoarseness (Nucleus ambigus lesion)

Diplopia, Nystagmus, Vertigo, Vomiting (Vestibular Nuclei lesion)

Loss of pain/temperature sensation in the ipsilateral face (Spinal Trigeminal Nuclei lesion)

Loss of pain/temperature sensation in the contralateral body (STT lesion)

Ipsilateral cerebellar signs: ataxia, dysmetria (Inf. Cerebellar Peduncle lesion)

Ipsilateral Horner syndrome: miosis, ptosis, anhidrosis (Descending Hypothalamic Spinal tract lesion)

Answer 68

Lateral Medullary Syndrome (Wallenberg)

PICA lesion

Question 69

___ stroke cause contralateral weakness with clasp-knife spastic rigidity, hyperreflexia, and a positive Babinski sign.

Answer 69

internal capsule

Question 70

Occlusion of the ____ typically results in contralateral hemiparesis and hemisensory loss of the face and upper limb with relative preservation of lower limb function. If the occluded artery is in the dominant (usually left) hemisphere, aphasia may also occur.

Answer 70

middle cerebral artery (MCA)