Vascular

Question 1

What is the histopathological hallmark of amyloid angiopathy?

Answer 1

beta-amyloid deposition within the media of leptomeningeal and cortical vessels, which demonstrates a characteristic yellow-green birefringence under polarized light microscopy when stained with Congo red dye. Fibrinoid necrosis may also be present.

Question 2

Which arteries supply the descending spinal nucleus of the trigeminal nerve?

Answer 2

Posterior inferior cerebellar artery (PICA) occlusion causes lateral medullary syndrome, also known as Wallenberg syndrome. One aspect of this syndrome is ipsilateral loss of facial sensation secondary to involvement of the spinal nucleus of the trigeminal nerve. Other findings in this syndrome include contralateral loss of pain and temperature sense in the body, decreased gag and taste, dysphagia and hoarseness, Horner’s syndrome, and cerebellar ataxia from involvement of cranial nerves IX and X, the lateral spinothalamic tract, the descending sympathetic fibers, and the inferior cerebellar peduncle.

Question 3

A 26-year-old man is evaluated because of a mass on the right side of his neck that has been slowly enlarging over the past 18 months. An angiogram and an MR image are shown. What is the most likely diagnosis?

Answer 3

Paraganglioma have a hyperintense ‘light bulb’ appearance on T2 weighted images and can have a “salt and pepper” enhancement. Historically, diagnostic angiography played an important role as a first-line imaging investigation for paragangliomas. These lesions originate from paraganglionic tissue located at the carotid bifurcation (carotid body tumors).

Question 4

Which is the most proximal segment of the posterior inferior cerebellar artery (PICA) that may be sacrificed with little risk of neurological compromise?

Answer 4

The PICA can be be divided into five segments. The proximal most segments (anterior and lateral medullary) segments contribute branches to the brainstem. The tonsillomedullary segment is a transitional zone which may produce some perforating vessels.

The distal most segments (telovelotonsillar and cortical) do not supply blood to the brainstem. The first three segments of the PICA are usually preserved, while the last 2 can be sacrificed without major neurological deficits.

Question 5

What does the anterior choroidal artery supply?

Answer 5

arises distal to the posterior communicating artery

supplies the posterior limb of the internal capsule, the optic tract, the lateral geniculate nucleus, the medial temporal lobe, and the globus pallidus pars interna (GPi), SN, chiasm, optic radiations, red nucleus

Ischemia of its territory classically results in contralateral hemisensory loss, hemiparesis, and hemianopia.

Question 6

What symptom could arise from compromise of the bilateral recurrent arteries of Huebner?

Answer 6

Akinetic mutism is a disorder of consciousness characterized by unresponsiveness but with the superficial appearance of alertness. The patient’s eyes are open and he may seem to look at the examiner but he neither speaks nor moves, nor is the examiner able to communicate with the patient.

Bilateral lesions of the head of the caudate nucleus associated with destruction of medial putamen, septum, medial frontal cortex, and cingulate cortex can result in akinetic mutism.

Question 7

Occlusion of which of the arteries would result in an infarct localized to the anterior limb of the internal capsule?

Answer 7

The recurrent artery of Heubner supplies the head of the caudate, anterior limb of the internal capsule, anterior putamen and globus pallidus, the septal nuclei, and the inferior frontal lobe.

Compromise of blood flow in the recurrent artery of Heubner classically results in contralateral arm and face weakness, and occasionally dysarthria.

Bilateral injury results in akinetic mutism.

Question 8

Which of the following structures is indicated by the arrow in the photograph shown?

Answer 8

The anterior choroidal artery exits the ICA just distal to the origin of the posterior communicating artery.

Question 9

The posterior interosseous nerve is a branch of which nerve? What muscles does it innervate?

Answer 9

radial nerve

provides innervation to the following muscles: extensor carpi radialis brevis, extensor digitorum, extensor digiti minimi, extensor carpi ulnaris, supinator, abductor pollicis longus, extensor pollicis brevis, extensor pollicis longus, extensor indicis.

Question 10

The internal auditory artery most often arises from which of the following arteries?

Answer 10

AICA, sometimes basilar

Question 11

Which anastomotic arteries is depicted in the lateral intracranial arteriogram shown?

Answer 11

Persistent primitive trigeminal artery is one of the several persistent carotid-vertebrobasilar anastomoses. It is the most common among the persistent persistent carotid-vertebrobasilar anastomoses (0.1-0.6%) seen on cerebral angiograms.

In utero, the trigeminal artery supplies the basilar artery prior the development of the posterior communicating and vertebral arteries. The persistent primitive trigeminal artery arises from the junction between petrous and cavernous ICA, and runs posterolaterally along the trigeminal nerve, or crosses over or through the dorsum sellae.

A characteristic tau sign or trident sign is described as its appearance on sagittal CT Angio or MR images or lateral angiogram.

Question 12

The persistent hypoglossal artery is a connection between the basilar artery and which artery?

Answer 12

The persistent hypoglossal artery arises at the level of C1 to C3 as a robust branch from the cervical internal carotid artery (ICA). The persistent trigeminal artery arises from the cavernous ICA, while the persistent otic artery arises from the petrous ICA.

Question 13

What does the PICA supply?

Answer 13

lateral medulla, posterior inferior cerebellum, and inferior cerebellar vermis

Question 14

AVM types, flow, pressure, and presentation:

Answer 14

Question 15

What disease has AVM of the retina or optic nerve?

Answer 15

Wyburn-Mason disease

Question 16

Basilar tip aneurysms projecting in which direction have the highest risk of perforating vessel injury during surgery?

Answer 16

posterior

Question 17

Branches of the petrous carotid?

Answer 17

vidian, caroticotympanic, and occasional stapedius

Question 18

Branches of ophthalmic segment of carotid:

Answer 18

ophthalmic a. and superior hypophyseal a.

Question 19

Morbidity risk of surgery based on SM grade:

Answer 19

surgical morbidity:

Grade 3, minor deficit 12%, major deficit 4%.

Grade 4, minor deficit 20%, major deficit 7%.

Grade 5, minor deficit 19%, major deficit 12%.

Question 20

What artery is at risk during a retrosigmoid approach for schwannoma resection?

Answer 20

AICA and labyrinth artery (branch of AICA)

The labyrinthine artery courses into the internal auditory meatus and damage to this artery can lead to hearing loss.

Question 21

What are the vascular changes seen in NF1?

Answer 21

associated with aortic, celiac, mesenteric, and renal vascular stenosis, and cerebrovascular stenosis, aneurysms, AVMs, and moyamoya disease. There are no vascular abnormalities associated with NF2

Question 22

What are the histologic changes after a stroke (timeline)?

Answer 22

After 1 hour: Axonal changes.

12–24 hours: Neuronal necrosis, eosinophilic neurons, neuronal pyknosis.

24 hours: Well-circumscribed necrosis in an arterial territory.

1–2 days: PMNs accumulate.

2–5 days: BBB breakdown, edema, and axon retraction balls at the edge.

5–7 days: Gitter cells (lipid-laden macrophages) and neovascularization.

10–20 days: Astrocytosis around infarct, rim of gemistocytes.

> 3 months: Cystic space with fibrillary astrocytes. A 1-cm stroke takes 3 months to become cystic. A stroke tends to preserve the outermost cortical layers, unlike a contusion, which usually extends to the pia and affects the crests of the gyri.

Question 23

What two pediatric tumor syndromes can lead to stroke?

Answer 23

congenital vascular stenosis associated with NF1 and tuberous sclerosis

Question 24

What are the angiogram findings of moya moya?, most common site of stroke? vascular diseases with similar vascular pattern? Associated with which syndrome?

Answer 24

Angiogram demonstrates enlarged lenticulostriate, thalamoperforate, and collateral vessels forming a “puff of smoke.” Eighty percent of patients develop stroke and 50% have atrophy, especially in the anterior circulation

A similar vascular pattern may be seen with any progressive occlusive vascular disease (radiation, atherosclerosis, and sickle cell disease)

downs syndrome

Question 25

Vascular changes seen in Ehlers–Danlos syndrome:

Answer 25

vascular fragility associated with carotid-cavernous fistulas and arterial narrowing

Question 26

Cerebral autosomal dominant inherited arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) mutation, symptoms and histology:

Answer 26

genetic disorder with a mutation of the Notch 3 gene on chromosome 19. Patients develop recurrent infarcts with subsequent dementia and demonstrate leukoencephalopathy with U fiber sparing. Pathologic examination of the cerebral vasculature demonstrates arteriopathy with granular osmiophilic material deposition.

Question 27

Medial medullary syndrome: site of lesion, clinical symptoms, responsible artery, and nuclei/tracts involved?

Answer 27

From a lesion in the medial medulla. Findings are ipsilateral tongue paralysis, contralateral paralysis of upper and lower extremities (spares face), and decreased body touch and proprioception. It is caused by vertebral artery or anterior spinal artery occlusion. It involves CN XII, pyramidal tract, and medial lemniscus.

Question 28

Klippel–Trenaunay–Weber syndrome is associated with which vascular disease?

Answer 28

associated with spinal AVMs and carotid aplasia

Question 29

Wegener’s granulomatosis: age group/sex, involved organs, cause, treatment?

Answer 29

Wegener’s granulomatosis: It occurs in adults with male predominance. It involves respiratory, renal, and CNS vessels and causes peripheral and cranial neuropathies. It is due to antineutrophil antibodies and is treated with cyclophosphamide.

Question 30

hereditary hemorrhagic telangiactasia (osler-weber-rendu) syndrome: inheritance, clinical symptoms, genes involved?

Answer 30

autosomal dominant

TGF)-β signaling superfamily in vascular endothelial cells leading to development of abnormal vascular structures with weak vessel walls

arteriovenous malformations in cns and other body systems are very common including, pulmonary (~50%), hepatic (~30%), spinal (~1%). Nosebleeds are very common from mucocutaneous telangiectasia (~90%) and up to 1/3 of HHT patients are anemic from chronic GI bleeding.

Question 31

Where are Charcot–Bouchard aneurysms found? what are the dilated perivascular spaced called and where are they formed?

Answer 31

form on the lenticulostriate arteries. There are dilated perivascular spaces, état lacunaire (in the centrum semiovale), and état criblé (in the basal ganglia), which form lacunae with gliosis but no symptoms.

Hemorrhage may be caused by rupture of Charcot–Bouchard aneurysms or by occlusion and secondary rupture of small penetrating arteries.

Question 32

What is Binswanger disease and where is it found?

Answer 32

hypertension and dementia with lacunae or demyelination in the centrum semiovale with arteriolar sclerosis

Question 33

ocular symptoms based on IPH location (putamen, thalamic, cerebellar, pontine):

Answer 33

Putamen: weakness by compression of the internal capsule and eye deviation toward the lesion

Thalamic: weakness, sensory loss, and ocular dysfunction (persistent downgaze)

Cerebellar: eye deviation away from the lesion and ocular bobbing although the latter sign is much more common with destructive pontine lesions

Pontine lesions cause fixed pinpoint pupils and ocular bobbing.

Question 34

Effect of cocaine and amphetamines on vessels?

Answer 34

Cocaine enhances platelet aggregation and spasm and may cause ischemic strokes. Amphetamines directly irritate the vessel wall and may cause vasculitis.

Question 35

Germinal matrix hemorrhage grades (1-4):

Answer 35

Grade 1: limited to the germinal matrix.

Grade 2: blood in the ventricles, but no increase in ventricular size.

Grade 3: blood in the ventricles with hydrocephalus.

Grade 4: intraparenchymal extension of the hemorrhage.

Question 36

Can arachnoid cysts hemorrhage?

Answer 36

Arachnoid cysts may hemorrhage and are associated with SDH

Question 37

What are Capillary telangiectasias? location? clinical symptoms? imaging appearance?

Answer 37

These are the second most common vascular malformations. They are small, multiple, clinically silent, firm capillary lesions, located in the white matter or classically the pons, and consist of multiple normal-sized and dilated thin vascular spaces without smooth muscle or elastic fibers. There is usually normal brain between lesions. Rarely there is evidence of old hemorrhage or gliosis. The angiogram is normal and the MRI reveals a lesion that is hypointense on T2-weighted images

different than HHT since the skin has telangactasias and the brain has AVMs

Question 38

Venous malformations: imaging features? treatment?

Answer 38

most common vascular malformations

There is intervening normal brain

consist of a large draining cortical vein receiving a collection of medullary veins (caput medusa) that usually occur near the angle of the ventricle

rarely require treatment

Question 39

Sinus pericranii: connections, how is it acquired?

Answer 39

A large communication between intracranial and extracranial veins. It may be congenital or caused by trauma. It is a soft mass that changes with head position. It is associated with other malformations.

Question 40

What is Foix–Alajouanine syndrome: location, associated vascular malformation, cause, clinical presentation?

Answer 40

Subacute necrotizing myelitis, especially in the gray matter, usually with a type 1 AVM, and caused by venous hypertension. It presents as spastic and then flaccid paraplegia with an ascending sensory loss and loss of sphincter control.

Question 41

spinal cord AVM with a cutaneous vascular nevus and an enlarged finger or upper limb (if cervical)?

Answer 41

Klippel–Trenaunay–Weber syndrome

Question 42

Inferolateral trunk is a branch of which part of the ICA, supply, anastomoses?

Answer 42

cavernous

Supply: Inferolateral cavernous sinus wall, tentorium, CN III, IV, VI, the gasserian ganglion

Anastamoses: ECA via the maxillary artery (through foramen rotundum) and the MMA

Question 43

In patients who receive medical therapy alone for asymptomatic carotid stenosis of 60-99%, what is the 5-year risk of stroke or death?

Answer 43

11%

if medical therapy and CEA then 5.1%

Question 44

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?

Answer 44

The draining vein immediately distal to the fistula.

Question 45

Occlusion of which artery causes the stroke shown in the figure?

Answer 45

Occlusion of the subcallosal artery after anterior communicating artery aneurysm clipping may cause a forniceal stroke leading to severe anterograde and retrograde amnesia

Question 46

A 61-year-old man presents with confusion. Susceptibility-weighted MR imaging demonstrates multiple abnormalities (figure). What is the most likely diagnosis?

Answer 46

Cerebral amyloid angiopathy

Question 47

what is The original classification of moyamoya disease by Suzuki and Takaku was intended to stratify patients according to the severity of the disease.

Answer 47

Stage 1 Stenosis of the carotid artery at its suprasellar portion, usually bilateral

Stage 2 Moyamoya vessels begin to develop at the base of the brain

Stage 3 Moyamoya vessels are prominent as major trunks in the anterior circulation become severely occluded

Stage 4 Posterior Cerebral Arteries occluded, moyamoya vessels begin to diminish and collateral pathways from extra cranial circulation develop

Stage 5 Moyamoya vessels are diminishing and extra cranial circulation progress

Stage 6 Moyamoya vessels and the major cerebral arteries completely disappear, the cerebral hemispheres receives blood through the abnormal extra cranial intracranial anastomosis

Question 48

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?

Answer 48

Posterior choroidal artery territory infarcts may lead to damage of the lateral geniculate body, pulvinar, posterior thalamus, hippocampus and parahippocampal gyrus. Clinical symptoms would include visual field defects, hemisensory disturbances, neuropsychological dysfunctions and abnormal movements, and rarely hemiparesis and eye movement disorders.

Question 49

During intraoperative aneurysm rupture, which medication can help achieve temporary flow arrest?

Answer 49

During intraoperative rupture of aneurysms, adenosine can be safely used to induce a short reversible hypotension and temporary asystole to decrease the bleeding from the ruptured aneurysm. This allows better visualization and control and limited time (30-45s) to place temporary clips

Question 50

Hunt and Hess grade classification for SAH:

Answer 50

Grade Description
1 Asymptomatic or mild headache and slight nuchal rigidity
2 Cranial nerve palsy on exam, moderate to severe headache, nuchal rigidity
3 Mild focal deficit, lethargy, or confusion
4 Stupor, moderate to severe hemiparesis, early decerebrate rigidity
5 Deep coma, decerebrate rigidity, moribund appearance
In the presence of a serious disease or vasospasm add 1 grade

Question 51

Types of CC fistulas

Answer 51

The internal maxillary artery usually supplies low-flow carotid cavernous fistulas. Indirect, low-flow carotid cavernous fistulas (CCFs) are categorized into type B, C, and D. Type B CCFs arise from meningeal branches of the internal carotid artery (ICA), Type C CCFs arise from meningeal branches of the external carotid artery (ECA), and Type D CCFs arise from meningeal branches of the ICA and ECA. Of the choices listed, the internal maxillary artery is the only meningeal branch of the ICA or ECA.

Question 52

What artery supplies the ventricles?

Answer 52

The choroid of the lateral ventricles is supplied by the posterior choroidal artery arising from the posterior cerebral artery. The medial posterior choroidal artery supplies the choroid plexus of the third ventricle. The lateral posterior choroidal artery supplies the choroid plexus of the lateral ventricles.

Question 53

neurotransmitter, receptor, and ion implicated in cellular necrosis after ischemia?

Answer 53

N-methyl-D-aspartate receptor binds glutamate and causes an influx of Ca2+, and has been implicated in cellular necrosis after ischemia. Glutamate levels are increased by ischemia.

Question 54

Most common location for aneurysm in children?

Answer 54

ICA

Question 55

An increased risk for rupture of an asymptomatic intracranial aneurysm is most commonly associated with which of the following disorders?

Answer 55

Autosomal dominant polycystic kidney disease

Question 56

where does the inferior petrosal sinus drain?

Answer 56

sigmoid sinus

Question 57

where does the superior petrosal sinus drain?

Answer 57

transverse sinus

Question 58

An 81-year-old man sustains a left hemispheric transient ischemic attack and is found to have 70% stenosis of the supraclinoid carotid artery. Which of the following is the most appropriate management?

Answer 58

Dual antiplatelet with aspirin and clopidrogrel

angioplasty can be used after 2 strokes