NEUROLOGY Flashcards
In patients with cerebellar hemorrhage, which of the following management plan is recommended?
a. Immediate referral to a neurosurgeon should be done to assist with patient evaluation
b. If the patient is alert without brainstem signs and hematoma is 3 - 5 cm, surgery is usually unnecessary
c. Hydrocephalus due to cerebellar hematoma should be treated solely with ventricular drainage
d. Surgical evacuation is not usually done because the lesion is infratentorial
The correct answer is: Immediate referral to a neurosurgeon should be done to assist with patient evaluation
Which of the following is seen in patients with thalamic hemorrhage?
a. Pinpoint (1mm) pupils that are reactive to light.
b. Aphasia with preserved verbal repetition.
c. Heteronymous visual field defects due to interruption of the visual pathway.
d. Contralateral Horner’s syndrome and retraction nystagmus.
The correct answer is: Aphasia with preserved verbal repetition.
Which of the following statement is true regarding the CSF examinations for viral encephalitis:
a. VZV CSF PCR test alone is sufficient in establishing the diagnosis of VZV encephalitis
b. CSF HSV PCR may be negative in the 1st 3 days of symptoms of HSV encephalitis
c. Negative CSF cultures would exclude the diagnosis of HSV or EBV encephalitis
d. Serum HSV serology tests alone may be used to diagnose HSV encephalitis
The correct answer is: CSF HSV PCR may be negative in the 1st 3 days of symptoms of HSV encephalitis
Which of the following is true in the management of patients with HSV encephalitis?
a. Intravenous Acyclovir at 20mg/kg q8 for 21 days in adults
b. Oral Valacyclovir is given as a supplemental therapy after IV acyclovir is given
c. IV acyclovir should be diluted at a concentration 7mg/mL and infused over 30 minutes
d. Seizure prophylaxis should be considered in severe cases of encephalitis
The correct answer is: Seizure prophylaxis should be considered in severe cases of encephalitis
Which management strategy should be done in a patient with suspected bacterial meningitis?
a. Adjunctive Dexamethasone should be started in patients with focal neurologic signs.
b. Blood cultures may be obtained before or after initiation of antibiotics
c. It is safe to do lumbar puncture without neuroimaging studies in all immunocompetent patients
d. Empiric antibiotic therapy should be started without delay
The correct answer is: Empiric antibiotic therapy should be started without delay
IV antibiotics should be given for 2 weeks in which causative agent of bacterial meningitis?
a. Neisseria meningitides
b. Streptococcal meningitis
c. Listeria monocytogenes
d. Pseudomonas aeruginosa
The correct answer is: Streptococcal meningitis
Which of the following statement correctly describes the pathophysiology of migraine?
a. The sensory sensitivity in migraine is due to the dysfunction of monoaminergic sensory control systems in the parietal cortex.
b. Constriction of the meningeal vessels triggers trigeminovascular input in the trigeminal ganglion and synapses on second-order neurons in the trigeminocervical complex.
c. Cell activation in the trigeminal nucleus results in the release of vasoactive neuropeptides, particularly calcitonin gene–related peptide (CGRP).
d. Neurons from the trigeminocervical complex project in the spinothalamic tract and projects to the ipsilateral neurons in the thalamus.
The correct answer is: Cell activation in the trigeminal nucleus results in the release of vasoactive neuropeptides, particularly calcitonin gene–related peptide (CGRP).
Which of the following treatment strategies for acute attacks in migraine is correct?
a. Patients should be advised to take NSAIDS early in the migraine attack.
b. Monotherapy with a selective oral 5HT receptor agonist result in rapid and complete relief of migraine in all patients.
c. Triptans are generally effective in migraine with aura, especially when given before the aura is completed.
d. 5HT receptor antagonists are safe for patients with cardiovascular and cerebrovascular diseases.
The correct answer is: Patients should be advised to take NSAIDS early in the migraine attack.
In patients brought to the ER with generalized tonic clonic seizures of 10 minute duration, which of the following drugs should be given first?
a. Midazolam 0.2mg/kg IV
b. Phenytoin 20mg/kg IV
c. Propofol 2mg/kg IV
d. Valproic Acid 20mg/kg IV
The correct answer is: Midazolam 0.2mg/kg IV
Which of the following statements regarding seizure initiation is correct?
a. Administration of Penicillin may sometimes trigger the release of glutamate via direct activation of excitatory amino acid receptors throughout the CNS and cause seizure.
b. Accidental ingestion of domoic acid lowers the seizure threshold by antagonizing the effects of GABA at its receptor thereby reducing neuronal inhibition.
c. Fever, alcohol withdrawal, hypoxia, and infection cause seizure due to analogous perturbations in neuronal excitability.
d. In focal seizure, oscillatory behavior involves an interaction between GABAB receptors, T-type Ca2+ channels, and K+ channels located within the cerebral cortex.
The correct answer is: Fever, alcohol withdrawal, hypoxia, and infection cause seizure due to analogous perturbations in neuronal excitability.
Which of the following drugs for migraine prophylaxis is correctly paired with its corresponding side effect?
a. Propranolol: hair loss
b. Flunarizine: drowsiness
c. Topiramate: weight gain
d. Valproic acid: weight loss
The correct answer is: Flunarizine: drowsiness
Intracerebral hemorrhages at the subcortical regions are commonly seen in patients with
a. Metastatic brain tumors
b. Cerebral amyloid angiopathy
c. Uncontrolled hypertension
d. Capillary telangiectasia
The correct answer is: Uncontrolled hypertension
A 42 year-old female was admitted for acute stroke in the middle cerebral artery distribution. She was born with an atrial septal defect (ASD), and admits to have used cocaine when she was in her 30s, for about 7 years. She currently takes oral contraceptive pills, and it was noted that she has atrial fibrillation of unknown duration. Which of her risk factors uncommonly cause ischemic stroke? (p.3084, Table 420-2)
a. Atrial fibrillation
b. ASD
c. Cocaine
d. Oral contraceptives
The correct answer is: Oral contraceptives
What is the standard imaging modality to detect the presence or absence of hemorrhage in the brain of a 63 year-old male with sudden-onset headache and drooping of one side of the face? (p. 3069)
a. Computed tomography imaging
b. Magnetic resonance imaging
c. Magnetic resonance angiography
d. Conventional x-ray cerebral angiography
The correct answer is: Computed tomography imaging
What is the best strategy to reduce the burden of stroke? (Tx; p. 3087-3091)
a. Identification and control of modifiable risk factors, and especially hypertension and diabetes
b. Administration of anti-platelet therapy to patients with history of TIA or atherothrombotic stroke
c. Long-term vitamin K antagonists (VKAs) for preventing atherothrombotic stroke for either intracranial or extracranial cerebrovascular disease
d. Balloon angioplasty coupled with stenting to open stenotic carotid arteries and maintain their patency
The correct answer is: Identification and control of modifiable risk factors, and especially hypertension and diabetes
Which of the following statements correctly describe the effect of atherothrombotic stroke primary preventive therapies in the general population? (pp. 3087-9)
a. Higher doses of aspirin have been proven to be more effective than lower doses.
b. Long-term use of clopidogrel in combination with aspirin is recommended for stroke prevention.
c. Statin drugs reduce the risk of stroke even in patients without elevated LDL or low HDL.
d. Ticlopidine is less effective and also may cause diarrhea, skin rash, and, in rare instances, neutropenia and thrombotic thrombocytopenic purpura.
The correct answer is: Statin drugs reduce the risk of stroke even in patients without elevated LDL or low HDL.
What is the most common primary headache syndrome?
a. Cluster headache
b. Migraine headache
c. Nummular headache
d. Tension type headache
The correct answer is: Tension type headache
Which of the following is incorrect regarding management of patients with coma? (p. 2074)
a. An oropharyngeal airway is adequate to keep the pharynx open in a drowsy patient who is breathing normally.
b. Hypotension should be corrected slowly to avoid reperfusion injury.
c. Naloxone and dextrose are administered if narcotic overdose or hypoglycemia is a possibility.
d. Thiamine is given along with glucose to avoid provoking Wernicke’s encephalopathy in malnourished patients.
The correct answer is: Hypotension should be corrected slowly to avoid reperfusion injury.
Which is not a hallmark of acute Wernicke’s disease? (p. 2080)
a. Confusion
b. Delirium
c. Impairment of eye movements
d. Gait ataxia
The correct answer is: Delirium
Which of the following is NOT part of the new classification system of seizures? (p.3051-2)
a. Atypical absence seizures
b. Focal seizures with intact awareness
c. Myoclonic seizures
d. Simple focal seizures
The correct answer is: Simple focal seizures
Focal seizures can spread to involve both cerebral hemispheres and produce a generalized seizure, usually of the tonic-clonic variety, and this evolution is observed frequently following focal seizures arising from a region in which part of the brain? (p.3051)
a. Frontal lobe
b. Parietal lobe
c. Occipital lobe
d. Temporal lobe
The correct answer is: Frontal lobe
Which epilepsy syndrome is the most common syndrome associated with focal seizures with impairment of consciousness and is an example of an epilepsy syndrome with distinctive clinical, electroencephalographic, and pathologic features? (pp3052-4)
a. Autosomal dominant partial epilepsy with auditory features (ADPEAF)
b. Juvenile myoclonic epilepsy
c. Lennox-Gastaut syndrome
d. Mesial temporal lobe epilepsy (MTLE)
The correct answer is: Mesial temporal lobe epilepsy (MTLE)
What is the cerebral blood flow (CBF) in gray matter? (p. 2070)
a. 30 mL per 100 g/min
b. 45 mL per 100 g/min
c. 75 mL per 100 g/min
d. 85 mL per 100 g/min
The correct answer is: 75 mL per 100 g/min
What ethanol level in mmol/L in non-habituated patients generally causes impaired mental activity?
a. 43
b. 54
c. 65
d. 76
The correct answer is: 43
A 45 year old male consulted due to recurrent headaches. On history, he had 2 previous hospital admissions due to intracerebral hemorrhages, as confirmed through plain Cranial CT scan. The last episode of intracerebral hemorrhage occurred 1 month prior to consult. What is the recommended cranial imaging technique for this patient?
a. Repeat Cranial CT Scan
b. Cranial MRI
c. 4 vessel angiogram
d. Transcranial doppler
Table 416-1 Guidelines for Use of CT, Ultrasound, and MRI. HPIM page 3030 - 3033
In patients with subacute hemorrhage, MRI is the imaging of choice because the MR sequences may detect micro- hemorrhages, and determine the etiology of the bleed (eg. Cavernous malformations, amyloid, hemorrhagic metastased – see Fig 416-5). CT scan is recommended for ACUTE Intracerebral hemorrhage as it can be done faster than MRI, and is reliable in detecting acute blood. 4 vessel angiogram is indicated for patients suspected to have vascular malformations and aneurysms. Transcranial doppler is used to monitor vasospasm and cerebral bloodflow.
The correct answer is: Cranial MRI
A 62 year old male was brought to the ER due to sudden onset of occipital headache, vomiting, left sided weakness, followed by decrease sensorium. The patient was seen drowsy, with a BP of 210/100 and Cranial CT scan done showed a 35cc bleed in the basal ganglia with a 1 cm midline shift. Which of the following would be part of your management plan for this patient?
a. Maintain MAP 110 – 130
b. Keep head on low back rest
c. Start IV Hydralazine to reach target BP <160/90
d. Initiate osmotic agents as soon as possible
This patient who has a 1cm midline shift on CT scan and is starting to have decreased sensorium should be started on osmotic agents such as Mannitol or hypertonic saline. Maintaining a MAP of 110-130 to facilitate permissive hypertension is done in the management of cerebral iINFARCTION. Recent trials in BP management for hypertensive ICH (INTERACT 2 AND ATTACH 2) showed that lowering the SBP to 140-180mmHg is likely safe and possibly beneficial. Patients with ICH are placed in moderate to high back rest to improve venous return to the heart. In lowering BP, Nonvasodilating IV meds such as Nicardipine, Labetalol and Esmolol should be used instead of Hydralazine.
The correct answer is: Initiate osmotic agents as soon as possible
A 35 year old male complained of sudden severe headache and vomiting. On PE, the patient is awake, oriented, with a right LR palsy, and no other sensorimotor deficits. Cranial CT Scan showed subarachnoid hemorrhage. What is this patient’s SAH Grade based on the Hunt-Hess Scale ?
a. 1
b. 2
c. 3
d. 4
The correct answer is: 2
After lifting a heavy object, a 40 year old male complained of sudden severe headache associated right sided eye pain. Upon shining a light on the right pupil, it was dilated, and non reactive to light. But upon shining a light on the left pupil, the contralateral pupillary reflex on the right was intact. Where is the most common likely site of the aneurysm?
a. Anterior Cerebral Artery
b. Inferior Cerebellar Artery
c. Middle Cerebral artery
d. Posterior Communicating Artery
An aneurysm of the posterior communicating artery will compress the third cranial nerve due to its proximity to the latter. This would result to an ipsilateral third cranial nerve is palsy, and present with pupillary dilation, and loss of ipsilateral (but retained contralateral) light reflex. Focal pain above or behind the eye, may occur with an expanding aneurysm at the junction of the posterior communicating artery and the internal carotid artery. Aneurysms of the Anterior circulation (ACA or Acomm) would present with leg weakness. Aneurysms involving the posterior inferior cerebellar artery or anterior inferior cerebellar artery often present with occipital and posterior cervical pain. MCA aneurysms may present with pain in or behind the eye and in the low temple but this would not present with third nerve palsies.
The correct answer is: Posterior Communicating Artery
What is the ICH score of an 78 year old male with a 35cc bleed on the right capsuloganglionic area with intraventricular extension, and is GCS 12 on examination?
a. 2
b. 3
c. 4
d. 5
The correct answer is: 3
A 34 year old female was brought to the Er due to a 3 day history of fever associated with disorientation, memory changes, olfactory and gustatory hallucinations. On the day of admission, the patient had 3 episodes of versive head turning to the left followed by generalized tonic clonic movements of all extremities. Cranial MRI showed increased signal abnormalities in the left temporal lobe on FLAIR sequence. What would the most likely diagnosis of the patient?
a. EBV encephalitis
b. HIV encephalitis
c. HSV encephalitis
d. Japanese B encephalitis
HSV encephalitis should be considered when clinical features suggest involvement of the inferomedial frontotemporal lobes. This includes olfactory and gustatory hallucinations, anosmia, bizaare behavior or memory changes.
The correct answer is: HSV encephalitis
A 32 year old patient with HIV developed gradually progressive mental impairment, ataxia and visual deficit. On examination, you noted homonymous hemianopia. These symptoms are most likely due to:
a. HIV encephalitis
b. Progressive multifocal leukoencephalopathy
c. CNS lymphoma
d. Autoimmune encephalitis
Progressive multifocal leukoencephalopathy is characterized by multiple areas of demyelination of varying sizes but sparing the optic nerves and spinal cord. This is due to crystalline arrays of JCV virus particles in oligodendrocytes. Patients often present with visual deficits typically a homonymous hemianopsia (45%), mental impairment (38%), weakness and ataxia. HIV encephalitis on the other hand present with waxing and waning episodes of psychomotor retardation and decreased concentration. Patients with CSF lymphoma would present focal symptoms depending on the site of the lesion, as opposed to multifocal symptoms seen in PML. Although autoimmune encephalitis would also present with behavioral changes, it is usually seen in patients with ovarian tumors, and not with HIV infection.
The correct answer is: Progressive multifocal leukoencephalopathy
A 40 year old diabetic female was brought to the ER due to a 5 day history of fever and cough followed by a 3 day history of headache and increased sleeping in time. On PE, there was note of nuchal rigidity and positive Kernig’s sign. What is the most likely causative agent of this patient’s infection?
a. Neisseria meningitidis
b. Haemiphilus influenzae
c. Listeria monocytogenes
d. Streptococcus pnuemoniae
The patient initially presented with community acquired pneumonia which is the most important risk factor in developing pneumococcal meningitis. The organisms most often responsible for community-acquired bacterial meningitis are Streptococcus pneumoniae (~50%), Neisseria meningitidis (~25%), group B streptococci (~15%), and Listeria monocytogenes (~10%). Haemophilus influenzae type b accounts for <10% of cases of bacterial meningitis in most series. There are a number of predisposing conditions that Additional risk factors include coexisting acute or chronic pneumococcal sinusitis or otitis media, alcoholism, diabetes, splenectomy, hypogammaglobulinemia, complement deficiency, and head trauma with basilar skull fracture and CSF rhinorrhea
The correct answer is: Streptococcus pnuemoniae
A 22 year old female was brought to the ER due to a 2 week history progressive headache, fever, and night sweats. On neurologic exam, there was positive Kernig’s and Brudzinski signs. Lumbar tap done showed CSF with lymphocytic pleocytosis and mildly decreased glucose. What is the most likely diagnosis of the patient?
a. TB meningitis
b. Viral meningitis
c. Bacterial meningitis
d. Aseptic meningitis
The combination of unrelenting headache, stiff neck, fatigue, night sweats, and fever with a CSF lymphocytic pleocytosis and a mildly decreased glucose concentration is highly suspicious for tuberculous meningitis. Signs and symptoms of viral and bacterial meningitis commonly develop within a few days to a week (acute presentation). The CSF in viral meningitis would have normal glucose. The CSF in bacterial meningitis would show neutrophilic pleocytosis. Aseptic meningitis would have unremarkable CSF findings
The correct answer is: TB meningitis
A 25 year old female was brought to the ER due to a 3 week history of headache, blurring of vision, nape pain and vomiting. She works in a zoo and is exposed to pigeons. On PE, papilledema and bilateral LR palsy were noted. Cranial CT scan showed slit like ventricles and CSF india ink was positive. What is the most likely etiology of this patient’s meningitis?
a. Histoplasma capsulatum
b. Cryptococcus neoformans
c. Coccidioides immitis
d. Candida spp.
The correct answer is: Cryptococcus neoformans
A 19 year old male was brought to the ER due to a 2 week history of low grade fever, cough, night sweats and headache. On the day of admission, the patient had sudden left sided weakness and nape pain. What is the most likely etiology of the patient’s weakness?
a. Arteritis
b. Brain abscess
c. Empyema
d. Metastasis
This is a typical case of TB meningitis, with a subacute onset of symptoms and sudden focal deficit or stroke due to arteritis. The focal deficits due to empyema, brain abscesses and metastasis usually present gradually.
The correct answer is: Arteritis
An 18 year old male was admitted and managed as a case of fungal meningitis. On the 7th day of treatment, the patient complained of bilateral lower extremity weakness, increased severity of headache and developed decrease in sensorium. What is the most likely cause of his symptoms?
a. Arteritis
b. Hydrocephalus
c. Status epilepticus
d. Spinal meningitis
Lower extremity weakness with headache and decreased sensorium are signs most compatible with increased intracranial pressure. In fungal meningitis, the most common complication is also hydrocephalus. Patients who develop hydrocephalus should receive a CSF diversion device. A ventriculostomy can be used until CSF fungal cultures are sterile, at which time the ventriculostomy is replaced by a ventriculoperitoneal shunt. Arteritis will present with focal neurologic deficits, while spinal meningitis will present with multiple radiculopathies. Status epilepticus would present with seizures
The correct answer is: Hydrocephalus
A 21/F consulted due to recurrent headache for 2 years. Headaches were described as pulsating, on the right frontotemporal to the right hemicranial area with a VAS of 7/10, lasting 4 – 6 hours, occurring 2-3x a month. This was associated with nausea and vomiting. Before the headache episodes, she notes flashing lights and neck discomfort. Neurologic exam and Cranial MRI were unremarkable. What is the most likely diagnosis of the patient?
a. Migraine with brainstem aura
b. Migraine with typical aura
c. Probable migraine with aura
d. Retinal migraine
The correct answer is: Migraine with typical aura
A 23 year old female complained of tunneling of vision and gradually lost consciousness. She then had tonic movements of her extremities lasting 10 seconds, afterwhich, she was noted to be pale and disoriented for 3 minutes. What is the most likely diagnosis of this patient?
a. Pseudoseizure
b. Seizure
c. Syncope
d. Transient Ischemic Attack
The patient’s premonitory symptom of tunneling of vision, gradual transition to unconsciousness and tonic movements lasting 10 seconds are features seen in syncope. Seizures usually present with immediate loss of consciousness lasting minutes, with tonic / clonic moevements lasting 30-60 seconds. Disorientation in seizures would last many minutes to hours while in syncope, it would last for less than 5 minutes. Patients with pseudoseizures present with side-to- side turning of the head, asymmetric and large-amplitude shaking movements of the limbs, twitching of all four extremities without loss of consciousness, and pelvic thrusting. In transient ischemic attack, there is usually a focal weakness that resolves in 1 hour with no evidence of infarction in imaging.
The correct answer is: Syncope
A 19 year old female consulted due to episodes of sudden lapses of consciousness lasting 10-15 seconds with rapid eye blinking and chewing. She regains consciousness spontaneously, with no post ictal confusion. EEG done showed 3 Hz spike and slow discharges with a normal background activity. What is the most likely diagnosis of this patient?
a. Atonic seizures
b. Focal seizures with impaired awareness
c. Myoclonic seizures
d. Typical absence seizures
Atonic seizures are characterized by sudden loss of postural muscle tone lasting 1–2s. The EEG shows brief, generalized spike-and-wave discharges followed immediately by diffuse slow waves that correlate with the loss of muscle tone. Focal seizures frequently begin with an aura, as opposed to the absence of aura in absence seizure. In focal seizures, the patient is typically confused following the seizure, and the transition to full recovery of consciousness may range from seconds up to an hour. In absence seizure, there is no post ictal confusion and the patient goes back to her previous activities as if nothing happened. The EEG in absence in typical absence seizure shows 3 Hz spike and slow discharges. Myoclonic seizures present with sudden and brief muscle contraction that may involve one part of the body or the entire body. The EEG shows bilaterally synchronous spike-and-slow-wave discharges immediately prior to the movement and muscle artifact associated with the myoclonus.
The correct answer is: Typical absence seizures
Which statement is true regarding intracerebral hemorrhage
a. Hypertensive hemorrhages usually result from spontaneous rupture of superficial arteries in the brain
b. In elderly nonhypertensive patients, cerebral amyloid angiopathy should be considered
c. Medium sized arteries in the basal ganglia are most prone to hypertension induced vascular injury
d. Most intracerebral hemorrhages would have significant hematoma expansion after 48 hours.
in elderly nonhypertensive patients, cerebral amyloid angiopathy should be considered, especially those with lobar hemorrhages and dementia. Hypertensive hemorrhages usually result from spontaneous rupture of DEEP PENETRATING arteries in the brain. This is because small sized arteries in the basal ganglia are most prone to hypertension induced vascular injury. Most intracerebral hemorrhages would have significant hematoma expansion within 24 hours of stroke onset; this is as opposed to large infarcts who would develop significant edema at Day 3-5 from the onset of stroke.
The correct answer is: In elderly nonhypertensive patients, cerebral amyloid angiopathy should be considered
Patients with primary white matter disorders often present with which of the following?
a. Seizures
b. Early cognitive decline
c. Movement disorders
d. Long tract signs
The gray matter is composed predominantly of neuronal cell bodies. Hence disorders in the grey matter would often present with seizures, early cognitive decline and movement disorders. On the other hand, the white matter is composed of axons, their myelin and glial cells which transmit signals to the other cells in the central nervous system. In white matter disorders, these signals are interrupted hence long track signs involving motor, sensory and cerebellar pathways are seen in these patients.
The correct answer is: Long tract signs
Which is true in the management of acute subarachnoid hemorrhage?
a. Immediate referral to a neurosurgeon or endovascular surgeon is recommended for all patients
b. Treatment with Nimodipine 30mg tab q4 is given to reduce vasospasm and prevent ischemic injury
c. Glucocorticoids are routinely recommended to reduce cerebral edema
d. Free water restriction is useful in patients at risk for delayed cerebral ischemia
The definitive management to prevent rerupture of aneurysm is through “clipping” by a neurosurgeon or “coiled” by an endovascular surgeon. These patients should be referred immediately since early aneurysm repair prevents rerupture and allows the safe application of techniques to improve blood flow in the brain. Treatment with the calcium channel antagonist nimodipine (60 mg or 2 tabs of 30mg q4) improves outcome, perhaps by preventing ischemic injury rather than reducing the risk of vasospasm. Glucocorticoids may help reduce the head and neck ache caused by the irritative effect of the subarachnoid blood. However, there is no good evidence that they reduce cerebral edema, are neuroprotective, or reduce vascular injury, and their routine use therefore is not recommended. Free-water restriction is contraindicated in patients with SAH at risk for DCI because hypovolemia and hypotension may occur and precipitate cerebral ischemia.
The correct answer is: Immediate referral to a neurosurgeon or endovascular surgeon is recommended for all patients
Which of the following is true in patients with reversible posterior leukoencephalopathy?
a. Aggressive blood pressure lowering to SBP 140-180mmHg must be done to avoid stroke
b. Cranial MRI would reveal edema in bilateral frontal lobes
c. The hypertension may be caused by acute toxemia of pregnancy
d. In most cases, CSF examination would reveal decreased CSF protein
Aggressive lowering of SBP to 140–180 mmHg acutely is usually considered in hypertensive ICH but less aggressive measures should be used in hypertensive encephalopathy and reversible posterior leukoencephalopathy. This is because stroke can occur if blood pressure is lowered too rapidly. MRI brain imaging shows a pattern of typically posterior (occipital > frontal) brain edema that is reversible The hypertension may be essential or due to chronic renal disease, acute glomerulonephritis, acute toxemia of pregnancy, pheochromocytoma, or other causes. In most cases, ICP and CSF protein levels are elevated.
The correct answer is: The hypertension may be caused by acute toxemia of pregnancy
Which of the following is true among patients with intracerebral hemorrhage and coagulopathies?
a. All patients on antiplatelet drugs should be transfused with platelet concentrate
b. Administration of 1 dose of Idarizucimab in patients on Dabigatran quickly reverses its anticoagulation effect
c. Recombinant factor VIIa is a recommended treatment to improve clinical outcomes in these patients
d. Thrombocytopenia should be corrected with platelet transfusion
Platelet transfusions should only be given in patients on antiplatelets if these patients present with thrombytopenia. In a recent trial, for ICH patients on antiplatelets but without thrombocytopenia, platelet transfusion suggested no benefit and was noted to have possible harm . Administration of two doses of Idarizucimab reverses the anticoagulation effect of dabigatran quickly. A phase 3 trial of treatment with recombinant factor VIIa reduced hematoma expansion in ICH patients. However, clinical outcomes were not improved, so use of this drug is not recommended. When ICH is associated with thrombocytopenia (platelet count <50,000/μL), transfusion of fresh platelets is indicated
The correct answer is: Thrombocytopenia should be corrected with platelet transfusion
In patients with cerebellar hemorrhage, which of the following management plan is recommended?
a. Immediate referral to a neurosurgeon should be done to assist with patient evaluation
b. If the patient is alert without brainstem signs and hematoma is 3 - 5 cm, surgery is usually unnecessary
c. Hydrocephalus due to cerebellar hematoma should be treated solely with ventricular drainage
d. Surgical evacuation is not usually done because the lesion is infratentorial
For cerebellar hemorrhages, a neurosurgeon should be consulted immediately to assist with the evaluation; most cerebellar hematomas >3 cm in diameter will require surgical evacuation. If the patient is alert without focal brainstem signs and if the hematoma is <1 cm in diameter, surgical removal is usually unnecessary. Patients with hematomas between 1 and 3 cm require careful observation for signs of impaired consciousness, progressive hydrocephalus, and precipitous respiratory failure. Hydrocephalus due to cerebellar hematoma requires surgical evacuation and should not be treated solely with ventricular drainage.
The correct answer is: Immediate referral to a neurosurgeon should be done to assist with patient evaluation
Which of the following is seen in patients with thalamic hemorrhage?
a. Pinpoint (1mm) pupils that are reactive to light.
b. Aphasia with preserved verbal repetition.
c. Heteronymous visual field defects due to interruption of the visual pathway.
d. Contralateral Horner’s syndrome and retraction nystagmus.
Pinpoint pupils are seen in patients with pontine hemorrhage. Aphasia, often with preserved verbal repetition, may occur after hemorrhage into the dominant thalamus. A homonymous visual field defect may also be seen in thalamic bleed. An ipsilateral Horner’s syndrome and retraction nystagmus may also be seen in these patients.
The correct answer is: Aphasia with preserved verbal repetition.
Which of the following statement is true regarding the CSF examinations for viral encephalitis:
a. VZV CSF PCR test alone is sufficient in establishing the diagnosis of VZV encephalitis
b. CSF HSV PCR may be negative in the 1st 3 days of symptoms of HSV encephalitis
c. Negative CSF cultures would exclude the diagnosis of HSV or EBV encephalitis
d. Serum HSV serology tests alone may be used to diagnose HSV encephalitis
The correct answer is: CSF HSV PCR may be negative in the 1st 3 days of symptoms of HSV encephalitis
Which of the following is true in the management of patients with HSV encephalitis?
a. Intravenous Acyclovir at 20mg/kg q8 for 21 days in adults
b. Oral Valacyclovir is given as a supplemental therapy after IV acyclovir is given
c. IV acyclovir should be diluted at a concentration 7mg/mL and infused over 30 minutes
d. Seizure prophylaxis should be considered in severe cases of encephalitis
In the treatment of HSV encephalitis, IV Acyclovir is given at 10mg/kg q8 for 21 days in adults. Neonates are given 20mg/kg IV Acvclovir q8. Oral Valacyclovir has not been evaluated as a supplemental therapy after IV acyclovir is given in patients with HSV encephalitis. IV acyclovir should be diluted at a concentration <7mg/mL prior to infusion and slowly infused over 1 hour to prevent renal dysfunction. Because of the high frequency of seizures in severe cases of encephalitis, seizure prophylaxis should be considered in severe cases of encephalitis.
The correct answer is: Seizure prophylaxis should be considered in severe cases of encephalitis
What is the recommendation of the Advisory Committee on Immunization Practices (ACIP) to decrease the incidence of meningitis due to Neiserria meningitidis?
a. Routine immunization of 6 – 12 year olds with quadrivalent meningococcal glycoconjugate vaccine
b. Vaccination with the serogroup B meningococcal (Men B) vaccine for young adults age 16-23
c. Vaccination with the quadrivalent meningococcal vaccine for immunocompromised individuals.
d. Routine immunization with the serogroup B meningococcal (Men B) vaccine for adults 65 years old and above
The quadrivalent (serogroups A, C, W-135 and Y) meningococcal glycoconjugate vaccine is routinely given to 11-16 year old children. However, since the vaccine does not contain the serogroup B, which is responsible to 1/3 of meningococcal disease, vaccination with the serogroup B meningococcal (Men B) vaccine may be done for young adults age 16-23. There was no recommendation for the vaccine for immunocompromised individuals and adults 65 years old and above.
The correct answer is: Vaccination with the serogroup B meningococcal (Men B) vaccine for young adults age 16-23
Why is the central nervous system susceptible to bacterial invasion?
a. Airborne bacteria can reach the intraventricular choroid plexus directly to access the CSF.
b. The CSF has small amounts of immunoglobulin and complement proteins.
c. Phagocytosis of bacteria is impaired by the solid tissue substrate of the brain parenchyma.
d. The fluid nature of the CSF prevents opsonization of the bacteria.
Airborne bacteria cannot directly access the CSF. They initially colonize the nasopharynx and has to become bloodborne in order for the them to reach the the intraventricular choroid plexus and access the CSF. The CSF has small amounts of immunoglobulin and complement proteins making them more susceptible to bacterial invasion. Phagocytosis of bacteria is impaired by the fluid nature of CSF, which is less conducive to phagocytosis than a solid tissue substrate like the brain parenchyma. The paucity of immunoglobulins and complement proteins, and not the fluid nature of CSF, prevent effective opsonization of bacteria.
The correct answer is: The CSF has small amounts of immunoglobulin and complement proteins.
Which of the following statements about the pathophysiology of bacterial meningitis is true?
a. Most neurologic manifestations of bacterial meningitis result from direct bacteria-induced tissue injury.
b. During the very early stages of meningitis, there is a decrease in cerebral blood flow.
c. Neurologic injury remains static once the CSF has been sterilized by antibiotic therapy.
d. Infiltration of the arteries by inflammatory cells may result in ischemia and infarction.
Many of the neurologic manifestations and complications of bacterial meningitis result from the immune response to the invading pathogen rather than from direct bacteria-induced tissue injury. As a result, neurologic injury can progress even after the CSF has been sterilized by antibiotic therapy. During the very early stages of meningitis, there is an increase in cerebral blood flow. Narrowing of the large arteries at the base of the brain due to encroachment by the purulent exudate in the SAS and infiltration of the arterial wall by inflammatory cells with intimal thickening (vasculitis) also occur and may result in ischemia and infarction, obstruction of branches of the middle cerebral artery by thrombosis, thrombosis of the major cerebral venous sinuses, and thrombophlebitis of the cerebral cortical veins.
The correct answer is: Infiltration of the arteries by inflammatory cells may result in ischemia and infarction.
Which management strategy should be done in a patient with suspected bacterial meningitis?
a. Adjunctive Dexamethasone should be started in patients with focal neurologic signs.
b. Blood cultures may be obtained before or after initiation of antibiotics
c. It is safe to do lumbar puncture without neuroimaging studies in all immunocompetent patients
d. Empiric antibiotic therapy should be started without delay
When bacterial meningitis is suspected, blood cultures should be immediately obtained and empirical antimicrobial and adjunctive dexamethasone therapy initiated without delay. In an immunocompetent patient with no known history of recent head trauma, a normal level of consciousness, and no evidence of papilledema or focal neurologic deficits, it is considered safe to perform LP without prior neuroimaging studies. Blood cultures should be obtained before empirical antibiotic therapy is initiated.
The correct answer is: Empiric antibiotic therapy should be started without delay
IV antibiotics should be given for 2 weeks in which causative agent of bacterial meningitis?
a. Neisseria meningitides
b. Streptococcal meningitis
c. Listeria monocytogenes
d. Pseudomonas aeruginosa
Uncomplicated meningococcal meningitis should be treated with IV antibiotic therapy for 1 week. Pneumococcal meningitis should be treated with IV antibiotics for 2 weeks. While meningitis due to L. monocytogenes and gram negative bacilli such as P. aeruginosa should be treated with IV antibiotics for 3 weeks.
The correct answer is: Streptococcal meningitis
Which is the correct dose in initiating anti TB medications for tuberculous meningitis?
a. Isoniazid (300mg/day), Rifampicin (10mg/kg/day) , Pyrazinamide (15-25mg/kg/day), Ethambutol (30mg/kg/day)
b. Isoniazid (300mg/day), Rifampicin (30mg/kg/day) , Pyrazinamide (10mg/kg/day), Ethambutol (15-25mg/kg/day)
c. Isoniazid (300mg/day), Rifampicin (10mg/kg/day),) , Pyrazinamide (30mg/kg/day), Ethambutol (15-25mg/kg/day)
d. Isoniazid (300mg/day), Rifampicin (15-25mg/kg/day) , Pyrazinamide (30mg/kg/day), Ethambutol (10mg/kg/day)
Empirical therapy of tuberculous meningitis is often initiated on the basis of a high index of suspicion without adequate laboratory support. Initial therapy is a combination of isoniazid (300 mg/d), rifampin (10 mg/kg per day), pyrazinamide (30 mg/kg per day in divided doses), ethambutol (15–25 mg/kg per day in divided doses).
The correct answer is: Isoniazid (300mg/day), Rifampicin (10mg/kg/day),) , Pyrazinamide (30mg/kg/day), Ethambutol (15-25mg/kg/day)
In tuberculous meningitis, how should dexamethasone be administered?
a. Dexamethasone should be given irregardless of HIV status
b. Dexamethasone is given at 20 mg/day for 4 weeks
c. After initial high dose Dexamethasone, it should be tapered over 3 weeks
d. Dexamethasone dose is dependent on the patient’s weight
Dexamethasone therapy is recommended for HIV-negative patients with tuberculous meningitis. The dose is 12–16 mg/d for 3 weeks, and then tapered over 3 weeks.
The correct answer is: After initial high dose Dexamethasone, it should be tapered over 3 weeks
Which symptom corresponds to the correct sign in patients with chronic meningitis?
a. Urinary incontinence : hydrocephalus
b. Clumsiness : myelopathy
c. Double vision: papilledema
d. Chronic headache: optic atrophy
The correct answer is: Urinary incontinence : hydrocephalus
Which of the following statements about intracranial meningitis is true?
a. CSF is produced by the arachnoid villi and is absorbed by the choroid plexus.
b. In basal meningitis, inflammatory deposits in the brainstem result to hydrocephalus
c. Stimulation of the nociceptive fibers in the brain parenchyma result to headache.
d. Raised intracranial pressure may present with palsy of the sixth cranial nerve.
CSF is produced by the choroid plexus and absorbed by the arachnoid villi. In basal meningitis, inflammatory deposits in the brainstem result to multiple cranial nerve palsies, not hydrocephalus. Stimulation of the nociceptive fibers in the meninges (not in the brain parenchyma) result to headache. Raised intracranial pressure may present with palsy of the sixth cranial nerve. Obstruction of CSF pathways at the foramina or arachnoid villi may produce hydrocephalus and signs and symptoms of raised intracranial pressure (ICP), including head- ache, vomiting, apathy or drowsiness, gait instability, papilledema, visual loss, impaired upgaze, or palsy of the sixth cranial nerve.
The correct answer is: Raised intracranial pressure may present with palsy of the sixth cranial nerve.
Which of the following increases the mortality risk in patients with bacterial meningitis?
a. Increased CSF glucose
b. Seizures after 24 hours of admission
c. Age >50
d. Decreased CSF protein
In general, the risk of death from bacterial meningitis increases with (1) decreased level of consciousness on admission, (2) onset of seizures within 24 h of admission, (3) signs of increased ICP, (4) young age (infancy) and age >50, (5) the presence of comorbid conditions including shock and/or the need for mechanical ventilation, and (6) delay in the initiation of treatment. Decreased CSF glucose concentration (<2.2 mmol/L [<40 mg/dL]) and markedly increased CSF protein concentration (>3 g/L [> 300 mg/dL]) have been predictive of increased mortality.
The correct answer is: Age >50
