Vascular Disease

Question 1

The anterior circulation comes from what main arteries?

Answer 1

the common carotids

Question 2

What areas are supplied by the ACA?

Answer 2

anterior medial cerebral hemispheres, caudate nuclei and basal frontal lobes

Question 3

What artery connects the two ACAs?

Answer 3

the anterior communicating artery

Question 4

True or false: the lenticulostriate arteries branches to the basal ganglia and internal capsule off the ACA.

Answer 4

false - they come off the MCA

Question 5

What areas are supplied by the MCA?

Answer 5

the basal ganglia/internal capsule
lateral cerebral hemispheres superior to the sylvian fissure
temporal and inferior parietal lobes

Question 6

What artery arises from the ICA after the ophthalmic and posterior communicating artery to course along the optic tract giving off branches to the globus pallidus and posterior limb of the internal capsule and then supplies the medial temporal lobe and the lateral genicular body?

Answer 6

the anterior choroidal artery

Question 7

In general terms, the posterior circulation comes from what vessels?

Answer 7

the vertebral arteries off the subclavian

Question 8

The intracranial vertebral arteries join to form what artery?

Answer 8

the basilar at the pontomedullary junction

Question 9

What percentage of strokes are ischemic?

Answer 9

80%

Question 10

What are the three general categories of ischemic stroke/

Answer 10

thrombosis
embolism
systemic hypoperfusion

Question 11

What are some causes of occlusive vascular pathologies affecting the brain?

Answer 11

atherosclerosis is the most common
vasoconstriction
fibromuscular dysplasia
arterial dissection

Question 12

WHere do emboli causing embolic strokes typically arise from?

Answer 12

heart, aorta, neck arteries or intracranial arteries

Question 13

In general, what will happen in a left cerebral hemisphere stroke?

Answer 13

right hemiparesis
right hemisensory loss
aphasia
in large lesions, conjugate deviation of the eye to the left, right hemianopia or hemi-inattention

Question 14

In general, what will happen in a right cerebral hemisphere stroke?

Answer 14

left hemiparesis
left hemisensory loss
poor drawing and copying
neglect of the left visual field
large lesions with conjugate deviation of the eyes to the right

Question 15

Occlusion of what vessel will give you lateral medullary syndrome (or wallenberg syndrome?

Answer 15

intracranial vertebral artery occlusion

Question 16

What are the signs and symptoms of lateral medullary syndrome?

Answer 16

ipsilateral facial pain or reduced pain and temp sensation on the ipsilateral face, or both

loss of pain and temp in the contralateral limbs and body

ipsilateral horner’s syndrome

nystagmus

incoordination of the ipsilateral arm

leaning and veering while sitting or walking with gait ataxia

in deep lesions: dysphagia and horseness

Question 17

What signs and symptoms will you see in a bilateral pontine base stroke due to basilar artery occlusion or pontine hemorrhage?

Answer 17

quadriparesis

unilateral or bilateral conjugate gaze paresis, sometimes internuclear ophthalmoplegia and VIth nerve palsy

if the medial tementum is involved bilaterally, coma

Question 18

What will you see in a cerebellar infarction?

Answer 18

gait ataxia, often inability to walk

dysarthria

ipsilateral arm dysmetria

Question 19

What symptoms would you see in a left PCA territory stroke?

Answer 19

right homonymou shemianopia
at times, amnesia
alexia without agraphia when the splenium of the corpus callosum is involved

Question 20

What symptoms would you see in a right PCA territory stroke?

Answer 20

left homonymous hemianopia

at times, left-sided visual neglect

Question 21

What are the four main lacunar stroke syndromes?

Answer 21

pure motor
pure sensory
dysarthria-clumsy hand syndrome
ataxic hemiparesis

Question 22

Where is the lesion in a pure motor stroke and what symptoms do you expect?

Answer 22

the posterior limb of the internal capsule with contralateral weakness of the arm, face and leg without sensory, visual or cognitive or behavioral signs

Question 23

Where is the lesion in a pure sensory stroke and what symptoms do you expect?

Answer 23

Thalamus

paresthesiae of the contralateral body, limbs and face without any other deficit

Question 24

WHere is the lesion in dysarthria-clumsy hand syndrome?

Answer 24

pons, with slurred speech and clumsiness of the contralateral hand

Question 25

Where is the lesion in ataxic hemiparesis?

Answer 25

pons with weakness and ataxia of the contralateral limbs, often greater in the leg and foot than in the arm and hand

Question 26

Patient presents with severe retro-orbital headache and horner syndrome (with preserved perspiration). What happened?

Answer 26

carotid dissection ipsilateral to where the pain is

Question 27

Why do you get a horner syndrome with preserved perspiration with a carotid dissection?

Answer 27

you get horner’s syndrome due to involvement of the ascending oculosympathetic tract but perspiration is preserved because sudomotor fibers ascend with the external carotid, not the internal carotid

Question 28

Patient presents with neck pain and a third nerve palsy after going to the chiropractor. What happened?

Answer 28

vertebral artery dissection

Question 29

What color will a hemorrhage be on CT? What color will infarction be on CT?

Answer 29

hemorrhage is white

infarction is dark

Question 30

Which imaging test is more sensitive than CT to identify acute infarction?

Answer 30

MRI with diffusion-weighted imaging

Question 31

What are the three general strategies for reperfusion?

Answer 31

intravenous thrombolysis with tPA
intra-arterial thrombolysis near the clot
mechanical clot retrieval

Question 32

What is the time limit for tPA administration?

Answer 32

4.5 hours

Question 33

What is the time limit for intra-arterial thrombolysis or mechanical clot retrieval?

Answer 33

6 hours

Question 34

Prevention of further ischemia is usually necessary 24 hours after tPA administration. What should you use if the stroke was caused by lacunar infarction or atherosclerotic disease?

Answer 34

high-dose aspirin

or if they had been on aspirin prior to the stroke (failed aspirin), clopidogrel

Question 35

What should you use to prevent further ischemia if the stroke was caused by atrial fibrillation with embolization?

Answer 35

heparin with eventual transition to warfarin

Question 36

Subarachnoid hemorrhage is usually bleeding from where?

Answer 36

an aneurysm in the circle of willis

Question 37

Describe management for SAH?

Answer 37

aneurysms can be surgically clipped or soiled

Nimodipine to minimize vasospasm and delayed brain ischemia

Question 38

What is the most common cause of intracerebral hemorrhage? WHat about in the elderly?

Answer 38

hypertension in general

in the elderly, consider cerebral amyloid angiopathy affecting the parietal and occipital lobes

Question 39

WHat are the most common locations for hypertensive intracerebral hemorrhage?

Answer 39

basal ganglia-internal capsule, caudate, thalamus, pons, cerebellum

Question 40

What are three congenital malformations that can lead to brain bleeds?

Answer 40

arteriovenous malformations
developmental venous anomalies
cavernous angiomas