Board Review Rachel Mehendale, PGY4

Question 1 Which of the following is incorrect regarding the posterior circulation? The posterior choroidal arteries arise from the posterior circulation The anterior choroidal arteries arise from the posterior circulation The anterior spinal artery arises from the intracranial vertebral arteries The posterior inferior cerebellar artery arises from the vertebral arteries A segment of the vertebral artery runs through the transverse foramina of C5-C6 to C2

Question 2 Which of the following is incorrect regarding the venous system? Veins of the scalp communicate with the dural venous sinuses via emissary veins Ophthalmic veins drain into the cavernous sinus Cavernous sinus drains to the superior and inferior petrosal sinuses The vein of Labbe is the superior anastomotic vein The vein of Rosenthal is a deep vein

Question 3 A 49-year-old right-handed man with a history of atrial fibrillation and hypertension presents with acute onset of right hemiparesis affecting the face, arm, and leg. His gaze is deviated toward the left and he seems to have a right homonymous hemianopsia. He has global aphasia. Localize the lesion. Trunk of the MCA before the bifurcation Left lenticulostriate branches of the MCA Inferior division of the left MCA Penetrating branches at the level of the pons Superior divisions of the left MCA

Question 4 A 30 year old man with a history of diabetes, hypertension, and hyperlipidemia presents with a BP of 60/30 and confusion. His troponin is elevated and EKG shows ST depressions. When he is stabilized, he has left sided weakness, most prominent in the shoulder abductors and hip flexors. Which of the following is the most likely underlying mechanism of his weakness? Myopathy Lacunar infarct Watershed infarction in the setting of L ICA stenosis Watershed infarction in the setting of R ICA stenosis Cardioembolic

Question 5 A 52 –year-old woman with diabetes comes to the clinic with a sudden onset of vertical diplopia with limited adduction and vertical movements of the right eye. She also has tremor and choreoathetosis of the left side of her body. Which of the following is the most likely diagnosis? Right ventral mesencephalic tegementum infarct Left ventral mesencephalic tegmentum infarct Right pontine infarct Left pontine infarct Quadrigeminal plate infarct

Question 6 A 49 year old woman with anxiety, depression, hypertension, and diabetes presents to the emergency department with sensory deficit affecting the right face, arm, leg, and trunk and started yesterday morning. Peak symptoms were the morning of presentation. No motor deficits are present. Which of the following is correct? No further w/u is needed and the patient can be discharged from the ED Given the lack of motor deficits, her symptoms are most likely anxiety-related The lesion localizes to the cortex The likely mechanism is cardioembolic Small vessel disease is the most likely cause

Question 7 A 50 year old woman with HTN presents to the clinic with a history of TIA about a month ago. ASA 81was started at that time. Cardioembolic w/u was negative, carotid US showed nonsignificant stenosis, and LDL was 110. Which of the following agents has been shown to prevent recurrent stroke and should be used in this patient? Statins Warfarin tPA Heparin Hormone replacement therapy

Question 8 52 year old man with history of migraines and multiple TIAs presents with a pure motor stroke. MRI shows multiple subcortical lacunes and diffuse white matter changes. A1c 5.5%, blood pressure is only mildly elevated during his hospital stay and TTE shows no LVH or LAE, LDL is 84. He has a family history of 3 brothers with strokes in their 40s, and his father had early onset dementia and strokes as well. He began to develop early signs of dementia a year later and suddenly died 6 months after that. Family requested autopsy, and brain pathology showed the following:

What is correct regarding this condition? It is autosomal recessive PD is a feature of this disease It is associated with NOTCH3 mutation It is x-linked Migraine is not a cardinal feature of the condition

CADASIL Associated with NOTCH3 mutation (ch 19) – transmembrane protein in vascular smooth muscle. It accumulates in vascular walls, particularly small vessels AD is the pattern of inheritance Clinical features Migraine with aura Seizure Small vessel stroke – recurrent Cognitive decline

Question 9 A 65 year old woman presents to the ED with an episode of transient left eye blindness. Three weeks prior she went on a roller coaster ride and had mild neck pain a couple of days after, which she attributed to a new pillow. She reports throbbing left sided headache for the past two weeks with scalp tenderness. She’s been feeling “under the weather.” Her shoulders and arms have been aching as well. Sometimes she has jaw pain when she chews; however, she reports a history of prior dental disease and TMJ. CT-A of the head was negative. What is the next best step? DSA CT-A of the neck Obtain ESR and start steroids Start warfarin Schedule a temporal artery biopsy

GCA (Giant Cell Arteritis) Older adults (> 50 years old) Characterized by inflammation of the temporal artery Headache, jaw claudication, scalp tenderness over temporal artery, blindness Co-morbid with polymyalgia rheumatica ESR and CRP are elevated Temporal artery biopsy should show granulomatous inflammation BUT…treat the patient first!

Question 10 Which of the following options is correct regarding the vascular supply of the thalamus? It is primarily provided by the anterior circulation The anterior choroidal artery supplies the ventral posteromedial nucleus The posterior choroidal artery supplies the ventral anterior nucleus The paramedian branches supply the dorsomedial nucleus The posterior choroidal artery arises from the posterior communicating artery and supplies the pulvinar

Polar (tuberothalamic artery) from Pcomm and supplies the anterior portion of the thalamus Thalamoperforating of paramedian artery originates from P1 and supplies medial, primarily the DM nucleus Thalamogeniculate artery P2 and supplies the lateral thalamus (VL group) Posterior choroidal artery from P2 supplies posterior thalamus (pulvinar)