Regarding ischaemic stroke in a young adult, which ONE of the following statements is INCORRECT?
Answer: D: The yearly incidence of ischaemic stroke increases with age. It is slightly more frequent in young females than males aged 20–30 years, as well as in males than females in those over 35 years. The traditional stroke risk factors such as diabetes, hypertension and other vascular risk factors are less frequently associated in young adults. The important stroke risk factors in young adults include:
Cardioembolism and cervical artery dissection are the most common causes of ischaemic stroke in this age group and each contributes to approximately 20% of cases. The sources of embolism include mitral stenosis, endocarditis, dilated cardiomyopathy, intracardiac thrombi, cardiac tumours (e.g. atrial myxoma) and prosthetic valves. Although patent foramen ovale (found in up to 25% of the normal population) is often attributed as a cause of paradoxical embolisation causing ischaemic stroke in young people, its direct association with stroke is uncertain. The causes of ischaemic stroke in young adults can be summarised as:
CT angiography demonstrates a very high sensitivity in detecting both carotid and vertebral artery dissections. See Table below regarding sensitivities of other diagnostic modalities.
References:
Regarding cervical artery dissection in a young patient, which ONE of the following statements is TRUE?
Answer: C: In both internal carotid artery and vertebral artery dissection the symptoms and signs can be transient initially and more devastating neurological consequences may occur later. The incidence of cervical arterial dissection peaks in the fifth decade of life. A variety of risk factors have been identified and those include major neck trauma, trivial neck manipulations, migraine and connective tissue disorders. Atherosclerosis and hypertension are not considered risk factors. Typical early symptoms are unilateral headache, neck pain and facial pain for internal carotid artery dissection and both unilateral or bilateral occipital headache and posterior neck pain for vertebral artery dissection. Later, other neurological symptoms and signs may appear (depending on the areas of cerebral ischaemia) and this may take from a few hours to up to 2 weeks.
Reference:
Regarding intracerebral haemorrhage in an elderly patient, all of the following statements are true EXCEPT:
Answer: D: Cerebral amyloid angiopathy follows hypertension as the second most important risk factor for intracerebral haemorrhage in the elderly. The haemorrhage is due to the rupture of small and medium-sized arteries secondary to deposition of beta amyloid protein. It causes lobar haemorrhage in patients older than 70 years of age. One-quarter to one-half of the patients with spontaneous intracerebral haemorrhage die within 6 months. A low Glasgow Coma Scale (GCS), large haematoma volume and presence of intraventricular blood on the initial CT are consistently associated with a high mortality rate. Ventricular blood may cause obstructive hydrocephalus or direct mass effect, both causing cerebral hypoperfusion. If the patient is on warfarin, the treatment of the coagulopathy is necessary and therefore any higher level of INR should be normalized.
Regarding spontaneous intracerebral haemorrhage, which ONE of the following statements is TRUE?
Answer: C: A non-contrast CT of the head is the investigation of choice in most instances for diagnosising intracerebral haemorrhage. However, contrast CT, CTA and MRI may show evidence of intracranial aneurysms, neoplasms, arteriovenous malformations and dural venous sinus thrombosis as an underlying cause. Conventional cerebral angiography is indicated in a select group of patients to identify the cause of haemorrhage. This group of patients includes all patients with no clear cause for the haemorrhage and who are candidates for surgery, as well as young patients (<45 years) who do not have hypertension. Decompression of supratentorial haemorrhages with open craniotomy have shown higher rates of death and dependency at 6 months. However, urgent neurosurgical consultation for possible surgical evacuation is necessary for cerebellar haemorrhage. There is a very high and unpredictable rate of neurological deterioration in these patients due to compression of the brainstem caused by haematoma. Early decompression of a cerebellar haemorrhage reduces morbidity and mortality, especially when the haemotoma is >3 cm and GCS is <14. Routine use of mannitol to reduce mass effect secondary to haematoma volume, oedema surrounding the haematoma and obstructive hydrocephalus is not recommended. Intravenous mannitol should be given and other measures to reduce the increased intracranial pressure should be applied to patients with severe mass effect with impending transtentorial herniation or brainstem compression.
Which ONE of the following is the MOST LIKELY cause in a 72-year-old woman who presents with severe vertigo and positive examination findings for otitis media?
Answer: B: In Ménière’s disease and viral or bacterial labyrinthitis, there is a sudden onset of vertigo of peripheral origin with associated nausea and vomiting. In Ménière’s disease tinnitus and reduced hearing may occur but the middle ear examination is usually normal. In acute labyrinthitis, in contrast, an associated otitis media may be present as an origin or sequelae of labyrinthitis. Meningitis is a serious complication of acute bacterial labyrinthitis. In Ramsay Hunt syndrome, grouped vesicles are visible in the external auditory canal and vertigo may be a symptom.
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