Vascular Pathology Practice Questions

Q: Which is true about the image shown?

Mönckeberg's Arteriosclerosis. ***Monckeberg's Arteriosclerosis*** - This condition involves **calcification of the media of muscular arteries**, typically in individuals over 50 years old. - It is characterized by **ring-like calcifications** in the vessel wall, which can be seen on imaging or histology, and is usually not clinically significant as it does not narrow the lumen. *Hyaline Arteriosclerosis* - This type is characterized by **homogeneous, pink, hyaline thickening** of the walls of arterioles, with narrowing of the lumen. - It is typically seen in **benign hypertension** and **diabetes mellitus**, affecting small arteries and arterioles. *Hyperplastic Arteriosclerosis* - This condition is associated with **malignant hypertension** and is characterized by **concentric, laminated thickening** of the arteriole walls, often described as "onion-skinning." [1] - It involves proliferation of smooth muscle cells and reduplication of the basement membrane, leading to severe luminal narrowing [1]. *Fibrinoid necrosis* - This is a form of **necrosis** seen in the walls of blood vessels, characterized by deposition of **fibrin-like material** that stains intensely eosinophilic. - It is typically associated with **malignant hypertension** [2], **vasculitis**, or immune-mediated vascular damage, and is not a primary form of arteriosclerosis. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Kidney, p. 945. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Cardiovascular Disease, pp. 276-277.

Q: Which of the following are correct about glomus tumour? 1. It arises from Suquet-Hoyer canals. 2. Its usual site is nail bed. 3. It is usually a small purple nodule. 4. It is painless.

1, 2 and 3. ***1, 2 and 3*** - Glomus tumors originate from the **Suquet-Hoyer canals**, specialized arteriovenous anastomoses involved in thermoregulation. - They are most frequently found in the **nail bed** (especially subungual region) as small, **purple** (reddish-blue) nodules and are typically very painful. - The classic triad includes severe pain, cold sensitivity, and point tenderness. *1, 2 and 4* - This option incorrectly states that glomus tumors are **painless**. In fact, they are characterized by severe pain due to their rich innervation. - While correct that they arise from Suquet-Hoyer canals and are found in the nail bed, the **painlessness** aspect is inaccurate. *2, 3 and 4* - This option incorrectly includes the statement that glomus tumors are **painless**, which contradicts a key distinguishing feature. - Although glomus tumors are typically found in the nail bed and appear as purple nodules, pain is a characteristic clinical feature, not absence of pain. *1, 3 and 4* - This option incorrectly states that glomus tumors are **painless** and omits the correct statement about the usual nail bed location. - While they do arise from Suquet-Hoyer canals and can be small purple nodules, their characteristic severe pain makes this option incorrect.

Q: Berry aneurysm most commonly occurs due to?

Medial layer and internal elastic lamina defect. ***Medial layer and internal elastic lamina defect*** - **Berry aneurysms** are most commonly saccular dilatations that occur at arterial bifurcations in the **Circle of Willis** [1]. - These aneurysms result from a congenital or acquired weakness in the **tunica media** and the **internal elastic lamina** at these bifurcation points, making the vessel wall susceptible to high pressures [1]. *Muscle and adventitial layer defect* - Defects primarily in the **muscle layer** (media) and **adventitia** are less commonly the primary cause of berry aneurysms. - While all layers contribute to vessel integrity, the specific absence in the medial and internal elastic lamina is key for berry aneurysms [1]. *Endothelial injury of vessel due to HTN* - While hypertension is a significant **risk factor** for aneurysm formation and rupture, it primarily exacerbates existing structural weaknesses rather than being the direct cause of the initial structural defect. - **Endothelial injury alone** is not the primary anatomical defect responsible for generating berry aneurysms; it contributes to atherosclerosis, which can lead to other types of aneurysms. *Adventitia defect* - A defect solely in the **adventitia** is not the primary predisposing factor for berry aneurysms. - The adventitia provides external support, but the integrity of the media and internal elastic lamina is crucial for maintaining the vessel's structural strength against intraluminal pressure [1]. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Central Nervous System, pp. 1272-1273.

Q: Which is associated with vasculitis of medium sized vessels

Polyarteritis nodosa. ***Polyarteritis nodosa*** - **Polyarteritis nodosa (PAN)** is a **necrotizing vasculitis** of **medium-sized or small arteries**, but not arterioles, capillaries, or venules [1]. - It classically affects the **renal and visceral arteries**, sparing the pulmonary circulation, and is associated with **aneurysms** and stenoses. *Temporal arteritis* - This is a form of **large-vessel vasculitis** primarily affecting the **temporal and other cranial arteries** [1]. - It is typically seen in older adults and can cause **headache**, **jaw claudication**, and **blindness**. *Wegener's granulomatosis* - Now known as **Granulomatosis with Polyangiitis (GPA)**, this vasculitis affects **small vessels** and is characterized by a **granulomatous inflammation** of the upper and lower respiratory tracts and kidneys [1]. - It is associated with **PR3-ANCA (c-ANCA)** positivity. *Henoch-Schönlein purpura* - This is an **IgA vasculitis** affecting **small vessels**, typically presenting with **palpable purpura**, arthritis, abdominal pain, and renal involvement (nephritis) [1]. - It is the most common form of vasculitis in children.

Q: In polyarteritis nodosa, aneurysms are seen in all organs EXCEPT:

Lung. ***Lung*** - Polyarteritis nodosa (PAN) typically **spares the pulmonary circulation**, which helps distinguish it from other vasculitides like granulomatosis with polyangiitis (Wegener's) or eosinophilic granulomatosis with polyangiitis (Churg-Strauss) [3]. - Aneurysms are characteristic of PAN and occur in **medium-sized arteries** of various organs but are notably absent in the lungs [1]. *Pancreas* - The pancreas is a common site for vasculitic involvement in PAN, with **microaneurysms** and infarctions frequently observed in its arteries [2]. - Pancreatic involvement can lead to abdominal pain, pancreatitis, and other gastrointestinal symptoms [2]. *Kidney* - The **renal arteries** are frequently affected in PAN, leading to aneurysms, infarctions, and stenosis [1]. - This often results in **hypertension, renal insufficiency**, and hematuria, making kidney involvement a major cause of morbidity and mortality. *Liver* - **Hepatic artery aneurysms** are a recognized feature of PAN, often identified incidentally during imaging studies. - While less common than renal involvement, hepatic vasculitis can lead to abdominal pain and deranged liver function tests. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of Infancy and Childhood, pp. 517-518. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Osteoarticular And Connective Tissue Disease, pp. 687-688. [3] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of Infancy and Childhood, pp. 519-520.

Q: True about Henoch-Schonlein purpura are the following, EXCEPT:

Is associated with a raised IgE in mesangium. ***Is associated with a raised IgE in mesangium*** - **Henoch-Schonlein Purpura (HSP)** is characterized by **IgA deposition** in the mesangium, not IgE. This IgA deposition is a key pathological feature driving the renal manifestations. - While IgE can be elevated in some allergic conditions, it is not a hallmark of HSP's immune complex deposition in the kidneys. *50% patients can present with GN* - This statement is largely true; **glomerulonephritis (GN)**, ranging from microscopic hematuria to advanced renal failure, is a common complication affecting approximately 30-50% of HSP patients. - The severity of renal involvement is highly variable and can significantly impact the long-term prognosis of the disease. *Can present with abdominal pain* - **Abdominal pain** is a very common gastrointestinal manifestation of HSP, often described as colicky and severe, sometimes accompanied by nausea, vomiting, and gastrointestinal bleeding [1]. - This symptom results from vasculitis affecting the small blood vessels of the gastrointestinal tract, leading to **edema** and **hemorrhage** in the bowel wall. *Primarily a small vessel vasculitis* - HSP is indeed a **leukocytoclastic vasculitis** [2] that predominantly affects **small vessels**, particularly post-capillary venules. - This vasculitis leads to the characteristic palpable purpura [2], as well as the involvement of the gastrointestinal tract, joints, and kidneys. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of Infancy and Childhood, pp. 518-519. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Cardiovascular Disease, pp. 279-280.

Q: Which one of the following does not cause small vessel vasculitis?

Kawasaki disease. ***Kawasaki disease*** - **Kawasaki disease** is a **medium vessel vasculitis** that primarily affects the coronary arteries in children, not small vessels [1]. - It is characterized by fever, rash, lymphadenopathy, and mucocutaneous involvement, with a risk of coronary artery aneurysms [1]. *Churg-Strauss syndrome* - **Churg-Strauss syndrome** (now known as **Eosinophilic Granulomatosis with Polyangiitis** or **EGPA**) is a type of **ANCA-associated vasculitis** that frequently involves small vessels [1]. - It is characterized by asthma, **eosinophilia**, and granulomatous inflammation, often affecting the lungs, skin, and kidneys [1]. *Henoch-Schönlein purpura* - **Henoch-Schönlein purpura** (**IgA vasculitis**) is a common form of **small vessel vasculitis** in children and young adults [1]. - It is characterized by a classic tetrad of palpable **purpura**, **arthralgia**, **abdominal pain**, and **renal disease** [1]. *Microscopic polyangiitis* - **Microscopic polyangiitis** (MPA) is a severe form of **ANCA-associated small vessel vasculitis**. - It typically causes necrotizing glomerulonephritis and pulmonary capillaritis without granuloma formation [2].

Question 1

Which is true about the image shown?

Accepted Answer

Mönckeberg's Arteriosclerosis

Answer

Hyaline Arteriosclerosis

Answer

Hyperplastic Arteriosclerosis

Answer

Fibrinoid necrosis

Question 2

Which of the following are the malignancies associated with lymphoedema?
I. Kaposi Sarcoma
II. Squamous cell carcinoma
III. Malignant melanoma
IV. Leukaemia

Select the correct answer using the code given below :

Accepted Answer

I, II and IV

Answer

II, III and IV

Answer

I, III and IV

Answer

I, II and III

Question 3

Which of the following are correct about glomus tumour?

1. It arises from Suquet-Hoyer canals.
2. Its usual site is nail bed.
3. It is usually a small purple nodule.
4. It is painless.

Accepted Answer

1, 2 and 3

Answer

1, 2 and 4

Answer

2, 3 and 4

Answer

1, 3 and 4

Question 4

The malignancy associated with Stewart-Treves syndrome is

Accepted Answer

Lymphangiosarcoma

Answer

Basal cell carcinoma

Answer

Liposarcoma

Answer

Malignant melanoma

Question 5

A 50-year-old man presents with headache, chest discomfort, and blurred vision. His headache started 2 days ago and has not improved. He describes it as severe, throbbing, localized to the occipital part of the head and worse at the end of the day. He says he has associated nausea but denies any vomiting. Past medical history is significant for hypertension diagnosed 15 years ago, managed with beta-blockers until the patient self d/c’ed them a month ago. He has not seen a physician for the past 2 years. Family history is significant for hypertension and an ST-elevation myocardial infarction in his father and diabetes mellitus in his mother. Vitals signs are a blood pressure of 200/110 mm Hg, a pulse rate of 100/min and respiratory rate of 18/min Ophthalmoscopy reveals arteriolar nicking and papilledema. His ECG is normal. Laboratory findings are significant for a serum creatinine of 1.4 mg/dL and a blood urea nitrogen of 25 mg/dL. Urinalysis has 2+ protein.  He is started on intravenous nitroprusside. Which of the following best explains the pathophysiology responsible for the neovascular changes present in this patient?

Accepted Answer

Smooth muscle hyperplasia and duplication of the basement membrane

Answer

Protein deposition in the vascular lumen

Answer

Transmural calcification of arterial walls

Answer

Weakening of vessel wall following endothelial injury

Answer

Cholesterol deposition in the vascular lumen

Question 6

Berry aneurysm most commonly occurs due to?

Accepted Answer

Medial layer and internal elastic lamina defect

Answer

Muscle and adventitial layer defect

Answer

Endothelial injury of vessel due to HTN

Answer

Adventitia defect

Question 7

Which is associated with vasculitis of medium sized vessels

Accepted Answer

Polyarteritis nodosa

Answer

Wegener's granulomatosis

Answer

Temporal arteritis

Answer

Henoch-Schönlein purpura

Question 8

In polyarteritis nodosa, aneurysms are seen in all organs EXCEPT:

Accepted Answer

Lung

Answer

Pancreas

Answer

Kidney

Answer

Liver

Question 9

True about Henoch-Schonlein purpura are the following, EXCEPT:

Accepted Answer

Is associated with a raised IgE in mesangium

Answer

50% patients can present with GN

Answer

Can present with abdominal pain

Answer

Primarily a small vessel vasculitis

Question 10

Which one of the following does not cause small vessel vasculitis?

Accepted Answer

Kawasaki disease

Answer

Churg - strauss syndrome

Answer

Henoch - Schonlein purpura

Answer

Microscopic polyangiitis

Vascular Pathology — MCQs

Vascular Pathology — MCQs

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