The arch angiogram in Figure 20.1a demonstrates which type of aortic arch morphology?

1. Type I
   
2. Type II
   
3. Type III
   
4. Type IV

What does the term “bovine” arch refer to?

1. The aortic arch morphology in cattle
   
2. A shared common origin of the brachiocephalic and left common carotid arteries
   
3. A shared common origin of the left subclavian and common carotid arteries
   
4. A shared common origin of the left and right common carotid arteries

Which of the following is the most frequent cause of extracranial cerebrovascular disease?

1. Fibromuscular dysplasia
   
2. Cystic medial necrosis
   
3. Atherosclerosis
   
4. Arteritis

A 74-year-old man presents for a routine clinical follow-up. He has a 20 pack-year smoking history, having quit smoking 10 years ago, hypertension, and diabetes mellitus. He is clinically asymptomatic and functionally independent. Physical examination is normal with the exception of an audible bruit over the right carotid artery. Which of the following is the most appropriate recommendation?

1. Medication optimization and continued abstinence from cigarette smoking
   
2. Medication optimization and continued abstinence from cigarette smoking and a carotid duplex ultrasound
   
3. Medication optimization and continued abstinence from cigarette smoking and a magnetic resonance angiography (MRA) of the head and neck
   
4. Medication optimization and continued abstinence from cigarette smoking and a computed tomography (CT) of the head and neck

A 50-year-old woman presents for a routine clinical evaluation. She has a past medical history of gastroesophageal reflux disease and bipolar disorders. She is a nonsmoker. Physical examination is normal with the exception of an audible bruit over the right carotid artery. An electrocardiogram demonstrates sinus rhythm with nonspecific ST–T wave changes. Which of the following is the most appropriate recommendation?

1. Medication optimization and routine health-care maintenance
   
2. Medication optimization and routine health-care maintenance and carotid duplex ultrasonography
   
3. Medication optimization and routine health-care maintenance and MRA of the head and neck
   
4. Medication optimization and routine health-care maintenance and CT of the head and neck

An 80-year-old right-handed woman with a past medical history of coronary artery disease, sinus node dysfunction status post pacemaker implantation, and hypertension presents to the emergency department. Her laboratory assessment and electrocardiogram are essentially normal. Her daughter reports that she noted that her mother was having some word-finding difficulty on the telephone. She also appeared to be bumping into objects to her left and appeared as though she had not seen them. Ischemia or infarction in which arterial distribution most likely explains this patient’s deficits?

1. Left vertebral artery
   
2. Left internal carotid artery
   
3. Right vertebral artery
   
4. Right internal carotid artery

Bilateral carotid duplex ultrasonography is performed in the patient in Question 20.6. Which criteria are most commonly utilized in assessing the severity of internal carotid artery stenosis by ultrasonography?

1. Visual estimation of the degree of internal carotid stenosis and comparison with the normal-caliber vessel distal to the stenotic segment
   
2. Measurement of the peak systolic velocity in the internal carotid artery and its ratio with the peak systolic velocity in the external carotid artery
   
3. Measurement of the peak systolic velocity in the internal carotid artery and its ratio with the peak systolic velocity in the common carotid artery
   
4. Measurement of the end-diastolic velocity in the internal carotid artery

The carotid duplex ultrasound performed on the patient in Question 20.6 has equivocal results due to conflicting velocity and ratio data. Which of the following would be most appropriate next step?

1. MRA
   
2. Repeat carotid duplex ultrasonography with pre-sedation
   
3. Conventional catheter based angiography
   
4. CT

Which of the following treatment strategies is not effective in stroke prevention given the current evidence-based literature?

1. Intensive glucose control and hemoglobin A1c reduction in-patient with diabetes mellitus type 2
   
2. Interventions aimed at lowering blood pressure below 140/90 mmHg
   
3. Initiation of high-dose statin medication in patients with recent stroke or transient ischemic attack (TIA)
   
4. Smoking cessation

Which of the following antiplatelet regimens is not indicated in reduction of stroke risk in an asymptomatic patient with carotid or vertebral artery atherosclerosis?

1. Aspirin 75–325 mg daily
   
2. Clopidogrel 75 mg daily
   
3. Aspirin 75–325 mg plus clopidogrel 75 mg daily
   
4. Aspirin plus extended-release dipyridamole twice daily

Which of the following is the recommended method of assessing stenosis severity on angiography?

1. Minimal residual lumen through the zone of stenosis is compared with the estimated diameter of the carotid bulb
   
2. Minimal residual lumen through the zone of stenosis is compared with the estimated diameter of the common carotid artery
   
3. Minimal residual lumen through the zone of stenosis is compared with the French size of the diagnostic catheter used during angiography
   
4. Minimal residual lumen through the zone of stenosis is compared with the diameter of the distal internal carotid artery

A 68-year-old patient with a past medical history of hypertension and dyslipidemia presents to the hospital with left motor deficit for 7 h. He has a 20 pack-year smoking history. He was previously active. He does not have any active cardiopulmonary disease. A carotid duplex ultrasound demonstrates >70% right internal carotid artery stenosis. Carotid angiography is shown in Figure 20.12. Which of the following is the most effective treatment strategy?

1. Optimization of medical therapy with a target blood pressure less than 140/90 mmHg and initiation of statin therapy in addition to smoking cessation counseling
   
2. Optimization of medical therapy with a target blood pressure less than 140/90 mmHg and initiation of statin therapy in addition to smoking cessation counseling plus carotid endarterectomy within 2 weeks
   
3. Optimization of medical therapy with a target blood pressure less than 140/90 mmHg and initiation of statin therapy in addition to smoking cessation counseling plus carotid artery stenting within 2 weeks
   
4. Optimization of medical therapy with a target blood pressure less than 140/90 mmHg and initiation of statin therapy in addition to smoking cessation counseling and discharge after stabilization; revascularization only if recurrent events

Which of the following patients would not be considered high risk for a carotid endarterectomy?

1. An 84-year-old man with a prior history of stroke. Carotid angiography now demonstrates a complete occlusion of the right internal carotid artery and a high-grade stenosis in the proximal left internal carotid artery.
   
2. A 75-year-old woman with a prior history of head and neck radiation for previous cancer now presents 2 weeks after an ischemic stroke. Carotid angiography demonstrates a high-grade right internal carotid artery stenosis. The left internal carotid artery is widely patent.
   
3. A 68-year-old man with a history of inferior wall myocardial infarction 1 year ago which was treated with implantation of a drug-eluting stent in the right coronary artery. He also has a history of diet-controlled diabetes mellitus type 2. He now presents with a left middle cerebral artery territory ischemic stroke. MRA demonstrates a high-grade left internal carotid artery stenosis. The right internal carotid artery is widely patent.
   
4. A 76-year-old man with a history of coronary artery disease, hypertension, and chronic left ventricular systolic dysfunction presents with dysarthria and right-sided motor deficit. MRI demonstrates an ischemic stroke. He was discharged from the hospital 3 weeks ago after undergoing coronary artery bypass graft surgery. His post-surgical course was uncomplicated. His estimated left ventricular ejection fraction prior to discharge was 30%.

A 72-year-old man with a past medical history of hypertension, dyslipidemia, and diabetes mellitus type 2 presents to the hospital with transient left-sided hemiparesis. He is evaluated by neurology, and noninvasive evaluation confirms a high-grade stenosis of the right internal carotid artery. He undergoes carotid endarterectomy with an uncomplicated post-operative course. He now presents to the outpatient clinical for post-discharge follow-up. Which of the following is correct regarding his ongoing management?

1. He should be on aspirin in addition to his antihypertensive and lipid-lowering medication and should have a follow-up carotid ultrasound in 1 month.
   
2. He should be continued on antihypertensive and lipid-lowering medication and have a follow-up carotid duplex ultrasound in 1 month. Aspirin is not indicated as he does not have a documented history of coronary artery disease and the bleeding risk is too high.
   
3. He should be on aspirin in addition to antihypertensive medications. A carotid duplex ultrasound should be performed in 1 month. Lipid-lowering medication is not indicated as he has had a successfully uncomplicated carotid endarterectomy unless he has markedly elevated lipid levels.
   
4. He should be on aspirin in addition to his antihypertensive and lipid-lowering medications. Carotid duplex ultrasound is not indicated for 1 year.