1. Board Review
Rachel Mehendale, PGY4

2. 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

4. 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

6. 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

7. 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

9. 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

11. 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

12. 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

13. 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:

15. 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

16. 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

18. 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

19. 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!

20. 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

21. 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)