Cerebrovascular Diseases — MCQs
A 68-year-old patient presents with sudden onset of right-sided weakness and slurred speech. The symptoms completely resolve within 30 minutes with no residual neurological deficits. This clinical presentation is most consistent with:
Thrombolysis can be considered in all of these conditions, except:
All of the following come under priority of Stroke control programme EXCEPT:
What is the imaging modality of choice for determining the etiology of subarachnoid hemorrhage?
Most common site of hypertensive intraparenchymal hemorrhage in the brain?
Which artery is the major supply of the medial surface of the cerebral hemisphere?
A woman presenting with abrupt onset of "the worst headache of her life" Which is the best investigation?
Thrombosis of the superior branch of the middle cerebral artery leads to:
Which of the following arteries is likely to be involved in a 3rd cranial nerve lesion?
The following are the psychiatric sequelae after stroke in the elderly: a) Depression b) Post-traumatic stress disorder c) Dementia d) Hysteria
Cerebrovascular Diseases Indian Medical PG Practice Questions and MCQs
Question 1: A 68-year-old patient presents with sudden onset of right-sided weakness and slurred speech. The symptoms completely resolve within 30 minutes with no residual neurological deficits. This clinical presentation is most consistent with:
- A. Transient Ischemic Attack (TIA) (Correct Answer)
- B. Subarachnoid hemorrhage
- C. Intracerebral hemorrhage
- D. Ischemic stroke
Explanation: ***Transient Ischemic Attack (TIA)*** - A TIA is characterized by **transient neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia**, without acute infarction [1]. - The key diagnostic feature here is the **complete resolution of symptoms within a short period** (30 minutes) with no residual deficits, fitting the definition of TIA [1]. *Subarachnoid hemorrhage* - This typically presents with a **sudden, severe headache** (often described as "thunderclap"), stiff neck, and altered mental status. - While it can cause sudden neurological deficits, these symptoms usually **do not resolve completely within minutes**, and often lead to persistent deficits or life-threatening complications. *Intracerebral hemorrhage* - An intracerebral hemorrhage involves **bleeding directly into the brain tissue**, leading to sudden onset of neurological deficits that **progress over time** [2]. - The symptoms are generally **severe and persistent**, and would not resolve completely within 30 minutes. *Ischemic stroke* - An ischemic stroke is caused by a **blockage of blood flow to the brain**, resulting in brain tissue damage (infarction) and persistent neurological deficits [2]. - While initial symptoms can be similar to a TIA [3], an ischemic stroke by definition involves **permanent damage and lasting deficits**, unlike what is described in the patient's presentation.
Question 2: Thrombolysis can be considered in all of these conditions, except:
- A. Blood pressure of more than 185/110 mmHg (Correct Answer)
- B. Ischemic stroke within 2 hours
- C. Onset of symptoms <4 hours
- D. MRI showing density in less than 1/3rd of the area supplied by MCA
Explanation: ***Blood pressure of more than 185/110 mmHg*** - A **blood pressure** greater than **185/110 mmHg** is an absolute contraindication for thrombolysis due to the significantly increased risk of developing **hemorrhagic transformation**. - **Aggressive blood pressure control** is necessary to reduce the risk of intracranial hemorrhage before considering thrombolytics. *Ischemic stroke within 2 hours* - This is within the **therapeutic window** for thrombolysis, which typically extends up to **4.5 hours** from symptom onset [1]. - Earlier administration of thrombolytics within this window generally leads to **better outcomes** and reduced disability [1]. *Onset of symptoms <4 hours* - An onset of symptoms less than **4.5 hours** is a primary **inclusion criterion** for intravenous thrombolysis in acute ischemic stroke [1]. - This timeframe allows for the maximum benefit from **clot dissolution** while minimizing the risk of adverse events. *MRI showing density in less than 1/3rd of the area supplied by MCA* - A **diffusion-weighted MRI** showing an infarct core of less than one-third of the **Middle Cerebral Artery (MCA)** territory is an indicator that the amount of **irreversibly damaged tissue** is small. - This suggests a larger volume of **salvageable penumbra**, making thrombolysis more likely to be beneficial.
Question 3: All of the following come under priority of Stroke control programme EXCEPT:
- A. Control of alcoholism (Correct Answer)
- B. Control of smoking
- C. Control of diabetes
- D. Control of hypertension
Explanation: ***Control of alcoholism*** - While **alcoholism** is a health concern, its direct and immediate impact as a primary modifiable risk factor for stroke in large-scale stroke control programs is generally less emphasized compared to other factors. - Stroke control programs typically prioritize risk factors with a more direct and significant impact on stroke incidence and severity, such as hypertension, diabetes, and dyslipidemia. *Control of smoking* - **Smoking** is a major modifiable risk factor for stroke, significantly increasing the risk of both ischemic and hemorrhagic stroke due to its effects on atherosclerosis and clotting. - Quitting smoking is a cornerstone of any stroke prevention strategy, and thus its control is a high priority. *Control of diabetes* - **Diabetes** significantly increases the risk of stroke by promoting atherosclerosis and affecting blood vessel health. - Strict glycemic control is essential in preventing stroke and is a priority in stroke control programs. *Control of hypertension* - **Hypertension** is the most important modifiable risk factor for stroke, contributing to both ischemic and hemorrhagic strokes. - Effective blood pressure management is critical for primary and secondary stroke prevention and is a top priority in stroke control programs.
Question 4: What is the imaging modality of choice for determining the etiology of subarachnoid hemorrhage?
- A. Non-contrast CT
- B. CECT
- C. Four vessel DSA (Correct Answer)
- D. MRI
Explanation: ***Four vessel DSA*** - **Four-vessel Digital Subtraction Angiography (DSA)** is considered the gold standard for identifying the source of subarachnoid hemorrhage (SAH). - It provides high-resolution images of the **cerebral vasculature**, enabling the detection of small aneurysms, arteriovenous malformations, or other vascular lesions. *Non-contrast CT* - **Non-contrast CT** is the imaging modality of choice for the initial diagnosis of SAH itself. - However, it primarily identifies the presence of blood and its location, but is not as effective in determining the **underlying cause** of the hemorrhage in many cases. *CECT* - **Contrast-enhanced CT (CECT)** can help identify some vascular abnormalities by highlighting vessels, but its sensitivity for detecting small aneurysms or complex vascular lesions is lower than DSA. - It is often used as an alternative or supplementary study when DSA is not immediately available or contraindicated. *MRI* - **MRI** is highly sensitive for detecting intraparenchymal and subtle SAH in later stages but is less effective than CT for acute blood detection, especially within the first few hours. - While MRA (Magnetic Resonance Angiography) can identify vascular lesions, its resolution and ability to detect smaller aneurysms are generally inferior to DSA.
Question 5: Most common site of hypertensive intraparenchymal hemorrhage in the brain?
- A. Putamen (Correct Answer)
- B. Thalamus
- C. Cerebellum
- D. Pons
Explanation: ***Putamen*** - The **putamen** is the most frequent site for **hypertensive intraparenchymal hemorrhages** [1] due to the presence of numerous small, thin-walled arterioles (lenticulostriate arteries) that are highly susceptible to damage from chronic hypertension [1]. - Hemorrhages in this region often cause **contralateral hemiparesis**, **hemianesthesia**, and **gaze deviation** towards the side of the lesion due to involvement of nearby motor and sensory pathways [1]. *Thalamus* - While the **thalamus** is a common site for hypertensive hemorrhages, it is less common than the putamen [1], [2]. - Thalamic hemorrhages typically cause **contralateral sensory loss**, **oculomotor dysfunction**, and sometimes **aphasia** if the dominant hemisphere is affected. *Cerebellum* - **Cerebellar hemorrhages** are less frequent than those in the basal ganglia or thalamus [1]. - Symptoms usually include **ataxia**, **nystagmus**, vomiting, and potential brainstem compression if large. *Pons* - **Pontine hemorrhages** are among the most severe and are often rapidly fatal due to damage to vital brainstem structures [1], [2]. - They typically present with **coma**, **quadriparesis**, **pinpoint pupils**, and rapid progression to respiratory arrest.
Question 6: Which artery is the major supply of the medial surface of the cerebral hemisphere?
- A. Anterior cerebral artery (Correct Answer)
- B. Posterior cerebral artery
- C. Middle cerebral artery
- D. Posterior inferior cerebellar artery
Explanation: ***Anterior cerebral artery*** - The **anterior cerebral artery (ACA)** is a primary branch of the internal carotid artery and is responsible for supplying blood to the **medial surface** of the frontal and parietal lobes of the cerebral hemispheres [1]. - It also supplies the **corpus callosum**, the superior aspect of the frontal and parietal lobes, and parts of the basal ganglia [1]. *Posterior cerebral artery* - The **posterior cerebral artery (PCA)** primarily supplies the **occipital lobe** and the inferior part of the **temporal lobe** [1]. - It also provides blood to parts of the midbrain and the **thalamus** [1]. *Middle cerebral artery* - The **middle cerebral artery (MCA)** is the largest cerebral artery and supplies most of the **lateral surface** of the cerebral hemispheres [1]. - It is crucial for the blood supply to the **motor and sensory cortices** for the face and upper limb, as well as language areas (Broca's and Wernicke's). *Posterior inferior cerebellar artery* - The **posterior inferior cerebellar artery (PICA)** is a branch of the **vertebral artery** and exclusively supplies the **cerebellum** and the lateral medulla. - It is not involved in the blood supply to the cerebral hemispheres.
Question 7: A woman presenting with abrupt onset of "the worst headache of her life" Which is the best investigation?
- A. Vessel carotid Doppler
- B. NCCT of the head (Correct Answer)
- C. No imaging
- D. MRI
Explanation: ***NCCT of the head*** - A **non-contrast CT scan of the head** is the immediate and most appropriate first imaging study for a suspected **subarachnoid hemorrhage (SAH)**, often presenting as the "worst headache of her life" [1]. - It can rapidly detect blood in the **subarachnoid space** with high sensitivity, particularly within the first 6-12 hours of symptom onset [1], [2]. *Vessel carotid Doppler* - **Carotid Doppler ultrasound** is primarily used to assess **carotid artery stenosis** or dissection, which would not be the initial investigation for a sudden severe headache [2]. - It does not visualize intracranial blood or vascular abnormalities within the brain parenchyma or subarachnspace. *No imaging* - Given the severe, abrupt onset "worst headache of her life," **subarachnoid hemorrhage (SAH)** is a critical differential, making no imaging an inappropriate and potentially dangerous choice. - Delaying imaging could lead to severe neurological consequences if SAH is missed. *MRI* - While **MRI** can detect SAH, it is generally less accessible, takes more time to perform, and is less suitable for the initial rapid assessment of **acute SAH** compared to NCCT [3]. - **MRI** is often used for follow-up evaluation or when CT findings are equivocal, but not as the first-line emergency investigation.
Question 8: Thrombosis of the superior branch of the middle cerebral artery leads to:
- A. Aphasia affecting speech production (Correct Answer)
- B. Inability to control urination
- C. Increased grasp reflex
- D. Loss of peripheral vision
Explanation: Aphasia affecting speech production - The **superior branch of the middle cerebral artery (MCA)** supplies the **Broca's area** (Brodmann areas 44 and 45) in the dominant hemisphere [1]. - Damage to Broca's area results in **expressive aphasia**, characterized by difficulty producing speech, while comprehension is relatively preserved [2]. *Inability to control urination* - **Urinary incontinence** is more commonly associated with lesions affecting the **frontal lobe** (especially the medial frontal cortex) or descending pathways, rather than the isolated superior MCA territory. - This symptom is often seen in conditions like **normal pressure hydrocephalus** or **anterior cerebral artery strokes** due to involvement of the paracentral lobule. *Increased grasp reflex* - An **increased grasp reflex** (palmo-mental reflex) is a **frontal release sign**, indicating damage to the frontal lobes, which are primarily supplied by the **anterior cerebral artery (ACA)** or more diffuse frontal lesions [1]. - While the superior MCA supplies part of the frontal lobe, an isolated grasp reflex is not the most typical or specific finding for a superior MCA stroke. *Loss of peripheral vision* - **Loss of peripheral vision** (hemianopia or quadrantanopia) is typically due to damage to the **optic radiations** or **visual cortex** in the occipital lobe. - These areas are primarily supplied by the **posterior cerebral artery (PCA)**, not the middle cerebral artery.
Question 9: Which of the following arteries is likely to be involved in a 3rd cranial nerve lesion?
- A. Anterior communicating
- B. Posterior communicating (Correct Answer)
- C. Posterior cerebral
- D. Anterior cerebral
Explanation: ***Posterior communicating*** - The **posterior communicating artery (PCoA)** is anatomically juxtaposed to the **oculomotor nerve (CN III)** as it exits the midbrain. - An **aneurysm** of the PCoA can compress the CN III, leading to findings such as **ptosis**, **mydriasis**, and **"down and out" deviation** of the eye [1]. *Anterior communicating* - The **anterior communicating artery (AComA)** is located more anteriorly and inferiorly, primarily associated with the **optic chiasm** and **olfactory tracts**. - While aneurysms here can cause visual field defects or frontal lobe dysfunction, they are less likely to directly compress the **oculomotor nerve**. *Posterior cerebral* - The **posterior cerebral artery (PCA)** supplies regions like the **visual cortex** and midbrain. - PCA aneurysms or infarctions typically result in deficits such as **hemianopia**, **alexia**, or specific midbrain syndromes, not isolated CN III compression. *Anterior cerebral* - The **anterior cerebral artery (ACA)** supplies the medial aspects of the frontal and parietal lobes. - Aneurysms or strokes in the ACA territory commonly lead to **contralateral leg weakness** or behavioral changes, not cranial nerve palsies due to its anatomical location.
Question 10: The following are the psychiatric sequelae after stroke in the elderly: a) Depression b) Post-traumatic stress disorder c) Dementia d) Hysteria
- A. bc
- B. a
- C. ac (Correct Answer)
- D. b
Explanation: ***ac (Depression + Dementia)*** Post-stroke psychiatric sequelae in the elderly primarily include: **a) Depression** - ✓ CORRECT - Post-stroke depression affects 30-50% of stroke survivors - Results from both neurobiological changes (disruption of monoaminergic pathways) and psychological reaction to disability - Significantly impacts rehabilitation and recovery outcomes - Recognized as the most common psychiatric complication after stroke **c) Dementia** - ✓ CORRECT - Vascular dementia is a well-established consequence of stroke - Risk of dementia doubles after stroke - Cognitive impairment occurs in 20-30% of post-stroke patients - Can result from strategic single infarcts or cumulative vascular damage *b) Post-traumatic stress disorder* - INCORRECT - While PTSD can occasionally occur after severe strokes with traumatic ICU experiences, it is NOT a common or primary psychiatric sequela - Incidence is low compared to depression and cognitive impairment - Not considered a typical post-stroke psychiatric complication *d) Hysteria* - INCORRECT - "Hysteria" is an outdated term no longer used in modern psychiatric classification - NOT a recognized psychiatric sequela of stroke in the elderly - Conversion disorders are rare after stroke and have different etiology
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