Vascular Neurology covers everything from the basics of neuroscience to “mustknow” clinical neurology to neurovascular specifics. It includes Board-formatted review questions and is divided into nine key sections for targeted topic study.
Vascular Neurology: Questions and Answers is a must-have review tool for anyone taking the vascular neurology subspecialty exam, the neurology Board exam, and the Residency In-service Training Exam, and for any physician who wants to review vascular neurology, test his or her skills, or better understand this important topic. It is the most effective way to prepare for exams and assess your knowledge of the field. TOPICS: Basic Science Clinical Stroke Clinical Hematology Imaging Rehabilitation
Pharmacology Clinical Cardiology Clinical Pediatrics Clinical Pathology
ISBN-13: 978-1-933864-24-2 ISBN-10: 1-933864-24-9
386 Park Avenue South New York, NY 10016 www.demosmedpub.com
EAN
Demos Medical Publishing
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90000
Futrell / Jamieson
Key features include: • Over 500 Board-type questions and answers used throughout • References for each question to further study • In-depth coverage of all key topics for the vascular neurology subspecialty examination • Profusely illustrated with nearly 100 black & white and color images • Applicability to a wide range of physicians, including medical students, neurology residents, vascular neurologists, cardiologists, neurosurgeons, internists, and hospitalists
Vascular Neurology
The only review book for the largest subspecialty in neurology, Vascular Neurology: Questions and Answers contains over 500 multiple-choice questions, each with an answer, detailed explanation, and references for further review.
Questions and Answeres
Nancy Futrell, MD and Dara G. Jamieson, MD
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Nancy Futrell, MD Director Intermountain Stroke Center Salt Lake City, Utah
Dara G. Jamieson, MD Associate Professor of Clinical Neurology New York Presbyterian Hospital Weill Medical College of Cornell University New York, New York
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AC Q U I SI T I O N S E D I TO R : R. Craig Percy C O V E R D E SI GN : A Good Thing C OP Y E D I TOR : Joann Woy C OMP O SI TOR : Patricia Wallenburg P R I N T E R : Transcontinental Printing
Visit our website at www.demosmedpub.com © 2008 Demos Medical Publishing, LLC. All rights reserved. This book is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the publisher. L I B R A RY O F C O N G R E S S C ATA L O G I N G - I N- P U B L I C ATI O N DATA
Futrell, Nancy. Vascular neurology : questions and answers / Nancy Futrell, Dara G. Jamieson. p. ; cm. Includes bibliographical references and index. ISBN-13: 978-1-933864-24-2 (pbk. : alk. paper) ISBN-10: 1-933864-24-9 (pbk. : alk. paper) 1. Cerebrovascular disease—Examinations, questions, etc. 2. Neurology— Examinations, questions, etc. I. Jamieson, Dara G. II. Title. [DNLM: 1. Cerebrovascular Accident—Examination Questions. 2. Neurology— Examination Questions. WL 18.2 F996v 2008] RC388.5.F88 2008 616.8’10076—dc22 2007046823 Medicine is an ever-changing science undergoing continual development. Research and clinical experience are continually expanding our knowledge, in particular our knowledge of proper treatment and drug therapy. The authors, editors, and publisher have made every effort to ensure that all information in this book is in accordance with the state of knowledge at the time of production of the book. Nevertheless, this does not imply or express any guarantee or responsibility on the part of the authors, editors, or publisher with respect to any dosage instructions and forms of application stated in the book. Every reader should examine carefully the package inserts accompanying each drug and check with a his physician or specialist whether the dosage schedules mentioned therein or the contraindications stated by the manufacturer differ from the statements made in this book. Such examination is particularly important with drugs that are either rarely used or have been newly released on the market. Every dosage schedule or every form of application used is entirely at the reader’s own risk and responsibility. The editors and publisher welcome any reader to report to the publisher any discrepancies or inaccuracies noticed. Special discounts on bulk quantities of Demos Medical Publishing books are available to corporations, professional associations, pharmaceutical companies, health care organizations, and other qualifying groups. For details, please contact: Special Sales Department Demos Medical Publishing 386 Park Avenue South, Suite 301 New York, NY 10016 Phone: 800–532–8663 or 212–683–0072 Fax: 212–683–0118 Email:
[email protected] M A D E I N T H E U N I T E D STATE S O F A ME R I C A
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Preface vii Acknowledgments xi
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Basic Science 1 Pharmacology 13 Clinical Stroke 60 Clinical Cardiology 161 Clinical Hematology 181 Clinical Pediatrics 194 Imaging 209 Clinical Pathology 255 Rehabilitation 269
References 283 Abbreviations 307
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S
of death and disability in the US. It is a complex disease, with many causes, many presentations, and many levels of severity. Despite recent medical advances, stroke remains a difficult disease to diagnose and treat. In recognition of the importance of this common disorder, the American Board of Psychiatry and Neurology (ABPN) instituted a new subspecialty examination in 2005. According to the ABPN’s website, this exam is intended “to officially establish the field of vascular neurology as a definite area of subspecialization in neurology and child neurology and to provide a means of identifying properly trained and experienced vascular neurologists.” Vascular Neurology: Questions and Answers, is intended to be a comprehensive study guide for the ABPN’s vascular neurology subspecialty exam. In addition, this book can be used by any physician who wants to thoroughly and systematically review the topic of vascular neurology, self-assess his or her skills, or prepare for another examination that contains questions on this important topic. While the ABPN’s exam consists of 200 multiple-choice questions administered during a 4-hour period, Vascular Neurology: Questions and Answers contains over 500 multipleT R O K E I S T H E T H I R D M O ST C O M M O N C AU S E
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choice questions, each with an answer, detailed explanation, and one or more references for further study and review as desired. We have included almost 100 illustrations (some in full color) keyed to many of the questions. The book is divided into chapters with questions providing detailed coverage of basic science, pharmacology, clinical stroke, hematology, cardiology, pediatrics, neuroimaging, neuropathology, and rehabilitation. All of these topics are important components to an in-depth understanding of the field, and all are important components of the ABPN’s vascular neurology subspecialty examination. Those readers who are preparing for the ABPN’s exam are strongly encouraged to visit the ABPN website for information about, and requirements for, the exam: www.abpn.org. It is important to note that there will be a “grandfathering period” through 2009. During this time, Board-certified neurologists may apply to take the exam if they can provide documentation that they have “a minimum of 25% of practice time devoted to vascular neurology.” After 2009, all applicants will need to have successfully completed a 1-year vascular neurology fellowship program. Stroke is a topic of critical relevance to neurologists, cardiologists, emergency room physicians, internists, vascular and neurosurgeons, and physiatrists worldwide. While not intended to be an authoritative reference source, Vascular Neurology: Questions and Answers will provide these professionals with an excellent (and fun) resource that will enable them to test their knowledge, clinical skills, and exam-readiness in a relatively short period of time. As with any book, the authors may learn the most. Developing questions in areas outside of neurology required gaining a higher level of understanding in some areas, such as fetal development of the heart and perinatal changes in circulation. The questions and answers contained in this book are designed to synthesize complex information into an easily understood format. As we wrote this book, each of us developed half of the questions and the other did a self-test with these questions. We found approaching the questions as a test, while comparing our
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answers with the correct answer, was fun and informative. We hope our readers will have the same experience. For those using this book to prepare for the ABPN’s vascular neurology subspecialty exam, we wish you luck. For those using this book as a means of better understanding this important topic, we wish you happy reading and learning. Nancy Futrell, MD Salt Lake City, Utah
Dara G. Jamieson, MD New York, New York
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T H E AU T H O R S W I SH TO T H A N K :
Ehud Lavi, MD, my husband, who encouraged me in the writing of this book and provided the neuropathology pictures. — DJ Clark Millikan, MD, my spouse and mentor in vascular neurology. The recognition of vascular neurology as a board certified specialty is the culmination of his lifetime work in establishing this field. — NF We would also like to thank NeuroLogica Corporation, Danvers, Massachusetts, for their generosity in making the color prints possible.
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1. The atherogenicity of lipoproteins is related to size. Which of the following statements is true? A. B. C. D. E.
The largest lipoproteins are the most atherogenic. The smallest lipoproteins are the most atherogenic. The intermediate sized lipoproteins are the most atherogenic. The large- and intermediate-sized lipoproteins are most atherogenic. The intermediate- and small-sized lipoproteins are most atherogenic.
2. The intimal layer of arteries is lined with endothelial cells and also contains: A. B. C. D. E.
Smooth muscle cells in humans and rodents. Smooth muscle cells in humans, but not in rodents. Extracellular matrix, but no smooth muscle cells in humans or animals. Adipose cells. T cells.
3. Which of the following substances is atherogenic? A. B. C. D. E.
Tissue factor. Interferon-γ. CD4+ T cells. Heat shock proteins. All of the above.
4. Intimal thickening at arterial bifurcations: A. Is present at birth. B. Is present in infancy and childhood only in individuals at high risk for the development of diffuse atherosclerosis during adulthood. C. Develops shortly after puberty. D. Develops in early adulthood. E. Develops in middle adulthood.
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BASIC SCIENCE: QUESTIONS
5. Fatty streaks in arteries: A. B. C. D.
Do not develop in the fetus. Can be seen in the aorta in children. Are composed of extracellular lipids. Form most often in individuals who will eventually develop significant atherosclerosis.
6. The main regulator of blood pressure is: A. B. C. D.
The sympathetic nervous system. The parasympathetic nervous system. The kidneys. The adrenal gland.
7. Which of the following contributes to elevated blood pressure? A. B. C. D.
Vasopressin. Renal sympathectomy. Atrial natriuretic peptide. The parasympathetic nervous system.
8. The artery of Percheron: A. B. C. D.
Arises from the distal basilar artery. Supplies the cerebellar peduncle. When occluded, results in bilateral thalamic/midbrain infarcts. Is a vestigial remnant seen in 1% of cerebral arteriograms.
9. Nitric oxide (NO): A. B. C. D.
Raises blood pressure. Lowers blood pressure. Has variable effects on blood pressure. Has no effect on blood pressure.
10. Shear stress causes: A. B. C. D.
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Stretching injury of the vessel. Alignment of endothelial cells along the linear axis of the laminar flow. Decreased release of NO. Increased superoxide levels.
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11. Vascular smooth muscle hypertrophy is stimulated by: A. B. C. D.
Mechanical vascular injury. Platelet-derived growth factor. Angiotensin II. Fibroblast-derived growth factor (FDGF).
12. Vascular smooth muscle hyperplasia is stimulated by: A. B. C. D.
Hypertension. Thrombin. Angiotensin II. Inflammatory cytokines.
13. Which statement best describes apolipoprotein A-1 (apoA-1)? A. Elevated levels of apoA-1 may indicate vascular risk in women. B. ApoA-1 comprises about 70% of the total protein mass of high-density lipoprotein (HDL). C. ApoA-1 plays a minimal role in reverse cholesterol transport. D. ApoA-1 is a less accurate predictor of vascular risk than is HDL. E. ApoA-1 levels must be measured after fasting leading to variable and poorly standardized results.
14. When decreased cerebral perfusion causes autoregulatory failure, what happens to each of the following parameters? Each response may be used more than once. A. B. C. D. E.
Cerebral blood flow (CBF). Cerebral blood volume (CBV). Mean transit time (MTT). Oxygen extraction fraction (OEF). Cerebral metabolic rate of O2 (CMRO2).
1. Increased. 2. Decreased. 3. Unchanged.
15. Lipoprotein-associated phospholipase A2 (Lp-PL A2): A. Is an enzyme that is secreted by macrophages, T lymphocytes, and mast cells. B. Is primarily bound to HDL and very low-density lipoprotein (VLDL). C. Should be assayed routinely to dictate patient management and vascular risk reduction. D. Is a risk factor for cardiovascular disease that is dependent on diabetes. E. All of the above.
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BASIC SCIENCE: QUESTIONS
16. Which of the following usually mediates neuronal apoptosis (programmed cell death) in brain ischemia? A. B. C. D. E.
Cysteine-requiring aspartate-directed proteases (caspases). Apoptosis-inducing factor (AIF). Endonucleases. Matrix metalloproteinases (MMPs). Bradykinin.
17. Vascular endothelial growth factor (VEGF): A. Affects blood vessels but not neurons or glial cells and plays no role in neurogenesis. B. Has no role in diseases of the peripheral nervous system. C. Is induced by hypoxia through hypoxia-inducible factor (HIF-1) transcription factor. D. Promotes angiogenesis, the differentiation of angioblasts into endothelial cells to form de novo blood vessels. E. Has a deleterious effect on recovery from cerebral ischemia.
18. Match the level of cerebral blood flow to the cellular events: A. B. C. D.
35–25 mL/100 g/min. 18–25 mL/100 g/min. 50–55 mL/100 g/min. < 10–12 mL/100 g/min.
1. Electrical failure. 2. Deterioration of transmembrane ionic gradients. 3. Homeostasis. 4. Increased glycolysis.
19. Which of the following statements best describes the role of glutamate in cerebral ischemia? A. Glutamate is released into the extracellular space with an rCBF of 10% of normal (
