Neurovascular Flashcards
A 51-year-old man presents with a severe thunderclap headache, meningismus, photophobia, and nausea. His CT scan is shown below, and his cerebral angiogram is negative. What is the appropriate treatment option at presentation?
A. Anticonvulsants
B. Observation
C. Hyperdynamic therapy
D. Endovascular treatment
E. Surgical exploration
B. Observation
Which one of the following is an absolute contraindication for the administration of intravenous tissue plasminogen activator (tPA) for acute cerebral infarction?
A. Warfarin use with INR 1.3
B. History of aneurysm clipping six months prior to stroke onset
C. Seizure at the onset of stroke symptoms
D. Platelet count of 80,000
E. Abdominal surgery six weeks prior to stroke onset
D. Platelet count of 80,000
A 34-year-old female presents with spontaneous proptosis and chemosis of the left eye. Cerebral angiography (left common carotid injection) is shown. What is the best management option?
A. Optic nerve sheath fenestration
B. Craniotomy
C. Transvenous embolization
D. Ventriculoperitoneal shunt
E. Transarterial carotid sacrifice
C. Transvenous embolization
What factor is most predictive of postoperative intracerebral hemorrhage after carotid endarterectomy?
A. Length of stenosis
B. Female sex
C. Young age
D. Cerebral hypoperfusion
E. Calcified plaque
D. Cerebral hypoperfusion
A patient presents with subarachnoid hemorrhage from intracranial vertebral artery dissection. What is the definitive treatment?
A. Microsurgical or endovascular intervention
B. Aminocaproic acid
C. Aspirin
D. Aspirin and clopidogrel
E. Intravenous heparin
A. Microsurgical or endovascular intervention
What structure is indicated by the arrow on this lateral projection angiogram?
A. Thalamostriate vein
B. Internal cerebral vein
C. Inferior sagittal sinus
D. Vein of Labbe
E. Basal vein of Rosenthal
D. Vein of Labbe
Which vein is indicated by the arrow in the figure?
A. Internal cerebral vein
B. Basal vein of Rosenthal
C. Vein of Galen
D. Thalamostriate vein
E. Vein of Trolard
B. Basal vein of Rosenthal
Which finding on clinical exam can distinguish a third cranial neuropathy that is caused by an aneurysm from that caused by diabetic neuropathy?
A. Double vision
B. Ptosis
C. Pain
D. Pupillary dilation
E. Miosis
D. Pupillary dilation
A 30-year-old female, 2 weeks post-partum, presents to the ED after 4 hours with acute onset right hemiplegia, lethargy, and left gaze deviation. Her NIHSS score is 24. Her angiogram is shown. What is the best management option?
A. IV tPA
B. Aspirin
C. ECAC bypass
D. Thrombectomy with stent-retrieval
E. IV abciximab
D. Thrombectomy with stent-retrieval
What is the most common presentation of a vein of Galen malformation in an adolescent patient?
A. Hydrocephalus
B. Headache or seizure
C. Focal neurological deficit
D. Hemorrhage
E. Heart failure
B. Headache or seizure
A 44-year-old man with a history of blunt head trauma 4 days earlier presents with a progressively swollen and red right eye, headache, and double vision. What is the most likely cause?
A. Indirect, low flow lesion between both ICA and ECA meningeal branches and the cavernous sinus
B. Cervical internal carotid dissection
C. Vertebral artery dissection
D. Direct, high flow lesion between ICA and cavernous sinus
E. Indirect, low flow lesion between meningeal ICA branches and cavernous sinus
D. Direct, high flow lesion between ICA and cavernous sinus
A 54-year-old female presented with recurrent headaches. The patient was found to have an arteriovenous malformation with a 4 cm diameter centered in the primary motor cortex. On angiography, the arteriovenous malformation was found to have deep draining veins. What is the Spetzler-Martin grade?
A. Grade 1
B. Grade 2
C. Grade 3
D. Grade 4
E. Grade 5
D. Grade 4
A 40-year-old patient presents with headache and aneurysmal subarachnoid hemorrhage. On physical exam, she is awake, alert, and nonfocal with the exception of a right third nerve palsy and evidence of nuchal rigidity. What is the Hunt and Hess grade for this patient?
A. 0
B. 1
C. 2
D. 3
E. 4
F. 5
C. 2
What is the mortality of acute basilar artery occlusion?
A. 30%
B. 50%
C. 5%
D. 90%
E. 15%
D. 90%
A 40-year-old woman presents with acute headache, mild right arm weakness, and a CT scan showing a small hemorrhage in the left frontoparietal region. A cerebral angiogram shows a 4 cm compact, superficial AVM with superficial venous drainage and deep perforating arteries. What factor increases this patient’s surgical risk?
A. Superficial location
B. Superficial venous drainage
C. Deep perforating arteries
D. Ruptured presentation
E. Compact architecture
C. Deep perforating arteries
In patients who receive medical therapy alone for asymptomatic carotid stenosis of 60-99%, what is the 5-year risk of stroke or death?
A. 29%
B. 23%
C. 5%
D. 11%
E. 17%
D. 11%
A 76-year-old female with a history of diabetes mellitus and hypertension has asymptomatic atrial fibrillation. What medical management paradigm would best reduce her future risk of stroke?
A. Warfarin and clopidogrel
B. Clopidogrel
C. Aspirin and clopidogrel
D. Warfarin
E. Aspirin
D. Warfarin
A 45-year-old man presents with sudden onset of vomiting, dysarthria, and ataxia, and a CT scan demonstrating a cerebellar infarction. Thirteen hours after the onset of symptoms, he develops abducens nerve palsy and depressed mental status. What is the most appropriate definitive management of this patient?
A. High-dose dexamethasone
B. Intravenous tPA
C. Hypertonic saline
D. Suboccipital craniectomy
E. Barbiturate coma
D. Suboccipital craniectomy
A 50-year-old male patient with a history of atrial fibrillation presents with acute onset left hemiparesis and drowsiness for 24 hours. MRI of the brain is shown. The National Institute of Health Stroke Scale (NIHSS) score is 16. What treatment option has been shown to decrease mortality rates for such a patient?
A. External ventricular drainage
B. Medical management only
C. Mechanical thrombectomy
D. Decompressive hemicraniectomy
E. Intra-arterial tPA
D. Decompressive hemicraniectomy
What structure does the arrow point to in the figure?
A. Cavernous sinus
B. Superior petrosal sinus
C. Superior ophthalmic vein
D. Internal jugular vein
E. Inferior petrosal sinus
C. Superior ophthalmic vein
A 61-year-old man presents with confusion. Susceptibility-weighted MR imaging demonstrates multiple abnormalities (figure). What is the most likely diagnosis?
A. Hypertensive hemorrhages
B. Cerebral amyloid angiopathy
C. Leptomeningeal carcinomatosis
D. CADASIL (cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy)
E. Creutzfeldt-Jakob disease
B. Cerebral amyloid angiopathy
A 60-year-old patient presents to the emergency department with a history suggestive of acute ischemic stroke. What is the best brain imaging modality to confirm the diagnosis?
A. Non-contrast CT scan
B. Magnetic resonance imaging
C. PET scan
D. CT angiography
E. Digital subtraction angiography
B. Magnetic resonance imaging
A 72-year-old female presents with an incidentally discovered lesion as shown in the figure. What is her estimated 5-year risk of hemorrhage or new neurological deficit related to this lesion?
A. 0-10%
B. 11-20%
C. 21-30%
D. 31-40%
E. 41-50%
A. 0-10%
What neurological deficit may result from embolization of the artery with liquid embolics indicated on this angiogram?
A. Unilateral facial palsy
B. Loss of smell
C. Contralateral hemiparesis
D. Blindness
E. Unilateral tongue atrophy
E. Unilateral tongue atrophy
During clipping of an anterior communicating artery aneurysm, an artery arising at the junction of the A1 and A2 segments was inadvertently occluded. This resulted in expressive aphasia and mild hemiparesis. The artery was most likely the:
A. Frontopolar artery
B. Anterior choroidal artery
C. Right A2
D. Orbitofrontal artery
E. Recurrent artery of Heubner
E. Recurrent artery of Heubner
In Yasargil’s classification, a type 4 vein of Galen malformation (VGA) is:
A. AVGA associated with a cavernoma
B. A VGA associated with hydrocephalus
C. A parenchymal arteriovenous malformation (AVM) which drains into the vein of Galen
D. A VGA associated with an aneurysm
E. A direct fistulous communication with the vein of Galen
C. A parenchymal arteriovenous malformation (AVM) which drains into the vein of Galen
Twelve months after undergoing Gamma Knife radiosurgery to treat an AVM, a patient experiences headaches and a seizure. What is the underlying cause of the new onset of symptoms and edema shown on the attached CT and MRI?
A. Radiation necrosis
B. Secondary tumor
C. Hemorrhage from the nidus
D. Acute thrombosis of the draining vein
E. Peri-lesional cyst
D. Acute thrombosis of the draining vein
A 54-year-old Hispanic male was incidentally found to have two cavernous malformations located in the left frontal and right temporal lobes on CT scan. What is the best study to rule out additional cavernous malformations?
A. Gradient echo magnetic resonance imaging
B. Contrast enhanced computed tomography
C. Digital subtraction angiography
D. Computed tomography angiography
E. Diffusion weighted magnetic resonance imaging
A. Gradient echo magnetic resonance imaging
According to the International Study of Unruptured Intracranial Aneurysms (ISUIA), what is the risk of rupture of a cavernous carotid artery aneurysm (< 7 mm) in a patient with a history of previous aneurysmal subarachnoid hemorrhage?
A. 0%
B. 1%
C. 2%
D. 3%
E. 4%
A. 0%
What is the most common location of cranial dural arteriovenous fistulas?
A. Posterior cavernous sinus
B. Transverse sinus
C. Straight sinus
D. Superior sagittal sinus
E. Inferior sagittal sinus
B. Transverse sinus
What is the most effective treatment in secondary stroke prevention in adults with Moyamoya disease?
A. Indirect revascularization
B. Direct revascularization
C. Dual antiplatelet therapy
D. Anticoagulation
E. Aspirin alone
B. Direct revascularization
Mutation of which of the following genes has been linked to cerebral amyloid angiopathy?
A. Presenilin (PS)
B. Apolipoprotein E
C. KRIT-1
D. Endoglin
E. Tau
A. Presenilin (PS)
What factor increases the risk of future hemorrhage from an AVM?
A. Female gender
B. Spetzler Martin Grade
C. AVM location
D. Previous hemorrhage
E. Older age
D. Previous hemorrhage
A 43-year-old patient experienced a visual field defect and hemisensory loss after clipping of a PCA aneurysm. What is the most likely site of injury?
A. Lateral posterior choroidal artery
B. Superior hypophyseal artery
C. Anterior choroidal artery
D. Superior cerebellar artery
E. Posterior communicating artery
A. Lateral posterior choroidal artery
A 54-year-old man presents with acute onset of right neck pain radiating to his jaw. He denies any other symptoms. His clinical findings are demonstrated on the photograph below. Which of the following would be the most appropriate imaging study to order?
A. CT angiogram of the head
B. CT angiogram of the neck
C. MRI of the brain and orbits
D. CT scan of the chest
E. MRI of the cervical spine
B. CT angiogram of the neck
A 38-year-old presents with a one-month history of difficulty swallowing, mild hoarseness, and right facial numbness and tingling. The imaging studies are shown below. What is the most likely diagnosis?
A. Arteriovenous malformation
B. Capillary hemangioma
C. Cavernous angioma
D. Medulloblastoma
E. PICA aneurysm
C. Cavernous angioma
What factor significantly impacts the rerupture risk of a previously treated ruptured intracranial aneurysm?
A. Fisher score
B. Gender
C. Age at initial rupture
D. Hypertension
E. Degree of aneurysm occlusion
E. Degree of aneurysm occlusion
A 24-year-old man presents to the ER with an acute subdural hematoma (ASDH) after falling down the stairs. A CT scan shows a hematoma of 13 mm thickness. What is the appropriate management?
A. Surgical evacuation regardless of the GCS
B. Medical management if Glasgow Coma Scale (GCS) > 11
C. Surgical evacuation only if GCS < 10
D. Surgical evacuation only if GCS > 11
E. Medical management if GCS < 10
A. Surgical evacuation regardless of the GCS
A 65-year-old male with a history of hypertension and diabetes presents to the emergency room after experiencing a severe headache. The Glasgow Coma Scale (GCS) is 14. On head CT scan, the patient was found to have a 2 cm acute cerebellar hematoma with no hydrocephalus. What is the most appropriate management?
A. Posterior fossa craniectomy
B. Stereotactic aspiration and infusion of thrombolytic agents
C. Medical management in an ICU setting
D. External ventricular drainage
E. Surgical evacuation
C. Medical management in an ICU setting
Occlusion of which artery causes the stroke shown in the figure?
A. Recurrent artery of Heubner
B. Subcallosal artery
C. Orbitofrontal artery
D. Artery of Percheron
E. Medial lenticulostriate perforator
B. Subcallosal artery
A 65-year-old woman on warfarin for her chronic atrial fibrillation has been diagnosed with an intracerebral hemorrhage after presenting to the emergency room. Her INR was found to be 6. What is the best next step in the management of the patient?
A. Administer cryoprecipitate
B. Observe the patient closely
C. Administer Fresh Frozen Plasma
D. Ultrasound of the liver and liver function tests
E. Administer Factor VIII
C. Administer Fresh Frozen Plasma
What is the most common presentation of an adult patient with moyamoya disease?
A. Seizure
B. Intracranial hemorrhage
C. Dystonia
D. Ischemic infarcts/transient ischemic attacks
E. Gait disturbances
B. Intracranial hemorrhage
What is the most likely mechanism underlying an intracranial hemorrhage associated with an intracranial dural fistula?
A. Venous hypertension
B. Increased intracranial pressure
C. Hyperemia
D. Brain edema
E. Arterial aneurysm rupture
A. Venous hypertension
A 50-year-old male is diagnosed with an acute ischemic stroke. He is a heavy smoker and admits occasional use of marijuana and oxycodone. He has a past medical history of deep vein thrombosis and varicose veins. What risk factor most likely contributed to his stroke?
A. Varicose veins
B. Deep venous thrombosis
C. Opioids
D. Marijuana
E. Smoking
E. Smoking
A 24-year-old pregnant woman in her third trimester presents with severe headache and a non-focal neurological examination. A head CT angiogram is shown. What is the most likely diagnosis?
A. Meningioma
B. Posterior reversible encephalopathy syndrome
C. Dural venous sinus thrombosis
D. Aneurysmal subarachnoid hemorrhage
E. Eclampsia
C. Dural venous sinus thrombosis
On this lateral projection angiogram, the indicated artery supplies the:
A. Cingulate gyrus
B. Dura
C. Scalp
D. Pre-central gyrus
E. Superior parietal lobule
B. Dura
What is the most common presenting symptom associated with vein of Galen malformation in a newborn?
A. Raised intracranial pressure
B. Focal neurological deficit
C. Seizures
D. Headache
E. Congestive heart failure
E. Congestive heart failure
What is the most likely appearance of a chronic subdural hematoma on MRI?
A. Hypointense on both T1 and T2
B. Hyperintense on T1 and hypointense on T2
C. Isointense on both T1 and T2
D. Hyperintense on both T1 and T2
E. Hypointense on T1 and hyperintense on T2
D. Hyperintense on both T1 and T2
Which of the following cerebrovascular pathologies exhibits early venous drainage on an angiogram?
A. Venous angioma
B. Capillary telangiectasia
C. Cavernous angioma
D. Arteriovenous malformation
E. Amyloid angiopathy
D. Arteriovenous malformation
What is the mortality rate of an MCA infarction with malignant cerebral edema managed with intensive non-operative care?
A. 80%
B. 60%
C. 20%
D. 40%
E. 0%
A. 80%
During surgical resection of a brainstem cavernous malformation, a developmental venous anomaly (DVA) was detected. Which of the following is an appropriate step to take during surgery?
A. Apply a clip to the DVA prior to removal of the cavernous malformation
B. Perform an intraoperative angiogram
C. Coagulate the associating DVA after removing the cavernous malformation
D. Perform indocyanine green (ICG) video angiography
E. Preserve the associated DVA
E. Preserve the associated DVA
Which artery is indicated by the arrow in the figure?
A. Posterior communicating artery
B. Bernasconi and Cassinari
C. Ophthalmic artery
D. Anterior choroidal artery
E. Vidian artery
B. Bernasconi and Cassinari
A 67-year-old man presents to the emergency room with worsening paresthesias of the ipsilateral face and contralateral extremity. The symptoms are provoked with head turning. Where is the most likely site of vascular compression in this patient?
A. Basilar artery
B. Posterior inferior cerebellar artery
C. Carotid bifurcation
D. Subclavian artery
E. Dominant vertebral artery
E. Dominant vertebral artery
When comparing carotid endarterectomy (CEA) to carotid artery stenting (CAS), what is the main difference between the two procedures in terms of stroke and cardiovascular complications?
A. CAS was associated with higher incidence of vessel rupture
B. Stroke had a greater adverse effect than did myocardial infarction
C. The rate of overall complications were higher in CAS than CEA
D. CAS was associated with more myocardial infarction
E. CEA was associated with more strokes
B. Stroke had a greater adverse effect than did myocardial infarction
A 39-year-old female presents with subarachnoid hemorrhage. Her angiogram is shown. What is the most likely diagnosis?
A. Infundibulum
B. Fusiform aneurysm
C. Saccular aneurysm
D. Blister aneurysm
E. Supraclinoid ICA dissection
A. Infundibulum
The North American Symptomatic Carotid Endarterectomy Trial (NASCET) reported the surgical results in patients who underwent carotid endarterectomy (CEA). According to the trial, what is the rate of perioperative permanent disabling stroke and death related to CEA?
A. 5-10%
B. 20-25%
C. 10-15%
D. <5%
E. 15-20%
D. <5%
To what structure does the arrow point?
A. Caroticotympanic artery
B. McConnel’s Capsular artery
C. Vidian artery
D. Persistent otic artery
E. Persistent stapedial artery
C. Vidian artery
What is the appropriate sequence of steps during AVM microsurgery?
A. Ligation of the draining vein(s) — nidus resection — coagulation of feeding arteries
B. Ligation of the draining vein(s) — coagulation of feeding artery — nidus resection
C. Coagulation of feeding arteries — ligation of the draining vein(s) — nidus resection
D. Nidus resection — ligation of the draining vein(s) — coagulation of feeding arteries
E. Coagulation of feeding arteries — nidus resection — ligation of the draining vein(s)
E. Coagulation of feeding arteries — nidus resection — ligation of the draining vein(s)
According to AHA guidelines for early ischemic stroke management, IV tPA should be administered within what time frame after the onset of symptoms?
A. 2.5 hours
B. 5.5 hours
C. 1.5 hours
D. 3.5 hours
E. 4.5 hours
E. 4.5 hours
During intraoperative aneurysm rupture, which medication can help achieve temporary flow arrest?
A. Protamine
B. Adenosine
C. Vitamin K
D. Nimodipine
E. Labetalol
B. Adenosine
According to the International Study of Unruptured Intracranial Aneurysms, what is the 5-year cumulative rupture rate of a 10 mm posterior communicating aneurysm?
A. 45%
B. 14.5%
C. 9.5%
D. 0%
E. 19.5%
B. 14.5%
After ischemic stroke, which medication is recommended for stroke prevention?
A. Dabigatran
B. Aspirin
C. Unfractionated Heparin
D. Warfarin
E. Rivaroxaban
B. Aspirin
Based on the ISUIA study, what is the 5-year cumulative rupture risk of an unruptured 5 mm middle cerebral artery aneurysm?
A. 5%
B. 0%
C. 7.5%
D. 10%
E. 25%
B. 0%
Five days after the rupture of a saccular aneurysm in a 30-year-old female, the patient experiences altered level of consciousness. Transcranial Doppler shows a Lindegaard (MCA-ICA) ratio of 5. What is the most likely diagnosis?
A. Severe vasospasm
B. Normal finding
C. Mild vasospasm
D. Rebleed
E. Hyperemia
C. Mild vasospasm
A pericallosal aneurysm would be found at which location on the lateral projection angiogram shown?
A. A
B. B
C. C
D. D
E. E
B. B
A 55-year-old man presents to the emergency department with an acute onset of right hemiplegia that occurred 30 minutes prior. A CT scan is negative for hemorrhage. What factor would contraindicate the administration of IV tPA?
A. Major surgery 12 months ago
B. INR of 1.5
C. Past medical history of bleeding stomach ulcer 2 years ago
D. Severe symptoms (NIHSS > 8)
E. Refractory hypertension (SBP > 180 mmHg)
A. Inhibition of the adenosine diphosphate (ADP) chemoreceptor, P2Y
A 65-year-old female presents with a spontaneous basal ganglia hemorrhage. Her blood pressure is 190/110 mmHg. The patient is not exhibiting signs of intracranial hypertension. How should the blood pressure of the patient be managed?
A. Reduce her blood pressure to less than 185/102 mmHg
B. Reduce her blood pressure to less than 160/90 mmHg
C. Target a mean arterial pressure of 120 mmHg
D. Reduce her blood pressure to less than 120/80 mmHg
E. Maintain current blood pressure
B. Reduce her blood pressure to less than 160/90 mmHg
A 54-year-old male presented with a ruptured anterior communicating artery aneurysm. The patient underwent surgical repair. On postoperative day 5, the patient complained of mild weakness in his left leg. Transcranial Doppler showed moderate vasospasm of the right anterior cerebral artery. What is the most appropriate initial management?
A. Hyperdynamic therapy
B. Angioplasty
C. Statins
D. Intraarterial verapamil injection
E. Nimodipine
A. Hyperdynamic therapy
A 44-year-old man with a history of blunt head trauma 4 days earlier presents with progressively pulsatile exophthalmos, headache, and double vision. A CT head performed after his initial trauma was normal. What is the most appropriate treatment for this condition?
A. Radiation
B. A trial of manual direct compression of cervical carotid 3-4 times daily
C. Delayed endovascular repair
D. Craniotomy for open repair
E. Urgent endovascular repair
E. Urgent endovascular repair
What is the main arterial supply of the motor tracts of the spinal cord from T8 to the conus medullaris?
A. Medial spinal artery
B. Median sacral artery
C. Posterior spinal artery
D. Artery of Adamkiewicz
E. Lateral spinal artery
D. Artery of Adamkiewicz
According to the North American Symptomatic Carotid Endarterectomy Trial (NASCET), symptomatic patients with 70-99% carotid stenosis are best treated by:
A. Aspirin
B. Aspirin and clopidogrel
C. Carotid endarterectomy
D. Warfarin
E. Observation
C. Carotid endarterectomy
A 68-year-old man presents with progressive neurologic deficit due to a spinal dural arteriovenous fistula fed by the left L4 radicular artery. Treatment for the spinal dural AV fistula requires occlusion of which vascular structure?
A. The draining vein immediately distal to the fistula
B. The L4 radicular artery
C. The anterior spinal artery
D. The arterial feeder immediately proximal to the fistula
E. The draining vein in the spinal cord
A. The draining vein immediately distal to the fistula
Which factor has been strongly associated with increased hemorrhage rate after radiosurgery of an arteriovenous malformation (AVM)?
A. Number of feeding arteries to the AVM
B. Superficial AVM location
C. Number of prior hemorrhages
D. Target volume
E. Margin dose
C. Number of prior hemorrhages
A 60-year-old female presents with sudden onset of vertigo, headache, vomiting, and imbalance. Her imaging (after 2 days) is shown. What is the cause of the patient’s symptoms?
A. Lhermitte-Duclos disease
B. Multiple sclerosis
C. Cerebellar infarction
D. Cerebellar astrocytoma
E. Cerebellar abscess
C. Cerebellar infarction
What are the standard radiographic criteria for ventriculomegaly in order to diagnose hydrocephalus?
A. Frontal horns are >30% of the brain width
B. Temporal horn’s width >0.5 mm
C. Frontal horns are >50% of brain width
D. Temporal horn’s width >1 mm
E. Frontal horns are >20% of the brain width
C. Frontal horns are >50% of brain width
What is a known genetic predisposition to cavernous malformations?
A. There is no genetic predisposition
B. BRAF gene
C. KRIT1 gene
D. IDH1 gene
E. VHL gene
C. KRIT1 gene
An 80-year-old female presents with an occipital lobe hemorrhage on CT imaging. She has a prior history of parietal and temporal hemorrhages. What is the most likely diagnosis?
A. Venous angioma
B. Vasculitis
C. Amyloid angiopathy
D. Coagulopathy
E. Arteriovenous malformation
C. Amyloid angiopathy
According to the NASCET trial, what is the best treatment for symptomatic carotid artery narrowing of 25%?
A. Carotid artery stenting
B. Observation
C. EC/IC bypass
D. Antiplatelet therapy
E. Carotid endarterectomy
D. Antiplatelet therapy
A 70-year-old female reports that she felt like a curtain dropped over her right eye and made her lose vision. CTA showed 70% stenosis in her right petrous intracranial carotid artery. Her most recent LDL level is 190 mg/dL and blood pressure is 120/75 mmHg. What is the best next step in managing the patient?
A. Vessel bypass
B. Discharge home and re-evaluate if symptoms recur
C. Aspirin, clopidogrel, rosuvastatin
D. Percutaneous carotid artery stenting
E. Carotid endarterectomy
C. Aspirin, clopidogrel, rosuvastatin
Which calcium channel blocker has been demonstrated to improve outcomes in patients with aneurysmal subarachnoid hemorrhage?
A. IV Felodipine
B. Oral Verapamil
C. Oral Felodipine
D. Oral Nimodipine
E. IV Diltiazem
D. Oral Nimodipine
Anterograde blood flowing in the indicated vascular structure on this lateral projection cerebral angiogram drains into which structure?
A. Inferior sagittal sinus
B. Cavernous sinus
C. Superior petrosal sinus
D. Vein of Galen
E. Inferior petrosal sinus
D. Vein of Galen
What is the most common location of a cavernous malformation of the central nervous system?
A. Cerebral hemisphere
B. Cerebellum
C. Optic pathway
D. Spinal cord
E. Brainstem
A. Cerebral hemisphere
Aside from bilateral ICA occlusions, what is a typical angiographic finding in moyamoya disease?
A. Fetal posterior cerebral artery
B. Diffuse hypertrophy of the lenticulostriate arteries
C. Persistent fetal trigeminal artery
D. Duplication of the M1 segment of the middle cerebral artery
E. Bilateral giant internal carotid artery aneurysms
B. Diffuse hypertrophy of the lenticulostriate arteries
A 28-year-old male presents with acute onset facial asymmetry, diplopia, and hemifacial numbness. The patient’s MRI is shown. What is the molecular mechanism for disease pathogenesis?
A. Activation of AKT1 signaling
B. Activation of MEK/KS3 signaling
C. Mutation of BRAF V600 E
D. Activation of ERK/MAPK signaling
E. Activation of SMO signaling
B. Activation of MEK/KS3 signaling
A 44-year-old man presents with seizure, headache, and left visual field cut. MRI is shown. What is the most likely benefit of embolization for this lesion?
A. Decreased risk of rupture before further therapy
B. Decreased risk of seizures
C. Reducing AVM volume for subsequent treatment
D. Improvement of vision
E. Complete obliteration of the AVM
C. Reducing AVM volume for subsequent treatment
According to randomized control trials of hemicraniectomy for malignant MCA infarction, what is the time frame for the performance of hemicraniectomy associated with reduced mortality?
A. 3 hours
B. 6 hours
C. 12 hours
D. 24 hours
E. 48 hours
E. 48 hours
A 30-year-old female presented with left third nerve palsy. The patient was found to have a posterior communicating artery aneurysm and was scheduled for surgery. Which anatomic variation could result in occipital lobe infarction if the posterior communicating artery is occluded?
A. Persistent trigeminal artery
B. Vertebral artery hypoplasia
C. Multiple aneurysms
D. Aneurysmal size <15 mm
E. Fetal posterior cerebral artery
E. Fetal posterior cerebral artery
What is the most significant risk factor for normal perfusion pressure breakthrough after AVM resection?
A. Large size
B. Single draining vein
C. Single feeding artery
D. Deep venous drainage
E. Infratentorial location
A. Large size
What is the maximal total dose of IV rtPA that can be administered for acute ischemic stroke?
A. 0.9 mg/kg
B. 0.7 mg/kg
C. 1.1 mg/kg
D. 0.8 mg/kg
E. 1 mg/kg
A. 0.9 mg/kg
What is the Fisher score in a patient with a 2 mm thick subarachnoid hemorrhage with no intraventricular or parenchymal extension?
A. I
B. II
C. IV
D. V
E. III
E. III
What is the most common location for a hypertensive hemorrhage?
A. Pons
B. Amygdala
C. Basal Ganglia
D. Cerebellum
E. Thalamus
C. Basal Ganglia
According to the Suzuki and Takaku classification of the angiographic appearance of moyamoya disease, what imaging findings are associated with stage 2 disease?
A. Stenosis of the carotid artery at the suprasellar portion with no moyamoya vessels
B. Near complete disappearance of the major cerebral arteries with the cerebral hemispheres receiving blood from the abnormal extracranial-intracranial anastomoses
C. Diminishing moyamoya vessels with progression of extracranial circulation
D. Moyamoya vessels begin to develop at the base of the brain
D. Moyamoya vessels begin to develop at the base of the brain
Which anatomic feature best predicts the risk of intracranial hemorrhage related to dural arteriovenous fistulae (DAVF)?
A. Number of draining veins
B. Number of arterial feeders
C. Presence of cortical venous drainage
D. Size of the fistula
E. Presence of sinus drainage
C. Presence of cortical venous drainage
How does the amount of radiation differ when standing 4 feet away from a radiation source as opposed to 1 foot?
A. 1/16
B. 1/4
C. 1/64
D. 1/8
E. 1/12
A. 1/16
During a pterional exposure of the sylvian fissure, you encounter significant brain swelling. In order to achieve rapid brain relaxation, identify the most appropriate point on the associated figure through which to place a ventriculosotomy and access the frontal horn of the lateral ventricle.
A. 4
B. 1
C. 3
D. 5
E. 2
E. 2
In the acute workup of clinically suspected subarachnoid hemorrhage, if the head CT is negative, the most appropriate next step in evaluation would be:
A. MRA circle of Willis
B. CT angiogram
C. MRI brain with GRE sequence
D. Lumbar Puncture for CSF analysis
E. CT with contrast
D. Lumbar Puncture for CSF analysis
The most appropriate management of a fusiform 4-mm M3 unruptured mycotic aneurysm in a patient with bacteremia and fever would be:
A. Direct surgical clipping
B. Antibiotics for 4 - 6 weeks
C. Endovascular coiling
D. Vascular bypass surgery
E. Observation
B. Antibiotics for 4 - 6 weeks
A 60-year-old male was found to have a 10 mm internal carotid artery aneurysm. The patient underwent surgical clipping of the aneurysm after which he experienced right hemiplegia, hemihypesthesia, and homonymous hemianopsia. Which artery was most likely occluded?
A. Anterior communicating artery
B. Recurrent artery of Heubner
C. Left middle cerebral artery
D. Anterior choroidal artery
E. Left A1
D. Anterior choroidal artery
What is the vascular malformation demonstrated in this figure?
A. Capillary telangiectasis
B. Arteriovenous malformation
C. Cavernous malformation
D. Venous angioma
E. Arteriovenous fistula
D. Venous angioma
What is the mechanism of action of clopidogrel (Plavix)?
A. Inhibition of the adenosine diphosphate (ADP) chemoreceptor, P2Y
B. Direct inhibition of factor Xa
C. Direct inhibition of thrombin
D. Activation of antithrombin
E. Inhibition of plasminogen
A. Inhibition of the adenosine diphosphate (ADP) chemoreceptor, P2Y
