Special Aneurysms and Nonaneurysmal SAH

Question 1

Which of the following are the factors that have been identified as risk for rupture of unruptured aneurysms?
● A. History of previous aneurysmal subarachnoid hemorrhage from a separate aneurysm and multiple aneurysms
● B. Medical conditions like smoking, hypertension, geographic location (North America/Europe < Japan < Finland)
● C. Annual risk of rupture of aneurysms less than 10 mm is estimated to be 0.05%/year by ISUIA study
● D. Larger aneurysms (10–25 mm) are estimated to have 3 to 18%/year risk of rupture
● E. Giant aneurysms have a risk of rupture of around 8 to 50%/ year
● F. All of the above statements are correct

Answer 1

F. All of the above statements are correct

Question 2

Following are the components of PHASES aneurysm rupture risk score except?
● A. Population
● B. Hypertension
● C. Smoking
● D. Age
● E. Size
● F. Earlier rupture from another aneurysm
● G. Site of aneurysm

Answer 2

C. Smoking

Question 3

Following are recommended management strategies for patients with unruptured aneurysms except?
● A. Large and symptomatic aneurysms (especially in younger patients) should be dealt with intervention
● B. Patients with age below 60 years and size of aneurysm less than 7 mm should undergo conservative management if it is anterior circulation aneurysm with no risk factors while if the same size aneurysm in the same patient is found in posterior circulation/PComA with symptoms present and strong family history then intervention should be done for this patient
● C. In a patient less than 60 years of age and aneurysm size more than 7 mm, intervention should be done (surgery or endovascular based on size and location)
● D. Patients more than 60 years of age with aneurysm size less than 7 mm with no family history and no risk factors should be dealt conservatively with medicines
● E. Patients more than 60 years old with aneurysm more 7 to 12 mm in size should be dealt with conservative management if in the anterior circulation or intervention should be done if aneurysm with same size is found in posterior circulation
● F. In patients with aneurysm size more than 12 mm, intervention should never be done regardless of the age or location of aneurysm

Answer 3

F. In patients with aneurysm size more than 12 mm, intervention should never be done regardless of the age or location of aneurysm

Question 4

Traumatic aneurysms may present with delayed intracranial hemorrhage, recurrent epistaxis, progressive cranial nerve palsy, enlarging skull fracture, or severe headache. What is the common location of traumatic aneurysms that arise due to
closed head injury?
● A. A1 portion of anterior cerebral artery
● B. Anterior communicating artery
● C. Distal anterior cerebral artery
● D. Middle cerebral artery
● E. Basilar artery

Answer 4

C. Distal anterior cerebral artery

Question 5

Mycotic aneurysms are infectious aneurysms that arise due to bacterial infection. These constitute 4% of intracranial aneurysms and have most common location at distal branches of middle cerebral artery. What is the most common pathogen implicated in the pathogenesis of mycotic aneurysms?
● A. Streptococcus
● B. Staphylococcus
● C. Miscellaneous
● D. Brucella species
● E. All of the above

Answer 5

A. Streptococcus

Question 6

Giant aneurysms are large aneurysms with size of more than 2.5 cm. These are of two types; the first one is saccular aneurysm while the other is fusiform aneurysm. Which of the following are included in the treatment options for these aneurysms?
● A. Direct surgical clipping
● B. Vascular bypass of aneurysm with subsequent clipping
● C. Trapping of aneurysm
● D. Proximal arterial ligation (Hunterian ligation)
● E. Endovascular treatment
● F. All of the above

Answer 6

F. All of the above

Question 7

Aneurysm that fails to be demonstrated on initial angiogram have the following causes except?
● A. Incomplete angiography
● B. Obliteration of aneurysm by the hemorrhage
● C. Thrombosis of aneurysm after SAH
● D. Good filling of aneurysm due to vasodilatation
● E. Aneurysms too small to be visualized

Answer 7

D. Good filling of aneurysm due to vasodilatation

Question 8

Which of the following are the CT or MRI criteria for diagnosis of pretruncal nonaneurysmal subarachnoid hemorrhage?
● A. Epicenter of bleeding located immediately anterior to and in contact with the brainstem
● B. Blood limited to the prepontine, interpeduncular cisterns, supracellar, interpeduncular, suprasellar, crural, ambient, and/or quadrigeminal cistern
● C. No extension of blood into the sylvian fissure or interhemispheric fissure
● D. Intraventricular blood limited to the filling of the 4th ventricle
● E. All of the above are correct

Answer 8

E. All of the above are correct

Question 9

When should repeat angiography be done in case of subarachnoid hemorrhage of unknown etiology in which there is no aneurysm found on first angiography?
● A. On the 7th day
● B. After 3 days of first angiography
● C. After 10 to 14 days of first angiography
● D. After 18 days
● E. Repeat angiography is never done in such case

Answer 9

C. After 10 to 14 days of first angiography

Question 10

When a patient presents with subarachnoid hemorrhage, then following may be the clues to find out which aneurysmhas bled except?
● A. Epicenter (area of greatest concentration) of blood on CT or MRI
● B. Area of focal vasospasm has no role in determining the site of bleed
● C. Irregularities in the shape of aneurysm (so-called Murphy’s teat)
● D. If no clue is being found, then the largest aneurysm is suspected to have bled
● E. None of the above

Answer 10

B. Area of focal vasospasm has no role in determining the site of bleed