Vascular Neurosurgery MCQ Quiz – Part 1

The mnemonic SALFOPSI is very useful in remembering the branches of the ECA in ascending order (proximal to distal)

1. Superior thyroid artery
2. Ascending pharyngeal artery
3. Lingual artery
4. Facial artery.
5. Occipital artery.
6. Posterior auricular artery.
7. Superficial temporal artery.
8. (Internal) maxillary artery

Vidian artery,  also called the artery of the pterygoid canal, or the pterygoid artery, originates from the petrous part (C2) of the internal carotid artery.

Ref: Greenberg Textbook of Neurosurgery, 9th Edition, Chapter 1.

Explanation:

Duret hemorrhage is a small hemorrhage (or multiple hemorrhages) seen in the medulla or pons of patients who are rapidly developing brain herniation, especially central herniation

Raised supratentorial pressure causes the brainstem and mesial temporal lobes to be forced downwards through the tentorial hiatus. As a result of this shift, it is believed that perforating branches from the basilar artery and/or draining veins are damaged with resultant parenchymal hemorrhage. Most commonly it is seen in patients with severe herniation 12 to 24 hours prior to death

Reference: Greenberg 9th Edition Chapter 18

• (Transient ischemic attack): transient neuronal dysfunction secondary to focal ischemia (of brain, spinal cord, or retina) without (permanent) acute infarction (note: obsolete operational definitions used an arbitrary 24-hour cutoff for duration of symptoms).
• 10–15% of patients with TIA have a stroke within 3 months, 50% of which occur within 48 hours.
• Stroke. Permanent (i.e., irreversible) death of neurons caused by inadequate perfusion of a region of the brain or brainstem.
• Watershed infarct. Ischemic infarction in a territory located at the periphery of two bordering arterial distributions due to a disturbance in flow in one or both of the arteries.

Reference: Greenberg 9th Edition Chapter 80

Explanation

• Narrowing of the arteries at the base of the brain following SAH occurs regularly.
• This vasospasm causes symptomatic ischemia and infarction in approximately 30% patients and is the major cause of delayed morbidity or death
• Sign of ischemia appear 4-14 days after the hemorrhage, most frequently at about 7 days

Reference: Greenberg 9th Edition Chapter 76

Head trauma is the most common cause of SAH. In patients without head trauma, SAH is most commonly caused by a brain aneurysm.

Berry aneurysms: MC intracranial aneurysm, saccular in appearance, arising at the bifurcation of intracranial arteries.

About 85% aneurysms occur in the anterior circulation

Following 3 most common locations:

• ACoA (single most common): 30%
• P-comm: 25%
• Middle cerebral artery (MCA): 20%

5–15% in posterior circulation (vertebro-basilar)

≈ 10% on basilar artery: basilar bifurcation, AKA basilar tip, is the most common in basilar, followed by

BA-SCA, BA-VA junction, AICA

≈ 5% on vertebral artery: VA-PICA junction is the most common in vertebral art

20–30% of aneurysm patients have multiple aneurysms

Reference: Greenberg 9th Edition Chapter 74

Explanation:

Intracerebral (Parenchymal) Hemorrhage

• MC type of intracranial hemorrhage
• MC cause is hypertension, causing rupture of small perforating arteries or arterioles
• MC site: Basal ganglia (Putamen)

Reference: Greenberg 9th Edition Chapter 84

Explanation:

Intracerebral (Parenchymal) Hemorrhage

• MC type of intracranial hemorrhage
• MC cause is hypertension, causing rupture of small perforating arteries or arterioles
• MC site: Basal ganglia (Putamen)

Reference: Greenberg 9th Edition Chapter 84

Explanation:

Intracerebral (Parenchymal) Hemorrhage

• MC type of intracranial hemorrhage
• MC cause is hypertension, causing rupture of small perforating arteries or arterioles
• MC site: Basal ganglia (Putamen)

Subarachnoid Hemorrhage

• 2nd MC cause of intracranial hemorrhage
• MC cause: Trauma >Spontaneous rupture of Berry aneurysm
• MC site of Berry aneurysm is anterior circulation of “circle of willis”

Reference: Greenberg 9th Edition Chapter 84

Answer: A

Explanation:

• Young women on OCPs are predisposed to stroke due to venous thrombosis of lateral saggital sinus or small cortical veins (cortical vein thrombosis)
• In Pregnancy/puerperium – Highest risk is in the third trimenster and for 6–8 weeks post-partum.
• Risk factors for CVT
  • infection
  • pregnancy & puerperium
  • oral contraceptives
  • dehydration and cachexia (marantic thrombosis): includes burns and cachexia of neoplastic disease
  • cardiac disease (including CHF)
  • ulcerative colitis (UC)
  • periarteritis nodosa
  • sickle cell trait
  • trauma: including closed head injury
  • iatrogenic: e.g. S/P radical neck surgery, transvenous pacemaker placement, post-craniotomy, internal jugular vein catheterization
  • malignancy: including myeloproliferative disorders
  • hypercoagulable state
  • diabetes mellitus: especially with ketoacidosis
  • homocystinuria
  • Behçet’s syndrome

Reference: Greenberg 9th Edition Chapter 82

Answer: A

Explanation:

Causes of Cerebrovascular Accidents

• Ischemic (85%)
  • Embolic (75%)
  • Thrombotic (25%)
• Hemorrhage (15%)
  • Parenchymal (10%)
  • Subarachnoid (1-2%)
  • Epidural (<1%)
  • Subdural (<1%)

Reference: Greenberg 9th Edition Chapter 80

Answer: A

Explanation

• MC cause is hypertension, causing rupture of small perforating arteries or arterioles
• MC site: Basal ganglia (Putamen)

• Intracerebral Hemorrhage is the second most common form of stroke (15–30% of strokes), but the most deadly
• unlike ischemic infarct: smooth progressive onset over minutes to hours, often with severe headache, vomiting, and alterations in level of consciousness
• unenhanced CT scan of the brain is the initial diagnostic study of choice
• the volume of the hematoma correlates highly with morbidity and mortality
• ICH enlarges in > 33% of cases within the first 3 hours of onset
• worse prognosis for patient on anticoagulants or with elevated cardiac troponins
• additional diagnostics (e.g. CTA, catheter angiogram, MRV…) if suspicion of underlying abnormality (e.g. AVM, dural sinus thrombosis, neoplasm…)
• hypertension (SBP > 150 mm Hg): reduce SBP to 140
• surgery

1. a) supratentorial ICH: still controversial. Surgery does not improve neurologic outcome, but may reduce length of ICU stay and mortality
2. b) cerebellar ICH with neurologic deterioration, or brainstem compression, or obstructive hydrocephalus from intraventricular clot: surgical evacuation ASAP (initial treatment with EVD is not recommended)

Reference: Greenberg 9th Edition Chapter 84

• Predisposing factors: Smoking and hypertension
• pregnancy—is NOT considered independent risk factor for aneurysmal SAH
• Wall of Berry aneurysm is made up of thickened hyalinized intima. The adventitia covering the sac is continuous with that of the parent artery.
• Increased Risk of Berry Aneurysm in
  • ADPKD
  • Ehlers-Danlos syndrome
  • NF-1
  • Marfan’s syndrome
  • Fibromuscular dysplasia
  • Coarctation of aorta
• Rupture of aneurysm usually occurs at the apex (dome) resulting in subarachnoid hemorrhage or intraparenchymal hemorrhage or both

Reference: Greenberg 9th Edition Chapter 74

Answer: B

Explanation:

Berry aneurysms: MC intracranial aneurysm, saccular in appearance, arising at the bifurcation of intracranial arteries.

About 85% aneurysms occur in the anterior circulation

Following 3 most common locations:

• ACoA (single most common): 30%
• P-comm: 25%
• Middle cerebral artery (MCA): 20%

5–15% in posterior circulation (vertebro-basilar)

≈ 10% on basilar artery: basilar bifurcation, AKA basilar tip, is the most common in basilar, followed by

BA-SCA, BA-VA junction, AICA

≈ 5% on vertebral artery: VA-PICA junction is the most common in vertebral art

20–30% of aneurysm patients have multiple aneurysms

Reference: Greenberg 9th Edition Chapter 74