Vascular Flashcards
A patient presents with a one-year history of intermittent twitching of the right side of the face. During surgery to address the twitching, the nerve indicated by the arrow in the image shown is injured. This injury will most likely cause which of the following neurological deficits?
A. Unilateral Facial Numbness B. Vertigo
C. Dysphagia
D. Sensorineural hearing loss
E. Unilateral Facial Weakness
Correct Answer: Dysphagia
Which of the following characteristics confers the highest risk of hemorrhage for patients harboring dural arteriovenous fistulae?
Answers:
A. Draining into cortical veins
B. No sinus or venous outflow occlusion
C. Draining into the transverse-sigmoid sinuses
D. Venous varix on a draining vein
Correct Answer:
Draining into cortical veins
A 23-year-old woman is evaluated because of Bell palsy. An MR image with contrast of the facial nerve is shown. The arrow corresponds to which of the following segments of the facial nerve?
A. Labyrinthine segment
B. Meatal (canalicular) segment
C. Tympanic segment
D. Mastoid segment
E. Extratemporal segment
Correct Answer: Mastoid segment
During arteriovenous malformation embolization, prior to the administration of the liquid embolic agent ethylene-vinyl alcohol copolymer, the microcatheter should be flushed with which of the following agents?
Answers:
A. Dimethyl sulfoxide (DMSO)
B. Heparin
C. Phosphate-buffered saline (PBS)
D. Lidocaine hydrochloride 1%
E. Dextrose 5% in water (D5W)
DMSO
The carotid sinus reflex is characterized by which of the following?
Answers:
A. Reduced vagal nerve activity following hypotension
B. Vasoconstriction due to acidosis
C. Tachycardia following systemic arterial hypertension
D. Bradycardia following systemic arterial hypertension
E. Hypertension following external manual compression
Correct Answer:
Bradycardia following systemic arterial hypertension
Aortic arch classification is based on the distance from the origin of which of the following arteries to the top of the aortic arch?
A. Right carotid
B. Innominate
C. Left carotid
D. Right vertebral
E. Left vertebral
B. Innominate
A 75-year-old woman is evaluated for complaints of a painful left eye, double vision, and a “buzzing” sound in her head when she goes to sleep. Ophthalmic examination shows the left eye is proptotic and chemotic. Which of the following is the most likely diagnosis?
Answers:
A. Tentorial Dural Arteriovenous Fistula
B. Giant Basilar Tip Aneurysm
C. Tinnitus
D. Carotid-cavernous Fistula
E. Benign Positional Vertigo
D. Carotid-cavernous Fistula
Six months after undergoing removal of a medial sphenoid wing and cavernous sinus wall meningioma, a 67-year-old man complains of persistent dysesthetic pain and numbness along his inferior eyelid, lateral nose, mid face, and upper lip. This was most likely caused by injury to a branch of the nerve that ultimately passes through which of the following openings?
Answers:
A. Superior Orbital Fissure
B. Vidian Canal
C. Foramen Rotundum
D. Foramen Spinosum
E. Foramen Ovale
Correct Answer: Foramen Rotundum
An angiogram and MR image of the brain are shown. Which of the following vessels supplies the posterior circulation in this patient?
A. Fetal posterior communicating artery
B. Persistent hypoglossal artery
C. Persistent otic artery
D. Persistent proatlantal segmental artery
E. Persistent trigeminal artery
B. Persistent hypoglossal artery
Which of the following is likely to provide the most conclusive evidence of the anatomic integrity of the facial nerve in a patient with a facial paralysis following a basilar skull fracture?
Answers:
A. High Quality MRI
B. Surgical Exploration
C. High-resolution CT
D. Schirmir’s test
E. Electroneurography (ENOG)
Electroneurography (ENOG)
Which of the following statements is true regarding Wilbrand’s knee?
A. Compression of Wilbrand’s knee occurs at the posterior chiasm
B. Compression of Wilbrand’s knee causes contralateral central scotoma.
C. A junctional scotoma includes an inferio-nasal defect
D. A junctional scotoma includes a superio-nasal defect
E. Compression of Wilbrand’s knee results in an ipsilateral central scotoma and contralateral temporal defect
E. Compression of Wilbrand’s knee results in an ipsilateral central scotoma and contralateral temporal defect
The cell bodies of the afferent fibers carrying proprioceptive information from the masseter muscle are located in which of the following structures?
Answers:
A. Trigeminal Ganglion
B. Principal Sensory Nucleus of CN V C. Spinal trigeminal nucleus
D. Nucleus Ambiguus
E. Mesencephalic nucleus of CN V
Correct Answer: Mesencephalic nucleus of CN V
Primary auditory sensory neurons are located in which of the following structures?
Answers:
A. Heschl’s gyrus
B. Medial geniculate nucleus
C. Cochlear nucleus
D. Cochlear duct
E. Spiral ganglion
E. Spiral ganglion
A 65-year-old man is evaluated ten hours after the sudden onset of aphasia and right hemiplegia. He has no history of bleeding disorders and takes no medications. A CT scan of the brain shows no hemorrhage; MR angiography shows an abrupt cutoff of the left M1 segment and no diffusion abnormalities. Which of the following is the most appropriate treatment for this patient?
Answers:
A. recombinant alteplase
B. Mechanical Thrombectomy
C. Observation
D. Decompressive Craniectomy
E. External Ventricular Drain
Correct Answer: Mechanical Thrombectomy
The numerical designation associated with a preparation of the liquid embolic agent ethylene-vinyl alcohol copolymer refers to which of the following characteristics?
Answers:
A. Viscosity in centipoise
B. Polymerization time in seconds C. Osmolality in osmoles per liter D. Concentration as a percentage E. Volume in milliliters
Correct Answer: Viscosity in centipoise
A patient requires dual antiplatelet therapy for a neuroendovascular procedure. However, upon genetic testing, the patient is found to have two nonfunctional copies of the CYP2C19 gene and is classified as a CYP2C19 poor metabolizer. In addition to aspirin, which of the following is the most appropriate drug choice for this patient?
Answers:
A. Ticagrelor
B. Clopidogrel
C. Argatroban
D. Dipyridamole
E. Cilostazol
Correct Answer: Ticagrelor
A 22-year-old woman with moyamoya disease undergoes cerebral angiography. Based on the lateral projection of the left external carotid artery shown, which of the labeled arteries (A–E) would be most appropriate to use for an extracranial/intracranial bypass?
Answers:
A. A
B. B
C. C
D. D
E. E
Correct Answer: D
Discussion:
The Superficial Temporal Artery (D) is the most-studied and traditionally used extracranial donor vessel in an EC-IC Direct Bypass surgery.
A - Facial Artery
B - Internal Maxillary Artery
C - Middle Meningeal Artery
D - Superficial Temporal Artery
E - Occipital Artery
A 45-year-old man is evaluated because of a two-week history of headaches. MR angiography shows a 13-mm smooth left middle cerebral artery aneurysm. Which of the following factors would put this patient at increased risk for future hemorrhage?
Answers:
A. Smoking Status
B. Use of statin drugs
C. Multiple unruptured aneurysms
D. Hypertension
E. Family history of subarachnoid hemorrhage
Correct Answer: Hypertension
Discussion:
The PHASES score was developed to help surgeons decide when to treat unruptured intracranial aneurysms based on an estimated 5-year aneurysm rupture risk using risk factor status and combined data from prospective cohort studies. Predictors were age, hypertension, history of subarachnoid hemorrhage, aneurysm size, aneurysm location, and geographical region. In study populations from North America and European countries other than Finland, the estimated 5-year absolute risk of aneurysm rupture ranged from 0.25% in individuals younger than 70 years without vascular risk factors with a small-sized (<7 mm) internal carotid artery aneurysm, to more than 15% in patients aged 70 years or older with hypertension, a history of subarachnoid haemorrhage, and a giant-sized (>20 mm) posterior circulation aneurysm.
The patient in this question had a large 13mm anterior circulation aneurysm in a patient less than 70 years old. For a patient under 70 with a never-ruptured MCA aneurysm 10.0-19.9mm in size, a patient without hypertension has a 1% predicted risk of ruputure in the next 5 years–or 2% if the patient also has hypertension–and is considered low to very low risk of rupture. In this case, a history of hypertension would put the patient at increased risk of future rupture. The PHASES study concluded that “sex, presence of multiple aneurysms, and smoking status had no added value for the prediction of aneurysm rupture when other risk factors were accounted for.”
References:
Greving JP, Wermer MJ, Brown RD Jr, et al. Development of the PHASES score for prediction of risk of rupture of intracranial aneurysms: a pooled analysis of six prospective cohort studies. Lancet Neurol. 2014 Jan;13(1):59-66.
Foreman PM, Hendrix P, Harrigan MR, Fisher WS 3rd, Vyas NA, Lipsky RH, Walters BC, Tubbs RS, Shoja MM, Griessenauer CJ. PHASES score applied to a prospective cohort of aneurysmal subarachnoid hemorrhage patients. J Clin Neurosci. 2018 Jul;53:69-73. doi: 10.1016/j.jocn.2018.04.014. Epub 2018 Apr 20. PMID: 29685416.
During arteriovenous malformation embolization, prior to the administration of the liquid embolic agent n-butyl cyanoacrylate, the microcatheter should be flushed with which of the following agents?
Answers:
A. Ethylene-vinyl alcohol (EVOH) B. Heparin
C. Normal saline
D. Dextrose 5% in water (D5W)
E. Dimethyl sulfoxide (DMSO)
Correct Answer:
Dextrose 5% in water (D5W)
Which of the following best describes cranial nerves that are contained within the superior orbital fissure?
Answers:
A. Damage to the nerves from superior orbital fissure syndrome (SOFS) can occur from craniofacial trauma and causes a down-and-out eye and blindness.
B. There are eight individual nerves from five cranial nerves which pass through the superior orbital fissure.
C. They pass through the tendinous ring of Zinn to get to the orbit.
D. They are traveling from the cavernous sinus to the apex of the orbit.
E. They are bordered by the greater and lesser wings of the sphenoid as well as the ethmoid bone.
Correct Answer:
They are traveling from the cavernous sinus to the apex of the orbit.
Axons of retinal ganglion cells project to which of the following structures?
Answers:
A. Meyer’s loop
B. Suprachiasmatic nucleus
C. Optic chiasm
D. Lateral geniculate body
E. Optic cortex
Correct Answer: Lateral geniculate body
A 63-year-old woman with breast cancer is evaluated after undergoing MR imaging of the brain; the MR image is shown (Figure 1). Cerebral angiograms from the anteroposterior vertebral view (Figure 2) and lateral vertebral view (Figure 3) are shown. Which of the following treatments provides the lowest risk of procedural-related neurological deficits?
Answers:
A. Radiosurgery
B. Endovascular Embolization
C. Surgical resection after endovascular embolization D. Microsurgery
E. Surgical resection after radiosurgery
Correct Answer:
Correct Answer: Radiosurgery
Which of the following nuclei is associated with the sympathetic nervous system?
Answers:
A. Edinger–Westphal
B. Dorsal motor nucleus of the vagus
C. Inferior salivatory
D. Intermediolateral
E. Suprachiasmatic
Correct Answer: Intermediolateral
Bedside hearing evaluation of a patient shows the following: Test Left Ear Right Ear Weber No lateralization Lateralization Rinne Air conduction > Bone conduction Bone conduction > Air conductionWhich of the following is the most likely diagnosis?
Answers:
A. Left Sensorineural hearing loss
B. Left Conductive hearing loss
C. Bilateral sensorineural hearing loss
D. Right Sensorineural hearing loss
E. Right Conductive hearing loss
Correct Answer:
Correct Answer:
Right Sensorineural hearing loss
Which of the following is a characteristic of supplementary motor area syndrome?
Answers:
A. Irreversible
B. Hyper-reflexia
C. Global akinesia
D. Occurs only after bilateral lesions
E. Decreased muscle strength
Correct Answer: Global akinesia
The chorda tympani nerve exits the skull from which of the following structures?
Answers:
A. Petrotympanic fissure
B. Stylomastoid foramen
C. Petromastoid canal
D. Mastoid foramen
E. Jugular foramen
Correct Answer: Petrotympanic fissure
Which of the following is a characteristic of dorsal midbrain syndrome
Answers:
A. Marcus-Gunn pupils
B. Preserved vertical saccades velocity
C. Preserved reflex eye movements
D. Divergence nystagmus with attempted upward voluntary gaze E. Limited upward voluntary gaze
Correct Answer:
Limited upward voluntary gaze
An 80-year-old woman with a history of atrial fibrillation held her anticoagulation prior to undergoing an epidural steroid injection. She acutely develops aphasia and right-sided hemiplegia. NIH Stroke Scale on presentation is 14. CT scan of the head shows no hemorrhage. The patient receives an intravenous bolus of tissue plasminogen activator (tPA) without improvement. CT angiogram (Figure 1) and CT perfusion scans (Figure 2) are shown. Which of the following is the most
appropriate next step in management?
A. Initiation of dual anti-platelet therapy with aspirin and clopidogrel
B. Decompressive hemicraniectomy
C. Administration of intra-arterial tPA
D. Supportive care with mean arterial blood pressure greater than 85 mmHg
E. Urgent mechanical thrombectomy
Correct Answer:
Urgent mechanical thrombectomy
Which of the following vessels is most often associated with glossopharyngeal neuralgia?
Answers:
A. Anterior Inferior Cerebellar Artery (AICA)
B. Superior Cerebellar Artery (SCA)
C. Vertebral Artery
D. Posterior Inferior Cerebellar Artery (PICA)
E. Unnamed Vein
Correct Answer:
Posterior Inferior Cerebellar Artery (PICA)
A stroke in which of the following vascular distributions is most likely to cause alexia?
Answers:
A. Posterior cerebral artery
B. Superior cerebellar artery
C. Anterior cerebral artery
D. Anterior choroidal artery
E. Middle cerebral artery
Correct Answer: Posterior cerebral artery
The greater superficial petrosal nerve contains which of the following types of autonomic fibers?
Answers:
A. Postganglionic Sympathetic
B. Preganglionic Sympathetic
C. Postganglionic Parasympathetic
D. Preganglionic Parasympathetic
E. It does not contain autonomic fibers
Correct Answer:
Preganglionic Parasympathetic
A 67-year-old man with type 2 diabetes mellitus, hyperlipidemia, and hypertension presents with transient aphasia and right-sided weakness. MR imaging demonstrates a watershed infarct in the left hemisphere. CT angiography shows focal 70% left M1 stenosis. Which of the following is the most appropriate treatment?
Answers:
A. Superficial temporal artery-middle cerebral artery (STA-MCA) bypass performed on a subacute basis
B. Medical management with dual antiplatelets, glycemic control, and statin therapy
C. Balloon angioplasty and stenting
D. Mechanical thrombectomy
E. Intra-arterial tissue plasminogen activator (tPA) infusion into left internal carotid artery
Correct Answer:
Medical management with dual antiplatelets, glycemic control, and statin therapy
A 25-year-old woman presents with a painless mass in her right neck. The mass is depicted in the MR image shown. Following surgery, she awakens with a droopy eyelid and a smaller pupil on that side. This is most likely a result of injury to which of the following structures?
Answers:
A. Sympathetic chain
B. Carotid body
C. Ansa cervicalis
D. Hypoglossal nerve
E. Vagus nerve
Correct Answer: Sympathetic chain
Which of the following contains the neurons that mediate the sense of taste in the anterior two- thirds of the tongue?
Answers:
A. Trigeminal ganglion
B. Geniculate ganglion
C. Spiral ganglion
D. Pterygopalatine ganglion
E. Inferior (petrosal) ganglion
Correct Answer: Geniculate ganglion
A 42-year-old man is brought to the emergency department because of sudden onset of syncope. On arrival, he is hoarse, with palatal deviation to the right and a decreased gag response. An MR image is shown. Which of the following is the most likely diagnosis?
Answers:
A. Cavernous Malformation
B. Metastatic tumor
C. Abscess
D. Ruptured Posterior Inferior Cerebellar Artery Aneurysm
E. Arteriovenous fistula
Correct Answer: Cavernous Malformation
A 65-year-old man is evaluated because of a slowly progressive, nine-month history of urinary dysfunction, midthoracic pain, and difficulty walking. Physical examination shows inability to tandem walk, a T8 sensory level, and weakness in the lower extremities graded at 4/5. The T2- weighted axial MR image of the thoracic spine at the T6 level shown is most consistent with which of the following?
Answers:
A. Type 4 Spinal Vascular Malformation
B. Type 2 Spinal Vascular Malformation
C. Spinal cord infarction
D. Type 1 Spinal Vascular Malformation
E. Type 3 Spinal Vascular Malformation
Correct Answer:
Type 1 Spinal Vascular Malformation
The 2018 stroke guidelines published by the American Heart Association/American Stroke Association (AHA/ASA) support endovascular thrombectomy in select patients. From symptom onset, which of the following best describes the longest time window in which patients are recommended to have endovascular thrombectomy?
Answers:
A. 18-24 hours
B. <2 hours
C. 6-16 hours
D. 16-18 hours
E. <6 hours
Correct Answer: 6-16 hours
In a patient with spinal dural arteriovenous fistula, which of the following is the most likely cause of symptoms?
Answers:
A. Spinal cord compression
B. Venous hypertension
C. Compression of exiting nerve roots
D. Hemorrhage
E. Spinal cord infarction
Correct Answer: Venous hypertension
A 72-year-old woman is evaluated for a lesion that was incidentally discovered on the axial T2- weighted MR image that is shown. Which of the following best describes this patient’s estimated five-year risk for hemorrhage or new neurological deficit because of this lesion?
Answers:
A. 7.1%
B. 9.4%
C. 3.8%
D. 48.6%
E. 1.02%
Correct Answer: 3.8%
A 74-year-old man is evaluated because of a four-year history of progressive bilateral leg numbness and gait instability. A T2-weighted thoracic sagittal MR image is shown. Which of the following is the most appropriate next step in management?
Answers:
A. Spinal Computed Tomography angiogram
B. Exploratory laminectomy
C. Observation
D. Spinal digital subtraction angiogram
E. Lumbar puncture
Correct Answer:
Spinal digital subtraction angiogram
A previously healthy 14-year-old girl is brought to the emergency department with sudden loss of consciousness. She is emergently intubated. A CT scan is performed and shown. Which of the following is the most likely cause of the abnormality seen?
Answers:
A. Cerebral aneurysm
B. Cerebral venous sinus thrombosis
C. Arteriovenous malformation
D. Parieto-occipital neoplasm
E. Cavernous malformation
Correct Answer: Arteriovenous malformation
A 23-year-old woman is evaluated because of Bell palsy. An MR image with contrast of the facial nerve is shown. The arrow corresponds to which of the following segments of the facial nerve?
Answers:
A. Extratemporal segment
B. Meatal (canalicular) segment
C. Labyrinthine segment
D. Tympanic segment
E. Mastoid segment
Correct Answer: Tympanic segment
A 44-year-old woman with Down syndrome has had increasingly frequent episodes of numbness, tingling, and weakness of her right upper extremity over the past four months. In the course of her cerebrovascular evaluation, an arteriogram is performed, and the left common carotid injection anteroposterior (Figure 1) and lateral (Figure 2) projections are shown. Which of the following therapeutic options has been best demonstrated to decrease the incidence of strokes in this population of patients?
Answers:
A. Cervical Carotid Stenting
B. Encephaloduroarteriosynangiosis
C. Encephaloduroarteriosynangiosis
D. Superficial temporal artery to internal carotid artery bypass
E. Calcium channel blockers
Correct Answer:
Superficial temporal artery to internal carotid artery bypass
A 16-year-old girl is evaluated for paresthesia in both legs and an unsteady gait. T2-weighted non- contrast sagittal (Figure 1) and axial (Figure 2) MR images are shown. Which of the following is the most likely diagnosis?
Answers:
A. Cavernous malformation
B. Spinal cord infarction
C. Glioma
D. Ependymoma
E. Arteriovenous
Correct Answer: Cavernous malformation
A 66-year-old asymptomatic woman undergoes a right vertebral artery angiogram. Based on the image shown, this patient is at risk for developing which of the following?
Answers:
A. Aphasia
B. Brain stem ischemia
C. Bitemporal hemianopsia
D. Right arm claudication
E. Retinal transient ischemic attack
Correct Answer: Brain stem ischemia
A 22-year-old woman with a history of multiple transient ischemic attacks and a recent small ischemic stroke undergoes cerebral angiography. On the basis of the images shown, which of the following is the most appropriate next step in management?
Answers:
A. Calcium channel blockers
B. Direct Revascularization
C. Warfarin
D. encephalomyoarteriosynangiosis
E. Indirect Revascularization
Correct Answer:
Direct Revascularization
A 42-year-old man is evaluated after sustaining an ischemic stroke caused by occlusion of the cervical internal carotid artery and the M1 segment of the middle cerebral artery. CT perfusion scans obtained 7 hours after the onset of the stroke are shown. Which of the following is the most appropriate next step in management?
Answers:
A. recombinant alteplase
B. Mechanical Thrombectomy
C. External Ventricular Drain
D. Decompressive Craniectomy
E. Observation
Correct Answer: Decompressive Craniectomy
An 81-year-old man with hypertension, hyperlipidemia, and an ejection fraction of 45% presents with two episodes of transient right arm weakness over the past month. An angiogram is shown. Which of the following carries the lowest 30-day risk of stroke?
Answers:
A. Carotid artery angioplasty and stenting
B. Carotid endarterectomy
C. Atorvastatin therapy
D. Aspirin and clopidogrel therapy
E. Warfarin therapy
Correct Answer: Carotid endarterectomy
The patient whose angiogram is shown most likely corresponds with which of the following etiologies?
Answers:
A. Infectious
B. Polycystic kidney disease
C. Marfan syndrome
D. Traumatic
E. Ehlers-Danlos syndrome
Correct Answer: Traumatic
A 73-year-old woman with breast cancer is evaluated after undergoing MR imaging of the brain. Results of the MR imaging prompted the physician to perform cerebral angiography; anteroposterior (Figure 1) and 3D rotational (Figure 2) right internal carotid injections are shown. Which of the following is the most appropriate management?
Answers:
A. Observation
B. EC-IC Bypass
C. Endovascular Embolization
D. Microsurgical Clipping
E. Huntarian Ligation
Correct Answer: Endovascular Embolization
The photograph shown demonstrates the standard surgical exposure for a left carotid endarterectomy. Injury to the structure indicated by the arrow would most likely result in which of the following symptoms?
Answers:
A. Ipsilateral tongue weakness
B. Dysphagia and loss of gag reflex
C. Weakness in lower lip muscles
D. Ipsilateral miosis and ptosis
E. Hoarseness
Correct Answer:
Ipsilateral tongue weakness
The photograph shown demonstrates the standard surgical exposure for a left carotid endarterectomy. An injury to the structure indicated by the black star would most likely result in which of the following symptoms?
Answers:
A. Hoarseness of voice
B. Pupillary dilatation
C. Weakness of the left sided lower lip depressor
D. Ptosis
E. Tongue deviation to the left side
Correct Answer: Hoarseness of voice
