09 Neuro Flashcards
A 62-year-old right-handed man has transient episodes of weakness in the right hand, blurred vision, and difficulty expressing himself. There is no associated headache, the episodes have sudden onset, lasting about 5 or 10 minutes at the most, and they resolve spontaneously, leaving no neurologic sequela.
What is it? Transient ischemic attacks in the territory of the left carotid artery, caused by stenosis or an ulcerated plaque at the left carotid bifurcation.
Management. Start workup with Duplex scanning. If stenosis exceeds 70% proceed to carotid endarterectomy.
A 61-year-old man presents with a 1-year history of episodes of vertigo, diplopia, blurred vision, dysarthria, and instability of gait. The episodes have sudden onset, last several minutes, have no associated headache, and leave no neurologic sequela.
What is it? Another version of transient ischemic attacks, but now the vertebrals may be involved.
Management. Start with Duplex scanning.
Last week, a 60-year-old diabetic man had abrupt onset of right third nerve paralysis and contralateral hemiparesis. There was no associated headache. The patient is alert, but the neurologic deficits have not resolved.
What is it? Neurologic catastrophes that begin suddenly and have no associated headache are vascular occlusive. The vernacular for this man’s problem is “a stroke.”
Management. Vascular surgery in the neck is designed to prevent strokes, not to treat them once they happen. There are very rare exceptions, but revascularization of an ischemic brain area risks making it bleed and get worse. This fellow will get a CT scan to assess the extent of the infarct and supportive treatment with emphasis on rehabilitation. Eventually his neck vessels will be looked at by Duplex to see whether a second stroke elsewhere may be preventable. If the vignette had given the patient a very early stroke, where intravenous infusion of tissue-type plasminogen activator (tPA) could be started within 90 minutes of the onset of symptoms, your choice would’ve been a CT scan (to rule out extensive or hemorrhagic infarcts), followed by the tPA infusion.
A 64-year-old black man complains of a very severe headache of sudden onset and then lapses into a coma. Past medical history reveals untreated hypertension, and examination reveals a stuporous man with profound weakness in the left extremities.
What is it? Neurologic catastrophes of sudden onset, with severe headache, are vascular hemorrhagic. This man has bled into his head. In the vernacular, he has also suffered “a stroke.”
Management. Again supportive with eventual rehabilitation efforts if he survives. CT scan is the universal first choice to see blood inside the head (we use it in trauma for the same purpose). This man will get one, to see exactly where he bled, and how bad it is.
A 39-year-old woman presents to the ER with a history of a severe headache of sudden onset that she says is different and worse than any headache she has ever had before. Her neurologic examination is completely normal, so she is given pain medication and sent home. She improves over the next few days, but 10 days after the initial visit she again gets a sudden, severe, and singular diffuse headache, and she returns to the ER. This time she has some nuchal rigidity on physical exam.
What is it? This one is a classic: subarachnoid bleeding from an intracranial aneurysm. The “sentinel bleed” that is not identified for what it is is a common feature. The “sudden, severe, and singular” nature of the pain are classics. And the nuchal rigidity betrays the presence of blood in the subarachnoid space.
Diagnosis. We are looking for blood inside the head, thus start with CT. Angiograms will eventually follow, in preparation for surgery to clip the aneurysm or endovascular coiling.
A 31-year-old nursing student developed persistent headaches that began approximately 4 months ago, have been gradually increasing in intensity, and are worse in the mornings. For the past 3 weeks, she has been having
projectile vomiting. Thinking that she may need new glasses, she seeks help from her optometrist, who discovers that she has bilateral papilledema.
What is it? Brain tumor. Neurologic processes that develop over a period of a few months and lead to increased ICP spell out tumor. Morning headaches are typical. If the tumor is in a “silent” area of the brain, there may be no other neurologic deficits.
Management. If given the option, pick MRI as your diagnostic test. If it is not offered, pick CT scan. Measures to decrease ICP while awaiting surgery include high-dose steroids (Decadron).
A 42-year-old right-handed man has a history of progressive speech difficulties and right hemiparesis for 5 months. He has had progressively severe headaches for the last 2 months. At the time of admission he is confused and vomiting and has blurred vision, papilledema, and diplopia. Shortly thereafter his blood pressure goes up to 190 over 110, and he develops bradycardia.
What is it? Again brain tumor, but now with two added features: there are localizing signs (left hemisphere, parietal, and temporal area), and he manifests the Cushing reflex of extremely high ICP.
Management. As above, but as an emergency.
A 42-year-old man has been fired from his job because of inappropriate behavior. For the past 2 months he has gradually developed very severe, “explosive” headaches that are located on the right side, above the eye. Neurologic examination shows optic nerve atrophy on the right, papilledema on the left, and anosmia.
What is it? Brain tumor in the right frontal lobe. A little knowledge of neuroanatomy can help localize tumors. The frontal lobe has to do with behavior and social graces, and is near the optic nerve and the olfactory nerve. If you want the fancy name, this is the Foster Kennedy syndrome.
Management. MRI and neurosurgery.
A 12-year-old boy is short for his age, has bitemporal hemianopsia, and has a calcified lesion above the sella in x-rays of the head.
What is it? Craniopharyngioma.
Management. Get the fancy MRI and proceed with craniotomy.
A 23-year-old nun presents with a history of amenorrhea and galactorrhea of 6 months’ duration. She is very concerned that others might think that she is pregnant, and she vehemently denies such a possibility.
What is it? Prolactinoma.
Management. First confirm that she indeed is not pregnant or hypothyroid. Then, since you suspect a functioning tumor of an endocrine gland, measure the appropriate hormone. So, here you want a prolactin level. You also want to see the tumor. The top choice for that is MRI. Bromocriptine therapy is favored by most, with surgery reserved for those who do not respond or who wish to become pregnant.
A 44-year-old man is referred for treatment of hypertension. His physical appearance is impressive: he has big, fat, sweaty hands, large jaw and thick lips, a large tongue, and huge feet. He is also found to have a touch of diabetes. In further questioning he admits to headaches, and he relates that his wedding ring no longer fits his finger.
What is it? Acromegaly. Appearance is so striking that the vignette is likely to come with a picture (or two: front including his hands, and lateral showing the large jaw).
Management. Somatomedin C determination, MRI, and eventually pituitary surgery or radiation therapy.
A 15-year-old girl has gained weight and become “ugly.” She shows a picture of herself taken a year ago, where she was a lovely young lady. Now she has a hairy, red, round face full of pimples; her neck has a posterior hump, and her supraclavicular areas are round and convex. She has a fat trunk and thin extremities. She has mild diabetes and hypertension.
What is it? Cushing. This one will also come with a picture, rather than a description. (Or two pictures, the before and after.)
Management. The sequence already described in the endocrine section: overnight low-dose dexamethasone suppression test. If no suppression, 24-hour urinary cortisol. If cortisol is high, do high-dose dexamethasone suppression test. If she suppresses at high dose, do MRI of the sella, and follow with trans-sphenoidal pituitary surgery.
A 27-year-old woman develops a severe headache of sudden onset, making her stuporous. She is taken to the hospital, where she is found at admission to have a blood pressure of 75 over 45. Funduscopic examination reveals
bilateral pallor of the optic nerves. Relatives indicate that for the past six months, she has been complaining of morning headaches, loss of peripheral vision, and amenorrhea. After she developed the severe headache, and just before she went into a deep stupor, she told her relatives that her peripheral vision had suddenly deteriorated even more than before.
What is it? Pituitary apoplexy. (She has bled into a pituitary tumor.)
Management. Steroid replacement is urgently needed. Other hormones will need to be replaced eventually. MRI or CT scan will determine extent of the problem.
A 32-year-old man complains of progressive, severe generalized headaches that began 3 months ago, are worse in the mornings, and lately have been accompanied by projectile vomiting. He has lost his upper gaze, and he exhibits the physical finding known as “sunset eyes.”
What is it? Another classic. This tumor is in the pineal gland, and if you want the fancy name it is Parinaud syndrome.
Management. MRI to start. The neurosurgeons will take care of the rest.
A 6-year-old boy has been stumbling around the house and complaining of severe morning headaches for the past several months. While waiting in the office to be seen, he assumes the knee-chest position as he holds his head. Neurologic examination demonstrates truncal ataxia.
What is it? Tumor of the posterior fossa. Most brain tumors in children are located there, and cerebellar function is affected.
Management. MRI, neurosurgery.
