Vascular neurology questions and answers - part 8 pps

At 6 months, she presented to the Intermountain Stroke Center after the CTs were obtained.. Which of the following statements best describes CT scanning done within 3 hours of an acute i

437. Th e vessel indicated by the arrow is the:

A Left superior cerebellar artery

B Left PCA

C Anterior cerebral artery

D Anterior spinal artery

438. Th e “delta sign” or the “empty delta sign” is most commonly associated with:

439. A 69-year-old woman with hypertension and osteoarthritis was admitted

to the hospital with crescendo TIAs consisting of left hemiparesis and

hemian-esthesia She had no history of headaches Noncontrasted MRI was ordered, but

when the image on the left was seen, contrast was injected Th e fi ndings on this

MRI are most consistent with:

A Developmental venous anomaly (DVA, previously referred to as venous

angioma), along with a cavernous malformation

B Cavernous malformation alone

C A DVA alone

D Sturge-Weber syndrome

E Acute right cerebellar hemorrhage

440. A 39-year-old white woman presented with a history of migraine-type

headaches accompanied by numbness in the left arm An MRI was obtained Th e

structure indicated by the arrow is most likely:

A Basilar aneurysm

B Pineal cyst

C Artifact of MRI

D Colloid cyst

441. A 77-year-old man with atrial fi brillation presented with a 30-minute sode of moderate aphasia He had a past history of trauma years prior that left him blind in the left eye His medications included aspirin and two antihyperten-sive medications His MRI showed multiple small strokes He was treated with warfarin Two years later, he went to his eye doctor complaining about his vision

epi-in the right eye No visual fi elds were done, and new glasses were prescribed Two weeks later, he presented in the neurology clinic for evaluation of worsening visual loss Th e INR was 3.8 Th e MRI obtained suggests:

A Hemorrhagic transformation of a cardioembolic infarct

B Abscess

C Primary brain tumor

D Lobar hemorrhage

442. Th is MRA illustrates a:

A Fenestrated basilar artery

B Basilar dissection with hematoma in the vessel wall

C Dolichoectasia of the basilar artery

D Basilar thrombosis

443. Th is is a suboccipital TCD tracing at a depth of 96 mm Th is is most likely a:

A Vertebral stenosis

B Basilar stenosis

C Subclavian steal with reversal of fl ow

D Venous signal

444. A disorder of which organ may be a contraindication for the use of

gado-linium-containing contrast agents?

445. An infant of African descent was adopted by a couple in the United States

Th e birth parents were both healthy, and the birth mother used no alcohol or drugs (prescription or recreational) during the pregnancy Pregnancy and deliv-ery were normal In the fi rst 3 to 4 months, the infant met developmental mile-stones normally, although it was noted that she reached for things preferentially with her left hand As her motor skills progressed, decreased fi ne motor skills and posturing in the right upper extremity were noted At 6 months, she presented to the Intermountain Stroke Center after the CTs were obtained She was alert and attentive to her environment Vision seemed intact She had hypertonia, postur-ing, and decreased fi ne motor control in the right hand with mild hypertonia in the right leg Th e most likely diagnosis is:

A Prenatal or perinatal left MCA ischemic stroke

B Schizencephaly

C Prenatal or perinatal intracranial hemorrhage

D Congenital absence of the left MCA

446. Which of the following statements best describes CT scanning done within

3 hours of an acute ischemic stroke?

A Attenuation of the lentiform nuclei is a poor prognostic sign

B A hyperdense MCA sign is a contraindication for thrombolytic therapy

C Attenuation of the lentiform nuclei accurately predicts the side of the acute stroke

D Hypodensity of 50% of the MCA territory is a poor prognostic sign

447. Th e defi nitive diagnosis of a developmental venous anomaly (DVA) is best

made by:

A Using catheter angiography

B Using either MR or CT angiography

C Using MRI with contrast

D Using MRI without contrast

E Using CT without contrast

448. A halo sign on duplex evaluation of the superfi cial temporal artery is most

consistent with:

A Previous EC-IC bypass surgery

B Right internal artery occlusion and internalization of the right ECA

branches

C 90% probability of temporal arteritis

D 70% probability of temporal arteritis

449. Th is velocity tracing from a carotid duplex study is most compatible with:

A Normal common carotid artery

B Normal ICA

C Normal ECA

D Normal vertebral artery

450. A 48-year-old man presented with a 75% symptomatic right carotid nosis Endarterectomy was performed His elevated cholesterol was controlled, and he was place on medication for platelet inhibition Six weeks later, the end-arterectomy was patent On his 3-month follow-up, no restenosis was found Six months, later mild endothelial thickening was seen in the proximal ICA, with what seemed to be a paradoxical elevation of PSV to 131 cm/sec with an end dia-stolic velocity of 40 cm/sec Six months, later a peak systolic of 466 cm/sec was obtained in the proximal ICA, with an end diastolic velocity of 275 cm/sec Th is

ste-CT angiogram was obtained on the CereTOM scanner

Th e most appropriate intervention is:

A Maintain the same regimen and repeat the duplex in 4 weeks

B Addition of anticoagulation to the platelet inhibition

C Repeat endarterectomy as soon as possible

D Angioplasty and stent placement

E Perform an EC-IC bypass

See color section following page 282.

451. Th is TCD tracing, taken at a depth of 96 mm from a suboccipital approach,

peak systolic 41 cm/cm, is most consistent with:

A Normal basilar artery

B Normal vertebral artery

C Fetal origin of both posterior cerebral arteries

D Subclavian steal

452. Th is is the relative blood fl ow component of a CT perfusion scan Th is is

most compatible with:

A Cerebral vasculitis

B Normal study

C Right carotid occlusion

D Postischemic hyperperfusion in the left hemisphere

453. Th e fi nding on this transesophageal echo (TEE) is:

stereo-A His ICA is occluded, so there is no point in attempted surgical tion

interven-B An MRA should be preformed, because a focal signal dropout will prove occlusion

C Catheter cerebral arteriography or CTA should be performed urgently

D He should stop aspirin and take either Plavix or Aggrenox

E Cardiac echo should be performed immediately

455. A 70 -year-old physician presented to the Intermountain Stroke Center for

evaluation of dizziness He usually enjoyed a dip in the hot tub following his daily

60 minute work-out One day, he noted that he was light headed for 30 to 60

sec-onds as he stepped out of the hot tub During his medical training, he was found

to have an occluded left carotid artery when residents were practicing carotid

Duplex on each other He assumed this was likely a traumatic occlusion from his

high school football escapades, but he was concerned that perhaps decreased

ce-rebral blood fl ow from this occlusion could be producing his symptoms A CTA

was done Figure A is the left common carotid with its distal course Figure B is a

source image What is the diagnosis?

A Atherosclerotic occlusion of the left ICA

B Probable traumatic occlusion of the left ICA, most likely related to old

dissection

C Congenital absence of the left ICA

D Internalization of the left ECA

E Occlusion of the ECA with an intact ICA

A

B

456. Th e most important factor in obtaining accurate velocity measurements when performing carotid duplex is:

A Th e use of a large sample volume

B Th e Doppler angle

C Th e use of color Doppler

D Th e use of power Doppler

457. Which carotid duplex fi ndings are most consistent with this CTA? Th e PSV

is peak diastolic velocity, EDV is end diastolic velocity All velocities are in cm/sec

A PSV 85, EDV 18

B PSV 155, EDV 35

C PSV 210, EDV 45

D PSV 380, EDV 160

458. Th ese MRIs are from a 55-year-old woman who was having episodic

neu-rologic events with variable combinations of garbled speech, distorted vision,

and right-sided arm numbness, arm pain, arm weakness, and/or poor

coordina-tion in the right arm She had 12 events in a 2-week period She was seen in the

emergency department, at which time her neurologic examination was normal

Stress was suspected, because her nephew had recently undergone bilateral leg

amputations following a motorcycle accident She was sent home Th e next day,

she presented with a moderate right hemiparesis and Wernicke aphasia Carotid

duplex suggested an occluded left ICA What is the most likely explanation for

the patient’s strokes?

A Cardiogenic emboli

B Emboli from a basilar stenosis entering the left PCA

C Fetal origin of the left PCA

D Hypotension with watershed infarcts

459. Which of the following is a defi nite contraindication to CTA?

A Shellfi sh allergy

B Claustrophobia

C Cardiac pacer

D Pregnancy

460. Match the window for insonation with the detected using TCD

A Transtemporal approach 1 Ophthalmic artery (OA)

B Transorbital approach 2 Basilar artery

C Transforaminal approach 3 Anterior cerebral artery (ACA)

D Submandibular approach 4 Distal ICA at the skull base

461. Cerebral microbleeds:

A Are most easily noted on gradient-echo T2*-weighted MRI sequences

B Indicate focal acute hemorrhage

C Are independent of increasing age

D Are independent of hypertension

E Are associated with increased serum cholesterol

462. Which of the following statements best describes the use of MRI in the diagnosis of TIA?

A In patients with TIAs, the diff usion-weighted imaging (DWI) lesions sistently evolve into completed infarctions

con-B Use of DWI off ers little added information over conventional MRI ing sequences

imag-C Most TIA patients have early DWI lesions but no later imaging evidence

of infarction

D In a study of TIA patients, a DWI lesion was found in 70% of patients who had symptom duration of 12 to 24 hours

E Perfusion-weighted imaging (PWI) appears to show no benefi t over DWI

in detecting acute ischemic changes in patients with TIA

463. A 58-year-old man had multiple episodes of transient bilateral blurred vision

Th e most recent and prolonged one occurred 5 hours prior to arrival in the gency department His blood pressure was elevated, but his neurologic examina-tion was normal Th e CT scan of the brain and the carotid ultrasound were normal Because of his recent chemotherapy for lymphoma, you are suspicious of posterior reversible encephalopathy syndrome (PRES) but your colleague thinks that he had posterior embolic ischemia Which MRI sequence will best resolve this dispute?

emer-A T1-weighted images

B T2-weighted images

C Fluid-attenuated inversion recovery (FLAIR)

D Diff usion-weighted images (DWI)

E Apparent diff usion coeffi cient (ADC) map

464. An acute ischemic stroke characteristically produces a hyperintense signal seen

on DWI Which of the following can also cause a hyperintense signal on DWI?

A A subacute ischemic stroke

465. Th e most characteristic MRI lesion in Susac syndrome is seen in which

466. Which is true about intracranial and extracranial dissections?

A Th e combination of MRI and MRA have specifi city for dissection

equiva-lent to conventional angiography

B Angioplasty and stenting is of proven value in the treatment of dissection

C Angiography is the preferred initial test if dissection is strongly suspected

D Intramural hematomas are not seen on MRI

467. Transcranial Doppler tracings become more diffi cult to obtain as the the

skull thickens with age Based on the ability to obtain TCD readings, the thickest

skulls are in:

A Men

B Women

C No gender diff erence

cating artery Th is computed tomography (CT) angiogram was obtained in the clinic using the CereTOM CT scanner; it reveals a 6 mm anterior communicating aneurysm Th is fi nding was confi rmed by digital subtraction angiography, and the aneurysm was clipped without complications Carotid duplex and echocar-diography are part of a full stroke work-up, but they would not explain the MRI

fi nding Transcranial Doppler (TCD) fi ndings are not diagnostic of cerebral eurysms (Osborn, Chapters I, 3, 15)

an-405 Th e answer is B Th e CT scan shows hypodensity of more than one-third

of the middle cerebral artery (MCA) territory Th e bleeding risk is increased in this patient, and the chances of clinical benefi t are very small with so much per-manently damaged tissue Interestingly, after tissue plasminogen activator (t-PA) was appropriately withheld from this patient, additional history became available from other individuals Th e patient’s wife apparently returned from a rendezvous with a male companion and found her husband on the fl oor unable to move his right side Because she did not want her children to know about the “other man,” she fabricated the story that she was with him at the time of onset Th e actual

See color section following page 282.

time of the stroke was in fact unknown Th e patient was last seen normal 6 hours

earlier Based on the degree of hypodensity, this stroke was probably over 3 hours

old in any case (Th e boyfriend bailed out of this relationship quickly.) (von

Kum-mer, Stroke 1999)

406 Th e answer is A Th is is an MRI of a patient with HHT—hereditary

hem-orrhagic telangiectasia, also know as Osler-Weber-Rendu syndrome, who was

evaluated at the Intermountain Stroke Center Th is disorder is inherited as an

autosomal dominant Th is patient had a history of epistaxis, which is the most

common presentation He had telangiectasias on his lips He also had a history

of gastrointestinal bleed When he had a transient ischemic attack (TIA), he was

placed on aspirin and clopidogrel with no CT scan of the brain When neurologic

symptoms recurred, this MRI was obtained Acute and chronic blood was

pres-ent on MRI and CT Th e symptoms and the acute hemorrhagic changes improved

when platelet inhibition was discontinued Computed tomography angiography

of the brain may demonstrate high fl ow arteriovenous malformations (AVMs)

(Osborn, Chapters I, 1, 14)

407 Th e answer is B Because of the autosomal inheritance pattern of HHT and

the potentially devastating consequences in those patients with HHT who do have

cerebral AVMs, screening of fi rst-degree relatives is recommended Th e test of

choice is MRI with and without contrast Invasive or noninvasive vascular imaging

may be appropriate in patients with abnormal MRIs, depending on the fi ndings

Th is screening should also be done in patients with systemic evidence of HHT,

in-cluding mucocutaneous and visceral telangiectasias In this case, the patient’s sister

had a history of epistaxis and hemorrhagic changes on MRI, as did his daughter

Th e patient recommended that his daughter come in for evaluation, but she

re-fused In the 2 years since this MRI, was done the patient’s daughter has become

disabled by a major hemorrhage from a cerebral AVM Since the antiplatelet agents

have been stopped in this patient, he has improved (Osborn, Chapters I, 1, 14)

408 Th e answer is E Th is patient was a chronic alcohol abuser with ataxia and

confusion A year previously, he had been seen in the emergency department with

an alcohol level of 230 His sodium level was corrected according to established

guidelines but, despite this, he became gradually more confused and somnolent

Th is particular MRI was taken 6 months later, when the patient presented for

evaluation of choreoathetotic movements Th is represents the outcome of central

pontine myelinolysis Th e sparing of the rim of tissue at the superfi cial portion of

the basis pontis rules out stroke, because no vessel has such a distribution

(Ad-ams, Victor, & Mancall, Arch Neurol Psychiatry 1959)

409 Th e answer is C Th e structure in question is the sinus confl uence, also called the torcular Herophili It forms the confl uence of the superior sagittal si-nus, the straight sinus, and the transverse sinuses Th e superior sagittal sinus, transverse sinus, and the inferior anastomotic vein are also demonstrated in this image Th e large arrow shows the superior sagittal sinus Th e curved arrow points

to the transverse sinus Th e small arrow points to the vein of Labbe, also known

as the inferior anastomotic vein (Harnsberger, Part 1, Section 8)

410 Th e answer is D Th is patient had a severe dilated cardiomyopathy with an ejection fraction of 26% Th is TCD is typical of low cardiac output with autoregu-lation producing an extremely low resistance pattern Th is tracing shows a very low pulse pressure in all arteries sampled, which improves following heart trans-plant Below is the TCD tracing of this patient following his heart transplant

It should be noted that TCD is not a measurement of cerebral blood fl ow, but

when blood fl ow drops maximal decreased resistance occurs, resulting in a lower pulse pressure

Middle cerebral artery stenosis would show high peak systolic velocities

in the MCA, with other waveforms being normal Increased resistance would produce a lower diastolic fl ow Alcohol abuse does not produce particular TCD

changes, unless it results in a cardiomyopathy (Gruhn et al., Stroke 2001;

Henne-rici, Chapter 3)