Cerebrovascular Diseases — MCQs
A 45-year-old man presents with weakness in his right arm and slurred speech that started suddenly 2 hours ago. Which diagnostic test is most appropriate to confirm the diagnosis?
Which of the following statements about deep venous thrombosis (DVT) is incorrect?
What is the imaging modality of choice for determining the etiology of subarachnoid hemorrhage?
Identify the condition in the image below?
A woman presenting with abrupt onset of "the worst headache of her life" Which is the best investigation?
A 50-year-old man suddenly developed right-sided weakness and aphasia within 2 hours. His BP recorded was 160/110mmHg and NCCT was clear. What is the next step in management?
A 55-year-old male, known smoker, complains of calf pain while walking. He experiences calf pain while walking but can continue walking with effort. Which grade of claudication does this patient fall under?
Which of the following abnormalities is most commonly detected as a vascular malformation on skull MRI?
Statement 1 - A 59-year-old patient presents with flaccid bullae. Histopathology shows a suprabasal acantholytic split. Statement 2 - The row of tombstones appearance is diagnostic of Pemphigus vulgaris.
Spine MRI shows 'pencil-sharpened' vertebral bodies and 'H-shaped' vertebrae on T1-weighted images. Most likely diagnosis?
Cerebrovascular Diseases Indian Medical PG Practice Questions and MCQs
Question 1: A 45-year-old man presents with weakness in his right arm and slurred speech that started suddenly 2 hours ago. Which diagnostic test is most appropriate to confirm the diagnosis?
- A. Nerve conduction study
- B. Electroencephalogram (EEG)
- C. CT scan of the head (Correct Answer)
- D. MRI of the spine
Explanation: ***CT scan of the head*** - A **CT scan of the head** is the most appropriate initial diagnostic test for sudden onset neurological deficits like **weakness** and **slurred speech** to rule out an acute intracranial hemorrhage or ischemic stroke [1]. - It is rapid, widely available, and crucial for guiding immediate management decisions [1]. *Nerve conduction study* - **Nerve conduction studies** are used to evaluate the function of peripheral nerves and muscles, typically for conditions like **neuropathy** or myasthenia gravis, which are not suggested by the acute, focal central nervous system symptoms. - These studies would not provide time-sensitive information about an acute stroke or hemisphere. *Electroencephalogram (EEG)* - An **EEG** measures electrical activity in the brain and is primarily used to diagnose **seizure disorders**, sleep disorders, or assess altered mental status. - It is not indicated for the initial evaluation of sudden focal neurological deficits such as stroke. *MRI of the spine* - An **MRI of the spine** is used to visualize the spinal cord and surrounding structures to diagnose conditions like **spinal cord compression**, disc herniation, or myelitis. - The patient's symptoms of right arm weakness and slurred speech clearly localize to the brain, not the spine.
Question 2: Which of the following statements about deep venous thrombosis (DVT) is incorrect?
- A. Mostly bilateral (Correct Answer)
- B. Most common clinically presents as pain and tenderness in calf
- C. Some cases may directly present as pulmonary thromboembolism
- D. Clinical assessment highly reliable
Explanation: ***Mostly bilateral*** - DVT is typically **unilateral**, affecting one limb [2]. Bilateral DVT is less common, making this statement incorrect [2]. - The symptoms of **pain, swelling, and tenderness** are usually localized to one leg [1]. *Most common clinically presents as pain and tenderness in calf* - **Calf pain and tenderness** are common clinical presentations of DVT, especially in the lower extremities [1]. - Other common signs include **swelling, warmth, and redness** in the affected leg [1]. *Some cases may directly present as pulmonary thromboembolism* - A significant concern with DVT is that a **clot can dislodge** and travel to the lungs, causing a **pulmonary embolism (PE)**, which can be the initial presentation [1]. - PE is a potentially life-threatening complication and may present with **dyspnea, chest pain, and hemoptysis**. *Clinical assessment highly reliable* - **Clinical assessment alone is not highly reliable** for diagnosing DVT due to its variable and often non-specific presentation [2]. - A definitive diagnosis usually requires objective diagnostic tests such as **compression ultrasonography** or **D-dimer assay** [3].
Question 3: 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 4: Identify the condition in the image below?
- A. Lacunar infarct (Correct Answer)
- B. Embolic infarct
- C. Thrombotic infarct
- D. Intracerebral hemorrhage
Explanation: ***Lacunar infarct*** - The image displays a small, well-demarcated **hypodensity** (darker area) in the basal ganglia region, characteristic of a lacunar infarct. - Lacunar infarcts are typically caused by **occlusion of small perforating arteries** and result in small, deep infarcts, often appearing as precise, round or ovoid lesions on CT. *Embolic infarct* - Embolic infarcts tend to be **larger**, wedge-shaped, and often extend to the cortical surface, unlike the deep, small lesion seen. - They are commonly associated with a **cardiac source** or large artery atherosclerosis leading to distal embolization. *Thrombotic infarct* - Thrombotic infarcts are usually **larger** areas of infarction due to occlusion of a major artery, often preceded by symptoms like TIAs. - While they also appear hypodense, they are typically **more extensive** and less precisely defined than a lacunar infarct in the early stages. *Intracerebral hemorrhage* - Intracerebral hemorrhage would appear as a **hyperdense** (bright white) area on a non-contrast CT scan due to the presence of acute blood. - The image clearly shows a **hypodense lesion**, ruling out acute hemorrhage.
Question 5: 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 6: A 50-year-old man suddenly developed right-sided weakness and aphasia within 2 hours. His BP recorded was 160/110mmHg and NCCT was clear. What is the next step in management?
- A. Tab labetalol 10 mg stat
- B. MRI brain with DWI
- C. Thrombolysis
- D. CT angiography to look for large vessel occlusion (Correct Answer)
Explanation: ***CT angiography to look for large vessel occlusion*** - The patient presents with **acute neurological deficits** (right-sided weakness and aphasia) occurring within 2 hours, making him a candidate for acute stroke intervention. A **clear NCCT** rules out hemorrhage but doesn't exclude an ischemic stroke [1]. - Given the acute onset and significant neurological deficits, it is crucial to determine if there is a **large vessel occlusion (LVO)** that could be treatable with endovascular thrombectomy, especially if the window for IV thrombolysis is closing or contraindicated [1]. *Tab labetalol 10 mg stat* - While the patient's **blood pressure is elevated (160/110 mmHg)**, aggressive lowering of blood pressure in acute ischemic stroke can worsen outcomes by reducing cerebral perfusion, especially before reperfusion strategies are initiated. - Blood pressure management guidelines for acute ischemic stroke without clear reperfusion options generally suggest allowing for higher blood pressure to maintain cerebral perfusion, unless it's excessively high (e.g., >220/120 mmHg or >185/110 mmHg if considering thrombolysis). *MRI brain with DWI* - **Diffusion-weighted imaging (DWI)** is highly sensitive for **acute ischemic changes** within minutes of onset and would confirm an ischemic stroke [2]. - However, in the hyperacute setting, especially with significant neurological deficits, the priority is to identify an LVO quickly for potential thrombectomy, which **CT angiography (CTA)** can provide more rapidly than MRI in many emergency settings [1]. *Thrombolysis* - **Intravenous thrombolysis** can be considered if the patient meets criteria, typically within **4.5 hours of symptom onset**. - While thrombolysis is a potential treatment, the **next most critical step** after ruling out hemorrhage in a potential LVO case is to identify the occlusion with CTA to determine eligibility for endovascular thrombectomy, which may be beneficial even beyond the IV thrombolysis window [1].
Question 7: A 55-year-old male, known smoker, complains of calf pain while walking. He experiences calf pain while walking but can continue walking with effort. Which grade of claudication does this patient fall under?
- A. Grade I (Mild claudication)
- B. Grade II (Moderate claudication) (Correct Answer)
- C. Grade III (Severe claudication)
- D. Grade IV (Ischemic rest pain)
Explanation: ***Grade II (Moderate claudication)*** - **Grade II claudication** is characterized by **intermittent claudication** where the patient experiences pain while walking but can **continue walking with effort**. - This level of claudication reflects a moderate degree of peripheral arterial disease, where blood flow is sufficiently compromised to cause pain with exertion but not severe enough to force immediate cessation of activity. - The patient in this scenario can continue ambulation despite discomfort, which is the defining feature of this grade. *Grade I (Mild claudication)* - **Grade I claudication** involves discomfort or pain that the patient can **tolerate without significantly altering their gait or pace**. - In this stage, the pain is minimal, and the patient may perceive it as a dull ache or mild fatigue rather than true pain. - Walking can continue without significant effort or limitation. *Grade III (Severe claudication)* - **Grade III claudication** is marked by pain that is **severe enough to stop the patient from walking within a short distance** (typically less than 200 meters). - The pain forces the patient to rest and recover before they can resume walking. - This represents significant functional limitation in daily activities. *Grade IV (Ischemic rest pain)* - **Grade IV**, also known as **critical limb ischemia**, involves **pain even at rest**, especially in the feet or toes, often worsening at night when the limb is elevated. - This stage indicates severe arterial obstruction and is frequently associated with **ulcers, non-healing wounds, or gangrene**. - This represents advanced peripheral arterial disease requiring urgent intervention. **Note:** This grading system is a simplified clinical classification. The standard medical classifications for peripheral arterial disease are the **Fontaine classification** (Stages I-IV) and **Rutherford classification** (Categories 0-6).
Question 8: Which of the following abnormalities is most commonly detected as a vascular malformation on skull MRI?
- A. Vein of Galen abnormalities (Correct Answer)
- B. Dandy Walker malformation
- C. Pneumocephalus presence
- D. Crouzon syndrome features
Explanation: ***Vein of Galen abnormalities*** - **Vein of Galen malformations (VOGM)** are the **most common symptomatic cerebral vascular malformations in neonates and infants**, accounting for approximately **30% of pediatric cerebral vascular malformations**. - They often present with **high-output cardiac failure**, hydrocephalus, or seizures in early life. - On **MRI**, they appear as a large, abnormal midline venous pouch in the quadrigeminal cistern with characteristic **flow voids** on T2-weighted images. - VOGM represents an **arteriovenous shunt** to a persistent embryonic vein (median prosencephalic vein of Markowski). *Dandy Walker malformation* - This is a **congenital brain malformation** involving the cerebellum and fourth ventricle, characterized by hypoplasia of the cerebellar vermis, cystic dilatation of the fourth ventricle, and an enlarged posterior fossa. - While readily seen on MRI, it is a **structural developmental anomaly**, not a vascular malformation. *Pneumocephalus presence* - **Pneumocephalus** refers to the presence of **air within the intracranial cavity**, usually resulting from trauma, neurosurgery, or skull base fractures. - It is an **acquired condition**, not a congenital vascular malformation, and appears as dark signal (air) on all MRI sequences. *Crouzon syndrome features* - **Crouzon syndrome** is a genetic disorder (FGFR2 mutation) characterized by **craniosynostosis** with premature fusion of coronal and sagittal sutures, leading to brachycephaly and midface hypoplasia. - It is a **craniofacial skeletal disorder**, not a vascular malformation.
Question 9: Statement 1 - A 59-year-old patient presents with flaccid bullae. Histopathology shows a suprabasal acantholytic split. Statement 2 - The row of tombstones appearance is diagnostic of Pemphigus vulgaris.
- A. Statements 1 & 2 are correct, 2 is not explaining 1 (Correct Answer)
- B. Statements 1 and 2 are correct and 2 is the correct explanation for 1
- C. Statements 1 and 2 are incorrect
- D. Statement 1 is incorrect
Explanation: ***Correct: Statements 1 & 2 are correct, 2 is not explaining 1*** **Analysis of Statement 1:** - A 59-year-old patient with **flaccid bullae** and **suprabasal acantholytic split** on histopathology is the classic presentation of **Pemphigus vulgaris** - The flaccid (easily ruptured) nature of bullae distinguishes it from tense bullae seen in bullous pemphigoid - The suprabasal location of the split (just above the basal layer) with acantholysis (loss of cell-to-cell adhesion) is pathognomonic - **Statement 1 is CORRECT** ✓ **Analysis of Statement 2:** - The **"row of tombstones" or "tombstone appearance"** is indeed a diagnostic histopathological feature of Pemphigus vulgaris - This appearance results from basal keratinocytes remaining attached to the basement membrane while suprabasal cells separate due to acantholysis - The intact basal cells standing upright resemble a row of tombstones - **Statement 2 is CORRECT** ✓ **Does Statement 2 explain Statement 1?** - Statement 2 describes a **histopathological appearance** (tombstone pattern) that is a **consequence** of the suprabasal split - However, it does NOT explain the **underlying cause** of the flaccid bullae or the suprabasal split - The true explanation involves **IgG autoantibodies against desmoglein 3 (and desmoglein 1)**, which attack intercellular adhesion structures (desmosomes), causing **acantholysis** - Therefore, **Statement 2 does NOT explain Statement 1** ✗ *Incorrect: Statement 2 is the correct explanation for Statement 1* - While both statements describe features of Pemphigus vulgaris, the tombstone appearance is a descriptive finding, not an explanatory mechanism *Incorrect: Statements 1 and 2 are incorrect* - Both statements are medically accurate descriptions of Pemphigus vulgaris features *Incorrect: Statement 1 is incorrect* - Statement 1 correctly describes the cardinal clinical and histopathological features of Pemphigus vulgaris
Question 10: Spine MRI shows 'pencil-sharpened' vertebral bodies and 'H-shaped' vertebrae on T1-weighted images. Most likely diagnosis?
- A. Thalassemia
- B. Osteopetrosis
- C. Sickle cell disease (Correct Answer)
- D. Paget's disease
Explanation: ***Sickle cell disease*** - **Sickle cell disease** can lead to vertebral body changes due to **bone infarction** and **hyperplasia of hematopoietic marrow**, causing central depression and characteristic 'H-shaped' or 'pencil-sharpened' vertebrae. - The abnormal hemoglobin in sickle cell anemia causes red blood cells to stiffen and form a crescent or "sickle" shape, leading to a host of debilitating symptoms and early death. *Thalassemia* - **Thalassemia** can cause widespread marrow expansion leading to generalized osteopenia and widened medullary spaces, but typically does not result in the focal 'H-shaped' vertebral changes seen with infarction. - While it also causes anemia and bone changes, the specific vertebral findings described are not characteristic of thalassemia. *Osteopetrosis* - **Osteopetrosis** is characterized by **increased bone density** and brittle bones, often described as a "stone bone" appearance. - This condition leads to thickened, sclerotic bones and does not produce the 'H-shaped' or 'pencil-sharpened' vertebral deformities. *Paget's disease* - **Paget's disease** is characterized by disorganized bone remodeling, leading to bone enlargement and deformity with a characteristic **"cotton wool" appearance** on imaging. - While it affects vertebrae, it typically results in cortical thickening and coarsened trabeculae, not the specific 'H-shaped' deformity.
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