Session 10 - Group Work

Question 1

1) A patient has a magnetic resonance angiogram of their brain which is reported as normal.
a) Which elements of the cerebral vasculature can you identify? Add some labels

Answer 1

Anterior communicating artery

Question 2

2) A 73 year old man presents to the emergency department with weakness in his right upper limb and expressive dysphasia. He admits to being a smoker and to not taking his ‘blood pressure pills’. He is seen by the stroke team who perform an MRI scan, shown below.
a) Which lobe of the brain has been predominantly affected? Give three reasons for your answer

Answer 2

• Weakness in the right upper limb suggests weakness in the left brain
• Expressive dysphagia would be a problem in Broca’s area which would be that kind of region (frontotemporal region)
• Side - weakness in the homunculus suggests this

Question 3

2) A 73 year old man presents to the emergency department with weakness in his right upper limb and expressive dysphasia. He admits to being a smoker and to not taking his ‘blood pressure pills’. He is seen by the stroke team who perform an MRI scan, shown below.
b) A branch of which vessel is most likely to have been occluded?

Answer 3

Middle cerebral artery

Question 4

2) A 73 year old man presents to the emergency department with weakness in his right upper limb and expressive dysphasia. He admits to being a smoker and to not taking his ‘blood pressure pills’. He is seen by the stroke team who perform an MRI scan, shown below.
c) Would you predict any visual field defect in this patient? Explain your answer.

Answer 4

One of the branches of the MCA is occluded, as shown by the scan. But that doesn’t mean the entire MCA supply is going to be affected. As we can see on the scan it is limited to the left frontal lobe so none of our optic tract travels throough our area, so NO, we will not have any visual field defects.

Question 5

3) A 53 year old woman was admitted to the emergency department with right leg weakness, incontinence of urine. Neurological examination reveals 2/5 power in the right lower limb and 4/5 power in the right upper limb with no facial asymmetry. Whilst being catheterised the woman described altered sensation in her perineum. Her MRI scan is shown below. In MRI scans, early ischaemic strokes typically appear as high signal areas.
a) In the absence of a scan, could this be easily placed in an Oxford stroke class? Which specific vessel is involved?

Answer 5

We can’t classify it yet because we don’t have enough information - we need information about her higher cortical function e.g. is her speech affected? So it could be but we don’t know which one it is because we need a better history to classify it.

Anterior cerebral artery

Question 6

3) A 53 year old woman was admitted to the emergency department with right leg weakness, incontinence of urine. Neurological examination reveals 2/5 power in the right lower limb and 4/5 power in the right upper limb with no facial asymmetry. Whilst being catheterised the woman described altered sensation in her perineum. Her MRI scan is shown below. In MRI scans, early ischaemic strokes typically appear as high signal areas.
b) Assuming the stroke was caused by an embolus, do you think it has lodged proximally or distally to the anterior communicating artery? Explain your answer. Hint: think about the role of communicating arteries

Answer 6

A proximal occlusion would be accounted for by the rest of the Circle of Willis, therefore the embolus must be at the distal end of the communicating artery, where there is no other collateral supply.

Question 7

3) A 53 year old woman was admitted to the emergency department with right leg weakness, incontinence of urine. Neurological examination reveals 2/5 power in the right lower limb and 4/5 power in the right upper limb with no facial asymmetry. Whilst being catheterised the woman described altered sensation in her perineum. Her MRI scan is shown below. In MRI scans, early ischaemic strokes typically appear as high signal areas.
c) Why is she incontinent, with altered perineal sensation?

Answer 7

So the ACA affects the frontal lobe, and in the frontal lobe you have the paracentral lobules that affect voluntary micturition. If this is affected then you get incontinence.

The ACA supplies this area of the sensory homunculus in the midline, where the genitalia is found, so there is altered sensation in her perineum.

Question 8

3) A 53 year old woman was admitted to the emergency department with right leg weakness, incontinence of urine. Neurological examination reveals 2/5 power in the right lower limb and 4/5 power in the right upper limb with no facial asymmetry. Whilst being catheterised the woman described altered sensation in her perineum. Her MRI scan is shown below. In MRI scans, early ischaemic strokes typically appear as high signal areas.
d) Are any major white matter pathways vulnerable in a stroke to this region? How might damage to these pathways manifest?

Answer 8

ACA also has an important white matter distribution which is to the corpus callosum – as it loops over the superior surface of CC it sends lots of little branches into white matter pathway supplying that CC – so a big stroke affecting the ACA could technically result in damage to the corpus callosum and the effects you might be familiar with in disconnecting two hemispheres e.g. alien hand syndrome.

Question 9

3) A 53 year old woman was admitted to the emergency department with right leg weakness, incontinence of urine. Neurological examination reveals 2/5 power in the right lower limb and 4/5 power in the right upper limb with no facial asymmetry. Whilst being catheterised the woman described altered sensation in her perineum. Her MRI scan is shown below. In MRI scans, early ischaemic strokes typically appear as high signal areas.
e) There is slight midline shift. If the brain swells further, which cortical region is at risk of herniation?

Answer 9

Subfalcine herniation (underneath falx but cingulate gyrus)

Question 10

4) A 53 year old man is brought to the stroke unit. He has no memory of what happened to him and is unsure of where he is. His daughter reports that she found her dad on the floor in his flat, complaining of a feeling of ‘numbness all down on side’. His MRI is shown below.
a) Which parts of the brain have been affected by the stroke? Look carefully, comparing both sides, and use information from the history!

Answer 10

Symptoms - lost his memory
- numbness all down one side

Scan - stroke towards the medial right side. It is the medial temporal artery that has been affected.

So the occipital and thalamus has been affected.

Question 11

4) A 53 year old man is brought to the stroke unit. He has no memory of what happened to him and is unsure of where he is. His daughter reports that she found her dad on the floor in his flat, complaining of a feeling of ‘numbness all down on side’. His MRI is shown below.
b) Which side is the sensory change likely to be on?

Answer 11

Left side of the body (right side of the brain)

Posterior cerebral artery affected

Question 12

4) A 53 year old man is brought to the stroke unit. He has no memory of what happened to him and is unsure of where he is. His daughter reports that she found her dad on the floor in his flat, complaining of a feeling of ‘numbness all down on side’. His MRI is shown below.
c) Is the visual system likely to have been affected? If so, how?

Answer 12

Yes as the occipital lobe has been affected - this is the visual cortex where visual processing occurs. This is likely to produce unilateral hemianopia - left homonymous hemianopia bc left visual field is affected - optic chiasm is covered bitemporal.

Question 13

4) A 53 year old man is brought to the stroke unit. He has no memory of what happened to him and is unsure of where he is. His daughter reports that she found her dad on the floor in his flat, complaining of a feeling of ‘numbness all down on side’. His MRI is shown below.

d) Can you explain his disorientation and lack of recall for the
event?

Answer 13

Temporal lobe involvement - this is involved in memory and orientation.

(Although whole brain is involved in memory, he only has a temporary memory loss and disorientation which is primarily supplied by the inferior part of temporal lobe.)

Question 14

5) A post-mortem examination is performed on a patient who died following a collapse. A cardiac cause of death is found, but the brain is found to have the following lesion.

The lesion is consistent with the appearance of a previous stroke.

a) To which of the Oxford classes does this stroke belong? Occlusion of which vessels can lead to this pattern?

Answer 14

LACs (Lacunar syndrome) - the lenticulostriate arteries (branch of MCA) giving you what’s called a lacunar stroke.

Question 15

5) A post-mortem examination is performed on a patient who died following a collapse. A cardiac cause of death is found, but the brain is found to have the following lesion.

The lesion is consistent with the appearance of a previous stroke.

b) Precisely, which region of grey matter has been damaged? Make sure you are happy with the plane and level of the section!

Answer 15

Coronal section under the lateral ventricles - so it is the globus pallidus.

Question 16

5) A post-mortem examination is performed on a patient who died following a collapse. A cardiac cause of death is found, but the brain is found to have the following lesion.

The lesion is consistent with the appearance of a previous stroke.

c) With reference to the grey matter lesion, speculate about the clinical features the patient may have displayed (would there have been excess movement or paucity of movement?). Use the following diagram to help you.

Answer 16

Loss of GPi leads to decreased inhibition on the thalamus. Decreased inhibition means that more glutamate is produced, acting on the cortex, so there is an excess of movement.

Question 17

5) A post-mortem examination is performed on a patient who died following a collapse. A cardiac cause of death is found, but the brain is found to have the following lesion.

The lesion is consistent with the appearance of a previous stroke.

d) The stroke affected the internal capsule. Which parts of the body might show an upper motor neurone lesion? Give reasons for your answer

Answer 17

Face and possibly hand/arm depending on how far down the internal capsule it went.

Question 18

6) A patient was seen in the stroke unit with left sided cerebellar signs. A series of MRI scans are shown below.
a) Which vascular territory is the lesion in?

Answer 18

Left superior cerebellum

Question 19

6) A patient was seen in the stroke unit with left sided cerebellar signs. A series of MRI scans are shown below.
b) Assuming that the patient only displayed cerebellar signs and no other neurology, was the vessel occluded near its origin or more distally? Give reasons for your answer.

Answer 19

More distally bc if you only get cerebellar signs it hasn’t affected the pons. If it was more proximal you would have contralateral hemiparesis due to cerebral peduncle involvement (where the motor tract falls).

Question 20

7) A patient presented with severe vertigo and nausea and subtle cerebellar signs on the left side, including nystagmus. A CT scan performed soon after presentation is shown below. Note that in CTs at this stage, strokes appear as hypodense.
a) How has the scan been done? I.e. in which plane and at which level approximately?

Answer 20

Sagittal plane and in the midline? Slightly off-centre on the left?

Question 21

7) A patient presented with severe vertigo and nausea and subtle cerebellar signs on the left side, including nystagmus. A CT scan performed soon after presentation is shown below. Note that in CTs at this stage, strokes appear as hypodense.
b) Which vascular territory has the stroke occurred in?

Answer 21

Posterior inferior cerebellar artery, but also anterior cerebral artery

Question 22

7) A patient presented with severe vertigo and nausea and subtle cerebellar signs on the left side, including nystagmus. A CT scan performed soon after presentation is shown below. Note that in CTs at this stage, strokes appear as hypodense.
c) Why can cerebellar strokes lead to the feeling of vertigo? Ask your CTF to demonstrate the ‘spinning chair trick’.

Answer 22

Cerebellum is responsible for motor coordination so loss can cause nystagmus due to malcoordination.

Question 23

7) A patient presented with severe vertigo and nausea and subtle cerebellar signs on the left side, including nystagmus. A CT scan performed soon after presentation is shown below. Note that in CTs at this stage, strokes appear as hypodense.
d) Is the brainstem vulnerable? If so, speculate how this might manifest (think about arterial supply to the brainstem as well as effects of swelling in the posterior fossa).

Answer 23

Yes, posterior inferior cerebellar arteries supplies the brainstem from the vertebral arteries.

Question 24

8) During a rugby match, a 13 year old boy receives a severe blow to the head which led to transient loss of consciousness on the pitch. He is taken to be seen by the school nurse and reports that he feels fine and would like to return to the match. The nurse decides to observe him for 30 minutes before making any further decisions.

After 20 minutes the boy starts complaining of headache and the nurse notices that he seems drowsy. After a further 2 minutes the boy has completely lost consciousness. The nurse puts him into the recovery position and calls for an ambulance.

At hospital the boy receives a CT scan of his head, showing the following.

a) What is your diagnosis? Which vessel has ruptured?

Answer 24

Extradural haemorrhage - middle meningeal artery.

Question 25

8) During a rugby match, a 13 year old boy receives a severe blow to the head which led to transient loss of consciousness on the pitch. He is taken to be seen by the school nurse and reports that he feels fine and would like to return to the match. The nurse decides to observe him for 30 minutes before making any further decisions.

After 20 minutes the boy starts complaining of headache and the nurse notices that he seems drowsy. After a further 2 minutes the boy has completely lost consciousness. The nurse puts him into the recovery position and calls for an ambulance.

At hospital the boy receives a CT scan of his head, showing the following.

b) Why has this led to impairment of consciousness?

Answer 25

This has caused RICP meaning the cortex is compressed meaning the inputs of synapses releasing histamine, glutamate,

Question 26

8) During a rugby match, a 13 year old boy receives a severe blow to the head which led to transient loss of consciousness on the pitch. He is taken to be seen by the school nurse and reports that he feels fine and would like to return to the match. The nurse decides to observe him for 30 minutes before making any further decisions.

After 20 minutes the boy starts complaining of headache and the nurse notices that he seems drowsy. After a further 2 minutes the boy has completely lost consciousness. The nurse puts him into the recovery position and calls for an ambulance.

At hospital the boy receives a CT scan of his head, showing the following.

c) Starting with the initial blow to the head, draw a graph showing the approximate trends seen in the boy’s GCS. Label the ‘lucid interval’.

Answer 26

Decrease (from 15 to 3)
Increase (from 3 to 15)
Plateau (at 15)
Decrease (to 3)

y-axis from 3 to 15.

Question 27

8) During a rugby match, a 13 year old boy receives a severe blow to the head which led to transient loss of consciousness on the pitch. He is taken to be seen by the school nurse and reports that he feels fine and would like to return to the match. The nurse decides to observe him for 30 minutes before making any further decisions.

After 20 minutes the boy starts complaining of headache and the nurse notices that he seems drowsy. After a further 2 minutes the boy has completely lost consciousness. The nurse puts him into the recovery position and calls for an ambulance.

At hospital the boy receives a CT scan of his head, showing the following.

On admission to hospital it is noted that the boy’s blood pressure and heart rate are 180/100 and 50 bpm.

d) Can you explain this trend? Speculate on the neural mechanism for this.

Answer 27

The Cushing response.

Question 28

8) During a rugby match, a 13 year old boy receives a severe blow to the head which led to transient loss of consciousness on the pitch. He is taken to be seen by the school nurse and reports that he feels fine and would like to return to the match. The nurse decides to observe him for 30 minutes before making any further decisions.

After 20 minutes the boy starts complaining of headache and the nurse notices that he seems drowsy. After a further 2 minutes the boy has completely lost consciousness. The nurse puts him into the recovery position and calls for an ambulance.

At hospital the boy receives a CT scan of his head, showing the following.

On admission to hospital it is noted that the boy’s blood pressure and heart rate are 180/100 and 50 bpm.

e) What needs to be done immediately to save the boy’s life?
Watch this video. https://www.youtube.com/watch?v=VTrIjdBBMnA
Beware, there is some blood!

Answer 28

Craniotomy

Question 29

9) Whilst at the gym a 25 year old woman developed ‘the worst headache’ of her life, which came on suddenly whilst she was on the cross-trainer. One of the gym staff called an ambulance as she was in tremendous pain and was also complaining of intolerance to the bright lights and ‘double vision’. Upon arrival the paramedics noted that she had a GCS of 10 and a third nerve palsy.
a) What is your provisional diagnosis? Find a suitable CT scan supporting this and paste it below.

Answer 29

Subarachnoid haemorrhage

Question 30

9) Whilst at the gym a 25 year old woman developed ‘the worst headache’ of her life, which came on suddenly whilst she was on the cross-trainer. One of the gym staff called an ambulance as she was in tremendous pain and was also complaining of intolerance to the bright lights and ‘double vision’. Upon arrival the paramedics noted that she had a GCS of 10 and a third nerve palsy.
b) Which vessel has most likely been affected? Give reasons for your answer including an explanation for why the third nerve has been affected.

Answer 30

Posterior communicating artery - the third nerve has been affected so this lies in close proximity to the PCA.

Question 31

10) Four days after ‘a slight bang to the head’, an 85 year old man with known dementia, on warfarin for AF, was admitted to his local district general hospital with worsening confusion.

The admitting doctor excluded the most common causes for acute on chronic confusion and requested a CT head.

a) What is the most likely diagnosis? Find a typical CT scan showing this and paste it below.

Answer 31

Subdural haemorrhage - bridging veins, thinning of the vessels.

Question 32

10) Four days after ‘a slight bang to the head’, an 85 year old man with known dementia, on warfarin for AF, was admitted to his local district general hospital with worsening confusion.

The admitting doctor excluded the most common causes for acute on chronic confusion and requested a CT head.

b) Can you give an anatomical explanation for why the scan looks as it does?

Answer 32

Not defined by the borders of the sutures but kept between the meninges. Your falx will affect it, hence why it crosses over the midline.

Question 33

10) Four days after ‘a slight bang to the head’, an 85 year old man with known dementia, on warfarin for AF, was admitted to his local district general hospital with worsening confusion.

The admitting doctor excluded the most common causes for acute on chronic confusion and requested a CT head.

c) What are the risk factors predisposing this patient to this condition?

Answer 33

• Recent head injury
• Increasing age (>60 y/o)
• Alcohol misuse
• Blood-thinning medication e.g. warfarin
• Other conditions e.g. epilepsy, haemophilia, brain aneurysms and cancerous (malignant) brain tumours

In this patient:

• Recent head injury
• Age
• Dementia
• Warfarin

Question 34

10) Four days after ‘a slight bang to the head’, an 85 year old man with known dementia, on warfarin for AF, was admitted to his local district general hospital with worsening confusion.

The admitting doctor excluded the most common causes for acute on chronic confusion and requested a CT head.

d) Do you think a DGH is likely to be able to treat this condition? If not, where should he be sent?

Answer 34

Yes, you want to call a trauma centre to treat them - ideally you would want them to be treated at a trauma centre but realistically a neurosurgeon won’t want to touch them with all their co-morbidities, so they will be treated at a District General Hospital.

(So in reality NO, because they won’t be accepted but you do want to try).