Vascular Neurology

Question 1

What feature of AICA infarct will not be seen in PICA infarct?

Answer 1

Hearing loss (unclear whether this is due to effect on lateral pontomedullary tegmentum or the inner ear itself (via labyrinthine artery off AICA)

Question 2

What single arterial lesion can cause bilateral thalamic strokes?

Answer 2

Artery of Percheron (anatomic variant, arises from P1 and supplies both medial thalami).

Question 3

Supply to anterior and posterior limbs of internal capsule:

Answer 3

Anterior: ACA deep penetrating vessels (including recurrent artery of Huebner) (These also supply inferior caudata head and anterior globus pallidus)

Posterior: MCA lenticulostriate branches (these also supply putamen, part of caudate head/body, outer globus pallidus, and corona radiata) + Anterior choroidal artery

Question 4

What is supply of thalamus (in broad terms)?

Answer 4

Branches of PCA and Pcomm

Question 5

Four major arteries supplying the thalamus

Answer 5

1. Tuberothalamic (off Pcomm): Anterior thalamus (especially ventral anterior nucleus)
2. Thalamoperforating/paramedian artery (off P1): Medial thalamus (especially dorsomedial nucleus)
3. Thalamogeniculate artery (off P2): Lateral thalamus (including ventral lateral nuclei)
4. Posterior choroidal artery (off P2): Posterior thalamus (including pulvinar ucleus)

Question 6

Anterior choroidal artery: Origin and structures supplied

Answer 6

Origin: ICA just above Pcomm origin

Supplies: GPi, part of posterior limb of internal capsule, part of geniculocalcarine track. Part of choroidal plexus (posterior choroidal artery from posterior circulation does the rest).

Question 7

Medial medullary syndrome

Answer 7

1. Contralateral limb weakness (pyramic)
2. Contralateral proprioception/vibration loss (medial lemniscus)
3. Ipsilateral tongue weakness (hypglossal fibers)

Question 8

What lesion causes alexia without agraphia?

Answer 8

L occipital infarct with involvement of splenium of corpus callosum

( R visual cortex information cannot cross to L language centers)

Question 9

Deficits in ventral mesencephalic tegmentum

Answer 9

1. Ipsilateral CN III palsy (fascicle of CN III)
2. Contralateral involuntary movements (tremor and choreoathetosis) (supserior cerebellar peduncle, also ventral red nucleus)
   (May also have contralateral weakness)

(Called Benedikt’s syndrome)

Question 10

Parinaud’s syndrome: localization and deficits

Answer 10

Localization: Dorsal midbrain / tegmentum / quadrigeminal plate (inferior and superior colliculi)

Syndrome:

1. Supranuclear vertical gaze palsy
2. Impaired convergence
3. Convergence-retraction nystagmus
4. Light-near dissociation
5. Lid retraction
6. Skew deviation

Question 11

Branches from 4 ICA segments

Answer 11

1. Cervical: no branches
2. Petrous: Vidian and caroticotympanic branches
3. Cavernous: meningohypophyseal trunk, inferolateral trunk, capsular arteries
4. Supraclinoid: Ophthalmic, superior hypophyseal, Pcomm, anterior choroidal
   (Then branches into MCA and ACA)

Question 12

“Popcorn” appearance on MRI.

How does it present?

Answer 12

Cavernous malformation

Usually incidental. Can be seizures, rarely hemorrhage

Question 13

Unusual or irregular arrangement of small veins that may look like the spokes of a wheel

How does it present?

Answer 13

DVA

Asymptomatic. Risk of hemorrhage very low

Question 14

Vascular malformation that can present with signs of elevated ICP

Answer 14

Dural AVF

Question 15

3 most common locations for saccular aneurysm?

Answer 15

1. Acomm (30%)
2. Pcomm (25%)
3. MCA bifurcation (20%).

Less common: ICA bifurcation (7.5%0, basilar apex (7%), pericallosal artery (4%), PICA origin (3%).

Question 16

Vascular malformation with pulsatile tinnitus and orbital edema with possible ophthalmoplegia.

Most common etiology?

Answer 16

Carotid-cavernous fistula (CCF).

Most commonly traumatic. (Can be spontaneous though)

Question 17

What is the arterial supply of a dural AV fistula?

Answer 17

Meningeal or dural artery branch

Question 18

What anatomical factor influences hemorrhage risk with dural AVF?

Answer 18

Whether or not have drainage to cortical veins - a/w higher hemorrhage risk.

[Can either be direct drainage from meningeal artery to cortical veins (type III) or drainage from meningeal artery to dural sinous with retrograde flow to cortical veins]

[Type I is drainage from neningeal artery to dural venous sinus without retrograde flow, lowest hemorrhage risk).

Question 19

Which carotid revascularization technique is preferred <70 yrs? >70?

Answer 19

<70: Carotid stent

>70: CEA

Question 20

Which carotid revascularization technique has lower risk periprocedural stroke?

MI?

Answer 20

Periprocedural stroke: lower with CEA

Periprocedural MI: lower with stent

Question 21

Gerstmann syndrome elements

Localization?

Answer 21

1. Agraphia
2. Acalculia
3. Finger agnosia
4. Left-right disorientation

Localization: Dominant temporo-parietal junction / angular gyrus