Vascular neurology questions and answers - part 8 pps

IMAGING: QUESTIONS 223 437.  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.  e “delta sign” or the “empty delta sign” is most commonly associated with: A. Airline strikes. B. Bilateral paramedian hemorrhages. C. Subdural hematoma. D. Transverse sinus thrombosis. Futrell 07.indd 223Futrell 07.indd 223 11/19/07 4:30:54 PM11/19/07 4:30:54 PM 224 IMAGING: QUESTIONS 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.  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.  e structure indicated by the arrow is most likely: A. Basilar aneurysm. B. Pineal cyst. C. Artifact of MRI. D. Colloid cyst. Futrell 07.indd 224Futrell 07.indd 224 11/19/07 4:30:54 PM11/19/07 4:30:54 PM IMAGING: QUESTIONS 225 441. A 77-year-old man with atrial fi brillation presented with a 30-minute epi- 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 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.  e INR was 3.8.  e MRI obtained suggests: A. Hemorrhagic transformation of a cardioembolic infarct. B. Abscess. C. Primary brain tumor. D. Lobar hemorrhage. 442.  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. Futrell 07.indd 225Futrell 07.indd 225 11/19/07 4:30:55 PM11/19/07 4:30:55 PM 226 IMAGING: QUESTIONS 443.  is is a suboccipital TCD tracing at a depth of 96 mm.  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? A. Liver. B. Kidneys. C. Pancreas. D.  yroid. E. Skin. Futrell 07.indd 226Futrell 07.indd 226 11/19/07 4:30:55 PM11/19/07 4:30:55 PM IMAGING: QUESTIONS 227 445. An infant of African descent was adopted by a couple in the United States.  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.  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. Futrell 07.indd 227Futrell 07.indd 227 11/19/07 4:30:55 PM11/19/07 4:30:55 PM 228 IMAGING: QUESTIONS 447.  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.  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. Futrell 07.indd 228Futrell 07.indd 228 11/19/07 4:30:55 PM11/19/07 4:30:55 PM IMAGING: QUESTIONS 229 450. A 48-year-old man presented with a 75% symptomatic right carotid ste- 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.  is CT angiogram was obtained on the CereTOM scanner.  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. Futrell 07.indd 229Futrell 07.indd 229 11/19/07 4:30:55 PM11/19/07 4:30:55 PM 230 IMAGING: QUESTIONS 451.  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.  is is the relative blood fl ow component of a CT perfusion scan.  is is most compatible with: A. Cerebral vasculitis. B. Normal study. C. Right carotid occlusion. D. Postischemic hyperperfusion in the left hemisphere. Futrell 07.indd 230Futrell 07.indd 230 11/19/07 4:30:55 PM11/19/07 4:30:55 PM IMAGING: QUESTIONS 231 453.  e fi nding on this transesophageal echo (TEE) is: A. A Eustachian valve. B. A long tunnel defect. C. A left-to-right shunt. D. An atrial myxoma. 454. A 60-year-old man, who was taking 81 mg aspirin a day, had fi ve stereo- typic episodes of transient numbness in the left arm and leg occurring periodi- cally over a week. With one episode, he had clumsiness of his left hand. When he awakened and had yet another similar episode, his wife brought him to the emer- gency department. No fl ow was seen in the right ICA by carotid duplex Doppler examination. What advice should be given to this patient? A. His ICA is occluded, so there is no point in attempted surgical interven- tion. 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. Futrell 07.indd 231Futrell 07.indd 231 11/19/07 4:30:55 PM11/19/07 4:30:55 PM 232 IMAGING: QUESTIONS 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 Futrell 07.indd 232Futrell 07.indd 232 11/19/07 4:30:56 PM11/19/07 4:30:56 PM [...]... 07.indd 233 PSV 85 , EDV 18 PSV 155, EDV 35 PSV 210, EDV 45 PSV 380 , EDV 160 11/19/07 4:30:56 PM 234 IMAGING: QUESTIONS 4 58 These MRIs are from a 55-year-old woman who was having episodic neurologic events with variable combinations of garbled speech, distorted vision, and right-sided arm numbness, arm pain, arm weakness, and/ or poor coordination in the right arm She had 12 events in a 2-week period She... Sections 7 and 8) 416 The answer is C Duplex systems were developed before the advent of color-flow technology The standard equipment is now a color-flow duplex sys- Futrell 07.indd 240 11/19/07 4:30:57 PM IMAGING: ANSWERS 241 tem Both external and internal carotid arteries can be imaged, but this has no relationship to the name of the technique Continuous-wave Doppler is single channel; pulse-wave Doppler... stenosis had progressed and she again became symptomatic The restenosis was longer than the initial stenosis and an EC-IC bypass was performed The patient has been symptom-free for 4 years Questions 435 and 415 show the intracranial and extracranial views of this patient’s EC-IC bypass Migraine headaches can result in asymmetrical flow, but not in stenotic velocities The depth and direction of flow tell... common carotid artery This is a high-resistance waveform, typical of the ECA The common carotid perfuses both high- and low-resistance beds Normal waveforms of the other arteries are shown on the next page The ICA has a low-resistance waveform, with a Futrell 07.indd 2 48 11/19/07 4:30: 58 PM IMAGING: ANSWERS 249 higher diastolic reading The vertebral artery is smaller and of a lower velocity, with vertebral... extracranial-intracranial (EC-IC) bypass This was obtained using the CereTOM CT scanner The CT angiogram has the advantage of imaging arteries and veins simultaneously In this situation, the superior temporal artery enters the intracranial space via the surgical skull defect and anastomoses with the MCA, representing an EC-IC bypass The other vessels are standard normal anatomy (Harnsberger, Part 1, Sections... DWI in detecting acute ischemic changes in patients with TIA 463 A 5 8- year-old man had multiple episodes of transient bilateral blurred vision The most recent and prolonged one occurred 5 hours prior to arrival in the emergency department His blood pressure was elevated, but his neurologic examination was normal The CT scan of the brain and the carotid ultrasound were normal Because of his recent chemotherapy... subtraction angiography, and the aneurysm was clipped without complications Carotid duplex and echocardiography are part of a full stroke work-up, but they would not explain the MRI finding Transcranial Doppler (TCD) findings are not diagnostic of cerebral aneurysms (Osborn, Chapters I, 3, 15) See color section following page 282 405 The answer is B The CT scan shows hypodensity of more than one-third of the middle... ophthalmic artery and the ICA siphon The transforaminal approach (also known as the nuchal or suboccipital approach) allows the insonation of the terminal vertebral arteries and the basilar artery (Alexandrov et al., J Neuroimaging 2007) Futrell 07.indd 252 11/19/07 4:30:59 PM IMAGING: ANSWERS 253 461 The answer is A Cerebral microbleeds (CMBs) are focal areas of signal loss on gradient-echo T2*-weighted MRI... associated with bleeding-prone small-vessel disease Increasing age and blood pressure, as well as decreased cholesterol, increase the risk for CMBs (Fiehler, Int J Stroke 2006) 462 The answer is D Diffusion-weighted imaging (DWI) has shown clinically relevant acute ischemic lesions in some patients with TIA, depending on the duration of the symptoms and the timing of the study Perfusion-weighted imaging (PWI)... veins or both are seen on a particular reconstruction The paired veins at the midline are the internal cerebral veins The structure between the internal cerebral veins is not an aneurysm It is a calcified structure that is not contiguous with any vessel It is calcified choroid plexus This black -and- white figure is an alternate view of the same image The veins in are now in a partial sagittal orientation . artery. Futrell 07.indd 228Futrell 07.indd 2 28 11/19/07 4:30:55 PM11/19/07 4:30:55 PM IMAGING: QUESTIONS 229 450. A 4 8- year-old man presented with a 75% symptomatic right carotid ste- nosis. Endarterectomy. PM 224 IMAGING: QUESTIONS 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. 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