Neurology - Cerebrovascular diseases Flashcards

Question

NEU - 1.26 What does Hunt and Hess Scale grade 4 stand for? A) somnolence, confusion, mild neurological symptoms B) deep coma, decerebration C) stupor, moderate or severe hemiparesis, vegetative disturbance D) severe headache, nuchal rigidity, cranial nerve palsy

Answer 1

ANSWER C) stupor, moderate or severe hemiparesis, vegetative disturbance EXPLANATION By Hunt and Hess Scale grade 4 stupor, moderate or severe hemiparesis, vegetative disturbance are the symptoms.

Answer 2

ANSWER B) 3 EXPLANATION The minimum point of Glasgow Coma Scale is 3, 1 point for each function.

Answer 3

ANSWER A) posterior communicating artery EXPLANATION Unilateral total oculomotor nerve lesion can be caused by the aneurysm of the posterior communicating artery, because of its localization it may compress the oculomotor nerve.

Answer 4

ANSWER B) hyponatraemia EXPLANATION Often hyponatraemia develops after subarachnoid haemorrhage (because of the disturbance of ADH-secretion).

Answer 5

ANSWER A) basal ganglia EXPLANATION The most common localization of intracerebral bleeding is the locus of the basal ganglia

Answer 6

ANSWER C) brainstem EXPLANATION The mortality is the highest if the bleeding is localized in the brainstem.

Answer 7

ANSWER D) polycystic kidney EXPLANATION Congenital cerebral aneurysms may be associated with polycystic kidney.

Answer 8

ANSWER B) pons EXPLANATION In case of intracranial haemorrhage, if the bulbi are in central position, the pupils are point like (myosis), and show poor reaction to light, the bleeding is in the pons probably.

Answer 9

ANSWER C) CT EXPLANATION With cranial CT the intracranial bleeding is detected immediately. On native scans homogenous hyperdensity is seen, according to the size it may have a space occupying effect, with a narrow oedema surrounding it in the acute phase.

Answer 10

ANSWER B) cranial MRI EXPLANATION Cranial MRI is necessary for the examination of the posterior scala, brainstem. On CT because of the bone artifacts it can be visualized poorly. MRI shows the ischaemic territory more precisely. The new MRI methods increased the probability of early and precise diagnosis.

Answer 11

ANSWER A) cranial CT EXPLANATION In case of sudden onset of cerebral symptoms the first examination must be cranial CT. The first diagnostic decision from the point of view of prognosis and therapeutic approaches should be whether the lesion responsible for the symptoms is bleeding or ischaemia. If there is no bleeding with contrast material large cerebral tumor can be excluded.

Answer 12

ANSWER D) haemorrhagic infarct EXPLANATION Haemorrhagic infarct is the diagnosis if on cranial CT in the so called watershed zone hypodensity is seen with smaller hyperdense territories inside.

Answer 13

ANSWER C) anterior spinal artery EXPLANATION The typical symptoms of occlusion of anterior spinal artery are: short (but not ictal) after pain in the thoracic/lumbar region flaccid paraplegia develops, with dissociated sensation disturbance (deep sensation is intact), incontinence (fecal and urinary). Prodromal symptoms (pain in the altitude of the lesion) may be reported before the severe symptoms. Pyramidal signs may be missing at the beginning. A space occupying procedure may compress the anterior spinal artery e.g. disc herniation.

Answer 14

ANSWER C) occlusion of the carotid artery EXPLANATION Examining the supraaortic arteries by auscultation is mandatory screening method. A bruit draws attention to stenosis of the artery if it is not conducted from the heart or the aortic valve. Mild stenosis usually does not cause bruit, but the bruit may also cease when the stenosis is severe. subtotal or occluded. When the character of the bruit changes inbleeding plaque or dissection of the wall of a blood vessel may be in the background. All the above mentioned options need urgent examination (e.g. angiography).

Answer 15

ANSWER A) two dimensional („real time”) picture, B mode picture, and it is possible to measure flow velocity with Doppler effect EXPLANATION Duplex ultrasound (duplex scan) is essential in the diagnostics of cerebral ischaemia and screening. The naming shows two functions: two dimension („real time”) picturing (B mode picture), and measuring the flow with the help of Doppler effect. In case of colour coding concerning the direction and velocity of the flow two colours (usually red, blue) are used.

Answer 16

ANSWER C) if the diastolic peak velocity is more than 100 cm/s EXPLANATION By judging the exact size of the stenosis with duplex scan measuring the systolic and diastolic velocity of the flow is important. Above the systolic peak velocity is 110-120 cm/s, a diastolic peak velocity 40 cm/s stenosis is diagnosed. Above approximately 250 cm/s systolic and 100 cm/s diastolic velocity means a stenosis of more than 90%.

Answer 17

ANSWER A) brainstem lesion EXPLANATION Appearance of alternating (crossed) sensory and/or motor symptoms show a localisation in the brainstem. The locus of the lesion is given by the cranial nerve’s symptom the contralateral „long tract” symptom is caused by the lesion of the tracts running in the base of the brainstem.

Answer 18

ANSWER D) more than 70% stenosis in cross section EXPLANATION Hemodynamically significant internal carotid artery stenosis according to duplex scan examination is when the stenosis is more than 70% of the diameter.

Answer 19

ANSWER B) neutropenia, especially in the first 3 months EXPLANATION An important side effect of ticlopidin in the first 3 months is neutrophil leukopenia. White blood cell count and qualitative blood count is necessary in the first 3 months, every 2 weeks, later less often.

Answer 20

ANSWER A) if the diastolic blood pressure exceeds 120 mmHg EXPLANATION Lowering of elevated blood pressure is not recommended in acute ischemic stroke only if systolic blood pressure exceeds 190-200 mmHg and diastolic blood pressure exceeds 120 mmHg, because decreased cerebral perfusion pressure may cause adverse effects. However, after acute phase of ischemic stroke, hypertension must be treated. Often, high blood pressure decreases spontaneously in a few days.

Answer 21

ANSWER D) within 4.5 hours EXPLANATION From the development of ischemic stroke symptoms, thrombolysis may be indicated within 4.5 hours if the patient does not have any other exclusion criteria. If the symptoms are noted upon morning awakening, the onset time of stroke symptoms is uncertain. In this case, the last time point, when the patient was symptom-free, should be considered (e.g. bedtime, night awakening).

Answer 22

ANSWER B) rt-PA (recombinant tissue - plasminogen activator) EXPLANATION In acute ischemic stroke, based on various clinical studies, systemic thrombolysis with rt-PA (recombinant tissue plasminogen activator) is the most effective method with the least bleeding complications.

Answer 23

ANSWER C) mannitol EXPLANATION Mannitol infusion (20%, 200 mg/kg body weight in 10-15 minutes) can be used to treat cerebral edema caused by brain ischemia. In severe cases, Mannitol administration can be repeated every 4-6 hours. After stop of the dehydration, a rebound effect might develop. To avoid renal failure no greater dose than 100 g of mannitol per day sholud be used.

Answer 24

ANSWER B) with Barthel index EXPLANATION The change of the functional status in patient with cerebrovascular disease can be evaluated by the Barthel scale.

Answer 25

ANSWER A) 1st, 2nd and 3rd answers are correct EXPLANATION Mechanisms involved in regulation of cerebral blood circulation include: neurogenic regulation, metabolic regulation and cerebral autoregulation.

Answer 26

ANSWER C) 2nd and 4th answers are correct EXPLANATION Disturbances of microcirculation, slowing of blood flow play an important role in development of stroke, and are influenced by different hemorheological parameters, as total blood and plasma viscosity, hematocrit, plasma fibrinogen level, deformability of red blood cells, degree of polymorphonuclear leukocyte aggregation, etc.

Answer 27

ANSWER C) 2nd and 4th answers are correct EXPLANATION Non-modifiable risk factors for stroke include (but not limited to): TIA, left ventricular hypertrophy, previous myocardial infarction, peripheral vascular disease, age, gender.

Answer 28

ANSWER D) only 4th answer is correct EXPLANATION Modifiable stroke risk factors include (but not limited to): drug use, alcohol consumption, smoking, obesity.

Answer 29

ANSWER E) all of the answers are correct EXPLANATION After blood vessel wall damage, platelets stick to the collagen fibers and become activated. Glycoprotein Ib receptor on the surface of activated platelets bind von Willenbrand factor (adhesion). Adhesion of platelets is followed by further platelet-to-platelet adhesion (aggregation) in the presence of fibrinogen and fibronectin, but another platelet receptor, the glycoprotein IIb / IIIa receptor is also involved. The release of the active substances stored in the platelet granules strengthens the process. Thrombocyte activation also triggers prostaglandin synthesis, thromboxane A2 is synthesized from arachidonic acid, resulting in additional platelet aggregation and vasoconstriction.

Answer 30

ANSWER C) 2nd and 4th answers are correct EXPLANATION The biochemical changes in acute ischemic lesion: NADH increases within seconds, NAD / NADH ratio decreases, the decreasing partial pressure of oxygen is compensated by increased oxygen release in the brain tissue. Lactic acid elevates within 1 minute after the ischemia caused by vessel occlusion. Intracellular and tissue pH decreases. Intracellular acidosis is one of the important causes of ischemic neuronal damage.

Answer 31

ANSWER B) 1st and 3rd answers are correct EXPLANATION In hemispheric damage diaschisis (loss of function in regions of the brain being in connection with a distant, impaired brain area) may occur in the contralateral brain hemisphere and in the contralateral cerebellar hemisphere.

Answer 32

ANSWER B) 1st and 3rd answers are correct EXPLANATION As a consequence of subarachnoid haemorrhage, vasospasm may develop in 15-45% of patients due to release of thromboxane, free radicals, serotonin etc. from the blood. Vasospasm usually appears 4-12 days after bleeding, and may lead to secondary ischemic damage. Other consequence of subarachnoid bleeding is inhibition of CSF circulation resulting in non-resorptive hydrocephalus.

Answer 33

ANSWER A) 1st, 2nd and 3rd answers are correct EXPLANATION Approximately 10% of all cerebrovascular diseases is transient ischemic attack (TIA). Symptoms develop very rapidly, but rarely last longer than 1 hour, and in half the cases last less than 30 minutes. There is a high rate of myocardial infarction among patients with TIA. The incidence of annual stroke after TIA is 2-8%.

Answer 34

ANSWER C) 2nd and 4th answers are correct EXPLANATION Intracranial aneurysm rupture is the most common cause of subarachnoid haemorrhage. However, blood also gets to the subarachnoid space in cases of cerebral contusion and rupture of arteriovenous malformation. Moreover, brain parenchyma bleeding breaking into the brain ventricle(s) causes subarachnoid haemorrhage as well

Answer 35

ANSWER E) all of the answers are correct EXPLANATION Hypertension is the most important risk factor for cerebral hemorrhage. However, other causes may also contribute to cerebral hemorrhage, including cocaine-, or amphetamine abuse (leads to high blood pressure and vessel wall injury), leukemia and other hematological disorders (result in coagulation disorder and low platelet count), various coagulopathies, overdose of anticoagulants, bleeding in primary brain tumors (glioblastoma multiforme) or in cerebral metastases (melanoma malignum, etc.).

Answer 36

ANSWER E) all of the answers are correct EXPLANATION Lacunar infarction is caused by occlusion of penetrating small arteries. The most common causes of lacunar infarction are polycythemia vera (disturbance of microcirculation), Heubner arteritis, microatheroma, microembolisation, lipohyalinosis and fibrinoid necrosis of the vessel wall.

Answer 37

ANSWER E) all of the answers are correct EXPLANATION Hypertensive encephalopathy is characterized by severe elevation of blood pressure, cerebral edema due to disturbance of cerebral autoregulation, general and focal symptoms of increased intracranial pressure, vomiting, and occasionally disturbance of consciousness and epileptic seizures.

Answer 38

ANSWER A) 1st, 2nd and 3rd answers are correct EXPLANATION The inferior branches of the middle cerebral artery (MCA) supply the inferior part of the parietal lobe and the superior gyrus of the temporal lobe. Symptoms resulted from occlusion of the inferior branches of MCA can be understood from the functions of the damaged anatomical structures: contralateral hemianopsia or rarely quadrant-anopsia, Wernicke (sensory) aphasia, conductive aphasia, ideomotor apraxia, rarely Gerstmann syndrome in case of lesion in the dominant hemisphere. Contralateral motor symptoms are mild (transient or mild faciobrachial paresis). In case of damage in the non-dominant hemisphere, mild contralateral faciobrachial paresis may be associated with anosognosia, prosopagnosia, dressing and constructive apraxia.

Answer 39

ANSWER E) all of the answers are correct EXPLANATION Jackson's (medial medulla oblongata) syndrome is caused by occlusion of the anterior spinal artery and the paramedian arteries. The symptoms can be understood from the function of the damaged area: ipsilateral peripheral hypoglossal lesion, contralateral hemiparesis (sparing the face). Tactile and proprioceptive hypesthesia may also develop on the contralateral side of the body.

Answer 40

ANSWER B) 1st and 3rd answers are correct EXPLANATION Sudden occlusion of basilar artery is often incompatible with life. Coma, tetrapyramidal symptoms, bilateral motor and sensory dysfunctions, as well as various cerebellar and intracranial nerve lesions can also be found. When the occlusion is before the bifurcation of the basilar artery, bilateral occipital lobe lesions develop with cortical blindness, or visualis agnosia. Basilar artery occlusion may cause locked-in syndrome as well, which usually occurs when the base of the pons is damaged. In this case the patient is alert, tetraplegic, detects different stimuli, however, because the motor innervation of the speech is also impaired, the patient can only communicate with eye closure or vertical eye movements.

Answer 41

ANSWER E) all of the answers are correct EXPLANATION Wallenberg (lateral oblongata) syndrome is caused by occlusion of the posterior inferior cerebellar artery. Symptoms include vertigo, nystagmus, gait ataxia, diplopia, dysphagia, dysarthria, ipsilateral Horner triad, and algetic and thermohypesthesia on the ipsilateral face and on the contralateral body side.

Answer 42

ANSWER A) 1st, 2nd and 3rd answers are correct EXPLANATION Since thalamus is related both anatomically and operationally to the hemispherial cortex, and all the afferent systems switch over in the thalamus, thalamic lesion may have several consequences. The ventrolateral nucleus is closely related to the cerebellum, therefore its damage causes hemihypesthesia with hemihyperkinesis (choreoathetosis-like involuntary movements). The so-called "thalamic hand" is also a typical symptom in case of thalamus injury: the basic joints are in flexion while the interphalangeal joints are in extension. Damage of the sensory nuclei often causes "central" or thalamic pain, which can hardly be influenced by medicines. Thalamic pain is characterised by burning, shooting pain that is difficult to localise and occurs in attacks. Thalamus plays a role in the regulation of consciousness as well. Furthermore, thalamus lesion may provoke focal epileptic seizure, and may also cause dementia.

Answer 43

ANSWER C) 2nd and 4th answers are correct EXPLANATION Increased deep-reflexes with pyramidal signs and spastic muscle tone always refer to a central type of lesion.

Answer 44

ANSWER D) only 4th answer is correct EXPLANATION Gerstmann's syndrome is characterized by left-to-right confusion, finger agnosia, agraphia and acalculia.

Answer 45

ANSWER E) all of the answers are correct EXPLANATION Symptoms of cerebral venous/sinus thrombosis depend on the size and localisation of the occluded vein, the extent and progression of thrombus formation, as well as the nature of the thrombotic process. However, there are some general symptoms which if occur together refer to sinus/venous thrombosis. These symptoms are headache, focal or generalized epileptic seizures, papilla edema, disturbance of consciousness, and sudden onset of focal neurological symptoms.

Answer 46

ANSWER A) 1st, 2nd and 3rd answers are correct EXPLANATION The cerebral sinus thrombosis can be caused by use of oral contraceptive pills, purulent otitis, purulent sinusitis and postpartum septic state.

Answer 47

ANSWER B) 1st and 3rd answers are correct EXPLANATION The most important symptoms of intracranial aneurysm rupture are the suddenly developed, very-very severe headache in the nuchal or frontal region and the neck stiffness.

Answer 48

ANSWER C) 2nd and 4th answers are correct EXPLANATION Bacterial pneumonia and endocarditis can cause septic aneurysm on the middle cerebral artery.

Answer 49

ANSWER E) all of the answers are correct EXPLANATION If headache and focal or secondarily generalized seizures develop and bruit can be heard in the supraorbital or occipital region, arteriovenous malformation is suspected. In that case the source of the subarachnoidal hemorrhage is probably the vascular malformation.

Answer 50

ANSWER E) all of the answers are correct EXPLANATION The intracerebral hemorrhage is associated with poor prognosis if the patient is over 70 years, has concomitant cardiopulmonal disease, severe disturbance of consciousness, i.e. coma develops, and wide, non-reactive pupil can be seen on the side of the lesion.

Answer 51

ANSWER A) 1st, 2nd and 3rd answers are correct EXPLANATION Intracerebral hemorrhage has extremely poor prognosis if a large intracerebral hemorrhage is associated with a mass effect, intraventricular bleeding, compression of the fourth ventricle or secondary pontine hemorrhage.

Answer 52

ANSWER B) 1st and 3rd answers are correct EXPLANATION Intracranial hemorrhage usually appears daytime, during physical activity. Sudden onset is typical, and in case of a large, space-occupying bleeding rapid, progressive disturbance of consciousness may also develop at the early phase of the disease.

Answer 53

ANSWER C) 2nd and 4th answers are correct EXPLANATION Aortic coarctation and subclavian steal syndrome could be diagnosed with blood pressure measurement.

Answer 54

ANSWER E) all of the answers are correct EXPLANATION In cerebral ischemia usually there is no abnormality on cranial CT scan in the first hours of the ischemic event. After 6-8 hours hyperacute ischemic signs could be seen. After 1-2 days clear hypodensity develops in the infracted territory. The hypodensity is mild and has blurred margin in the beginning, however, later it becomes demarcated. Contrast enhancement occurs in the subacute stage, and usually begins at the end of the first week of stroke. Contrast enhancement reaches its maximum at week 2 and 3, and fades over the following weeks. Contrast enhancement usually shows a gyriform pattern on the surface of the brain, but may also occur in the deep parenchyma. It is likely due to a combination of blood brain barrier breakdown, neovascularisation and impaired autoregulation. This phenomenon was previously referred to as 'luxury perfusion'. Two-three weeks after ischemic stroke, the cortex may show near-normal density (isodense) on native CT, it is the so-called fogging phenomenon. Fogging phenomenon is explained by macrophage invasion, proliferation of capillaries, and sometimes extravasation of blood cells through damaged vessel walls. If in doubt, the administration of IV contrast will demarcate the region of infarction at this stage. Later (week 5-6) the residual swelling passes, and gliosis develops resulting in a region of low density with negative mass effect.

Answer 55

ANSWER A) 1st, 2nd and 3rd answers are correct EXPLANATION Cranial MRI is suggested to detect cavernoma, in case of brainstem stroke symptoms or when intracerebral hemorrhage is suspected and ionizing radiation is contraindicated (i.e. first trimester of pregnancy).

Answer 56

ANSWER B) 1st and 3rd answers are correct EXPLANATION Cerebral SPECT is able to detect perfusion deficit and functional abnormality in the early phase of the ischemic event, even when cranial CT and cranial MRI cannot detect abnormality. It can be used to measure cerebral vascular reserve capacity (Diamox test) or to study the diaschisis effect. It is suitable to assess the efficacy of the treatment and define prognosis.

Answer 57

ANSWER E) all of the answers are correct EXPLANATION MR-angiography is able to localise AVM, it can show the relation of the vessels to other cerebral structures, and it can visualize the feeding artery and the draining vein. Large artery occlusion and aneurysms are also visible with MRA. Degree of large vessel stenosis can be assessed by contrast enhanced MRA.

Answer 58

ANSWER B) 1st and 3rd answers are correct EXPLANATION 1. and 3. statements are true. Sub- and epidural hematomas are diagnosed with noncontrast cranial CT and there is neither indication for angiography in cerebral contusion.

Answer 59

ANSWER E) all of the answers are correct EXPLANATION All four statements are true.

Answer 60

ANSWER A) 1st, 2nd and 3rd answers are correct EXPLANATION The most important psychological characteristics that hinder the early rehabilitation after stroke are emotional lability, dysthimia, anxiety, anger and aggressive behavior. Euphoria is rare.

Answer 61

ANSWER E) all of the answers are correct EXPLANATION The rate of neurological consequences of heart surgery is increasing with the age of the patient. The most important factors are intraoperative hypotension and embolic stroke. The most frequent complications are: amnesia, para-, hemi-, tetraparesis, cortical blindness, epileptic seizures, extrapyramidal symptoms, visual agnosia. The frequency of myelon lesion is not rare, hypotonic paraparesis, sensory abnormality, urinary retention are characteristic. Prognosis of the spinal symptoms are worse than the cerebral ones.

Answer 62

ANSWER B) 1st and 3rd answers are correct EXPLANATION Carotid duplex ultrasound examination should be ordered after TIA, in case of ichemic stroke, and if murmur can be heard above the carotid arteries. Moreover, carotid duplex is also used to follow up the degree of carotid stenosis and to check whether restenosis develops after endarterectomy or carotid stenting.

Answer 63

ANSWER E) all of the answers are correct EXPLANATION The indications of transcranial Doppler ultrasound (TCD) examination: to monitor vasospasm after subarachnoidal bleeding to examine the flow parameters in intracranial arteries in case of ischemic stroke to detect microemboli, if cardiogenic stroke or unstable carotid plaque is suspected to determine the cerebrovascular reserve capacity with use of acetazolamide test or breath-holding test before carotid surgery

Answer 64

ANSWER A) 1st, 2nd and 3rd answers are correct EXPLANATION Regarding the B mode ultrasound imaging, exulcerated, hemorrhagic and heterogeneous plaques are considered as source of embolisation.

Answer 65

ANSWER A) 1st, 2nd and 3rd answers are correct EXPLANATION Therapy in secondary stroke prevention (daily intake): orally 100-325 mg acetylsalicylic acid, or 1x75 mg clopidogrel, or 2x25 mg acetylsalicylic acid + 2x200 mg dipyridamole. Previously, 2x250 mg ticlopidine was also used, however, this drug is not recommended nowadays because ticlopidine was shown to cause life-threatening hematological adverse reactions (neutropenia/agranulocytosis, thrombotic thrombocytopenic purpura and aplastic anemia) in some patients. (Certainly, in case of cardiogenic stroke, anticoagulant treatment is recommended instead of antiplatelet drugs.)

Answer 66

ANSWER C) 2nd and 4th answers are correct EXPLANATION In case of suspicion of cardiogenic stroke, detailed cardiologic examination is needed, including transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) if TTE couldn’t identify the source of embolisation and if the origin of stroke was unknown in young patients. Although blood pressure monitoring does not help, Holter ECG is highly recommended if cardiogenic stroke is suspected.

Answer 67

ANSWER B) 1st and 3rd answers are correct EXPLANATION Indication(s) for carotid endarteriectomy: after TIA, if the stenosis of the internal carotid artery (ICA) is larger then 70% showed by angiography. in case of repeated TIAs or after crescendo TIA if exulcerated plaque or floating thrombus is found in the ipsilateral internal carotid artery after hemispheric minor stroke, if the patient’s symptoms are not too severe, the patient’s condition is stable and there’s significant ICA stenosis (>70%). in case of symptom-free ICA stenosis, there is no absolute indication for carotid reconstruction. However, exhausted cerebrovascular reserve capacity or presence of microembolus signals in the ipsilateral MCA is indication for surgery in these patients as well. (In symptom-free patients with preserved cerebrovascular reserve capacity or without microembolic signals in the ipsilateral MCA, however, carotid endarterectomy is not indicated or can only be considered with relative indication, if the ICA stenosis is very severe + the vascular surgeon’s morbidity and mortality rate is under 3% + the patient’s life expentancy is at least 5 years + the patient prefers surgery to conservative treatment after giving detailed information about the advantages and disadvantages of the treatments. In every case, the patient should be operated by a skillful vascular surgeon team with low morbidity and mortality data.

Answer 68

ANSWER B) 1st and 3rd answers are correct EXPLANATION Vascular surgery is contraindicated in acute stroke (cranial CT showed large acute ischemic lesion), or if there’s chronic carotid artery occlusion. The surgical treatment of unilateral stenosis of the vertebral artery is neither indicated.

Answer 69

ANSWER A) 1st, 2nd and 3rd answers are correct EXPLANATION Anticoagulant treatment is contraindicated in case of dementia, bad compliance of the patient, gastrointestinal ulcer, bacterial endocarditis, untreatable hypertension, diabetic retinopathy, and bleeding disorders (coagulopathies).

Answer 70

ANSWER A) 1st, 2nd and 3rd answers are correct EXPLANATION Anticoagulant treatment should be considered for prevention of ichemic stroke in cardiogenic stroke. Anticoagulant treatment is indicated after implantation of arteficial heart valve, in nonischemic dilated cardiomyopathy, in coexistence of atrial fibrillation and high stroke risk, and for a certain period after myocardial infarction (especially with aneurysm formation). In other cases with low risk of stroke (mitral valve prolapse, mitral annular calcification, etc.) anticoagulation is usually not indicated.

Answer 71

ANSWER E) all of the answers are correct EXPLANATION In case of anticoagulation treatment, the risk of bleeding may be increased due to drug interactions. E.g. simultaneous use of oral anticoagulants with carbamazepine, acetylsalicylic acid, ticlopidine or clopidogrel, some oral antibiotics, anabolic steroids may elevate the risk of bleeding. Furthermore, alcoholic hepatopathy or other coagulation disorders, as well as extremely high blood pressure may also increase the bleeding risk.

Answer 72

ANSWER E) all of the answers are correct EXPLANATION The most important complications of cerebrovascular diseases are deep vein thrombosis of the paretic lower extremity, pulmonary embolism, bronchopneumonia (because the lying position), bronchitis, bed sore, and myocardial infarction. Decubitus (bed sore) develops on the skin as a result of pressure. Uroinfections (urocystitis and pyelonephritis) may be caused by use of urinary catheter.

Answer 73

ANSWER NEU - 1.104 - its occlusion causes ipsilateral limb and gait ataxia - E) NEU - 1.105 - its aneurysm may cause ipsilateral oculomotor nerve lesion - B) NEU - 1.106 - its stenosis may cause subclavian steal syndrome - A) NEU - 1.107 - the acute occlusion of this artery causes coma and bilateral pyramidal signs - C) NEU - 1.108 - this artery is swollen, painful and tender in giant cell arteriitis - D)

Answer 74

ANSWER NEU - 1.109 - it causes subdural hematoma - E) NEU - 1.110 - the soft tissue over the mastoid process is swollen and focal epileptic seizure, lesion of the IX-XI. cranial nerves, disturbance of consciousness might be present - C) NEU - 1.111 - it can causes epidural hematoma - D) NEU - 1.112 - scalp edema, symptoms of increased intracranial pressure, epileptic seizures, disturbance of consciousness, coma might be present - B) NEU - 1.113 - characteristic symptoms are paresis of the extraocular muscles, chemosis, retrobulbar pain - A)

Answer 75

ANSWER NEU - 1.114 - It is used for secundary stroke prevention in case of lacunar stroke - B) NEU - 1.115 - Treatment of superior sagittal sinus thrombosis - D) NEU - 1.116 - Treatment of space-occupying cerebellar hemorrhage - E) NEU - 1.117 - These belong to primary stroke prevention - A) NEU - 1.118 - Treatment of significant internal carotid artery stenosis - C)

Answer 76

ANSWER NEU - 1.119 - hypertension induced destructive parenchymal cerebral hemorrhage that ruptured into the ventricules - B) NEU - 1.120 - The CT examination was performed after the onset of ischemic stroke within 2 hours - A) NEU - 1.121 - Picture of a chronic, extended cerebral infarction - D) NEU - 1.122 - ischemic lesion with hemorrhagic transformation (picture of hemorrhagic infarction) - C) NEU - 1.123 - subcortical arteriosclerotic encephalopathy (Binswanger) - E)

Answer 77

ANSWER NEU - 1.124 - caused by a lesion of the pole of the superior temporal gyrus - B) NEU - 1.125 - caused by bilateral damage of the corticobulbar fibers - C) NEU - 1.126 - caused by a lesion of the lateral part of the medulla, part of the Wallenberg’s syndrome - E) NEU - 1.127 - caused by damage of the left supramarginal gyrus in right-handed patients - A) NEU - 1.128 - caused by a lesion of the left angular gyrus - D)

Answer 78

ANSWER NEU - 1.129 - the clinical course may refer to completed stroke - D) NEU - 1.130 - transient ischemic attack (TIA) - A) NEU - 1.131 - the clinical course raises suspicion for cerebral tumor rather than stroke - E) NEU - 1.132 - the symptoms may refer to stroke in the dominant parietal lobe - B) NEU - 1.133 - the clinical course and syndrome are specific for progressing stroke - C)

Answer 79

ANSWER C) the statement is true, but the explanation is false; EXPLANATION The patient has to be transported to a stroke center when the symptoms of an acute stroke begin, because the time window for reperfusion therapy is rather short. Immediate reduction of the elevated blood pressure is incorrect because it would decrease the cerebral perfusion pressure. Of course, high blood pressure reduction is needed in well-founded conditions (see above)

Answer 80

ANSWER B) both the statement and the explanation are true but there is no causal relationship between them; EXPLANATION After transient ischemic attack the patient should undergo cerebrovascular checkup. Brain cancer can be in the backgroud of TIA-like symptoms. Both statements are true, but there is no connection.

Answer 81

ANSWER E) both the statement and the explanation are false EXPLANATION If the patient is likely to have a brain haemorrhage, usually cranial CT is the first choice (CT is less sensitive to movement artifacts, faster and cheaper, than MRI, and sensitive in brain haemorrhage), because CT can show the bleeding immediately after cerebral haemorrhage and therefore it is able to differentiate brain haemorrhage from ischemic stroke. (There is a growing evidence that MRI is as sensitive as CT to detect intracranial haemorrhage.)

Answer 82

ANSWER C) the statement is true, but the explanation is false; EXPLANATION For secunder stroke prevention acetylsalicilic acid is used, but this medication does not always inhibit platelet aggregation in every patients, because there are non-responding patients too. Non-responding patients can be recognised by a laboratory test and these patients can be treated by clopidogrel. However, it has not been clarified whether the lack of laboratory effectiveness correlates with clinical inefficiency.

Answer 83

ANSWER C) the statement is true, but the explanation is false; EXPLANATION After occipital lobe damage homonymous hemianopsia is found, but this sypmtom can also be present in case of optic tract or temporal+parietal lobe (optic radiation) damage.

Answer 84

ANSWER C) the statement is true, but the explanation is false; EXPLANATION The flow of the middle cerebral artery can already be examined with use of transcranial duplex ultrasound. Unfortunately the absence of temporal bone window does not allow the transcranial Doppler examination in about 10 % of the patients.

Answer 85

ANSWER C) the statement is true, but the explanation is false; EXPLANATION The occlusion of the external carotid artery usually does not cause neurological symptoms. However, there is a collateral connection between the external and the internal carotid arteries.

Answer 86

ANSWER D) the statement is false, but the explanation itself is true EXPLANATION The damage of the corticospinal tract always causes central type of paresis. However, the corticospinal tract during its course can be damaged in several areas (not only in the internal capsule), therefore injuries at other sites can result hemiparesis as well.

Answer 87

ANSWER B) both the statement and the explanation are true but there is no causal relationship between them; EXPLANATION In case of a sudden, twinge pain in the frontal and nuchal areas during strain, intracerebral aneurysm rupture should be suspected. In addition to numerous early and later complications, subarachnoidal bleeding can cause cardiac arrythmia too. Both statements are true, however, there is no connection between them.

Answer 88

ANSWER A) both the statement and the explanation are true and a causal relationship exists between them; EXPLANATION In case of post-stroke depression antidepressant drugs should be used, because depression can inhibit the rehabilitation.

Answer 89

ANSWER A) both the statement and the explanation are true and a causal relationship exists between them; EXPLANATION In leukemic patients with low platelet count, lumbar tap is not performed, because subarachnoidal bleeding can happen. (Below 50 G/L platelet count the lumbar puncture is prohibited; moreover, lumbar tap can also be contraindicated if the platelet count is less than 100 G/L and there are other bleeding syptoms, like petechias, blood in the urine, retinal bleeding…)

Answer 90

ANSWER D) the statement is false, but the explanation itself is true EXPLANATION In case of endocarditis lenta cerebral embolisation can develop, but anticoagulation therapy is prohibited, because it can increase the chance of cerebral embolisation.

Answer 91

ANSWER A) both the statement and the explanation are true and a causal relationship exists between them; EXPLANATION ECG monitoring in the acute phase of stroke is necessary, becasue stroke can cause arrhythmia.

Answer 92

ANSWER B) both the statement and the explanation are true but there is no causal relationship between them;

Answer 93

ANSWER A) both the statement and the explanation are true and a causal relationship exists between them; EXPLANATION Before cardiac surgery, duplex scan ultrasound of the cervical arteries and transcranial Doppler examination (and vascular reconstructive surgery in case of severe carotid stenosis) are necessary, because significant stenosis of extra- and intracranial arteries may cause cerebral hypoperfusion leading to severe neurological symptoms during cardiac surgery.

Answer 94

ANSWER B) ischemic lesion in the territory of the left middle cerebral artery EXPLANATION Considering the symptoms, the onset of symptoms, and atrial fibrillation in the history, the most likely diagnosis is ishemic lesion in the territirry of the left middle cerebral artery. To verify the diagnosis, the following investigations are needed: cranial CT, duplex scan ultrasound, cardiologic examination with echocardiography. The onset of symptoms is determined by the last time when the patient was symptom-free, in this case 2 a.m. Since atrial fibrillation is known, the heart is the most likely to be the source of embolization, therefore the most probable etiology is cardioembolic.

Answer 95

ANSWER A) 1., 2. and 3. answers are correct EXPLANATION Considering the symptoms, the onset of symptoms, and atrial fibrillation in the history, the most likely diagnosis is ishemic lesion in the territirry of the left middle cerebral artery. To verify the diagnosis, the following investigations are needed: cranial CT, duplex scan ultrasound, cardiologic examination with echocardiography. The onset of symptoms is determined by the last time when the patient was symptom-free, in this case 2 a.m. Since atrial fibrillation is known, the heart is the most likely to be the source of embolization, therefore the most probable etiology is cardioembolic.

Answer 96

ANSWER C) 2 a.m. EXPLANATION Considering the symptoms, the onset of symptoms, and atrial fibrillation in the history, the most likely diagnosis is ishemic lesion in the territirry of the left middle cerebral artery. To verify the diagnosis, the following investigations are needed: cranial CT, duplex scan ultrasound, cardiologic examination with echocardiography. The onset of symptoms is determined by the last time when the patient was symptom-free, in this case 2 a.m. Since atrial fibrillation is known, the heart is the most likely to be the source of embolization, therefore the most probable etiology is cardioembolic.

Answer 97

ANSWER B) cardioembolic EXPLANATION Considering the symptoms, the onset of symptoms, and atrial fibrillation in the history, the most likely diagnosis is ishemic lesion in the territirry of the left middle cerebral artery. To verify the diagnosis, the following investigations are needed: cranial CT, duplex scan ultrasound, cardiologic examination with echocardiography. The onset of symptoms is determined by the last time when the patient was symptom-free, in this case 2 a.m. Since atrial fibrillation is known, the heart is the most likely to be the source of embolization, therefore the most probable etiology is cardioembolic.

Answer 98

ANSWER C) cerebral sinus (venous) thrombosis EXPLANATION Considering the patient’s hystory, the symptoms, and the progress of the disease, cerebral sinus (venous) thrombosis is suspected. (Based on scalp edema and the other symptoms, superior sagittal sinus thrombosis seems to be the most probable diagnosis.) To verify the diagnosis, cranial CT or MRI with venous CT-angiography or MR-angiography is necessary. (More precise diagnosis can be established by DSA). Searching for the source of infection is also necessary (in this case gynaecological source is the most likely). Treatment: wide spectrum antibiotics, mannitol, therapeutic dose of heparin (even if there is a haemorrhagic transformation).

Answer 99

ANSWER B) number 1 and 3 answers are correct EXPLANATION Considering the patient’s hystory, the symptoms, and the progress of the disease, cerebral sinus (venous) thrombosis is suspected. (Based on scalp edema and the other symptoms, superior sagittal sinus thrombosis seems to be the most probable diagnosis.) To verify the diagnosis, cranial CT or MRI with venous CT-angiography or MR-angiography is necessary. (More precise diagnosis can be established by DSA). Searching for the source of infection is also necessary (in this case gynaecological source is the most likely). Treatment: wide spectrum antibiotics, mannitol, therapeutic dose of heparin (even if there is a haemorrhagic transformation).

Answer 100

ANSWER A) number 1, 2 and 3 answers are correct EXPLANATION Considering the patient’s hystory, the symptoms, and the progress of the disease, cerebral sinus (venous) thrombosis is suspected. (Based on scalp edema and the other symptoms, superior sagittal sinus thrombosis seems to be the most probable diagnosis.) To verify the diagnosis, cranial CT or MRI with venous CT-angiography or MR-angiography is necessary. (More precise diagnosis can be established by DSA). Searching for the source of infection is also necessary (in this case gynaecological source is the most likely). Treatment: wide spectrum antibiotics, mannitol, therapeutic dose of heparin (even if there is a haemorrhagic transformation).

Answer 101

ANSWER D) subarachnoidal haemorrhage caused by rupture of intracranial aneurysm EXPLANATION Based on the patient’s history and neurological signs, the most likely diagnosis is intracranial aneurysm rupture resulting in subarachnoidal bleeding. In order to verify the diagnosis, cranial CT and cranial CT-angiography or DSA are necessary. CT scan may reveal subarachnoidal bleeding, sometimes the source of bleeding can also be seen. Cranial CT-angiography, or DSA shows the localisation, size and morphology of the aneurysm. Multiple aneurysms may be found, in that case CT (localisation of subarachnoidal bleeding) might help localise the ruptured aneurysm. Vasospasm is a complication of subarachnoidal bleeding, which may cause cerebral ischemia.

Answer 102

ANSWER B) 1st and 3rd answers are correct EXPLANATION Based on the patient’s history and neurological signs, the most likely diagnosis is intracranial aneurysm rupture resulting in subarachnoidal bleeding. In order to verify the diagnosis, cranial CT and cranial CT-angiography or DSA are necessary. CT scan may reveal subarachnoidal bleeding, sometimes the source of bleeding can also be seen. Cranial CT-angiography, or DSA shows the localisation, size and morphology of the aneurysm. Multiple aneurysms may be found, in that case CT (localisation of subarachnoidal bleeding) might help localise the ruptured aneurysm. Vasospasm is a complication of subarachnoidal bleeding, which may cause cerebral ischemia.

Answer 103

ANSWER C) cerebral vasospasm EXPLANATION Based on the patient’s history and neurological signs, the most likely diagnosis is intracranial aneurysm rupture resulting in subarachnoidal bleeding. In order to verify the diagnosis, cranial CT and cranial CT-angiography or DSA are necessary. CT scan may reveal subarachnoidal bleeding, sometimes the source of bleeding can also be seen. Cranial CT-angiography, or DSA shows the localisation, size and morphology of the aneurysm. Multiple aneurysms may be found, in that case CT (localisation of subarachnoidal bleeding) might help localise the ruptured aneurysm. Vasospasm is a complication of subarachnoidal bleeding, which may cause cerebral ischemia.

Answer 104

ANSWER D) left hemispheric intracerebral bleeding with mass effect EXPLANATION Based on the symptoms and the positive medical history for untreated hypertension, the most likely diagnosis is left sided intracerebral bleeding with mass effect. Urgent cranial CT is needed. The dilated, and barely reacting pupil on the left side indicates the side of the bleeding (due to the mass effect causing transtentrial herniation the ipsilateral oculomotor nerve is compressed). Tetra-extension to pain stimulus refers to bad prognosis.

Answer 105

ANSWER B) cranial CT EXPLANATION Based on the symptoms and the positive medical history for untreated hypertension, the most likely diagnosis is left sided intracerebral bleeding with mass effect. Urgent cranial CT is needed. The dilated, and barely reacting pupil on the left side indicates the side of the bleeding (due to the mass effect causing transtentrial herniation the ipsilateral oculomotor nerve is compressed). Tetra-extension to pain stimulus refers to bad prognosis.