Neuro Scenarios Flashcards
A 45yo pt with a known seizure disorder has been noncompliant with her anti-convulsant medication d/t side effects she has been experiencing. While in your office, she starts convulsing at a frequency that does not allow consciousness. Which of the following is the most appropriate initial drug tx?
a) loraxepam
b) phenytoin
c) phenobarbitol
d) valproic acid
a: status epilepticus, defined as a continuous seizure or repeated seizures in which interval consciousness is not obtained, is a medical emergency! An IV infusion of a longer acting benzodiazepine, such as lorazepam, has been shown to be effective in terminating a seizure. IF the seizures persist, then other potential agents to use after the initial lorazepam infusion include fosphenytoin (phenytoin) or valproic acid (phenobarbital)
While performing a routine hx and physical exam on a 70yo pt, you note a right carotid bruit. He denies any symptoms suggestive of a TIA or stroke. A carotid doppler ultrasound shows a 50% stenosis of the R carotid artery. The next most appropriate step would be:
a) stat carotid arteriogram
b) initiate antiplatelet therapy with aspirin
c) anticoagulate with warfarin
d) intra-arterial tissue plasminogen activator (t-PA)
e) carotid endarterectomy
b: The pt exhibits an asymptomatic carotid bruit. The most appropriate step would be to initiate antiplatelet therapy with daily aspirin. Arteriography would NOT be indicated for an asymptomatic carotid bruit. Anticoagulation with warfarin (coumadin) should be limited to symptomatic bruits manifested as multiple TIAs. Carotid endarterectomy is reserved for carotid stenosis that is >70% in pts who have had recurrent TIAs on medical therapy.
A CSF analysis reveals the following results: opalescent color, increased protein, decreased glucose, and increased polymorphonuclear WBCs. The most likely dx would be:
a) SAH
b) bacterial meningitis
c) viral meningitis
d) multiple sclerosis
e) encephalitis
b: The CSF analysis in bacterial meningitis includes a cloudy appearance with a markedly elevated protein and WBC count. The white cells are predominantly polymorphonuclear leukocytes. Bacterial utilization of CSF glucose causes it to be low. Gram stain may or may not be positive for bacteria. The dx of bacterial meningitis requires a culture of the CSF. CSF pressures at the time of the lumbar puncture are elevated in 90% of cases. In viral meningitis, the CSF white cell count is usually 1,000/mL. The cell types are lymphocytes or monocytes but early in the disease polymorphonuclear leukocytes may dominate. CSF glucose is normal in viral meningitis and protein is elevated (like bacterial). Gram stain will be negative and culture will show no growth. The CSF in MS may have mild lymphocytosis with an increased protein concentration. CSF protein electrophoresis in MS shows discrete bands of IgG called oligoclonal bands*. These oligoclonal bands are present in 90% of pts with MS. The CSF in SAH is grossly bloody. Because bleeding can be caused by a traumatic puncture, the RBC count should be done first and last tubes and the counts compared. In SAH, the RBC count will be the same, whereas in a traumatic lumbar puncture, the RBCs will not be present in the last tube that is collected. The CSF in SAH may reveal xanthochromia. This is a yellow appearance in the CSF caused by the degradation of RBCs in CSF. CSF becomes xanthochromic after it has been exposed to blood for several hours.
A 41yo woman presents to the ED complaining of a sudden onset of the “worst HA of my life.” A stat CT scan of her head is found to be normal. The next appropriate step in the dx of this pt would be:
a) outpatient MRI of the brain
b) CBC with diff
c) injection of sumatriptan
d) lumbar puncture
e) repeat CT scan in 48 hrs
d: The hallmark of a subarachnoid hemorrhage (SAH) is the very sudden onset of a severe HA. The HA is often described as,”the worst HA of my life.” A CT scan will detect a SAH in >95% of cases. When hx suggests SAH and CT scan fails to detect bleeding, a lumbar puncture will yield bloody CSF in SAH. Outpatient MRI or repeat CT in 48 hours would create a potentially harmful delay in dx. CBC w/ diff may be ordered but would not confirm dx. Tx with sumatriptan is c/i in presence of potential cerebrovascular syndrome.
A 45yo man presnets to the office with a 24hr hx of right facial droop, slurred speech, and drooling from the right side of his mouth. On exam, the pt is found to have a right facial droop, and he is unable to close his right eye and raise his right eyebrow. The remainder of the physical exam in completely normal. What would be the most appropriate therapy at this time?
a) Prednisone for 1 week and reevaluate in office
b) stat CT scan of the head and neurology consult
c) Obtain Lyme disease titers
d) aspirin
a: This is a typical presentation of Bell’s palsy. Bell’s palsy is an idiopathic facial nerve palsy that results in unilateral weakness or PARALYSIS of facial muscles. This results in facial drooping, slurred speech, drooling, as well as the inability to close the eye and raise the affected eyebrow. Facial weakness caused by a stroke does NOT affect the ability to close the affected eye or to move the forehead. This weakness is characteristic of peripheral 7th nerve palsy (facial nerve). In a stroke, there are often other abnormalities beyond the facial nerve. Bell’s palsy is often preceded or accompanied by PAIN AROUND THE EAR. It is more common in pregnancy and diabetes. It is believed that starting prednisone within 5 days of the onset of symptoms increases the number of patients who recover completely. The weakness or paralysis is usually maximal between 2-5 days. 80% of pts recover in several weeks. In some cases, it may take up to 2 months to resolve. Improvement in facial motor function with the first 5-7 days is the most favorable prognostic sign! A CT scan of the head and neurological consult are NOT indicated in this pt. Lyme disease would be a rare cause of facial nerve paralysis and is not part of the routine evaluation for it. Aspirin is not indicated, since this is not cause by CVD
A 30yo man presents complaining of back pain radiating down his right leg. On exam, you note his knee jerk reflex is absent on the right. This finding suggests compression of which spinal nerve root?
a) L1-L2
b) L3-L4
c) S1-S2
d) T11-T12
e) C5-C6
b: Absence of the knee jerk reflex suggests compression of the L3-L4 spinal nerve root. The four most commonly tested deep tendon reflexes are the Achilles (ankle jerk) reflex, quadriceps (knee jerk) reflex, triceps reflex, and the biceps reflex. The nerve roots that each tests in ascending order are 1 &2, 3 & 4, 5 & 6 (biceps), and 7 & 8 (triceps). One only needs to remember that the ankle jerk is a lumbar nerve root, and the beeps and triceps are cervical nerve roots.
A 62yo obese woman presents with progressive numbness/tingling in her feet for the past 3 months. On physical exam, the pt is found to have decreased sensation to pinprick and vibration, absence of ankle reflexes, and difficulty with tandem walking. Which is the most common etiology of her symptoms?
a) DM
b) alcoholism
c) Vit B12 deficiency
d) Spinal cord tumor
e) RA
a: Peripheral neuropathy is a syndrome that is manifest by muscle weakness, paresthesias, decreased DTRs and autonomic disturbances most commonly in the hands and feet, such as coldness and sweating. There are many cases of peripheral neuropathy ranging from metabolic conditions to malignant neoplasms, RA, and drug and alcohol abuse. The increase in non-insulin-dependent DM d/t obesity is the American population has increased the incidence of associated disease states.
A 19yo woman presents to the ED complaining of HA. The HAs are generalized and increasing in intensity. They have not responded to OTC meds. She complains of approx 1 week blurred vision, intermittent diplopia, and vague dizziness. Her medical hx includes obesity and acne. She take Accutane and OCPs. She is found to have bilateral papilledema, visual acuity of 20/30 on exam, and a normal MRI of the brain. The next most appropriate step would be:
a) CT scan of head
b) Lumbar puncture
c) therapy with high dose prednisone
d) stat cerebral arteriogram
e) reassurance and f/u in 6 months
b: The presence of HAs associated with papilledema raises the concern for a brain tumor. The MRI excluded a mass lesion, raising a strong suspicion of pseudo tumor cerebri. This is aka benign intracranial HTN*. It is not a benign condition, however, since it causes severe HA and may result in visual loss. It is particularly frequent in obese adolescent girls and young women. The etiology is unknown but may be associated with the use of OCPs, vitamin A, and tetracycline. The presentation consists of HAs caused by an increase ICP and blurring of vision. There may be diplopia, but the remainder of the neuro exam is unremarkable. Papilledema is virtually always part of the presentation. Mental status is normal. The differential diagnosis includes venous sinus thrombosis, sarcoidosis, and TB. An abnormal CSF is not consistent with pseudotumor cerebri. The dx is made by excluding mass lesions with CT scan or MRI and demonstrating markedly increased ICP by lumbar puncture. The tx involves weight loss, diuretics, and steroids. Repeat LP to remove CSF and decrease ICP. In cases that are unresponsive to these measures, Lumbar-peritoneal shunting is effective, as is unilateral optic nerve sheath fenestration. Effective tx can improve HAs and prevent vision loss
A 12yo, left-hand dominant girl is being evaluated for “spells” that she has been experiencing. According to her parents, she was born following an uncomplicated PG and was a healthy child until last year when she was struck by a drunk driver when she was walking home from a friend’s house. The episodes begin by her complaining of an upset stomach and then she appears confused, turns her head to the left, and raises her left arm in the air. Each episode lasts for about 30-60s, after which she is very tired for another hour. This scenario best describes which type of seizure disorder?
a) absence
b) tonic-clonic
c) simple partial
d) complex partial
e) pseudoseizures
d: Complex partial seizures are usually proceeded by some type of sensory AURA*. This is followed by an impairment of consciousness but not total loss of consciousness along with an involuntary motor activity. The seizure will resolve in about 30 min and is followed by postictal confusion. Simple partial seizures have NO alteration of consciousness. Absence and tonic-clonic seizures are GENERALIZED seizure disorders in which consciousness is LOST. Absence seizures are character by starting spells without motor involvement, whereas tonic-clonic seizures involve strong muscle extension and contraction in many major muscle groups. Pseudoseziures are a dx of exclusion. All tests results including an EEG are normal, and the seizures may be a manifestation of an underlying psychiatric disturbance.
A 65 yo man presents to the ED with an acute ischemic stroke. His CT scan is normal. His BP is 180/100mmHg. What is the most appropriate tx at this time?
a) Labetalol 20mg IV
b) Nifedipine 10mg PO
c) Nitroprusside drip at 1mg/kg/min
d) Clonidine 0.1mg PO
e) no antihypertensive at this time
e: BP is typically elevated at the time of presentation in acute ischemic stroke. IT will decline without medication in the first few hours to days. Aggressively lowering BP in an acute ischemic stroke may decrease the blood flow to the ischemic but salvageable brain tissue. This potentially salvageable brain tissue is referred to as the penumbra. Decreasing blood flow to the ischemic penumbra by actually lowering BP may result i eventual infarction of the brain tissue. Tx of previously undiagnosed HTN should be deferred for several days. BP should be tx if there are other indications, such as angina or HF. Control of BP is appropriate in pts who are receiving t-PA for their stroke. BP should be lowered cautiously to a systolic of less than 185mmHg and a diastolic of less than 110mmHg. This is thought to decrease the incidence of intracerebral hemorrhage in these pts.
A 28yo man presents with complaints of new-onset HA. The pain awakens him early in the morning and is described as sharp, lancinating pain around his right eye, which is a 9/10. When he looks in the mirror he notices tearing of his right eye as well as redness and a different sized pupil compared to the left. The pain lasts only for a few minutes but can recur later in the morning. This has happened for the past several days. The pt has a hx of recurrent HAs that follow this pattern and usually last for 5-7days. Prior to this occurrence it has been 4 years since his last episode. Which of the following is the most appropriate preventative tx the pt should be offered?
a) sumatriptan
b) dihydroergotamine
c) verapamil
d) oral corticosteroids
e) oxygen
d: Oral corticosteroids started immediately will often force a cluster cycle into remission and prevent future HAs. The infrequent recurrence pattern of the cluster HAs does not support the chronic use of verapamil. Sumatriptan, dihydroergotamine, and oxygen are very useful abortive agents but do not work on stopping the cluster cycle. Both sumatriptan and hihydroergotamine have maximum daily doses and may not be used for all attack during the day as some cluster pts may have multiple attacks throughout the day.
An otherwise healthy 16yo girl presents to your office with a complaint of HA. Reportedly, this is the second time she has experienced such a HA, the last time being last month. The pain builds up over several hours to 9/10 and can last into the next day. It is holocephalic and throbs when she moves. She has to stop what she is doing to go lay down in a dark quiet room or she vomits. No OCT medication that she tried has worked. Her hx is consistent with:
a) migraine with aura
b) cluster HA
c) tension-type HA
d) migraine without aura
e) medication withdrawal HA
d: The hx is consistent with a migraine without aura. Migraine is a HA that is defined by a pain that is usually unilateral, is pounding quality with activity, can be made worse with physical activity, is associated with both light and sound sensitivity, and is associated with N/V. if the HA is preceded by an abnormal sensory experience s/a visual disturbance that lasts no longer than 60 minutes and totally remits, it is classified as a migraine with aura. Cluster HAs are usually unilateral as well but tend to be periorbital and are of shorter duration but greater intensity, often described as a stabbing pain. In addition, pts may experience ipsilateral autonomic sxs s/a lacrimation, rhinorrhea, and ptosis. Tension-type HA are mostly d/t contraction of cranial and cervical muscles and are described as bilateral, tight, or squeezing in nature, and are sometimes relieved by physical activity*. Medication withdrawal HA typically present as daily, constant HA.
A 20 month-old boy is brought into the ED by his parents. They state he has not been feeling well for 2 days and this morning noted he was “shaking all over” and was not responding to commands. This went on for 10 minutes and has never happened before. His current rectal temperature is 100.7F. The seizures are characteristic of:
a) absence seizures
b) Lennox-Gastaut syndrome
c) Febrile seizures
d) infantile spasms
e) juvenile myoclonic epilepsy
c: Febrile seizures can occur in children younger than 5 years when accompanied by a fever. They are characterized by a brief generalized motor seizure. Absence seizures are generalized seizures characterized by a loss of consciousness without motor involvement, typically seen in older children. Lenox-Gastuat syndrome presents in childhood as well but is usually associated with developmental delay and seizures of akinetic and myoclonic nature (referred to a drop attacks). Infantile spasms occur without relation to systemic illness and are massive myoclonic events w/ bending at the waist.
A previously healthy, 27yo woman experiences an episode of vision loss in her left eye. She state it developed over hours and was like she was “looking through fog.” The vision in her right eye was never affected. She denies any paresthesias, weakness, or bladder dysfunction. The sight in her left eye improved after several days but has not returned to baseline. Which of the following is the most likely dx?
a) diabetic retinopathy
b) pseudotumor cerebri
c) amaurosis fugax
d) MS
e) carotid artery dissection
d: MS is a demyelinating disease that is thought to have an autoimmune pathophys. The presenting symptoms of MS are highly variable but can include focal weakness, paresthesia, or visual disturbance. Once the pt experiences a set of symptoms, they may improve but will NOT return to baseline function. The visual loss associated with diabetic retinopathy is usually bilateral. Pseudotumor cerebri is often accompanied by HA and presents as diplopia. Amaurosis fugax is unilateral but will resolve over 10-20 minutes and is caused by an embolic source. Carotid artery dissection can also cause unilateral vision loss but is usually total and followed by other, more send:ere neuro defects.
A 73yo man is brought into your office by his adult children with a concern of memory loss. They report their father’s memory has been declining since the death of their mother a few months ago but are now concerned because he is losing weight, sleeping during the daytime, and is not keeping up with current events like he usually does. This type of behavior is most associated with which of the following?
a) Picks disease
b) Creutzfeldt-Jakob disease
c) depression
d) Alzheimer disease
e) Vit B12 deficiency
c: This pts symptoms are most consistent with situation depression over the loss of his spouse. Transient memory problems can be a component of depression as a result of decreased attention and interest. Dementia is a progressive impairment of higher cognitive function, and initially, the pts social graces are preserved. It has many causes, of which Pick tease, Creutzfeldt-Jakob disease, and Alzheimers disease are irreversible.
