1. Cerebrovascular Disease 2/22/06 Basic Science

2. Which of the following contributes to ischemic strokes: 1) Embolization of atherosclerotic and thrombotic material 2) Thrombotic occlusion 3) Hypoperfusion 4) All of the above

3. Which of the following contributes to ischemic strokes: 4) Atherosclerosis of arteries supplying the brain is a leading cause of ischemic strokes. Large- artery atherosclerosis, most often involving the carotid bifurcations, causes stroke by three principle mechanisms: embolization of atherosclerotic and thrombotic material, thrombotic occlusion, and hypoperfusion from advanced hemodynamically significant stenoses

4. A 66-year-old woman has the sudden loss of movement on part of the left side of her body. She has smoked a pack of cigarettes a day for the past 45 years. A cerebral angiogram reveals occlusion of a branch of her middle cerebral artery. Laboratory findings include a hemoglobin A1C of 9%. Which of the following components of blood lipids is most important in contributing to her disease? 1) Chylomicrons 2) Lipoprotein lipase 3) Oxidized LDL 4) VLDL 5) HDL cholesterol

5. Answer 3 is CORRECT. She has had a 'stroke' which is most often a consequence of cerebral atherosclerosis or embolic disease from the heart as a consequence of ischemic heart disease from atherosclerosis. LDL brings cholesterol to arterial walls, and when increased LDL is present or when there is hypertension, smoking, and diabetes, there is more degradation of LDL to oxidized LDL which is taken up into arterial walls via scavenger receptors in macrophages to help form atheromas.

6. Which of the following are true of TIAs? 1) Episodes typically last 2-15 Minutes 2) Episodes can last up to 48 Hours 3) Episodes are likely to leave persistent deficit 4) Have similar manifestations regardless of Vascular System affected (eg. LCA vs RCA vs Vertebrobasilar Artery)

7. Which of the following are true of TIAs? 1 is True

8. Which of the following are characteristic of vertebrobasilar system TIA’s? 1) Motor dysfunction ( weakness, paralysis and clumsiness) 2) Loss of vision in one or both homonymous visual fields 3) Vertigo, loss of balance, disequilibrium 4) Amaurosis fugax

9. Which of the following are characteristic of vertebrobasilar system TIA’s? 1-3 are true. Amaurosis fugax is characteristic of carotid artery disease.

10. Amaurosis fugax: 1) Usually involves both eyes 2) Effects are permanent 3) Symptoms are described as loss of lateral visual fields 4) Results from embolization to corresponding retinal artery 5) Associated with Macular sparing

11. What is the single best initial test to evaluate Carotid occlusive disease? 1) MRA 2) CT angio 3) Arteriography 4) Carotid Duplex

12. What is the single best initial test to evaluate Carotid occlusive disease? Carotid Duplex

13. Describe the Two diagnostic modalities of carotid duplex scanning:

14. Current indications for Carotid Endarterectomy include: 1) Carotid stenosis of 50% or greater with ipsilateral TIA’s 2) Amaurosis fugax 3) Large stroke 4) Recurrent, symptomatic carotid stenosis

15. Current indications for Carotid Endarterectomy include: 1,2 and 4

16. What is the risk of stroke in the first three years after TIA? 1) 50% 2) <5% 3) 10-30% 4) >80%

17. Risk of stroke after TIA Answer 10-30% in first year At 5years 30-50%

18. Neurologic deficits beginning after 12 hours post-op can be due to? 1) Thromboembolism from the endarterectomy site 2) Post-op Hypoperfusion Syndrome 3) Intracerebral Hematoma 4) Intimal Flap

19. Neurological deficits after CEA? Answer all of the above

20. During CEAs nerve injury occurs most frequently in which order? 1)Recurrent Laryngeal> Hypoglossal>Marginal Mandibular Nerve>Superior Laryngeal>Spinal Accesory 2)Hypoglossal>Recurrent Laryngeal>Superior Laryngeal>Marginal Mandibular>Spinal Accesory 3)Superior Laryngeal>Recurrent Laryngeal>Spinal Accesory>Marginal Mandibular>Hypoglossal 4)Marginal Mandibular>Spinal Accessory>Hypoglossal>Superior Laryngeal

21. Nerve Damage? Answer: Recurrent>Hypoglossal>Marginal Mandibular>Sup. Laryngeal>Spinal Accessory

22. Regarding non-neurological complications after CEA, Hypotension and bradycardia are usually the result of? 1) Interruption of the Carotid Sinus Nerve 2) Hypovolemia 3) Increased baroreceptor activity during dissection or 4) Stimulation of the sinus nerve following removal of a rigid atheromatous plaque

23. What is the most common non-stroke related cause of morbidity and mortality immediately and long term after CEA? 1) Myocardial Infarction 2) PVD 3) ESRD 4) Hypertension

24. Hypotension and Bradycardia after CEA? Secondary to 3,4, Baroreflex stimulation or stimulation of the sinus nerve. Interruption of the sinus nerve results in Hypertension