Vascular/NCC

Question 1

Anterior choroidal -

Answer 1

off ICA branch - posterior limb internal capsule and caudate TAIL
(anterior limb internal capsule=recurrent A Heubner)
Homonymous hemianopsia - LGN in thalamus
(Like MCA but normal speech)

(posterior choroidal A off PCA)

Question 2

carotid anatomy

Answer 2

Atherosclerosis =no increase risk carotid dissection

-C4: CC to ECA, ICA

Question 3

CARASIL

Answer 3

cerebral autosomal recessive arteriopathy with subcortical infarcts and leukoencephalopathy - HTRA1 mutation on 10q26.13; lacunar ischemia (hemorrhage)
-like CADASIL plus premature alopecia, back pain, spondylosis
-NO MIGRAINE vs CADASIL

Question 4

CADASIL

Answer 4

Missense mutation in gene NOTCH3 on chromosome 19q13.1
granular osmiophilic material in basal laminal cutaneous arrterioles and CNS arteries
-p/w migraine with aura, stroke, dementia, FHx stroke, dementia
-Dx: genetic testing or skin biopsy
MRI: anterior temporal lobes

Question 5

(other genetic stroke disorders)

Answer 5

Fabry - alpha galactosidase , build up ceramide trihexoside
-sm fiber neuropathy hands + feet, worse with heat
-strokes dolieoctasia

COL4A1-laucnar ischemia or hemorrhage; extensive white matter involved; also with aneurysms, CKD, muscle cramps

Deficiency of ADA2-associated polyarteritis nodosa vasculopathy-ADA2 on 22q11.1-HSM, recurrent fevers, small vessel vasculitis

Retinal vasculopathy with cerebral leukodystrophy (RCVL)-TREX1-ischemic strokes - visual loss, retinal microangiopathy, kidney/liver disease

Question 6

MELAS

Answer 6

mitochondrial encephalopathy with lactic acidosis and stroke like episodes

-transfer RNA gene (mt)

Question 7

Familial moyamoya

Answer 7

-nonathero intracranial stenosis in ICAs
- puff of smoke angio with useless collaterals;
-histo: intimal thickening of fibrous tissue, no inflammatory cells/atheromas

SPARES white matter vs. other genetic stroke disordres
(AD or AR-ACTA2, MTCP1, RNF213 genes)

Question 8

cerebrovascular fibromuscular dysplasia

Answer 8

alternating beading of intracranial vessels due to skip areas of stenosis

Question 9

ACA

Answer 9

A1 segment/Acomm occlusion (if normal circle of Willis)= no deficits, b/c proximal to Acomm which communicates with BL ACAs

distal to Acomm-leg weak, urinary incontinence, medial micturition-paracentral lobule, paratonic rigidity, +/- eye deiviation to lesion

Recurrent artery Heubner-ACA branch
Head caudate-inferior
Ant limb internal capsule
anterior globus pallidus
Nuc accumbens, basal Nuc Meynert

-ACA most common site for aneurysm

Question 10

ABCD2 score

Answer 10

Age 60, DM, BP>140/90
Duration: 1 pt if 10-59 min, 2 pts if >60 min
HLD not included

Question 11

brainstem localization/respiratory patterns

Answer 11

top of basilar - midbrain, thalamus, temp, occipital - impaired consciousness, pupil abnormalities

Locked in - basilar occlusion-base of Pons-no horizontal movements, quadriplegia, preserved consciousness
-apneustic breathing-respiratory pause at inspiration + expiration (lateral tegmentum) - pons has a pause

Medulla: ataxic breathing -irregular -upper medulla

BL hemisphere/diencephlon: cheyne-stokes -intact brainstem -cycle hyperpnea + apnea

Question 12

AICA

Answer 12

lateral pons, inner ear (labyrinthine A branch), middle cerebellar peduncle-anterior inferior cerebellum
ipsilateral hearing loss vs PICA

Question 13

CVST

Answer 13

seizures-40%
HA-90%
-middle ear infection, mastoiditis-transverse sinus thrombosis

Deep veins: internal cerebral, thalamostriate/septal, basal vein Rosenthal->** vein of Galen +inferior saggital sinus->straight sinus**
-infarct straight sinus - thalamic infarcts

superior saggital sinus (parasaggital cortex)->confluence of sinuses->meets straight sinus (drains Galen)->transverse sinus (cavernous/superior petrosal)->sigmoid sinus-> internal jugular vein

ophthalmic vein ->cavernous sinus
->superior petrosal->transverse sinus
cavernous sinus->inferior petrosal
->sigmoid sinus/jugular bulb

scalps veins->emissary veins->dural venous sinus

anastomoses along Sylvian fissues
superior anastomotic vein of Trolard-sylvian V to superior saggital
-**inferior anastomotic vein of Labbe **-temporal lobe->sylvian V to transverse sinus

Question 14

PICA

Answer 14

Wallenberg- PICA-off vert
-ipsilat: face sense-CN V
-vestibular nuclei CN VIII-nystagmus, vertigo
-STT-pain/temp contralateral body
sympathetics - Horner’s
-nuc tractus solitarius-loss taste

inferior cerebellum-lateralpulsion, ataxia

Question 15

vert dissection

Answer 15

C1-C2
-vert runs through transverse foramina at C5-C6 + C2
Dx: MRA TOF-flow at dissection
MRI fat suppression-eval vessel wall-nonocclusive dissection

gold standard-angio-but no info about vessel wall
-dont need TTE b/c thrombus from dissection
Tx: AP or AC, endovascular open vessel

Question 16

amarousis fugax

Answer 16

most common - retinal A from ophthalmic A from ICA

Question 17

artery of Percheron

Answer 17

Varient where supplies medial thalamus bilaterally
-off P1 of PCA

Question 18

MCA

Answer 18

lenticulostriate branches - putamen, GPe/GPi, caudate head/body (caudate tail=anterior choroidal off ICA)
-no supply to thalamus

superficial brances: frontal, parietal, temporal lobe, * insula*
LCA lenticulostriate/MCA watershed
strip down corona radiata - internal watershed

homonymous hemianopsia b/c hit optic radiations

Question 19

Thalamus supply

Answer 19

tuberothalamic A- Pcomm- anterior-(ventral anterior nuc) (Tubero Top)

paramedian / thalamoperforating A- P1 - medial (dorsomedial nuc)

thalamogeniculate - P2 - lateral (ventral lateral nuc)

posterior choroidal- P2 - posterior-pulvinar nuc

Question 20

cerebellum

Answer 20

superior cerebellum: leve midbrain: SCA + superior colliculus/pretectum (dorsal, quadrigeminal plate)
inferior cerebellum: level medulla: PICA

Question 21

lacunes

Answer 21

lipohyalinosis -occlusion small penetrating branches (not microhemorrhages)

Question 22

Dejerine-rossey

Answer 22

• post thalamus stroke pain syndrome - hypersensitivity to pain

Question 23

medial medullary

Answer 23

occlusion vert
-contralateral A/L and spares face
-contralateral loss position and vibration
-ipsilateral tongue weak

Question 24

aneurysmal rupture

Answer 24

Posterior circulation higher risk rupture
-Marfans, Ehlers Danlos

-ACA most common

Question 25

PCA infarct

Answer 25

L occipital-alexia, anomia, achromotapsia (color anomia) Alexia WITH agraphia - L angular gyrus Alexia without agraphia - L PCA - spares angular gyrus; involves splenium corpus callosum Gerstmann - L angular gyrus - agraphia, finger agnosia, acalculia and right left confusion Midbrain PCA branches: Benedikt's syndrome -paramedian midbrain- mesencephalic tegmentum-**ventral midbrain* -Benedikt involved **red nucleus** =contra lat choreoathetosis, ataxia + ipsi CN III vs Claude, brachium conjunctivum, CN III -ipsi CN III, contralateral tremor + ataxia, no choreoathetosis

Question 26

TPA contraindications

Answer 26

absolute contraindications: -**glucose<50** **head trauma/stroke in last 3 months, prior ICH, neoplasm, AVM, aneurysm** SBP>185 or DBP>110 Sx SAH **arterial puncture at noncompressible site < 7 days** -active internal bleeding, plt <100,000 -heparin within 48 hrs+elevated aPTT -CT infarct >1/3 hemisphere -INR >1.7 or PT >15 sec relative contraindications: -Major surgery or serious trauma within prior 14 days -GI tract hemorrhage, recent MI, pregnancy, minor/improving stroke Sx -can't give TPA >3 hours if: NIHSS>25, age>80

Question 27

ASPECTS

Answer 27

-two Axial cuts-one high and one at BG/thalamus -10 total: 4 deep-caudate, IC, lentiform (putamen/GP), insular 6 cortical No stroke=10 full points; 0=full MCA 7 or less: increased dependent and death

Question 28

carotid stenosis CEA/CAS

Answer 28

symptomatic stenosis 50-69%: CEA better outcomes for men **CAS: higher risk stroke** -better if neck surgery, prior radiation, contralateral carotid occlusion, contralat CN X paralysis **CEA: higher risk MI**

Question 29

RCVS

Answer 29

-thunderclap then can have persistent HA -small cortical SAH -beading on angiogram -vessels should normalize after 3 months-**angio confirms Dx** -Tx: CCB, mag -more common in women (~PRES) -no vessel wall inflammation

Question 30

primary CNS angiitis

Answer 30

-beading on angiogram -small and medium vessels -women=men affected -**definitive Dx: brain biopsy** with wall inflammation, but poorly sensitive MRI: GAD+ meninges or pareynchyma Tx: steroids +/- cyclophosphamide

Question 31

vascular malformations

Answer 31

Dural AVF: meningeal/dural A branches, drain into venous sinus -if **cortical venous drainage vs dural venous sinus, highest risk hemorrhage** -*acquired* - CVST, arterialization draining veins -cranial or spinal, no brain or capillary in between -**Sx of high venous pressure** -pulsatile tinnitus MRI: thick worms **AVM: pial arterial supply + nidus that draws draining veins and arteries congenital** draining vessel -high pressure blood in low pressure -brain in between; no capillary beds in between, (no stroke if embolize AVM) -hemorrhage cavernous malformation - popcorn with dark rim -low pressure capillary malformation -no smooth muscle/elastic fiber, thin walled vessels -seizures developmental venous anomaly=venous angioma-caput medusa/palm tree sign -Asx

Question 31

blood on MRI

Answer 31

**I B hyperacute <12 hours** I D acute **B D early subacute 2-7 days** **B B late subacute 1 week-1 month** D D chronic

Question 32

cerebral edema

Answer 32

-**interstitial edema - (transependymal)-low attenuation periventricular changes around the lateral ventricles**-acute obstructive hydrocephalus-causes hydrostatic pressure cytotoxic -cell death->**failure Na+/K+ ATPase pumps** ->alters permeability cell membrane->intracellular accumulation fluid -also with changes in serum osmolality vasogenic - extravasation of fluid DDx - high altitude, lead intoxication

Question 33

herniation syndromes

Answer 33

uncal - contralateral hemiparesis if ipsilateral CSF - or if displacement against contralateral Kernohan's notch->compress contralateral CST->ipsilateral hemiparesis -**uncal - compresses PCA** in tentorial notch -specific to uncal hernation no ipsilateral pupil + contra hemiparesis + PCA infarct: -subfalcine (cingulate gyrus) - tonsillar (medulla, 4th ventricle), -central transtentorial (diencephalon down on midbrain) -transcalvarial (through bony defect in skull):

Question 34

ICP crisis

Answer 34

-normal **5-15 mm Hg ** / 7.5-20 cm H2O -hyperventilation: reduce pCo2 ->hypocapnia -> cerebral vasocontriction -mannitol-BOLUS -target serum osm <320 mOsm/L - depletes K, Mg, phos Hypertonic saline - continuous infusion-sodium 150 target Propofol-can reduce ICP; causes hypotension, hyperTG, infection, lactic acidosis, HLD Pentobarbital - Tx ICP waveforms: **Lundberg A - plateau waves - intracranial HTN** - amplitude 50-100 B waves, C waves normal

Question 35

states of consciousness

Answer 35

unresponsiveness wakefulness - *return of sleep-wake cycles* in previous comatose pt - vegetative state coma - reflex responses only

Question 36

sodium nitroprusside

Answer 36

produces NO and cyanide -increases ICP, decreases MAP-> can decrease cerebral perfusion pressure -**Tx cyanide toxicity-> sodium thiosulfate** (converts to thiocyanate) or methemoglobin -not if renal disease -thiocyanate toxicity: pupillary constriction, tinnitus, seizures, Tx: dialysis

Question 37

epidural vs SDH

Answer 37

SDH: does not respect suture lines - banana shape epidural: respects suture; lemon shaped (biconvex) -**MMA-foramen spinosum**

Question 38

SAH

Answer 38

ABCs first vasospasm - 3-15 days, peak 6-8 days -triple H therapy once aneurysm secured: hypervolemia, HTN, hemodilution -nimodipine x21 days Hunt Hess score: CLINICAL 1. ASx/minimal HA, slight nuchal rigid 2. moderate-severe HA, nuchal rigid, **CN palsy only** **3. drowsy/confused, moving all 4**, mild neuro deficit 4. stupor, severe hemiparesis 5. deep coma, posturing Fisher - CT 1. no SAH 2. thin blood 3. thick blood 4.ICH or IVH clots

Question 39

fat embolization

Answer 39

**axillary, thorax, conjunctiva petechial** hemorrhage -petechial hemorrhages in brain after bone fractures -CT usually normal vs. coup/contrecoup - CTH with blood

Question 40

GBS

Answer 40

-ABG not indicator of intubation b/c drop later in resp failure

Question 41

central pontine myolinolysis

Answer 41

correct mo faster than 12 Na+ per day -Sx 3-10 days after correction -myelin destruction in ventral pons (or deep matter cortex), spares axons, bodies -burns, liver transplant

Question 42

AC reversal

Answer 42

**warfarin - prothrombin complex concentrate PCC (Kcentra) fastest and less complications vs FFP**; IV vit K heparin- protamine sulfate **dabigatran - direct thrombin inhibitor - idarucizumab** factor Xa inhibitors - DOACs - PCC

Question 43

cardiac arrest

Answer 43

**24-72 hrs: best predictor- absent BL N20 response on SSEPs with median N stim OR no pupils (cortical potentials N19-P22) **>72 hours: no corneals, no eye movements** EEG-2 uV 10 cm apart x 30 min

Question 44

decorticate vs decerebrate

Answer 44

decort: above red nuc, disinhibits red nucleus, and activates rubrospinal path decerebrate: at red nuc/superior colliculi, above vestibular nuc below vestibular nuc: flaccid response, no extensor posturing

Question 45

malignant hyperthermia

Answer 45

AD defect Ry R-release Ca into SR when given halogenated anesthetics-depolarizing (succinylcholine) -central core disease - congenital myopathy - increased risk malignant hyperthermia -dantrolene only for malignant hyperthermia [NMS - Tx-bromocriptine, dantrolene]

Question 46

ICH

Answer 46

30 day outcome - die at 30 days if 5 pts; no die at 30 days if 0 points -GCS - -ICH volume - >30 cc=1 pt -intraventricular hemorrhage -infratentorial -age: >80=1 pt

Question 47

dexmedetomidine

Answer 47

alpha2 agonist (precedex) -no resp depression, can arouse