Cerebrovascular System

Front 1

Lower-limb motor strip is in _______distribution while upper-extremity motor strip is supplied by _______.

A. ACA/MCA
B. MCA/ACA
c. PCA/MCA
d. PCA/ACA

Back 1

Major vascular supply to brain and functional diagram of motor strip. It is evident that lower-limb motor strip is in anterior cerebral artery distribution while upper-extremity motor strip is supplied by middle cerebral artery. (from Rosen P. Emergency Medicine–Stroke 3rd ed. St. Louis: Mosby; 1992.)

Front 2

Circle of Willis Arteries
1. anterior cerebral artery (a)
2. internal carotid artery (b)
3. posterior communicating artery (c)
4. posterior cerebral artery (d)
5. basilar artery (e)
6. middle cerebral (f)artery
7. anterior communicating artery (minute connection between the left and right anterior cerebral arteries)(g)

Back 2

Identify the structures a-g

Front 3

1. Occlusion of the internal carotid artery may cause all of the following except:
a. Interruption of blood supply to an entire middle cerebral artery
b. Infarct of the thalamus
c. No neurologic deficit
d. Artery-to-artery embolus

Back 3

b

Front 4

2. Stroke etiology is felt to be:
a. About 50% hemorrhagic, 50% embolic
b. About 1/3 cardioembolic, 1/3 atherothrombotic
c. Often due to a hematologic abnormality
d. Indeterminate in most cases

Back 4

b

Front 5

3. Prominent risk factors for stroke include:
a. Hypertension
b. Cardiac arrhythmias, atrial fibrillation or valvular heart disease
c. Diabetes mellitus
d. All of the above

Back 5

d

Front 6

4. All of the following is true about subarachnoid hemorrhage except:
a. It is usually surgically curable
b. It may result from rupture of a saccular aneurysm
c. It can occur in young, healthy people
d. Berry aneurysms tend to occur at major arterial bifurcations

Back 6

a

Front 7

5. The following is true about lacunar infarcts except:
a. They are seen in hypertensive and diabetic patients
b. They may be seen asymptomatically on brain scans
c. They do not usually cause problems clinically
d. They are seen frequently in the basal ganglia and internal capsule region

Back 7

c

Front 8

1. The lateral medullary syndrome may have the following components:
a. Ipsilateral cerebellar ataxia
b. Ipsilateral Horner's syndrome
c. Contralateral facial numbness
d. Acute hoarseness and dysphagia
e. All except c

Back 8

e

Front 9

2. The lateral medullary syndrome:
a. Is often a vertebral artery occlusion
b. Is typically embolic in nature
c. Results in contralateral hemiparesis
d. Results in ipsilateral hemisensory deficit
e. Is likely to be fatal

Back 9

a

Front 10

3. Lacunar infarctions: Updated 4/2005
a. Are most commonly seen in the face of hypertension
b. Raise the need for angiography
c. Require full anticoagulation
d. Are never asymptomatic

Back 10

a

Front 11

4. Hypertensive cerebral hemorrhages occur most frequently in:
a. Cerebral deep white matter and cerebellum
b. Pons and deep white matter
c. Putamen and thalamus
d. Pons and cerebellum
e. Thalamus and cerebellum

Back 11

c

Front 12

5. Other causes of intracerebral hemorrhage include:
a. Amyloid angiopathy
b. Ruptured AVM
c. Hemorrhagic infarct
d. Closed head trauma
e. All of the above

Back 12

e

Front 13

ACA – MCA border zone may include the following key functional areas:
A• Hip, shoulder or less usually arm region of primary motor or somatosensory cortex
B• Areas related to language production – in the dominant hemisphere
C• Frontal eye fields
D• Frontal lobe motor planning areas
E. All of the Above

Back 13

E. ACA – MCA border zone may include the following key functional areas:
• Hip, shoulder or less usually arm region of primary motor or somatosensory cortex
• Areas related to language production – in the dominant hemisphere
• Frontal eye fields
• Frontal lobe motor planning areas

Front 14

ACA/MCA – PCA border zone may include the following functional areas:
A• Visual radiations
B• Foveal region of the striate cortex in some people (in others it may be in PCA territory)
C• Inferior temporal lobe cortex important for visual recognition
D• Areas related to language comprehension, word finding, and possibly reading –in the
dominant hemisphere
E• Areas of parietal lobe important for visuospatial perceptions –in the nondominant hemisphere
F. All of the Above

Back 14

F. ACA/MCA – PCA border zone may include the following functional areas:
• Visual radiations
• Foveal region of the striate cortex in some people (in others it may be in PCA territory)
• Inferior temporal lobe cortex important for visual recognition
• Areas related to language comprehension, word finding, and possibly reading –in the
dominant hemisphere
• Areas of parietal lobe important for visuospatial perceptions –in the nondominant
hemisphere

Front 15

Penetrating branches of PCA participate in supplying the following key functional areas:
A. OPTIC RADIATION AND OCCIPITAL LOBE
B DIENCEPHALON & MIDBRAIN
C. PARIETAL & OCCIPITAL LOBE
D. OCCIPITAL & DIENCEPHALON

Back 15

B. Penetrating branches of PCA participate in supplying the following key functional areas:
• DIENCEPHALON including thalamus, subthalamic nucleus, and hypothalamus
• MIDBRAIN including cerebral peduncle, third nerve and nucleus, red nucleus and its
connections, superior cerebellar peduncle, reticular formation

Front 16

Posterior Cortical branches of PCA participate in supplying the following key functional areas:
A. parietal and occipital lobe
B. primary visual cortex and motor strip
C. Medial temporal lobe
D. Frontal lobes

Back 16

A Cortical branches of PCA participate in supplying the following key functional areas:
Posterior branches to the parietal and occipital lobe
• Optic radiations and striate cortex (the primary visual cortex may be entirely supplied
by PCA, or the tip of the occipital lobe where the fovea is mapped may be located in
the border zone shared by PCA and MCA)
• Splenium of the corpus callosum (these crossing fibers participate in the transfer of
visual information to the language-dominant hemisphere)

Front 17

Anterior Cortical branches of PCA participate in supplying the following key functional areas:
A. parietal and occipital lobe
B Medial temporal lobe
C. Frontal Lobes
D. Motor strip

Back 17

B. Anterior branches to the medial temporal lobe
• Hippocampal formation and the posterior fornix (these structures are critical for laying
down new declarative memories)

Front 18

_____sends small branches
penetrating deeply into the deep nuclei of the cerebellum.
A. inferior cebrebral artery
B.inferior cerebellar artery
C.superior cerebellar artery
D. middle cerebral artery

Back 18

C. The superior cerebellar artery also sends small branches
penetrating deeply into the deep nuclei of the cerebellum.

Hint 18

Although it is less common, these
penetrating vessels are also at risk for hypertensive hemorrhage, with bleeding often occurring
near the dentate nucleus. Such a cerebellar hemorrhage can produce deficits related to the
cerebellum such as postural instability or limb ataxia, or may affect brainstem function by
compression or by rupture into the fourth ventricle.

Front 19

The vertebral and basilar arteries supply the _____________________

Back 19

The vertebral and basilar arteries supply the brainstem and cerebellum

Front 20

Superior branches of MCA participate in supplying the following key functional areas:

Back 20

• Primary motor cortex for face and arm, and axons originating in the leg as well as
face and arm areas that are headed for the internal capsule as part of the corticobular
or corticospinal tracts
• Broca’s area and other related gray and white matter important for language
expression -- in the language-dominant (usually L) hemisphere
• Frontal eye fields (important for ‘looking at’ eye movements to the opposite side)
• Primary somatosensory cortex for face and arm
• Parts of lateral frontal and parietal lobes important for 3-D visuospatial perceptions
of one’s own body and of the outside world, and for the ability to interpret and
express emotions -- in the nondominant (usually R) hemisphere

Front 21

Inferior branches of MCA participate in supplying the following key functional areas:

Back 21

• Wernicke’s and other related areas important for language comprehension in the
language- dominant (usually L) hemisphere
• Parts of the posterior parietal lobe important for 3-D visuospatial perceptions
perceptions of one’s own body and of the outside world, and for the ability to
interpret emotions -- in the nondominant (usually R) hemisphere
• Optic radiations, particularly fibers that represent information from the contralateral
superior quadrants and loop forward into the temporal lobe (they are located anterior
and lateral to the temporal horn of the lateral ventricle) as they travel from the lateral
geniculate body to the striate cortex, located in the occipital lobe

Front 22

The lenticulostriate vessels are small diameter arteries that originate as right angle branches
from the _______stem

A. ACA
B. PCA
C. MCA
D. AICA

Back 22

C. The lenticulostriate vessels are small diameter arteries that originate as right angle branches
from the MCA stem (a large diameter vessel with a brisk, high pressure blood flow). These small
arteries are particularly susceptible to damage from hypertension. They may either rupture
(producing an intracerebral hemorrhage that is initially centered in the region they supply) or
become occluded (producing a lacunar infarct in the tissue they supply). The lenticulostriate
arteries are ‘end arteries’ and regions that they supply do not have significant collateral blood
supply. Therefore occlusion of these vessels leads to stereotyped stroke syndromes.
In the case of the lenticulostriate vessels, hemorrhage may remain localized to the putamen (and
caudate), may involve neighboring structures like the internal capsule and other more distant
white matter of the hemisphere, or may even rupture into the ventricular system. Lacunar
infarcts may have serious functional consequences if they involve motor or sensory fibers in the
internal capsule but may be ‘silent’ if they involve other small regions of white matter or the
basal ganglia.

Front 23

ACA supplies the medial and superior parts of the frontal lobe, and of the anterior parietal lobe.
These regions include the following key functional areas:

Back 23

• septal area
• primary motor cortex for the leg and foot areas, and the urinary bladder
• additional motor planning areas in the medial frontal lobe, anterior to the precentral gryus
• primary somatosensory cortex for the leg and foot

-ACA also supplies most of the corpus callosum except its posterior part. These callosal fibers enable the language-dominant hemisphere to find out what the other hemisphere is doing, and to
direct its activities.

Front 24

______supplies much of the inferior surface of the cerebellar hemispheres.

A. AICA
B. PICA
C. MCA
D. ACA

Back 24

B. Posterior Inferior Cerebellar Artery

"PICA" supplies much of the inferior surface of the cerebellar hemispheres.

Front 25

What deficits associated with Left MCA/superior division infarct

Back 25

-R face & arm weakness of the upper neuron type
-nonfluent/Broca's aphasia
-possible R face & arm cortical type sensory loss

Front 26

What deficits associated with Left MCA/inferior division infarct

Back 26

-Fluent/Wernicke's aphasia
-R visual field deficit
-possible R face & arm cortical type sensory loss
-NO MOTOR findings
-pt may seem confused/"crazy", but otherwise intact
-some mild R sided weakness may be present

Front 27

What deficits associated with Left MCA/deep territory infarct

Back 27

-R pure motor hemiparesis of upper neuron type
-larger infacts may produce "cortical" deficits as well, such as aphasia

Front 28

What deficits associated with Left MCA/stem infarct

Back 28

-combination of L MCA/deep infacrt (R pure motor hemiparesis of upper neuron type)&
-R hemiplegia
-R hemianesthesia
-R homonymous hemianopia
-GLOBAL APHASIA
-OFTEN: L GAZE PREFERENCE

Front 29

What deficits associated with Right MCA/superior division infarct

Back 29

-L face and arm weakness of upper neuron type
-L hemineglect is present/to variable extent
-In some cases, L arm and face cortical type sensory loss

Front 30

What deficits associated with Right MCA/inferior division infarct

Back 30

-PROFOUND L HEMINEGLECT
-L visual field & somatosensory deficits often present (difficult to test bc of hemineglect)
-MOTOR NEGLECT with decreased voluntary or spontaneous initiation of movements on the L side
-normal strength L side
-OFTEN R GAZE PREFERENCE

Front 31

What deficits associated with Right MCA/deep territory infarct

Back 31

-L pure motor hemiparesis of teh upper neuron type
-Large infarcts may produce "cortical" deficits, such as hemineglect

Front 32

What deficits associated with Right MCA/stem infarct

Back 32

combination of R MCA deep &
-L hemiplegia
-L hemianesthesia
-L homonymous hemianopia
-PROFOUND L hemineglect
-OFTEN R GAZE PREFERENCE

Front 33

What deficits associated with Left ACA infarct

Back 33

-R leg weakness of the upper neuron type
-R leg cortical sensory loss
-grasp reflex
-frontal lobe bxral abnormalities
-TRANSCORTICAL APHASIA
-large infarcts cause R hemiplegia

Front 34

What deficits associated with Right ACA infarct

Back 34

-L leg weakness of the upper neuron type
-L leg cortical sensory loss
-grasp reflex
-frontal lobe bxral abnormalities
-L hemineglect
-large infarcts cause L hemiplegia

Front 35

What deficits associated with Left PCA infarct

Back 35

-R homonymous hemianopia
-Extension to the splenium of corpus callosum can cause ALEXIA WITHOUT AGRAPHIA
-large infarcts including thalamus & internal capsule can cause R hemisensory loss and R hemiparesis

Front 36

What sx associated with R PCA infarct?

Back 36

-L homonymous hemianopia
-large infacrts that include the thalamus and internal capsule may cause L hemisensory loss and hemiparesis

Front 37

List CVAs assciated with Broca's, Wernicke's, Global and transcortical aphasia

Back 37

Broca's = L MCA, superior divison
Wernicke's = = L MCA, inferior divison
Global = = L MCA, stem
Transcortical = L ACA stroke

Front 38

R homomymous hemianopia can be produced by CVA to: _____ or ________

Back 38

L PCA or L MCA stem CVA

Front 39

L homomymous hemianopia can be produced by CVA to: _____

Back 39

R PCA

Front 40

___ territory lesions usually result in gaze preference towards side of lesion
A. MCA
B. ACA
C. PCA
D. PICA

Back 40

A MCA

Front 41

___ territory lesions are ususally associate with lower extremity cortical type sensory loss

Back 41

ACA

Front 42

________infarcts cause proximal arm and leg weakness

Back 42

watershed region (MCA-ACA), known as "man in barrel" syndrome