Good morning and happy new year and welcome to the companion episode for episode 125. Here we are going to go through some questions, some ideas, some thoughts on what we covered in last week’s episodes with cerebral aneurysms, AVMs, and intracranial hemorrhages to hopefully make all of this stick better in your mind and make it available to you on test day and then further down the road when you actually need this stuff. That’s really the goal here with these companion episodes to make them more active, more engaged and get you to participate and do what needs to be done in order for you to build out the neural networks to make you remember the information. Just remember, just listening to it’s not going to be enough. You have to engage. You have to be part of the system.

Now, before we jump in, I just want to remind you that some very exciting stuff is going on very, very soon. January is a huge month around here because two things are happening. One is on January 14th and January 16th at 8 p.m. I’m going to be hosting a absolutely free Master Class on passing the PANCE. I’m going to whittle down 10 plus years experience, hundreds of students I’ve helped and pack into about 45 minutes the most actionable, important philosophies, methods, and techniques for passing the PANCE. So if you’re interested in that, go to physicianassistantexamreview.com/masterclass. That’s physicianassistantexamreview.com/masterclass to choose which night you’d like to come to and to register for that.

I strongly encourage you to do that because these have been great courses. I’ve helped a lot of people and had a lot of great feedback from these over the years. And again, they’re 100% free. So really worth your time and effort to show up. And please share that with a friend who might be struggling as well. Something that I really would ask you to do here is share the program, share the show if you’re getting out of it. But in addition to that, share the Master Class with someone or your entire cohort.

You don’t know who might be suffering, who might be struggling, who might be worried, who might be on the cusp of falling out of PA school, of not passing their PANCE. And you sharing that information can make you the silent hero, can make you someone’s savior without even really knowing it sometimes. So I’m going to ask you, please, for their sake and for mine, because it helps me, obviously. The more people who show up, the better and the more fun it is for me. So if you could do, and the more impact I can have. So those are the two things I would ask you is share that information, physicianassistantexamreview.com/masterclass. On top of that, I’m also going to be opening registration for the February cohort of the 33 Days to Pass the PANCE program.

It’s at physicianassistantexamreview.com/33, just the numbers. Really simple. On January 14th, I’m going to open registration for the first cohort of 2025, really exciting. And that’s another program that has gone on to help hundreds of students who have failed the PANCE, who have struggled with end of rotation exams, who’ve struggled in didactic year, to train them in tools, techniques, and methods for excelling in PA school, excelling on the PANCE, excelling on end of rotation exams by going deep into advanced study skills, testing techniques, anxiety management, peak performance, that kind of thing. And we absolutely have been crushing it with average scores skyrocketing for students who come participate and play all out and learn the things I’m teaching inside of that program. So again, that registration will open on January 14th. Really excited about that for that first cohort.

I already have a number of people who are excited and interested and who are going to be registering for that. I’m already hearing from a bunch of people who want to be in. So make sure that you’re on top of that if that’s something you want to do.

All right, so let’s jump in and continue our discussion on cerebral aneurysms, AVMs, and intracranial hemorrhages. I like to start out talking just about how do we look at these differently? How do we come to the conclusions about how they’re going to be asked on tests, what we’re going to be looking at? So for our aneurysms, remember, what is an aneurysm? So stop and think for a second. What’s an aneurysm? What are we talking about?

What’s an AVM? What are we talking about? Don’t just listen to me speak it. You voice the words out loud. If you’re in the car by yourself, great. If you’re in the car with other people, even more fun. Go for it.

What’s a cerebral aneurysm? What’s an AVM? Out loud right now. Go for it. So an aneurysm is a weakening or bulging of an arterial wall. And this is where you get the brain bleeds or the hemorrhages from in a lot of cases. An AVM is an abnormal connection between arteries and veins where there’s no capillaries, right?

So we get a pressure gradient that’s much too high for the veins, and this can lead to bleeding over time. This is a congenital defect. The aneurysm is usually something that develops over time, where the AVM is a congenital defect. It just gets worse over time. Remember, we also went through anterior versus posterior circulation and the strokes and the symptoms that come up there. We talked about the MCA versus the ACA. In an MCA stroke, you get contralateral face and arm weakness greater than leg weakness.

In an ACA stroke, you get contralateral leg weakness greater than face and arm weakness. Posterior circulation is the brain stem stroke, so you get cranial nerve deficits, vertigo, ataxia, or decreased consciousness. Cerebellar strokes, you get ataxia, intention tremors, and vertigo. PCA strokes, you get contralateral hemianopsia, hemianopia, got that, nailed that, much, terrible. Visual agnosia and thalamic sensory loss. So there’s a whole bunch going on there. The other thing I wanted to hit on in this section was, and I spent some time on this last week, but what are the imaging modalities that you’re going to choose, right?

So we’re going to walk through these real quick, but I’m going to ask them of you rather than me just reading them off to you. So if you have an unruptured aneurysm, you suspect that there’s an aneurysm seen, what’s the gold standard? What’s the first thing you’re going to do? Well, a CT angiogram is going to be the gold standard, right? What if you have a strong suspicion of a subarachnoid hemorrhage, but the CT is negative? What are you going to do? Well, in that case, you’re going to get a lumbar puncture.

What about a complex aneurysm or surgical planning? We’re going to do a cerebral angiogram. That’s the gold standard. What about if you suspect someone has a subarachnoid hemorrhage? Non-contrast CT, right? The non-contrast CT. It’s fast, and we’ll get to see the information we want most likely.

Excellent. We also wrapped up last week talking about treatment plans for these, right? So, the treatment plans are pretty straightforward, is how I kind of closed out last week’s episode. So, a cerebral aneurysm, what’s the treatment plan for an unruptured versus ruptured for a cerebral aneurysm? Well, unruptured is going to be blood pressure control, right? I want to make sure that I don’t rupture that aneurysm, and I want to also do some imaging follow up and make sure it’s not growing, because if it’s growing, then I have some concerns. If it’s ruptured, what’s my management?

Well, job number one is lower blood pressure. Job number two is manage intracranial pressure. And then we’re going to talk about surgical clipping and endovascular coiling. What about an AVM? Well, if it’s unruptured, we’re going to look at surgical resection. We’re going to look at blood pressure control. We’re going to look at endovascular embolization, depending on size or stereotactic radiosurgery.

And again, if we wind up with a ruptured AVM, we’re going to look at blood pressure control, reduce intracranial pressure with mannitol or hypertonic saline, and surgical intervention like craniotomy clipping or coiling. Really, really straightforward, regardless of why I have a bleed, pretty much going to have the same things there.

Perfect. So, just a short, tight review. Get your brain thinking, get you moving a little bit.

Now, let’s jump into some questions. I’m going to run through these all at once, and then we’re going to go through them, and I’m going to give you the answers afterwards.

Okay? So, I’m going to ask you to answer them to yourself, and then we’ll go back over them. But I want you to hold it in your head for just a second. I’ve got nine questions here for you on this topic. What imaging modality is considered the gold standard for diagnosing complex cerebral aneurysms? What imaging modality is considered the gold standard for diagnosing complex cerebral aneurysms? What medication is used to reduce intracranial pressure in hemorrhagic strokes?

What medication is used to reduce intracranial pressure in hemorrhagic strokes? What phenomenon in AVMs diverts blood away from surrounding normal brain tissue? What phenomenon in an AVM diverts blood away from surrounding normal brain tissue? Which type of stroke commonly presents with contralateral homonymous hemianopia. There you go. I think I nailed it. I’m not going to read that one again.

When would a lumbar puncture be indicated for a suspected subarachnoid hemorrhage? What imaging is first line for diagnosing a subarachnoid hemorrhage? Name two congenital syndromes associated with cerebral aneurysm. What symptom is more pronounced in an MCA stroke compared to an ACA stroke? What is the most common location for a berry aneurysm within the circle of Willis? That was one of our priming questions last week, right?

All right, hopefully you gave those a shot and let’s see how we did. What imaging modality is considered the gold standard for diagnosing complex cerebral aneurysm? Hopefully you nailed that. We just talked about it. Cerebral angiogram. What medication is used to reduce intracranial pressure in a hemorrhagic stroke? Just talked about that too, mannitol or a hypertonic saline.

What phenomenon in AVM diverts blood away from surrounding normal brain tissue? That’s the steal effect or the steal phenomenon. Which type of stroke commonly presents with contralateral homonymous hemianopia? How’d I do? It’s posterior cerebral artery, PCA strokes. When would a lumbar puncture be indicated for a suspected subarachnoid hemorrhage? This is when the CT, the non-contrast CT is negative, but clinical suspicion for the hemorrhage remains very high.

What imaging is first line for diagnosing a subarachnoid hemorrhage? Well, I just said it, so if you’re paying attention, non-contrast CT scan. I should switch the order around on these. Name two congenital syndromes associated with cerebral aneurysms. It’s a good question. Name two congenital syndromes associated with cerebral aneurysms. Remember, what were our risk factors?

What were the causes? Think about how an aneurysm forms and what happens. There will be others, but Marfan syndrome and Ehlers-Danlos are two that I have here. These are connective tissue problems that create weak blood vessels. What symptom is more pronounced in an MCA stroke compared to an ACA stroke? This is on the list of things that I said last week, that you can know one or two things and it can maybe help you get above average number of questions right or at least help you tilt the odds in your favor. So in this case, an MCA stroke compared to an ACA stroke, which is more pronounced, will contralateral face and arm weakness more than legs, right?

What’s the most common location for a berry aneurysm within the circle of Willis? Do you remember from last week? The junction of the anterior communicating artery and the anterior cerebral artery. Yikes.

All right, so one of the things I like to do is show you how those questions can build up into longer form questions, right? And still be straightforward, but still be just longer form, more words, more things like you’ll see on the PANCE. They’re still the type of question that you will see, but they’re just come out of those building blocks. So here we go. A 67-year-old woman presented a sudden onset of 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 their subarachnoid hemorrhage remains high.

What is the next step in confirming the diagnosis? A, MRI of the brain. B, lumbar puncture. C, CT angiography. D, a cerebral angiogram. Well, here it’s B, lumbar puncture, right? Question number two.

A 72-year-old man with a history of hypertension and smoking presents with 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? Non-contrast CT, CT angiography, cerebral angiogram, MR angiography. C, cerebral angiogram. Question number three.

A 70-year-old man presents with a 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’s the most likely location of this stroke? A, anterior cerebral artery. B, middle cerebral artery. C, posterior cerebral artery.

D, basilar artery. The answer here is B, middle cerebral artery. But I want you to see how these questions get structured, right? How you can work through these by knowing just a little bit. Question number four. A 55 year old man woman presents with a sudden severe headache, nausea, vomiting, and photophobia. Her neurological exam reveals neck stiffness and no focal deficits.

Lumbar puncture exam… I’m sorry, lumbar puncture confirms xanthochromia. Which of the following interventions is most appropriate to reduce the risk of re-bleeding? Initiate anticoagulation therapy. B, strict blood pressure control. C, start corticosteroids to reduce swelling. D, perform a lumbar drain.

Answer is B, strict blood pressure control. So I want you to see how those stack, how those become more not complicated. They’re still pretty straightforward, but you just have to read between the lines a little bit. Now I want to move on to things that are a little bit more complicated but in the same ideas in the same places.

So let’s take a look at these. A 65-year-old woman presents with progressive headaches, visual disturbances, and intermittent right-sided weakness. CTA reveals a 5mm unruptured fusiform aneurysm in the basilar artery. Based on the patient’s presentation and imaging findings, which management strategy is most appropriate? A, immediate surgical clipping. B, endovascular coiling. C, routine follow-up and imaging, as well as blood pressure control.

And D, lumbar puncture to assess for subarachnoid hemorrhage. Well, your answer here is C, routine follow-up and imaging and blood pressure control. Right? We’re not looking at a subarachnoid hemorrhage, and this patient doesn’t need immediate surgical clipping or even at five millimeters to get an endovascular coiling to prevent the rupture, right? We’re just going to watch this for a while. But this is a little harder. You have to think a little bit, right?

It’s not just a very clear memorization type question. You have to think. Next one, a 70-year-old man is brought to the emergency department by his son after suddenly developing right-sided weakness and difficulty speaking earlier in the day. The son reports that about two hours ago, he noticed his father struggling to lift his right arm and slurring his words. Neurological exam reveals expressive aphasia and weakness, primarily affecting the face and arm more than the leg. Non-contrast CT shows no evidence of hemorrhage. CTA identifies an occlusion in the middle cerebral artery.

Which treatment option would provide the best outcome for this patient? Endovascular thrombectomy, B, intravenous thrombolysis after lowering blood pressure, C, antiplatelet therapy with aspirin and clopidogrel, D, surgical revascularization. Well, this one’s a little bit trickier because it brings back in the episode 124. In this case, it’s going to be TPA. If we have somebody with an ischemic stroke within a four and a half hour window, I don’t really care about the location so much, right? What I care about is I’m going to do TPA in that window. Beautiful.

All right, I’ve got one more for you. A 48-year-old man is evaluated after a sudden onset of severe headache, nausea, vomiting, and photophobia. Non-contrast CT is negative for hemorrhage, but lumbar puncture confirms xanthochromia. CTA reveals a 7mm saccular aneurysm at the junction of the posterior communicating artery and internal carotid artery. Given this scenario, which of the following findings would be most critical to assess before planning definitive surgical intervention? So now it’s easy to see as you’re reading this question that xanthochromia is that CSF in the lumbar puncture, right? So you know that he’s got something going on, so we have to do something.

A, the patient’s coagulation. I’m sorry.

So let’s go back to the question. Given the scenario, which of the following findings would be most critical to assess before planning definitive surgical intervention? A, the patient’s coagulation profile. B, presence of cranial nerve deficits. C, extent of steal phenomenon on imaging. And D, degree of cerebral edema on the MRI. With these answer choices, this is really straightforward.

And the answer is A, the patient’s coagulation profile. Right? Because I’m talking about a surgical intervention, I’m talking about an active bleed. So, I need to get a move on, and I need to know if I’m going to cause more bleeding, where we’re going to be at. Cranial nerve deficits. I care about, but I have my CTA to show me exactly where the aneurysm is. I don’t, the physical exam findings become less of an issue.

Extent of the steal phenomenon on imaging, again, not really relevant here at the moment. Degree of cerebral edema, yes, it’s important, but again, I’m going to want that. Coagulation factors is going to be my primary thing at the moment. Beautiful. So like I said, this is a tough section for me. This is not my strong suit, neuro, not at all. And I find it difficult to keep all of this straight.

There’s a couple different ways you can do it, things you can work on. We’ve talked about some of them in last week’s episode, but a lot of it’s just that engagement, figuring out how they’re going to, questions are going to come, working through them, figuring out how the answers are going to come, how they stage things up against each other. And that’s a big, big part of what you’re going to need to be doing. It’s also a big part of what I’m going to be showing next week in the Master Class on how to pass the PANCE. I’m going to be doing a little bit of work on preparing for the PANCE in the sense of studying and showing you some techniques. But then we’re going to dive deep into my top 10 test taking principles and how to move through the exam. So I really want if you’re struggling, if you’re on the edge, if you have some kind of questions and you don’t aren’t getting the grades that you want, it’s going to be an excellent resource for you 100% free.

Go to physicianassistantexamreview.com/masterclass to get the details. But that’s going to be next week on the 14th and the 16th. I think it’s the 16th. Let me just look. Yes, the 14th and the 16th of January. You can go ahead and sign up for that and get registered for that so that you make sure that you’re there. On top of that, don’t forget, if you’re interested in the 33 Days to Pass Your PANCE program, that also starts next Tuesday.

Registration begins next Tuesday. The program begins on February 1st and we’ll run through the beginning of March. So if your exam is coming up the middle of March or April, that’s going to be an excellent time for you to get involved. Also, if you’re struggling in your clinical work or your didactic work, again, a great, great time. I’m going to be hosting, I’m not going to talk about them here yet, but I’m also going to be hosting Q&A sessions on the 33 Days to Pass Your PANCE program because I know people always have questions that don’t quite understand exactly how that works. I’m going to be hosting those in a couple of weeks. So if you have questions or thoughts, just keep keep tuned in and I will definitely let you know when those are going to be.

All right. I think that’s it for today. Once again, happy new year. I’m excited for 2025, the things that are coming, the 33 Days program, and a couple other things I’ve got coming for you guys this year, the podcast in particular, but also Wallace’s Notebook that I’ve been working on for well over, it’s well past due out and a couple other ideas I’ve got rolling out this year. I can’t wait to get them to you, but happy new year. Take care and best of luck. See you next week.