Cerebrovascular Disease Question Bank

A 62-year-old male was admitted with sudden onset dizziness and slurred speech. He has a past medical history of hypertension, BPPV, epilepsy and episodic migraine with aura. His medications include lisinopril, atorvastatin, carbamazepine and flunarazine.

On examination, there is evidence of left-sided appendicular ataxia and hemifacial sensory loss with contralateral hemisensory spinothalamic loss below the face. His left pupil is 3mm and right pupil is 5mm. Power examination is normal.

What is the most likely cause of his symptoms?

You are analysing a local UK population of 10,000 and asked to estimate number of TIAs expected to occur within the catchment. 

What is the closest estimate to this number?

A 52-year-old female with a background of hypertension, psoriasis and vestibular neuritis is admitted with reduced consciousness. Her medications include methotrexate, folic acid, amlodipine and PRN prochlorperazine. The evening prior to admission, she had been on a roller-coaster ride after having a few drinks. Her friends tell you she complained of spinning vertigo afterwards and had to take herself home. She is brought to the Emergency Department the next day with prolonged confusion. 

On examination she is drowsy but rousable. Her GCS is 8 (M3 V2 E3). There is vertical skew deviation of gaze. Her limbs are moving but you are unable to test her power formally.

An MRI is performed and shown below.

What is the cause of her presentation?

A 64-year-old right-handed male unexpectedly attends the Emergency Department with FAST positive symptoms. He works as an accountant and has a background of type 2 diabetes mellitus. He has a 20-pack year smoking history.

Further questioning reveals that he has been unable to calculate basic sums at work today and examination reveals some inability to co-ordinate his left and right.

An acute stroke is suspected and an urgent CT-brain is ordered whilst awaiting the stroke team’s arrival. Which area of the brain is most likely to be affected?

A 74-year-old female with a background of ischaemic heart disease and migraine without aura presents with recurrent sensory symptoms spreading from the right hand to the elbow and then the face over minutes. This has happened four times without any impairment of consciousness, weakness or headache.

There are no other neurological findings and a CT-brain in the emergency department reveals a left-sided cortical subarachnoid haemorrhage (SAH). Her medications include clopidogrel, atorvastatin, bisoprolol and ramipril. 

What is the next most helpful investigation for the probable diagnosis?

A 72-year-old male presents to the Emergency Department with an acute onset of altered (warm) sensation and later numbness affecting right hemi-face and right upper limb. He has a past medical history of type 2 diabetes (recent HbA1c 72 mmol/mol), hypertension and depression. His symptoms started 48 hours previously and fluctuated over this time. 

On examination, his NIHSS is 0 with a normal neurological examination. His ECG shows normal sinus rhythm. 

His MRI (DWI) is shown below.

What is the diagnosis?

A 68-year-old male attends outpatients with dysesthesia and burning of moderate intensity in the region of his previous stroke. He suffered an acute stroke three months ago affecting the right arm and leg (see image below).

What is the name of this condition?

A 76-year-old female attends the Emergency Department with sudden onset right facial droop and diplopia. She has a past medical history of left Bell’s palsy, pre-diabetes and left-eye esotropia in childhood. 

On examination, you note a right facial droop without forehead sparing and with weakness of orbicularis oculi. On assessment of eye movements there is non-fatigable painless horizontal diplopia, an esotropic left squint and right eye abduction failure. Limb examination reveals no tremor, hemi-ataxia or choreoathetosis but there is some subtle weakness of the right-upper limb (MRC grade 4/5). 

What is the most likely eponymous syndrome in question?

A 62-year-old female presents to the Emergency department with sudden onset rotary vertigo, left-sided hypoacusis, hemiataxia and hemifacial sensory loss with loss of pain and temperature sensation affecting the right arm and leg.

On examination, she has a Horner’s syndrome on the left

Which of the following is the most likely diagnosis?

A 64-year-old gentleman attends the Emergency Department with acute onset diplopia and imbalance. He has a past medical history of essential tremor and hypercholesterolaemia. His medications include primidone 250mg BD and atorvastatin 20mg ON. 

On examination, his right eye is in the ‘down and out’ position with no anisocoria. There is also a left hand tremor and left hemiataxia. 

Where is the lesion most likely to be?

A 45-year-old male is admitted with an acute total anterior circulation stroke. There is a family history of young strokes on his father’s side. 

Diagnostic work-up with carotid dopplers, trans-thoracic echocardiogram and serological tests are unremarkable. 

An MRI-brain reveals white matter signal change within the anterior temporal poles bilaterally with dilated perivascular spaces and subcortical lacunes. A skin biopsy is done given diagnostic suspicion, which reveals granular osmophilic material in the small arterioles on electron microscopic examination.

Given the likely diagnosis, which gene mutation is most likely to be identified?

A 64-year-old female presents with acute onset visual changes. She has a past history of migraine and hypertension. She takes sumatriptan and amlodipine. 

On examination, her GCS is 15 but when walking she is bumping in to objects and confabulates, describing objects in her visual field that do not exist. She fails to recognise the difference between light and dark when you test her pupil response with a pen torch. She fails to recognise simple objects you display, including a pen and a watch. She is unable to identify colours in a book and when talking to you her eyes fail to track your movements. Pupil responses, eye movements and fundoscopy are normal. 

Her imaging is shown below. 

What is the described phenomenon in this vignette?

A 62-year-old male is admitted to a District General Hospital with sudden onset right-sided weakness and expressive dysphasia. His symptoms started 4 hours ago. He has a past medical history of atrial fibrillation, hypertension and a previous stroke 4 months ago. His medications include amlodipine and apixaban, which his wife reports he has not taken for two days ago. 

On examination he has a dense right-sided hemiplegia, facial droop with forehead sparing, expressive dysphasia and right homonymous hemianopia. His National Institute of Health Stroke Scale score (NIHSS) is 18. His observations reveal a heart rate of 92bpm, respiratory rate 18/min, blood pressure is 210/111mmHg and he is afebrile. An ECG reveals atrial fibrillation. Labetolol is administered with his blood pressure reducing to 190/108mmHg. 

A CT-brain is performed, which is normal, and a CT-angiogram confirms a left M2 occlusion. 

You are planning on thrombolysis and discussing with the regional thrombectomy team. Which of the following is a contraindication to thrombolysis in this patient?

A 62-year-old male is admitted with acute onset diplopia. 

On examination, you notice impairment of vertical gaze bilaterally and upon vertical upgaze there is some retraction of the globe and involuntary convergence. Voluntary convergence is impaired and the pupils respond minimally to light but are responsive during attempt at the accommodation reflex. 

Where is the location of this lesion?

A 72-year-old gentleman presents to the Emergency Department via ambulance with acute-onset right-sided weakness. 

He has an M1 thrombus on plain CT brain with associated territorial hypodensity. He was last seen well 5 hours ago. 

His past medical history includes type 2 diabetes, hypercholesterolaemia and atrial fibrillation. His modified Rankin score is 3. Medications include metformin, dapagliflozin, atorvastatin and apixaban. 

His National Institutes of Health Stroke Scale score (NIHSS) is 19 and the Alberta Stroke Program Early CT Score (ASPECTS) is 8. You have discussed the patient with the on-call interventional radiologist for consideration of thrombectomy. 

What is the absolute contraindication to thrombectomy?

A 53-year-old female presents with acute hemiplegia progressing to quadriplegia over hours. On assessment, she gives no verbal or gestural response to questions.

Bidirectional horizontal gaze palsy is noted on examination with retained vertical gaze movement and blinking. 

Where is the likely anatomical location of the presumed vascular event?

A 62-year-old female presents to the emergency department with acute-onset lefthand wrist drop.  

An MRI-brain with diffusion weighted sequences (left figure) and apparent diffusion coefficient sequences (right figure) is performed following a normal CT-brain. This confirms your examination findings of a central wrist drop caused by a cerebrovascular event.  

What examination findings will help identify a cortical hand stroke?

A 72-year-old male presents to the Emergency Department with sudden onset leftsided weakness and numbness, as well as difficulty speaking.  

On examination, the patient has left hemiplegia, partial left hemi-facial droop, complete left hemianopia, mild-moderate left hemi-sensory loss and severe dysarthria without dysphasia. The patient is unable to lift his left arm against gravity with some anti-gravity effort in the left leg, but he is able to follow simple commands and responds to two standard questions correctly. There is no left-sided ataxia on heel-shin testing (inaccuracy is congruent with his weakness) and no visual hemi-inattention.  

What is the best estimate for the NIHSS score for this patient?

Which of the following is the correct ASPECTS score for a patient who presents with symptoms of a stroke and has hypoattenuation in the caudate and putamen consistent with an acute vascular event? 

A 67-year-old woman attends the Emergency Department after waking with weakness of the left wrist and hand. 

On examination, cranial nerves are intact and lower limb examination is unremarkable. Upper limb examination reveals normal tone and reflexes. Sensation is intact to all modalities in all dermatomes tested with no distal sensory impairment to pinprick or proprioception. Coordination of right-hand movement is normal but the left hand is clumsy, with difficulty manipulating small objects. Power on the right is normal. There is weakness of left wrist and finger extension (2/5 on the MRC power scale) with mild weakness of finger flexion (4+/5), although the wrist extends normally when the patient is instructed to make a fist.  

What is the most likely cause of this deficit?

You are asked to review a 76-year-old in the Accident and Emergency Unit. He presented that evening with acute-onset visual disturbance. The patient is able to tell you that he was suddenly aware he was not able to see what was happening on the television, although he was able to see his wife clearly when she came to help. 

On assessment, he is alert and oriented. Visual acuity is 6/6 (corrected with spectacles) and fields seem full on confrontational testing. His discs appear normal. He is unable to saccade to fixate on your finger. There is no facial asymmetry, dysarthria or dysphasia. Upper and lower limb tone and power are normal. Vibration is detected at the knee bilaterally but proprioception is intact distally. He is areflexic. He has no dysdiadochokinesis but is unable to reach your finger with either of his hands when you assess dysmetria. When you show him the Boston Cookie Theft picture as part of the NIHSS stroke assessment, he is able to tell you a boy is reaching for the cookie jar but fails to notice any other features. 

Which of the following is most likely to explain his symptoms and signs?