Lange Review Ultrasonography Examination, 4th Edition

Questions

GENERAL INSTRUCTIONS: For each question, select the best answer. Select only one answer for each question unless otherwise specified.

1. What is the annual rank of stroke in the United States as a cause of death?

(A) 1st with 800,000 deaths

(B) 2nd with 600,500 deaths

(C) 3rd with 500,000 deaths

(D) none of the above

2. The emphasis of stroke as a national issue is based on which of the following?

(A) defining the stroke as ischemic or hemorrhagic

(B) preventing long-term disability

(C) deciding which treatment is to be used

(D) early diagnosis and treatment to prevent long-term disability

3. Which of the following imaging modalities is the newest technique for early determination of a stroke as hemorrhagic or ischemic?

(A) ultrasound of the carotid arteries

(B) computerized axial tomography (CT)

(C) magnetic resonance imaging (MRI) diffusion imaging

(D) digital subtraction arteriography (DSA)

4. Which of the following best defines stroke?

(A) a sudden increase of blood flow to the brain causing syncope

(B) a sudden increase in blood flow to the brain causing eye damage

(C) any motor sensory deficit lasting greater than 24 hours

(D) any motor sensory deficit lasting less than 24 hours

Match the following terms with the correct definition.

5. Transient ischemic attack (TIA) ______

6. Stroke in evolution (SIE) ______

7. Reversible ischemic neurologic deficit (RIND) ______

8. Completed stroke ______

9. Acute brain death ______

(A) neurologic symptoms that last longer than 24 hours, but completely resolve

(B) this is caused by either lack of blood supply or effect of blood outside of normal vessels

(C) ischemic neurologic symptoms that last less than 24 hours and completely resolve

(D) stable neurologic deficit that had sudden onset and persists longer than 3 weeks

(E) ischemic neurologic symptoms that actively worsen during a period of observation

10. Which of the following is currently the major cause of vascular disease?

(A) hypertension

(B) intracerebral hemorrhage

(C) smoking more than one pack of cigarettes per day

(D) atherosclerosis

11. Internal carotid artery symptoms include all of the following except?

(A) paralysis on the contralateral side

(B) decreased level of consciousness

(C) amaurosis fugax

(D) ataxia

12. Which of the following is a neurologic symptom related to atherosclerotic disease in the posterior circulation (vertebrobasilar disease)?

(A) amaurosis fugax

(B) contralateral extremity weakness

(C) orthostatic hypotension

(D) vertigo

13. Continuous wave (CW) Doppler or pulse wave (PW) Doppler is not used in which of the following?

(A) periorbital Doppler

(B) extracranial arteries

(C) ocular pneumoplethysmography

(D) transcranial Doppler

14. Ocular pneumoplethysmography (OPG) can be used to detect which of the following?

(A) hemodynamically significant lesions (greater than 60%)

(B) for the assessment of collateral circulation

(C) both A and B

(D) none of the above

15. Color Doppler units provide which of the following information?

(A) real-time imaging

(B) Doppler waveform analysis

(C) color depiction of the flow characteristics

(D) all of the above

(E) both B and C

16. The optimal transducer for high-resolution gray-scale image is obtained by which frequency transducer?

(A) 2.5 MHz linear array

(B) 5 MHz curved array

(C) 5 MHz linear array

(D) 7.5 MHz linear array

17. Doppler information in the extracranial arterial system is best achieved using which of the following angles?

(A) 60–70° angle to the artery

(B) 0° angle to the artery

(C) 45–60° angle to the artery

(D) 20–35° angle to the artery

18. Which of the following is the most utilized of the Doppler criteria for estimation of percentage diameter stenosis?

(A) end diastolic velocity

(B) peak diastolic velocity divided by end diastolic velocity

(C) peak systolic velocity

(D) none of the above

19. What is mandatory when using velocity to represent the Doppler shift?

(A) angle correction

(B) high-frequency linear array transducer

(C) electronic steering of transducer

(D) both B and C

20. Which of the following is one of the artifacts with pulsed Doppler in a hemodynamically significant stenosis?

(A) spectral broadening

(B) turbulence

(C) aliasing

(D) both A and B

21. Aliasing occurs when high frequencies exceed the Nyquist limit and may be corrected by which of the following?

(A) increasing the transducer frequency and increasing the sample volume

(B) positioning the sample volume deeper by transducer manipulation

(C) change in probe position, decreasing the depth, increasing the PRF, increasing the Doppler angle or lowering the frequency

(E) none of the above

22. Which of the following are two advantages of power Doppler?

(A) extremely sensitive to high flow state of intracranial arteries

(B) more sensitive frequency shift information

(C) beneficial in defining occlusive vessels

(D) is not dependent on beam angle and free from aliasing artifact

(E) both A and B

(F) both C and D

Match the following three layers of an artery wall with the correct definition.

23. Media ______

24. Adventitia ______

25. Intima ______

(A) elastic inner layer

(B) layer of muscle and elastic tissue

(C) outer loose filmy layer

26. Which of the following terms best describes variable plaque morphology?

(A) soft (homogeneous low-level gray echoes)

(B) dense (highly echogenic)

(C) calcified (increased echogenicity with acoustic shadowing)

(D) ulcerated (irregular margins or craters)

(E) heterogeneous

27. The cerebrovascular vessels arise from which of the following?

(A) vertebral artery

(B) costocervical trunk

(C) internal thoracic

(D) aortic arch

28. Branches of the subclavian artery include

(A) vertebral

(B) internal thoracic

(C) thyrocervical and costocervical trunk

(D) dorsal scapular

(E) all of the above

Match the following to Fig. 12–31.

Image

FIGURE 12–31.

29. ______

30. ______

31. ______

32. ______

33. ______

34. ______

35. ______

36. ______

37. ______

(A) basilar artery

(B) right external carotid artery

(C) left subclavian artery

(D) right common carotid artery

(E) left vertebral artery

(F) right subclavian artery

(G) left common carotid artery

(H) aortic arch

(I) brachiocephalic trunk

(J) right internal carotid artery

38. Which of the following is the most important branch of the carotid system?

(A) internal carotid artery

(B) vertebral artery

(C) common carotid artery

(D) external carotid artery

Match the following extracranial arteries with the correct spectral analysis description.

39. internal carotid artery ______

40. external carotid artery ______

41. common carotid artery ______

42. carotid bulb ______

(A) exhibits a complicated turbulent flow pattern

(B) demonstrates a rapid increase in velocity during systole with a clear window and a continuous antegrade flow during diastole

(C) combination of the pattern of internal and external carotid arteries

(D) demonstrates a brisk systolic upstroke, sharp peak, abrupt downstroke

Match the following extracranial waveforms with the proper normal waveform.

Image

Image

Image

43. external carotid artery ______

44. internal carotid artery ______

45. common carotid artery ______

46. Which of the following radiographic modalities is the method of choice for opacifying the entire cerebral arterial system?

(A) carotid duplex examination with transcranial Doppler

(B) computerized axial tomography with contrast

(C) magnetic resonance imaging with contrast

(D) digital subtraction angiography

Place the transverse scans of the extracranial carotid arteries in the proper order according to examination protocol.

47. ______

48. ______

49. ______

50. ______

51. ______

(A) origin of the vertebral artery

(B) carotid bifurcation with internal and external carotid arteries

(C) common carotid artery

(D) carotid bulb

(E) brachiocephalic artery and bifurcation of the subclavian and carotid arteries

Place the following longitudinal scans of the extracranial carotid arteries in the proper order according to examination protocol.

52. ______

53. ______

54. ______

55. ______

56. ______

(A) vertebral artery from origin and as far distal as possible

(B) carotid bifurcation (carotid bulb and proximal portion of internal and external carotid arteries)

(C) external carotid artery as far distal as possible

(D) common carotid artery (from clavicle to mandible)

(E) internal carotid artery as far distal as possible

Match the following gray-scale image to the normal extracranial carotid arteries.

Image

57. ______ external carotid artery.

58. ______ internal carotid artery

59. ______ common carotid artery.

60. ______ carotid bulb

A

B

C

D

61. Which of the following terms is used to describe normal flow in the normal carotid artery?

(A) laminar

(B) turbulent

(C) helical

(D) parabolic

62. Which of the following is the first major branch of the internal carotid artery with clinical significance?

(A) middle cerebral artery

(B) anterior cerebral artery

(C) ophthalmic artery

(D) posterior communicating artery

63. The internal carotid artery supplies blood to which of the following structures?

(A) cerebral hemispheres of the brain only

(B) cerebral hemispheres of the brain, eyes and accessory organs, forehead, and part of the nose

(C) posterior portion of the brain and face

(D) none of the above

64. The external carotid artery supplies blood to which of the following structures?

(A) cerebellum

(B) scalp, face, and most of the neck

(C) face, eyes, and temporal portion of the brain

(D) all of the above

65. Which of the following maneuvers will identify that the Doppler signal is coming from the external carotid artery?

(A) swallowing

(B) compression of the mandibular artery

(C) temporal tapping

(D) none of the above

66. Which common carotid artery arises directly from the aortic arch?

(A) the right common carotid artery

(B) the left common carotid artery

(C) the right subclavian artery

(D) the left innominate artery

67. Nonatheromatous causes of turbulent flow in the carotid arteries may include which of the following?

(A) sudden increase in the diameter of the vessel

(B) kinking of the internal carotid artery

(C) tortuosity of the internal carotid artery

(D) all of the above

(E) none of the above

68. An increased resistivity index in the common carotid artery may indicate which of the following?

(A) stenotic disease proximal to the sample site

(B) stenotic disease distal to the sample site

(C) disease at the sample site

(D) sample volume site placed too close to the arterial wall

69. Which of the following are factors affecting the Doppler shift frequency?

(A) Doppler angle

(B) transducer

(C) velocity of the red blood cells

(D) both B and C

(E) A, B, and C

70. What is the most common site for atherosclerotic plaque formation?

(A) distal internal carotid artery

(B) distal common carotid artery

(C) carotid bifurcation

(D) vertebral artery origin

71. Which branch of the internal carotid artery is in the cervical section of the neck?

(A) ophthalmic

(B) cavernous

(C) posterior communicating

(D) none of the above

72. The gradual decrease in blood flow due to narrowing does not produce symptoms until it reaches the point of “critical stenosis.” Which of the following diameter reductions constitute a critical stenosis?

(A) 20% diameter reduction

(B) 30–45% diameter reduction

(C) 70% diameter reduction (“critical” is a >70% diameter reduction; but hemodynamically significant is >50%?)

(D) 25–30% diameter reduction (“critical” is a <70% diameter reduction; but hemodynamically significant is <50%?)

Identify the following plaque morphology with the appropriate image.

Image

Image

73. soft ______

74. dense

75. calcified ______

76. ulcerated ______

77. intraplaque hemorrhage ______

Match the following with the appropriate image:

Image

Image

78. critical stenosis ______

79. occlusion of ICA ______

80. reversal of flow in bulb proximal to ICA occlusion ______

81. moderate stenosis by diameter reduction ______

82. mild stenosis by diameter reduction ______

83. Distal to a critical stenosis, the spectral analysis depicts which of the following characteristics?

(A) peak systole velocities decrease

(B) end diastole velocities decrease

(C) turbulent flow is present in the spectral analysis

(D) all of the above

84. Which of the following best describes carotid body tumors?

(A) rare neoplasms

(B) composed of paraganglionic tissue

(C) occur only at the carotid bifurcation

(D) both A and B

(E) all of the above

85. Which of the following variations of the extracranial carotid artery is associated with the symptom of ischemia?

(A) coiling of the internal carotid artery

(B) kinking of the internal carotid artery

(C) tortuosity of the internal carotid artery

(D) all of the above

86. According to the North American Symptomatic Carotid Endarterectomy Trial (NASCET), which one of the following is the most common treatment to risk reduction for stroke?

(A) identifying and operating on appropriately severe common carotid bifurcation lesions.

(B) treating all patients with aspirin therapy and perform carotid Doppler exam once a year

(C) once the stenosis reaches a moderate level, perform the endarterectomy before symptoms occur

(D) none of the above

Match the following vessels to Fig. 12–32.

Image

FIGURE 12–32.

87. ______

88. ______

89. ______

90. ______

91. ______

92. ______

93. ______

94. ______

95. ______

96. ______

(A) superficial temporal artery

(B) supraorbital artery

(C) subclavian artery

(D) internal carotid artery

(E) ophthalmic artery

(F) common carotid artery

(G) external carotid artery

(H) superior thyroid artery

(I) brachiocephalic trunk

(J) vertebral artery

97. Which of the following is not a branch of the subclavian?

(A) vertebral

(B) internal thoracic

(C) thyrocervical trunk

(D) costocervical trunk

(E) hypophyseal

98. The extracranial posterior circulation is composed of which of the following?

(A) paired vertebral arteries in the back of the neck

(B) basilar artery

(C) brachiocephalic

(D) both B and C

99. Subclavian steal syndrome causes which of the following symptoms?

(A) ataxia

(B) limb paralysis

(C) vertigo

(D) syncope

(E) all of the above

(F) both C and D

100. Which of the following is the hallmark sign of the subclavian steal syndrome?

(A) difference of blood pressure (10–20 mm Hg) between the two arms

(B) decreased peripheral pulse in the affected upper extremity

(C) difference of blood pressure (20–30 mm Hg) between the two arms

(D) all of the above

(E) both A and B

(F) both B and C

101. Which of the following are Doppler waveform characteristics of the subclavian steal syndrome?

(A) deceleration, reversed, or alternating flow in the contralateral vertebral artery

(B) decreased velocities/frequencies at the site of subclavian stenosis

(C) diminished waveform distal to the stenosis or occlusion

(D) all of the above

(E) both A and C

102. Which of the following will be depicted in the normal vertebral artery spectral analysis?

(A) high-resistant flow similar to external carotid artery

(B) monophasic flow

(C) low-resistance waveform pattern similar to the internal carotid artery

(D) none of the above

103. Normally the vertebrobasilar system provides what percentages of blood flow to intracranial system?

(A) 40%

(B) 10–20%

(C) 20–30%

(D) none of the above

104. In which view can the vertebral artery be visualized?

(A) medial to the jugular

(B) transverse just lateral to the common carotid artery

(C) longitudinal plane at the level of the common carotid with the transducer angled laterally until the vertebral is seen passing through the transverse processes

(D) both A and C

(E) both B and C

105. When is subclavian steal syndrome asymptomatic?

(A) when exercising contralateral side

(B) when exercising ipsilateral side

(C) at rest

(D) none of the above

Match the following arteries in Fig. 12–33.

Image

FIGURE 12–33.

106. ______

107. ______

108. ______

109. ______

110. ______

111. ______

112. ______

113. ______

(A) anterior cerebral artery

(B) posterior communicating artery

(C) anterior communicating artery

(D) middle cerebral artery

(E) basilar artery

(F) internal carotid artery

(G) vertebral artery

(H) posterior cerebral artery

114. Which of the following transducer is required for performing a transcranial Doppler examination?

(A) high-frequency continuous-wave transducer

(B) high-frequency linear array

(C) low-frequency (2 MHz) transducer

(D) appropriate computerized software for calculations

(E) both C and D

115. Which of the following does the suboccipital window examine?

(A) vertebral arteries

(B) posterior communicating arteries

(C) basilar artery

(D) both A and C

(E) both A and B

116. Which of the following best describes transcranial Doppler?

(A) invasive technique that measures and visualizes the major intracranial vessels

(B) displays intracerebral hemorrhages

(C) noninvasive technique used to measure the velocity of blood flow in the major intracranial brain vessels by using Doppler

(D) both B and C

117. Which of the following is an advantage of transcranial imaging?

(A) observation of narrowing of the vessel lumen

(B) visual assessment of the transcranial vessels for localization

(C) observation of vessel tortuosity

(D) calculation of the vessel lumen

(E) all of the above

(F) both B and D

118. Which of the following arteries is the largest branch of the cerebral internal carotid artery?

(A) ophthalmic artery

(B) middle cerebral artery

(C) anterior cerebral artery

(D) all of the above

119. The middle cerebral artery supplies blood to which of the following lobes?

(A) occipital lobe

(B) frontal lobe

(C) temporal lobe

(D) parietal lobe

(E) A, B, and C

(F) B, C, and D

120. The middle cerebral artery is divided into which of the following segments?

(A) M1

(B) M2

(C) M3

(D) A-1

(E) A, B, and C

121. The posterior communicating artery anastomoses with which of the following arteries?

(A) anterior cerebral artery

(B) posterior cerebral artery

(C) posterior cerebral artery and middle cerebral artery

(D) both A and C

122. The ophthalmic artery forms extensive anastomoses with which of the following arteries?

(A) anterior communicating artery

(B) anterior cerebral artery

(C) middle cerebral artery

(D) external carotid artery

123. The anterior cerebral artery and its branches supply blood to which of the following structures?

(A) frontal and parietal lobes

(B) corpus callosum

(C) septum pellucidum

(D) basil ganglia

(E) anterior limb of the internal capsule

(F) all of the above

(G) A, B, and C

124. The vertebral arteries unite to form which of the following arteries?

(A) posterior communicating artery

(B) posterior cerebral artery

(C) basilar artery

(D) both A and C

125. The various parts of the brainstem are supplied by which of the following arteries?

(A) middle cerebral artery

(B) posterior communicating artery

(C) basilar artery

(D) all of the above

126. The basilar artery does not give rise to which one of the following arteries?

(A) anterior inferior cerebellar artery

(B) posterior communicating artery

(C) superior cerebellar artery

(D) posterior cerebral arteries

127. Which of the following are the anastomotic arteries that are formed by the major cerebral arteries?

(A) middle cerebral and anterior communicating artery

(B) vertebral and basilar arteries

(C) anterior cerebral and anterior communicating arteries

(D) circle of Willis

(E) both A and C

Match the following collateral pathway systems that supply blood by existing anastomoses in the brain.

128. right-to-left anastomoses provide redistribution of blood flow between the sides of the body and occur via ______

129. carotid-to-vertebral anastomoses via ______

130. subclavian-to-carotid and subclavian-to-vertebral anastomoses

131. ICA-to-ECA ipsilateral anastomoses ______

132. optical anastomoses can provide collateral flow between ______

(A) involve the deep cervical artery, spinal branches of the vertebral arteries, and the ascending cervical artery

(B) superorbital and supratrochlear arteries

(C) anterior communicating and basilar arteries

(D) posterior communicating arteries

(E) anterior cerebral artery, middle cerebral artery and posterior communicating artery

133. Pulsatility index represents the degree of

(A) pliability of the artery

(B) stenosis of the artery

(C) peripheral resistance

(D) all of the above

134. A pulsatility index of >1.2 may indicate which of the following findings?

(A) increased intracranial pressure

(B) vasospasm

(C) hypercapnia

(D) aortic insufficiency

(E) all of the above

135. Transtemporal window allows insonation of the

(A) middle cerebral artery (M1-M2 segments)

(B) anterior cerebral artery

(C) posterior cerebral artery and C1 segment of the carotid siphon

(D) distal ICA

(E) A, B, and C

136. Suboccipital window allows insonation of which of the following?

(A) carotid siphon (C2, C3, and C4)

(B) vertebral arteries

(C) basilar artery

(D) B and C

(E) A, B, and C

137. Submandibular window allows insonation of which of the following?

(A) ophthalmic artery

(B) carotid siphon

(C) retromandibular ICA (distal)

(D) both A and B

138. Transorbital window allows insonation of which of the following?

(A) ophthalmic artery

(B) carotid siphon (C2, C3, and C4)

(C) anterior communicating artery

(D) both A and B

(E) all of the above

Match the following acoustic windows with the proper name.

139. transorbital window ______

140. transtemporal window ______

141. transoccipital window ______

142. Each transcranial Doppler examination includes all of the following except

(A) color Doppler imaging

(B) spectral waveform analysis with notation of depth, speed, and direction of flow

(C) mean velocity

(D) measurements of all arteries in the circle of Willis

Match the direction of flow for the following vessels.

143. carotid siphon. ______

144. ICA bifurcation ______

145. Ml segment of MCA. ______

146. vertebral artery ______

147. basilar artery ______

148. ACA ______

149. PCA, P1 segment ______

150. PCA, P2 segment ______

151. ophthalmic artery ______

(A) flow is bidirectional

(B) away from the probe

(C) toward the probe

(D) can flow in any direction

152. Which of the following will occur with the occlusion or a critical stenosis of the ipsilateral extracranial carotid artery?

(A) Middle cerebral artery velocity is decreased or absent.

(B) Middle cerebral artery end diastole is increased.

(C) Ophthalmic artery will decrease in flow or may have reverse flow.

(D) Both A and C

(E) Both A and B

153. Subclavian steal syndrome can be detected in which of the following intracranial vessels?

(A) cervical vertebrals

(B) intracranial vertebral arteries

(C) basilar artery

(D) all of the above

(E) both B and C

154. Intracranial vessel stenosis will exhibit which of the following characteristics?

(A) focal increase in the mean blood flow velocity distal to the stenosis

(B) focal increase in the mean blood flow velocity at the site of the vessel stenosis

(C) color-flow Doppler will show multiple color patterns

(D) all of the above

(E) both A and C

(F) both B and C

155. Which of the following intracranial vessels is the most common to occlude and is seen with acute stroke?

(A) basilar artery

(B) anterior cerebral artery

(C) ophthalmic artery

(D) middle cerebral artery

156. Transcranial color Doppler can be used to examine which of the following conditions?

(A) brain death

(B) vasospasms

(C) arteriovenous malformations

(D) embolus

(E) all of the above