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125b Retention Practice & PANCE Questions for Cerebrovascular disorders

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Companion Episode: Cerebral Aneurysms, AVMs, and Intracranial Hemorrhage

Companion Episode: Cerebral Aneurysms, AVMs, and Intracranial Hemorrhage

Differentiation

Cerebral Aneurysms vs. Arteriovenous Malformations (AVMs)

  • Cause of Hemorrhage:
    • Cerebral Aneurysm: Weakening and bulging of an arterial wall.
    • AVM: Abnormal connection between arteries and veins without capillaries.
  • Location:
    • Cerebral Aneurysms: Frequently at arterial bifurcations in the Circle of Willis.
    • AVMs: Most common in the cerebral hemispheres (supratentorial).
  • Symptoms Before Rupture:
    • Cerebral Aneurysms: Asymptomatic or localized mass effect (e.g., cranial nerve palsies, visual changes).
    • AVMs: Seizures, headaches, or progressive neurologic deficits due to “steal phenomenon.”

Stroke Types and Locations

  • Anterior Circulation:
    • MCA Stroke: Contralateral face and arm weakness > leg; aphasia (dominant hemisphere) or neglect (non-dominant).
    • ACA Stroke: Contralateral leg weakness > face and arm; urinary incontinence and personality changes.
  • Posterior Circulation:
    • Brainstem Stroke: Cranial nerve deficits, vertigo, ataxia, or decreased consciousness.
    • Cerebellar Stroke: Ataxia, intention tremor, vertigo.
    • PCA Stroke: Contralateral homonymous hemianopia, visual agnosia, or thalamic sensory loss.

Imaging Findings by Scenario

Clinical Scenario Preferred Imaging Modality
Suspected SAH Non-contrast CT
Strong suspicion of SAH, negative CT Lumbar puncture, then CTA
Unruptured aneurysm localization CTA (first), MRA (alternative)
Complex aneurysms or surgical planning Cerebral Angiogram (gold standard)
Chronic aneurysm follow-up MRA

Treatments

  • Cerebral Aneurysms:
    • Unruptured: Blood pressure control (<140/90 mmHg), cholesterol management, imaging follow-up.
    • Ruptured: Immediate management of ICP (e.g., mannitol), surgical clipping, or endovascular coiling.
  • Arteriovenous Malformations:
    • Management includes surgical resection, stereotactic radiosurgery, or endovascular embolization depending on size and location.
  • Intracranial Hemorrhage:
    • Reduce ICP (mannitol or hypertonic saline).
    • Control blood pressure to prevent rebleeding.
    • Surgical interventions as needed: craniotomy, clipping, or coiling.

The Final Step Questions

  1. What imaging modality is considered the gold standard for diagnosing complex cerebral aneurysms?
  2. What medication is used to reduce intracranial pressure in hemorrhagic strokes?
  3. What phenomenon in AVMs diverts blood away from surrounding normal brain tissue?
  4. Which type of stroke commonly presents with contralateral homonymous hemianopia?
  5. When would a lumbar puncture be indicated for suspected SAH?
  6. What imaging is first-line for diagnosing a subarachnoid hemorrhage?
  7. Name two congenital syndromes associated with cerebral aneurysms.
  8. What symptom is more pronounced in an MCA stroke compared to an ACA stroke?
  9. What is the most common location for a berry aneurysm within the Circle of Willis?

PANCE Style Questions from Building Blocks

Question 1: A 67-year-old woman presents with a sudden onset of a severe headache described as “the worst of her life,” along with nausea, vomiting, and altered mental status. Non-contrast CT of the head reveals no abnormalities, but suspicion for subarachnoid hemorrhage remains high. What is the next step in confirming the diagnosis?

  • A. MRI of the brain
  • B. Lumbar puncture
  • C. CT angiography (CTA)
  • D. Cerebral angiogram

Question 2: A 72-year-old man with a history of hypertension and smoking presents with a severe, thunderclap headache and neck stiffness. Non-contrast CT confirms a subarachnoid hemorrhage. Subsequent imaging reveals a saccular aneurysm at the junction of the anterior communicating artery and the anterior cerebral artery. Which imaging modality is most appropriate for planning surgical intervention?

  • A. Non-contrast CT
  • B. CT angiography (CTA)
  • C. Cerebral angiogram
  • D. MR angiography (MRA)

Question 3: A 70-year-old man presents with sudden onset of right-sided weakness and slurred speech. On examination, he has contralateral face and arm weakness greater than leg weakness. His family reports he has also been struggling to find words when speaking. What is the most likely location of the stroke?

  • A. Anterior cerebral artery (ACA)
  • B. Middle cerebral artery (MCA)
  • C. Posterior cerebral artery (PCA)
  • D. Basilar artery

Question 4: A 55-year-old woman presents with a sudden severe headache, nausea, vomiting, and photophobia. Her neurological exam reveals neck stiffness and no focal deficits. Lumbar puncture confirms xanthochromia. Which of the following interventions is most appropriate to reduce the risk of rebleeding?

  • A. Initiate anticoagulation therapy
  • B. Strict blood pressure control
  • C. Start corticosteroids to reduce swelling
  • D. Perform a lumbar drain