Cases

Question 1

 A 43-year-old woman presents with a chief
complaint of a numbness and weakness below her chest level.
 Her neurological symptoms started 4 years ago.
Since that time, she has experienced at least 5 neurological episodes (e.g., left facial numbness, left hand numbness, blurriness of vision on the left or the right sides).
 Each episode has lasted for several weeks and
was not associated with symptomatic infection.
-transverse myelitis
-black holes in noncontrast MRI

Answer 1

Multiple sclerosis

Question 2

A man has weakness of right side, he is confused, sees double and speech is slurred.

Upon examination patient has right hemipareiss with diminished pinprick and two point discrimination on the right side of his head and arm. His deep tendon reflexes are brisk of the right and there is positive babinski on the right.

he has difficulty answering or repeating words, when he speaks he says only a few words. His ability to respond to complicated verbal commands whether spoken or written is not impaired.

what is the speaking difficulty and the likely site of infarct

Answer 2

1. Broca

2. Left superior middle cerebral artery

Question 3

Elderly female patient suffered stroke resultingp in weakness of left limbs, inability to gaze to the left and loss of facial expression on the left mouth. She failed to verbally acknowledge anyhing was wrong with her. When she was asked to draw a clock, she did not put any numbers on the left face of the clock. What was occluded.

What visual deficit would you expect

Answer 3

Right middle cerebral artery (superior and inferior)

(Right FEF, right posterior parietal cortex)

left contralateral homonymous hemianopsia

Question 4

During the past year, a 15-year-old girl became ob ese and listless, had episodes of high fever without apparent cause, ceased menstruating, drank copious amounts of water owing to severe thirst, passed excessive amounts of urine, frequently fell asleep during the day, often had reversed sleep-wake cycles, and on occasion erupted into a violent state of rage without provocation.

Answer 4

Hypothalamic syndrome - obese, listless, high fever, ceased menstruating, severe thirst, excessive amounts of urine, fell asleep, reverse sleep wake cycles, rage without provocation

Question 5

A six year old boy has been noted to have brief
pauses throughout the day, lasting only a few
seconds.

Answer 5

This is an absence seizure. You elect to start him on ethosuximide.

Question 6

You are asked to see a seven year old girl who has had two seizures at night. Just before going to bed, her
mother heard a

Answer 6

Benign rolandic epilepsy (focal onset) - SPS, CPS, SGTC

treat with a first line partial seizure drug

You reassure her parents that
the prognosis is excellent and discuss starting
oxcarbazepine.

Question 7

A two year old boy has been having nighttime

seizures and

Answer 7

You elect to start him on valproic acid although many treatments

Atonic seizure: lennox-gastaut

<2.5 Hz spike and wave

Question 8

A 6 month old baby girl has been having events of body flexion in clusters around naptime and bedtime. Her
parents feel she is not looking right and losing milestones. Her EEG demonstrates chaotic background
activity with multifocal spikes and sharp waves. An event
during the study correlates with diffuse background attenuation for only two seconds. Treatment?

Answer 8

You elect to start the
patient on adrenocorticotropin hormone (ACTH) daily
injections.

Infantile spasms (mad cute)

Question 9

a 36 yr old woman comes to the office due to firm, nontender swelling of her right cheek for the past 4 months. The patient has had no fever, runny nose, sore throat, or cough. She drinks a glass of wine with dinner on most nights but does not use tobacco. Physcial examination shows fullness of the preauricular space on the right side. An MRI of the region identifies a 2.2 cm mass in the right parotid gland and a follow up core needly biopsy shows lesion to be neoplastic. 
What is likely going to happen 
A. Bitemporal hemianopsia 
B. Facial numbness
C. Facial droop
D. Hoarsness
E. Horner syndrome 
F. Strabismus

Answer 9

Answer: facial droop

The extracranial portion of the facial nerve CN VII carries motor innervation to the muscles of facial expression. The nerve exits the skull through the stylomastoid foramen and courses within the substance of the parotid gland. Within this gland, the facial nerve divides into its 5 terminal branches (temporal, zygomatic, buccal, mandibular, and cervical). Parotid gland tumors can compress and disrupt the ipsilateral facial nerve and its branches, causing facial droop. In fact, most parotid gland tumors causing facial nerve paralysis are malignant neoplasms.

Question 10

66 yr old man develops transient painless vision loss in the left eye. He has history of hypertension, hyperlipidemia, type 3 diabetes (insulin resistance in the brain) . Evaluation reveals significant stenosis of the left internal caroid artery. Carotid endarterectomy is performed, during the surgery the left glossopharyngeal nerve is accidentally transected. Which of the following is most likely to be seen due to nerve injury

A. deviation of the protruded tongue towards the left
B. Hoarseness due to left vocal cord dysfunction
C. impaired taste sensation from anterior 2/3 of tongue
D. loss of general sensation at the tonsillar lining
E. reduced salivary secretion from submandibular gland

Answer 10

Correct answer: Loss of general sensation at the tonsillar lining

The glosspharyngeal nerve, or cranial nerve *CN IX), originates in the medulla and exits the cranial cavity via the jugular foramen. This nerve has numerous functions, including: somatic motor (elevates larynx during swallowing), parasympathetic (inferior salivatory nucleus –> CN IX -> otic ganglion -> parotid gland secretion), general sensory (tympanic membrane (inner surface), eustachian tube, posterior third of the tongue, tonsillar region, upper pharynx (afferent portion of the gag reflex)), general sensory (taste: posterior one third of tongue). Glossopharyngeal nerve lesions therefore result in loss of the gag reflex (afferent limb); loss of general sensation in the upper pharynx, posterior tongue, tonsils, and middle ear cavity, and loss of taste sensation on the posterior third of the tongue. A: CN XII; B: CN X (particularly the recurrent laryngeal nerve); C: CN VII; E: CN VII (from superior salivatory nucleus).

Question 11

35 yr old man comes to office with painful tongue sore. For 2 weeks he has had a fever. An ulcer is located on the median sulcus of the tongue and is 2 cm anterior to the foramen cecum. Blood is drawn for an HIV test. The pain sensation from his ulcer is most likely carried by which of the following nerves

Answer 11

Mandibular division of the trigeminal nerve

Innervation of the tongue is complex, as there are motor, general sensory, and gustatory (taste components.
Motor innervation of the tongue is provided by CN XII with the exception of the palatoglossus muscle, which is innervated by the CN X.
General sensory innervation of the tongue (including touch pain pressure, and temperature sensation) is provided by CN V (V3, mandibular branch) for anterior 2/3 of the tongue, CN IX for the posterior 1/3 of the tongue, and CN X for the posterior area of the tongue root.
Gustatory (special) innervation (taste buds) gets covered as follows: anterior 2/3 of the tongue by chorda tympani branch of CN VII, posterior 1/3 of the tongue by CN IX, posterior area of the tongue, epiglottis, taste buds of the larynx and upper esophagus by CN X. So, any lesion anterior to the terminal sulcus and foramen cecum, including patients oral ulcer

Question 12

You are asked to see a seven year old girl who has had
two seizures at night. Just before going to bed, her
mother heard a

Answer 12

You reassure her parents that
the prognosis is excellent and discuss starting
oxcarbazepine.

Benign Rolandic epilepsy

Question 13

In bacterial meningitis the most common route by which pathogens enter the CSF is through

Answer 13

the bloodstream

Question 14

What feature of a women undergoing sevoflurane would you expect of her respiration.

Answer 14

decreased tidal volume, increased respiratory rate, decreased minute volume

Question 15

66 yr old woman with history of afib and hypertension is brought to emergency room by her husband. She suddenly fell to the ground and was unable to move or speak. In the ER she was intubated because she could not breathe and was thought to be in a coma. After 1 week her husband noticed that she was moving her eyes up and down to get his attention, This woman most likely had a stroke in which structure

Answer 15

Ventral pons:

locked in syndrome in which the motor pathways are affected usually at the level of the pons.

Question 16

17 yr old experiences an episode consisting of bed smell which he knows he then needs to sit down. He then develops sudden turning of his eyes and forced deviation of his head to the right and a stiff extended posture of his right arm and hand. After making an odd sound, his right arm starts to jerk repeatedly for a minute. Then he loses consciousness as moth arms begin jerking rhythmically together, first fast and then slower until they stop. he remains silent for a while and then gradually awakens but his consciousness seems impaired as he does not respond to questions or commands. What do you describe this as?

Answer 16

Simple partial seizure evolving into a generalized seizure. Starts by affecting only the sense of smell, suggesting involvement of one neural system (simple) and likely originated from one focal region. As the seizures spreads to both sides of the brain, consciousness is interrupted and bilateral symmetric motor activation occurs, consistent with a generalized abnormality.

Question 17

30 yr old gentleman with temporal lobe epilepsy has continued to have seizures despite oxcarbazepine, and valproic acid. He recalls his prior MRI and EEG both demonstrate abnormality in his left temporal lobe. What would be the next best treatment?

Answer 17

Epilepsy surgery.

additional epileptic drug (new or old) after two failed is very low, about 3-4%
IN patients with focal onset seizures especially those with identifiable causative lesion, the next best option is to offer patients resective surgery of the epileptic focus.
*another point - patients with temporal lobe epilepsy have an additional likelihood of success moreso than patients with non-temporal lobe focus.

Question 18

20 yr old has bilateral hearing loss, tinnitus, ambulatory difficulty, bilateral posterior fossa tumors and mononeuropathy. His MRI shows lesions that are external to the brain. His most likely clinical diagnosis is.

Answer 18

Neurofibromatosis type 2.

-development of unilateral or bilateral vestibular nerve schwannomas commonly occurs by early adulthood.

Question 19

40 yr old man previously in good health slowly developed some weight loss palpitations, tremulousness, difficulty in sleeping, excessive sweating and fatigue. HE developed visual loss that began to bother him.

Answer 19

TSH producing pituitary adenoma w/ bitemporal hemianopsia.

Question 20

Middle aged man develops a choreiform movement disorder including writhing movements of the extremities. He subsequently developed forgetfulness and lastly profound dementia. There is a family history of similar symptoms. WHat genetic lesion caused this

Answer 20

Trinucleotide repeat expansion. CAG

Question 21

3 yr old is referred to neurologist because he has not reached typical milestones in walking and talking. Neuroimaging is ordered and he is found to have a large cyst replacing the cerebellar vermis in an enlarged posterior fossa. The most likely cause is

Answer 21

Dandy walker malformation -congenital abnormality that affects some or all of the cerebellar components. It is associated with an enlarged posterior fossa.

Question 22

70 yr old man is admitted to hospital for increasing confusion. He has no fevers and his strength exam is normal. He is oriented and has good reflexes but decreased vibratory sense on exam. His lumbar puncture reveals 30 lymphocytes, normal glucose and elevated protein. You would also expect to find a positive serologic test for

Answer 22

Syphilis - CSF findings classic for neurosyphilis and decreased vibratory sense.

West Nile and herpes encephalitis should have associated fever and nothing suggests brain or epidural abscess.

Question 23

32 yr old man comes to office because of 3 yr history of knife like headaches centered on his left eye. They awaken him at night and are associated with left eye lacrimation and rhinorrhea. Over a 2 month period they occur nightly last 30 minutes and resolve. They typically do not occur again for another year. What is the most likely diagnosis

Answer 23

Cluster headache

unilateral headache with male preponderance and associated autonomic symptoms including lacrimation, rhinorrhea and horners syndrome occurring ipsilateral to the pain. They occur in clusters nightly for weeks to months and last around 1/2 and hour, which differentiates them from longer acting headaches such as migraine and tension type headaches.

Question 24

28yr old woman comes to physician because of a 5 month history of severe throbbing headaches followed by exhaustion. She says the headaches are sometimes preceded by slowly enlarging C-shaped flashing lights. She is a teacher and often spends much time reading. What is the diagnosis if neurologic examination shows no abnormalities

Answer 24

Migraine. Migraines are unilateral severe headaches typically associated with nausea and photo or phonophobia. Often they occur with auras and positive phenomena including flashing lights and typically in patterns such as a C shape. Sinusitis usually presents with fevers and congestive symptoms.

Question 25

What are found in neuritic/senile plaques of postmortem AD patients

Answer 25

composed largely of insoluble aggregates of Ab-42 protein

Question 26

14 yr old boy is present to ER after being tackled in football game. Child is unresponsive. He has decerebrate posture and pupils are fixed and dilated. You suspect cerebral herniation. The hit is not hard but he did get hit in practice recently. CT scan of the head shows diffuse cerebral swelling and cerebral herniation. What has happened and what is the mechanism?

Answer 26

Second Impact Syndrome

-there is abnormality of cerebrovascular regulation that leads to rapid engorgement of cerebral vasculature, cerebral edema and ultimately cerebral herniation.

(no hemmorhage, full recovery can not be expected 100% morbidity

Question 27

34 yr old complains she is afflicted by migraine attacks that predominate during her menses. Which of the following drugs would be most appropriate first line agent for prevention of her recurrent menstrual migraines

Answer 27

Sumatriptan or NSAID (taken at the time of vulnerability)

Because this is a predictable pattern of migraine

Question 28

Caregiver for patient who is treated with donepezil for vascular dementia asks if giving (diphenhydramine) is appropriate.

Answer 28

NO. Because of its anticholinergic properties, diphenhydramine may counteract activity of the cholinesterase inhibitor treatment.

• can also contribute to orthostatic hypotension by blocking alpha receptors which may increase risk of fall in ALL elderly, not just demented
• also can cause urinary retention - anticholinergics.

Question 29

59 yr old man with history of hypertension and diabetes suddenly experiences headache and inability to see anything in left visual field together with hemiparesis of both the upper and lower extremities on the left side. What stroke would be consistent with this

Answer 29

Anterior choroidal -
-although a stroke in the PCA would also produce a contralalteral visual field defect, the combined motor deficits is what did it. A larger or more proximal PCA would lead to sensory deficits from interruption of blood supply to the thalamus

Question 30

70 yr old collapses. Woman continued to talk alot in the ER but made no sense. She could not follow basic directions. She was diagnosed with a stroke and her communcation problems determined to be a language deficit. What would you expect additionally vision wise?

Answer 30

A right visual field deficit.
This woman has Wernicke’s aphasia. The inferior branch of left MCA also supplies white matter visual projections to the occipital lobe.

Question 31

Woman suffers a lesion to the ventromedial, what would you expect

a. hypersexuality
b. uncontrolled anger
c. passiveness
d. uncontrolled laughing

Answer 31

uncontrolled anger

Question 32

Patient is feeling feverish secondary to brain injury which of the following nuclei are most likely affected

Answer 32

Anterior hypothalamus. Heat loss center which will initiate sweating and vasodilation when body temp increases .

Question 33

Asian woman is diagnosed with complex parital seizures of the temporal lobe with secondary generalization. The drug her doctor wants to prescribe, recommends an allelic screening to look for the HLA-B*1502 allele first. What is this drug?

Answer 33

Carbamazepine

Question 34

38 yr old is brought to ER after he developed a generalized convulsive seizure at home. Patient is still convulsing 25 min later. What to give as initial treatment

Answer 34

Benzodiazepines (larazepam, diazepam or midazolam) are recommended as the initial therapy for the treatment of status epilepticus. `

Question 35

Patient with paranasal sinusitis presents with fever, severe headache, neckpain and seizures. On physical exam patient is lethargic. What is the best next course

Answer 35

Subdural empyema -triad of fever preceding sinus disease, focal neurologic deficits.

Subdural empyema is a neurologic emergency and can rapidly progress and requires prompt surgical evacuation in addition to antibiotics. Lumbar puncture is contraindicated. Serologic studies would not be helpful. Steroids not indicated.

Question 36

80 yr old man presents with fever, headache, personality change with progression to confusion. ON exam patient is febrile to 101 and not able to follow commands. CT head is negative. MRI shows increased signal in bilateral temporal lobes. What would the next best diagnostic test

Answer 36

CSF HSV CR. This patient has HSV encephalitis. The most sensitive and specific test for diagnosis is HSV PCR. Viral