1. True or False. Which of the following statements accurately describes an arteriovenous (AV) fistula?

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a. They are low flow, high pressure lesions with a low incidence of hemorrhage.

false

b. They are high flow, high pressure lesions with a high incidence of hemorrhage.

false

c. They are high flow, high pressure lesions with a low incidence of hemorrhage.

true (Think: counterintuitive: low bleeding rates even though they are high flow and high pressure lesions.)

d. They are low flow, low pressure lesions with a high incidence of hemorrhage.

false

2. Complete the following about vascular malformations:

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a. True or False? A vein of Galen aneurysm is actually:

     i. an arteriovenous malformation (AVM)

false

     ii. a cavernous malformation

false

     iii. an AV fistula

true

     iv. a venous malformation

false

b. Name the other AV fistulas:

     i. d_____ _____

dural AVM

     ii. c_____ c_____ f_____

carotid cavernous fistula

3. True or False. Regarding arteriovenous malformations:

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a. AVMs are characterized by dilated arteries and veins with dysplastic vessels, no capillary bed, and no intervening neural parenchyma.

true

b. In adulthood, AVMs are medium to high pressure and high flow.

true

c. AVMs usually present with seizures, less often with hemorrhage.

false (They usually present with hemorrhage and less often with seizures.)

d. These are congenital lesions with a lifelong risk of bleeding of ˜2 to 4% per year.

true

4. True or False. The average age of patients diagnosed with AVMs is

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a. 11 years

false

b. 21 years

false

c. 33 years

true

d. 45 years

false

5. True or False. AVMs can

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a. cause bleeding

true

b. cause seizures

true

c. steal blood from surrounding parenchyma

true

d. cause heart failure

true

e. cause headache

true

6. Complete the following about AVMs:

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a. What is the peak age for hemorrhage?

15 to 20 years

b. What is the mortality for each bleed?

10%

c. What is the morbidity for each bleed?

30 to 50%

d. What is the average risk of rebleeding per year?

4% (2 to 4%)

e. What is the risk of mortality per year?

1%

f. What is the combined mortality and morbidity per year?

2.7%

7. True or False. Regarding AVMs:

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a. Small AVMs tend to present more often as hemorrhages than do large ones.

true (Hint: The little ones bleed more.)

b. Small AVMs are less lethal than large ones.

false

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8. True or False. As with aneurysms there is an increased rate of rebleeding with AVMs that have ruptured.

false (Although some say rebleeding rate increases to 6% for every year after bleed, most agree the rates stay the same at 4%/yr.)

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9. True or False. Regarding AVM bleeding rates:

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a. Studies suggest a higher risk of bleeding depending on whether the initial presentation was hemorrhage (3.7%/yr) vs seizure (1 to 2%/yr).

true

b. The hemorrhage risk may be higher in pediatric or with posterior-fossa AVMs.

true

c. The younger the patient at diagnosis, the higher the risk of developing convulsions.

true

d. The accepted risk of major bleeding is 6% per year.

false (The accepted risk of major bleeding is 4% per year. A study of 166 symptomatic AVMs with long average follow-up found the risk of major bleeding was constant at 4% per year.)

10. What is the risk of bleeding (at least once) from an AVM during the lifetime of a 35-year-old healthy male, assuming a 3% annual bleeding risk?

73%

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11. Complete the following about AVMs:

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a. True or False. 11% of patients with AVM have aneurysms.

false (7% of patients with AVMs have aneurysms.)

b. Aneurysms associated with AVMs usually arise from a _____artery.

feeding (75%)

c. If it is not clear which bled, the AVM or the aneurysm, it is usually the _____.

aneurysm

d. Do aneurysms regress after AVM removal?

yes (66%)

12. Matching. Match the pathology and the numbered magnetic resonance imaging (MRI) criterion.

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tumor; AVM

a. flow void on T1-weighted imaging (T1WI) or T2-weighted imaging (T2WI)

b. feeding arteries

c. edema

d. draining veins

e. complete ring of low density surrounding the lesion

13. Which magnetic resonance (MR) sequence best shows hemosiderin?

gradient echo

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14. Complete the following about AVMs:

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a. Presence of edema can help differentiate AVM from _____.

tumor (Edema is more likely in tumors.)

b. True or False. A hemosiderin ring may suggest an AVM rather than a neoplasm.

true (The AVM may have bled in the past, whereas hemosiderin ring in tumors is rare.)

15. True or False. Criteria for the Spetzler-Martin grading of AVMs include the following:

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Hint: SED size eloquence drainage

a. presence of associated aneurysm

false

b. size

true

c. pattern of venous drainage

true

d. eloquence of adjacent brain

true

16. Complete the following about AVMs:

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a. True or False. The Spetzler-Martin grade of a 4 cm AVM that drains into the vein of Galen and is located in the visual cortex is

     i. grade 1

false

     ii. grade 2

false

     iii. grade 3

false

     iv. grade 4

true (size 4 cm = 2, eloquence = 1 drainage, deep = 1)

     v. grade 5

true

b. and has a morbidity rate of _____%

27%

     i. of which _____% is minor

20%

     ii. and _____% is major

7%

17. Complete the following about AVMs:

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a. Using the Spetzler-Martin AVM grading system, what grade is an AVM located in the visual cortex of a 38-year-old man that has a nidus measuring 2.5 cm in diameter and shows on angiogram high flow and drainage into a cortical vein?

size: <3.0 cm size 1 point, eloquent brain 1 point, superficial venous drainage – 0 points = 2 points = grade 2

b. We expect a minor deficit of _____%

5%

c. and a major deficit of _____%.

0%

18. Complete the following about AVMs:

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a. True or False. An AVM that lies over the left motor cortex, is 5.9 cm, and drains superficially is a Spetzler-Martin grade:

     i. 6

false

     ii. 3

true (size: 3 to 6 cm 2 points, for eloquent area 1 point, for superficial drainage 0 points; 3 = 3 points)

     iii. 4

false

     iv. 1

false

b. and has a morbidity of _____%

16%

     i. minor being _____%

12%

     ii. major being _____%

4%

19. True or False. Regarding AVMs:

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a. Conventional radiation is effective in less than 20% of cases.

true

b. Stereotactic radiosurgery eliminates the risk of bleeding almost immediately.

false (Stereotactic radiosurgery takes 1 to 3 years to work, during which the patient is still at risk of bleeding from the AVM.)

c. Surgery eliminates the risk of bleeding almost immediately.

true

d. Stereotactic radiosurgery should be considered for small AVMs in eloquent cortex.

true

20. Complete the following about embolization of AVM:

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a. Does not permanently _____ AVMs

obliterate

b. Does _____ surgery

facilitate

c. Induces acute _____ changes

hemodynamic

d. May require _____ procedures

multiple

e. Embolization prior to stereotactic

     i. Radiosurgery _____ obliteration rate

reduces

     ii. From _____ to _____%

70 to 47%

21. True or False. Endovascular embolization is usually adequate by itself to treat

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a. conventional AVMs

false (Embolization alone is inadequate to treat AVMs.)

b. direct fistulas

true (It is usually adequate to primarily treat direct fistulas without the use of other methods such as surgery and stereotactic radiosurgery.)

22. What can be predicted about the 2-year result from the 6-month angiographic assessment after embolization?

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a. If no residual is seen, it will _____.

also not be seen at 2 years

b. If residual is seen, it will _____.

not progress to obliteration; that is, the AVM will not progress on its own to obliteration in 2 years

23. What pretreatment can be used to reduce the incidence of perfusion pressure breakthrough?

propranolol 20 mg four times a day for 3 days

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24. True or False. Propranolol used for 3 days prior to AVM resection can minimize the incidence of postop normal perfusion pressure breakthrough.

true

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25. True or False. Regarding venous angiomas:

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a. They are usually demonstrable on angiography as a starburst pattern.

true

b. Typically seizures are rare.

true

c. Typically hemorrhage is rare.

true

d. Surgery is usually indicated to prevent bleeding.

false (Surgery is not indicated to prevent bleeding. Surgery is very rarely indicated. Surgery may be considered for documented bleeding or for intractable seizures definitely attributed to the lesion.)

26. True or False. Neural parenchyma is not found between the vessels of a venous angioma.

false

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27. True or False. Venous angiomas require prompt surgical attention.

false (Venous angiomas require no treatment.)

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28. True or False. Venous angiomas are low flow, low pressure lesions.

true

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29. True or False. The incidence of angiographically occult vascular malformations (AOVMs) among all cerebrovascular malformations is

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a. 2%

false

b. 5%

false

c. 10%

true

d. 4%

false

30. True or False. Angiographically occult vascular malformations most often present with hemorrhage.

false (seizures or headache)

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31. True or False. The following cerebrovascular malformations are the most common angiographically occult vascular malformations:

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a. venous angioma

false

b. capillary telangiectasia

false

c. cavernous angioma

false

d. arteriovenous malformation

true (Arteriovenous malformation is the most common angiographically occult vascular malformations [AOVM]. AVM 44 to 60%; cavernous angioma 19 to 31%; venous angioma 9 to 10%; telangiectasias 4 to 12%; mixed or unclassified 11%.)

32. True or False. The following vascular malformations contain intervening brain tissue:

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a. AVM

false

b. venous angioma

true

c. cavernous angioma

false

d. capillary telangiectasia

true

33. True or False. Each of the following syndromes is associated with capillary telangiectasias except:

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a. Sturge-Weber

true

b. Osler-Weber-Rendu

true

c. Louis-Barr

true

d. Myburn-Mason

true

e. Waardenburg

false

34. True or False. The following is true regarding cavernous malformation:

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a. They most often present with seizures.

true

b. They are angiographically occult.

true

c. They occur more commonly in the brain stem vs supratentorially.

false

d. They can occur sporadically or in a hereditary form.

true

35. True or False. The following are characteristics of cavernous malformations (CMs):

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a. high flow malformation

false

b. no intervening brain parenchyma

true

c. usually not demonstrable on angiogram

true

d. no large draining veins or arteries

true

36. True or False. The percentage of central nervous system (CNS) vascular malformations that cavernous malformations represent is

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a. 2%

false

b. 20%

false

c. 10%

true (10%, quoted prevalence is 5 to 13% of all CNS vascular malformations)

d. 1%

false

37. Complete the following regarding cavernous malformations (CMs):

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a. There are _____ genetic subtypes of CM.

three

b. They may present with

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     i. s_____ in 60%

seizures

     ii. p_____ n_____ deficit in 50%

progressive neurological

     iii. h_____ in 20%

hemorrhage

     iv. i_____ finding in 50%

incidental

c. Risk of significant bleeding is

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     i. _____ to _____% per year.

2 to 3%

     ii. True or False. It is higher in females.

true

     iii. Risk in females is _____%.

4.2%

     iv. Risk in males is _____%.

0.9%

     v. True or False. Risk is increased by

            prior bleed

controversial

            pregnancy

false

            parturition

false

38. Complete the following regarding cavernous malformations:

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a. The risk of bleeding is _____.

low (and only rarely significant)

b. The best test is _____ _____.

T2WI MRI

c. Radiologic appearance is _____.

pathognomonic

d. New onset seizures

     i. may be an indication for _____ _____

surgical resection

     ii. because removal before _____ may reduce future seizures.

kindling

e. Stereotactic radiosurgery

     i. may have a limited place in cavernous malformation treatment (True or False.)

true (but very limited)

     ii. except in r_____ h_____.

recurrent hemorrhage

39. True or False. Venous angiomas may be seen adjacent to

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a. solitary cavernous malformations

true

b. multiple cavernous malformations

false

40. True or False. The most common location of dural AVM is

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a. superior sagittal sinus

false

b. tentorial

false

c. transverse sinus

true

d. torcula

false

41. True or False. Dural AVMs are most commonly found in

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a. men > 40 years of age

false

b. men < 40 years of age

false

c. women > 40 years of age

true

d. women < 40 years of age

false

42. Complete the following about dural AVMs:

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a. True or False. Etiology is thought to be related to

     i. trauma

false

     ii. congenital cause

false

     iii. thrombosis and revascularization

true

     iv. chronic infection

true

b. True or False. The sinus that is most commonly occluded is

     i. superior sagittal

false

     ii. straight

false

     iii. transverse

false

     iv. sigmoid

true

     v. confluens

false

c. Which artery is the dominant feeder in most cases?

occipital

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43. True or False. Each of the following is a common presenting sign or symptom of dural AV fistula (AVF), also known as dural AV malformation:

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a. hydrocephalus

false

b. bruit

true

c. headache

true

d. tinnitus

true

e. visual impairment

true

f. papilledema

true

g. blindness

true

44. True or False. Vein of Galen malformations cause symptoms by

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a. causing obstructive hydrocephalus

true

b. hemorrhage

false

c. congestive heart failure

true

d. seizures

false

45. Complete the following regarding vein of Galen malformations:

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a. If untreated mortality is _____%.

60 to 100%

b. Hydrocephalus usually presents at age _____ _____.

1 year

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