Neurology - Cerebrovascular diseases Flashcards

1
Q

NEU - 1.1
Epidural hematoma is caused by the rupture of:
A) middle meningeal artery
B) choroidal anterior artery
C) middle cerebral artery
D) superficial temporal artery

A

ANSWER
A) middle meningeal artery

EXPLANATION
The middle menigeal artery is the branch of external carotid artery and runs between the dura mater and the temporal bone. In case of bone fracture (temporal or parietal region), the middle meningeal artery could be ruptured and arterial hematoma develops quickly by compressing the ipsilateral hemisphere resulting in first contralateral hemiparesis thereafter somnolence, stupor, coma and finally herniation.

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2
Q

NEU - 1.2
The importance of external carotid artery is:
A) important for the blood flow supply of posterior scala
B) important potential collateral source in case of ipsilateral ICA occlusion
C) participates in blood supply of brainstem
D) its occlusion results in amaurosis fugax
E) supplies the frontobasal part of the brain

A

ANSWER
B) important potential collateral source in case of ipsilateral ICA occlusion

EXPLANATION
The collateral circulation between the branches of external carotid artery (facial, angular arteries etc.) and ophthalmic artery (ICA branch) is important. In case of severe ICA stenosis or occlusion the good collateral circulation can sustain asymptomatic status. The reversed flow (extra-intracranial direction) in the ophthalmic artery can be detected by ultrasound.

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3
Q

NEU - 1.3
The ratio between carotid area and vertebrobasilar stroke:
A) 1:1
B) 1:3
C) 10:1
D) 1:10
E) 4:1

A

ANSWER
E) 4:1

EXPLANATION
The carotid area strokes are 4-5x more frequent than the vertebrobasilar ones

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4
Q

NEU - 1.5
The role of sagittal superior sinus:
A) participates in the absorption of CSF
B) collects the blood of sagittal inferior sinus
C) transfers the blood of confluent sinus
D) collects the blood of transverse and cavernous sinus

A

ANSWER
A) participates in the absorption of CSF

EXPLANATION
The sagittal superior sinus collects the blood from the convexity of the brain and participates in the absorption of CSF via Pacchioni granulates

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5
Q

NEU - 1.6
The risk of stroke in hypertension:
A) 2–8x
B) 0,3–3x
C) 2x
D) 50x

A

ANSWER
A) 2–8x

EXPLANATION
The hypertension increases the stroke risk by 2-8x

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6
Q

NEU - 1.7
Symptoms of TIA, EXCEPT:
A) Transient unilateral blindness
B) Transient limb numbness
C) Transient aphasia
D) Transient loss of consciousness with epileptic seizure

A

ANSWER
D) Transient loss of consciousness with epileptic seizure

EXPLANATION
Transient focal deficits (unilateral blindness, aphasia, transient focal numbness, transient paresis) are typical symptoms of TIA. A transient loss of consciousness could be caused by quick blood pressure decrease, arhythmias (pump-function), blood glucose decrease or increase, and epilepsy but not by TIA.

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7
Q

NEU - 1.8
The ischemic stroke occurs frequently:
A) after waking
B) after going to bed
C) in the summer
D) in the afternoon

A

ANSWER
A) after waking

EXPLANATION
The ischemic stroke occurs frequently after waking and in the morning hours. Hypoperfusion and prothrombotic status are frequent in the night and the morning activity could provocate embolisation.

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8
Q

NEU - 1.9
Cerebral blood flow in the penumbra (region around the ischemic core):
A) 0–10 ml/min/100 g brain tissue
B) 10–20 ml/min/100 g brain tissue
C) 55–60 ml/min/100 g brain tissue
D) 100-120 ml/min/100 g brain tissue

A

ANSWER
B) 10–20 ml/min/100 g brain tissue

EXPLANATION
The iv. thrombolysis or thrombectomy target the penumbra (10-20 ml/min/100g brain tissue, in healthy person 50ml/100g/min). The structures of the neurons are still preserved with impaired function.

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9
Q

NEU - 1.10
Global cerebral ischemia causes irreversible cerebral damage after:
A) 20–25 min
B) 10–15 min
C) 3–5 min
D) 1–2 min

A

ANSWER
C) 3–5 min
EXPLANATION
Globalis cerebral ischemia causes irreversible cerebral damage after 3-5 minutes.

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10
Q

NEU - 1.11
Which mechanism plays the most important role in the ischemic cascade?
A) calcium influx
B) potassium influx
C) sodium influx
D) decrease of monoamine level

A

ANSWER
A) calcium influx

EXPLANATION
During acute ischemia the calcium influx activates the ischemic cascade.

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11
Q

NEU - 1.12
The carotid ultrasound is recommended in acute stroke, EXCEPT:

A) for the measurement of intima-media thickness.
B) to diagnose carotid occlusion/stenosis.
C) to determine the plaque characteristic: in case of ulcerated or inhomogenous plaque, endareterectomy could be suggested instead of stenting.
D) because it is the optimal method to detect carotid floating thrombus.

A

ANSWER
A) for the measurement of intima-media thickness.

EXPLANATION
The intima-media thickness is a marker of arteriosclerosis but not the part of acute stroke care.

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12
Q

NEU - 1.13
Symptoms of vertebrobasilar insufficiency, EXCEPT:
A) diplopia
B) vertigo
C) dysarthria
D) alternating brainstem syndromes
E) apraxia

A

ANSWER
E) apraxia

EXPLANATION
A supratentorial lesion results in apraxia but not infratentorial one.

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13
Q

NEU - 1.14
These diseases could result in cardiogenic stroke, EXCEPT:

A) atrial fibrillation
B) endocarditis
C) bicuspidal and aortic valve diseases
D) lower leg deep venous thrombosis without patent foramen ovale
E) after MI

A

ANSWER
D) lower leg deep venous thrombosis without patent foramen ovale

EXPLANATION
Embolisation from deep venous thrombosis without patent foramen ovale results in pulmonary embolisation not cerebral ischemia.

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14
Q

NEU - 1.15
Typical symptoms of transient global amnesia, EXCEPT:
A) loss of anterograde memory
B) the patient is alert
C) shorter than 24 hours
D) cortical blindness
E) unknown cause

A

ANSWER
D) cortical blindness
EXPLANATION
Cortical blindness is caused by the bilateral occlusion of the posterior cerebral artery, which is not typical for transient global amnesia (TGA).

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15
Q

NEU - 1.16
Cause of amaurosis fugax:
A) giant cell arteriitis
B) migraine with scotoma
C) thromboembolisation of the ophthalmic artery (terminal branch) from the ulcerated plaque of the ipsilateral internal carotid artery

A

ANSWER
C) thromboembolisation of the ophthalmic artery (terminal branch) from the ulcerated plaque of the ipsilateral internal carotid artery

EXPLANATION
The thromboembolisation of the ophthalmic artery may origin from the ulcerated plaque of the internal carotid artery, causing ipsilateral amaurosis fugax (transient monocular blindness). Contrarily occlusion of the calcarina artery causes contralateral heteronymous hemianopia, in case of migraine scotoma can develop. In case of giant cell arteriitis the lesion of the anterior part of the optic nerve or lesion of the central retinal artery is responsible for the deterioration of visual acuity.

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16
Q

NEU - 1.17
Cortical lesion is probable in case of stroke in the territory of the internal carotid artery, if:
A) hemiparesis with dominance in the facial and brachial area
B) if the severity of the paresis is similar on the upper and lower limb
C) visual field defect is also seen
D) permanent vertigo develops

A

ANSWER
A) hemiparesis with dominance in the facial and brachial area

EXPLANATION
If facial-brachial-dominant hemiparesis is seen in case of stroke affecting the territory of the internal carotid artery cortical lesion is probable, whilst the severity is similar in the face, upper limb and lower limb subcortical lesion (internal capsule) is more likely.

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17
Q

NEU - 1.18
Which is NOT part of the symptoms of the unilateral occlusion of the anterior cerebral artery and its branches?
A) urinary and fecal incontinence
B) contralateral lower limb dominant hemiparesis
C) changes in behaviour and character
D) gnostic disturbance

A

ANSWER
D) gnostic disturbance

EXPLANATION
Gnostic dysfunction appear in lesions next to the primary sensory centers, supplied by the branches of the middle cerebral artery.

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18
Q

NEU - 1.19
Which is NOT part of the symptoms in case of occlusion of the middle cerebral artery (M1)?
A) contralateral severe hemiparesis
B) homonymous hemianopia
C) conjugate deviation of eyes
D) hemihypaesthesia
E) thalamus-syndrome, thalamus-hand

A

ANSWER
E) thalamus-syndrome, thalamus-hand

EXPLANATION
Thalamus-syndrome, thalamus-hand occur as a consequence of the occlusion of the branches of the thalamogeniculate artery (branches of the posterior cerebral artery), when the ventral posteromedial and posterolateral thalamic nuclei are damaged.

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19
Q

NEU - 1.20
Which artery’s circulation disturbance causes the following symptoms: apathy, liberation reflexes, disturbance of attention, perseveration and echolalia?A) anterior cerebral artery and branches
B) perforating branches of the middle cerebral artery
C) anterior choroidal artery
D) superior terminal branch of the middle cerebral artery

A

ANSWER
A) anterior cerebral artery and branches

EXPLANATION
In case of circulation disturbance of the anterior cerebral artery the following symptoms may develop: apathy, liberation reflexes, disturbance of attention, perseveration, echolalia.

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20
Q

NEU - 1.21
NOT part of Weber-syndrome:
A) ipsilateral oculomotor nerve lesion
B) contralateral hemiparesis
C) contralateral increase deep tendon reflexes with pyramidal signs
D) contralateral hyperkinesia

A

ANSWER
D) contralateral hyperkinesia

EXPLANATION
Weber-syndrome is an alternating motor brainstem syndrome: ipsilateral oculomotor nerve lesion, contralateral hemiparesis. When contralateral involuntary movements (hyperkinesis) occur not only the oculomotor nerve, but the red nucleus is damaged as well (Benedikt-syndrome).

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21
Q

NEU - 1.22
Disturbance of gaze (vertical upwards), with vertical nystagmus is typical in:
A) Benedikt-syndrome
B) Parinaud-syndrome
C) Nothnagel-syndrome
D) Raymond- (ventral pontine) syndrome

A

ANSWER
B) Parinaud-syndrome

EXPLANATION
The disturbance of gaze (vertical upwards) with vertical nystagmus is typical for Parinaud-syndrome. In the background tumor (especially pinealoma), sometimes vascular lesion and inflammation is found.

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22
Q

NEU - 1.23
The cause of pseudobulbar palsy:
A) bilateral lesion of the corticobulbar fibers
B) lesion of the cranial nerves in the medulla oblongata
C) lesion of the dentate nucleus
D) lesion of the peripheral nerves responsible for articulation (speech) and swallowing

A

ANSWER
A) bilateral lesion of the corticobulbar fibers

EXPLANATION
Bilateral lesion of the corticobulbar tracts causes pseudobulbar palsy.

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23
Q

NEU - 1.24
Symptoms of occlusion of the superior cerebellar artery (lateral superior pontine syndrome), EXCEPT:
A) ipsilateral limb and truncal ataxia
B) dizziness, nystagmus
C) contralateral hypaesthesia, decreased vibration and joint position sensation
D) diplopia, deafness

A

ANSWER
D) diplopia, deafness

EXPLANATION
The following symptoms are detected in case of occlusion of the cerebellar superior artery (lateral superior pontine syndrome): Ipsilateral limb- and truncal ataxia, vertigo, horizontal nystagmus, contralateral hypaesthesia, vibration, joint position sensation The lesion may affect the superior and middle cerebellar peduncles, dentate nucleus, the vestibular nuclei of the cerebellum, the spinothalamic tract, dorsal part of medial lemniscus and the descending sympathic fibers.

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24
Q

NEU - 1.25
Symptoms of cavernous sinus thrombosis:
A) lesion of the III., IV., VI., V/1. cranial nerves
B) lesion of the IX–XII. cranial nerves
C) lesion of the III., V., VI., VII. cranial nerves
D) Gradenigo-syndrome develops

A

ANSWER
A) lesion of the III., IV., VI., V/1. cranial nerves

EXPLANATION
The following structures are in the cavernous sinus cranial nerves III, IV, VI, V/1 and the internal carotid artery. In case of thrombosis of cavernous sinus the lesion of these nerves will appear.

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25
Q

NEU - 1.26
What does Hunt and Hess Scale grade 4 stand for?

A) somnolence, confusion, mild neurological symptoms
B) deep coma, decerebration
C) stupor, moderate or severe hemiparesis, vegetative disturbance
D) severe headache, nuchal rigidity, cranial nerve palsy

A

ANSWER
C) stupor, moderate or severe hemiparesis, vegetative disturbance

EXPLANATION
By Hunt and Hess Scale grade 4 stupor, moderate or severe hemiparesis, vegetative disturbance are the symptoms.

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26
Q

NEU - 1.27
What score will the patient get on Glasgow Coma Scale in case of fatal intracerebral bleeding if:
the patient does not open his eye to any stimuli, does not respond to loud verbal stimulus, no movement reaction is seen?
A) 0
B) 3
C) 1
D) 2

A

ANSWER
B) 3

EXPLANATION
The minimum point of Glasgow Coma Scale is 3, 1 point for each function.

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27
Q

NEU - 1.28
Which artery’s aneurysm may cause unilateral oculomotor nerve palsy?
A) posterior communicating artery
B) anterior communicating artery
C) ophthalmic artery
D) posterior cerebral artery

A

ANSWER
A) posterior communicating artery

EXPLANATION
Unilateral total oculomotor nerve lesion can be caused by the aneurysm of the posterior communicating artery, because of its localization it may compress the oculomotor nerve.

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28
Q

NEU - 1.29
What type of electrolyte abnormality may develop after subarachnoid haemorrhage?
A) hypokalaemia
B) hyponatraemia
C) both of them
D) none of them

A

ANSWER
B) hyponatraemia

EXPLANATION
Often hyponatraemia develops after subarachnoid haemorrhage (because of the disturbance of ADH-secretion).

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29
Q

NEU - 1.30
Which localization is typical for intracerebral bleeding?
A) basal ganglia
B) thalamus
C) pons
D) cerebellum

A

ANSWER
A) basal ganglia

EXPLANATION
The most common localization of intracerebral bleeding is the locus of the basal ganglia

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30
Q

NEU - 1.31
The mortality is the highest if the bleeding is localized in the:
A) thalamus
B) basal ganglia
C) brainstem
D) frontal lobe

A

ANSWER
C) brainstem

EXPLANATION
The mortality is the highest if the bleeding is localized in the brainstem.

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31
Q

NEU - 1.32
What type of developmental disorder may be associated with congenital intracranial aneurysms?
A) endometriosis
B) ovarian cyst
C) diaschisis
D) polycystic kidney

A

ANSWER
D) polycystic kidney

EXPLANATION
Congenital cerebral aneurysms may be associated with polycystic kidney.

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32
Q

NEU - 1.33
Where the bleeding is localized in case of the following symptoms: eye-balls in the midline, bilateral miosis and pupils react poorly to light?
A) thalamus
B) pons
C) cerebellum
D) putamen

A

ANSWER
B) pons

EXPLANATION
In case of intracranial haemorrhage, if the bulbi are in central position, the pupils are point like (myosis), and show poor reaction to light, the bleeding is in the pons probably.

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33
Q

NEU - 1.34
With the help of which examination can the bleeding be seen immediately?
A) EEG
B) SPECT
C) CT
D) PET

A

ANSWER
C) CT

EXPLANATION
With cranial CT the intracranial bleeding is detected immediately. On native scans homogenous hyperdensity is seen, according to the size it may have a space occupying effect, with a narrow oedema surrounding it in the acute phase.

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34
Q

NEU - 1.35
If the patient has symptoms of definite brainstem lesion and 6 hours after the symptom onset cranial CT excluded bleeding, which examination will help the diagnosis?
A) within 24–72 hours repetition of cranial CT with posterior scala programme
B) cranial MRI
C) auditory evoked potential (BAEP)
D) transcranial Doppler sonography (vertebral artery, basilar artery, posterior cerebral artery)

A

ANSWER
B) cranial MRI

EXPLANATION
Cranial MRI is necessary for the examination of the posterior scala, brainstem. On CT because of the bone artifacts it can be visualized poorly. MRI shows the ischaemic territory more precisely. The new MRI methods increased the probability of early and precise diagnosis.

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35
Q

NEU - 1.36
Which examination should be done first when ictal cerebral symptoms develop?
A) cranial CT
B) transcranial ultrasound
C) echocardiography
D) Doppler-ultrasonography of the carotid arteries

A

ANSWER
A) cranial CT

EXPLANATION
In case of sudden onset of cerebral symptoms the first examination must be cranial CT. The first diagnostic decision from the point of view of prognosis and therapeutic approaches should be whether the lesion responsible for the symptoms is bleeding or ischaemia. If there is no bleeding with contrast material large cerebral tumor can be excluded.

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36
Q

NEU - 1.37
On cranial CT in the so called watershed area hypodens lesion is detected, with hyperdense petechia. This is typical for:
A) bleeding
B) chronic infarct
C) fresh infarct
D) haemorrhagic infarct
E) cavernoma

A

ANSWER
D) haemorrhagic infarct

EXPLANATION
Haemorrhagic infarct is the diagnosis if on cranial CT in the so called watershed zone hypodensity is seen with smaller hyperdense territories inside.

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37
Q

NEU - 1.38
The following symptoms are typical for the occlusion of the ………. artery: short after backpain (but not ictally) flaccid paraplegia with dissociated disturbance of sensation (deep sensation is preserved), urinary and bowel incontinence.

A) posterior spinal artery
B) sulcocommissural artery
C) anterior spinal artery
D) none of them

A

ANSWER
C) anterior spinal artery

EXPLANATION
The typical symptoms of occlusion of anterior spinal artery are: short (but not ictal) after pain in the thoracic/lumbar region flaccid paraplegia develops, with dissociated sensation disturbance (deep sensation is intact), incontinence (fecal and urinary). Prodromal symptoms (pain in the altitude of the lesion) may be reported before the severe symptoms. Pyramidal signs may be missing at the beginning. A space occupying procedure may compress the anterior spinal artery e.g. disc herniation.

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38
Q

NEU - 1.39
On auscultation of the carotid arteries no bruit can be heard in case of:
A) aortastenosis
B) 70% stenosis of the carotid artery
C) occlusion of the carotid artery
D) inbleeded atherosclerotic plaque

A

ANSWER
C) occlusion of the carotid artery

EXPLANATION
Examining the supraaortic arteries by auscultation is mandatory screening method. A bruit draws attention to stenosis of the artery if it is not conducted from the heart or the aortic valve. Mild stenosis usually does not cause bruit, but the bruit may also cease when the stenosis is severe. subtotal or occluded. When the character of the bruit changes inbleeding plaque or dissection of the wall of a blood vessel may be in the background. All the above mentioned options need urgent examination (e.g. angiography).

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39
Q

NEU - 1.40
Duplex ultrasonography (duplex scan) is essential in the diagnosis and screening of cerebrovascular diseases. What functions are covered with this name?
A) two dimensional („real time”) picture, B mode picture, and it is possible to measure flow velocity with Doppler effect
B) colour picture
C) indicates flow direction
D) shows the source of embolus

A

ANSWER
A) two dimensional („real time”) picture, B mode picture, and it is possible to measure flow velocity with Doppler effect

EXPLANATION
Duplex ultrasound (duplex scan) is essential in the diagnostics of cerebral ischaemia and screening. The naming shows two functions: two dimension („real time”) picturing (B mode picture), and measuring the flow with the help of Doppler effect. In case of colour coding concerning the direction and velocity of the flow two colours (usually red, blue) are used.

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40
Q

NEU - 1.42
By evaluating the severity of stenosis with duplex scan the measurement of velocity of the systolic and diastolic blood flow is necessary. When should one suspect more than 90% stenosis of the internal carotid artery?
A) if the systolic peak velocity is 110–120 cm/s
B) if the diastolic peak velocity is less than 40 cm/s
C) if the diastolic peak velocity is more than 100 cm/s
D) if the systolic velocity is less than110, diastolic less than 40 cm/s

A

ANSWER
C) if the diastolic peak velocity is more than 100 cm/s

EXPLANATION
By judging the exact size of the stenosis with duplex scan measuring the systolic and diastolic velocity of the flow is important. Above the systolic peak velocity is 110-120 cm/s, a diastolic peak velocity 40 cm/s stenosis is diagnosed. Above approximately 250 cm/s systolic and 100 cm/s diastolic velocity means a stenosis of more than 90%.

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41
Q

NEU - 1.43
Alternating sensory /motor syndrome is typical of:
A) brainstem lesion
B) bilateral internal carotid artery occlusion
C) occlusion of the posterior cerebral artery
D) occlusion of the posterior choroidal artery

A

ANSWER
A) brainstem lesion

EXPLANATION
Appearance of alternating (crossed) sensory and/or motor symptoms show a localisation in the brainstem. The locus of the lesion is given by the cranial nerve’s symptom the contralateral „long tract” symptom is caused by the lesion of the tracts running in the base of the brainstem.

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42
Q

NEU - 1.44
When an internal carotid artery stenosis haemodinamically is significant examined with duplex scan ultrasonography?
A) more than 40%-stenosis in cross section
B) more than 20% decrease of diameter
C) more than 30% decrease of the diameter
D) more than 70% stenosis in cross section

A

ANSWER
D) more than 70% stenosis in cross section

EXPLANATION
Hemodynamically significant internal carotid artery stenosis according to duplex scan examination is when the stenosis is more than 70% of the diameter.

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43
Q

NEU - 1.45
What are the important side effects of ticlopidine?
A) thrombin time will be doubled
B) neutropenia, especially in the first 3 months
C) thrombocyte aggregation inhibition
D) vertigo

A

ANSWER
B) neutropenia, especially in the first 3 months

EXPLANATION
An important side effect of ticlopidin in the first 3 months is neutrophil leukopenia. White blood cell count and qualitative blood count is necessary in the first 3 months, every 2 weeks, later less often.

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44
Q

NEU - 1.46
Lowering of elevated blood pressure in acute ischemic stroke is not recommended, except:
A) if the diastolic blood pressure exceeds 120 mmHg
B) if systolic blood pressure is 180 mmHg
C) if the symptoms improve dramatically
D) if the ultrasound test does not reveal significant internal carotid artery stenosis

A

ANSWER
A) if the diastolic blood pressure exceeds 120 mmHg

EXPLANATION
Lowering of elevated blood pressure is not recommended in acute ischemic stroke only if systolic blood pressure exceeds 190-200 mmHg and diastolic blood pressure exceeds 120 mmHg, because decreased cerebral perfusion pressure may cause adverse effects. However, after acute phase of ischemic stroke, hypertension must be treated. Often, high blood pressure decreases spontaneously in a few days.

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45
Q

NEU - 1.47
From the onset of ischemic stroke symptoms, systemic thrombolysis can be indicated:
A) within 6 hours
B) within 12 hours
C) within 24 hours
D) within 4.5 hours

A

ANSWER
D) within 4.5 hours

EXPLANATION
From the development of ischemic stroke symptoms, thrombolysis may be indicated within 4.5 hours if the patient does not have any other exclusion criteria. If the symptoms are noted upon morning awakening, the onset time of stroke symptoms is uncertain. In this case, the last time point, when the patient was symptom-free, should be considered (e.g. bedtime, night awakening).

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46
Q

NEU - 1.48
In acute ischemic stroke, based on various clinical studies, the following systemic thrombolytic agent has the best effect, with minimal bleeding complications:
A) urokinase
B) rt-PA (recombinant tissue - plasminogen activator)
C) streptokinase
D) ancrod

A

ANSWER
B) rt-PA (recombinant tissue - plasminogen activator)

EXPLANATION
In acute ischemic stroke, based on various clinical studies, systemic thrombolysis with rt-PA (recombinant tissue plasminogen activator) is the most effective method with the least bleeding complications.

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47
Q

NEU - 1.49
Treatment of cerebral edema in ischemic stroke:
A) high-dose steroid
B) furosemid
C) mannitol
D) dextran

A

ANSWER
C) mannitol

EXPLANATION
Mannitol infusion (20%, 200 mg/kg body weight in 10-15 minutes) can be used to treat cerebral edema caused by brain ischemia. In severe cases, Mannitol administration can be repeated every 4-6 hours. After stop of the dehydration, a rebound effect might develop. To avoid renal failure no greater dose than 100 g of mannitol per day sholud be used.

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48
Q

NEU - 1.50
How can the functional status in patient with cerebrovascular disease be evaluated?
A) with Mathew Scale
B) with Barthel index
C) with Canadian Stroke Scale
D) with Orgogozo Scale
E) with combined use of Unified and Motor Score Scales

A

ANSWER
B) with Barthel index

EXPLANATION
The change of the functional status in patient with cerebrovascular disease can be evaluated by the Barthel scale.

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49
Q

NEU - 1.51
Mechanisms involved in regulation of cerebral blood circulation:
1) neurogenic regulation
2) metabolic regulation
3) cerebral autoregulation
4) no-reflow phenomenon

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

A

ANSWER
A) 1st, 2nd and 3rd answers are correct

EXPLANATION
Mechanisms involved in regulation of cerebral blood circulation include: neurogenic regulation, metabolic regulation and cerebral autoregulation.

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50
Q

NEU - 1.52
The following(s) play(s) important role in development of stroke:
1) occlusion of external carotid artery
2) hemorheologic changes
3) lack of development of trigeminal primitive artery
4) disturbance of microcirculation

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

A

ANSWER
C) 2nd and 4th answers are correct

EXPLANATION
Disturbances of microcirculation, slowing of blood flow play an important role in development of stroke, and are influenced by different hemorheological parameters, as total blood and plasma viscosity, hematocrit, plasma fibrinogen level, deformability of red blood cells, degree of polymorphonuclear leukocyte aggregation, etc.

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51
Q

NEU - 1.54
What are the non-modifiable risk factors for stroke?
1) stress
2) TIA
3) alcoholism
4) left ventricular hypertrophy

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

A

ANSWER
C) 2nd and 4th answers are correct

EXPLANATION
Non-modifiable risk factors for stroke include (but not limited to): TIA, left ventricular hypertrophy, previous myocardial infarction, peripheral vascular disease, age, gender.

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52
Q

NEU - 1.55
What are the modifiable risk factors for stroke?
1) previous stroke
2) myocardial infarct
3) peripherial artery disease
4) drug consumption

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

A

ANSWER
D) only 4th answer is correct

EXPLANATION
Modifiable stroke risk factors include (but not limited to): drug use, alcohol consumption, smoking, obesity.

53
Q

NEU - 1.56
After blood vessel wall damage, which mechanisms play a role in coagulation?
1) adhesion
2) aggregation
3) release reaction
4) platelet activation

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

A

ANSWER
E) all of the answers are correct

EXPLANATION
After blood vessel wall damage, platelets stick to the collagen fibers and become activated. Glycoprotein Ib receptor on the surface of activated platelets bind von Willenbrand factor (adhesion). Adhesion of platelets is followed by further platelet-to-platelet adhesion (aggregation) in the presence of fibrinogen and fibronectin, but another platelet receptor, the glycoprotein IIb / IIIa receptor is also involved. The release of the active substances stored in the platelet granules strengthens the process. Thrombocyte activation also triggers prostaglandin synthesis, thromboxane A2 is synthesized from arachidonic acid, resulting in additional platelet aggregation and vasoconstriction.

54
Q

NEU - 1.57
Which biochemical changes are typical in acute ischemic lesion?
1) NAD / NADH elevation
2) lactic acid elevation
3) oxygen release in tissue decreases as compensation
4) pH decrease

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

A

ANSWER
C) 2nd and 4th answers are correct

EXPLANATION
The biochemical changes in acute ischemic lesion: NADH increases within seconds, NAD / NADH ratio decreases, the decreasing partial pressure of oxygen is compensated by increased oxygen release in the brain tissue. Lactic acid elevates within 1 minute after the ischemia caused by vessel occlusion. Intracellular and tissue pH decreases. Intracellular acidosis is one of the important causes of ischemic neuronal damage.

55
Q

NEU - 1.58
The diaschisis could occur:
1) in the contralateral hemisphere
2) in the ipsilateral putamen, in case of frontal lesion
3) in the contralateral cerebellum
4) in the brainstem

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

A

ANSWER
B) 1st and 3rd answers are correct

EXPLANATION
In hemispheric damage diaschisis (loss of function in regions of the brain being in connection with a distant, impaired brain area) may occur in the contralateral brain hemisphere and in the contralateral cerebellar hemisphere.

56
Q

NEU - 1.59
Consequence(s) of subarachnoid haemorrhage:
1) vasospasm, leading to secondary ischemic damage
2) diaschisis effect
3) nonresorptive hydrocephalus
4) chronic subdural bleeding

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

A

ANSWER
B) 1st and 3rd answers are correct

EXPLANATION
As a consequence of subarachnoid haemorrhage, vasospasm may develop in 15-45% of patients due to release of thromboxane, free radicals, serotonin etc. from the blood. Vasospasm usually appears 4-12 days after bleeding, and may lead to secondary ischemic damage. Other consequence of subarachnoid bleeding is inhibition of CSF circulation resulting in non-resorptive hydrocephalus.

57
Q

NEU - 1.60
Characteristics of Transient Ischemic Attack (TIA):
1) 10% of cerebrovascular diseases
2) in half the cases, the symptoms last for less than 30 minutes
3) in these patients the rate of myocardial infarction is high
4) with CT scan, lacunar infarction rate is above 50%

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

A

ANSWER
A) 1st, 2nd and 3rd answers are correct

EXPLANATION
Approximately 10% of all cerebrovascular diseases is transient ischemic attack (TIA). Symptoms develop very rapidly, but rarely last longer than 1 hour, and in half the cases last less than 30 minutes. There is a high rate of myocardial infarction among patients with TIA. The incidence of annual stroke after TIA is 2-8%.

58
Q

NEU - 1.61
Possible causes of subarachnoid hemorrhage:
1) rupture of bridging veins
2) cerebral contusion
3) immunogenic vasculitis
4) rupture of arteriovenous malformation

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

A

ANSWER
C) 2nd and 4th answers are correct

EXPLANATION
Intracranial aneurysm rupture is the most common cause of subarachnoid haemorrhage. However, blood also gets to the subarachnoid space in cases of cerebral contusion and rupture of arteriovenous malformation. Moreover, brain parenchyma bleeding breaking into the brain ventricle(s) causes subarachnoid haemorrhage as well

59
Q

NEU - 1.62
Possible causes of intraparenchymal hemorrhage:
1) cocaine, amphetamine abuse
2) leukaemia and other hematological diseases
3) hemostasis disorders
4) bleeding of primary brain tumor (glioblastoma multiforme)

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

A

ANSWER
E) all of the answers are correct

EXPLANATION
Hypertension is the most important risk factor for cerebral hemorrhage. However, other causes may also contribute to cerebral hemorrhage, including cocaine-, or amphetamine abuse (leads to high blood pressure and vessel wall injury), leukemia and other hematological disorders (result in coagulation disorder and low platelet count), various coagulopathies, overdose of anticoagulants, bleeding in primary brain tumors (glioblastoma multiforme) or in cerebral metastases (melanoma malignum, etc.).

60
Q

NEU - 1.63
Possible causes of lacunar infarction:
1) polycythemia vera
2) Heubner arteritis
3) microatheroma
4) microembolisation

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

A

ANSWER
E) all of the answers are correct

EXPLANATION
Lacunar infarction is caused by occlusion of penetrating small arteries. The most common causes of lacunar infarction are polycythemia vera (disturbance of microcirculation), Heubner arteritis, microatheroma, microembolisation, lipohyalinosis and fibrinoid necrosis of the vessel wall.

61
Q

NEU - 1.64
Symptoms of hypertensive encephalopathy:
1) epileptic seizures
2) vomiting
3) disturbance of consciousness
4) cerebral edema

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

A

ANSWER
E) all of the answers are correct

EXPLANATION
Hypertensive encephalopathy is characterized by severe elevation of blood pressure, cerebral edema due to disturbance of cerebral autoregulation, general and focal symptoms of increased intracranial pressure, vomiting, and occasionally disturbance of consciousness and epileptic seizures.

62
Q

NEU - 1.65
Symptoms caused by occlusion of the inferior branches of middle cerebral artery:
1) contralateral hemianopsia, rarely quadrant anopsia
2) Wernicke- (sensory) aphasia in case of lesion in the dominant hemisphere
3) contralateral transient or mild faciobrachial paresis
4) motor (Broca-) aphasia in case of lesion in the dominant hemisphere

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

A

ANSWER
A) 1st, 2nd and 3rd answers are correct

EXPLANATION
The inferior branches of the middle cerebral artery (MCA) supply the inferior part of the parietal lobe and the superior gyrus of the temporal lobe. Symptoms resulted from occlusion of the inferior branches of MCA can be understood from the functions of the damaged anatomical structures: contralateral hemianopsia or rarely quadrant-anopsia, Wernicke (sensory) aphasia, conductive aphasia, ideomotor apraxia, rarely Gerstmann syndrome in case of lesion in the dominant hemisphere. Contralateral motor symptoms are mild (transient or mild faciobrachial paresis). In case of damage in the non-dominant hemisphere, mild contralateral faciobrachial paresis may be associated with anosognosia, prosopagnosia, dressing and constructive apraxia.

63
Q

NEU - 1.66
Characteristic clinical features of the medial medullary lesion (Jackson-syndrome):
1) ipsilateral peripheral hypoglossal lesion
2) contralateral hemiparesis
3) the syndrome is caused by occlusion of the anterior spinal artery and paramedian arteries
4) contralateral tactile and proprioceptive hypesthesia

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

A

ANSWER
E) all of the answers are correct

EXPLANATION
Jackson’s (medial medulla oblongata) syndrome is caused by occlusion of the anterior spinal artery and the paramedian arteries. The symptoms can be understood from the function of the damaged area: ipsilateral peripheral hypoglossal lesion, contralateral hemiparesis (sparing the face). Tactile and proprioceptive hypesthesia may also develop on the contralateral side of the body.

64
Q

NEU - 1.67
Characteristic clinical features of the basilar artery occlusion:
1) locked-in syndrome
2) severe gnostic dysfunction
3) sudden onset of coma, tetra-pyramidal signs
4) apraxia

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

A

ANSWER
B) 1st and 3rd answers are correct

EXPLANATION
Sudden occlusion of basilar artery is often incompatible with life. Coma, tetrapyramidal symptoms, bilateral motor and sensory dysfunctions, as well as various cerebellar and intracranial nerve lesions can also be found. When the occlusion is before the bifurcation of the basilar artery, bilateral occipital lobe lesions develop with cortical blindness, or visualis agnosia. Basilar artery occlusion may cause locked-in syndrome as well, which usually occurs when the base of the pons is damaged. In this case the patient is alert, tetraplegic, detects different stimuli, however, because the motor innervation of the speech is also impaired, the patient can only communicate with eye closure or vertical eye movements.

65
Q

NEU - 1.68
Clinical features of the lateral medullary lesion (Wallenberg syndrome):
1) dysphagia, dysarthria
2) vertigo, nystagmus
3) algetic- and thermo-hypesthesia on the ipsilateral face and contralateral body
4) Horner’s triad on the ipsilateral side of the lesion

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

A

ANSWER
E) all of the answers are correct

EXPLANATION
Wallenberg (lateral oblongata) syndrome is caused by occlusion of the posterior inferior cerebellar artery. Symptoms include vertigo, nystagmus, gait ataxia, diplopia, dysphagia, dysarthria, ipsilateral Horner triad, and algetic and thermohypesthesia on the ipsilateral face and on the contralateral body side.

66
Q

NEU - 1.69
Clinical features of the thalamic lesion:
1) hemihypaesthesia with hemihyperkinesia
2) the basic joints are in flexion position, the interphalangeal joints are in extension postion
3) hyperpathy -burning, shooting pain that is difficult to localise, occurs in attacks and can hardly be influenced by medicines
4) Millard–Gubler syndrome

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

A

ANSWER
A) 1st, 2nd and 3rd answers are correct

EXPLANATION
Since thalamus is related both anatomically and operationally to the hemispherial cortex, and all the afferent systems switch over in the thalamus, thalamic lesion may have several consequences. The ventrolateral nucleus is closely related to the cerebellum, therefore its damage causes hemihypesthesia with hemihyperkinesis (choreoathetosis-like involuntary movements). The so-called “thalamic hand” is also a typical symptom in case of thalamus injury: the basic joints are in flexion while the interphalangeal joints are in extension. Damage of the sensory nuclei often causes “central” or thalamic pain, which can hardly be influenced by medicines. Thalamic pain is characterised by burning, shooting pain that is difficult to localise and occurs in attacks. Thalamus plays a role in the regulation of consciousness as well. Furthermore, thalamus lesion may provoke focal epileptic seizure, and may also cause dementia.

67
Q

NEU - 1.70
The following symptoms are always characteristic for central type of lesion:
1) increased abdominal reflexes
2) increased deep reflexes with pyramidal signs
3) anarthria
4) spastic muscle tone

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

A

ANSWER
C) 2nd and 4th answers are correct

EXPLANATION
Increased deep-reflexes with pyramidal signs and spastic muscle tone always refer to a central type of lesion.

68
Q

NEU - 1.71
Which symptom is not characteristic for the Gerstmann syndrome?
1) left-right confusion
2) finger agnosia
3) acalculia
4) alexia

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

A

ANSWER
D) only 4th answer is correct

EXPLANATION
Gerstmann’s syndrome is characterized by left-to-right confusion, finger agnosia, agraphia and acalculia.

69
Q

NEU - 1.72
In cases of cerebral venous (sinus) thrombosis, the following symptoms may develop:
1) headache
2) focal or generalized epileptic seizures
3) papilla edema
4) disturbance of consciousness

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

A

ANSWER
E) all of the answers are correct

EXPLANATION
Symptoms of cerebral venous/sinus thrombosis depend on the size and localisation of the occluded vein, the extent and progression of thrombus formation, as well as the nature of the thrombotic process. However, there are some general symptoms which if occur together refer to sinus/venous thrombosis. These symptoms are headache, focal or generalized epileptic seizures, papilla edema, disturbance of consciousness, and sudden onset of focal neurological symptoms.

70
Q

NEU - 1.73
Possible causes of cerebral venous (sinus) thrombosis:
1) use of oral contraceptive pills
2) purulent otitis or sinusitis (purulent middle ear infection, or purulent infection of paranasal sinuses)
3) postpartum septic state
4) hypertension

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

A

ANSWER
A) 1st, 2nd and 3rd answers are correct

EXPLANATION
The cerebral sinus thrombosis can be caused by use of oral contraceptive pills, purulent otitis, purulent sinusitis and postpartum septic state.

71
Q

NEU - 1.74
The most important symptoms of cerebral aneurysm rupture:
1) sudden onset of a severe, throbbing nuchal or frontal headache
2) gradually developing headache, dizziness
3) neck stiffness
4) focal neurological signs are already present at the onset of the disease

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

A

ANSWER
B) 1st and 3rd answers are correct

EXPLANATION
The most important symptoms of intracranial aneurysm rupture are the suddenly developed, very-very severe headache in the nuchal or frontal region and the neck stiffness.

72
Q

NEU - 1.75
What can cause septic aneurysm in the middle cerebral artery?
1) dissection
2) bacterial pneumonia
3) viral infection
4) endocarditis

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

A

ANSWER
C) 2nd and 4th answers are correct

EXPLANATION
Bacterial pneumonia and endocarditis can cause septic aneurysm on the middle cerebral artery.

73
Q

NEU - 1.76
Arteriovenous malformation is suspected in case of the following symptoms and complaints:
1) epileptic seizures
2) supraorbital or occipital bruits
3) headache
4) subarachnoideal hemorrhage

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

A

ANSWER
E) all of the answers are correct

EXPLANATION
If headache and focal or secondarily generalized seizures develop and bruit can be heard in the supraorbital or occipital region, arteriovenous malformation is suspected. In that case the source of the subarachnoidal hemorrhage is probably the vascular malformation.

74
Q

NEU - 1.77
Intracerebral hemorrhage is associated with poor prognosis if:
1) the patient is over 70 years of age
2) concomitant cardiopulmonal disease is present
3) severe disturbance of consciousness, i.e. coma develops
4) there is a wide, non-reactive pupil on the side of the lesion

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

A

ANSWER
E) all of the answers are correct

EXPLANATION
The intracerebral hemorrhage is associated with poor prognosis if the patient is over 70 years, has concomitant cardiopulmonal disease, severe disturbance of consciousness, i.e. coma develops, and wide, non-reactive pupil can be seen on the side of the lesion.

75
Q

NEU - 1.78
Intracerebral hemorrhage has extremely poor prognosis if the following abnormalities can be seen on cranial CT scan:
1) hemorrhage ruptures into the ventricles, the fourth ventricle is compressed
2) putaminal hemorrhage with huge midline shift
3) secondary pontine hemorrhage
4) small thalamic hemorrhage with no rupture into the ventricle and lacunar infarctions on the contralateral side to the lesion

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

A

ANSWER
A) 1st, 2nd and 3rd answers are correct

EXPLANATION
Intracerebral hemorrhage has extremely poor prognosis if a large intracerebral hemorrhage is associated with a mass effect, intraventricular bleeding, compression of the fourth ventricle or secondary pontine hemorrhage.

76
Q

NEU - 1.79
Which of the following statements is (are) typical for intracranial hemorrhage?
1) appears mostly daytime, during physical activity
2) appears during sleep, symptoms are recognized after waking up
3) sudden onset, rapid, progressive disturbance of consciousness
4) TIA in the past medical history

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

A

ANSWER
B) 1st and 3rd answers are correct

EXPLANATION
Intracranial hemorrhage usually appears daytime, during physical activity. Sudden onset is typical, and in case of a large, space-occupying bleeding rapid, progressive disturbance of consciousness may also develop at the early phase of the disease.

77
Q

NEU - 1.80
Which of the following diseases can be diagnosed by blood pressure measurement?
1) stenosis of the internal carotid artery
2) aortic coarctation
3) TIA
4) subclavian steal syndrome

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

A

ANSWER
C) 2nd and 4th answers are correct

EXPLANATION
Aortic coarctation and subclavian steal syndrome could be diagnosed with blood pressure measurement.

78
Q

NEU - 1.81
Signs of cerebral ischemia with cranial CT scan:
1) fogging phenomenon
2) hypodensity
3) gyral contrast enhancement
4) usually there is no abnormality in the first hours of the ischemic event

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

A

ANSWER
E) all of the answers are correct

EXPLANATION
In cerebral ischemia usually there is no abnormality on cranial CT scan in the first hours of the ischemic event. After 6-8 hours hyperacute ischemic signs could be seen. After 1-2 days clear hypodensity develops in the infracted territory. The hypodensity is mild and has blurred margin in the beginning, however, later it becomes demarcated. Contrast enhancement occurs in the subacute stage, and usually begins at the end of the first week of stroke. Contrast enhancement reaches its maximum at week 2 and 3, and fades over the following weeks. Contrast enhancement usually shows a gyriform pattern on the surface of the brain, but may also occur in the deep parenchyma. It is likely due to a combination of blood brain barrier breakdown, neovascularisation and impaired autoregulation. This phenomenon was previously referred to as ‘luxury perfusion’. Two-three weeks after ischemic stroke, the cortex may show near-normal density (isodense) on native CT, it is the so-called fogging phenomenon. Fogging phenomenon is explained by macrophage invasion, proliferation of capillaries, and sometimes extravasation of blood cells through damaged vessel walls. If in doubt, the administration of IV contrast will demarcate the region of infarction at this stage. Later (week 5-6) the residual swelling passes, and gliosis develops resulting in a region of low density with negative mass effect.

79
Q

NEU - 1.82
Cranial MRI is suggested in the following cases:
1) brainstem stroke symptoms
2) if cavernoma is suspected
3) suspected intracerebral haemorrhage in the early phase of pregnancy
4) in subarachnoidal hemorrhage to examine the cerebral glucose metabolism

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

A

ANSWER
A) 1st, 2nd and 3rd answers are correct

EXPLANATION
Cranial MRI is suggested to detect cavernoma, in case of brainstem stroke symptoms or when intracerebral hemorrhage is suspected and ionizing radiation is contraindicated (i.e. first trimester of pregnancy).

80
Q

NEU - 1.83
Indication of cerebral SPECT in stroke:
1) to assess cerebral vascular reserve capacity with Diamox-test
2) to detect intracranial hemorrhage in the early phase
3) to examine diaschisis effect and assess prognosis
4) to detect aneurysms, if angiography is negative

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

A

ANSWER
B) 1st and 3rd answers are correct

EXPLANATION
Cerebral SPECT is able to detect perfusion deficit and functional abnormality in the early phase of the ischemic event, even when cranial CT and cranial MRI cannot detect abnormality. It can be used to measure cerebral vascular reserve capacity (Diamox test) or to study the diaschisis effect. It is suitable to assess the efficacy of the treatment and define prognosis.

81
Q

NEU - 1.84
MR-angiography (MRA) is suitable to:
1) assess the degree of large vessel stenosis
2) confirm large vessel (carotid, vertebral, basilar artery) occlusion
3) detect and follow-up aneurysms
4) diagnose arteriovenous malformation (AVM)

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

A

ANSWER
E) all of the answers are correct

EXPLANATION
MR-angiography is able to localise AVM, it can show the relation of the vessels to other cerebral structures, and it can visualize the feeding artery and the draining vein. Large artery occlusion and aneurysms are also visible with MRA. Degree of large vessel stenosis can be assessed by contrast enhanced MRA.

82
Q

NEU - 1.85
Indication of cerebral angiography:
1) in urgent cases, when angiography helps in clinical decisions and treatments (e.g. subarachnoideal hemorrhage, local thrombolysis in acute large vessel occlusion)
2) in cerebral contusion to localize the source of the bleeding
3) to plan intra-arterial intervention like intraluminal angioplasty
4) to localise sub- and epidural hematoma

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

A

ANSWER
B) 1st and 3rd answers are correct

EXPLANATION
1. and 3. statements are true. Sub- and epidural hematomas are diagnosed with noncontrast cranial CT and there is neither indication for angiography in cerebral contusion.

83
Q

NEU - 1.87
Lacunar infarcts are seen by cranial CT in a young female patient in the MCA territory. MRI confirms the vascular origin of the lesions. The patient has unremarkable medical history, with no heart disease. Which diagnostic steps could be useful during the work-up?
1) transosephageal echocardiography (TEE) to assess the heart and the ascendent aorta
2) lactate test, if it is pathological muscle biopsy to rule out mitochondrial encephalopathy (MELAS)
3) detailed immunological tests to rule out immune mediated vasculitis
4) screening tests for haemostasis to rule out thrombophilia

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

A

ANSWER
E) all of the answers are correct

EXPLANATION
All four statements are true.

84
Q

NEU - 1.88
Which are the major psychological factors that hinder the effective rehabilitation after stroke?
1) emotional lability
2) anxiety, anger
3) avoiding, aggressive behavior
4) mania

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

A

ANSWER
A) 1st, 2nd and 3rd answers are correct

EXPLANATION
The most important psychological characteristics that hinder the early rehabilitation after stroke are emotional lability, dysthimia, anxiety, anger and aggressive behavior. Euphoria is rare.

85
Q

NEU - 1.90
Possible neurological complication of cardiac surgery:
1) myelon lesion
2) epileptic seizure
3) extrapyramidal symptoms
4) cortical blindness

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

A

ANSWER
E) all of the answers are correct

EXPLANATION
The rate of neurological consequences of heart surgery is increasing with the age of the patient. The most important factors are intraoperative hypotension and embolic stroke. The most frequent complications are: amnesia, para-, hemi-, tetraparesis, cortical blindness, epileptic seizures, extrapyramidal symptoms, visual agnosia. The frequency of myelon lesion is not rare, hypotonic paraparesis, sensory abnormality, urinary retention are characteristic. Prognosis of the spinal symptoms are worse than the cerebral ones.

86
Q

NEU - 1.92
In which of the following case(s) should carotid duplex ultrasound examination be ordered?
1) after TIA
2) in case of cerebral haemorrhage to predict the prognosis
3) if auscultation reveals murmur over the carotid arteries
4) on the 7. day after subarachnoid bleeding to check for vasospasm

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

A

ANSWER
B) 1st and 3rd answers are correct

EXPLANATION
Carotid duplex ultrasound examination should be ordered after TIA, in case of ichemic stroke, and if murmur can be heard above the carotid arteries. Moreover, carotid duplex is also used to follow up the degree of carotid stenosis and to check whether restenosis develops after endarterectomy or carotid stenting.

87
Q

NEU - 1.93
Transcranial Doppler ultrasound (TCD) examination has to be ordered:
1) to monitor vasospasm after subarachnoid bleeding
2) for emboli detection, if cardiogen stroke is suspected
3) to determine the cerebrovascular reserve capacity with acetazolamide test before carotid endarterectomy
4) in case of vacular lesion in the territory of the middle cerebral artery

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

A

ANSWER
E) all of the answers are correct

EXPLANATION
The indications of transcranial Doppler ultrasound (TCD) examination: to monitor vasospasm after subarachnoidal bleeding to examine the flow parameters in intracranial arteries in case of ischemic stroke to detect microemboli, if cardiogenic stroke or unstable carotid plaque is suspected to determine the cerebrovascular reserve capacity with use of acetazolamide test or breath-holding test before carotid surgery

88
Q

NEU - 1.94
Which plaque type(s) is (are) considered as source of embolisation on B-mode ultrasound image?
1) exulcerated
2) haemorrhagic
3) heterogeneous
4) homogeneous

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

A

ANSWER
A) 1st, 2nd and 3rd answers are correct

EXPLANATION
Regarding the B mode ultrasound imaging, exulcerated, hemorrhagic and heterogeneous plaques are considered as source of embolisation.

89
Q

NEU - 1.95
Therapy in secondary stroke prevention (daily intake):
1) 100-325 mg acetylsalicylic acid
2) 75 mg clopidogrel
3) 2x25 mg acetylsalicylic acid + 2x200 mg dipyridamole
4) 3x400 mg pentoxifylline

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

A

ANSWER
A) 1st, 2nd and 3rd answers are correct

EXPLANATION
Therapy in secondary stroke prevention (daily intake): orally 100-325 mg acetylsalicylic acid, or 1x75 mg clopidogrel, or 2x25 mg acetylsalicylic acid + 2x200 mg dipyridamole. Previously, 2x250 mg ticlopidine was also used, however, this drug is not recommended nowadays because ticlopidine was shown to cause life-threatening hematological adverse reactions (neutropenia/agranulocytosis, thrombotic thrombocytopenic purpura and aplastic anemia) in some patients. (Certainly, in case of cardiogenic stroke, anticoagulant treatment is recommended instead of antiplatelet drugs.)

90
Q

NEU - 1.97
Which of the following examination(s) is (are) needed if cardiogenic stroke is suspected:
1) detailed haematologic examination
2) transthoracic echocardiography (TTE)
3) blood pressure monitoring for 24 hours
4) transesophageal echocardiography (TEE), if TTE couldn’t detect the source of embolisation and if the origin of stroke was unknown in young patient

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

A

ANSWER
C) 2nd and 4th answers are correct

EXPLANATION
In case of suspicion of cardiogenic stroke, detailed cardiologic examination is needed, including transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) if TTE couldn’t identify the source of embolisation and if the origin of stroke was unknown in young patients. Although blood pressure monitoring does not help, Holter ECG is highly recommended if cardiogenic stroke is suspected.

91
Q

NEU - 1.98
Indication(s) for carotid endarteriectomy:
1) after TIA, if the stenosis of the internal carotid artery is larger then 70% measured by angiography
2) if the internal carotid artery is occluded on either side
3) in case of repeated or crescendo TIA on the side of the exulcerated plaque or floating thrombus
4) in case of acute stroke

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

A

ANSWER
B) 1st and 3rd answers are correct

EXPLANATION
Indication(s) for carotid endarteriectomy: after TIA, if the stenosis of the internal carotid artery (ICA) is larger then 70% showed by angiography. in case of repeated TIAs or after crescendo TIA if exulcerated plaque or floating thrombus is found in the ipsilateral internal carotid artery after hemispheric minor stroke, if the patient’s symptoms are not too severe, the patient’s condition is stable and there’s significant ICA stenosis (>70%). in case of symptom-free ICA stenosis, there is no absolute indication for carotid reconstruction. However, exhausted cerebrovascular reserve capacity or presence of microembolus signals in the ipsilateral MCA is indication for surgery in these patients as well. (In symptom-free patients with preserved cerebrovascular reserve capacity or without microembolic signals in the ipsilateral MCA, however, carotid endarterectomy is not indicated or can only be considered with relative indication, if the ICA stenosis is very severe + the vascular surgeon’s morbidity and mortality rate is under 3% + the patient’s life expentancy is at least 5 years + the patient prefers surgery to conservative treatment after giving detailed information about the advantages and disadvantages of the treatments. In every case, the patient should be operated by a skillful vascular surgeon team with low morbidity and mortality data.

92
Q

NEU - 1.99
Vascular surgery is NOT suggested in the following case(s):
1) unilateral stenosis of the vertebral artery
2) significant internal carotid artery stenosis and contralateral internal carotid artery occlusion in case of symptomatic stenosis
3) cranial CT showed large acute ischemic lesion
4) symptomatic, 90% stenosis of the internal carotid artery

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

A

ANSWER
B) 1st and 3rd answers are correct

EXPLANATION
Vascular surgery is contraindicated in acute stroke (cranial CT showed large acute ischemic lesion), or if there’s chronic carotid artery occlusion. The surgical treatment of unilateral stenosis of the vertebral artery is neither indicated.

93
Q

NEU - 1.100
Anticoagulant treatment is NOT suggested in the following case(s):
1) gastrointestinal ulcer
2) dementia, bad compliance
3) bacterial endocarditis
4) dilated cardiomyopathy

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

A

ANSWER
A) 1st, 2nd and 3rd answers are correct

EXPLANATION
Anticoagulant treatment is contraindicated in case of dementia, bad compliance of the patient, gastrointestinal ulcer, bacterial endocarditis, untreatable hypertension, diabetic retinopathy, and bleeding disorders (coagulopathies).

94
Q

NEU - 1.101
Anticoagulant treatment is indicated in the following case(s):
1) after myocardial infarction, especially with aneurysm formation
2) after arteficial heart valve implantation
3) coexistence of atrial fibrillation and high stroke risk
4) tachycardia

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

A

ANSWER
A) 1st, 2nd and 3rd answers are correct

EXPLANATION
Anticoagulant treatment should be considered for prevention of ichemic stroke in cardiogenic stroke. Anticoagulant treatment is indicated after implantation of arteficial heart valve, in nonischemic dilated cardiomyopathy, in coexistence of atrial fibrillation and high stroke risk, and for a certain period after myocardial infarction (especially with aneurysm formation). In other cases with low risk of stroke (mitral valve prolapse, mitral annular calcification, etc.) anticoagulation is usually not indicated.

95
Q

NEU - 1.102
In case of anticoagulation treatment, the risk of bleeding is increased in the following case(s):
1) simultaneous treatment with carbamazepine
2) alcoholic hepatopathy
3) simultaneous administration of acetylsalicylic acid, or ticlopidine, or clopidogrel
4) extremely high blood pressure

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

A

ANSWER
E) all of the answers are correct

EXPLANATION
In case of anticoagulation treatment, the risk of bleeding may be increased due to drug interactions. E.g. simultaneous use of oral anticoagulants with carbamazepine, acetylsalicylic acid, ticlopidine or clopidogrel, some oral antibiotics, anabolic steroids may elevate the risk of bleeding. Furthermore, alcoholic hepatopathy or other coagulation disorders, as well as extremely high blood pressure may also increase the bleeding risk.

96
Q

NEU - 1.103
Most important complication(s) of cerebrovascular diseases:
1) deep vein thrombosis of the lower extremities, pulmonary embolism
2) bronchopneumonia
3) bed sore (decubitus)
4) urocystitis, pyelonephritis

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

A

ANSWER
E) all of the answers are correct

EXPLANATION
The most important complications of cerebrovascular diseases are deep vein thrombosis of the paretic lower extremity, pulmonary embolism, bronchopneumonia (because the lying position), bronchitis, bed sore, and myocardial infarction. Decubitus (bed sore) develops on the skin as a result of pressure. Uroinfections (urocystitis and pyelonephritis) may be caused by use of urinary catheter.

97
Q

NEU-1.104-1.108
Match the following arteries and the statements!
A) subclavian artery
B) posterior communicating artery
C) basilar artery
D) superficial temporal artery
E) superior cerebellar artery

NEU - 1.104 - its occlusion causes ipsilateral limb and gait ataxia

NEU - 1.105 - its aneurysm may cause ipsilateral oculomotor nerve lesion

NEU - 1.106 - its stenosis may cause subclavian steal syndrome

NEU - 1.107 - the acute occlusion of this artery causes coma and bilateral pyramidal signs

NEU - 1.108 - this artery is swollen, painful and tender in giant cell arteriitis

A

ANSWER
NEU - 1.104 - its occlusion causes ipsilateral limb and gait ataxia - E)

NEU - 1.105 - its aneurysm may cause ipsilateral oculomotor nerve lesion - B)

NEU - 1.106 - its stenosis may cause subclavian steal syndrome - A)

NEU - 1.107 - the acute occlusion of this artery causes coma and bilateral pyramidal signs - C)

NEU - 1.108 - this artery is swollen, painful and tender in giant cell arteriitis - D)

98
Q

NEU-1.109-1.113
Make pairs!
A) thrombosis of cavernous sinus
B) thrombosis of superior sagittal sinus
C) occlusion of the transvere sinus
D) damage of the middle meningeal artery
E) damage of the bridging veins

NEU - 1.109 - it causes subdural hematoma

NEU - 1.110 - the soft tissue over the mastoid process is swollen and focal epileptic seizure, lesion of the IX-XI. cranial nerves, disturbance of consciousness might be present

NEU - 1.111 - it can causes epidural hematoma

NEU - 1.112 - scalp edema, symptoms of increased intracranial pressure, epileptic seizures, disturbance of consciousness, coma might be present

NEU - 1.113 - characteristic symptoms are paresis of the extraocular muscles, chemosis, retrobulbar pain

A

ANSWER
NEU - 1.109 - it causes subdural hematoma - E)

NEU - 1.110 - the soft tissue over the mastoid process is swollen and focal epileptic seizure, lesion of the IX-XI. cranial nerves, disturbance of consciousness might be present - C)

NEU - 1.111 - it can causes epidural hematoma - D)

NEU - 1.112 - scalp edema, symptoms of increased intracranial pressure, epileptic seizures, disturbance of consciousness, coma might be present - B)

NEU - 1.113 - characteristic symptoms are paresis of the extraocular muscles, chemosis, retrobulbar pain - A)

99
Q

NEU-1.114-1.118
Make pairs!
A) quit smoking, diet, treatment of hypertension
B) administration of clopidogrel, or acetylsalicyclic acid
C) endarterectomy
D) administration of heparin and antiepileptic drugs
E) surgical intervention: partial resection, shunt implantation

NEU - 1.114 - It is used for secundary stroke prevention in case of lacunar stroke

NEU - 1.115 - Treatment of superior sagittal sinus thrombosis

NEU - 1.116 - Treatment of space-occupying cerebellar hemorrhage

NEU - 1.117 - These belong to primary stroke prevention

NEU - 1.118 - Treatment of significant internal carotid artery stenosis

A

ANSWER
NEU - 1.114 - It is used for secundary stroke prevention in case of lacunar stroke - B)

NEU - 1.115 - Treatment of superior sagittal sinus thrombosis - D)

NEU - 1.116 - Treatment of space-occupying cerebellar hemorrhage - E)

NEU - 1.117 - These belong to primary stroke prevention - A)

NEU - 1.118 - Treatment of significant internal carotid artery stenosis - C)

100
Q

NEU-1.119-1.123
Make pairs!
A) there is no abnormality in CT scans
B) hyperdens lesion in the territory of basal ganglia and in the lateral ventricle can be seen in CT scans
C) there is extended cortical hypodens lesion with small, patchy hyperdens areas in CT scans
D) hypodens area with sharp border and dilation of the ventricle and the subarachnoid space next to the lesion
E) hypodensity in the periventricular white matter, cortical atrophy

NEU - 1.119 - hypertension induced destructive parenchymal cerebral hemorrhage that ruptured into the ventricules

NEU - 1.120 - The CT examination was performed after the onset of ischemic stroke within 2 hours

NEU - 1.121 - Picture of a chronic, extended cerebral infarction

NEU - 1.122 - ischemic lesion with hemorrhagic transformation (picture of hemorrhagic infarction)

NEU - 1.123 - subcortical arteriosclerotic encephalopathy (Binswanger)

A

ANSWER
NEU - 1.119 - hypertension induced destructive parenchymal cerebral hemorrhage that ruptured into the ventricules - B)

NEU - 1.120 - The CT examination was performed after the onset of ischemic stroke within 2 hours - A)

NEU - 1.121 - Picture of a chronic, extended cerebral infarction - D)

NEU - 1.122 - ischemic lesion with hemorrhagic transformation (picture of hemorrhagic infarction) - C)

NEU - 1.123 - subcortical arteriosclerotic encephalopathy (Binswanger) - E)

101
Q

NEU-1.124-1.128
Match the symptoms with the site of the lesion
A) ideomotor apraxia
B) amusia
C) dysarthria
D) Gerstmann’s syndrome
E) Horner’s syndrome

NEU - 1.124 - caused by a lesion of the pole of the superior temporal gyrus

NEU - 1.125 - caused by bilateral damage of the corticobulbar fibers

NEU - 1.126 - caused by a lesion of the lateral part of the medulla, part of the Wallenberg’s syndrome

NEU - 1.127 - caused by damage of the left supramarginal gyrus in right-handed patients

NEU - 1.128 - caused by a lesion of the left angular gyrus

A

ANSWER
NEU - 1.124 - caused by a lesion of the pole of the superior temporal gyrus - B)

NEU - 1.125 - caused by bilateral damage of the corticobulbar fibers - C)

NEU - 1.126 - caused by a lesion of the lateral part of the medulla, part of the Wallenberg’s syndrome - E)

NEU - 1.127 - caused by damage of the left supramarginal gyrus in right-handed patients - A)

NEU - 1.128 - caused by a lesion of the left angular gyrus - D)

102
Q

NEU-1.129-1.133
Match the statements.
A) Speech disturbance and mild right sided hemiparesis developed and resolved within 3 minutes. On cranial CT, lacunar infarctions are seen on the right side.
B) Agraphia with alexia, acalculia, finger agnosia, lower quadrant anopsia evolved, and the symptoms resolved within 2 days.
C) Moderate hemiparesis developed in several hours in the patient admitted with mild left sided hemiparesis, next day hemiplegia evolved and the patient became somnolent and incontinent.
D) Right sided homonymous hemianopsia was detected at the beginning, and pronounced limb ataxia, latent hemiparesis was still present 4 weeks later.
E) Occasionally, the patient complained of severe headache and nausea, which relieved and reoccured, on fundoscopy spontaneous venous pulsation was missing, on the right side brisk deep tendon reflexes were found.

NEU - 1.129 - the clinical course may refer to completed stroke

NEU - 1.130 - transient ischemic attack (TIA)

NEU - 1.131 - the clinical course raises suspicion for cerebral tumor rather than stroke

NEU - 1.132 - the symptoms may refer to stroke in the dominant parietal lobe

NEU - 1.133 - the clinical course and syndrome are specific for progressing stroke

A

ANSWER
NEU - 1.129 - the clinical course may refer to completed stroke - D)

NEU - 1.130 - transient ischemic attack (TIA) - A)

NEU - 1.131 - the clinical course raises suspicion for cerebral tumor rather than stroke - E)

NEU - 1.132 - the symptoms may refer to stroke in the dominant parietal lobe - B)

NEU - 1.133 - the clinical course and syndrome are specific for progressing stroke - C)

103
Q

NEU - 1.134
The patient has to be transported to a stroke center when the symptoms of an acute stroke begin because high blood pressure has to be reduced immediately.
A) both the statement and the explanation are true and a causal relationship exists between them;
B) both the statement and the explanation are true but there is no causal relationship between them;
C) the statement is true, but the explanation is false;
D) the statement is false, but the explanation itself is true
E) both the statement and the explanation are false

A

ANSWER
C) the statement is true, but the explanation is false;

EXPLANATION
The patient has to be transported to a stroke center when the symptoms of an acute stroke begin, because the time window for reperfusion therapy is rather short. Immediate reduction of the elevated blood pressure is incorrect because it would decrease the cerebral perfusion pressure. Of course, high blood pressure reduction is needed in well-founded conditions (see above)

104
Q

NEU - 1.135
After transient ischemic attack the patient should undergo cerebrovascular checkup, because brain cancer can be in the backgroud of TIA-like symptoms.
A) both the statement and the explanation are true and a causal relationship exists between them;
B) both the statement and the explanation are true but there is no causal relationship between them;
C) the statement is true, but the explanation is false;
D) the statement is false, but the explanation itself is true
E) both the statement and the explanation are false

A

ANSWER
B) both the statement and the explanation are true but there is no causal relationship between them;

EXPLANATION
After transient ischemic attack the patient should undergo cerebrovascular checkup. Brain cancer can be in the backgroud of TIA-like symptoms. Both statements are true, but there is no connection.

105
Q

NEU - 1.136
If the patient is likely to have a brain haemorrhage, cranial MRI should always be done first, because CT cannot differentiate brain haemorrhage and brain ischemia.
A) both the statement and the explanation are true and a causal relationship exists between them;
B) both the statement and the explanation are true but there is no causal relationship between them;
C) the statement is true, but the explanation is false;
D) the statement is false, but the explanation itself is true
E) both the statement and the explanation are false

A

ANSWER
E) both the statement and the explanation are false

EXPLANATION
If the patient is likely to have a brain haemorrhage, usually cranial CT is the first choice (CT is less sensitive to movement artifacts, faster and cheaper, than MRI, and sensitive in brain haemorrhage), because CT can show the bleeding immediately after cerebral haemorrhage and therefore it is able to differentiate brain haemorrhage from ischemic stroke. (There is a growing evidence that MRI is as sensitive as CT to detect intracranial haemorrhage.)

106
Q

NEU - 1.137
For secunder stroke prevention acetylsalicilic acid (ASA) is used, because this medication always inhibits platelet aggregation in every patient.
A) both the statement and the explanation are true and a causal relationship exists between them;
B) both the statement and the explanation are true but there is no causal relationship between them;
C) the statement is true, but the explanation is false;
D) the statement is false, but the explanation itself is true
E) both the statement and the explanation are false

A

ANSWER
C) the statement is true, but the explanation is false;

EXPLANATION
For secunder stroke prevention acetylsalicilic acid is used, but this medication does not always inhibit platelet aggregation in every patients, because there are non-responding patients too. Non-responding patients can be recognised by a laboratory test and these patients can be treated by clopidogrel. However, it has not been clarified whether the lack of laboratory effectiveness correlates with clinical inefficiency.

107
Q

NEU - 1.138
Occipital lobe damage causes homonymous hemianopsia, because this symptom is present only in case of occipital lobe injury.
A) both the statement and the explanation are true and a causal relationship exists between them;
B) both the statement and the explanation are true but there is no causal relationship between them;
C) the statement is true, but the explanation is false;
D) the statement is false, but the explanation itself is true
E) both the statement and the explanation are false

A

ANSWER
C) the statement is true, but the explanation is false;

EXPLANATION
After occipital lobe damage homonymous hemianopsia is found, but this sypmtom can also be present in case of optic tract or temporal+parietal lobe (optic radiation) damage.

108
Q

NEU - 1.139
Transcranial colour-coded duplex ultrasound can detect the flow in the middle cerebral artery, because the temporal bone never hinders the transcranial Doppler examination.
A) both the statement and the explanation are true and a causal relationship exists between them;
B) both the statement and the explanation are true but there is no causal relationship between them;
C) the statement is true, but the explanation is false;
D) the statement is false, but the explanation itself is true
E) both the statement and the explanation are false

A

ANSWER
C) the statement is true, but the explanation is false;

EXPLANATION
The flow of the middle cerebral artery can already be examined with use of transcranial duplex ultrasound. Unfortunately the absence of temporal bone window does not allow the transcranial Doppler examination in about 10 % of the patients.

109
Q

NEU - 1.140
The occlusion of the external carotid artery usually does not cause neurological symptoms, because it has no collateral connection with the internal carotid artery.
A) both the statement and the explanation are true and a causal relationship exists between them;
B) both the statement and the explanation are true but there is no causal relationship between them;
C) the statement is true, but the explanation is false;
D) the statement is false, but the explanation itself is true
E) both the statement and the explanation are false

A

ANSWER
C) the statement is true, but the explanation is false;

EXPLANATION
The occlusion of the external carotid artery usually does not cause neurological symptoms. However, there is a collateral connection between the external and the internal carotid arteries.

110
Q

NEU - 1.141
Hemiparesis is always caused by the lesion in the internal capsule, because the damage of the corticospinal tract always causes central type of paresis.
A) both the statement and the explanation are true and a causal relationship exists between them;
B) both the statement and the explanation are true but there is no causal relationship between them;
C) the statement is true, but the explanation is false;
D) the statement is false, but the explanation itself is true
E) both the statement and the explanation are false

A

ANSWER
D) the statement is false, but the explanation itself is true

EXPLANATION
The damage of the corticospinal tract always causes central type of paresis. However, the corticospinal tract during its course can be damaged in several areas (not only in the internal capsule), therefore injuries at other sites can result hemiparesis as well.

111
Q

NEU - 1.142
In case of a sudden, twinge pain in the frontal and nuchal area during strain, rupture of an intracerebral aneurism should be suspected, because subarachnoidal bleeding could cause cardiac arrythmia.
A) both the statement and the explanation are true and a causal relationship exists between them;
B) both the statement and the explanation are true but there is no causal relationship between them;
C) the statement is true, but the explanation is false;
D) the statement is false, but the explanation itself is true
E) both the statement and the explanation are false

A

ANSWER
B) both the statement and the explanation are true but there is no causal relationship between them;

EXPLANATION
In case of a sudden, twinge pain in the frontal and nuchal areas during strain, intracerebral aneurysm rupture should be suspected. In addition to numerous early and later complications, subarachnoidal bleeding can cause cardiac arrythmia too. Both statements are true, however, there is no connection between them.

112
Q

NEU - 1.143
In case of post-stroke depression antidepressant drugs should be used, because depression can inhibit rehabilitation.
A) both the statement and the explanation are true and a causal relationship exists between them;
B) both the statement and the explanation are true but there is no causal relationship between them;
C) the statement is true, but the explanation is false;
D) the statement is false, but the explanation itself is true
E) both the statement and the explanation are false

A

ANSWER
A) both the statement and the explanation are true and a causal relationship exists between them;

EXPLANATION
In case of post-stroke depression antidepressant drugs should be used, because depression can inhibit the rehabilitation.

113
Q

NEU - 1.144
In case of patients with leukaemia, who have low platelet count, lumbar tap is not performed, because subarachnoidal bleeding may occur.
A) both the statement and the explanation are true and a causal relationship exists between them;
B) both the statement and the explanation are true but there is no causal relationship between them;
C) the statement is true, but the explanation is false;
D) the statement is false, but the explanation itself is true
E) both the statement and the explanation are false

A

ANSWER
A) both the statement and the explanation are true and a causal relationship exists between them;

EXPLANATION
In leukemic patients with low platelet count, lumbar tap is not performed, because subarachnoidal bleeding can happen. (Below 50 G/L platelet count the lumbar puncture is prohibited; moreover, lumbar tap can also be contraindicated if the platelet count is less than 100 G/L and there are other bleeding syptoms, like petechias, blood in the urine, retinal bleeding…)

114
Q

NEU - 1.145
In case of endocarditis lenta anticoagulation therapy is needed, because cerebral embolisation can develop.
A) both the statement and the explanation are true and a causal relationship exists between them;
B) both the statement and the explanation are true but there is no causal relationship between them;
C) the statement is true, but the explanation is false;
D) the statement is false, but the explanation itself is true
E) both the statement and the explanation are false

A

ANSWER
D) the statement is false, but the explanation itself is true

EXPLANATION
In case of endocarditis lenta cerebral embolisation can develop, but anticoagulation therapy is prohibited, because it can increase the chance of cerebral embolisation.

115
Q

NEU - 1.146
ECG monitoring in acute phase of stroke is necessary, because stroke may cause cardiac arrythmia.
A) both the statement and the explanation are true and a causal relationship exists between them;
B) both the statement and the explanation are true but there is no causal relationship between them;
C) the statement is true, but the explanation is false;
D) the statement is false, but the explanation itself is true
E) both the statement and the explanation are false

A

ANSWER
A) both the statement and the explanation are true and a causal relationship exists between them;

EXPLANATION
ECG monitoring in the acute phase of stroke is necessary, becasue stroke can cause arrhythmia.

116
Q

NEU - 1.147
In case of intracranial arterial occlusion, the lactic acid level raises, NADH/NAD ratio decreases, because superoxide radicals play important role in damaging the mitochondrial membrane.
A) both the statement and the explanation are true and a causal relationship exists between them;
B) both the statement and the explanation are true but there is no causal relationship between them;
C) the statement is true, but the explanation is false;
D) the statement is false, but the explanation itself is true
E) both the statement and the explanation are false

A

ANSWER
B) both the statement and the explanation are true but there is no causal relationship between them;

117
Q

NEU - 1.148
Before cardiac surgery duplex scan ultrasound of carotid vessels and transcranial Doppler examination (and vascular reconstructive surgery in case of severe carotid stenosis) are necessary, because significant stenosis of extra- and intracranial arteries may result in cerebral hypoperfusion and thus severe neurological symptoms during surgery.
A) both the statement and the explanation are true and a causal relationship exists between them;
B) both the statement and the explanation are true but there is no causal relationship between them;
C) the statement is true, but the explanation is false;
D) the statement is false, but the explanation itself is true
E) both the statement and the explanation are false

A

ANSWER
A) both the statement and the explanation are true and a causal relationship exists between them;

EXPLANATION
Before cardiac surgery, duplex scan ultrasound of the cervical arteries and transcranial Doppler examination (and vascular reconstructive surgery in case of severe carotid stenosis) are necessary, because significant stenosis of extra- and intracranial arteries may cause cerebral hypoperfusion leading to severe neurological symptoms during cardiac surgery.

118
Q

NEU - 1.149
The most likely diagnosis is:

After waking up at 6 a.m., a 74-year-old male patient’s wife noticed that her husband couldn’t speak and was unable to move his right extremities. She saw him last at 2 a.m. when her husband went to the toilet and was symptom-free. She called the family doctor, who measured 180/110 mmHg blood pressure and 88/min heart rate. They called the ambulance and arrived at the hospital by 8 a.m. Status: pulmonary emphysema, fundoscopy showed hypertensive retinopathy, right sided central facial palsy, right sided hypotonic, severe hemiparesis predominantly in upper extremities, increased deep tendon reflexes, complete motoric, severe sensoric aphasia. ECG: atrial fibrillation. Electrolytes and blood sugar levels were within the normal ranges.

A) arteriosclerotic encephalopathy
B) ischemic lesion in the territory of the left middle cerebral artery
C) hypertensive encephalopathy
D) Biswanger’s disease

A

ANSWER
B) ischemic lesion in the territory of the left middle cerebral artery

EXPLANATION
Considering the symptoms, the onset of symptoms, and atrial fibrillation in the history, the most likely diagnosis is ishemic lesion in the territirry of the left middle cerebral artery. To verify the diagnosis, the following investigations are needed: cranial CT, duplex scan ultrasound, cardiologic examination with echocardiography. The onset of symptoms is determined by the last time when the patient was symptom-free, in this case 2 a.m. Since atrial fibrillation is known, the heart is the most likely to be the source of embolization, therefore the most probable etiology is cardioembolic.

119
Q

NEU - 1.150
Choose the relevant investigations.

After waking up at 6 a.m., a 74-year-old male patient’s wife noticed that her husband couldn’t speak and was unable to move his right extremities. She saw him last at 2 a.m. when her husband went to the toilet and was symptom-free. She called the family doctor, who measured 180/110 mmHg blood pressure and 88/min heart rate. They called the ambulance and arrived at the hospital by 8 a.m. Status: pulmonary emphysema, fundoscopy showed hypertensive retinopathy, right sided central facial palsy, right sided hypotonic, severe hemiparesis predominantly in upper extremities, increased deep tendon reflexes, complete motoric, severe sensoric aphasia. ECG: atrial fibrillation. Electrolytes and blood sugar levels were within the normal ranges.

1) cranial CT and CT-angiography
2) duplex scan ultrasound of the cervical arteries and transcranial Doppler
3) cardiological examination with echocardiography
4) SPECT examination (single-photon emission computer-tomography)

A) 1., 2. and 3. answers are correct
B) 1. and 3. answers are correct
C) 2. and 4. answers are correct
D) only the 4. answer is correct
E) all of the answers are correct

A

ANSWER
A) 1., 2. and 3. answers are correct

EXPLANATION
Considering the symptoms, the onset of symptoms, and atrial fibrillation in the history, the most likely diagnosis is ishemic lesion in the territirry of the left middle cerebral artery. To verify the diagnosis, the following investigations are needed: cranial CT, duplex scan ultrasound, cardiologic examination with echocardiography. The onset of symptoms is determined by the last time when the patient was symptom-free, in this case 2 a.m. Since atrial fibrillation is known, the heart is the most likely to be the source of embolization, therefore the most probable etiology is cardioembolic.

120
Q

NEU - 1.151
Regarding the treatment, the onset of symptoms is important. When can we count surely the onset of symptoms?

After waking up at 6 a.m., a 74-year-old male patient’s wife noticed that her husband couldn’t speak and was unable to move his right extremities. She saw him last at 2 a.m. when her husband went to the toilet and was symptom-free. She called the family doctor, who measured 180/110 mmHg blood pressure and 88/min heart rate. They called the ambulance and arrived at the hospital by 8 a.m. Status: pulmonary emphysema, fundoscopy showed hypertensive retinopathy, right sided central facial palsy, right sided hypotonic, severe hemiparesis predominantly in upper extremities, increased deep tendon reflexes, complete motoric, severe sensoric aphasia. ECG: atrial fibrillation. Electrolytes and blood sugar levels were within the normal ranges.

A) 6 a.m.
B) mean time between 2 a.m. and 6 a.m., that is 4 a.m.
C) 2 a.m.
D) the time when the patient went to the bed in the previous evening

A

ANSWER
C) 2 a.m.

EXPLANATION
Considering the symptoms, the onset of symptoms, and atrial fibrillation in the history, the most likely diagnosis is ishemic lesion in the territirry of the left middle cerebral artery. To verify the diagnosis, the following investigations are needed: cranial CT, duplex scan ultrasound, cardiologic examination with echocardiography. The onset of symptoms is determined by the last time when the patient was symptom-free, in this case 2 a.m. Since atrial fibrillation is known, the heart is the most likely to be the source of embolization, therefore the most probable etiology is cardioembolic.

121
Q

NEU - 1.152
What is the most probable origin of stroke?

After waking up at 6 a.m., a 74-year-old male patient’s wife noticed that her husband couldn’t speak and was unable to move his right extremities. She saw him last at 2 a.m. when her husband went to the toilet and was symptom-free. She called the family doctor, who measured 180/110 mmHg blood pressure and 88/min heart rate. They called the ambulance and arrived at the hospital by 8 a.m. Status: pulmonary emphysema, fundoscopy showed hypertensive retinopathy, right sided central facial palsy, right sided hypotonic, severe hemiparesis predominantly in upper extremities, increased deep tendon reflexes, complete motoric, severe sensoric aphasia. ECG: atrial fibrillation. Electrolytes and blood sugar levels were within the normal ranges.

A) hemodynamic
B) cardioembolic
C) atherothrombotic
D) artery to artery embolisation

A

ANSWER
B) cardioembolic

EXPLANATION
Considering the symptoms, the onset of symptoms, and atrial fibrillation in the history, the most likely diagnosis is ishemic lesion in the territirry of the left middle cerebral artery. To verify the diagnosis, the following investigations are needed: cranial CT, duplex scan ultrasound, cardiologic examination with echocardiography. The onset of symptoms is determined by the last time when the patient was symptom-free, in this case 2 a.m. Since atrial fibrillation is known, the heart is the most likely to be the source of embolization, therefore the most probable etiology is cardioembolic.

122
Q

NEU - 1.153
Which neurological disease could it be?

A 24 years old, primipara woman had strong headache and fever 3 days after delivery. Although the fever was relieved by antipyretic drugs, she became somnolent and developed left sided focal motoric seizure with secondary generalisation. A few hours later the seizures repeated. dministration of 1 mg intravenous clonazepam stopped the seizures. Neurologist found left sided hemiparesis, increased deep tendon reflexes and disturbance of consciousness (somnolence). Prominent scalp edema was also noticed.

A) subarachnoidal bleeding due to aneurysm rupture
B) cerebral embolisation
C) cerebral sinus (venous) thrombosis
D) cerebral hypoxia associated with pneumonia
E) postpartum deep vein thrombosis with cerebral embolization

A

ANSWER
C) cerebral sinus (venous) thrombosis

EXPLANATION
Considering the patient’s hystory, the symptoms, and the progress of the disease, cerebral sinus (venous) thrombosis is suspected. (Based on scalp edema and the other symptoms, superior sagittal sinus thrombosis seems to be the most probable diagnosis.) To verify the diagnosis, cranial CT or MRI with venous CT-angiography or MR-angiography is necessary. (More precise diagnosis can be established by DSA). Searching for the source of infection is also necessary (in this case gynaecological source is the most likely). Treatment: wide spectrum antibiotics, mannitol, therapeutic dose of heparin (even if there is a haemorrhagic transformation).

123
Q

NEU - 1.154
Which investigations should be done in order to verify the diagnosis?

A 24 years old, primipara woman had strong headache and fever 3 days after delivery. Although the fever was relieved by antipyretic drugs, she became somnolent and developed left sided focal motoric seizure with secondary generalisation. A few hours later the seizures repeated. dministration of 1 mg intravenous clonazepam stopped the seizures. Neurologist found left sided hemiparesis, increased deep tendon reflexes and disturbance of consciousness (somnolence). Prominent scalp edema was also noticed.
1) cranial CT or MRI with venous CTA, or MRA
2) duplex ultrasound examination of cervical arteries
3) search for source of infection (in this case gynecologic source is likely)
4) lumbar puncture, CSF can be bloody

A) number 1, 2 and 3 answers are correct
B) number 1 and 3 answers are correct
C) number 2 and 4 answers are correct
D) only the number 4 answer is correct
E) all answers are correct

A

ANSWER
B) number 1 and 3 answers are correct

EXPLANATION
Considering the patient’s hystory, the symptoms, and the progress of the disease, cerebral sinus (venous) thrombosis is suspected. (Based on scalp edema and the other symptoms, superior sagittal sinus thrombosis seems to be the most probable diagnosis.) To verify the diagnosis, cranial CT or MRI with venous CT-angiography or MR-angiography is necessary. (More precise diagnosis can be established by DSA). Searching for the source of infection is also necessary (in this case gynaecological source is the most likely). Treatment: wide spectrum antibiotics, mannitol, therapeutic dose of heparin (even if there is a haemorrhagic transformation).

124
Q

NEU - 1.155
Which is the correct treatment?

A 24 years old, primipara woman had strong headache and fever 3 days after delivery. Although the fever was relieved by antipyretic drugs, she became somnolent and developed left sided focal motoric seizure with secondary generalisation. A few hours later the seizures repeated. dministration of 1 mg intravenous clonazepam stopped the seizures. Neurologist found left sided hemiparesis, increased deep tendon reflexes and disturbance of consciousness (somnolence). Prominent scalp edema was also noticed.
1) administration of wide spectrum antibiotics
2) mannitol
3) therapeutic dose of heparine, even if there is haemorrhagic transformation
4) carotid endarterectomy

A) number 1, 2 and 3 answers are correct
B) number 1 and 3 answers are correct
C) number 2 and 4 answers are correct
D) only the number 4 answer is correct
E) all answers are correct

A

ANSWER
A) number 1, 2 and 3 answers are correct

EXPLANATION
Considering the patient’s hystory, the symptoms, and the progress of the disease, cerebral sinus (venous) thrombosis is suspected. (Based on scalp edema and the other symptoms, superior sagittal sinus thrombosis seems to be the most probable diagnosis.) To verify the diagnosis, cranial CT or MRI with venous CT-angiography or MR-angiography is necessary. (More precise diagnosis can be established by DSA). Searching for the source of infection is also necessary (in this case gynaecological source is the most likely). Treatment: wide spectrum antibiotics, mannitol, therapeutic dose of heparin (even if there is a haemorrhagic transformation).

125
Q

NEU - 1.156
What is the most likely diagnosis?

A 42 years old man lifted a heavy timber made of concrete when he suddenly developed a severe, intolerable headache at the occipital and forehead regions. Hypertension was known in his medical history which was treated by oral medications. He lied down, but his symptoms became worse, furthermore, nausea and photophobia also developed. He became somnolent during transport to neurology ward. Moving the head aggarvated his headache. The neurologist found neck stiffness, increased deep tendon reflexes on both sides. There was no paresis. Blood pressure: 180/100 Hgmm, heart rate: 98/bpm.
A) intracerebral bleeding
B) arteriovenous malformation
C) haemorrhagic infarct
D) subarachnoidal haemorrhage caused by rupture of intracranial aneurysm

A

ANSWER
D) subarachnoidal haemorrhage caused by rupture of intracranial aneurysm

EXPLANATION
Based on the patient’s history and neurological signs, the most likely diagnosis is intracranial aneurysm rupture resulting in subarachnoidal bleeding. In order to verify the diagnosis, cranial CT and cranial CT-angiography or DSA are necessary. CT scan may reveal subarachnoidal bleeding, sometimes the source of bleeding can also be seen. Cranial CT-angiography, or DSA shows the localisation, size and morphology of the aneurysm. Multiple aneurysms may be found, in that case CT (localisation of subarachnoidal bleeding) might help localise the ruptured aneurysm. Vasospasm is a complication of subarachnoidal bleeding, which may cause cerebral ischemia.

126
Q

NEU - 1.157
Which investigations can verify the diagnosis?

A 42 years old man lifted a heavy timber made of concrete when he suddenly developed a severe, intolerable headache at the occipital and forehead regions. Hypertension was known in his medical history which was treated by oral medications. He lied down, but his symptoms became worse, furthermore, nausea and photophobia also developed. He became somnolent during transport to neurology ward. Moving the head aggarvated his headache. The neurologist found neck stiffness, increased deep tendon reflexes on both sides. There was no paresis. Blood pressure: 180/100 Hgmm, heart rate: 98/bpm.
1) cranial CT
2) magnetencephalography
3) CT-angiography or DSA (digital substractional angiography)
4) SPECT

A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct

A

ANSWER
B) 1st and 3rd answers are correct

EXPLANATION
Based on the patient’s history and neurological signs, the most likely diagnosis is intracranial aneurysm rupture resulting in subarachnoidal bleeding. In order to verify the diagnosis, cranial CT and cranial CT-angiography or DSA are necessary. CT scan may reveal subarachnoidal bleeding, sometimes the source of bleeding can also be seen. Cranial CT-angiography, or DSA shows the localisation, size and morphology of the aneurysm. Multiple aneurysms may be found, in that case CT (localisation of subarachnoidal bleeding) might help localise the ruptured aneurysm. Vasospasm is a complication of subarachnoidal bleeding, which may cause cerebral ischemia.

127
Q

NEU - 1.158
Which severe complication may be caused by subarachnoidal bleeding?

A 42 years old man lifted a heavy timber made of concrete when he suddenly developed a severe, intolerable headache at the occipital and forehead regions. Hypertension was known in his medical history which was treated by oral medications. He lied down, but his symptoms became worse, furthermore, nausea and photophobia also developed. He became somnolent during transport to neurology ward. Moving the head aggarvated his headache. The neurologist found neck stiffness, increased deep tendon reflexes on both sides. There was no paresis. Blood pressure: 180/100 Hgmm, heart rate: 98/bpm.
A) pneumonia
B) deep vein thrombosis
C) cerebral vasospasm
D) urocystitis because of bladder catheterisation

A

ANSWER
C) cerebral vasospasm

EXPLANATION
Based on the patient’s history and neurological signs, the most likely diagnosis is intracranial aneurysm rupture resulting in subarachnoidal bleeding. In order to verify the diagnosis, cranial CT and cranial CT-angiography or DSA are necessary. CT scan may reveal subarachnoidal bleeding, sometimes the source of bleeding can also be seen. Cranial CT-angiography, or DSA shows the localisation, size and morphology of the aneurysm. Multiple aneurysms may be found, in that case CT (localisation of subarachnoidal bleeding) might help localise the ruptured aneurysm. Vasospasm is a complication of subarachnoidal bleeding, which may cause cerebral ischemia.

128
Q

NEU - 1.159
What can be the diagnosis?

A 64 years old, heavy drinker man suddenly collapsed on the street. He lost his consciousness and his face became red. His friend mentioned that the patient had hypertension, however, he did not take any medication. The ambulance team measured 240/120 mmHg blood pressure. Endotracheal intubation was performed because the patient vomited and his respiration was not stable. He had neck stiffness and pain stimulus induced tetraextension in the extremities. His left pupil was dilated and the light reacion on the left side was almost absent. The blood sugar was 14 mmol/L and ECG showed bradycardia.

A) right hemispheric intracerebral bleeding
B) pons haemorrhage
C) cerebellar haemorrhage
D) left hemispheric intracerebral bleeding with mass effect
E) none of them

A

ANSWER
D) left hemispheric intracerebral bleeding with mass effect

EXPLANATION
Based on the symptoms and the positive medical history for untreated hypertension, the most likely diagnosis is left sided intracerebral bleeding with mass effect. Urgent cranial CT is needed. The dilated, and barely reacting pupil on the left side indicates the side of the bleeding (due to the mass effect causing transtentrial herniation the ipsilateral oculomotor nerve is compressed). Tetra-extension to pain stimulus refers to bad prognosis.

129
Q

NEU - 1.160
Which urgent investigation is needed?

A 64 years old, heavy drinker man suddenly collapsed on the street. He lost his consciousness and his face became red. His friend mentioned that the patient had hypertension, however, he did not take any medication. The ambulance team measured 240/120 mmHg blood pressure. Endotracheal intubation was performed because the patient vomited and his respiration was not stable. He had neck stiffness and pain stimulus induced tetraextension in the extremities. His left pupil was dilated and the light reacion on the left side was almost absent. The blood sugar was 14 mmol/L and ECG showed bradycardia.

A) cranial SPECT
B) cranial CT
C) skull X-ray
D) None of them because of the severe symptoms.

A

ANSWER
B) cranial CT

EXPLANATION
Based on the symptoms and the positive medical history for untreated hypertension, the most likely diagnosis is left sided intracerebral bleeding with mass effect. Urgent cranial CT is needed. The dilated, and barely reacting pupil on the left side indicates the side of the bleeding (due to the mass effect causing transtentrial herniation the ipsilateral oculomotor nerve is compressed). Tetra-extension to pain stimulus refers to bad prognosis.