CAPLAN CH9: Penetrating and Branch Artery

Question 1

Can chronic white matter abnormalities present as Parkinson’s disease?

Answer 1

Yes. Multiple dilated perivascular spaces can be accompaned by WM changes and can be accompanied by cognitive and behavioral abnormalities and basal ganglioninc clinical dysfunction resembling PD.

Question 2

What was the finding in the SPS 3 trial in terms of medications and bleeding?

Answer 2

Aspirin 325mg/day vs Aspirin 325mg/day + Clopidogrel 75mg/day

There is no significant reduction in recurrent stroke but inreased risk of bleeding and death

Question 3

Small, discrete, often irregular lesions, ranging from 1 to 15mm in size

Answer 3

Lacunar infarcts

Question 4

Most common locations of lacunes

Answer 4

putamen and pallidum
pons, thalamus, caudate, IC and corona radiata

RARE: peduncles, pyramid, SC white matter

NOT found: cerebral and cerebellar cortices

Question 5

Characteristic vascular pathology

Answer 5

Focal enlargements and small hemorrhagic extravasation through the walls of the arteries

Question 6

Arteries in spots being replaced by whorls, tangles and wisps of connective tissue obliterating the usual vascular layers

Answer 6

segmental arterial disorganization, fibrinoid degeneration and lipohyalinosis

Question 7

Similar pathophysiology of penetrating artery disease and ICH?

Answer 7

Lipohyalinosis

Question 8

The clinical-neurological findings of CADASIL are similar to CARASIL except___

Answer 8

1. Premature baldness and back pain and severe spondylitis are additional major features.
2. Arteries in CARASIL do not contain osmiophiliic materials

Question 9

COL4A1 vs CADASIL

Answer 9

Unlike CADASIL, the in COL4A1, the temporal lobes are spared of the chronic white matter abnormalities

Question 10

Major cause of fibrinoid degeneration and lipohyalinosis?

Answer 10

Hypertension

Question 11

TRUE/FALSE. Headache caused by vascular distension OCCURS in patient with lacunes?

Answer 11

FALSE. Lacunes are small and deep. Because there is no accompanying overdistension of superficial arteries and deep arteries have no pain fibers.

Question 12

Prior TIA occur in approximately __% of patients with lacunes?

Answer 12

20%

Question 13

Most common cause of worsening of clinical neurological signs during the first week after stroke onset?

Answer 13

Lacunar infarction

Question 14

TRUE OR FALSE. Lacunar syndromes are highly suggestive of deep cerebral infarction. 100% of the time, lacunar infarcts are found.

Answer 14

FALSE. In 16% of the time, it is not due to lacunar infarcts.

Question 15

Combination of weakness, pyramidal signs and cerebellar-type ataxia

Answer 15

Homolateral ataxia and crural paresis (predominantly the lower limbs)

Question 16

Abnormalities of motor function on one side of the body BUT no true paralysis and reflexes are not exaggerated, plantar response is flexor

Answer 16

non-pyramidal hemimotor syndrome (affected usually is the striatum and globus pallidus)

Question 17

Can lacunar infarcts present with aphasia?

Answer 17

YES. In some patients with left caudate infarcts, the aphasia is slight and transient.

Question 18

Three major syndromes in the pons related to infarcts in the basis pontis?

Answer 18

1. pure-motor hemiparesis (paramedian basis pontis)
2. ataxic hemiparesis
3. dysarthria clumsy-hand syndrome

Question 19

Compare the location of the lesions of ataxic hemiparesis vs pure motor syndrome in the pons?

Answer 19

smaller, more rostral, dorsal and lateral than lesions of pure motor syndrome

Question 20

Describe the development of a rubral tremor.

Answer 20

Usually develops as the hemiparesis improves and is present at rest and on intention.

Question 21

Describe the ataxia in patients with midbrain infarcts.

Answer 21

If focal lesions involve the decussation of the brachium conjunctivum in the midbrain, patient present with bilateral limb ataxia and tremor. (Wernekick commissure syndrome).

Question 22

What are the two most important and consistent paramedian thalamoperforating arteries?

Answer 22

1. polar (tuberothalamic) artery- from the middle third PCOM

2. thalamic- subthalamic artery- from the medial PCA

Question 23

Usual presentation of polar artery infarction?

Answer 23

Polar artery supplies teh anteriomedial and anterolateral thalamic nuclei hence present with cognitive and behavioral changes.

Question 24

Counterpart of the lenticulostriate branches of the MCA?

Answer 24

thalamogeniculate group of arteries

Question 25

TRUE OR FALSE. The numbness of the inner mouth, eye, ear, scalp, chest, back, abdomen and genitalia is MUCH MORE COMMON in thalamic lacunes than in superfiicial lesions of the parietal cortex?

Answer 25

TRUE

Question 26

Hemianopia, hemisensory symptoms, and behavioral abnormalities may occur in patients with ____ infarcts.

Answer 26

Posterior choroidal artery territorial infarcts

Question 27

Characteristic visual field defect in a patient with PChA territory infarct vs AChA territory

Answer 27

Sectoranopia

In AchA territory: loss of the upper and lower quadrants, with sparing of vision in a line along the median horizontal meridian.

Question 28

What is the finding of the SPS 3 (Secondary Prevention of Small Subcortical Strokes) in terms of cognitive impairment?

Answer 28

Nearly half of stroke patients recruited presented with mild cognitive impairment between 2 weeks and 6 months after the qualifying lacunar stroke.

Question 29

What was the finding in the ESPS 2 (European Stroke PRevention Studies 2)?

Answer 29

That a combination of ASA + Dipyridamole is better than ASA or Dipyridamole alone.

Question 30

How many percent of lacunes were there in the WARRS trial?

Answer 30

40%

Question 31

What was the finding in the PROFESS trial?

Answer 31

No difference between Clopidogrel and Aspirin + extended-release dipyridamole with regard to effectiveness in prevention of recurrent strokes.

Question 32

What is the iMAGES trial?

Answer 32

Intravenous Magnesium Efficacy in Stroke- this checked the utility of Magnesium as vasodilator

Question 33

Where are the white matter lesions of CADASIL found?

Answer 33

Usually in the external capsule and anterior temporal lobes. (Characteristic lesion)

Question 34

What are the findings of the LADIS study (Leukoaraiosis and disability study)?

Answer 34

Increasing severity of whit matter abnormalities and number of lacunes were related to poorer cognitive performance.

When WM and lacunes were considered together, strong association of WM than number of lacunes.

Question 35

What is the usual age of onset of CADASIL?

Answer 35

less than 40 years old

Question 36

What is the difference between leukocariosis and white matter disease?

Answer 36

Leukoaraiosis is a general term and many patients with white matter abnormalities do not have a vascular disease.

Question 37

Cerebral microbleeds are present in approximately __ of patients with ICH and ischemic CVD?

Answer 37

70%

40%

Question 38

Mechanisms when white matter abnormalities are larger than the territory of a single penetrator?

Answer 38

1. tandem penetrating arterial lesions.

2. increased vascular permeability

Question 39

What metalloproteinase is elevated in patients with Binswanger-type pathology?

Answer 39

Matrix metalloproteinase-9

Question 40

How does matrix metalloproteinases affect the BBB?

Answer 40

They degrade the tight junction proteins found within the blood vessels.

Question 41

Mechanism of brain edema in patients with Binswanger disease?

Answer 41

Degenerative changes in the veins within the white matter.