Neurology

Question 1

This type of stroke presents as weakness or sensory loss on the opposite side of the lesion, homonymous hemianopsia, and aphasia

Answer 1

Middle cerebral artery (MCA)

Question 2

This is loss of visual field on the opposite side of the stroke. A left-sided MCA stroke results in loss of the right visual fields. The eyes can’t see the right side.

Answer 2

homonymous hemianopsia

Question 3

This type of stroke presents as personality/cognitive defects such as confusion, urinary incontinence, and leg more than arm weakness.

Answer 3

Anterior cerebral artery (ACA)

Question 4

This type of stroke presents as ipsilateral sensory loss of the face, 9th and 10th cranial nerves, contralateral sensory loss of the limbs, and limb ataxia

Answer 4

Posterior cerebral artery (PCA)

Question 5

What is the best initial test for any kind of stroke?

Answer 5

CT Scan

Question 6

What is the best initial therapy for a nonhemorrhagic stroke?

Answer 6

Less than 3 hours since onset of stroke: thrombolytics
More than 3 hours since onset of stroke: aspirin
Hemorrhagic stroke: nothing

Question 7

What if the patient is already on aspirin at the time of the stroke? What would you give?

Answer 7

Add dipyridamole or Switch to Clopidogrel

Question 8

What would you give for prevention of a stroke?

Answer 8

Aspirin or Clopidogrel

Do not combine them!

Question 9

When will you do a surgical correction for carotid stenosis?

Answer 9

symptomatic CVD and more than 70% stenosis

Question 10

This type of headache is associated with visual disturbance (flashes, sparks, stars, luminous hallucinations), photophobia, aura, relationship to menses, association with food (chocolate, red wine, cheese). It may be precipitated by emotions. It is also associated with nausea and vomiting.

Answer 10

Migraine Headache

Question 11

This type of headache is frequent, short duration, high intensity headaches, with men affected 10 times more than women.

Answer 11

Cluster headache

Question 12

This type of headache is associated with visual disturbance, systemic symptoms such as muscle pain, fatigue, and weakness. Jaw claudication is also present.

Answer 12

Giant cell (temporal) arteritis

Question 13

This type of headache is associated with obesity, venous sinus thrombosis, oral contraceptives, and vitamin A toxicity. It can mimic a brain tumor with nausea, vomiting, and visual disturbance.

Answer 13

Pseudotumor cerebri

Question 14

How would you diagnose Pseudotumor cerebri?

Answer 14

CT or MRI to exclude an intracranial mass lesion and a lumbar puncture (LP) showing increased pressure

Question 15

How would you diagnose Giant cell arteritis?

Answer 15

Biopsy (most accurate test)

markedly elevated ESR

Question 16

How would you treat Tension headache?

Answer 16

NSAIDs and other analgesics

Question 17

How would your treat Migraine?

Answer 17

triptans, ergotamine, or 100% oxygen as abortive therapy

Question 18

How would you treat Giant cell (temporal) arteritis?

Answer 18

Prednisone

Question 19

How would you treat Pseudotumor cerebri?

Answer 19

Weight loss and Acetazolamide

Question 20

This is the best preventive therapy for migraine.

Answer 20

Propanolol

Question 21

Patient presents with bilateral “bandlike” pressure headache that can last up to 4-6 hours with normal physical exam. What is the most likely diagnosis?

Answer 21

Tension headache

Question 22

Patient presents with or without aura, photopobia, can be related to food/emotions/menses, and sometimes aphasia, numbness, and dysarthria. What is the most likely diagnosis?

Answer 22

Migraine

Question 23

Patient presents with episodic head pain, unilateral periorbital intense pain, lacrimation, eye reddening, nasal stuffiness, and lid ptosis. What is the most likely diagnosis?

Answer 23

Cluster headache

Question 24

This is an idiopathic disorder of the fifth cranial nerve resulting in severe, overwhelming pain in the face. Attacks of pain can be precipitated by chewing, touching the face, or pronouncing certain words in which the tongue strikes the back of the front teeth. Patients describe the pain as feeling as if a knife is being stuck into the face.

Answer 24

Trigeminal Neuralgia

Question 25

How would you treat Trigeminal Neuralgia?

Answer 25

Oxcarbazepine or carbamazepine

Question 26

If after giving oxcarbazepine, trigeminal neuralgia doesn't improve, what is the next step?

Answer 26

Gamma Knife Surgery

Question 27

This is a seizure that us focal to one part of the body. For instance, a patient may have a seizure that is limited just to an arm and leg. It can either be simple or complex.

Answer 27

Partial seizure

Question 28

This is a generalized seizure with varying phrases of muscular rigidity followed by jerking of the muscles of the body for several minutes.

Answer 28

Tonic-clonic seizure

Question 29

This is the best initial therapy for a persistent seizure.

Answer 29

Benzodiazepine (Lorazepam or diazepam IV)

Question 30

If the seizure persists after benzodiazepine, what would you give?

Answer 30

Phenytoin or Fosphenytoin

Question 31

This is the best therapy for absence seizures

Answer 31

Ethosuximide

Question 32

A 38-year-old man is evaluated for seizures. He achieves partial control with the addition of a second antiepileptic medication. He drives to work each day. What do you do about his ability to drive? a. Confiscate his license b. Allow him to drive if he is seizure-free for 1 year. c. Allow him to drive as long as his seizure history is noted on his license. d. Recommend that he find an alternative means of transportation e. Do not let him leave the office unless he is picked up by someone; no further driving f. Allow him to drive as long as he is accompanied

Answer 32

D

Question 33

``` This is caused by the rupture of an aneurysm that is usually located in the anterior portion of the circle of Willis. Aneurysms are present in 2% of routine autopsies. The vast majority never rupture. They are more frequent in those with: Polycystic kidney disease Tobacco smoking Hypertension Hyperlipidemia High alcohol consumption ```

Answer 33

Subarachnoid Hemorrhage

Question 34

This is a sudden onset of an extremely severe headache with meningeal irritation (stiff neck, photophobia) and fever. Loss of consciousness occurs in 50% of patients. What is the most likely diagnosis?

Answer 34

Subarachnoid Hemorrhage

Question 35

What is the best initial test for Subarachnoid Hemorrhage?

Answer 35

CT without contrast

Question 36

This is the most accurate test for Subarachnoid Hemorrhage.

Answer 36

Lumbar puncture showing blood

Question 37

This drug can prevent subsequent ischemic stroke.

Answer 37

Nimodipine

Question 38

A woman comes to the emergency department with a severe headache starting one day prior to admission. On physical examination she has a temperature of 103F, nuchal rigidity, and photophobia. Her head CT is normal. LP shows CSF with 1250 white blood cells and 50,000 red blood cells. What is the most appropriate next step in the management of this patient? a. Angiography b. Ceftriaxone and vancomycin c. Nimodipine d. Embolization e. Surgical clipping f. Repeat the CT scan with contrast g. Neurosurgical consultation

Answer 38

B. The number of WBCs in the CSF in this patient far exceeds the normal ratio of 1 WBC to each 500 to 1000 RBCs. With 50,000 RBCs, there should be no more than 50 to 100 WBCs. The presence of 1250 WBCs indicates an infection, and ceftriaxone and vancomycin are the best initial therapy for bacterial meningitis. Contrast is not useful when looking for blood.

Question 39

This presents as loss of all function except for the posterior column (position and vibratory sensation intact), flaccid paralysis below the level of the infarction, loss of deep tendon reflexes (DTRs) at the level of the infarction. What is the most likely diagnosis?

Answer 39

Anterior Spinal Artery Infarction

Question 40

Patient can have B12 deficiency or neurosyphilis. Position and vibratory sensation are lost. a. Subacute Combined Degeneration of the cord b. Spinal Trauma c. Brown-Sequard Syndrome d. Syringomyelia

Answer 40

A

Question 41

There is acute onset of limb weakness and/or sensory disturbances below the level of the injury with the severity in proportion to the degree of injury. Sphincter function is impaired. Loss of DTRs at the level of the injury followed by hyperreflexia below the level of the trauma.

Answer 41

Spinal Trauma

Question 42

After unilateral hemisection of spinal cord from an injury such as a knife wound cutting half the cord or compression from a mass lesion, patients lose pain and temperature on the contralateral side from the injury, and lose motor function as well as position and vibratory sense on the ipsilateral side of the injury.

Answer 42

Brown-Sequard Syndrome

Question 43

There is loss of pain and temperature bilaterally across the upper back and both arms. It also causes loss of reflexes and muscle atrophy in the same bilateral distribution. What is the most likely diagnosis?

Answer 43

Syringomyelia

Question 44

What is the most accurate test for Syringomyelia?

Answer 44

MRI

Question 45

This is the best treatment for Syringomyelia.

Answer 45

Surgical removal of tumor if present and drainage of fluid from cavity

Question 46

This is a collection of infected material within the parenchyma of the brain tissue acting as a space-occupying lesion.

Answer 46

Brain abscess

Question 47

What is the best initial test for brain abscess?

Answer 47

CT or MRI

Question 48

What is the most accurate test for brain abscess?

Answer 48

Brain biopsy

Question 49

What is the empiric therapy for brain abscess?

Answer 49

Penicillin plus metronidazole plus ceftriaxone

Question 50

This disease presents with neurological abnormalities such as seizures, progressive psychomotor retardation, slowly progressive mental disorientation, skin abnormalities such as adenoma sebaceum, shahreen pateches, and ash leaf patches. Retinal lesions and cardiac rhabdomyomas can also occur.

Answer 50

Tuberous Sclerosis

Question 51

What is the treatment for Tuberous Sclerosis?

Answer 51

No specific treatment. Control seizures.

Question 52

This disease presents with soft, flesh-colored lesions attached to peripheral nerves, eight cranial nerve tumors, cutaneous hyperpigmented lesions (cafe au lait spots), meningioma and gliomas.

Answer 52

Neurofibromatosis (von Recklinghausen Disease)

Question 53

This disease presents with port-wine stain of the face, seizures, CNS problems such as homonymous hemianopsia, hemiparesis, mental subnormality.

Answer 53

Sturge-Weber Syndrome

Question 54

This is the best therapy for Essential tremor

Answer 54

Propanolol

Question 55

Patient is usually at age 50 to 60 or older who presents with a tremor, muscular rigidity, bradykinesia (slow movements), and a shuffling gait with unsteadiness on turning and a tendency to fall. There is also cogwheel rigidity, hypomimia, and micrographia.

Answer 55

Parkinsonism

Question 56

What is the treatment for Parkinsonism with mild symptoms?

Answer 56

Anticholinergic medications (benztropine and trihexyphenidyl) relive tremor and rigidity.

Question 57

You can give this in older patients with Parkinsonism intolerant of anticholinergic medications.

Answer 57

Amantadine

Question 58

This is the best initial therapy for those with severe parkinsonism (inability to care for themselves, orthostatic.)

Answer 58

Dopamine agonists (Pramipexole and Ropinirole)

Question 59

This is the most effective medication for severe parkinsonism.

Answer 59

Levodopa/carbidopa

Question 60

This extend the duration of levodopa/carbidopa by blocking the metabolism of dopamine.

Answer 60

COMT inhibitors (Tolcapone, Entacapone)

Question 61

This is used as adjunct to levodopa/carbidopa which also block metabolsim of dopamine.

Answer 61

MAO inhibitors (rasagiline, selegiline)

Question 62

Why should you avoid tyramine-containing foods (cheese) with MAO inhibitors?

Answer 62

they precipitate hypertension

Question 63

Which of the following is most likely to slow the progression of parkinsonism? a. Pramipexole b. Levodopa/carbidopa c. Rasagiline d. Tolcapone e. Amantadine

Answer 63

C. Only the MAO inhibitors are associated with the possibility of retarding the progression of parkinsonism

Question 64

A 70-year-old man with extremely severe parkinsonism comes by ambulance to the emergency department secondary to psychosis and confusion developing at home. He is maintained on levodopa/carbidopa, ropinirole, and tolcapone. What is the most appropriate next step in management? a. Stop levodopa/carbidopa b. Start clozapine c. Stop ropinirole d. Stop tolcapone e. Start haloperidol

Answer 64

B. When a patient has very severe parkinsonism, you cannot stop medications because the patient will become "locked in" with severe bradykinesia. Psychosis and confusion are a known adverse effect of antiparkinsonian treatment. Use antipsychotic medications with the fewest extrapyramidal (antidopaminergic) effects

Question 65

Patients report an uncomfortable sensation in the legs that is "creepy" and "crawly" at night. The discomfort is worsened by caffeine and relieved by moving the legs.

Answer 65

Restless Leg Syndrome

Question 66

How would you treat Restless Leg Syndrome?

Answer 66

Dopamine Agonists (Pramipexole)

Question 67

This is a hereditary disease characterized by CAG trinucleotide repeat sequences on chromosome 4. It presents with choreaform movement disorder (dyskinesia), dementia, behavior changes (irritability, moodiness, antisocial behavior), and onset between 30 and 50 with positive family history.

Answer 67

Huntington Disease

Question 68

This is an idiopathic disorder that presents as vocal tics, grunts, and coprolalia, motor tics (sniffing, blinking, frowning), obsessive-compulsive behavior.

Answer 68

Tourette Disorder

Question 69

This is an idiopathic disorder exclusively of CNS (brain and cord) white matter. MS is more common in white women who live in colder climates. The most common presentation is focal sensory symptoms, with gait and balance problems. Blurry vision or visual disturbance from optic neuritis is no longer common as the first presentation.

Answer 69

Multiple Sclerosis

Question 70

Internuclear ophthalmoplegia (INO) is the inability to adduct one eye with nystagmus in the other eye and i characteristic of _______.

Answer 70

Multiple Sclerosis

Question 71

This is the best initial and most accurate test for Multiple Sclerosis.

Answer 71

MRI

Question 72

This is the best initial therapy for acute exacerbation for Multiple Sclerosis.

Answer 72

High-dose steroids

Question 73

Patient presents with weakness of unclear etiology starting in 20s to 40s with unique combination of upper and lower motor neuron loss. The most serious presentation is difficulty in chewing and swallowing and a decrease in gag reflex. This leads to pooling of saliva in the pharyns and frequent episodes of aspiration. What is the most likely diagnosis?

Answer 73

Amyotrophic Lateral Sclerosis

Question 74

This is the most common cause of death in ALS

Answer 74

Respiratory Failure

Question 75

This is a genetic disorder with loss of both motor and sensory innervation leading to distal weakness and sensory loss, wasting in the legs, decreased deep tendon reflexes, and tremor. Foot deformity with a high arch is common (pes cavus). The legs look like inverted champagne bottles.

Answer 75

Charcot-Marie-Tooth Disease

Question 76

A 38-year-old carpenter comes with pain near his ear that is quickly followed by weakness of one side of his face. Both the upper and lower parts of his face are weak, but sensation is intact. What is the most common complication of his disorder? a. Corneal ulceration b. Aspiration pneumonia c. Sinusitis d. Otitis media e. Deafness f. Dental carries

Answer 76

A. Corneal ulceration occurs with seventh cranial nerve palsy because of difficulty in closing the eye, especially at night. This leads to dryness of the eye and ulceration. This is prevented by taping the eye shut and using lubricants in the eye. Dental caries don't happen because although there is drooling from difficulty closing the mouth, saliva production is normal. Rather than deafness, sounds are extra loud. Aspiration does not occur because gag reflex and cough are normal.

Question 77

This is an autoimmune damage of multiple peripheral nerves. There is no CNS involvement. A circulating antibody attacks the myelin sheaths of the peripheral nerves, removing their insulation.

Answer 77

Guillain-Barre Syndrome

Question 78

This presents as weakness in the legs that ascends from the feet and moves toward the chest, associated with a loss of DTRs. It is associated with respiratory muscle weakness.

Answer 78

Guillain-Barre Syndrome

Question 79

This is the most specific diagnostic test for GBS.

Answer 79

Nerve conduction studies/electromyography

Question 80

This is the treatment for GBS.

Answer 80

IVIG or plasmapheresis (only one, combining them is a wrong answer)

Question 81

A woman comes to the emergency department with bilateral leg weakness developing over the last few days. She has lost her knee jerk and ankle jerk reflexes. The weakness started in her feet and progressed up to her calves and her thighs. She is otherwise asymptomatic. Which of the following is the most urgent step? a. Pulmonary function testing b. Arterial blood gas c. Nerve conduction study d. Lumbar puncture e. Peak flow meter

Answer 81

A. The most dangerous thing that can happen with GBS is dysautonomia or involvement of the respiratory muscles. Peak inspiratory pressure or a decrease in forced vital capacity (FVC) is the earliest way to detect impending respiratory failure.

Question 82

It is a disorder of muscular weakness from the production of antibodies against acetylcholine receptors at the neuromuscular junction. It presents with double vision and difficulty chewing, dysphonia, or weakness of limb muscles worse at the end of the day.

Answer 82

Myasthenia Gravis

Question 83

This is the best initial test for Myasthenia Gravis

Answer 83

Acetylcholine Receptor Antibodies

Question 84

This is the most accurate test for Myasthenia Gravis

Answer 84

Electromyography - shows decreased strength with repetitive stimulation

Question 85

This is the best initial treatment for Myasthenia gravis

Answer 85

Neostigmine or Pyridostigmine

Question 86

If medications does not control disease progression of Myasthenia Gravis, what is the most appropriate next step in management?

Answer 86

Thymectomy (if patient is under 60) Prednisone (if patient above 60)

Question 87

This is an anticholinergic drug that blocks muscarinic receptors; decreases the drooling and diarrhea that occur as adverse effects of neostigmine and pyridostigmine.

Answer 87

Glycopyrrolate

Question 88

How would you treat acute myasthenic crisis.

Answer 88

IVIG or Plasmapheresis

Question 89

This is the most common cause of dementia

Answer 89

Alzheimer disease

Question 90

These are treatment options for Alzheimer disease

Answer 90

Donepezil, rivastigmine, and galantamine -> all increase acetylcholine levels Memantine

Question 91

This is a rapid progressive dementia with myoclonic jerks. It is normal in MRI or CT. CSF with 14-3-3 protein.

Answer 91

Creutzfeldt-Jakob Disease

Question 92

This is the most accurate test for Creutzfeldt-Jakob Disease.

Answer 92

Biopsy